Value of scar imaging and inotropic reserve combination for the prediction of segmental and global left ventricular functional recovery after revascularisation

Background

This study sought to prospectively and directly compare three cardiovascular magnetic resonance (CMR) viability parameters: inotropic reserve (IR) during low-dose dobutamine (LDD) administration, late gadolinium enhancement transmurality (LGE) and thickness of the non-contrast-enhanced myocardial rim surrounding the scar (RIM). These parameters were examined to evaluate their value as predictors of segmental left ventricular (LV) functional recovery in patients with LV systolic dysfunction undergoing surgical or percutaneous revascularisation. The second goal of the study was to determine the optimal LDD-CMR- and LGE-CMR-based predictor of significant (≥ 5%) LVEF improvement 6 months after revascularisation.

Methods

In 46 patients with chronic coronary artery disease (CAD) (63 ± 10 years of age, LVEF 35 ± 8%), wall motion and the above mentioned CMR parameters were evaluated before revascularisation. Wall motion and LGE were repeatedly assessed 6 months after revascularisation. Logistic regression analysis models were created using 333 dysfunctional segments at rest.

Results

An LGE threshold value of 50% (LGE50) and a RIM threshold value of 4 mm (RIM4) produced the best sensitivities and specificities for predicting segmental recovery. IR was superior to LGE50 for predicting segmental recovery. When the areas under the ROC curves is compared, the combined viability prediction model (LGE50 + IR) was significantly superior to IR alone in all analysed sets of segments, except the segments with an LGE from 26% to 75% (p = 0.08). The RIM4 model was not superior to the LGE50 model. A myocardial segment was considered viable if it had no LGE or had any LGE and produced IR during LDD stimulation. ROC analysis demonstrated that ≥ 50% of viable segments from all dysfunctional and revascularised segments in a patient predict significant improvement in LVEF with a 69% sensitivity and 70% specificity (AUC 0.7, p = 0.05). The cut-off of ≥ 3 viable segments was a less useful predictor of significant global LV recovery.

Conclusions

LDD-CMR is superior to LGE-CMR as a predictor of segmental recovery. The advantage is greatest in the segments with an LGE from 26% to 75%. The RIM cut-off value of 4 mm had no superiority over the LGE cut-off value of 50% in predicting the segmental recovery. Patients with ≥ 50% of viable segments from all dysfunctional and revascularised had a tendency to improve LVEF by ≥ 5% after revascularisation.     

Cost-Utility Analysis of Methadone Maintenance Treatment: A Methodological Approach

Economic considerations influence the substance user treatment system. These considerations influence who gets treatment and for how long, as well as determining what services they receive and in what setting. Current medical literature argues that maintenance treatment reduces risk-taking behavior, such as injection drug use and needle sharing. Treatment also reduces the mortality associated with abuse of opiates by injection and can cause decreases in costs incurred by the criminal justice system and social services agencies. This suggests the need for complex economic evaluations of a maintenance treatment to find out the optimum treatment program. This paper describes methods of economic evaluation in healthcare and reviews the methodology of cost–utility analysis in economic evaluations of methadone maintenance treatment.     

Resultados a muy largo plazo tras la implantación de stents liberadores de fármacos en la estenosis de arteria coronaria principal izquierda no protegida: experiencia de un centro

Introduction and objectives

Encouraging results at long-term follow-up have been reported from non-randomized registries and randomized trials following percutaneous coronary intervention with drug-eluting stent implantation for unprotected left main stenosis. However, information on very long-term (>5-year) outcomes is limited. The aim of this study was to assess the very long-term outcomes (6-years) following drug-eluting stent implantation for left main disease.

Methods

All consecutive patients with unprotected left main stenosis electively treated with drug-eluting stent implantation, between March 2002 and May 2005, were analyzed according to the location of the left main lesion (distal bifurcation vs ostial/body).

Results

The study included 149 patients: 113 with distal bifurcation and 36 with ostial/body lesion. Triple-vessel disease was significantly higher in the distal than in the ostial/body group (52.2% vs 33.2%, P=.05). At 6-years of follow-up, the cumulative major adverse cardiovascular event rate was 41.6% (45.1% distal vs 30.6% ostial/body, P=0.1), including 18.8% any death (22.1% distal vs 8.3% ostial/body, P=.08), 3.4% myocardial infarction (3.5% distal vs 2.8% ostial/body, P=1), and 15.4% target lesion revascularization (18.6% distal vs 5.6% ostial/body, P=.06). The composite of cardiac death and myocardial infarction was 10.7% (13.3% distal vs 2.8% ostial/body, P=.1) while the definite/probable stent thrombosis rate was 1.4% (all in the distal group).

Conclusions

At 6-year clinical follow-up, percutaneous coronary intervention with drug-eluting stent implantation for unprotected left main disease was associated with acceptable rates of cardiac death, myocardial infarction and stent thrombosis. Favorable long-term outcomes in ostial/body lesions compared to distal bifurcation lesions were confirmed at long-term clinical follow-up.Full English text available from:www.revespcardiol.org/en     

Assessment of validity for EuroSCORE risk stratification system

Prognostic scoring helps doctors, patients and their families to weigh the risks and benefits of medical care and clarifies their expectations. OBJECTIVE: We aimed to analyze the risk stratification performance of the EuroSCORE system because of its common use in Lithuania. DESIGN: EuroSCORE performance is assessed in terms of sensitivity, specificity, accuracy and area under the receiver operating characteristic (ROC) curve (AUC). Logistic regression is carried out for modeling categorical data and odds ratio calculations of being a non-survivor case for each EuroSCORE risk group. RESULTS: The study was completed on 1002 patients. Mean score for EuroSCORE was 4.77 +/- 2.8; ROC curve of 0.71; accuracy was 65.5%; 65.4% sensitivity and 67.2% specificity. CONCLUSIONS: EuroSCORE created a moderately predictive area under the ROC curve for our patient population. Probability of non-survival by logistic regression model for each EuroSCORE risk group is statistically significantly higher compared to the lower risk group. Predictions available from prognostic scoring systems could be useful in decision making when there is uncertainty in whether to carry out surgery or not.     

Receiver operating characteristic curves and comparison of cardiac surgery risk stratification systems

We use past experiences every day when we choose one therapy over another; we frequently base our decisions on the relative probability that a particular treatment will be successful in an individual patient. Preoperative risk score systems are an essential tool for risk assessment in cardiac surgery. If we use just any risk stratification we will make diagnostic errors. During the last decade the examination of the performance of cardiac surgery risk stratification systems became very popular. There are a lot of studies, which show that risk stratification systems have high predictive value but they overpredict mortality rates for sample population. When reading these articles it is unclear what influences the mortality overprediction? We review main principles of receiver operating characteristic curve use for risk stratification systems' performance assessment and describe basic statistical explanations regarding errors in mortality prediction.     

Global effects of feature-based attention in human visual cortex

The content of visual experience depends on how selective attention is distributed in the visual field. We used functional magnetic resonance imaging (fMRI) in humans to test whether feature-based attention can globally influence visual cortical responses to stimuli outside the attended location. Attention to a stimulus feature (color or direction of motion) increased the response of cortical visual areas to a spatially distant, ignored stimulus that shared the same feature.     

Tumor-related factors and patient’s age influence survival after resection for ampullary adenocarcinoma

Background/Purpose

The majority of surgeons agree that ampullary adenocarcinoma should be removed by partial pancreatoduodenectomy. Favoring extended resection, based on the uncertainty of the preoperative diagnosis and the higher probability of clear resection margins, we aimed to disclose the results of this surgical procedure in terms of postoperative morbidity and mortality, and to identify prognosticators of long-term survival.

Methods

We documented, prospectively, 25 consecutive patients with adenocarcinoma of the papilla of Vater in whom pylorus-preserving pancreatoduodenectomy was performed. Clinical data, pathology reports, International Union Against Cancer (UICC) tumor stage, postoperative morbidity, mortality, and long-term follow-up results were evaluated. The Kaplan-Meier method and log-rank test were applied for univariate analysis. The Cox proportional hazard model was used for multivariate analysis.

Results

Postoperative mortality was 4%, overall morbidity was 32%, and pancreas-associated morbidity was 8%. Mean survival time was 53.8 months. Tumor size, N status, UICC stage, lymphatic invasion, blood vessel infiltration, R0 resection, and age of patient at the cutoff of 70 years were independent predictors of survival on univariate analysis. Multivariate analysis, however, disclosed no independent predictors of prognosis.

Conclusions

Pancreatoduodenectomy for ampullary carcinoma is reasonable in terms of postoperative morbidity and mortality. Tumor-related factors, R0 resection, and advanced age appeared as the main predictors of survival.