Lesion area progression in eyes with neovascular age-related macular degeneration treated using a proactive or a reactive regimen

BACKGROUND

To compare the change in lesion area over 4 years of follow-up in eyes with neovascular age-related macular degeneration (nAMD) treated with anti-vascular endothelial growth factor (VEGF) agents using either a proactive or a reactive regimen in routine clinical practice.

METHODS

This was a multicentre, retrospective comparative study. Totally, 202 treatment-naïve nAMD eyes (183 patients) received anti-VEGF therapy according to a proactive (n = 105) or reactive (n = 97) regimen. Eyes were included if they had received anti-VEGF injections for a period of at least 4 years and had baseline fluorescein angiography and annual optical coherence tomography (OCT) imaging. Two masked graders independently delineated the lesion's margins from serial OCT images and growth rates were calculated.

RESULTS

At baseline, the mean [SD] lesion area was 7.24 [5.6] mm2 in the proactive group and 6.33 [4.8] mm2 in the reactive group respectively (p = 0.22). After four years of treatment, the mean [SD] lesion area in the proactive group was 5.16 [4.5] mm2 showing a significant reduction compared to the baseline (p < 0.001). By contrast, the mean [SD] lesion area kept expanding in the reactive group during the follow-up and was 9.24 [6.0] mm2 at four years (p < 0.001). The lesion area at 4 years was significantly influenced by treatment regimen, baseline lesion area, and proportion of visits with active lesions.

CONCLUSIONS

Eyes treated using a reactive strategy had an increased lesion area and worse visual outcomes at 4 years. By contrast, the proactive regimen was associated with fewer recurrences of active disease, shrinkage of the lesion area, and better vision at four years.

Multimodal imaging of retinitis pigmentosa associated with Mainzer-Saldino syndrome

Background: Syndromic ciliopathies have been variably linked to different retinal dystrophies. However, to date, few reports have characterized by means of multimodal imaging the retinal degeneration occurring in Mainzer-Saldino syndrome (MSS).Methods: Two siblings with history of kidney disease and other systemic abnormalities presented at our eye clinic in October 2017 complaining of night blindness and visual loss. They underwent a complete ophthalmologic examination including visual acuity (VA) assessment, optical coherence tomography (OCT) and blue-light autofluorescence (BAF). A screen for inherited retinal dystrophies was performed in this occasion.Results: At baseline, the youngest sister had slightly worse VA (20/30 vs. 20/20-25 Snellen equivalents). On fundoscopy, both siblings had severe thinning of the peripheral retina, attenuation of retinal vessels and widespread accumulation of pigmented deposits. Significant outer retinal atrophy with apparent foveal sparing was appreciable on OCT.During the 3 years of follow-up, vision remained overall stable in both patients whereas minimal progression of outer retinal atrophy was observed by means of OCT. Genetic analysis revealed compound heterozygosity in the IFT172 gene. Based on these findings, a diagnosis of retinitis pigmentosa (RP) associated with MSS was formulated.Conclusions: Our report describes the cases of two siblings affected by retinitis pigmentosa associated with MSS. Although both carrying the same mutations and a severe RP phenotype, the youngest sister had slightly more advanced retinal degeneration highlighting the remarkable variability related to the IFT172 retinopathy.

Ultrabiomicroscopy Anterior Segment Evaluation of Ocular Contusive Trauma Caused by Pressurized Bottled Drink Caps: A Case Report

We report the case of a patient presented to the emergency department because of a contusive trauma from a pressurized bottled drink cap. During the visit, the patient indicated that he had been hit in his left eye by a cork while he was opening a sparkling wine bottle. He underwent a total ophthalmology examination. He had an important reduction of visual acuity, corneal swelling, Descemet's folds, and hyphema. Therefore, we decided to perform ultrabiomicroscopy (UBM) of the anterior segment to study the endothelial damage and Descemet's membrane. UBM images confirmed the direct biomicroscopy, highlighting the damaged location.

Ocriplasmin in the Treatment of Vitreomacular Traction in a Patient with Central Retinal Vein Occlusion: A Case Report

Aim

To investigate the efficacy of intravitreal injection of ocriplasmin (JETREA®) in the treatment of vitreomacular traction (VMT).

Materials and Methods

An 81-year-old man with VMT associated with central retinal vein occlusion in his left eye, was treated with a single intravitreal injection of ocriplasmin (25 μg). Best corrected visual acuity (BCVA), ocular fundus, and optical coherence tomography were examined before and after treatment.

Results

Complete release of VMT produced a reduction of central macular thickness, ranging from 459 to 141 μm. BCVA remained stable.

Discussion and Conclusions

The use of ocriplasmin was effective in the treatment of VMT. Ocriplasmin represents a valid alternative to conventional pars plana vitrectomy.

Late results of isolated mitral annuloplasty for "functional" ischemic mitral insufficiency

BACKGROUND

Repair of functional ischemic mitral regurgitation (MR) due to annular deformity and leaflet restriction remains a challenge for the surgeon and lacks well-documented outcomes. We investigated outcomes in the treatment of functional ischemic MR corrected by annuloplasty techniques alone.

METHODS

From May 1980 to July 1999, 174 patients underwent repair for functional ischemic mitral insufficiency with annuloplasty alone (128 ring annuloplasty; 46 suture annuloplasty). Acute insufficiency was present in 25 (14.4%). Concomitant procedures included CABG (n = 152; 87.4%). Patients were studied longitudinally with annual follow-up and echocardiograms.

RESULTS

Overall hospital mortality was 17.8% and was increased by NYHA Class 4 (23.8% vs. 8.7%; p = 0.011), diabetes (25.0% vs. 13.6%; p = 0.059), and chronic mitral insufficiency (16.4% vs. 8.0%; p = 0.070). Multivariate analysis revealed age (beta = 0.099; p = 0.049) and ejection fraction < 30% (beta = 1.260; p = 0.097) as significant predictors of hospital death. Mean postoperative mitral insufficiency was 0.84 +/- 0.86 (scale of 0-4). NYHA Class 4 (beta = 2.33; p = 0.034) and simple suture annuloplasty (beta = 2.08; p = 0.07) were associated with increased risk of late cardiac death. Cumulative incidence of mitral reoperation was 7.7% at 5 years. At follow-up, 89.7% of patients were in NYHA Class 1 or 2 with 83.4% having none or only mild mitral insufficiency.

CONCLUSIONS

Ring annuloplasty is associated with a survival benefit when compared to simple suture repair in ischemic patients who require annuloplasty alone to correct the MR. Mitral reconstruction with a ring annuloplasty offers durable results in this homogeneous subset of functional ischemic MR patients. Ischemic mitral insufficiency is associated with significant late mortality.

Ischemic mitral valve reconstruction and replacement: comparison of long-term survival and complications

OBJECTIVE

This study reviews the 223 consecutive mitral valve operations for ischemic mitral insufficiency performed at New York University Medical Center between January 1976 and January 1996. The results for mitral valve reconstruction are compared with those for prosthetic mitral valve replacement.

METHODS

From January 1976 to January 1996, 223 patients with ischemic mitral insufficiency underwent mitral valve reconstruction (n = 152) or prosthetic mitral valve replacement (n = 71). Coronary artery bypass grafting was performed in 89% of cases of mitral reconstruction and 80% of cases of prosthetic replacement. In the group undergoing reconstruction, 77% had valvuloplasty with a ring annuloplasty and 23% had valvuloplasty with suture annuloplasty. In the group undergoing prosthetic replacement, 82% of patients received bioprostheses and 18% received mechanical prostheses.

RESULTS

Follow-up was 93% complete (median 14.6 mo, range 0-219 mo). Thirty-day mortality was 10% for mitral reconstruction and 20% for prosthetic replacement. The short-term mortality was higher among patients in New York Heart Association functional class IV than among those in classes I to III (odds ratio 5.75, confidence interval 1.25-26.5) and was reduced among patients with angina relative to those without angina (odds ratio 0.26, confidence interval 0.05-1.2). The 30-day death or complication rate was similarly elevated among patients in functional class IV (odds ratio 5.53; confidence interval 1.23-25.04). Patients with mitral valve reconstruction had lower short-term complication or death rates than did patients with prosthetic valve replacement (odds ratio 0.43, confidence interval 0.20-0.90). Eighty-two percent of patients with mitral valve reconstruction had no insufficiency or only trace insufficiency during the long-term follow-up period. Five-year complication-free survivals were 64% (confidence interval 54%-74%) for patients undergoing mitral valve reconstruction and 47% (confidence interval 33%-60%) for patients undergoing prosthetic valve replacement. Results of a series of statistical analyses suggest that outcome was linked primarily to preoperative New York Heart Association functional class.

CONCLUSIONS

Initial mortalities were similar among patients undergoing prosthetic replacement and valve reconstruction. Poor outcome was primarily related to preexisting comorbidities. Patients undergoing valve reconstruction had fewer valve-related complications. Valve reconstruction resulted in excellent durability and freedom from complications. These findings suggest that mitral valve reconstruction should be considered for appropriate patients with ischemic mitral insufficiency.

Assisted venous drainage presents the risk of undetected air microembolism

OBJECTIVES

The proliferation of minimally invasive cardiac surgery has increased dependence on augmented venous return techniques for cardiopulmonary bypass. Such augmented techniques have the potential to introduce venous air emboli, which can pass to the patient. We examined the potential for the transmission of air emboli with different augmented venous return techniques.

METHODS

In vitro bypass systems with augmented venous drainage were created with either kinetically augmented or vacuum-augmented venous return. Roller or centrifugal pumps were used for arterial perfusion in combination with a hollow fiber oxygenator and a 40-micrometer arterial filter. Air was introduced into the venous line via an open 25-gauge needle. Test conditions involved varying the amount of negative venous pressure, the augmented venous return technique, and the arterial pump type. Measurements were recorded at the following sites: pre-arterial pump, post-arterial pump, post-oxygenator, and patient side.

RESULTS

Kinetically augmented venous return quickly filled the centrifugal venous pump with macrobubbles requiring continuous manual clearing; a steady state to test for air embolism could not be achieved. Vacuum-augmented venous return handled the air leakage satisfactorily and microbubbles per minute were measured. Higher vacuum pressures resulted in delivery of significantly more microbubbles to the "patient" (P <.001). The use of an arterial centrifugal pump was associated with fewer microbubbles (P =.02).

CONCLUSIONS

Some augmented venous return configurations permit a significant quantity of microbubbles to reach the patient despite filtration. A centrifugal pump has air-handling disadvantages when used for kinetic venous drainage, but when used as an arterial pump in combination with vacuum-assisted venous drainage it aids in clearing air emboli.

Selective approach to descending thoracic aortic aneurysm repair: a ten-year experience

BACKGROUND

A variety of surgical techniques has been developed to attempt to minimize the risk of paraplegia after descending thoracic aortic aneurysm repair. This study reviews our institutional experience with several basic techniques over a period of 10 years.

METHODS

Seventy-eight consecutive patients underwent repair of descending thoracic aortic aneurysm between 1983 and 1993. Two basic repair strategies were used: (1) distal perfusion with somatosensory evoked potential monitoring (n = 54) and (2) cross-clamping (n = 24), alone (n = 6) or with controlled distal exsanguination (n = 18).

RESULTS

The operative mortality rate was 6.5% for elective repair (n = 62), 25.0% for emergent repair (n = 16), and 10.3% overall. Univariate predictors of increased operative risk were emergent operation, rupture, and shock. Neither death nor paraplegia was related to the operative technique used. The incidence of paraplegia was 3.7% in perfused patients and 4.2% in cross-clamping patients (p > 0.05). Paraplegia did not occur after any elective operation (zero of 62) but occurred in 18.6% of emergent cases (p < 0.01). In perfused patients, paraplegia did not occur when the distal pressure was maintained above 55 mm Hg and somatosensory evoked potentials remained intact. When somatosensory evoked potentials were lost (n = 7) in perfused patients, the operative technique was altered successfully in 5 patients, whereas in 2 patients (28.6%), paraplegia developed.

CONCLUSIONS

The risks associated with elective descending thoracic aortic aneurysm repair were extremely low using an operative strategy that was flexible but skewed toward perfusion with somatosensory evoked potential monitoring. In perfused patients, paraplegia did not occur when distal pressure was greater than 55 mm Hg and somatosensory evoked potentials remained intact. However, the risks of death and paraplegia were primarily related to emergent presentation, not to technique, and the technique of cross clamping with controlled distal exsanguination was found to be valuable in unstable or in anatomically complicated subsets of patients.

Effects of graded reductions in internal mammary artery bypass flow on left ventricular function

This study investigated the controversial relationship between reduction in internal mammary artery (IMA) graft blood flow and left ventricular function in a canine model. Ten dogs underwent IMA grafting to the left anterior descending coronary artery. The left anterior descending coronary artery proximal to the IMA graft was intermittently occluded while IMA flow was mechanically controlled for 5-minute periods to produce four IMA flow groups representing 100%, 75%, 50%, and 25% of unoccluded IMA graft blood flow. As a control, the left ventricle was reperfused with native left anterior descending coronary artery flow between each IMA graft flow period to allow return to steady state. Sonomicrometry was used to obtain stroke work end-diastolic dimension relationship data for regional and global left ventricular function for each of the four flow groups. The global pressure recruitable work area relationship showed a significant rightward shift at 25% of unoccluded IMA flow, whereas the regional pressure recruitable work area relationship shifted at 50% of unoccluded IMA flow. Thus, regional myocardial function is more sensitive to reductions in IMA blood flow than is global left ventricular performance, and there is a significant IMA flow reserve for global left ventricular function.

Direct-current injury from external pacemaker results in tissue electrolysis

In two patients undergoing open heart operations, electrochemical burns developed at the sites of connection to an external pacing system. Investigation revealed that failure of the pacing generator caused a small, continuous, direct current to pass through the patients, resulting in electrolysis at the sites of contact with the pacing and grounding wires. This electrolytic reaction was recreated in a mock pacing system and resulted in tissue injury and disintegration of the pacing wire. Guidelines to help recognize and prevent this complication are presented.

Cardiac valve replacement in patients infected with the human immunodeficiency virus

Major surgical procedures, especially when performed under general anesthesia, can depress immunological parameters measured in vitro. Therefore concern has been expressed that operation might have an adverse effect on the immune status of individuals infected with the human immunodeficiency virus (HIV). Four HIV-positive patients without symptoms of HIV disease underwent cardiac valve replacement in consequence of infective endocarditis. After up to 15 months postoperatively, 3 patients are alive and well without signs of progressive immunodeficiency or recurrent endocarditis. One patient died of recurrent endocarditis without evidence of HIV-related disease on autopsy. Cardiac operation does not seem to accelerate HIV-related immunodeficiency.

Surgical implications of transesophageal echocardiography to grade the atheromatous aortic arch

Stroke is an especially serious complication of cardiopulmonary bypass with an incidence of 2% to 5%. This prospective study used transesophageal echocardiography (TEE) in 97 patients more than 65 years of age (mean age, 73 years) to identify those at high risk for aortic atheroemboli. The atheromatous disease of the aorta was graded by TEE: grade I = minimal intimal thickening (n = 29); II = extensive intimal thickening (n = 33); III = sessile atheroma (n = 15); IV = protruding atheroma (n = 10); V = mobile atheroma (n = 10). Clinical evaluation was also performed by intraoperative aortic palpation. Four patients who were graded as having normal aortas by palpation had intraoperative strokes. In contrast, 3 of these 4 patients were in grade V on TEE. The relationship of TEE to incidence of stroke was statistically significant (p less than 0.006), whereas there was no significant correlation between clinical grade and stroke incidence. Four of 10 TEE grade V patients were treated with hypothermic circulatory arrest and aortic arch debridement, and none suffered strokes. The other 6 patients were treated with standard techniques, and 3 had strokes. These results suggest that patients with mobile atheromatous disease are at high risk for embolic strokes that are not predicted by routine clinical evaluation. Selective use of circulatory arrest in the presence of TEE-detected mobile arch atheromas may reduce the risk of intraoperative stroke.

Successful treatment of postpartum shock caused by amniotic fluid embolism with cardiopulmonary bypass and pulmonary artery thromboembolectomy

We report the successful treatment of a moribund patient as a result of amniotic fluid embolism with cardiopulmonary bypass and open pulmonary artery thromboembolectomy. Review of the literature indicates that this is the first reported case of treatment of amniotic fluid embolism with cardiopulmonary bypass and pulmonary thromboembolectomy.

Surgical treatment for aneurysm of aberrant subclavian artery based on a case report and a review of the literature

Experiences with the recent successful treatment of a patient with an aneurysm arising from an aberrant subclavian artery are described. The reported experiences with surgical treatment by others were reviewed in detail: Only 16 such patients were found, with a surprising frequency of serious complications. These data led to the conclusion that a two-stage approach, through right cervical and left thoracotomy incisions, seems to offer the ideal method of treatment for this unusual problem.

The effect of pericardial insulation on hypothermic phrenic nerve injury during open-heart surgery

Phrenic nerve injury was evaluated prospectively in 133 patients undergoing open-heart surgery using iced saline slush for topical hypothermia. In the control group of 70 patients no attempt was made to shield the phrenic nerves from direct exposure to ice. Phrenic nerve damage occurred in 73% of these patients, as assessed by persistent diaphragm paralysis evident on inspiratory chest roentgenogram. In 2 patients the paralysis was bilateral. In the second group of 63 patients a pericardial insulation pad was used to prevent contact of the iced slush to the phrenic nerve. Diaphragm paralysis was observed in 17% of these patients. This difference was highly significant (p less than .001). Diaphragm paralysis in the control group was clinically significant; life-threatening respiratory complications developed in 7 patients (14%), frequently resulting in multiple reintubations, tracheostomy, and prolonged mechanical ventilation. In addition, 4 patients with phrenic nerve injury exhibited a clinical syndrome consistent with gastric ileus, which may possibly represent hypothermic injury to the thoracic vagi. The likelihood of phrenic nerve injury when iced saline slush is used for topical myocardial cooling and the possibility of developing serious respiratory disability would support the routine use of pericardial insulation when this method of hypothermia is used.

The value of computed tomography in postoperative pneumothorax following open-heart surgery

Two patients with postoperative pneumothorax following open-heart surgery are described. The diagnostic usefulness of computed tomography and chest roentgenogram in this complication is discussed.

The role of the activated clotting time in heparin administration and neutralization for cardiopulmonary bypass

Precise guidelines for heparin administration and neutralization during cardiopulmonary bypass (CPB) are not established. To a large extent, the uncertainty originates from a disparity between the heparin dosage, the plasma heparin concentration, and the clinical heparin effect. We investigated these relationships in 44 consecutive patients at New York University Medical Center. Following serial loading doses of heparin (2 and 4 mg/kg) there was a wide variation in both the measured clinical heparin effect (activated clotting time--ACT) and the plasma heparin concentration. When the Act was compared to the heparin concentration, there was no linear relationship noted after heparin does commonly employed for CPB. The calculated heparin sensitivity varied over a fourfold range and was not related to the baseline antithrombin III activity. At the completion of CPB, heparin was neutralized with a 2 mg/kg protamine dose regardless of the total heparin dose. Heparin levels fell from 4.17 +/- 1.29 to 0.19 +/- 0.20 units/ml. Additional protamine was given to 49% of the patients as the ACT had not returned to pre-heparin levels. The total protamine dose rarely exceeded 3 mg/kg. This technique resulted in the administration of 30% to 50% less protamine than predicted by other commonly used protocols. In the subsequent 4 hours after protamine administration, heparin levels remained insignificant. Mild heparin rebound was found in two patients (4.5%) but was not associated with excessive bleeding. Following bypass a comparison of heparin levels and ACTs demonstrated the ACT to be a poor indicator of residual circulating heparin. These data show: (1) that neither the heparin dosage nor the plasma heparin concentration can accurately predict the magnitude of the clinical heparin effect in patients undergoing CPB and emphasize the importance of the ACT as the best available measurement of safe anticoagulation, (2) heparin "rebound" was not clinically significant, and (3) heparin was neutralized with 2 to 3 mg/kg protamine in virtually all patients, regardless of the total heparin dose.

Cultivation of mycoplasmas in a modified tissue culture medium

A new medium, which contained a chemically defined tissue culture base ("medium 199"), was developed for the cultivation of mycoplasmas. When supplemented with albumin, glucose, serum, and yeast extract, the new medium adequately supported the growth of Mycoplasma and Acholeplasma species.