Citations

VT Ablation in LVAD RecipientsBackgroundPatients with advanced heart failure (HF) are predisposed to ventricular arrhythmias (VAs), particularly following implantation of a left ventricular assist device (LVAD). There is minimal evidence for appropriate management strategies.ObjectivesThis study aimed to compare the burden of VA and response to ablation performed either before or following LVAD implantation.MethodsWe created a retrospective cohort of patients who underwent both VA ablation and Heart Mate II (Thoratec, Pleasanton, CA, USA) LVAD implantation at Mayo Clinic (Rochester, MN, USA). Patients were stratified based on whether they underwent VA ablation before (pre‐LVAD) or after LVAD (post‐LVAD) implantation. Descriptive analyses assessed 6‐month arrhythmia burden in relation to LVAD implantation and VA ablation.ResultsA total of 9 patients underwent both LVAD implantation and VA ablation. There were 3 and 6 patients, respectively, in the pre‐LVAD and post‐LVAD cohorts. Among patients in the pre‐LVAD cohort, the median number of VAs tended to increase after ablation (9 vs. 72) and decreased after LVAD implantation (72 vs. 63). Similarly among patients in the post‐LVAD cohort, the median burden of VAs increased after LVAD implantation (1 vs. 22) and the median burden decreased after ablation (22 vs. 13). Two of 6 patients had substrate related to the LVAD inflow cannula site, while other substrate was not related directly to the cannula.ConclusionsIn patients with progressive HF and LVAD implantation, ablation is associated with reduced VA rates. In LVAD patients, most VAs arise from substrate unrelated to the inflow cannula site.

Objective To examine the use of the Prostate Health Index ( PHI ) as a continuous variable in multivariable risk assessment for aggressive prostate cancer in a large multicentre US study. Materials and Methods The study population included 728 men, with prostate‐specific antigen ( PSA ) levels of 2–10 ng/ mL and a negative digital rectal examination, enrolled in a prospective, multi‐site early detection trial. The primary endpoint was aggressive prostate cancer, defined as biopsy Gleason score ≥7. First, we evaluated whether the addition of PHI improves the performance of currently available risk calculators (the Prostate Cancer Prevention Trial [ PCPT ] and European Randomised Study of Screening for Prostate Cancer [ ERSPC ] risk calculators). We also designed and internally validated a new PHI ‐based multivariable predictive model, and created a nomogram. Results Of 728 men undergoing biopsy, 118 (16.2%) had aggressive prostate cancer. The PHI predicted the risk of aggressive prostate cancer across the spectrum of values. Adding PHI significantly improved the predictive accuracy of the PCPT and ERSPC risk calculators for aggressive disease. A new model was created using age, previous biopsy, prostate volume, PSA and PHI , with an area under the curve of 0.746. The bootstrap‐corrected model showed good calibration with observed risk for aggressive prostate cancer and had net benefit on decision‐curve analysis. Conclusion Using PHI as part of multivariable risk assessment leads to a significant improvement in the detection of aggressive prostate cancer, potentially reducing harms from unnecessary prostate biopsy and overdiagnosis.

Abstract Extrauterine spread of leiomyomas is rare and most commonly occurs in the lungs. We present a case of simultaneous metastatic leiomyomatosis to the lungs and peritoneal cavity following laparoscopic myomectomy with power morcellation. The patient presented to our institution for further management where she underwent a robotically assisted hysterectomy with bilateral salpingo-oophorectomy. Leiomyomatous implants measuring up to 2.4 cm were resected from bowel mesentery and bladder peritoneum. Subsequent serial computed tomography imaging confirmed stable pulmonary nodules without new intraperitoneal lesions. Increasing number of cases involving extrauterine spread of leiomyomas has been reported with the introduction of power morcellation. The exact pathogenesis is unknown but is likely multifactorial. We emphasize that although the incidence of spread of benign disease is low, it is important to recognize this phenomenon as we will likely continue to encounter similar cases in the coming years.

Abstract Background: The precise mechanism by which the immune system is adversely affected in cancer patients remains poorly understood, but the accumulation of immunosuppressive/protumorigenic myeloid-derived suppressor cells (MDSCs) is thought to be a prominent mechanism contributing to immunologic tolerance of malignant cells in epithelial ovarian cancer (EOC). To this end, we hypothesized genetic variation in MDSC pathway genes would be associated with survival after EOC diagnoses. Methods: We measured the hazard of death due to EOC within 10 years of diagnosis, overall and by invasive subtype, attributable to SNPs in 24 genes relevant in the MDSC pathway in 10,751 women diagnosed with invasive EOC. Versatile Gene-based Association Study and the admixture likelihood method were used to test gene and pathway associations with survival. Results: We did not identify individual SNPs that were significantly associated with survival after correction for multiple testing (P < 3.5 × 10−5), nor did we identify significant associations between the MDSC pathway overall, or the 24 individual genes and EOC survival. Conclusions: In this well-powered analysis, we observed no evidence that inherited variations in MDSC-associated SNPs, individual genes, or the collective genetic pathway contributed to EOC survival outcomes. Impact: Common inherited variation in genes relevant to MDSCs was not associated with survival in women diagnosed with invasive EOC. Cancer Epidemiol Biomarkers Prev; 26(3); 420–4. ©2016 AACR.

De novo progressive aortic insufficiency (AI) is a side effect frequently related to prolonged support with continuous-flow left ventricular assist devices (CF-LVAD). Its progression can result in recurrent clinical heart failure symptoms and significantly increased mortality. Recently, percutaneous intervention methods, such as transcatheter aortic valve replacement (TAVR) and percutaneous occluder devices, have emerged. However, given the very scarce global experience with these approaches, evidence in the literature is lacking. We sought to assess the outcomes of CF-LVAD patients who had undergone percutaneous intervention for AI. A systematic search of six databases from inception to April 2016 was performed by two independent reviewers. Eligible studies were those that included series or cases where patients had percutaneous transcatheter interventions for AI in CF-LVAD patients. Data were extracted and meta-analyzed from the identified studies. A total of 29 patients from 15 published studies and 3 unpublished records were included in the analysis. Mean patient age was 56.6 ± 13.7 years, and 72.4% were male. The etiology of heart failure resulting in LVAD placement was ischemic cardiomyopathy in 17.2%. The two intervention groups were TAVR (27.6%) and occluder devices (72.4%). A transfemoral approach (69%), apical approach (10%), brachial approach (7%), subclavian approach (3%), and mini-sternotomy (3%) were used. The preintervention AI grade was severe with a median grade of 4 (interquartile range, 4–4). Postoperatively, the AI grade improved significantly to a median grade of 0 (0–2). At long-term follow-up AI grade was still trivial with a median AI grade of 1 (0–1). Subgrouping the treatments into the occluder device and TAVR, it was found that both interventional techniques were similarly effective in reducing the AI grade from severe to trivial. In terms of complications, from the occluder group, two patients were complicated with device migration and another two with transient hemolysis. In the TAVR cohort, two patients experienced device migration and another had significant postimplant perivalvular leakage. Our results indicate that percutaneous interventions for AI in CF-LVAD patients with TAVR, and closure devices demonstrate similar efficacy in significantly reducing severe AI. Current results are encouraging, potentiating viability as a treatment option, particularly in nonsurgical candidates. Future research with larger patient cohorts and comparative controls is required to sufficiently evaluate the efficacy of this technique and promote its widespread acceptance as a mainstay treatment.

Objectives: We sought to determine the incidence of hardware removal or persistent irritation after tension band arthrodesis of the thumb metacarpophalangeal joint (MCPJ), and whether these outcomes were related to patient age, gender, body mass index (BMI), or angle of fusion. Materials and Methods: A retrospective review was performed of all (n = 39) thumb MCPJ arthrodesis done using tension band wire fixation by a single hand surgeon at a large tertiary academic medical center over a 14-year period. Thirty procedures in 28 patients (4 men, 24 women) with an average age of 65 years (range, 35-81 years) were available for long-term follow-up (mean, 82 months; range, 12-171 months). Average BMI was 26.2 (range, 17.4-35).Most were done in conjunction with a basal joint suspensionplasty. Results: One hundred percent of arthrodesis healed radiographically at a mean 3.8 months (range, 3-7 months). Mean fusion angle was 24° (range, 9°-45°). Of patients available for long-term follow-up (n = 30), 7 (23%) required hardware removal for pain at a mean of 36 months postoperatively, and another needed revision of hardware at 4 months postoperatively. An additional 3 patients (10%) expressed dissatisfaction with the hardware in place, but declined removal. There was no significant influence of the above variables on hardware removal or dissatisfaction. Conclusions: Tension band wire arthrodesis of the thumb MCPJ results in predictable bony union. Although it is a very cheap means of fixation, there is a 33% incidence of significant hardware-related pain after tension band arthrodesis of the thumb MCPJ. Twenty-five percent of patients may require a second surgery to revise or remove symptomatic hardware, which can negate any cost savings through the use of this technique. A study comparing this method with plate or single screw fixation would be beneficial.

Background: Proximal interphalangeal joint (PIPJ) arthroplasty in border digits is controversial because of unprotected external loading forces and limited canal sizes in the small finger. The use of neither a semiconstrained, surface replacement proximal arthroplasty (SRA) nor a lateral approach that preserves the external collateral ligament has been well described. Methods: Eight women (mean age, 66 years) underwent SRA of 5 index and 4 small digits for osteoarthritis. Active range of motion, deformity, and grip and pinch strengths were measured, and patients completed a visual analog pain scale, QuickDASH, and satisfaction survey. Radiographs were assessed for implant loosening or subsidence. Results: Mean follow-up was 29 months. Mean pain score decreased from 8.0 to 0.8. Mean coronal deformity decreased from 22° ulnar deviation to 6°. Average PIPJ arc of motion improved from 51° to 56°. No lateral instability was observed. Final lateral pinch averaged 4.4 kg in affected vs 4.0 kg in opposite hand. Average final grip strength was 19 kg in affected vs 16 kg in opposite hand. Postoperative QuickDASH averaged 24; postoperative satisfaction score averaged 3.7 (5-point Likert scale). Radiographic analysis showed no implant subsidence or radiolucent lines. Conclusions: PIPJ SRA appears to be a reasonable option in border digits, as is a lateral approach on the inside border of the affected digit. Pain relief and lateral stability are predictable, and motion improves slightly. If a longitudinal incision is made, placement slightly dorsal to the midaxial line away from the digital nerve may help to avoid a tender scar.