Dawn S. Hui

Atrial fibrillation: A major risk factor for cognitive decline

Atrial fibrillation is a common disease of the elderly, conferring considerable morbidity and mortality related to cardiovascular effects and thromboembolic risks. Anticoagulation, antiarrhythmic medications, and rate control are the cornerstone of contemporary management, whereas ablation and evolving surgical techniques continue to play important secondary roles. Growing evidence shows that atrial fibrillation is also a risk factor for significant cognitive decline through a multitude of pathways, further contributing to morbidity and mortality. At the same time, cognitive decline associated with cryptogenic strokes may be the first clue to previously undiagnosed atrial fibrillation. These overlapping associations support the concept of cognitive screening and rhythm monitoring in these populations. New research suggests modulating effects of currently accepted treatments for atrial fibrillation on cognition; however, there remains the need for large multicenter studies to examine the effects of novel oral anticoagulants, rhythm and rate control, and left atrial appendage occlusion on long-term cognitive function.

A comparison of aortic valve replacement via an anterior right minithoracotomy with standard sternotomy: a propensity score analysis of 492 patients

OBJECTIVES Right anterior minithoracotomy with central arterial cannulation is our preferred technique of minimally invasive aortic valve replacement (AVR). We compared perioperative outcomes with this technique to those via sternotomy. METHODS Between March 1999 and December 2013, 492 patients underwent isolated AVR via either sternotomy (SAVR, n = 198) or minimally invasive right anterior thoracotomy (MIAVR, n = 294) in our institution. Univariate comparisons between groups were made to evaluate overall outcomes and adverse events. To control treatment selection bias, propensity scores were constructed from core patient characteristics. A propensity score-stratified analysis of outcome and adverse events was then performed. RESULTS Overall mortality was 2.5 and 1.0% in the SAVR and MIAVR groups, respectively. Hospital and ICU stays were shorter, there was less intraoperative blood product usage, and fewer wound infections in the MIAVR group. There were no differences in other adverse events, including strokes. The composite end-point of alive and adverse event-free was significantly more common in the MIAVR group (83 vs 74%, P = 0.002). After adjusting for the propensity score, hospital and ICU stays remained shorter and intraoperative blood product usage remained less in the MIAVR group. There was no difference in mortality, stroke or other adverse events between groups. CONCLUSION Minimally invasive AVR via an anterior right thoracotomy with predominately central cannulation can be performed with morbidity and mortality similar to that of a sternotomy approach. There appear to be advantages to this minimally invasive approach when compared with sternotomy in terms of less intraoperative blood product usage, lower wound infection rates and decreased hospital stays. If mortality and the occurrence of adverse events are taken together, MIAVR may be associated with better outcomes. As minimally invasive AVR becomes more common, further long-term follow-up is needed and a prospective multicentre randomized trial would be warranted.

Quantitation of thiol metabolites from mammalian cells using fluorous tagging and HILIC-MS

Oxidative stress diminishes reduced thiols by decreasing their production or by forming disulfide bonds. This instigates an equilibrium shift in further downstream metabolic pathways. The goal of this work is to develop a rapid and selective fluorous labeling strategy for improved sensitivity in LC-MS analysis of reduced thiols in biological samples. Fluorous tagging is used to augment the MS signal and has limited stationary phase interactions. Thiol standards were reacted with a fluorous maleimide at a ratio of 100 : 1 in an 80% acetonitrile buffer containing 5 mM ammonium formate at pH 8. The reaction time and temperature were optimized. The mixture of thiol metabolites was then separated using a cyano HILIC column with a linear gradient from 90% to 70% acetonitrile. Signal intensity from fluorous-tagged thiols was improved over the untagged thiols by at least four fold. This demonstrates a quick method that can be used to compare levels of reduced thiols in diabetic and normal mammalian endothelial cells. Human tissue was also analyzed using this tagging method. This method will further elucidate the impact of oxidative stress on thiol metabolism and therefore help identify therapeutic targets for the treatment of diabetic complications.

Contemporary Use of Balloon Aortic Valvuloplasty in the Era of Transcatheter Aortic Valve Implantation

The development of transcatheter aortic valve implantation (TAVI) has increased the use of balloon aortic valvuloplasty (BAV) in treating aortic stenosis. We evaluated our use of BAV in an academic tertiary referral center with a developing TAVI program. We reviewed 69 consecutive stand-alone BAV procedures that were performed in 62 patients (mean age, 77 ± 10 yr; 62% men; baseline mean New York Heart Association functional class, 3 ± 1) from January 2009 through December 2012. Enrollment for the CoreValve(®) clinical trial began in January 2011. We divided the study cohort into 2 distinct periods, defined as pre-TAVI (2009-2010) and TAVI (2011-2012). We reviewed clinical, hemodynamic, and follow-up data, calculating each BAV procedure as a separate case. Stand-alone BAV use increased 145% from the pre-TAVI period to the TAVI period. The mean aortic gradient reduction was 13 ± 10 mmHg. Patients were successfully bridged as intended to cardiac or noncardiac surgery in 100% of instances and to TAVI in 60%. Five patients stabilized with BAV subsequently underwent surgical aortic valve replacement with no operative deaths. The overall in-hospital mortality rate (17.4%) was highest in emergent patients (61%). The implementation of a TAVI program was associated with a significant change in BAV volumes and indications. Balloon aortic valvuloplasty can successfully bridge patients to surgery or TAVI, although least successfully in patients nearer death. As TAVI expands to more centers and higher-risk patient groups, BAV might become integral to collaborative treatment decisions by surgeons and interventional cardiologists.

Left atrial appendage thrombus after successful surgical exclusion on anticoagulation: a need for closer postintervention monitoring.

59-year-old man with long-standing persistent atrial Afibrillation underwent the first stage of a hybrid Maze by bilateral video-assisted thoracoscopy. Preoperative transesophageal echocardiogram (TEE) showed no atrial clot or mitral regurgitation. The left atrial appendage (LAA) was excluded with Endoloops (Ethicon, Somerville, NJ). He was discharged in sinus rhythm with prescriptions and instructions for continuing antiarrhythmic medications and warfarin. After 2 months, TEE demonstrated a 0.7-cm appendage stump (dotted arrow, Fig 1A) with thrombus (arrow, Figs 1A and 1B) despite adequate anticoagulation (INR 3.2). Six weeks later, TEE showed persistent, though smaller, thrombus (Fig 1C). Expert consensus on atrial fibrillation recommends complete LAA occlusion. Surgical literature defines remnant LAA as a stump or pouch longer than 1 cm [1]. After exclusion, late neurologic events occur at 0.2%

Massive Hemoptysis From an Aortobronchial Fistula Secondary to BCG-Related Mycotic Thoracic Aortic Aneurysm

Intravesical bacillus Calmette-Guérin (BCG) is first-line therapy for noninvasive bladder cancer. Although side effects are rare, systemic dissemination can result in mycotic aneurysms. We report the case of a rapidly developing thoracic aortic mycotic aneurysm presenting as massive hemoptysis from an aortobronchial fistula. This case was unusual in its location, rapidity of development, and failure of medical therapy. The diagnostic challenges and the need for a high index of suspicion are discussed.

Modified internal ligation of the left atrial appendage

From the Center for Comprehensive Cardiovascular Care, Saint Louis University, St Louis, Mo. Disclosures: Authors have nothing to disclose with regard to commercial support. Received for publication Feb 28, 2017; revisions received March 23, 2017; accepted for publication April 18, 2017; available ahead of print June 9, 2017. Address for reprints: Richard Lee, MD, MBA, 3635 Vista Ave, DT 13th Floor, St Louis, MO 63110 (E-mail: rlee@slu.edu). J Thorac Cardiovasc Surg 2017;154:847-8 0022-5223/

Transapical mitral replacement with anterior leaflet splitting: A novel technique to avoid left ventricular outflow tract obstruction

36.00 Copyright 2017 Published by Elsevier Inc. on behalf of The American Association for Thoracic Surgery http://dx.doi.org/10.1016/j.jtcvs.2017.04.077

Discordant Aortic Valve Morphology in Monozygotic Twins: A Clinical Case Series

From the Center for Comprehensive Cardiovascular Care, Saint Louis University, St Louis, Mo. Disclosure: Authors have nothing to disclose with regard to commercial support. Received for publication July 20, 2017; revisions received Sept 28, 2017; accepted for publication Oct 20, 2017; available ahead of print Dec 2, 2017. Address for reprints: Richard Lee, MD, MBA, 3635 Vista Ave, DT 13th Floor, St Louis, MO 63110 (E-mail: rlee@slu.edu). J Thorac Cardiovasc Surg 2018;155:e95-8 0022-5223/

Use of a Vascular Sheath in the Axillary Artery as an Alternative Access Approach for Placing an Impella 5.0 Device.

36.00 Copyright 2017 by The American Association for Thoracic Surgery https://doi.org/10.1016/j.jtcvs.2017.10.059