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JA Clinical Reports May 2024There is currently limited research on the clinical use of remimazolam in severely obese patients. In this report, we describe the anesthesia management of transcatheter...
INTRODUCTION
There is currently limited research on the clinical use of remimazolam in severely obese patients. In this report, we describe the anesthesia management of transcatheter aortic valve implantation (TAVI) in a severely obese patient using remimazolam.
CASE DESCRIPTION
A 76-year-old woman (height 1.54 m; total body weight 104 kg; body mass index 43.9 kg/m) was scheduled for TAVI via the femoral artery approach for aortic valve stenosis. Preoperative echocardiography showed an aortic valve peak flow of 4.0 m/s and an effective orifice area of 0.75 cm. Anesthesia induction was performed with a bolus dose of 100 μg fentanyl, 15 mg remimazolam, 60 mg rocuronium, and a continuous infusion of remifentanil at 0.4 mg/h. Intraoperatively, remimazolam was administered at a rate of 35 mg/h. General anesthesia management was completed without any complications, although the patient required temporary catecholamine and inhalation anesthesia assistance due to hemodynamic changes.
CONCLUSION
Owing to its pharmacological advantages, remimazolam may be an option for anesthesia induction and maintenance in severely obese patients with unstable circulation.
PubMed: 38797801
DOI: 10.1186/s40981-024-00716-1 -
Asian Journal of Surgery May 2024
PubMed: 38797587
DOI: 10.1016/j.asjsur.2024.05.062 -
Gels (Basel, Switzerland) May 2024This review focuses on the use of conventional gel or coil and "new" generation hydrogel used as an embolic agent in endovascular applications. In general, embolic... (Review)
Review
This review focuses on the use of conventional gel or coil and "new" generation hydrogel used as an embolic agent in endovascular applications. In general, embolic agents have deep or multidistrict vascular penetration properties as they ensure complete occlusion of vessels by exploiting the patient's coagulation system, which recognises them as substances foreign to the body, thus triggering the coagulation cascade. This is why they are widely used in the treatment of endovascular corrections (EV repair), arteriovenous malformations (AVM), endoleaks (E), visceral aneurysms or pseudo-aneurysms, and embolisation of pre-surgical or post-surgical (iatrogenic) lesions. Conventional gels such as Onyx or coils are now commercially available, both of which are frequently used in endovascular interventional procedures, as they are minimally invasive and have numerous advantages over conventional open repair (OR) surgery. Recently, these agents have been modified and optimised to develop new embolic substances in the form of hydrogels based on alginate, chitosan, fibroin and other polymers to ensure embolisation through phase transition phenomena. The main aim of this work was to expand on the data already known in the literature concerning the application of these devices in the endovascular field, focusing on the advantages, disadvantages and safety profiles of conventional and innovative embolic agents and also through some clinical cases reported. The clinical case series concerns the correction and exclusion of endoleak type I or type II appeared after an endovascular procedure of exclusion of aneurysmal abdominal aortic (EVAR) with a coil (coil penumbra released by a LANTERN microcatheter), the exclusion of renal arterial malformation (MAV) with a coil (penumbra coil released by a LANTERN microcatheter) and the correction of endoleak through the application of Onyx 18 in the arteries where sealing by the endoprosthesis was not guaranteed.
PubMed: 38786229
DOI: 10.3390/gels10050312 -
Renal Failure Dec 2024Recent studies have shown that the baseline values of absolute aortic root diameter (ARD) and indexed diameter are associated with all-cause mortality and...
Recent studies have shown that the baseline values of absolute aortic root diameter (ARD) and indexed diameter are associated with all-cause mortality and cardiovascular events in the general population, even in the absence of aneurysmal aortic disease. However, there is limited available data on the association between ARD and prognosis in end-stage renal disease (ESRD) patients receiving maintenance hemodialysis (MHD). Accordingly, the purpose of this study is to investigate the predictive value of ARD for all-cause mortality and cardiovascular events in this specific population. ARD was measured by echocardiography at the level of the sinuses of Valsalva at end diastole and indexed to body surface area (BSA). The primary endpoint was all-cause mortality. The secondary endpoint was major adverse cardiovascular events (MACE), including cardiovascular mortality, myocardial infarction and stroke. Cox proportional hazards models were conducted to evaluate the association between baseline ARD/BSA and clinical outcomes. A total of 391 patients were included in this study. The primary endpoint occurred in 95 (24.3%) patients while the secondary endpoint occurred in 71 (18.2%) patients. Multivariate Cox regression analysis showed that ARD/BSA was an independent prognostic factor for all-cause mortality (HR, per 1-SD increase, 1.403; 95% CI, 1.118-1.761; = 0.003) as well as MACE (HR, per 1-SD increase, 1.356; 95% CI, 1.037-1.772; = 0.026). Our results show that ARD/BSA is predictive of all-cause mortality and MACE in MHD patients with ESRD and support the view that assessment of ARD/BSA may refine risk stratification and preventive strategies in this population.
Topics: Humans; Male; Kidney Failure, Chronic; Female; Renal Dialysis; Middle Aged; Prognosis; Aged; Echocardiography; Aorta; Retrospective Studies; Proportional Hazards Models; Cardiovascular Diseases; Risk Factors
PubMed: 38785291
DOI: 10.1080/0886022X.2024.2355352 -
Arteriosclerosis, Thrombosis, and... Jul 2024Epidemiological and mechanistic data support a potential causal link between cardiovascular disease (CVD) and cancer. Abdominal aortic aneurysms (AAAs) represent a...
BACKGROUND
Epidemiological and mechanistic data support a potential causal link between cardiovascular disease (CVD) and cancer. Abdominal aortic aneurysms (AAAs) represent a common form of CVD with at least partially distinct genetic and biologic pathogenesis from other forms of CVD. The risk of cancer and how this risk differs compared with other forms of CVD, is unknown among AAA patients. We conducted a retrospective cohort study using the IBM MarketScan Research Database to test whether individuals with AAA have a higher cancer risk independent of traditional shared risk factors.
METHODS
All individuals ≥18 years of age with ≥36 months of continuous coverage between 2008 and 2020 were enrolled. Those with potential Mendelian etiologies of AAA, aortic aneurysm with nonspecific anatomic location, or a cancer diagnosis before the start of follow-up were excluded. A subgroup analysis was performed of individuals having the Health Risk Assessment records including tobacco use and body mass index. The following groups of individuals were compared: (1) with AAA, (2) with non-AAA CVD, and (3) without any CVD.
RESULTS
The propensity score-matched cohort included 58 993 individuals with AAA, 117 986 with non-AAA CVD, and 58 993 without CVD. The 5-year cumulative incidence of cancer was 13.1% (12.8%-13.5%) in participants with AAA, 10.1% (9.9%-10.3%) in participants with non-AAA CVD, and 9.6% (9.3%-9.9%) in participants without CVD. Multivariable-adjusted Cox proportional hazards regression models found that patients with AAA exhibited a higher cancer risk than either those with non-AAA CVD (hazard ratio, 1.28 [95% CI, 1.23-1.32]; <0.001) or those without CVD (hazard ratio, 1.32 [95% CI, 1.26-1.38]; <0.001). Results remained consistent after excluding common smoking-related cancers and when adjusting for tobacco use and body mass index.
CONCLUSIONS
Patients with AAA may have a unique risk of cancer requiring further mechanistic study and investigation of the role of enhanced cancer screening.
Topics: Humans; Aortic Aneurysm, Abdominal; Male; Incidence; Female; Retrospective Studies; Middle Aged; Aged; Risk Factors; Neoplasms; Risk Assessment; United States; Time Factors; Databases, Factual; Adult; Aged, 80 and over
PubMed: 38779853
DOI: 10.1161/ATVBAHA.123.320543 -
Revista Da Associacao Medica Brasileira... 2024This study aimed to compare the effectiveness of resection and extended end-to-end anastomosis between neonate and infant patients with coarctation. (Comparative Study)
Comparative Study
OBJECTIVE
This study aimed to compare the effectiveness of resection and extended end-to-end anastomosis between neonate and infant patients with coarctation.
METHODS
This study was designed retrospectively and included 41 neonate (<30 days) and infant (30 days to 1 year) patients who were operated on using the resection and extended end-to-end anastomosis technique for aortic coarctation. Preoperative aortic annulus diameters and Z scores, all aortic arch diameters and Z scores, the presence of hypoplastic aortic segment, and the presence of prematurity were reviewed in both groups. Subsequently, we investigated whether these parameters were statistically related to the residual gradient in the operation area, whether there was a need for early re-intervention, and what was the incidence of mortality in the early postoperative period. In addition, the aortic arch Z scores of the patients at 6 months postoperatively were examined.
RESULTS
While the mean age (p<0.001), body weight (p<0.001), and proximal arch Z score (p=0.029) were found to be significantly lower in the neonate group than in the infant group, the total length of the intensive care unit stay (p=0.013) and the total length of hospital stay (p=0.017) were found to be significantly higher. In addition, significant enlargement was detected in the proximal arch, distal arch, and isthmus segments in both patient groups.
CONCLUSION
The resection and extended end-to-end anastomosis is an equally effective technique that can provide a marked decrease in gradient in the coarctation area and a significant enlargement of the aortic arch segments in the early period after coarctation repair in both neonate and infant patients.
Topics: Humans; Aortic Coarctation; Infant, Newborn; Infant; Treatment Outcome; Retrospective Studies; Female; Male; Length of Stay; Anastomosis, Surgical; Aorta, Thoracic; Age Factors
PubMed: 38775513
DOI: 10.1590/1806-9282.20231626 -
Interdisciplinary Cardiovascular and... May 2024Ascending aorta (AA) dilatation in patients with bicuspid aortic valve (AV) is related both to genetic and haemodynamic factors. The aim of this study is to compare late...
OBJECTIVES
Ascending aorta (AA) dilatation in patients with bicuspid aortic valve (AV) is related both to genetic and haemodynamic factors. The aim of this study is to compare late progression of AA dilatation in bicuspid AV patients undergoing surgical aortic valve replacement (SAVR) versus transcatheter aortic valve implantation (TAVI).
METHODS
Data of 189 consecutive patients who underwent AV replacement for severe bicuspid AV stenosis were prospectively collected. Patients who underwent SAVR were compared to patients who underwent TAVI. Indication to the procedure was validated by the institutional Heart Team. Aortic diameters were evaluated by transthoracic echocardiogram. Differences between preoperative and long-term follow-up AA diameters were compared in the 2 groups.
RESULTS
Between January 2015 and December 2021, 143 (76%) patients underwent SAVR and 46 (24%) patients underwent TAVI. At 4.6 (standard deviation 1.7) years follow-up, patients in the TAVI group showed significantly lower survival (P = 0.00013) and event-free survival (P < 0.0001). AA diameter progression was lower in surgical compared to transcatheter patients, 0.95 (0.60, 1.30) vs 1.65 (0.67, 2.63) mm, P = 0.02. AA diameter progression indexed for body surface area and height was lower in the surgical group: 0.72 (0.38, 1.05) vs 1.05 (0.39, 1.71) mm/m2, P = 0.02, and 0.59 (0.36, 0.81) vs 1.11 (0.44, 1.78) mm/m, P = 0.001, respectively. At multivariable linear regression analysis transcatheter procedure, baseline aortic diameter and paravalvular leak were significantly associated with increased postoperative AA dilatation.
CONCLUSIONS
Bicuspid AV patients who underwent SAVR, showed significantly less long-term AA diameter progression than patients who underwent transcatheter procedure.
PubMed: 38775458
DOI: 10.1093/icvts/ivae100 -
Cureus Apr 2024Abdominal aortic aneurysms (AAAs) pose significant challenges in clinical management, particularly in female patients, whose unique anatomical and physiological... (Review)
Review
Abdominal aortic aneurysms (AAAs) pose significant challenges in clinical management, particularly in female patients, whose unique anatomical and physiological characteristics influence rupture risk. While aortic diameter (AD) has traditionally been the primary metric for predicting rupture, its limitations, especially in women, have spurred exploration into alternative measures such as the aortic size index (ASI). This review examines the anatomy and physiology of AAAs in women, gender-specific challenges in diagnosis and management, and the comparative effectiveness of ASI versus AD in predicting rupture risk. ASI, calculated as AD divided by body surface area (BSA), offers a more nuanced assessment by adjusting for individual body size differences, potentially mitigating gender disparities in rupture rates. Comparative analyses indicate ASI's superiority in predicting adverse aortic events, particularly in women, thereby advocating for its integration into clinical practice to improve patient outcomes. Additionally, emerging techniques such as 3D volumetric measurements and biomechanical assessments show promise in enhancing rupture risk prediction, heralding a shift toward more personalized and effective management strategies for AAA patients.
PubMed: 38774170
DOI: 10.7759/cureus.58673 -
Circulation Journal : Official Journal... May 2024The relationships of the clinical and biological attributes of epicardial adipose tissue (EAT) with aortic valve calcification (AVC) have not been characterized. We...
BACKGROUND
The relationships of the clinical and biological attributes of epicardial adipose tissue (EAT) with aortic valve calcification (AVC) have not been characterized. We evaluated the relationships of the clinical and histological features of EAT with AVC assessed using computed tomography (CT).Methods and Results: We enrolled 43 patients undergoing cardiac CT examination prior to elective cardiac surgery in whom AVC was identified on CT. EAT volume and density, coronary calcium score (CCS), AVC score (AVCS), and coronary atherosclerosis on CT angiography were evaluated in each patient. During cardiac surgery, 2 EAT samples were obtained for immunohistochemistry. The number of CD68- and CD11c-positive macrophages and osteocalcin-positive cells was counted in 6 random high-power fields of EAT sections. EAT density, but not EAT volume normalized to body surface area, was positively correlated with the number of macrophages and osteocalcin-positive cells in EAT. There was a positive correlation between ln(AVCS), but not ln(CCS+1), and the number of macrophages and osteocalcin-positive cells in EAT. Multivariate analysis revealed significant positive correlations for ln(AVCS) with EAT density (β=0.42; P=0.0072) and the number of CD68-positive macrophages (β=0.57; P=0.0022), CD11c-positive macrophages (β=0.62; P=0.0003), and osteocalcin-positive cells (β=0.52; P=0.0021) in EAT.
CONCLUSIONS
Inflammation and osteogenesis in EAT, reflected by high CT density, are associated with the severity of AVC representing aortic valve degeneration.
PubMed: 38763753
DOI: 10.1253/circj.CJ-24-0226 -
EJVES Vascular Forum 2024To instantly stop life threatening abdominal bleeding (e.g., a ruptured abdominal aneurysm), every surgeon should be familiar with the principles of emergency laparotomy...
OBJECTIVE
To instantly stop life threatening abdominal bleeding (e.g., a ruptured abdominal aneurysm), every surgeon should be familiar with the principles of emergency laparotomy (EL) and aortic clamping. Simulation training in a safe environment can be used to rehearse these situations like other medical emergencies. Owing to the lack of a suitable commercial simulator, a homemade task trainer was constructed. This study aimed to evaluate the feasibility of an EL simulation training course among surgical residents using this low cost task trainer.
METHODS
To enable simulation training for massive abdominal bleeding with subsequent EL and aortic clamping, a multiprofessional team developed an EL task trainer. A structured evaluation of the trainer and its applicability was performed by external consultants, who tested the trainer themselves. Instructions for constructing the trainer were created and costs were calculated. During the EL simulation course targeted for surgical trainees early in their careers, 34 participants familiarised themselves with EL. Their experiences of the feasibility of the course and increase in self assessed clinical competence in managing the situation were studied using a questionnaire. In a subgroup of trainees, the simulation was compared with a real life EL subsequent to the course.
RESULTS
Participants found that the trainer was fit for its purpose (mean score, 4.7 out of 5). Their self assessed clinical competence increased in several domains: EL as a procedure ( < 0.01), handling of intra-abdominal tissues and organs during EL ( = 0.008), and emergency procedures in intra-abdominal haemorrhage ( < 0.001). The cost for the body of the trainer was €108 and there was an additional €42 for the disposables for one training scenario.
CONCLUSION
A low cost task trainer with pulsatile flow enabling surgical residents to rehearse EL with aortic clamping can be constructed from commonly available materials. Preliminary experience of its feasibility and effects on learning in a simulation training course have been positive.
PubMed: 38746648
DOI: 10.1016/j.ejvsvf.2024.04.002