Quantitative frame by frame analysis of regional contraction and lengthening on left ventricular cineangiograms: application to the study of normal left ventricles and left ventricles with mitral valve prolapse

This work attempted to study the segmental wall motion on left ventriculograms, in terms of segmental shortening, velocity of segmental shortening, and temporal sequences of various events in systole as well as in diastole. The ability of such a method to characterize patterns of normal regional wall motion and to detect mild abnormalities such as isolated asynchronisms, was tested on two groups of patients. Group I included 25 patients presenting evidence of a normal left ventricle (LV) after left heart catheterization. Group II consisted of 21 patients suffering from an isolated pure idiopathic mitral valve prolapse (MVP), with no mitral insufficiency and with an unaffected global LV function. In all patients left ventriculography was filmed in the right anterior oblique view at a rate of 50 frames/s. For each patient a cycle was chosen, distant from any premature beat, with acceptably contrasted outlines, and a quantitative frame by frame study of the motion of 10 segments was performed using a semiautomated method derived from the Stanford method. In the control group (Group I), analysis of the segmental motion by means of this method demonstrates a mild nonuniformity of the normal wall motion. This is principally marked by a stronger and faster contraction in anterolateral segments (segments 7, 8, 9) and by a shorter duration of the contraction in this region. In contrast the MVP group (Group II), exhibited a frank asynergy of the anterolateral region occurring from end systole to early diastole.(ABSTRACT TRUNCATED AT 250 WORDS)     

Effects of injectable calcium blockers on cardiac function and relaxation in left ventricular hypertrophy

Nineteen patients with left ventricular hypertrophy were given intravenous calcium antagonists: 9 patients received intravenous verapamil (VPM IV) and 10 patients diltiazem (DTZ) by intracoronary and then intravenous injection. Systemic and pulmonary resistances, cardiac output, left ventricular and aortic pressures, isometric contractility, isometric relaxation and left ventricular compliance were studied in sinus rhythm, during atrial and then ventricular pacing at 120/min and finally after tachycardia before and after administration of calcium antagonists. Left ventriculography in the 30 degrees RAO projection in sinus rhythm was performed before and after injection of the calcium antagonists to study the variations in the end diastolic volume, mass and mass-volume ratio. Finally, frame by frame numerisation of the ventriculographies during systole and diastole helped evaluate variations in amplitude, time and velocity of fibre shortening or lengthening. The administration of the calcium antagonists did not have any significant effect on heart rate (-2.8 +/- 10 p. 100, NS) or indices of isometric contractility (delta Vmax + 4 +/- 43 p. 100, NS). Significant falls in systemic and pulmonary resistances (-15 +/- 23 p. 100, p less than 0.05 and - 26 +/- 32 p. 100, p less than 0.05, respectively) and an increase in systolic index (+ 15.5 p. 100 +/- 12 p. 100, p less than 0.01) were observed. The improvement in left ventricular ejection was independent of the variation in resistances but was closely related to variations of parameters of relaxation. The effects on volumic compliance and filling velocities were also closely related to variations in relaxation (p less than 0.05 and p less than 0.01). Calcium antagonists protected left ventricular ejection during supraventricular tachycardia and prevented the changes in left ventricular relaxation observed during arrhythmias and after tachycardia.(ABSTRACT TRUNCATED AT 250 WORDS)     

Educational Impact on Apixaban Adherence in Atrial Fibrillation (the AEGEAN STUDY): A Randomized Clinical Trial

Adherence to non-vitamin-K oral anticoagulants (NOACs) may be lower than to vitamin K antagonists because NOACs do not require routine monitoring. We assessed the impact of an educational program on adherence and persistence with apixaban in patients with non-valvular atrial fibrillation (NVAF). Patients with NVAF eligible for NOACs with one or more stroke risk factor (prior stroke/transient ischemic attack, age ≥ 75 years, hypertension, diabetes, or symptomatic heart failure) were randomized (1:1) to standard of care (SOC) or SOC with additional educational (information booklet, reminder tools, virtual clinic access). The primary outcome was adherence to apixaban (2.5 or 5 mg twice daily) at 24 weeks. Patients receiving the educational program were re-randomized (1:1) to continue the program for 24 further weeks or to switch to secondary SOC. Implementation adherence and persistence were reassessed at 48 weeks. In total, 1162 patients were randomized (SOC, 583; educational program, 579). Mean implementation adherence ± standard deviation (SD) at 24 weeks was 91.6% ± 17.1 for SOC and 91.9% ± 16.1 for the educational program arm; results did not differ significantly between groups at any time-point. At 48 weeks, implementation adherence was 90.4% ± 18.0, 90.1% ± 18.6, and 89.3% ± 18.1 for continued educational program, SOC, and secondary SOC, respectively; and corresponding persistence was 86.1% (95% confidence interval [CI] 81.3–89.7), 85.2% (95% CI 81.5–88.2), and 87.8% (95% CI 83.4–91.1). Serious adverse events were similar across groups. High implementation adherence and persistence with apixaban were observed in patients with NVAF receiving apixaban. The educational program did not show additional benefits. This study is registered at ClinicalTrials.gov [NCT01884350].     

Hemostatic plug formation in normal and von Willebrand pigs: the effect of the administration of cryoprecipitate and a monoclonal antibody to Willebrand factor

Hemostatic plug (HP) formation was investigated in the ear bleeding time incision in normal and von Willebrand pigs. HP volume was calculated by integrating the areas of serial sections. In normal pigs (n = 11), platelets immediately formed a layer on the surface of the cut channel. Platelet aggregates formed at the ends of transected vessels and gradually enlarged. Finally, all transected vessels were occluded by HP and bleeding stopped. In contrast, large HPs were formed in the incision in von Willebrand's disease (vWD) pigs (n = 4); these HPs did not cover the ends of the transected vessels, which continued to bleed, allowing the formation of large hemostatically ineffective platelet aggregates in the incision. Canals traversed these HPs, and bleeding from the open vessels may have continued through them. After infusion of cryoprecipitate into a vWD pig, the bleeding time shortened, and the morphological findings of the HPs were similar to those of normal pigs. In normal pigs (n = 3) infused with an anti- Willebrand factor monoclonal antibody, which prolonged the bleeding time, a large HP formed in the incision, similar to that observed in the vWD pig. The volume of the normal and vWD HPs increased with time. These in vivo findings suggest that Willebrand factor is involved in the localization of the HP to the damaged vessel and may also play a role in platelet-platelet interaction. A computerized morphometric technique was used for measuring the volume of the hemostatic plugs and the distance of sequential points on the perimeter of the HP from the center of selected bleeding vessels.     

Reduction in length of stay for patients undergoing oesophageal and gastric resections with implementation of enhanced recovery packages

Introduction

The high mortality and morbidity associated with resection for oesophagogastric malignancy has resulted in a conservative approach to the postoperative management of this patient group. In August 2009 we introduced an enhanced recovery after surgery (ERAS) pathway tailored to patients undergoing resection for oesophagogastric malignancy. We aimed to assess the impact of this change in practice on standard clinical outcomes.

Methods

Two cohorts were studied of patients undergoing resection for oesophagogastric malignancy before (August 2008 – July 2009) and after (August 2009 – July 2010) the implementation of the ERAS pathway. Data were collected on demographics, interventions, length of stay, morbidity and in-hospital mortality.

Results

There were 53 and 55 oesophagogastric resections undertaken respectively for malignant disease in each of the study periods. The median length of stay for both gastric and oesophageal resection decreased from 15 to 11 days (Mann– Whitney U, p<0.001) following implementation of the ERAS pathway. There was no significant increase in morbidity (gastric resection 23.1% vs 5.3% and oesophageal resection 25.9% vs 16.7%) or mortality (gastric resection no deaths and oesophageal resection 1.8% vs 3.6%) associated with the changes. There was a significant decrease in the number of oral contrast studies used following oesophageal resection, with a reduction from 21 (77.8%) in 2008–2009 to 6 (16.7%) in 2009–2010 (chi-squared test, p<0.0001).

Conclusions

The introduction of an enhanced recovery programme following oesophagogastric surgery resulted in a significant decrease in length of median patient stay in hospital without a significant increase in associated morbidity and mortality.