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Cancers Sep 2023Bladder cancer (BC) diagnosis and prediction of prognosis are hindered by subjective pathological evaluation, which may cause misdiagnosis and under-/over-treatment.... (Review)
Review
Bladder cancer (BC) diagnosis and prediction of prognosis are hindered by subjective pathological evaluation, which may cause misdiagnosis and under-/over-treatment. Computational pathology (CPATH) can identify clinical outcome predictors, offering an objective approach to improve prognosis. However, a systematic review of CPATH in BC literature is lacking. Therefore, we present a comprehensive overview of studies that used CPATH in BC, analyzing 33 out of 2285 identified studies. Most studies analyzed regions of interest to distinguish normal versus tumor tissue and identify tumor grade/stage and tissue types (e.g., urothelium, stroma, and muscle). The cell's nuclear area, shape irregularity, and roundness were the most promising markers to predict recurrence and survival based on selected regions of interest, with >80% accuracy. CPATH identified molecular subtypes by detecting features, e.g., papillary structures, hyperchromatic, and pleomorphic nuclei. Combining clinicopathological and image-derived features improved recurrence and survival prediction. However, due to the lack of outcome interpretability and independent test datasets, robustness and clinical applicability could not be ensured. The current literature demonstrates that CPATH holds the potential to improve BC diagnosis and prediction of prognosis. However, more robust, interpretable, accurate models and larger datasets-representative of clinical scenarios-are needed to address artificial intelligence's reliability, robustness, and black box challenge.
PubMed: 37760487
DOI: 10.3390/cancers15184518 -
Surgical treatment of post-infarction papillary muscle rupture: systematic review and meta-analysis.Annals of Cardiothoracic Surgery May 2022Papillary muscle rupture (PMR) is a rare but potentially fatal complication following acute myocardial infarction (AMI). Surgical treatment is considered the standard of...
BACKGROUND
Papillary muscle rupture (PMR) is a rare but potentially fatal complication following acute myocardial infarction (AMI). Surgical treatment is considered the standard of care. This systematic review and meta-analysis aims to evaluate the early outcomes after surgical correction of post-AMI PMR.
METHODS
Electronic databases were searched from January 1990 to December 2020. Studies reporting patients undergoing mitral valve surgery for post-AMI PMR were analysed. The primary outcome assessed was operative mortality. Differences were expressed as risk ratio (RR) with 95% confidence interval (CI) to assess the relationships between predefined surgical variables and clinical prognosis.
RESULTS
A total of 1,851 adult patients, from 12 observational studies, were identified. Operative mortality was 21%. Meta-analysis revealed reduced operative risk in patients undergoing mitral valve repair (MVr) as compared to replacement (MVR) (RR, 0.33; 95% CI: 0.14 to 0.79; P=0.01), and an increased risk of operative mortality in patients with complete PMR (RR, 2.54; 95% CI: 1.12 to 5.74; P=0.03). No significant differences in terms of operative mortality were observed between patients with or without pre/peri-operative intra-aortic balloon pump (IABP) support and between subjects who underwent mitral valve surgery with or without concomitant coronary artery bypass grafting (CABG).
CONCLUSIONS
Mitral valve surgery for post-AMI PMR carries a high operative mortality. Patients with complete PMR and subjects undergoing MVR have increased risks of operative mortality. The preoperative use of IABP and concomitant CABG seem not to influence the early postoperative course in this context.
PubMed: 35733726
DOI: 10.21037/acs-2021-ami-15 -
Annals of Cardiothoracic Surgery May 2022Mechanical complications following acute myocardial infarction (AMI), though rare, are associated with significant morbidity and mortality. Surgical management remains a...
BACKGROUND
Mechanical complications following acute myocardial infarction (AMI), though rare, are associated with significant morbidity and mortality. Surgical management remains a mainstay of therapy for these complications. The purpose of this review is to evaluate long-term outcomes data of surgical management for postinfarction free wall rupture, ventricular septal defect, papillary muscle rupture, and pseudoaneurysm.
METHODS
An electronic literature search was performed to identify original studies reporting long-term outcomes data of surgical management of one of the four mechanical complications following AMI. Studies were considered to have long-term outcomes if they at minimum included survival or mortality data up to one year.
RESULTS
A total of 285 studies were identified from the literature search. Of these, 29 studies with long-term survival data on surgically managed mechanical complications of AMI are included in the review. The majority of these are retrospective cohort studies or single-center case series. Five studies are included on free wall rupture, 18 on ventricular septal defect, 4 on papillary muscle rupture, and 2 on pseudoaneurysm. Detailed results are tabulated according to complication.
CONCLUSIONS
Long-term surgical outcomes of postinfarction mechanical complications remain understudied. Outcomes for ventricular septal defect repair are better represented in the literature than are outcomes for other mechanical complications, though available studies are still limited by small sample sizes and retrospective design. Further research is warranted, particularly for outcomes of acute pseudoaneurysm repair.
PubMed: 35733723
DOI: 10.21037/acs-2021-ami-20 -
Annals of Cardiothoracic Surgery May 2022Mechanical complications of acute myocardial infarction represent life-threatening events, including ventricular septal rupture (VSR), left ventricular free-wall rupture...
Effects of concomitant coronary artery bypass grafting on early and late mortality in the treatment of post-infarction mechanical complications: a systematic review and meta-analysis.
BACKGROUND
Mechanical complications of acute myocardial infarction represent life-threatening events, including ventricular septal rupture (VSR), left ventricular free-wall rupture (LVFWR) and papillary muscle rupture (PMR). In-hospital mortality is high, even when prompt surgery can be offered. The role of concomitant coronary artery bypass grafting (CABG) in the surgical treatment of these conditions is still debated.
METHODS
A systematic review of the literature, from 2000 onwards, about these complications was performed, analyzing data of subjects receiving versus not-receiving concomitant CABG. Primary outcome was early mortality. Secondary outcome was late mortality for hospital survivors. Subgroup analysis for VSR, LVFWR and PMR was also performed.
RESULTS
Thirty-six studies were identified, including 4,321 patients (mostly VSR-related). Preoperative coronarography was performed in 92.2% of the cases, showing single-vessel disease in 54.3% of patients. Concomitant CABG rate was 49.0%. Early mortality was 32.6% and late mortality was 40.0% with 5.2 years of mean follow-up. The analysis showed no difference in early (OR 0.96; P=0.60) or late mortality (RR 0.91; P=0.49) between CABG and non-CABG group. In subgroup analysis, concomitant CABG was associated with significantly lower mortality at long term for PMR (RR 0.42; P=0.001), although it showed a higher, but not significant, mortality in VSR (RR 1.24; P=0.20).
CONCLUSIONS
Concomitant CABG in the treatment for post-infarction mechanical complications showed no significant impact on both early and late mortality, although deserving some distinctions among different types of complication and single versus multiple vessel disease. However, larger, dedicated studies are required to provide more consistent data and evidence.
PubMed: 35733718
DOI: 10.21037/acs-2021-ami-19 -
Annals of Cardiothoracic Surgery May 2022Improvements in revascularisation, including pharmacological, catheter-based and surgical, have resulted in improved outcomes for patients with acute myocardial...
Systematic review and meta-analysis of the mechanical complications of ischemic heart disease: papillary muscle rupture, left ventricle rupture and post-infarct ventricular septal defect.
BACKGROUND
Improvements in revascularisation, including pharmacological, catheter-based and surgical, have resulted in improved outcomes for patients with acute myocardial infarction (AMI), leading to decreased frequency of mechanical complications. Improvements in both techniques and technology have permitted select patients to be managed with a purely percutaneous, transcatheter strategy. Through systematic review, this study aims to synthesise the collective experience of percutaneous treatment of the mechanical complications of ischaemic heart disease.
METHODS
The search strategy queried the electronic databases PubMed, Embase and the Cochrane Central Register of Controlled Trials, from 1 January 2000 to 31 December 2020. Studies highlighting the outcomes of patients receiving percutaneous treatment of post-myocardial infarction papillary muscle rupture (PMR), ventricular septal defect (VSD), left ventricular free wall rupture (FWR) and pseudoaneurysm (PA) were included. A qualitative review of studies was conducted for PMR, FWR and PA. A quantitative analysis was conducted for VSD.
RESULTS
Fifteen studies were included in the qualitative synthesis of the percutaneous management of PMR, 4 were included in the qualitative analysis of the percutaneous management of left ventricular FWR, 7 studies defined the outcomes of the percutaneous management of PA and 25 were included in the quantitative meta-analysis of the primary percutaneous management of post-MI VSD. For VSD, there were 43 failed procedures in 314 patients. The proportion of failed procedures was 15.9% and there were 174 deaths in 428 patients. 37.5% of patients experienced early mortality.
CONCLUSIONS
Although surgical techniques remain the gold standard, we have shown that percutaneous management may be a viable option in certain cases.
PubMed: 35733707
DOI: 10.21037/acs-2022-ami-24 -
Journal of Cardiovascular... Jul 2022Conventional transvenous pacemaker leads may interfere with the tricuspid valve leaflets, tendinous chords, and papillary muscles, resulting in significant tricuspid... (Meta-Analysis)
Meta-Analysis Review
INTRODUCTION
Conventional transvenous pacemaker leads may interfere with the tricuspid valve leaflets, tendinous chords, and papillary muscles, resulting in significant tricuspid valve regurgitation (TR). Leadless pacemakers (LLPMs) theoretically cause less mechanical interference with the tricuspid valve apparatus. However, data on TR after LLPM implantation are sparse and conflicting. Our goal was to investigate the prevalence of significant TR before and after LLPM implantation.
METHODS
Patients who received a leadless LLPM (Micra™ TPS, Medtronic) between May 2016 and May 2021 at our center were included in this observational study if they had at least a pre- and postinterventional echocardiogram (TTE). The evolution of TR severity was assessed. Following a systematic literature review on TR evolution after implantation of a LLPM, data were pooled in a random-effects meta-analysis.
RESULTS
We included 69 patients (median age 78 years [interquartile range (IQR) 72-84 years], 26% women). Follow-up duration between baseline and follow-up TTE was 11.4 months (IQR 3.5-20.1 months). At follow-up, overall TR severity was not different compared to baseline (p = .49). Six patients (9%) had new significant TR during follow-up after LLPM implantation, whereas TR severity improved in seven patients (10%). In the systematic review, we identified seven additional articles that investigated the prevalence of significant TR after LLPM implantation. The meta-analysis based on 297 patients failed to show a difference in significant TR before and after LLPM implantation (risk ratio 1.22, 95% confidence interval 0.97-1.53, p = .11).
CONCLUSION
To date, there is no substantial evidence for a significant change in TR after implantation of a LLPM.
Topics: Aged; Aged, 80 and over; Echocardiography; Female; Humans; Male; Observational Studies as Topic; Pacemaker, Artificial; Retrospective Studies; Treatment Outcome; Tricuspid Valve; Tricuspid Valve Insufficiency
PubMed: 35614867
DOI: 10.1111/jce.15565 -
Pacing and Clinical Electrophysiology :... Apr 2022Catheter ablation of papillary muscle ventricular arrhythmias (PM-VAs) has been associated with unsatisfactory results. Features that may affect acute and long-term...
BACKGROUND
Catheter ablation of papillary muscle ventricular arrhythmias (PM-VAs) has been associated with unsatisfactory results. Features that may affect acute and long-term procedural outcomes are not well established.
OBJECTIVE
To systematically review the available data in the literature assessing efficacy and safety of PM-VAs catheter ablation.
METHODS
An online search of PubMed, Cochrane Registry, Web of Science, Scopus and EMBASE libraries (from inception to March 1, 2021) was performed, in addition to manual screening. Twenty-one observational noncontrolled case-series were considered eligible for the systematic review, including 536 patients.
RESULTS
Postero-medial PM harbored 60.8% of PM-VAs, while antero-lateral PM and right ventricular PMs 34.9% and 4.3% of cases, respectively. The mean acute success rate of the index ablation procedure was 88.1% (95% CI 82.8% to 91.9%, p < .001, I 0%). After a mean follow-up period of 15.5 ± 17.4 months, pooled long-term arrhythmia-free rate was 69.2%, while the pooled long-term success rate after multiple ablation procedure was 84.9%. Overall, procedure complications occurred in nine patients (1.7%) and no procedure-related deaths were reported. The use of intracardiac echocardiography (ICE) as well as contact force sensing (CFS) and irrigated catheters during ablation was associated with higher rates of arrhythmia-freedom at long-term follow-up.
CONCLUSIONS
Catheter ablation is an effective and safe strategy for PM-VAs, with an acute success rate of 88.1%, a long-term success rate of 69.2%, with a relatively low procedural complication rate. The use of ICE, irrigated catheters and catheters with CFS capability was associated with higher rates of arrhythmia-freedom at long-term follow-up.
Topics: Catheter Ablation; Heart Ventricles; Humans; Papillary Muscles; Tachycardia, Ventricular; Treatment Outcome; Ventricular Premature Complexes
PubMed: 35147225
DOI: 10.1111/pace.14462 -
Cureus Dec 2021The presence of mitral valve prolapse (MVP) varies from asymptomatic to life-threatening arrhythmias. Catheter ablation (CA) is widely used to treat ventricular... (Review)
Review
The presence of mitral valve prolapse (MVP) varies from asymptomatic to life-threatening arrhythmias. Catheter ablation (CA) is widely used to treat ventricular arrhythmias (VAs) associated with MVP. Despite having high procedural success, outcome data after CA is limited, especially in a long-term setting. Therefore, this systematic review and meta-analysis were performed. Literature searching was conducted in Pubmed, EuropePMC, Proquest, and Ebsco from inception to December 2020 using keywords: ventricular arrhythmia, premature ventricular complex, ventricular tachycardia, ventricular fibrillation, mitral valve prolapse, and catheter ablation. A total of 407 potential articles were retrieved for further review. The final review resulted in six articles for systematic review and meta-analysis. The study was registered in PROSPERO (CRD42020219144). The most common origin of VAs was papillary muscle. The acute success rate of CA in the MVP group varies between 66% and 94%. Follow-up studies reported a higher percentage of VAs recurrence after CA in the MVP group (22.22%) compared with the non-MVP group (11.38%). However, the difference is not significant (P-value = 0.16). Other studies reported a 12.5%-36% rate and 40% of repeat ablation in the medium term and the long term, respectively. Episodes of sudden cardiac death during exertion could still occur following CA in patients with MVP. Distinct origin of VAs was observed during repeated ablation procedures, which may explain arrhythmic substrate progression. Diffuse left ventricular fibrosis around papillary muscle rather than local fibrosis was observed among older patients. Furthermore, the presence of mitral annular disjunction (MAD) and Filamin C mutation might increase the risk of recurrent VAs. CAn has been done as the treatment of VAs associated with MVP. The acute success rate of CA varies between studies and the number of patients requiring repeat CA varied from 12.5% to 40%. Sudden cardiac death could still occur after CA. Older age during CA, genetic predisposition, deep arrhythmic foci, multifocal VAs origin, diffuse fibrosis, and the presence of MAD may contribute to the recurrence of VAs. Further studies, stratification, and evaluation are needed to prevent fatal outcomes in VA associated with MVP, even after CA.
PubMed: 35024259
DOI: 10.7759/cureus.20310 -
Ontario Health Technology Assessment... 2021Bladder cancer begins in the innermost lining of the bladder wall and, on histological examination, is classified as one of two types: non-muscle-invasive bladder cancer... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Bladder cancer begins in the innermost lining of the bladder wall and, on histological examination, is classified as one of two types: non-muscle-invasive bladder cancer (NMIBC) or muscle-invasive bladder cancer. Transurethral resection of bladder tumour (TURBT) is the standard treatment for people with NMIBC, but the high rate of cancer recurrence after first TURBT is a challenge that physicians and patients face. Tumours seen during follow-up may have been missed or incompletely resected during first TURBT. TURBT is conventionally performed using white light to see the tumours. However, small papillary or flat tumours may be missed with the use of white light alone. With the emergence of new technologies to improve visualization during TURBT, better diagnostic and patient outcomes may be expected. We conducted a health technology assessment of two enhanced visualization methods, both as an adjunct to white light to guide first TURBT for people with suspected NMIBC-hexaminolevulinate hydrochloride (HAL), a solution that is instilled into the bladder to make tumours fluoresce under blue-violet light, and narrow band imaging (NBI), a technology that filters light into wavelengths that can be absorbed by hemoglobin in the tumours, making them appear darker. Our assessment included an evaluation of effectiveness, safety, cost-effectiveness, and the budget impact of publicly funding these new technologies to improve patient outcomes following first TURBT. The use of NBI in diagnostic cystoscopy was out of scope for this health technology assessment.
METHODS
We performed a systematic literature search of the clinical evidence from inception to April 15, 2020. We searched for randomized controlled trials (RCTs) that compared the outcomes of first TURBT with the use of HAL or NBI, both as an adjunct to white light, with the outcomes of first TURBT using white light alone, or studies that made such comparison between HAL and NBI. We conducted pairwise meta-analyses using a fixed effects model where head-to-head comparisons were available. In the absence of any published RCT for comparison between HAL and NBI, we indirectly compared the two technologies through indirect treatment comparison (ITC) analysis. We assessed the risk of bias of each included study using the Cochrane risk-of-bias tool. We assessed the quality of the body of evidence according to the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) Working Group criteria. We performed a systematic economic literature search and conducted a cost-utility analysis with a 15-year time horizon from a public payer perspective. We also analyzed the budget impact of publicly funding HAL and NBI as an adjunct to white light in people undergoing their first TURBT for suspected non-muscle-invasive bladder cancer in Ontario.
RESULTS
In the clinical evidence review, we identified 8 RCTs that used HAL or NBI as an adjunct to white light during first TURBT. Pairwise meta-analysis of HAL studies showed that HAL-guided TURBT as an adjunct to white light significantly reduces recurrence rate at 12 months compared with TURBT using white light alone (risk ratio 0.70, 95% confidence interval [CI] 0.51-0.95) (GRADE: Moderate). Five-year recurrence-free survival was significantly higher when HAL was used as an adjunct to white light than when white light was used alone (GRADE: Moderate). There was little to no difference in the tumour progression rate (GRADE: Moderate).Meta-analysis of NBI studies did not show a significant difference between NBI-guided TURBT as an adjunct to white light and TURBT using white light alone in reducing the rate of recurrence at 12 months (risk ratio 0.94, 95% CI 0.75-1.19) (GRADE: Moderate). No evidence on the effect on recurrence-free survival or tumour progression rate was identified for NBI-guided TURBT. The indirect estimate from the network analysis showed a trend toward a lower rate of recurrence after HAL-guided TURBT than after NBI-guided TURBT but the difference was not statistically significant (risk ratio 0.76, 95% CI 0.51-1.11) (GRADE: Low). Studies showed that use of HAL or NBI during TURBT was generally safe.The incremental cost-effectiveness ratio of HAL-guided TURBT compared with NBI-guided TURBT, both as an adjunct to white light, is $12,618 per quality-adjusted life-year (QALY) gained. Compared with TURBT using white light alone and using adjunct NBI, the probability of HAL-guided TURBT being cost-effective is 69.1% at a willingness-to-pay value of $50,000 per QALY gained and 74.6% at a willingness-to-pay of $100,000 per QALY gained. The annual budget impact of publicly funding HAL-guided TURBT in Ontario over the next 5 years ranges from an additional $0.6 million in year 1 to $2.5 million in year 5.
CONCLUSIONS
First TURBT guided by HAL as an adjunct to white light likely reduces the rate of recurrence at 12 months and increases 5-year recurrence-free survival when compared with first TURBT using white light alone. There is likely little to no difference in the tumour progression rate. First TURBT guided by NBI as an adjunct to white light likely results in little to no difference in the rate of recurrence at 12 months when compared with first TURBT using white light alone. Based on an indirect comparison, there may be little to no difference in cancer recurrence rate between HAL-guided and NBI-guided first TURBT. Use of HAL or NBI during first TURBT is generally safe. For people undergoing their first TURBT for suspected non-muscle-invasive bladder cancer, using HAL as an adjunct to white light is likely to be cost-effective compared with using white light alone or with using NBI as an adjunct to white light. We estimate that publicly funding HAL as an adjunct to white light to guide first TURBT for people in Ontario with suspected NMIBC would result in additional costs of between $0.6 million and $2.5 million per year over the next 5 years.
Topics: Cost-Benefit Analysis; Humans; Neoplasm Recurrence, Local; Quality-Adjusted Life Years; Technology Assessment, Biomedical; Urinary Bladder Neoplasms
PubMed: 34484486
DOI: No ID Found -
BioMed Research International 2021Mitral valve disease surgery is an evolving field with multiple possible interventions. There is an increasing body of evidence regarding the optimal strategy in...
BACKGROUND
Mitral valve disease surgery is an evolving field with multiple possible interventions. There is an increasing body of evidence regarding the optimal strategy in secondary mitral regurgitation where the pathology lies within the ventricle. We conducted a systematic review to identify the benefits and limitations of each surgical option.
METHODS
A systematic review of the literature was performed to identify pertinent randomized controlled trials (RCTs), propensity-matched observational series, and meta-analyses which were considered initially and followed by unmatched observational series using the MEDLINE, Ovid EMBASE, and Cochrane Library.
RESULTS
We identified 6 different strategies for treating secondary mitral valve regurgitation: mitral valve replacement, restrictive mitral annuloplasty, surgical revascularization (with and without mitral annuloplasty), subvalvular procedures (papillary muscle approximation, papillary muscle relocation, ring and string procedure), and procedures directly targeting the mitral valve (edge-to-edge repair and anterior leaflet enlargement) alongside transcatheter heart valve therapy. We also highlighted the role of left ventricular assist devices in the management of this condition. The benefits and limitations of each intervention are highlighted.
CONCLUSION
There is currently no unanimous and shared strategy for the optimal treatment of patients with secondary IMR. The management of patients with secondary mitral regurgitation must be entrusted to a multidisciplinary Heart Team to ensure ideal intervention and patient matching for the best outcomes.
Topics: Apoptosis; Fibrosis; Heart Valve Prosthesis Implantation; Humans; Mitral Valve Annuloplasty; Mitral Valve Insufficiency; Papillary Muscles; ROC Curve; Treatment Outcome; Vascular Surgical Procedures
PubMed: 34258260
DOI: 10.1155/2021/3466813