Therapeutic options for young females with rheumatic mitral valve disease include mitral valve surgery with frequent valve replacement due to disease pathology. For young patients, the prosthetic valve choice is currently restricted to mechanical valves requiring accurate anticoagulation. Pregnancy poses challenges due to the need to stop or adjust warfarin dosing during different trimesters. Studies show better fetal outcomes with warfarin doses of 5mg or less. Surgery combining mitral valve repair/replacement and the Maze procedure reduces atrial fibrillation and improves survival rates without increasing operative risk compared to mitral surgery alone.
Post Myocardial infarction vsd repair by infarct exclusion techniqueJyotindra Singh
This case study examines outcomes of 26 patients who underwent surgical repair of a post-myocardial infarction ventricular septal defect (PMIVSD) over a 15-year period. 20 patients underwent defect closure with concomitant coronary artery bypass grafting (CABG), while 6 had defect closure alone. In-hospital mortality was 30.9%, with higher mortality seen in those with cardiogenic shock, posterior defects, and surgery over 3 weeks after infarction. 15 of the 20 patients who had CABG survived, compared to 3 of the 6 who had defect closure alone. Residual shunts occurred in 5 patients but did not require reoperation. Predictors of poor prognosis included cardiogenic shock, timing of surgery, and total
Ventricular septal rupture (VSR) is a rare but lethal complication of myocardial infarction (MI).
Bimodal peak
Range: few hours 2 weeks
Average time to rupture
2-8 days
Time course may be accelerated by thrombolysis, possible related to intramyocardial hemorrhage
This document discusses when revascularization may be appropriate for asymptomatic patients with carotid artery stenosis.
It summarizes evidence from clinical trials showing a reduction in stroke risk from revascularization compared to medical therapy alone. Revascularization risks have decreased over time with improvements in technology and operator experience.
The document recommends identifying high-risk patients for revascularization based on plaque characteristics like morphology and microemboli, as well as factors like impaired vasomotor reactivity, silent cerebral infarcts, and progression of stenosis over time. Detection of these high-risk features can help select asymptomatic patients that may benefit from revascularization.
Thrombus aspiration prior to primary percutaneous coronary intervention (PCI) shows the most promise for preventing distal embolization in ST-segment elevation myocardial infarction (STEMI) based on clinical trial evidence. New devices like the MGuard stent, which combines a stent and embolic protection mesh, also show potential benefits. The presentation reviewed various pharmacologic and mechanical approaches and their supporting clinical trial data, ultimately recommending thrombus aspiration as the current best therapy to reduce distal embolization in STEMI patients undergoing primary PCI.
Ventricular septal defect after myocardial infarctionRamachandra Barik
This document discusses ventricular septal defects (VSDs) that occur after a myocardial infarction. It provides several key points:
1. Surgical repair is the gold standard treatment for post-infarction VSD, but patients are at high risk for complications and mortality rates remain poor.
2. Transcatheter device closure of VSDs is an emerging alternative to surgery, with studies showing high rates of technical success but also risks of major complications and death within 30 days.
3. Factors associated with increased mortality from both surgical repair and device closure include older age, cardiogenic shock, renal dysfunction, and larger defect size. Overall, post-infarction VSD continues to carry
This study evaluated outcomes of 26 patients who underwent surgical repair of post-myocardial infarction ventricular septal defect (VSD) at Nizams Institute of Medical Sciences between 1997-2012. 20 patients underwent VSD repair with concomitant coronary artery bypass grafting, while 6 had VSD closure alone. The mean time between MI and VSD appearance was 7.2 days, and between VSD appearance and surgery was 27.2 days. Overall in-hospital mortality was 30.9% and 30-day mortality was 33%. Patients who underwent emergency surgery within 3 days of MI had 100% mortality, while those operated on after 3 weeks had 100% survival. Concomitant CABG during VSD repair was associated with lower
This document discusses carotid artery disease and carotid stenting procedures. It provides background on carotid artery atherosclerosis and how vulnerable plaques can lead to strokes. It then summarizes guidelines for diagnosing and treating symptomatic and asymptomatic carotid stenosis, including the risks and benefits of medical therapy, carotid endarterectomy, and carotid artery stenting. The document concludes by outlining the key steps for performing carotid artery stenting, including patient selection, imaging, vascular access, stent placement, and complications to consider.
This document discusses carotid artery stenting (CAS) as an alternative to carotid endarterectomy (CEA) for treatment of carotid artery stenosis. It provides details on patient selection criteria and describes the CAS procedure, including diagnostic arteriography, embolic protection device placement, stent placement, and post-procedure care. Several major clinical trials are summarized that demonstrated CAS to be non-inferior to CEA for reducing risk of stroke in both symptomatic and asymptomatic patients.
Post Myocardial infarction vsd repair by infarct exclusion techniqueJyotindra Singh
This case study examines outcomes of 26 patients who underwent surgical repair of a post-myocardial infarction ventricular septal defect (PMIVSD) over a 15-year period. 20 patients underwent defect closure with concomitant coronary artery bypass grafting (CABG), while 6 had defect closure alone. In-hospital mortality was 30.9%, with higher mortality seen in those with cardiogenic shock, posterior defects, and surgery over 3 weeks after infarction. 15 of the 20 patients who had CABG survived, compared to 3 of the 6 who had defect closure alone. Residual shunts occurred in 5 patients but did not require reoperation. Predictors of poor prognosis included cardiogenic shock, timing of surgery, and total
Ventricular septal rupture (VSR) is a rare but lethal complication of myocardial infarction (MI).
Bimodal peak
Range: few hours 2 weeks
Average time to rupture
2-8 days
Time course may be accelerated by thrombolysis, possible related to intramyocardial hemorrhage
This document discusses when revascularization may be appropriate for asymptomatic patients with carotid artery stenosis.
It summarizes evidence from clinical trials showing a reduction in stroke risk from revascularization compared to medical therapy alone. Revascularization risks have decreased over time with improvements in technology and operator experience.
The document recommends identifying high-risk patients for revascularization based on plaque characteristics like morphology and microemboli, as well as factors like impaired vasomotor reactivity, silent cerebral infarcts, and progression of stenosis over time. Detection of these high-risk features can help select asymptomatic patients that may benefit from revascularization.
Thrombus aspiration prior to primary percutaneous coronary intervention (PCI) shows the most promise for preventing distal embolization in ST-segment elevation myocardial infarction (STEMI) based on clinical trial evidence. New devices like the MGuard stent, which combines a stent and embolic protection mesh, also show potential benefits. The presentation reviewed various pharmacologic and mechanical approaches and their supporting clinical trial data, ultimately recommending thrombus aspiration as the current best therapy to reduce distal embolization in STEMI patients undergoing primary PCI.
Ventricular septal defect after myocardial infarctionRamachandra Barik
This document discusses ventricular septal defects (VSDs) that occur after a myocardial infarction. It provides several key points:
1. Surgical repair is the gold standard treatment for post-infarction VSD, but patients are at high risk for complications and mortality rates remain poor.
2. Transcatheter device closure of VSDs is an emerging alternative to surgery, with studies showing high rates of technical success but also risks of major complications and death within 30 days.
3. Factors associated with increased mortality from both surgical repair and device closure include older age, cardiogenic shock, renal dysfunction, and larger defect size. Overall, post-infarction VSD continues to carry
This study evaluated outcomes of 26 patients who underwent surgical repair of post-myocardial infarction ventricular septal defect (VSD) at Nizams Institute of Medical Sciences between 1997-2012. 20 patients underwent VSD repair with concomitant coronary artery bypass grafting, while 6 had VSD closure alone. The mean time between MI and VSD appearance was 7.2 days, and between VSD appearance and surgery was 27.2 days. Overall in-hospital mortality was 30.9% and 30-day mortality was 33%. Patients who underwent emergency surgery within 3 days of MI had 100% mortality, while those operated on after 3 weeks had 100% survival. Concomitant CABG during VSD repair was associated with lower
This document discusses carotid artery disease and carotid stenting procedures. It provides background on carotid artery atherosclerosis and how vulnerable plaques can lead to strokes. It then summarizes guidelines for diagnosing and treating symptomatic and asymptomatic carotid stenosis, including the risks and benefits of medical therapy, carotid endarterectomy, and carotid artery stenting. The document concludes by outlining the key steps for performing carotid artery stenting, including patient selection, imaging, vascular access, stent placement, and complications to consider.
This document discusses carotid artery stenting (CAS) as an alternative to carotid endarterectomy (CEA) for treatment of carotid artery stenosis. It provides details on patient selection criteria and describes the CAS procedure, including diagnostic arteriography, embolic protection device placement, stent placement, and post-procedure care. Several major clinical trials are summarized that demonstrated CAS to be non-inferior to CEA for reducing risk of stroke in both symptomatic and asymptomatic patients.
Experience in management of complicated vascular injuryuvcd
1) This study reviewed 850 patients with complex vascular injuries in Yemen between 1999-2012. Most injuries were due to penetrating trauma (87%) rather than blunt trauma (13%) and involved arteries, veins, bones and soft tissues.
2) Vascular reconstruction was commonly needed and included interposition vein grafts (48%), primary artery repair (10%), and synthetic grafts (5%). Skeletal trauma often required external or internal fixation (78% and 7% respectively).
3) Morbidity and mortality rates were significant, including re-operation (4.2%), renal failure (2.7%), graft rupture (2.7%), primary amputation (3.3%), secondary amputation (4%), and
Carotid artery disease is a major cause of stroke. Left untreated, carotid stenosis over 75% carries a risk of stroke of 2-5% per year. Carotid endarterectomy has been shown in clinical trials such as NASCET and ACAS to significantly reduce stroke risk compared to medical management alone, with perioperative stroke or death rates of less than 6% for symptomatic patients and 3% for asymptomatic patients. Carotid artery stenting is an alternative treatment that utilizes embolic protection devices and stent placement to treat carotid stenosis, but requires technical expertise to achieve outcomes comparable to surgery.
This document discusses treatment options for middle cerebral artery (MCA) aneurysms, specifically clipping versus coiling. It provides data from multiple studies showing improved outcomes with coiling compared to clipping, including lower rates of poor outcome, complications, and rebleeding. The document also reviews new endovascular devices that have increased the feasibility of coiling for more complex MCA aneurysms. It concludes that while both treatments are reasonable options, coiling is now generally preferred for MCA aneurysms due to improved outcomes demonstrated in clinical trials and registry data.
How should recently symptomatic patients be treated urgent cea or casuvcd
Recent symptomatic patients with carotid artery stenosis can be treated with either urgent carotid endarterectomy (CEA) or carotid artery stenting (CAS). While early studies found CEA to have better outcomes, more recent trials like CREST showed comparable rates of stroke and death between CEA and CAS. For recently symptomatic patients specifically, CEA may still be preferred to CAS due to concerns about stabilizing carotid plaque after stenting. Operator experience also impacts outcomes, so treatment should be individualized based on each patient's clinical situation.
This document summarizes surgical management of complex aortic arch pathology. It discusses techniques for aortic arch surgery including conventional approaches using median sternotomy with cannulation of the axillary or femoral artery and selective cerebral perfusion. It also discusses hybrid techniques combining endovascular stent grafting with open surgery. Outcomes from one institution treating 29 patients with complex aortic arch pathology using conventional surgery are presented, with in-hospital mortality of 35% and stroke rate of 3.4%. The document concludes that aortic arch surgery remains challenging but some advances have been made, though drawbacks still exist.
New strategies for endovascular recanalization of acute ischemic stroke. 2013Javier Pacheco Paternina
1) The document discusses new strategies for endovascular recanalization of acute ischemic stroke, including intra-arterial thrombolysis, combined intravenous and intra-arterial thrombolysis, endovascular angioplasty and stenting, and neurothrombectomy.
2) Early trials showed intra-arterial thrombolysis improved recanalization rates and outcomes compared to heparin alone, but had high rates of intracranial hemorrhage. Combined intravenous and intra-arterial thrombolysis achieved recanalization in over half of patients with moderate rates of intracranial hemorrhage.
3) Neurothrombectomy devices that mechanically remove blood clots
- Clinical trials have shown that carotid endarterectomy (CEA) reduces the risk of stroke compared to best medical treatment (BMT) alone in patients with asymptomatic carotid stenosis over 50%-60%.
- However, more recent evidence suggests the risk of stroke for asymptomatic patients on BMT alone has declined over time and is now under 1% annually. Intensive medical management may further reduce stroke risks.
- While CEA remains an option for very high-risk asymptomatic patients, the marginal benefit is small and BMT alone may now be preferred for most asymptomatic carotid stenosis cases given the low stroke risks with improved medical therapy.
This case report describes a late pseudoaneurysm that developed at the puncture site in a 30-year old male with systemic lupus erythematosus (SLE) and antiphospholipid antibody syndrome (APLA) who underwent coronary angiography. Two weeks after the procedure, an enlarging pulsatile bulge was detected at the puncture site. Ultrasound-guided thrombin injection resolved the pseudoaneurysm. The authors speculate that patients with chronic inflammatory diseases treated with anticoagulation and steroids may be predisposed to late pseudoaneurysm formation due to vessel wall weakness. Close follow-up is recommended for high-risk patients.
Endovascular treatments are minimally invasive procedures that are done inside the blood vessels and can be used to treat peripheral arterial disease. Treatments like Anti Platelets, Anti-Diabetics, Statins, Promote Collaterals, etc.
Trial 1 analyzed data from 4 randomized clinical trials comparing carotid artery stenting (CAS) to carotid endarterectomy (CEA). It found that about two-thirds of procedural strokes or deaths from CAS occurred on the day of the procedure, compared to half for CEA. The risk of these adverse events was significantly higher for CAS but similar between the procedures 1-30 days later.
Trial 2 followed patients from 1 randomized clinical trial for up to 10 years. It found moderate or higher restenosis occurred more frequently after CAS than CEA. Restenosis after either procedure significantly increased the risk of subsequent stroke, and this risk was higher for CEA. Independent risk factors for restenosis included older age, female
This document discusses interventions for acute ischemic stroke. It summarizes that intra-arterial recanalization can provide good outcomes when performed by experts in high-volume centers. Recent trials show stent retrievers like Solitaire provide high recanalization rates of 80-90% compared to older devices like MERCI. However, case selection using imaging of penumbra is important, and speed of treatment is crucial, as delays can reduce chances of independence. Ongoing randomized trials continue to refine techniques and selection criteria for endovascular stroke interventions.
Carotid endarterectomy versus carotid stentingKrishna Prasad
Carotid endarterectomy (CEA) and carotid artery stenting (CAS) are procedures used to treat carotid artery stenosis. While CEA has been shown to be beneficial in clinical trials, CAS was developed to provide a less invasive option. However, concerns with CAS include higher risks of periprocedural complications like stroke. Several studies have compared CEA and CAS, finding CAS to be noninferior with similar composite outcomes, but higher risks of periprocedural stroke with CAS. Long term results are inconclusive, and patient factors like age, plaque characteristics, and vessel anatomy influence outcomes for each procedure. Ongoing studies continue to evaluate optimal treatment of carotid artery stenosis.
Carotid artery stenting – an update on atheroscleroticNeurologyKota
Carotid artery stenting is an alternative to carotid endarterectomy for treating carotid artery stenosis caused by atherosclerosis. The document provides recommendations for treatment of asymptomatic and symptomatic carotid stenosis. It summarizes data from trials comparing outcomes of carotid endarterectomy and stenting to medical management. The risks and benefits of carotid endarterectomy and stenting are discussed, along with indications, contraindications, procedural details, complications, and long-term outcomes of the procedures. Guidelines recommend carotid endarterectomy or stenting only when the risk of perioperative stroke and death is low (<6%).
Hybrid tevar for the treatment of aortic dissectionuvcd
- Hybrid TEVAR involves using open surgery and endovascular stent grafting to treat aortic dissection.
- It can be used for acute type A dissection to allow total arch repair followed by TEVAR for the descending thoracic aorta. It is also indicated for chronic type B dissection when there is no suitable proximal landing zone by creating one through open surgery.
- The author presents results from their hospital demonstrating the safety and effectiveness of hybrid TEVAR for both acute type A and chronic type B dissection, with favorable outcomes including high rates of false lumen thrombosis and regression.
This document discusses indications and techniques for carotid artery stenting (CAS). It notes that symptomatic stenosis over 70% on non-invasive imaging or over 50% on catheter angiography are indications for revascularization. Asymptomatic stenosis over 70% may also be treated if life expectancy is over 5 years and stenosis is over 80%. The technique involves pre- and post-dilation of stents with the use of protection devices to prevent embolic strokes. Results depend on the operator's experience and complications include strokes, hypotension, and restenosis. Larger trials found CAS and CEA to have similar outcomes, with CAS preferred for younger patients, though CEA is preferred in certain high risk cases.
This document discusses PCI (percutaneous coronary intervention) versus CABG (coronary artery bypass grafting) for treating stable coronary artery disease. It provides historical context on the evolution of both procedures and summarizes key randomized controlled trials comparing outcomes of PCI versus CABG. The trials show that CABG provided better long-term outcomes than balloon angioplasty or bare metal stents in multivessel disease. Later trials with drug-eluting stents still found CABG superior for left main or multivessel disease, though the differences were smaller. CABG remains the standard of care for more complex anatomies while PCI is preferred for simpler cases.
Left main disease pci vs cabg excel trial 2016Kunal Mahajan
This randomized controlled trial compared percutaneous coronary intervention (PCI) using everolimus-eluting stents to coronary artery bypass grafting (CABG) for the treatment of left main coronary artery disease. The primary outcome was a composite of death, stroke, or myocardial infarction at 3 years. PCI was found to be non-inferior to CABG for the primary outcome. At 30 days, PCI had fewer adverse events like infections and bleeding, but more deaths, strokes and MIs. Between 30 days and 3 years, ischemia-driven revascularization was more common with PCI. Longer follow-up is still needed given differences in long-term medication use and revascularization between the treatments.
Experience in management of complicated vascular injuryuvcd
1) This study reviewed 850 patients with complex vascular injuries in Yemen between 1999-2012. Most injuries were due to penetrating trauma (87%) rather than blunt trauma (13%) and involved arteries, veins, bones and soft tissues.
2) Vascular reconstruction was commonly needed and included interposition vein grafts (48%), primary artery repair (10%), and synthetic grafts (5%). Skeletal trauma often required external or internal fixation (78% and 7% respectively).
3) Morbidity and mortality rates were significant, including re-operation (4.2%), renal failure (2.7%), graft rupture (2.7%), primary amputation (3.3%), secondary amputation (4%), and
Carotid artery disease is a major cause of stroke. Left untreated, carotid stenosis over 75% carries a risk of stroke of 2-5% per year. Carotid endarterectomy has been shown in clinical trials such as NASCET and ACAS to significantly reduce stroke risk compared to medical management alone, with perioperative stroke or death rates of less than 6% for symptomatic patients and 3% for asymptomatic patients. Carotid artery stenting is an alternative treatment that utilizes embolic protection devices and stent placement to treat carotid stenosis, but requires technical expertise to achieve outcomes comparable to surgery.
This document discusses treatment options for middle cerebral artery (MCA) aneurysms, specifically clipping versus coiling. It provides data from multiple studies showing improved outcomes with coiling compared to clipping, including lower rates of poor outcome, complications, and rebleeding. The document also reviews new endovascular devices that have increased the feasibility of coiling for more complex MCA aneurysms. It concludes that while both treatments are reasonable options, coiling is now generally preferred for MCA aneurysms due to improved outcomes demonstrated in clinical trials and registry data.
How should recently symptomatic patients be treated urgent cea or casuvcd
Recent symptomatic patients with carotid artery stenosis can be treated with either urgent carotid endarterectomy (CEA) or carotid artery stenting (CAS). While early studies found CEA to have better outcomes, more recent trials like CREST showed comparable rates of stroke and death between CEA and CAS. For recently symptomatic patients specifically, CEA may still be preferred to CAS due to concerns about stabilizing carotid plaque after stenting. Operator experience also impacts outcomes, so treatment should be individualized based on each patient's clinical situation.
This document summarizes surgical management of complex aortic arch pathology. It discusses techniques for aortic arch surgery including conventional approaches using median sternotomy with cannulation of the axillary or femoral artery and selective cerebral perfusion. It also discusses hybrid techniques combining endovascular stent grafting with open surgery. Outcomes from one institution treating 29 patients with complex aortic arch pathology using conventional surgery are presented, with in-hospital mortality of 35% and stroke rate of 3.4%. The document concludes that aortic arch surgery remains challenging but some advances have been made, though drawbacks still exist.
New strategies for endovascular recanalization of acute ischemic stroke. 2013Javier Pacheco Paternina
1) The document discusses new strategies for endovascular recanalization of acute ischemic stroke, including intra-arterial thrombolysis, combined intravenous and intra-arterial thrombolysis, endovascular angioplasty and stenting, and neurothrombectomy.
2) Early trials showed intra-arterial thrombolysis improved recanalization rates and outcomes compared to heparin alone, but had high rates of intracranial hemorrhage. Combined intravenous and intra-arterial thrombolysis achieved recanalization in over half of patients with moderate rates of intracranial hemorrhage.
3) Neurothrombectomy devices that mechanically remove blood clots
- Clinical trials have shown that carotid endarterectomy (CEA) reduces the risk of stroke compared to best medical treatment (BMT) alone in patients with asymptomatic carotid stenosis over 50%-60%.
- However, more recent evidence suggests the risk of stroke for asymptomatic patients on BMT alone has declined over time and is now under 1% annually. Intensive medical management may further reduce stroke risks.
- While CEA remains an option for very high-risk asymptomatic patients, the marginal benefit is small and BMT alone may now be preferred for most asymptomatic carotid stenosis cases given the low stroke risks with improved medical therapy.
This case report describes a late pseudoaneurysm that developed at the puncture site in a 30-year old male with systemic lupus erythematosus (SLE) and antiphospholipid antibody syndrome (APLA) who underwent coronary angiography. Two weeks after the procedure, an enlarging pulsatile bulge was detected at the puncture site. Ultrasound-guided thrombin injection resolved the pseudoaneurysm. The authors speculate that patients with chronic inflammatory diseases treated with anticoagulation and steroids may be predisposed to late pseudoaneurysm formation due to vessel wall weakness. Close follow-up is recommended for high-risk patients.
Endovascular treatments are minimally invasive procedures that are done inside the blood vessels and can be used to treat peripheral arterial disease. Treatments like Anti Platelets, Anti-Diabetics, Statins, Promote Collaterals, etc.
Trial 1 analyzed data from 4 randomized clinical trials comparing carotid artery stenting (CAS) to carotid endarterectomy (CEA). It found that about two-thirds of procedural strokes or deaths from CAS occurred on the day of the procedure, compared to half for CEA. The risk of these adverse events was significantly higher for CAS but similar between the procedures 1-30 days later.
Trial 2 followed patients from 1 randomized clinical trial for up to 10 years. It found moderate or higher restenosis occurred more frequently after CAS than CEA. Restenosis after either procedure significantly increased the risk of subsequent stroke, and this risk was higher for CEA. Independent risk factors for restenosis included older age, female
This document discusses interventions for acute ischemic stroke. It summarizes that intra-arterial recanalization can provide good outcomes when performed by experts in high-volume centers. Recent trials show stent retrievers like Solitaire provide high recanalization rates of 80-90% compared to older devices like MERCI. However, case selection using imaging of penumbra is important, and speed of treatment is crucial, as delays can reduce chances of independence. Ongoing randomized trials continue to refine techniques and selection criteria for endovascular stroke interventions.
Carotid endarterectomy versus carotid stentingKrishna Prasad
Carotid endarterectomy (CEA) and carotid artery stenting (CAS) are procedures used to treat carotid artery stenosis. While CEA has been shown to be beneficial in clinical trials, CAS was developed to provide a less invasive option. However, concerns with CAS include higher risks of periprocedural complications like stroke. Several studies have compared CEA and CAS, finding CAS to be noninferior with similar composite outcomes, but higher risks of periprocedural stroke with CAS. Long term results are inconclusive, and patient factors like age, plaque characteristics, and vessel anatomy influence outcomes for each procedure. Ongoing studies continue to evaluate optimal treatment of carotid artery stenosis.
Carotid artery stenting – an update on atheroscleroticNeurologyKota
Carotid artery stenting is an alternative to carotid endarterectomy for treating carotid artery stenosis caused by atherosclerosis. The document provides recommendations for treatment of asymptomatic and symptomatic carotid stenosis. It summarizes data from trials comparing outcomes of carotid endarterectomy and stenting to medical management. The risks and benefits of carotid endarterectomy and stenting are discussed, along with indications, contraindications, procedural details, complications, and long-term outcomes of the procedures. Guidelines recommend carotid endarterectomy or stenting only when the risk of perioperative stroke and death is low (<6%).
Hybrid tevar for the treatment of aortic dissectionuvcd
- Hybrid TEVAR involves using open surgery and endovascular stent grafting to treat aortic dissection.
- It can be used for acute type A dissection to allow total arch repair followed by TEVAR for the descending thoracic aorta. It is also indicated for chronic type B dissection when there is no suitable proximal landing zone by creating one through open surgery.
- The author presents results from their hospital demonstrating the safety and effectiveness of hybrid TEVAR for both acute type A and chronic type B dissection, with favorable outcomes including high rates of false lumen thrombosis and regression.
This document discusses indications and techniques for carotid artery stenting (CAS). It notes that symptomatic stenosis over 70% on non-invasive imaging or over 50% on catheter angiography are indications for revascularization. Asymptomatic stenosis over 70% may also be treated if life expectancy is over 5 years and stenosis is over 80%. The technique involves pre- and post-dilation of stents with the use of protection devices to prevent embolic strokes. Results depend on the operator's experience and complications include strokes, hypotension, and restenosis. Larger trials found CAS and CEA to have similar outcomes, with CAS preferred for younger patients, though CEA is preferred in certain high risk cases.
This document discusses PCI (percutaneous coronary intervention) versus CABG (coronary artery bypass grafting) for treating stable coronary artery disease. It provides historical context on the evolution of both procedures and summarizes key randomized controlled trials comparing outcomes of PCI versus CABG. The trials show that CABG provided better long-term outcomes than balloon angioplasty or bare metal stents in multivessel disease. Later trials with drug-eluting stents still found CABG superior for left main or multivessel disease, though the differences were smaller. CABG remains the standard of care for more complex anatomies while PCI is preferred for simpler cases.
Left main disease pci vs cabg excel trial 2016Kunal Mahajan
This randomized controlled trial compared percutaneous coronary intervention (PCI) using everolimus-eluting stents to coronary artery bypass grafting (CABG) for the treatment of left main coronary artery disease. The primary outcome was a composite of death, stroke, or myocardial infarction at 3 years. PCI was found to be non-inferior to CABG for the primary outcome. At 30 days, PCI had fewer adverse events like infections and bleeding, but more deaths, strokes and MIs. Between 30 days and 3 years, ischemia-driven revascularization was more common with PCI. Longer follow-up is still needed given differences in long-term medication use and revascularization between the treatments.
1) The Aam Aadmi Party (AAP) is facing a monumental crisis in Maharashtra where its state unit was dissolved in October 2015 and it has lacked a solid organizational structure since.
2) AAP received around 11.5 lakh votes in the 2014 Lok Sabha elections in Maharashtra, representing around 0.12% of the vote share, but it has struggled to sustain that initial enthusiasm and support.
3) AAP lacks credible leadership in Maharashtra comparable to Arvind Kejriwal in Delhi or Bhagwant Mann in Punjab, and has no one who can command a crowd as a dynamic leader, which is important for a national political party's ambitions.
El documento proporciona información sobre el Servicio Nacional de Aprendizaje (SENA) de Colombia. SENA es una institución pública encargada de ofrecer formación profesional e invertir en el desarrollo técnico de los trabajadores colombianos. El documento describe la visión, misión y símbolos de SENA, así como sus programas de formación virtual, el rol de los aprendices y tutores, y sistemas de administración del aprendizaje como Sofía Plus y Blackboard.
Global retailers have recognized the potential of exclusive niche beauty brands to create loyalty and differentiation. These brands fill the white space between national brands and more expensive prestige brands. Many retailers are developing exclusive beauty brands using various strategies like leveraging internationally proven brands, extending existing lines, building brands around ingredient trends, and marketing support. The key to future success is creating destinations that meet the needs of diverse consumers through continuous innovation and marketing of exclusive brands.
Background : Approaching the year 2020 cardiovascular disease will become the leading cause of death in the world before the age of 65 years. National Health Survey in 2001 showed that deaths due to cardiovascular diseases including coronary heart disease amounted to 26.4%, and until now CHD is also a major cause of premature death. Thus, responsibility for the disease is not only done by the medical worker but also every individual. Recent research suggests that increasing HDL cholesterol can prevent cardiovascular disease. Anthocyanins that are found in various plants Including strawberrie may reduce the risk of cardiovascular disease. Purpose : to identify the effect of strawberry juice administration on levels of HDL in old people with dyslipidemia.
Methods : The study design used in this study is quasi experimental research (quasi experiment) with the type of control group pretest-postest design that examines the influence of strawberry juice on the levels of HDL in patients with dyslipidemia by measuring the levels of HDL before treatment and after treatment. The population in this study were old people with dyslipidemia aged 55-65 years old . The population is divided into two groups, which were the control group and test group. The control group did not receive any treatment,while the test group consume strawberry juice for 14 days with a dose of 100g/day. Result : The results in each group obtained by calculating the average difference in the control group and test group. In the control group decreased HDL cholesterol levels of 0.285 mg / dl and in the test group there was an increase in HDL cholesterol of 24.582 mg / dl.
Conclusion : Juice of strawberries which contain anthocyanin can increase levels of HDL in old people with dyslipidemia
This document outlines 12 principles for teaching language:
1. Automaticity - Learning through repetition until it becomes habit. Lessons should focus on using language for real purposes.
2. Meaningful learning - Relating new knowledge to prior knowledge. Avoid rote learning and explain concepts clearly.
3. Anticipation of reward - People are motivated by rewards, so provide praise, encouragement, and opportunities for students to support each other.
4. Intrinsic motivation - Motivation comes from interest and challenge rather than external rewards.
5. Strategic investment - Investing time, effort and attention to improve comprehension and production.
6. Autonomy - Students need opportunities to take initiative and continue
The document discusses electricity safety and provides information on various safety devices used in homes. It explains that fuses and circuit breakers are used to prevent overloads and fires, with circuit breakers having the advantage of being reusable. Earth wires are important for appliance safety to prevent electric shocks. The document also cautions against illegal electricity connections, noting they are dangerous and a form of theft.
Revised hiring guidelines for teacher i positionsJanice Gabriel
The document outlines revisions to the hiring guidelines for Teacher I positions in the Philippines' Department of Education (DepEd) effective for the 2007-2008 school year. It establishes committees at the school, district, and division levels to evaluate applicants and create a Registry of Qualified Applicants. The guidelines standardize the recruitment, evaluation, selection, and hiring process for filling teaching vacancies according to education, certification exam scores, experience, and other criteria. Regional DepEd directors are tasked with monitoring implementation of the new procedures.
This document outlines guidelines for implementing the Senior High School Voucher Program in the Philippines. It details student eligibility requirements, including automatic qualification for grade 10 completers of public junior high schools. It also describes voucher validity, redemption procedures, and conditions for remaining in the program such as continued enrollment and promotion to the next grade level. Voucher recipients are not allowed to transfer schools within a school year or shift tracks/strands after their first semester of grade 11.
Jürgen Habermas es uno de los filósofos y sociólogos alemanes más importantes actualmente. Trabajó en el Instituto de Investigación Social de Frankfurt entre 1955 y 1959. Representa la segunda generación de la Escuela de Frankfurt.
XIII Reunión anual de la sección de Insuficiencia Cardiaca de la SEC
OVIEDO, 16-18 JUNIO 2016 HOSPITAL UNIVERSITARIO CENTRAL DE ASTURIAS (HUCA)
http://secardiologia.es/insuficiencia/cientifico/ic-oviedo-2016
Simposio: Abordaje integral y multidisciplinar de la Insuficiencia Mitral
VIERNES, 17 DE JUNIO 12:45-14:00 SALA A
Posibilidades del tratamiento percutáneo
Xavi Freixa Rofastes, Barcelona
Mitral stenosis surgery is recommended for adolescent or young adult patients with congenital mitral stenosis who have symptoms such as shortness of breath (NYHA class III or IV) and a mean mitral valve gradient over 10 mm Hg on echocardiography. Mitral valve surgery is also reasonable for asymptomatic patients with mild symptoms (NYHA class II) and a mean gradient over 10 mm Hg, or asymptomatic patients with pulmonary artery systolic pressure over 50 mm Hg and a mean gradient over 10 mm Hg. The effectiveness of surgery is uncertain for asymptomatic patients with new onset atrial fibrillation or embolisms while on anticoagulation.
Mitral stenosis surgery is recommended for adolescent or young adult patients with congenital mitral stenosis who have symptoms and a mean mitral valve gradient greater than 10 mm Hg. Mitral valve surgery is also reasonable for asymptomatic patients with mild symptoms and a mean gradient over 10 mm Hg, or asymptomatic patients with pulmonary artery systolic pressure over 50 mm Hg and a mean gradient over 10 mm Hg. The effectiveness of surgery is uncertain for asymptomatic patients with new onset atrial fibrillation or embolisms while on anticoagulation.
Managing Complications; First Prevent Complications
Examples of ComplacencySleeve Gastrectomy Failure:
“Sleeve Gastrectomy & Risk of Leak: Systematic Analysis of 4,888 Patients”
“Risk of leak is low at 2.4%"
Surg Endosc. 2012 Jun;26(6):1509-15. Epub 2011 Dec 17. Aurora AR, Khaitan L, Saber AA. Department of Surgery, University Hospitals Case Medical Center, Cleveland, Ohio
This document discusses ventricular septal rupture (VSR) which is a mechanical complication of myocardial infarction. It provides details on:
- The history, incidence, timing, anatomy and clinical presentation of VSR
- Diagnostic tools including echocardiography and hemodynamic monitoring
- Treatment approaches including medical management, percutaneous device closure and surgical repair
- Outcomes of different treatment options which show high mortality despite improvements, though percutaneous closure may be a viable alternative to surgery in some cases.
- Current guidelines which recommend urgent surgical repair for VSR complicating STEMI.
This document provides information about warfarin therapy for patients with mechanical heart valves, including:
1) Warfarin is the anticoagulant most commonly prescribed for patients with mechanical heart valves to reduce the risk of blood clots and thromboembolism by inhibiting vitamin K-dependent clotting factors.
2) The main risk of warfarin is hemorrhage, with 2-5% of patients experiencing major bleeding annually. Intracranial bleeding risk is 0.2-0.4% annually and fatal bleeding risk is 0.5-1.0% annually.
3) Warfarin is given orally once daily and the international normalized ratio (INR)
The role of uterine artery embolization in gynecology practiceApollo Hospitals
Uterine artery embolization (UAE) is a minimally invasive interventional radiological procedure to occlude the arterial
supply to the uterus. UAE has been very useful for controlling hemorrhage following delivery/abortion, in ectopic or cervical pregnancy, gestational trophoblastic disease or carcinoma cervix. Currently it is being mostly used for treating uterine fibroids. It requires a shorter Hospital stay with early resumption to normal activity. This review briefly summarizes the role of this relatively new technique in gynecologic practice.
Adult patient with functioning prosthetic mitral valve withoutmohamadobedat
This case report describes a 57-year-old male patient who had a mechanical mitral valve replacement 12 years ago but had not been taking anticoagulant medication since then. He presented with leg trauma and was found to have a functioning prosthetic valve without signs of thrombosis. The report discusses the risks of thromboembolism for patients with mechanical heart valves who do not take anticoagulants as recommended and the diagnostic and treatment approaches for prosthetic valve thrombosis.
This document summarizes guidelines for preventing deep vein thrombosis and pulmonary embolism in surgical patients. It discusses the causes of VTE including stasis, intimal injury, and hypercoagulability due to surgery. It also describes methods for assessing patient risk and different prophylaxis options including unfractionated heparin, low molecular weight heparin, and pentasaccharide. The summary provides an overview of dosing and administration for various prophylaxis modalities.
Successful Valve in Ring Abolishing the Stenosis and Regurgitation with Robus...Premier Publishers
Transcatheter mitral valve-in ring implantation (TMViRI), is a novel alternative treatment strategy and promising technique for patients at high risk of repeat open-heart surgery. In this report we demonstrate a case of 61 years old male with multiple co morbidities who underwent mitral valve repair long time ago who successfully treated and dramatically improved through trans-septal approach, under trans oesophageal echocardiography and fluoroscopic guidance in Hybrid catheterization laboratory.
It took another 10 years, after a positive response of a different Review Board,before the first alcohol septal ablation (ASA) could be performed at the Royal Brompton Hospital in London 25 years ago.1
The very first patient, after having been informed in great length and meticulous detail about all possible risks,agreed to an experimental procedure, the outcome of which could not be defined.
She had severe left ventricular hypertrophy that created an impressive and highly
symptomatic outflow tract gradient despite pacing and drug treatment; after the ablation on June 18, 1994, she remained asymptomatic for >20 years.
- The patient presented with new onset AF after recent PCI for NSTEMI. Managing anticoagulation and antiplatelet therapy in such patients is challenging due to risk of bleeding from triple therapy. Shortening triple therapy duration does not significantly reduce bleeding risk. Dual antiplatelet and anticoagulant therapy may reduce bleeding compared to triple therapy.
1) A 31-year-old man presented with a stab wound to the chest and became unresponsive. Emergency thoracotomy is indicated to treat pericardial tamponade, control hemorrhage, perform open cardiac massage, and temporarily occlude the thoracic aorta.
2) A 29-year-old pregnant woman at 34 weeks gestation collapsed in PEA. Perimortem cesarean section should be considered to deliver the fetus within 5 minutes of maternal cardiac arrest.
3) A 37-year-old man with a GCS of 6 following an MVC had proptosis and firmness of the left eye. He was diagnosed with orbital compartment syndrome and treated with lateral
Percutaneous Transvenous Mitral Commissurotomy in 71 Years Old Woman with Mit...M A Hasnat
Rheumatic mitral stenosis is a progressive disease that carries significant risks if left untreated. Percutaneous transvenous mitral commissurotomy (PTMC) is a standard nonsurgical procedure that can help delay the need for mitral valve replacement by enlarging the valve opening. The document reports a case of successful PTMC in a 71-year-old woman with severe mitral stenosis, enlarged left atrium, and mitral valve score of 7. Immediate results found improved hemodynamics and mitral valve area over 1.5 cm2. At 5-month follow up, echocardiography showed sustained benefits with trivial regurgitation and normal left ventricular function. PTMC can thus be an effective treatment even
Rheumatic mitral stenosis is a progressive disease that carries significant risks if left untreated. Percutaneous transvenous mitral commissurotomy (PTMC) is a standard nonsurgical procedure that can help delay the need for mitral valve replacement by enlarging the valve opening. The document reports a case of successful PTMC performed in a 71-year-old woman with severe mitral stenosis, enlarged left atrium, and mitral valve score of 7. Immediate results found an increased mitral valve area and decreased pressures. Follow up after 5 months showed maintained benefits with trivial regurgitation and good left ventricular function. PTMC can thus be an effective treatment even in elderly patients with mitral stenosis who are not candidates
Non cardiac surgery in cardiac patients moTamer Taha
This document discusses guidelines for evaluating and managing cardiac risk in patients undergoing non-cardiac surgery. It outlines factors that increase surgical risk like prolonged stress and changes in thrombotic factors. Complication rates are reported to be 7-11% with 0.8-1.5% mortality depending on precautions. Up to 42% of complications are cardiac related. It provides recommendations on pre-operative testing and risk stratification using indices. Risk reduction strategies discussed include use of beta-blockers, statins, and revascularization. Perioperative management of antiplatelets and anticoagulants is also covered.
The document discusses complications that can arise with arteriovenous (AV) access for hemodialysis and their management. It covers types of complications such as hematomas, significant steal syndrome, non-maturing fistulas, venous outflow stenosis, aneurysmal degeneration, and central venous stenosis. It describes techniques for managing these complications, including balloon angioplasty, coil embolization, stent graft placement, and open surgery. The overall message is that timely intervention is important to address access complications in order to maintain patency and usability of AV access for hemodialysis.
The document discusses complications that can arise with arteriovenous (AV) access for hemodialysis and their management. It covers types of complications such as hematomas, significant steal syndrome, non-maturing fistulas, venous outflow stenosis, aneurysmal degeneration, and central venous stenosis. It describes techniques for managing these complications, including balloon angioplasty, coil embolization, stent graft placement, and open surgery. The overall message is that timely intervention is important to address access complications in order to maintain patency and usability of AV access for hemodialysis.
PERCUTANEOUS TREATMENT STRATEGIES OF VALVULAR HEART DISEASEPraveen Nagula
This document discusses various percutaneous treatment strategies for valvular heart disease, focusing on mitral valve repair techniques. It provides an overview of early balloon valvuloplasty procedures and more recent advances like the MitraClip device for mitral regurgitation repair. The document reviews clinical trials that demonstrated the safety and efficacy of the MitraClip, as well as its current FDA approval status. It also discusses alternative percutaneous mitral repair approaches like indirect annuloplasty via the coronary sinus.
Surgical Treatment of Ischemic Mitral RegurgitationNora Albogami
This document discusses surgical treatment options for ischemic mitral regurgitation (IMR). It begins by describing the anatomy and physiology behind IMR, as well as medical therapies. Revascularization alone often does not sufficiently reduce IMR. The document then reviews evidence on mitral valve repair versus replacement. While repair traditionally had higher recurrence rates, newer techniques like leaflet augmentation and edge-to-edge repair are showing promise. Overall, the optimal surgical approach for treating IMR remains unclear due to heterogeneity in patient populations and outcomes data.
The document discusses a presentation given by Anwar Abd-Elfattah at the 18th Egyptian Society of Cardiothoracic Surgery conference on targeting post-ischemic reperfusion injury. It focuses on using selective adenosine deaminase inhibitors and nucleoside transport blockers to entrap intracellular adenosine and protect against reperfusion injury during cardiac surgery involving aortic cross-clamping. The presentation examines the role of the adenosine A1 receptor in this protective effect.
This document expresses gratitude to various teachers and mentors. It provides advice for running a department, including not starting with mediocre facilities, attaching new residents with senior staff mentors, disciplining with love rather than law alone, avoiding humiliation of juniors, rewarding extra research efforts with privileges with transparency, and being open to learning from anyone.
Myocardial revascularisation using radial artery presentationescts2012
This study evaluated the midterm results of using the radial artery as a bypass graft in 50 patients undergoing coronary artery bypass grafting. Preoperatively, patients had significant coronary artery disease, risk factors like diabetes and smoking, and left ventricular dysfunction in some cases. The radial artery was used as a graft in addition to the left internal mammary artery, with follow-up of patients for at least 2 years postoperatively to assess graft patency and clinical outcomes.
The document discusses surgical treatment of bacterial endocarditis based on the experience at Kasr Elaini Hospital in Cairo, Egypt. It summarizes that decisions about when to operate are based on a team approach considering the patient's clinical condition, laboratory tests, and echocardiography findings. The main indications for surgery seen were heart failure, large vegetations, uncontrolled infection, and recurrent emboli. The most common surgeries performed were prosthetic mitral valve replacement, mitral valve repair, and aortic valve replacement. Post-operative mortality was 19%. Careful evaluation and reluctance to operate can lead to patient deterioration, so surgery is often needed within a few days of initiating antibiotics.
1) The study evaluated the authors' learning curve for septal myectomy to treat hypertrophic obstructive cardiomyopathy (HOCM) in 19 Egyptian patients between 2000-2010.
2) Immediate postoperative peak gradients dropped significantly from a mean of 105+30 mmHg to 11.5+6.1 mmHg in all patients, and MR was reduced.
3) At follow-up of 34.4 months on average, most patients were free of symptoms. Two patients died, one from renal failure and one during dialysis. Egyptian HOCM patients tended to be younger with higher gradients than large international series.
The document discusses different frameworks for conceptualizing competence in medical education. It summarizes four frameworks:
1) Sabiston & Spencer's Textbook framework views competence as knowledge and emphasizes foundational knowledge, basic science facts, and multiple-choice tests.
2) Miller's Pyramid framework views competence as performance and emphasizes skills assessment using simulated patients, feedback, and objective structured clinical exams.
3) Cronbach's Alpha framework views competence as reliable test scores.
4) Donald Schon's framework views competence as reflection.
Does the medschool need an ecc science program or a perfusion techschoolescts2012
The document discusses whether a medical school needs an extracorporeal circulation (EC) science program or a perfusion technoschool. It describes a study that evaluated a perfusion skills course for perfusionists on handling difficult perfusion situations. The study found that perfusionists who took the course had significant improvements in self-efficacy and performance compared to the control group, as measured by questionnaires and an objective structured clinical exam. The document concludes that a short perfusion skills course can help perfusionists improve their ability to handle difficult clinical situations.
The Egyptian Fellowship of Cardiothoracic Surgery (EFCTS) provides a 4-year training program to certify cardiothoracic surgeons. Trainees undergo rigorous evaluation of their knowledge, skills, behavior, and surgical volume at high-volume training centers. Evaluations are conducted monthly and annually through exams, logbooks of procedures and activities, and assessments of clinical skills. Over a decade, 56 candidates enrolled but only 11 successfully completed the full program and certification exams, demonstrating the strict standards of the EFCTS.
The document summarizes the collaboration between Cairo University and Italian institutions, specifically IRCCS Policlinico San Donato, over nearly 20 years providing pediatric cardiac care. It details 59 surgical missions where over 500 patients were operated on and 66 grants were provided for doctors. The collaboration established a neonatal intensive care unit and new operating room at Cairo University's Pediatric Hospital and continues the exchange of expertise between the universities.
Outcome of pregnancy in prosthetic valve patientsescts2012
This document summarizes three studies from 1989-2009 on pregnancy outcomes in Egyptian women with prosthetic heart valves. The first study from 1989-1999 found a 44% fetal loss rate compared to 24% in controls. Later studies from 2002-2007 and 2008-2009 showed decreasing fetal and maternal loss rates, with improved outcomes associated with younger maternal age, heparin in the first trimester, and newer generation prosthetic valves. Overall, pregnancy for women with prosthetic heart valves remains high risk but outcomes have improved with advances in medical care.
Anticoagulation of pregnant women with mechanical heart valve prosthesis. a s...escts2012
This document summarizes guidelines and studies on anticoagulation treatment for pregnant women with mechanical heart valve prostheses. It finds that oral anticoagulants (OA) appear safer for mothers but heparin appears safer for fetuses. The guidelines recommend 3 regimens: OA throughout pregnancy, substituting OA with heparin from weeks 6-13, or heparin throughout pregnancy. The document reviews 19 studies comparing outcomes of these regimens. It finds higher rates of fetal complications like embryopathy, prematurity and abortion with OA, but higher rates of maternal complications like thrombosis with heparin. The document aims to determine if fetal embryopathy risk from OA was overstated or decreasing
Mitral valve repair in rheumatic patientsescts2012
1) Mitral valve repair has advantages over replacement such as lower mortality, better left ventricular function, and lower risks of complications.
2) While most degenerative mitral valves can be repaired, only 75% of rheumatic valves are suitable for repair due to the aggressive nature of rheumatic disease.
3) For rheumatic mitral disease, repair has better long-term outcomes than replacement in reducing mortality and reoperation risks, but repair durability is limited by the progressive nature of rheumatic pathology.
Chronic ischemic mitral regurgitation is a common complication of myocardial infarction that severely impacts mortality and morbidity, with multiple pathophysiological mechanisms involved in its generation. The study compared early and late results of 157 patients who underwent CABG and repair of grade II or higher ischemic mitral regurgitation to 5124 patients who underwent isolated CABG. Early results showed higher mortality, complications, and longer hospital stays for the group that underwent CABG and mitral valve repair. Residual mitral regurgitation and the Alfieri edge-to-edge repair technique were predictors of higher hospital mortality. Late follow-up is still ongoing but showed higher recurrence and mortality rates for patients with residual reg
The document discusses early experience with aortic valve repair in 10 patients with severe aortic incompetence. Two groups were studied - 6 with rheumatic aortic valves, and 4 with subaortic VSD and aortic valve prolapse. Various repair techniques were used. Post-operative echocardiograms showed mild or less aortic incompetence in all patients. The conclusion is that aortic valve repair yields encouraging short-term results for pediatric patients with aortic incompetence from VSD or rheumatic disease, but longer follow-up is still needed.
The document discusses transcatheter aortic valve implantation (TAVI), including its approval and increasing use in Europe and the United States. It provides details on the team approach, devices, procedures, outcomes, and complications of TAVI based on clinical trials such as PARTNER. TAVI is an alternative to surgical aortic valve replacement for high-risk or inoperable patients with severe aortic stenosis.
1) Most patients with asymptomatic severe aortic stenosis will develop symptoms within 5 years if not operated on, and the risk of sudden cardiac death is 1% per year.
2) Independent predictors of reduced survival in non-operated patients include advanced age, low left ventricular ejection fraction, heart failure, renal failure, and hypertension.
3) Aortic valve replacement dramatically improves survival outcomes, with 5-year survival rates of 90% for operated patients compared to 38% for non-operated patients.
TAVI has become an accepted treatment for severe aortic stenosis, especially in high-risk patients. The PARTNER trial showed non-inferiority of TAVI compared to surgery in high-risk patients, with lower rates of major bleeding and new onset atrial fibrillation for TAVI. A team approach including cardiologists and cardiac surgeons is recommended for optimal patient outcomes with TAVI.
Posterior approach aortic root enlargement in redo aorticescts2012
This document discusses aortic root enlargement using a posterior approach for redo aortic valve replacement. It provides details on the surgical technique used, which involves extending the aortotomy incision along the commissure between the left coronary and noncoronary sinuses across the anterior mitral leaflet and using a Dacron patch to enlarge the annulus. Results from a study of 25 patients found a hospital mortality rate of 8% due to low cardiac output, with 3 patients requiring reexploration for bleeding. The conclusion is that aortic root enlargement using this posterior approach can be done safely and does not increase surgical risk. However, the main limitation is the small number of patients and lack of long-term follow-
Impact of previous stenting on the outcome of (2)escts2012
This study examined the impact of previous coronary stenting on outcomes of subsequent CABG surgery in patients with multivessel disease. The study divided 200 patients into two groups: Group A with no previous stents, and Group B with previous stents. Group B had worse postoperative outcomes such as longer hospital stays, higher morbidity rates, and less improvement in echocardiogram measurements after surgery compared to Group A. Previous studies also found worse outcomes for patients who had undergone prior PCI compared to those without prior stenting. The presence of previous stents is associated with more severe coronary artery disease and worse clinical status preoperatively.
Muktapishti is a traditional Ayurvedic preparation made from Shoditha Mukta (Purified Pearl), is believed to help regulate thyroid function and reduce symptoms of hyperthyroidism due to its cooling and balancing properties. Clinical evidence on its efficacy remains limited, necessitating further research to validate its therapeutic benefits.
Cell Therapy Expansion and Challenges in Autoimmune DiseaseHealth Advances
There is increasing confidence that cell therapies will soon play a role in the treatment of autoimmune disorders, but the extent of this impact remains to be seen. Early readouts on autologous CAR-Ts in lupus are encouraging, but manufacturing and cost limitations are likely to restrict access to highly refractory patients. Allogeneic CAR-Ts have the potential to broaden access to earlier lines of treatment due to their inherent cost benefits, however they will need to demonstrate comparable or improved efficacy to established modalities.
In addition to infrastructure and capacity constraints, CAR-Ts face a very different risk-benefit dynamic in autoimmune compared to oncology, highlighting the need for tolerable therapies with low adverse event risk. CAR-NK and Treg-based therapies are also being developed in certain autoimmune disorders and may demonstrate favorable safety profiles. Several novel non-cell therapies such as bispecific antibodies, nanobodies, and RNAi drugs, may also offer future alternative competitive solutions with variable value propositions.
Widespread adoption of cell therapies will not only require strong efficacy and safety data, but also adapted pricing and access strategies. At oncology-based price points, CAR-Ts are unlikely to achieve broad market access in autoimmune disorders, with eligible patient populations that are potentially orders of magnitude greater than the number of currently addressable cancer patients. Developers have made strides towards reducing cell therapy COGS while improving manufacturing efficiency, but payors will inevitably restrict access until more sustainable pricing is achieved.
Despite these headwinds, industry leaders and investors remain confident that cell therapies are poised to address significant unmet need in patients suffering from autoimmune disorders. However, the extent of this impact on the treatment landscape remains to be seen, as the industry rapidly approaches an inflection point.
Does Over-Masturbation Contribute to Chronic Prostatitis.pptxwalterHu5
In some case, your chronic prostatitis may be related to over-masturbation. Generally, natural medicine Diuretic and Anti-inflammatory Pill can help mee get a cure.
share - Lions, tigers, AI and health misinformation, oh my!.pptxTina Purnat
• Pitfalls and pivots needed to use AI effectively in public health
• Evidence-based strategies to address health misinformation effectively
• Building trust with communities online and offline
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• Assessing risk and mitigating harm from adverse health narratives in communities, health workforce and health system
Basavarajeeyam is a Sreshta Sangraha grantha (Compiled book ), written by Neelkanta kotturu Basavaraja Virachita. It contains 25 Prakaranas, First 24 Chapters related to Rogas& 25th to Rasadravyas.
Histololgy of Female Reproductive System.pptxAyeshaZaid1
Dive into an in-depth exploration of the histological structure of female reproductive system with this comprehensive lecture. Presented by Dr. Ayesha Irfan, Assistant Professor of Anatomy, this presentation covers the Gross anatomy and functional histology of the female reproductive organs. Ideal for students, educators, and anyone interested in medical science, this lecture provides clear explanations, detailed diagrams, and valuable insights into female reproductive system. Enhance your knowledge and understanding of this essential aspect of human biology.
Osteoporosis - Definition , Evaluation and Management .pdfJim Jacob Roy
Osteoporosis is an increasing cause of morbidity among the elderly.
In this document , a brief outline of osteoporosis is given , including the risk factors of osteoporosis fractures , the indications for testing bone mineral density and the management of osteoporosis
Basavarajeeyam is an important text for ayurvedic physician belonging to andhra pradehs. It is a popular compendium in various parts of our country as well as in andhra pradesh. The content of the text was presented in sanskrit and telugu language (Bilingual). One of the most famous book in ayurvedic pharmaceutics and therapeutics. This book contains 25 chapters called as prakaranas. Many rasaoushadis were explained, pioneer of dhatu druti, nadi pareeksha, mutra pareeksha etc. Belongs to the period of 15-16 century. New diseases like upadamsha, phiranga rogas are explained.
NVBDCP.pptx Nation vector borne disease control programSapna Thakur
NVBDCP was launched in 2003-2004 . Vector-Borne Disease: Disease that results from an infection transmitted to humans and other animals by blood-feeding arthropods, such as mosquitoes, ticks, and fleas. Examples of vector-borne diseases include Dengue fever, West Nile Virus, Lyme disease, and malaria.
- Video recording of this lecture in English language: https://youtu.be/kqbnxVAZs-0
- Video recording of this lecture in Arabic language: https://youtu.be/SINlygW1Mpc
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
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1. Therapeutic options
for young females
in need of mitral valve surgery
Magued Zikri, M.D.
Professor of Cardiothoracic surgery
Cairo University
2012
2. Rheumatic mitral valve disease
in young females
Therapeutic options:
– Mitral valve surgery , frequently valve
replacement , in view of pathology.
– Choice of valve in young patient
presently restricted to mechanical
prosthesis
– Large Lt atria, AF, mechanical valve is a
triad necessitating very accurate INR
Control.
– Warfarin based anticoagulation regimen.
3. Rheumatic mitral valve disease
in young females
Pregnancy and anticoagulation:
– The physiologic hypercoagulable of
pregnancy dictates increasing warfarin .
– The regimen of anticoagulation divided
into three phases:
» First trimester : stop warfarin because of
teratogenicity and use heparin ,
» Second trimester: safer with warfarin , though
dose related > 5 mg still hazardous,
» Third trimester :back to heparin in anticipation
of caesarian section and placental bleeding.
4. Rheumatic mitral valve disease
in young females
Real life implications:
– Planed pregnancy and early detection of
gestation .
– Combined clinics for obstetrics and
cardiology.
– Accurate laboratory analysis for INR.
– Availability of warfarin in all
concentrations in a fresh preparation.
6. Rheumatic mitral valve disease
in young females
Results:
Gestations on warfarin 5 mg or less versus
gestations on > 5 mg : 33 pregnancies versus 25.
Gestation outcome, warfarin 5 mg as a cut off point:
» Incidence of full term pregnancy = 28 vs 3,
» Incidence of fetal complications = 5 vs 22,
» Significant statistical difference (p>0.0001).
Correlation Analysis for linear relationship between
probability of fetal complications and warfarin doses:
p =0.7316
Maternal valve thrombosis one in each group.
7. Rheumatic mitral valve disease
in young females
Actual outcome of pregnacy :
– Lost fetus secondarily to teratogenisis.
– Complicated delivery , usually caesarian.
– Valve related complications , mainly valve
thrombosis requiring emergency
reoperation.
– Incidence of maternal and fetal loss peri
operatively.
9. Rheumatic mitral valve disease
in young females
How to stop this vicious circle:
– Identify the central culprit which is
anticoagulation regimen.
– Eliminate the two reasons for its use:
Metallic mitral prosthesis,
Atrial fibrillation .
11. ESC Guidelines
Patient selection criteria: for a bioprosthesis
Criteria in favour of bioprosthesis:
Desire of informed patient
Limited life expectancy, severe comorbidity, or age > 65-70
Patient for whom future redo valve surgery would be at low risk
Unavailability of good quality anticoagulation
Young woman contemplating pregnancy
Re-operation for mechanical valve thrombosis in a patient with proven
poor anticoagulation control
11
12. Composition of a bioprosthesis:
1. Stent = Flexible Acetal Copolymer
2. Cloth = Polyester
3. Cuff = Sewing Ring
4. Suture markers
5. Steel bar
6. Porcine Leaflets 3x
7. Pericardial shield
13. Rheumatic mitral valve disease
in young females
Present status of biological valves
Newer valves have longevity extended into the second
decades with a predicted failure mode.
The risk of planed reoperative valve surgery is only
slightly more than in initial operation.
Price gap between metallic and bioprosthesis has
consistently decreased .
16. Myken’s paper: excellent 17-year durability data
in Aortic and Mitral positions
1. Mykén, P., Seventeen-Year Experience with the St. Jude Medical Biocor Porcine Bioprosthesis, JHVD, 2005;14:486-92.
18. AF surgery
Atrial Fibrillation : How common?
General population= 0.4 %-1%(Age related)
Mitral valve surgery candidates = 60%
Ischaemic Cardiomyopathy = 30%
In patients with ASD:
Incidence relates to age at time of surgery
up to 60 % in patients older than 40 y
19. AF surgery
Risk of Thromboembolism
1% per year in general population & Lone AF.
More frequent in elderly, DM, CHF , RHD .
Farmingham Study embolic stroke data :
5 folds increase risk of Stroke in non Rheumatic AF
17 folds increase risk in Rheumatic AF
Adequate anticoagulation reduces rate of
thromboembolism by only 50% .
20. AF surgery
Types of atrial fibrillation:
Paroxysmal:
– Pulmonary veins trigger.
Non paroxysmal:
– Multiple sustained rotor drivers
» Persistent
» Long standing persistent
» Permanent.
21. AF surgery
Indications for surgery for AF
Previous thromboembolic event.
Adjunct to mitral valve surgery if AF > 1 y
AF rate uncontrolled by medications.
Failure to control AF related symptoms.
Intolerance to efficient medications.
22. AF surgery
The case for addressing AF surgery in
setting of concomitant surgery:
No increase in surgical risk ,
Less post operative morbidity ,
Fewer thromboembolic events,
Decreased valve related events,
Decreased tricuspid regurge,
Better quality of life,
Increase long term survival .
23. Mitral Valve surgery/MAZE III
Clinical impact of AF & rheumatic mitral valve .
Rate control within the setting of often impaired
hemodynamic .
Highly thrombogenic situation :
» endothelial injury within left atrial cavity,
» Stasis within left atrium :
impaired atrial emptying in mitral stenosis,
lack of synchronous atrial contraction,
enlarged left atrial appendage.
24. Mitral Valve surgery/MAZE III
Conventional management.
Correct mitral valve, eliminating stasis/turbulence :
» Mitral valvuloplasty,
» Mitral valve replacement.
Obliteration of left atrial appendage.
Post operative pharmacologic tuning :
» Optimize post op anticoagulation regimen,
» Optimize AF rate control.
25. AF surgery
Aim of atrial lesions in MAZE
Prevent impulse from propagating except
in one direction.
Fractionate atrial mass to reach a size less
than that needed for a reentrant circuit to
get perpetuated.
26. AF surgery
Surgical Tools
All aim towards trans mural lesion causing
electric interruption of impulse propagation
Ultimate goals include ease of application ,
rapidity & absence of collateral damage .
Cut and sew
Cryosurgery
Radiofrequency
Ultrasonic waves
Laser energy
32. Mitral Valve surgery/MAZE III
The impact of mitral valve surgery combined
with maze procedure
Akinobu Itoh, Junjiro Kobayashi * , Ko Bando, Kazuo
Niwaya, Osamu Tagusari, Hiroyuki Nakajima,
Shigeru Komori, Soichiro Kitamura Department of
Cardiovascular Surgery, National Cardiovascular
Center, 5-7-1 Fujishirodai, Suita, Osaka 565-8565,
Japan
Eur J Cardiothorac Surg 2006;29:1030-1035
33. Mitral Valve surgery/MAZE III
Methods:
521 consecutive patients underwent combined maze
procedures with MVR or valvuloplasties.
Three kinds of maze techniques were primarily used:
Cox–maze III, Kosakai maze, and cryo-maze procedure.
At 3 months post op, 394 pts were in NSR(Group S)
while the remaining 116 patients were in continuous or
intermittent AF (Group F), excluding 11 early deaths.
Risk factors for Group F were determined by the
analysis of all patient demographics. Survival,
freedom from stroke, cardiac events, and AF recurrence
were analyzed.
34. Mitral Valve surgery/MAZE III
Results:
The proportion of pts without any other simultaneous
procedures was greater in Group S (41% vs 29%, P = 0.02).
Risk factors for unsuccessful maze procedures :
» left atrium > 70 mm (HR = 2.6)
» preop AF > 10 yrs (HR = 8.2, P < 0.001)
» f-wave voltage in V1 < 0.1 mV (HR = 6.2, P < 0.001).
Actuarial survival rates (HR = 2.7, P = 0.035), freedoms
from stroke (HR = 3.0, P = 0.003) and cardiac events (HR =
4.3, P < 0.001) by Cox proportional hazards models
showed superiority in Group S.
Freedom from AF n Group S was 98.4% at 5 yrs and 81.0%
at 12 yrs , and in overall pts was 73.0% and 60.1%.
35. Mitral Valve surgery/MAZE III
Conclusions:
Patients with successful maze procedures resulted
in higher survival rate, greater freedom from stroke
and cardiac events.
The large left atrium, small f-wave, and long AF
duration were significant risk factors for failed maze
procedures, suggesting that earlier surgical
interventions would result in superior results in
mitral valve surgery combined with maze procedure.
36. Mitral Valve surgery/MAZE III
Successful Cox Maze Procedure During Mitral
Valve Surgery Restores Patient Survival Without
Increasing Operative Risk
Niv Ad, Linda Henry, Sharon Hunt, Sari D. Holmes, Linda
Halpin.
Inova Heart and Vascular Institute, Falls Church, VA,
USA
6 th Biennial meeting , the Society of Heart Valve Disease, Barcelona ,
June 25 th – June 28 th , 2011.
37. Mitral Valve surgery/MAZE III
Methods:
N=410 had an isolated MV surgery.
NSR n=311 and AF n=99 .
Pts with AF had additionally a Cox Maze procedure.
Rhythm was verified by EKG/24-hour holter.
Kaplan-Meier analysis compared cumulative
survival between the two surgery groups, plus a third
group with isolated MV and untreated AF (n=34).
38. Mitral Valve surgery/MAZE III
Results:
Isolated MV group was younger, p=0.002 and at lower
risk, p=0.005 compared to MV plus CM group.
Length of stay was longer for MV plus CM patients (8.5
[7.4] vs 5.5 [7.1] days, p<0.001),
BOTH were comparable on perioperative
complications and operative mortality (1%).
MV plus CM patients had similar survival as isolated
MV patients (Log Rank=0.01, p=0.91).
Cumulative survival in isolated MV with untreated AF
patients was lower than in MV plus CM.
40. Mitral Valve surgery/MAZE III
Kasr el eini University H. experience:
Initial case for AF surgery started in 2000.
Sporadic cases to 2005.
Approved for a Doctorate thesis in 2006.
Departmental policy since 2010.
41. Mitral Valve surgery/MAZE III
Inclusion criteria
• Chronic atrial fibrillation > 1 year duration
• Rh H.D. with significant stenosis and/or
regurgitation dictating surgery.
• +/- Previous thromboembolic event.
• +/- AF rate uncontrolled by ttt.
• +/- AF controlled by ttt causing side effects.
• Lately , all new comers with non paroxysmal
AF and undergoing mitral valve surgery.
42. Mitral Valve surgery/MAZE III
Exclusion Criteria
• Redo op (closed mitral commissurotomy).
• Combined surgical aortic valve disease.
• Ejection fraction < 45%.
• Pulmonary hypertension > 70 mmHg.
• Hepatic dysfunction 2 ry to tricuspid disease.
• Rare blood groups.
• Lately , left atrial size above 6 cm.
45. Mitral Valve surgery/MAZE III
Echocardiographic findings
Mitral Stenosis : 22/38
Mitral Regurge : 10/38
Combined stenosis/regurge : 6/38
Tricuspid valve disease , TR > 2+ : 20/38
Aortic regurge, moderate : 5/38
P A pressure : 35-80 mean 62mmhg
Left atrial size : 5.5-8.0 mean 6.1 cm
Left atrial thrombus : 14/38
46. Mitral Valve surgery/MAZE III
Operative technique
Complete set of biatrial maze ,
Start with right atrial incision after going on
bypass while maintaining normothermia,
Finish left side incisions before addressing
mitral valve,
Tricuspid repair and closure of right atrial
incision while rewarming.
47. Mitral Valve surgery/MAZE III
Operative technique
First 15 cases:
– Extensive mobilization along roof of left atrium,
– Amputation of right atrial appendage,
– Vertical atrial septal incision,
– Cryothermy , vaporized liquid N2O :
» On tricuspid annulus in two points,
» Mitral annulus at P2-P3 junction,
» Two points on base of amputated left atrial
appendage which is closed independently.
– One stay stitch in mid of post left atrial incision .
48. Mitral Valve surgery/MAZE III
Operative technique
Current technique :
– Omit left atrial roof pre-bypass exposure.
– Vertical incision along crest of right RA appendage,
– omit atrial septal incision and cryothermy,
– low intensity diathermy coagulation on tricuspid
and mitral annuli,
– single , transplant like , encircling left atrial
incision guided by three stay stitches, two at the
base of amputated LA appendage .
49. Mitral Valve surgery/MAZE III
Operative Data
Myocardial protection.
– Ante / Retrograde Cold blood cardioplegia .
– Systemic cooling ( 28 degrees centigrade).
– Terminal hot shot (autologous blood )
Mitral valve replacement 29/38 cases :
– Cross clamp time : 108 min. Bypass time : 139 min.
Mitral valve repair 9 cases :
– Cross clamp time : 93 min, bypass time : 132 min.
Tricuspid annuloplasty: 12 cases.
50. Mitral Valve surgery/MAZE III
Results
• Mean mediastinal blood shed 459 cc.
• Mean use of blood transfusion 600 cc,
• No blood products 22/38 pts.
• Mean Ventillation time 15 h.
• In 18 pts = Adrenaline 100 Ng/kg/min x 36 h.
• In seven pts = Isuprel x 24 h.
• Mean ICU stay 2.5 days, hospital stay 11.5 days.
51. Mitral Valve surgery/MAZE III
Results
Echocardiography findings
Well functioning Mitral Prosthesis : 28/29
1 Pt., in NSR, prosthetic thrombosis 9 months post op.
Mitral valve repair : 8 /9
no MR = 6/9, MR Grade I-II = 2/9, MR III/IV = 1/9.
Mean gradient 6 mmHg.
Regression of left atrial size to a mean of 5.6 cm.
Documented atrial contraction :
MVR : A-wave in tricuspid Doppler flow .
MV repair : A-wave in mitral Doppler flow .
53. Mitral Valve surgery/MAZE III
Results
Abnormal impulse generation or conduction
Sinus node dysfunction: 6/38
AV block, 1 rst degree, transient postop : 22/38
AF during hospital stay :
Reversible , cordarone / electric cardioversion 6/38
On Discharge post op day 5 for 12 h. 2/18
55. Mitral Valve surgery/MAZE III
Results
Morbidity:
– Reopening for bleeding : 4/38:
Origin of bleed :
» Two cases unidentified,
» One case right atrial incision,
» One case base of left atrial appendage.
– Complete AV block: 1/38:
» post op day 5 , resuscitated , resolved in 4 days
discharged home in controlled A flutter.
– Lower limb aedema: 3/38 :
» All from amputated right atrial appendage grp.
56. Mitral Valve surgery/MAZE III
Results
Follow up duration : 2- 115, mean 38 months .
Completion of follow up : 24/38 = 63%.
Follow up protocol:
Quarterly first year, than biannually,
History for dizziness/palpitations,
ECG, for rhythm & chronotropic response,
Holter when required.
Rhythms on follow up :
NSR : 33/38 = 86.8%,
two NSR +AV block 1rst degree : 2/38,
AF , first year 3/38, 36 month 5/38.
57. Mitral Valve surgery/MAZE III
Conclusion
• Combined Mitral valve surgery / Maze III
operation is both safe and reproducible .
• Fact :
Adequate anticoagulation reduces by 50%
thrombo embolic risk of AF .
• Recommendation :
Maze op is warranted even if anticoagulant ttt
is dictated by use of a prosthetic valve.
58. Mitral Valve surgery/MAZE III
Conclusion
• Young females anticipating childbirth are
candidates for mitral repair or bioprosthesis
combined with a cut and sew Maze procedure .
• The increased fetal and maternal safety due to
anticoagulation free regimen justify calculated
risk of a planned redo mitral valve surgery.
59. Rheumatic mitral valve disease
in young females
Why not a tissue valve in
younger patients
combined
with surgery to ablate
atrial fibrillation?
60. Thank you
for the privilege
of sharing
these information.