Goran Rimac

FDG-PET/CT for pre-operative staging and prognostic stratification of patients with high-grade prostate cancer at biopsy

BackgroundThe role of 18F-fluorodeoxyglucose positron emission tomography/computed tomography (FDG-PET/CT) in prostate cancer (PCa) has not been well defined yet. Because high-grade PCa tends to exhibit increased glycolytic rate, FDG-PET/CT could be useful in this setting. The aim of this study was to assess the value of FDG-PET/CT for pre-operative staging and prognostic stratification of patients with high-grade PCa at biopsy.MethodsFifty-four patients with a Gleason sum ≥8 PCa at biopsy underwent FDG-PET/CT as part of the staging workup. Thirty-nine patients underwent radical prostatectomy (RP) and pelvic lymph node (LN) dissection, 2 underwent LN dissection only, and 13 underwent non-surgical treatments. FDG-PET/CT findings from clinical reports, blinded reading and quantitative analysis were correlated with clinico-pathological characteristics at RP.ResultsSuspicious foci of increased FDG uptake were found in the prostate, LNs and bones in 44, 13 and 6% of patients, respectively. Higher clinical stage, post-RP Gleason sum and pattern, and percentage of cancer involvement within the prostate were significantly associated with the presence of intraprostatic FDG uptake (IPFU) (P < 0.05 in all cases). Patients without IPFU who underwent RP were downgraded to Gleason ≤7 in 84.6% of cases, as compared to 30.8% when IPFU was reported (P = 0.003). Qualitative and quantitative IPFU were significantly positively correlated with post-RP Gleason pattern and sum, and pathological T stage. Absence and presence of IPFU were associated with a median 5-year cancer-free survival probability of 70.2 and 26.9% (P = 0.0097), respectively, using the CAPRA-S prognostic tool.ConclusionThese results suggest that, among patients with a high-grade PCa at biopsy, FDG-PET/CT could improve pre-treatment prognostic stratification by predicting primary PCa pathological grade and survival probability following RP.

Efficacy and safety of preoperative intra-aortic balloon pump use in patients undergoing cardiac surgery: a systematic review and meta-analysis

BACKGROUND Intra-aortic balloon pump (IABP) can be used prior to coronary artery bypass graft surgery (CABG) in high-risk patients. Whether this technique remains safe and effective in contemporary practice is controversial. OBJECTIVE We have completed a systematic review and meta-analysis of randomized trials and observational studies to evaluate the safety and benefits of IABP prior to CABG surgery. METHODS We searched PubMed, EMBASE, Cochrane Library databases, with cross-referencing of relevant articles for studies assessing the impact of IABP prior to and after isolated CABG. Two investigators independently sorted the potentially relevant studies, and three extracted data. The assessed outcomes included in-hospital and 30-day mortality, IABP-related complications and length of intensive care unit and hospital stay. RESULTS From 1977 to 2015 we included 11 randomized controlled trials (n=1293) (RCTs) and 22 observational studies, including a total of 46,067 patients. Analyses from RCTs suggested that IABP prior to CABG was associated with a significant reduction in hospital mortality (odds ratio (OR) 0.20; 95% confidence interval (CI): 0.09-0.44; P<0.0001) and 30-day mortality compared to no preoperative IABP (OR 0.43, 95% CI: 0.25-0.76; P=0.003). IABP prior to CABG was also associated with shorter intensive care unit (weighted mean difference (WMD) -1.47day; 95% CI: -1.82 to -1.12day; P<0.00001) and hospital length of stay (WMD -3.25days; 95% CI: -5.18 to -1.33days; P=0.0009). However, there were significant bias and limitations among included studies. Furthermore, results for similar outcomes from observational studies remained inconclusive. CONCLUSIONS In contemporary practice, evidence showing clinical benefit for preoperative IABP in high-risk patients remains limited and requires further validation in an appropriately sized multicenter randomized trial.

Early and late mortality after repair or replacement in mitral valve prolapse and functional ischemic mitral regurgitation: A systematic review and meta-analysis of observational studies

Mitral regurgitation (MR) is the most prevalent valvular pathology in the USA affecting 1.7% of the population [1]. The two predominant forms of MR in the Western World are mitral valve prolapse (MVP) and ischemic mitral regurgitation (IMR) [2]. The optimal surgical strategy is still debated in both entities. Previous data comparing mitral valve repair (MVr) and replacement (MVR) approaches are based on a heterogeneous population in terms of LV function and baseline characteristics. The purpose of this study was to perform a systematic review and meta-analysis of all the relevant studies and to compare the mortality between the 2 surgical treatment strategies in patients with MVP and IMR. Using PubMed database, EMBASE, and the Cochrane Library we performed literature searches and thereafter individually reviewed relevant articles, extracted relevant data and entered in Review Manager software ([RevMan] version 5.1.20 (Nordic Cochrane Centre, Copenhagen, Denmark)).

Clinical value of post-percutaneous coronary intervention fractional flow reserve value: A systematic review and meta-analysis.

Background Fractional flow reserve (FFR) prior to percutaneous coronary intervention (PCI) is useful to guide treatment. Whether post‐PCI FFR assessment might have clinical impact is controversial. The aim of this study is to evaluate the range of post‐PCI FFR values and analyze the relationship between post‐PCI FFR and clinical outcomes. Methods We systematically searched the PubMed, EMBASE, and Cochrane Library databases with cross‐referencing of articles reporting post‐PCI FFR and correlating post‐PCI FFR values and clinical outcomes. The outcomes of interest were the immediate post‐PCI FFR values and the correlations between post‐PCI FFR and the incidence of repeat intervention and major adverse cardiac events (MACE). Results From 1995 to 2015, a total of 105 studies (n = 7470) were included, with 46 studies reporting post‐PCI FFR and 59 studies evaluating relationship between post‐PCI and clinical outcomes up to 30 months after PCI. Overall, post‐PCI FFR values demonstrated a normal distribution with a mean value of 0.90 ± 0.04. There was a positive correlation between the percentage of stent use and post‐PCI FFR (P < .0001). Meta‐regression analysis indicated that higher post‐PCI FFR values were associated with reduced rates of repeat intervention (P < .0001) and MACE (P = .0013). A post‐PCI FFR ≥0.90 was associated with significantly lower risk of repeat PCI (odds ratio 0.43, 95% CI 0.34‐0.56, P < .0001) and MACE (odds ratio 0.71, 95% CI 0.59‐0.85, P = .0003). Conclusions FFR measurement after PCI was associated with prognostic significance. Further investigation is required to assess the role of post‐PCI FFR and validate cutoff values in contemporary clinical practice.

Comparison of radiation exposure during transradial diagnostic coronary angiography with single- or multi-catheters approach.

To compare radiation exposure during transradial diagnostic coronary angiography (DCA) using standard single‐ or multi‐catheters with different shapes.

Feasibility and Safety of Early Repeat Transradial Access Within 30 Days of Previous Coronary Angiography and Intervention

Transradial approach (TRA) is the default access site for diagnostic angiography and intervention in many centers. Repeat ipsilateral radial artery access late after index procedure has been associated with failures. It is unknown whether early (≤30 days) and very early (<24 hours) repeat radial access is technically feasible and safe. Study population consisted of consecutive patients undergoing repeat (≥2) procedures within 30 days in a high-volume TRA center. Transradial access failure and resulting femoral approach was categorized as primary (no repeat attempt) or secondary (crossover). Timing of repeat access and reasons for failure were recorded. From November 2012 to December 2014, repeat catheterization by TRA was performed twice in 573 of 626 patients (92%) (median delay 4 [2 to 9] days), 3 times in 29 of 38 (76%) patients (median delay 15 [5 to 26] days), and 4 times in 1 patient within 21 days. When repeat catheterization occurred during the first 24 hours following the index procedure, 53% and 75% of patients had second and third procedures using the same ipsilateral radial artery, respectively. Primary radial failure occurred in 5.8% for second attempt and 13% for a third attempt, whereas crossovers were noted in 2.7% and 2.6%, respectively. Main reasons for failed re-access of ipsilateral radial artery were related either to operators reluctance to repeat attempt (primary failure) or to issues with puncture site (crossover). In a high-volume TRA center, patients who required repeat catheterization within 24 hours and within the first 30 days had the same radial artery re-accessed in the majority of cases.

The Transradial Approach and Antithrombotic Therapy: Rationale and Outcomes

This article reviews antithrombotic strategies for percutaneous coronary interventions according to the access site and the current evidence with the aim of limiting ischemic complications and preventing radial artery occlusion (RAO). Prevention of RAO should be part of the quality control of any radial program. The incidence of RAO postcatheterization and interventions should be determined initially using the echo-duplex and then frequently assessed using the more cost-effective pulse oximetry technique. Any evidence of higher risk of RAO should prompt internal analysis and multidisciplinary mechanisms to be put in place.