The Journal of thoracic and cardiovascular surgery
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J. Thorac. Cardiovasc. Surg. · Jun 2016
Proinflammatory gene expression in patients undergoing mitral valve surgery and maze ablation for atrial fibrillation.
It is difficult to achieve rhythm control in patients with long-standing persistent atrial fibrillation (AF). The radiofrequency maze procedure is an effective means in curing AF with a variable recurrence rate depending on patient characteristics and AF duration. In these patients, the characteristics of the atrial substrate have not been well investigated. Because the inflammatory process has been shown to be important in the pathogenesis of AF, we sought to characterize the proinflammatory gene expression in left atria obtained from patients with AF undergoing mitral valve surgery combined with the maze procedure to distinguish the changes associated with AF and its recurrence after the surgical ablation. ⋯ Differential expression profiles of proflammatory genes were presented between SR and AF and between maintained SR and recurrent AF after the maze procedure. The identified inflammatory molecules associated with AF and failed surgical ablation may provide clues for developing new potential therapeutic targets to improve AF rhythm control.
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In the interest of advancing evidenced-based medicine, enthusiasm for clinical practice guidelines has skyrocketed. They have a genuine impact on clinical practice and are frequently referenced in the literature. Their construction is complex and labor intensive, and has significant limitations given the necessary process as well as the data available. ⋯ It is worthwhile taking a step back and considering how we know what we think we know based on statistical analysis of biomedical data sets and the real implications of those population data for making predictions about the individual patient we encounter in the clinic. These data as used to establish guidelines for care should be the foundation and starting point for our thoughtful recommendations and decision making, not the final word. The importance of nuance in clinical judgment remains even in this "evidence-based" world.
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J. Thorac. Cardiovasc. Surg. · Jun 2016
Reduced continuous-flow left ventricular assist device speed does not decrease von Willebrand factor degradation.
Nonsurgical bleeding is a frequent complication of continuous-flow left ventricular assist device (LVAD) support. Abnormal von Willebrand factor (vWF) metabolism plays a major role. However, the relationship between LVAD speed and vWF degradation is unknown. Recent evidence has demonstrated that supraphysiologic shear stress from continuous-flow LVADs accelerates vWF degradation and causes an acquired vWF deficiency and bleeding. To manage LVAD-associated bleeding, it has been proposed that reduced LVAD speed may decrease shear stress and thereby reduce pathologic vWF metabolism. However, there are little published data to support this clinical practice. We tested the hypothesis that reduced continuous-flow LVAD speed decreases vWF degradation. ⋯ Reduced LVAD speed (within the clinical operational range) did not significantly decrease vWF degradation in a mock circulatory loop with human blood. During bleeding events, reduced LVAD speed, itself, may not diminish vWF degradation.
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J. Thorac. Cardiovasc. Surg. · Jun 2016
Endograft repair for pseudoaneurysms and penetrating ulcers of the ascending aorta.
The aim of this paper is to report midterm results of thoracic endovascular aortic repair (TEVAR) for ascending aortic pseudoaneurysms (AAPs) and penetrating aortic ulcers (PAUs) of the ascending aorta. ⋯ Ascending TEVAR was feasible, safe, and effective for AAPs and PAUs. In a very select subset of lesions, midterm results were favorable, with both standard and custom-designed endografts.
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J. Thorac. Cardiovasc. Surg. · Jun 2016
Lower-extremity complications with femoral extracorporeal life support.
Patients undergoing emergency peripheral arteriovenous extracorporeal life support were evaluated for lower-extremity complications on the basis of the ipsilateral limb perfusion strategy. ⋯ No superficial femoral artery perfusion strategy is associated with a high lower-extremity complication rate. If percutaneous cannulation is performed, then angiographic confirmation of superficial femoral artery run-off is highly recommended. The open superficial femoral artery approach remains a safe alternative to the other strategies.