Smaller Body Surface Area Research Articles

Clinical outcome in patients with end-stage heart failure who underwent continuous-flow left ventricular assist devices in a single center.

Background/AimsThe continuous flow left ventricular assist device (cf-LVAD) has improved the survival of chronic end-stage heart failure (HF) patients. Here we describe our clinical experience of the initial 50 LVAD patients from a single center.MethodsA total of 50 patients underwent LVAD implantation as bridge to transplantation (BTT; n = 28, 56%), bridge to candidacy (BTC; n = 2, 4%), or as destination therapy (DT; n = 20, 40%) from 2012 to 2019. Pre-implant characteristics and clinical outcomes were compared between BTT/BTC and DT.ResultsThe median age of patients was 67 years (range, 59 to 73). Men were more likely to receive LVAD (76% vs. 24%) than women. DT patients were older, had smaller body surface area, and worse laboratory profiles than BTT/BTC patients. There was no in-hospital mortality. During an average of 14 months (range, 8 to 23), the all-cause mortality was 22%. The first-year survival was 86 and 90% in BTT/BTC and DT groups, respectively. Hemorrhagic stroke was the most common cause (27%) of death. In the BTT/BTC group, 22 patients successfully underwent heart transplantation during median duration of 10 months (range, 7 to 14). The most common post-LVAD complication during the first year of LVAD implantation was major bleeding (44%). A significant proportion (76%) of patients experienced rehospitalization with gastrointestinal bleeding as the most common cause.ConclusionsWe describe short-term clinical outcome of LVAD patients from a single center for the first time in Korea. With the newer generation LVAD and a dedicated team approach, improved clinical outcomes of LVAD for end-stage HF are expected.

Outcomes in patients with smaller body surface area after HeartMate 3 left ventricular assist device implantation.

Due to anatomic and physiologic concerns, prior generations of the left ventricular assist devices (LVAD) have frequently been denied to patients with small body size. However, outcomes in patients with small body surface area (BSA) following HeartMate 3 (HM3) LVAD implantation remain relatively unknown. A cohort of 220 patients implanted at a single center was divided into two groups: BSA ≤1.8 m2 (small BSA, n=37) and BSA >1.8 m2 (large BSA, n=183). We investigated baseline characteristics and clinical outcomes including survival and incidence of adverse events. Small BSA patients were older (60 vs. 57years), more likely female (60% vs. 20%), had a lower body mass index (24 vs. 32kg/m2 ), lower incidence of diabetes (32% vs. 51%), history of stroke (5% vs. 19%), and left ventricular thrombus (0% vs. 11%). They had smaller left ventricular end diastolic diameter (64.8 vs. 69.3mm). Pump speed and pump flows at discharge were lower in the small BSA group. Survival at 1year and 2years was 86% versus 87% and 86% versus 79% for small versus large BSA groups (p=0.408), respectively. The rates of adverse events were similar between groups and there were no cases of confirmed pump thrombosis. The incidence of readmissions for low flow alarms was higher in the small BSA group (0.55 vs. 0.24 EPPY). These findings demonstrate comparable outcomes in patients with small body size and suggest that this parameter should not be an exclusion criterion on patients who are otherwise candidates for HM3 LVAD implantation.

Body surface area may explain sex differences in findings from the oral glucose tolerance test among subjects with normal glucose tolerance

Background and aimsCurrent guidelines on prediabetes and diabetes (T2D) recommend to regularly perform an oral glucose tolerance test (OGTT) on subjects at risk of T2D. However, it is not known why women tend to have relatively higher 2-h post-load plasma (2hPG) glucose concentrations during OGTT than men. The aim of the present study is to investigate if there are sex differences in fasting plasma glucose (FPG) and 2hPG concentrations in relation to body size in apparently healthy non-diabetic subjects with normal glucose tolerance. We hypothesized that sex differences in glucose tolerance are physiological and related to different body surface area (BSA) in men and women. Methods and resultsA 2-h 75 g OGTT was performed on 2010 subjects aged 45–70 years. Their BSA was calculated using the Mosteller formula. Men and women were separately divided into five BSA levels. Within the normal 2hPG range, women had higher mean 2hPG concentrations during the OGTT than men in all BSA levels estimated by sex-standardized BSA (p for linearity < 0.001). BSA adjusted for age, waist circumference, leisure-time physical activity, and smoking, showed an inverse association with 2hPG concentration in both sexes. Mean FPG concentrations were higher in men than in women. ConclusionsBody size has a negative inverse association with 2hPG concentration in an OGTT even within a physiological plasma glucose range. This may cause underestimation of glucose disorders in individuals with larger BSA and overestimation in individuals with smaller BSA when using an OGTT.

Clinical phenotypes and prognosis of thyrotoxic heart failure and cardiomyopathy in patients hospitalized for acute heart failure.

BackgroundWe sought to examine clinical characteristics and outcomes in patients hospitalized for acute heart failure (HF) and thyrotoxicosis.MethodsPatients with thyrotoxic HF were compared with age and gender‐matched patients hospitalized for acute HF (controls). Thyr‐HF was defined by the Framingham criteria for HF and clinical hyperthyroidism. Thyrotoxic cardiomyopathy was defined as left ventricular ejection fraction (LVEF) < 55%.ResultsOf 11 109 consecutive patients hospitalized for acute HF between 1 January 2002 and 1 January 2017, 92 patients (0.8%) had thyrotoxic HF. Clinical and echocardiographic data were available in 87 patients (age 51 ± 16 years; 74% female), representing the study population. Compared with controls, patients with Thyr‐HF had a smaller body surface area (BSA), a higher LVEF, a lower LV end‐diastolic diameter, a higher tricuspid annular plane systolic excursion (TAPSE), higher blood pressure, higher heart rate, and were more likely to have right‐sided HF at presentation (P < 0.01 for all). The survival rate among patients with thyrotoxic HF was higher than the control group (HR: 4.3; 95% CI: 2.1–9.5). Fifty‐eight percent of patients with thyrotoxic HF had thyrotoxic cardiomyopathy. In multivariate analysis, TAPSE (OR = 46; 95% CI: 1.04–2008.20; P = 0.047) and leukocytosis (OR = 16; 95% CI 1.01–259.39; P = 0.049) correlated with thyrotoxic cardiomyopathy. LV recovery was observed in 69% of these patients.ConclusionsThyrotoxic HF was uncommon among patients hospitalized for acute HF. However, after definitive therapy, these patients had a more favourable prognosis than those hospitalized for acute HF without thyrotoxic HF. Clinical phenotypes of thyrotoxic HF include small BSA, middle‐aged female, HF‐pEF, and right‐sided HF. Thyrotoxic cardiomyopathy affected over half of the patients with thyrotoxic HF with a two‐third recovery rate.

Pitfalls in comparison of coronary artery measurements of Indian population with different geographical area studies

IntroductionCoronary artery disease (CAD) is the most common cause of morbidity and mortality especially in the developing countries. Coronary artery measurements (CAM) are the most important factor affecting the procedure and outcome of coronary angioplasty (PCI) as well as coronary by-pass operations (CABG). In this study, we aimed to establish a database for the normal CAM as well as for gender difference among the Indian population using quantitative coronary angiography (QCA) with an objective of assessing normal coronary vessel morphology of patients with normal coronaries. Materials and methodsFour thousand angiograms from patients of Indian origin were studied prospectively after procuring the sanction for the same from the ethical committee of the pre-selected hospitals of four states in India. Informed consents were obtained. Post CABG, post PCI patients and patient being diabetic for ≥5 years were also excluded from the study. ResultsTen segments from right and left coronary arteries were taken for diameter measurements. These coronary diameters were indexed to body surface area (BSA) (mean diameter mm/m2 BSA). Among, 4000 patients, 933(23.3%) [M:F-521:412] had normal coronaries and 3067 (76.7%) were diseased. Discussion and conclusionThe dimensions of the coronary artery segments of Indians were smaller (in BSA indexed and non-indexed data), compared to studies from other continents which can be due to their smaller BSA.

HeartMate-III Implantation in Small Body Surface Area, a Case Series

Purpose The use of Durable Left Ventricular assist devices (LVAD) as treatment option is still evolving in pediatric patients with a falling heart refractory to medical therapy. Many challenges facing clinicians dealing with patients including small body surface area that limits implantation of the intracorporeal devices. With advancements in technology and device engineering, a newer LVAD generation provides a smaller pump size that could facilitate intrapericardial implantation. In this case series we report a successfully implanted HeartMate-III (HMIII) LVAD in four heart failure patients with small body surface area. Methods Between 2017-2019, 4 pediatric age group (11-18 yrs old) with dilated cardiomyopathy (DCM) underwent HMIII implantation. 1st and 2nd patient BSA of 1.2m2, 3rd and 4th patient BSA of 1.6 and 1.7m2, respectively. Results Two patients were transplanted, two other are ongoing on HMIII therapy and all survived. No major complications post HMIII implantation was observed. Conclusion Patients with small body surface area can safely, receive durable LVAD devices depending on their disease etiology. DCM with enlarged pericardium permits implantation.

Pulmonary valve replacement following repair of tetralogy of Fallot: comparison of outcomes between bio- and mechanical prostheses.

The aims of this study were to evaluate and compare the outcomes after pulmonary valve replacement (PVR) with a mechanical prosthesis (MP) and a bioprosthesis (BP). From 2004 through 2017, a total of 131 patients, who had already been repaired for tetralogy or Fallot or its variants, underwent their first PVR with an MP or a BP. Outcomes of interests were prosthesis failure (stenosis >3.5 m/s, regurgitation >mild or infective endocarditis) and reintervention. The median age at PVR was 19 years. BP and MP were used in 88 (67.2%) and 43 (32.8%) patients, respectively. The median follow-up duration was 7.4 years, and the 10-year survival rate was 96.4%. Risk factors for prosthesis failure were smaller body surface area [hazard ratio (HR) 0.23 per 1 m2, P = 0.047] and smaller prosthesis size (HR 0.73 per 1 mm, P = 0.039). Risk factors for prosthesis reintervention were smaller body surface area (HR 0.11 per 1 m2, P = 0.011) and prosthesis size (HR 0.67 per 1 mm, P = 0.044). Probability of prosthesis failure and reintervention at 10 years were 24.6% (19.5% in BP vs 34.8% in MP, P = 0.34) and 7.8% (5.6% in BP vs 11.9% in MP, P = 0.079), respectively. Anticoagulation-related major thromboembolic events were observed in 4 patients receiving an MP. MP might not be superior to BP in terms of prosthesis failure or reintervention. MP should be carefully considered for highly selected patients in the era of transcatheter PVR.

Angiographic evaluation of radial artery injury after transradial approach for percutaneous coronary intervention

The transradial approach for percutaneous coronary intervention (TRA-PCI) has been increasingly gaining popularity in clinical practice. However, its association with risk for long-term radial artery injury has not been yet thoroughly defined. We retrospectively examined the patients undergoing radial artery angiography (RAG) after TRA-PCI to determine the incidence and risk factors of radial artery injury. The study included 558 patients undergoing follow-up radial artery angiography at 12 month after TRA-PCI. Radial artery injury occurred in 140 patients (25%) with 3 distinct morphological patterns: focal radial artery stenosis (RAS) P.7,7: in 7 patients (1%), diffuse radial artery stenosis (RAS) in 78 patients (14%), and radial artery occlusion (RAO) in 55 patients (10%). Patients with RAS/RAO were more likely to be female, had smaller height and body weight, smaller body mass index and smaller body surface area (BSA) as compared with those without RAS/RAO. Multivariable logistic regression analysis identified BSA (odds ratio, 1.34 per 0.1 m2 increase; 95% confidence interval, 1.07–1.71; p = 0.01) and a history of TRA-PCI (odds ratio, 2.35; 95% confidence interval, 1.16–5.08; p = 0.017) as independent predisposing factors of radial artery injury. In a sub-analysis of 323 patients undergoing both pre-PCI RAG and follow-up RAG, pre-PCI radial diameter as well as BSA and a history of TRA-PCI were independently associated with radial artery injury. Long-term injury after TRA-PCI is considerably common and care should be paid for RAS/RAO, especially for those patients with lower BSA, history of TRA-PCI and small radial artery diameter.

Hinge point fibrosis is highly prevalent in male elite water polo players

Abstract Background/Introduction The grey zone between cardiac adaptation to sports and exercise and (early stages of) cardiac pathology constitutes one of the greatest challenges for clinicians involved in the care for (elite level) athletes. Cardiac magnetic resonance imaging (CMR) with late gadolinium enhancement (LGE) is a central diagnostic tool to help differentiate between physiological adaptation and pathology. LGE as seen in myocardial fibrosis has been shown to be a strong predictor for cardiac events. While general (ie. dynamic, static sports) levels of physiological adaptation in athletes have been described, sports-specific CMR findings are essentially lacking, and a systematic sport-specific investigation of LGE is absent. Purpose To establish a sports-specific baseline for CMR indices in apparently healthy, male elite water polo players. Methods We performed a cross-sectional study in Olympic-level male water polo players. All athletes were asymptomatic and were examined during pre-participation screening. The athletes underwent a comprehensive CMR protocol consisting of long- and short-axis cine imaging, LGE and was performed on two 3 Tesla MRI-scanners (Philips). CMR data were analysed using Circle Cardiovascular Imaging software, and statistical analyses were performed in R. Results We screened 24 athletes with a mean age (±SD) of 24.2±3.6 years and body surface area (BSA) of 2.23±0.2 m2. The athletes had indexed end-diastolic volumes of 101.87±33.01 ml and 104.51±43.24 ml, stroke volumes of 140.70±33.23 and 139.44±29.93 ml, and ejection fractions of 56.68±9.07% and 52.98±8.18%, in the left- and right ventricle, respectively. Thirteen athletes (54.2%) had LGE consistent with hinge point fibrosis (HPF+) (one case example presented in the figure). Another two athletes had other patterns of LGE (LGE+). There was a trend towards having a smaller BSA in the LGE+ and HPF+ groups (2.18±0.17 m2 in LGE+ vs 2.31±0.10 m2 in LGE−, p=0.056, and 2.18±0.18 m2 in HPF+ vs 2.29±0.10 m2 in HPF−, p=0.072). Conclusion Myocardial fibrosis is present in more than 50% of asymptomatic elite water polo players, with a predilection for the inferior hinge point. Our findings in asymptomatic elite athletes suggest that HPF could be a normal finding in athletes instead of an early sign of pathology. Further studies are warranted to investigate if the HPF is associated with long-term cardiac changes or the development of cardiac pathology. Figure 1. Late gadolinium enhanced short axis image (left) combined with a polar map of cardiac segmentation (right) depicting the fibrosis pattern in a case of an elite male water polo player alongside the inferior hinge point - as expressed in the percentage of myocardium exceeding the mean signal intensity of reference myocardium plus six-times standard deviation. Funding Acknowledgement Type of funding source: Public grant(s) – National budget only. Main funding source(s): Harald Jørstad has received funding from the Amsterdam Movement Sciences and the National Olympic Committee &amp; National Sports Federation

Clinical outcomes of TAVI or SAVR in men and women with aortic stenosis at intermediate operative risk: a post hoc analysis of the randomised SURTAVI trial.

In patients with aortic stenosis randomised to transcatheter aortic valve implantation (TAVI) or surgical aortic valve replacement (SAVR), sex-specific differences in complication rates are unclear in intermediate-risk patients. The purpose of this analysis was to identify sex-specific differences in outcome for patients at intermediate surgical risk randomised to TAVI or SAVR in the international Surgical Replacement and Transcatheter Aortic Valve Implantation (SURTAVI) trial. A total of 1,660 intermediate-risk patients underwent TAVI with a supra-annular, self-expanding bioprosthesis or SAVR. The population was stratified by sex and treatment modality (female TAVI=366, male TAVI=498, female SAVR=358, male SAVR=438). The primary endpoint was a composite of all-cause mortality or disabling stroke at two years. Compared to males, females had a smaller body surface area, a higher Society of Thoracic Surgeons score (4.7±1.6% vs 4.3±1.6%, p<0.01) and were more frail. Men required more concomitant revascularisation (23% vs 16%). All-cause mortality or disabling stroke at two years was similar between TAVI and SAVR for females (10.2% vs 10.5%, p=0.90) and males (14.5% vs 14.4%, p=0.99); the difference between females and males was 10.2% vs 14.5%, for TAVI (p=0.08) and 10.5% vs 14.4%, SAVR (p=0.13). Functional status improvement was more pronounced after TAVI in females than in males. Aortic valve replacement, either by surgical or transcatheter approach, appears similarly effective and safe for males and females at intermediate surgical risk. Functional status appears to improve most in females after TAVI. http://clinicaltrials.gov NCT01586910.

Transcatheter aortic valve replacement with Evolut R versus Sapien 3 in Japanese patients with a small aortic annulus: The OCEAN‐TAVI registry

To compare safety, efficacy, and hemodynamics of transfemoral transcatheter aortic valve replacement (TAVR) using self-expanding and balloon-expandable transcatheter heart valves (THVs) in patients with a small aortic annulus. Few studies have directly compared TAVR outcomes using third-generation THVs, focusing on patients with small aortic annuli. In a multicenter TAVR registry, we analyzed data from 576 patients with a small annulus and who underwent transfemoral TAVR using third-generation THVs. Propensity score matching was used to adjust baseline clinical characteristics. The device success rate in the overall cohort was 92.0% (Evolut R: 92.1% vs. Sapien 3:92.0%, p=0.96). One year after TAVR, patients treated with Evolut R maintained a lower mean pressure gradient (mPG) and a higher indexed effective orifice area (iEOA) in the matched cohort {mPG: 9.0 [interquartile range (IQR): 6.0-11.9] vs. 12.0 [IQR: 9.9-16.3] mmHg, p < .001; iEOA: 1.20 [IQR: 1.01-1.46] vs. 1.08 [IQR: 0.90-1.28] cm2 /m2 , p < .001}. However, no significant differences were reported in the incidence of severe prosthesis-patient mismatch and aortic regurgitation at 1 year. Furthermore, both groups showed comparable outcomes with no differences in terms of all-cause mortality (log-lank test, p=.81). TAVR for patients with a small annulus using third-generation THVs was associated with high device success. Evolut R seems to be superior to Sapien 3 in hemodynamic performance for patients with a small annulus and body surface area up to 1 year after TAVR. Nevertheless, all-cause mortality at 1 year was similar between both groups.

Stentless Pericarbon Freedom Versus Stented Perimount Aortic Bioprosthesis: Propensity-Matched Long-Term Follow-Up.

Stentless aortic valves have shown superior hemodynamic performance and faster left ventricular mass regression compared to stented bioprostheses. Yet, controversies exist concerning the durability of stentless valves. This case-matched study compared short- and long-term clinical outcomes of stentless LivaNova-Sorin Pericarbon Freedom™ (SPF) and stented Carpentier-Edwards Perimount (CEP) aortic prostheses. From 2003 through 2006, 134 consecutive patients received aortic valve replacement with SPF at our institution. This cohort was matched, according to 20 preoperative clinical parameters, with a control group of 390 patients who received CEP prosthesis during the same time. The resulting 55 + 55 matched patients were analyzed for perioperative results and long-term clinical outcomes. Early mortality was 0% for both groups. Lower transvalvular gradients were found in the SPF group (10.6 ± 2.9 versus 15.7 ± 3.1 mmHg, P < 0.001). Overall late mortality (mean follow-up: 10.03 years) was similar for both groups (50.1% versus 42.8%, P = 0.96). Freedom from structural valve degeneration (SVD) at 13 years was similar for both groups (SPF = 92.3%, CEP = 73.9%, P = 0.06). Freedom from aortic valve reinterventions did not differ (SPF = 92.3%, CEP = 93.5%, P = 0.55). Gradients at 13-year follow-up remained significantly lower in SPF group (10.0 ± 4.5 versus 16.2 ± 9.5 mmHg, P < 0.001). Incidence of acute bacterial endocarditis (ABE) and major adverse cardiovascular and cerebrovascular events (MACCE) was similar. SPF and CEP demonstrated comparable long-term outcomes related to late mortality, SVD, aortic valve reinterventions, and incidence of ABE and MACCE. Superior hemodynamic performance of SPF over time can make this valve a suitable choice in patients with small aortic root and large body surface area.

History and Practice of Acute Normovolemic Hemodilution

The purpose of this review is to provide an overview of recent literature on acute normovolemic hemodilution (ANH) and conclude a consensus of beneficial effects. Newfound interest in blood conservation has increased the generalizability of ANH. Overall ANH reduces transfusion rate by 20–30% with a minimum of 650 ml whole blood (WB) removed. Greater effects have also been experienced with ≥ 1000 ml WB. With ANH, allogenic red blood cells (RBCs) and non-RBC transfusion rates are reduced intraoperatively and postoperatively. In addition, decreased length of stay and decreased incidence of pulmonary infections have been experienced. However, large volume resuscitation with colloid or crystalloid increases the risk for endothelial dysfunction and dilutional coagulopathy. ANH is still limited by anemia and small body surface area (BSA) but could be overcome by blood substitutes. ANH might be helpful in decreasing perioperative blood transfusions in addition to current blood conservation techniques. Further investigation is needed to expand applicable patient demographic and to define the optimal method for performing ANH.

Impact of Preoperative Occult Renal Dysfunction on Early and Late Outcomes After Off-Pump Coronary Artery Bypass

Renal dysfunction is independently associated with increased early and late mortality after coronary artery bypass graft (CABG) surgery. Off-pump CABG (OPCABG) avoids postoperative complications from the cardiopulmonary bypass, but it is unclear how it is impacted by occult renal dysfunction (ORD). This study aimed to investigate the effects of ORD on early and late outcomes after OPCABG. This retrospective and observational cohort study reviewed data on 1,188 patients who underwent first isolated OPCABG with normal serum creatinine (SCr) levels. According to preoperative estimated creatinine clearance (eCrCl) by the Cockcroft-Gault formula, the patients were divided into an ORD group (n=260, eCrCl <60 mL/min/1.73 m2) and a control group (n=928, eCrCl ≥60 mL/min/1.73 m2). The ORD patients presented with older age, higher incidence of small body surface area, hypertension, low preoperative eCrCl, cerebrovascular accident, peripheral vascular disease, New York Heart Association (NYHA) Ⅲ, and high risk score. The prevalence of hospital mortality, postoperative acute kidney injury (AKI), peak postoperative SCr, and prolonged hospital stay were greater in the ORD patients than the control patients. Multivariable logistic regression analysis showed that the ORD patients were at significantly higher risk of postoperative AKI (OR, 2.702; 95% CI, 1.994-3.662) and in-hospital mortality (OR, 2.884; 95% CI, 1.293-6.432). Multivariate Cox proportional hazard models confirmed that ORD was significantly associated with high later mortality (HR, 2.847; 95% CI, 1.262-6.425). Occult renal dysfunction is an independent risk factor for postoperative AKI in-hospital and later mortality in patients undergoing OPCABG with normal SCr levels.

Extensive Primary Anetoderma Refractory to Erbium YAG Fractionally Ablative Laser

Primary anetoderma is a rare elastolytic disorder characterized by well-circumscribed flaccid, atrophic macules and patches caused by focal loss of elastic fibers. Anetoderma is divided into two forms: primary, which is idiopathic and occurs on clinically normal skin, and secondary, which follows a prior dermatosis. Although it is indolent, the lesions of anetoderma persist and may be associated with significant aesthetic changes causing potential psychosocial difficulties. Anetoderma has been successfully treated with ablative, pulsed dye and non-ablative fractionated lasers. Patients with secondary anetoderma and anetoderma limited to a relatively small body surface area may be more amenable to laser treatment than patients with extensive involvement.

Effects of red blood cell concentrate transfusion on blood tacrolimus concentration.

Background Elevated blood concentration of tacrolimus is frequently observed following transfusion of red blood cell concentrate in patients after allogeneic hematopoietic stem cell transplantation. Objective The aim of this retrospective study was to clarify the effects of transfusion of red blood cell concentrate on the blood concentration of tacrolimus. Setting Chiba University Hospital in Japan. Method Fifty-two patients (aged 0-65years) receiving both tacrolimus and transfusion after allogeneic hematopoietic stem cell transplantation were enrolled. The ratio of measurement after transfusion to measurement before transfusion was calculated for hematocrit and blood concentration/dose ratio of tacrolimus (termed the hematocrit ratio and the tacrolimus ratio, respectively). Main outcome measure Change in blood concentration/dose ratio of tacrolimus and variable factors associated with variation in tacrolimus ratio. Results The blood concentration/dose ratio of tacrolimus was increased after transfusion compared with before transfusion (p < 0.001). A statistically significant correlation was seen between the hematocrit ratio and tacrolimus ratio (r = 0.32, p < 0.001). Hematocrit ratio, age or body surface area, and difference in aspartate aminotransferase level before and after transfusion were associated with the variation in tacrolimus ratio. There was no correlation between tacrolimus ratio and change in serum creatinine or potassium level in the short term. Conclusion Change in the blood concentration/dose ratio of tacrolimus was associated with change in the hematocrit ratio after transfusion, and more attention is required for children or patients with small body surface area. Dose adjustment of tacrolimus is required if the blood concentration of tacrolimus is much higher than the target concentration.

Surgical Thoracoabdominal Aortic Aneurysm Repair in a Non-High-Volume Institution.

Surgical thoracoabdominal aortic aneurysm (TAAA) repair remains challenging. Apart from mortality, spinal cord injury (SCI) is a dreaded complication. We analyzed our experience to identify predictors for SCI in a nonhigh-volume institution. All patients who underwent TAAA repair between February 1996 and November 2016 (n = 182) were enrolled. Most were male (n = 121; 66.4%), median age was 68 years (range: 21-84). Elective operations were performed in 153 instances (84.1%). Our approach to minimize SCI includes distal aortic perfusion, mild hypothermia, identification of the Adamkiewicz artery, and sequential aortic clamping. Cerebrospinal fluid drainage was introduced in 2001 and liberal use of selective visceral perfusion in 2006. Early mortality was 12.1%; it was 8.5% after elective procedures. Reduced left ventricular function, nonelective setting, older age, and longer bypass time were identified as independent predictors for mortality in multivariable logistic regression model. Permanent SCI was observed in nine patients (4.9%), of whom seven (3.8%) developed paraplegia. In a multivariable logistic regression model for paraplegia, peripheral arterial disease (PAD), Crawford type II repair, smaller body surface area, and era before 2001 were identified as independent predictors, whereas only PAD was significant for SCI. The incidence of paraplegia was 13.8% in extensive repair out of the first 91 cases, whereas it was improved up to 2.7% thereafter. Using an integrated approach, acceptable outcome of TAAA repair can be achieved, even in a nonhigh-volume center. PAD and extensive involvement of the aorta are strong independent predictors for spinal cord deficit after TAAA repair.

Outcomes in Patients with Small Body Surface Area after HeartMate 3 (HM3) Left Ventricular Assist Device (LVAD) Implantation

Outcomes of patients with small body size following HM3 LVAD implantation have not been well characterized. We sought to compare preoperative characteristics and clinical outcomes among patients stratified by body surface area. Patients who received a HeartMate 3 LVAD at our institution between October 1, 2015 and June 30, 2019 were analyzed. Patients who received a HM3 LVAD as pump exchange were excluded. The cohort was divided in 4 groups: BSA ≤1.8 m2 (group 1), BSA >1.8 - ≤2.0 m2 (group 2), BSA >2.0 - ≤2.2 m2 (group 3) and BSA >2.2 (group 4). One hundred and nineteen patients were included in this analysis. Preoperative characteristics and postoperative results of each group are shown in Table 1. Group 1 patients were older and mostly females. A history of diabetes was less common in this group. Mean postoperative length of stay was similar between groups. Pump speed at the time of discharge was lower in group 1 patients. Mean follow-up was similar between groups. Mean days out of the hospital after discharge did not differ among the groups. One-year survival was 93% for group 1, 85% for group 2, 86% for group 3 and 84% for group 4 (p=0.69). Kaplan Meier survival curves are shown in Figure 1 (log rank: 0.692). Outcomes following HM3 LVAD implantation were comparable between patients with small body surface area and patients with larger body size. Small body size should not be an exclusion criteria for HM3 LVAD implantation in patients with advanced heart failure who are otherwise candidates for durable mechanical support.

Sex Differences in Characteristics and Outcomes Following HeartMate 3 Left Ventricular Assist Device Implantation

In addition to goal-directed therapies, advanced therapies for heart failure including left ventricular assist devices (LVADs) remain underutilized in women. Sex-specific data in the area of mechanical circulatory support remains sparse and women are often underrepresented in heart failure trials. Even less is known about sex differences in outcomes with the HeartMate 3 LVAD, an FDA approved centrifugal-flow device. Consecutive patients who received HeartMate 3 LVAD as bridge-to-transplant or destination therapy at a single institution were included in the study. Demographics, co-morbidities, device-related factors, and outcomes were comparatively examined between women and men. 175 patients (28 women, 16.0%) were identified. Women were significantly younger than men (53.9 vs. 60.1 years, p=0.023) with smaller body surface area (1.83 vs 2.08, p <0.001). Women were less likely to have hypertension (42.9% vs 64.6%, p=0.030), to use tobacco (35.7% vs 57.5%, p=0.034), and to have an ischemic etiology of HF (21.4% vs 52.4%, p=0.003). There were no differences in the use of temporary mechanical circulatory support and INTERMACS profiles. There were similar rates of RVAD use (35.7% vs. 30.6%, p=0.594) and continuous veno-venous hemofiltration (10.7% vs 8.2%, p=0.659) in women and men. There were no differences in in-hospital mortality (3.7% vs 6.3%, p=0.595) or 90-day mortality (8.7% vs 6.9%, p=0.762) between women and men. There was no difference in post-implant survival (82.8% vs 87.7%, log-rank p=0.944) [Figure], freedom from gastrointestinal bleeding (70.5% vs 69.1%, log-rank p =0.278) or freedom from stroke (96.4% vs 91.4%, log-rank p = 0.471) at 2-year follow-up between women and men. In our single-center experience with HeartMate 3 LVADs, there were no significant differences in early morbidity and mortality between women and men.

In psoriasis treatment, greater improvement in skin severity predicts greater improvement in nail severity

Background Nail are important for both function and esthetic appearance and although they represent a small body surface area, dermatologic disorders affecting the nails can have a detrimental effect to the patient. Deciding on the best systemic antipsoriatic drug to treat nail psoriasis can be difficult due to the lack of nail data on their Food and Drug Administration-approved labels, as well as the variety of scoring systems used for nail psoriasis. Methods We performed a literature review and included randomized control trials or articles based on randomized control trials for different systemic antipsoriatic drugs. Only articles and studies utilizing Nail Psoriasis Severity Index (NAPSI) or target NAPSI as outcome measures were included. Data was taken directly from articles, directly from clincaltrials.gov or directly from data on file at various pharmaceutical companies. Results Data for NAPSI and PASI were collected for 10 antipsoriatic drugs including three oral medications and seven biologic agents. We found that NAPSI or target NAPSI was strongly predicted based on the change in PASI and duration of treatment (R 2 = 0.71, p = .0002). PASI alone (R 2 = 0.52, p = .001) and duration alone (R 2 = 0.21, p = .07) predict NAPSI response. Conclusion According to this model, there is a relationship between skin and nail response, with improvement in nails correlating with improvement in skin and longer duration of treatment.