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Gaudino M, Dangas GD, Angiolillo DJ, Brodt J, Chikwe J, DeAnda A, Hameed I, Rodgers ML, Sandner S, Sun LY, Yong CM. Considerations on the Management of Acute Postoperative Ischemia After Cardiac Surgery: A Scientific Statement From the American Heart Association. Circulation 2023; 148:442-454. [PMID: 37345559 DOI: 10.1161/cir.0000000000001154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/23/2023]
Abstract
Acute postoperative myocardial ischemia (PMI) after cardiac surgery is an infrequent event that can evolve rapidly and become a potentially life-threatening complication. Multiple factors are associated with acute PMI after cardiac surgery and may vary by the type of surgical procedure performed. Although the criteria defining nonprocedural myocardial ischemia are well established, there are no universally accepted criteria for the diagnosis of acute PMI. In addition, current evidence on the management of acute PMI after cardiac surgery is sparse and generally of low methodological quality. Once acute PMI is suspected, prompt diagnosis and treatment are imperative, and options range from conservative strategies to percutaneous coronary intervention and redo coronary artery bypass grafting. In this document, a multidisciplinary group including experts in cardiac surgery, cardiology, anesthesiology, and postoperative care summarizes the existing evidence on diagnosis and treatment of acute PMI and provides clinical guidance.
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Robinson NB, Sef D, Gaudino M, Taggart DP. Postcardiac surgery myocardial ischemia: Why, when, and how to intervene. J Thorac Cardiovasc Surg 2023; 165:687-695. [PMID: 34556355 DOI: 10.1016/j.jtcvs.2021.05.052] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Revised: 04/21/2021] [Accepted: 05/30/2021] [Indexed: 01/18/2023]
Affiliation(s)
- N Bryce Robinson
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY
| | - Davorin Sef
- Department of Cardiac Surgery, Barts Heart Centre, Barts Health NHS Trust, London, United Kingdom
| | - Mario Gaudino
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY
| | - David P Taggart
- Nuffield Department of Surgical Sciences, John Radcliffe Hospital, University of Oxford, Oxford, United Kingdom.
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Quach HT, Hou Z, Bellis RY, Saini JK, Amador-Molina A, Adusumilli PS, Xiong Y. Next-generation immunotherapy for solid tumors: combination immunotherapy with crosstalk blockade of TGFβ and PD-1/PD-L1. Expert Opin Investig Drugs 2022; 31:1187-1202. [PMID: 36448335 PMCID: PMC10085570 DOI: 10.1080/13543784.2022.2152323] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Accepted: 11/23/2022] [Indexed: 12/05/2022]
Abstract
INTRODUCTION In solid tumor immunotherapy, less than 20% of patients respond to anti-programmed cell death 1 (PD-1)/programmed cell death 1 ligand 1 (PD-L1) agents. The role of transforming growth factor β (TGFβ) in diverse immunity is well-established; however, systemic blockade of TGFβ is associated with toxicity. Accumulating evidence suggests the role of crosstalk between TGFβ and PD-1/PD-L1 pathways. AREAS COVERED We focus on TGFβ and PD-1/PD-L1 signaling pathway crosstalk and the determinant role of TGFβ in the resistance of immune checkpoint blockade. We provide the rationale for combination anti-TGFβ and anti-PD-1/PD-L1 therapies for solid tumors and discuss the current status of dual blockade therapy in preclinical and clinical studies. EXPERT OPINION The heterogeneity of tumor microenvironment across solid tumors complicates patient selection, treatment regimens, and response and toxicity assessment for investigation of dual blockade agents. However, clinical knowledge from single-agent studies provides infrastructure to translate dual blockade therapies. Dual TGFβ and PD-1/PD-L1 blockade results in enhanced T-cell infiltration into tumors, a primary requisite for successful immunotherapy. A bifunctional fusion protein specifically targets TGFβ in the tumor microenvironment, avoiding systemic toxicity, and prevents interaction of PD-1+ cytotoxic cells with PD-L1+ tumor cells.
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Affiliation(s)
- Hue Tu Quach
- Thoracic Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY, 10065, USA
| | - Zhaohua Hou
- Thoracic Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY, 10065, USA
| | - Rebecca Y. Bellis
- Thoracic Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY, 10065, USA
| | - Jasmeen K. Saini
- Thoracic Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY, 10065, USA
| | - Alfredo Amador-Molina
- Thoracic Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY, 10065, USA
| | - Prasad S. Adusumilli
- Thoracic Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY, 10065, USA
- Director, Mesothelioma Program; Head, Center for Cell Engineering, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY, 10065, USA
| | - Yuquan Xiong
- Thoracic Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY, 10065, USA
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Gavrielatos G, Buttner HJ, Lehane C, Neumann FJ. Complex interventional procedures for the management of early postoperative left main coronary artery embolism after bioprosthetic aortic valve insertion. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2010; 12:68.e1-4. [PMID: 21241978 DOI: 10.1016/j.carrev.2010.05.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2010] [Revised: 05/06/2010] [Accepted: 05/20/2010] [Indexed: 11/28/2022]
Abstract
The incidence of calcified debris coronary embolism after aortic valve replacement (AVR) with a bioprosthesis is a rare but potentially life-threatening condition. We sought to describe a case of immediate postoperative left main coronary artery embolism, resulting to severe acute coronary syndrome and cardiogenic shock, after aortic valve surgery due to severe aortic valve stenosis, with the use of bioprosthesis. Complex interventional procedures and possible diagnostic challenges are being described.
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Baxt WG. Sudden death from acute thromboembolic occlusion of the left coronary ostium. Am J Emerg Med 2010; 27:1172.e1-3. [PMID: 19931785 DOI: 10.1016/j.ajem.2009.01.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2009] [Accepted: 01/09/2009] [Indexed: 11/30/2022] Open
Abstract
The patient was a 55-year-old woman who experienced anterior chest pain after drinking a cup of coffee. The patient had no risk factor for cardiac disease other than mild non- insulin-dependent diabetes mellitus. The patient did have a history of asthma and was on a steroid taper, taking 20 mg of prednisone daily. The patient's physical examination results were within normal limits. Her laboratory data were normal, except for a glucose level of 499 mg/dl and a urinalysis revealing more than 4+ glucose with large ketones. Venous blood gas pH was 7.36, and troponin I, creatinine kinase-MB, electrocardiogram, and chest film were normal. The patient was admitted to rule out acute coronary syndrome. During the placement into an inpatient bed, the patient sustained a cardiac arrest with a narrow complex ventricular rhythm without pulse, from which she could not be resuscitated. The postmortem examination of the lungs revealed no evidence of thromboemboli. The coronary arteries revealed mild atherosclerosis. Examination of the aortic root revealed complete occlusion of the left coronary ostium by a large premortem nonorganized fresh thromboembolus, which was easily removed by passing a probe retrograde from the left main coronary artery (Fig. 1). Microscopically, there were also small thromboemboli in both the distal right and left coronary intramyocardial vessels. An extensive search of the heart and all major vessels was undertaken to identify the source of the possible thromboemboli, and none could be identified. A Medline search of the literature revealed no other similar case.
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Affiliation(s)
- William Gordon Baxt
- Department of Emergency Medicine, Ground Ravdin, Hospital of University of Pennsylvania, Philadelphia, PA 19104, USA.
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Chikazawa G, Nakano H, Nagata H, Tabuchi T. Huge thrombus growing on an aortic prosthetic valve detected in acute coronary syndrome. ACTA ACUST UNITED AC 2005; 53:386-8. [PMID: 16095241 DOI: 10.1007/s11748-005-0056-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
A 74-year-old woman with a history of aortic valve replacement (AVR) with a tilting prosthesis at the age of 59 was referred to our hospital with chest pain at rest. Following conservative treatment after admission, the laboratory findings demonstrated acute myocardial infarction. Although bilateral coronary arteries exhibited no significant stenosis and embolism on the emergency coronary angiogram, a huge mobile mass above the prosthetic valve was recognized on the aortography, computed tomography, and trans-esophageal echocardiography. Operative findings demonstrated that the huge mobile thrombus was growing from the sawing ring on the side of minor orifice and almost covered the ostium of the left coronary artery. Emergency re-AVR with 21 mm SJM HP valve was performed. This clinical course suggested that the acute coronary syndrome might be caused by the isolated thrombus on the aortic prosthetic valve without any insufficiency of prosthesis and embolic findings due to the thrombosed valve.
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Affiliation(s)
- Genta Chikazawa
- Department of Cardiovascular Surgery, Tokyo Medical University Kasumigaura Hospital, Ami-machi, Ibaraki, Japan
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