Research Spotlight

Lehman, L. L., J. C. Khoury, J. M. Taylor, S. Yeramaneni, H. Sucharew, K. Alwell, C. J. Moomaw, K. Peariso, M. Flaherty, P. Khatri, J. P. Broderick, B. M. Kissela and D. O. Kleindorfer (2018). “Pediatric Stroke Rates Over 17 Years: Report From a Population-Based Study.” J Child Neurol 33(7): 463-467.

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We previously published rates of pediatric stroke using our population-based Greater Cincinnati Northern Kentucky Stroke Study (GCNK) for periods July 1993-June 1994 and 1999. We report population-based rates from 2 additional study periods: 2005 and 2010. We identified all pediatric strokes for residents of the GCNK region that occurred in July 1, 1993-June 30, 1994, and calendar years 1999, 2005, and 2010. Stroke cases were ascertained by screening discharge ICD-9 codes, and verified by a physician. Pediatric stroke was defined as stroke in those <20 years of age. Stroke rates by study period, overall, by age and by race, were calculated. Eleven children died within 30 days, yielding an all-cause case fatality rate of 15.7% (95% confidence interval 1.1%, 26.4%) with 3 (27.3%) ischemic, 6 (54.5%) hemorrhagic, and 2 (18.2%) unknown stroke type. The pediatric stroke rate of 4.4 per 100 000 in the GCNK study region has not changed over 17 years.

Leal-Leyte, P., G. J. McKenna, R. M. Ruiz, T. L. Anthony, G. Saracino, T. Giuliano, G. B. Klintmalm and P. T. Kim (2018). “Eversion Bile Duct Anastomosis: A Safe Alternative for Bile Duct Size Discrepancy in Deceased Donor Liver Transplantation.” Liver Transpl. Apr 10. [Epub ahead of print].

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Introduction: Bile duct size discrepancy in liver transplantation may increase the risk of biliary complications. The aim of this study was to evaluate the safety and outcomes of the eversion bile duct anastomosis technique in deceased donor liver transplantation (DDLT) with duct to duct anastomosis. Methods: A total of 210 patients who received a DDLT with duct to duct anastomosis from 2012 to 2017 were divided into two groups: those who had eversion bile duct anastomosis (N=70) and standard bile duct anastomosis (N=140). Biliary complications rates were compared between the two groups. Results: There was no difference in the cumulative incidence of biliary strictures (P=0.20) and leaks (P=0.17) between the two groups. The biliary complication rate in the eversion group was 14.3% and 11.4% in the standard anastomosis group. All the biliary complications in the eversion group were managed with endoscopic stenting. A severe size mismatch (>/=3:1 ratio) was associated with a significantly higher incidence of biliary strictures (44.4%) compared to 2:1 ratio (8.2%), (P=0.002). Conclusion: The use of the eversion technique is a safe alternative for bile duct discrepancy in deceased donor liver transplantation; however, severe bile duct size mismatch may be a risk factor for biliary strictures with such technique.

Konda, V. J. A. and R. F. Souza (2018). “Biomarkers of Barrett’s Esophagus: From the Laboratory to Clinical Practice.” Dig Dis Sci. Apr 30. [Epub ahead of print].

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The currently recommended approach to managing cancer risk for patients with Barrett’s esophagus is endoscopic surveillance including a biopsy protocol to sample the esophageal tissue randomly to detect dysplasia. However, there are numerous limitations in this practice that rely on the histopathological grading of dysplasia alone to make clinical decisions. The availability of in silico models demonstrating the potential cost-effectiveness of biomarker-based stratification has increased interest in finding a clinically relevant “Barrett’s biomarker.” The success of endoscopic eradication therapy in preventing neoplastic progression of dysplastic Barrett’s esophagus has promoted the desire to stratify non-dysplastic Barrett’s esophagus to those with “high risk” that may benefit from endotherapy. Furthermore, on the other end of the spectrum, there is interest in searching for a “low risk” marker that may identify those that would not likely benefit from endoscopy screening or surveillance. This review highlights recent data from the genomics (r)evolution revealing new genetic biomarkers of susceptibility to the development of Barrett’s esophagus and novel pathways for its neoplastic progression, addresses the development of new modes of tissue sampling and imaging to detect early neoplasia in Barrett’s esophagus, and discusses current progress in moving biomarkers from the laboratory into clinical practice in the era of precision medicine.

Khoynezhad, A., J. DelaRosa, M. R. Moon, W. T. Brinkman, R. B. Thompson, N. D. Desai, S. C. Malaisrie, L. N. Girardi, J. E. Bavaria and T. B. Reece (2018). “Facilitating Hemostasis After Proximal Aortic Surgery: Results of The PROTECT Trial.” Ann Thorac Surg 105(5): 1357-1364.

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BACKGROUND: This study intended to evaluate the safety and hemostatic efficacy of a novel vascular sealant (Tridyne; Neomend, Inc, Irvine, CA) compared with an accepted adjunctive hemostatic agent applied to aortotomy and sutures lines in cardiovascular operations. METHODS: Patients undergoing aortic valve replacement, ascending aortic replacement, or aortic root replacement were randomly assigned 2:1 to Tridyne (n = 107) or Gelfoam Plus (Baxter Healthcare Corp, Hayward, CA) (n = 51). These groups were similar with regard to age, sex, race, medical history, duration of bypass and cross-clamping, and number of suture lines treated. Suture lines were treated after confirmation of some leakage but before formal removal of the clamp. RESULTS: The median bleeding time was significantly lower for Tridyne versus Gelfoam Plus (0 versus 10.0 minutes, p < 0.0001). Immediate hemostasis was achieved in 59.4% of the Tridyne group versus 16.0% of Gelfoam Plus group (p < 0.0001). A significantly greater proportion of patients in the Tridyne group achieved successful hemostasis at the aortic suture line than patients in the Gelfoam Plus group (85.7% versus 40.0%, p < 0.0001). The Clinical Events Committee adjudicated 7 patients with possible device-related serious adverse events: 3 patients (2.9%) in the Tridyne group and 4 patients (8.2%) in the Gelfoam Plus group (p = 0.2097). CONCLUSIONS: Tridyne was safe and effective when used as an adjunct to conventional hemostasis to treat high-pressure vessels in patients who receive anticoagulation agents, in reducing time to hemostasis, and in promoting both immediate and persistent hemostasis.

Jabbour, R. J., A. Tanaka, A. Finkelstein, M. Mack, C. Tamburino, N. Van Mieghem, O. de Backer, L. Testa, P. Gatto, P. Purita, Z. Rahhab, V. Veulemans, A. Stundl, M. Barbanti, R. Nerla, J. M. Sinning, D. Dvir, G. Tarantini, M. Szerlip, W. Scholtz, S. Scholtz, D. Tchetche, F. Castriota, C. Butter, L. Sondergaard, M. Abdel-Wahab, H. Sievert, O. Alfieri, J. Webb, J. Rodes-Cabau, A. Colombo and A. Latib (2018). “Delayed Coronary Obstruction After Transcatheter Aortic Valve Replacement.” J Am Coll Cardiol 71(14): 1513-1524.

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BACKGROUND: Delayed coronary obstruction (DCO) is an uncommon and barely reported complication following transcatheter aortic valve replacement (TAVR). OBJECTIVES: The aim of this study was to describe the incidence and pathophysiological features of DCO after TAVR, obtained from a large international multicenter registry. METHODS: Data were retrospectively collected from an international multicenter registry consisting of 18 centers between November 2005 and December 2016. RESULTS: During the study period, 38 DCO (incidence 0.22%) cases were identified from a total of 17,092 TAVR procedures. DCO occurred more commonly after valve-in-valve procedures (0.89% vs. 0.18%; p < 0.001) and if self-expandable valves were used during the index procedure (0.36% vs. 0.11% balloon expandable; p < 0.01). DCO was most likely to occur /=60 days. The most frequent presentation was cardiac arrest (31.6%; n = 12), followed by ST-segment elevation myocardial infarction (23.7%; n = 9). The left coronary artery was obstructed in most cases (92.1%; n = 35). Percutaneous coronary intervention was attempted in the majority of cases (74.3% left main; 60% right coronary), and stent implantation was successful in 68.8%. The overall in-hospital death rate was 50% (n = 19), and was higher if DCO occurred