Predictors of immediate and long-term outcomes of coronary bypass surgery in patients with left ventricular dysfunction

Despite encouraging improvements, outcomes of coronary artery bypass grafting (CABG) in the presence of left ventricular (LV) dysfunction remain poor. In the present study, the authors’ experience on this subject was reviewed to establish the predictors of immediate and long-term results of surgery. Out of 4383 consecutive patients with multivessel coronary artery disease who underwent primary isolated CABG at the authors’ institution from January 1999 throughout September 2014, 300 patients (mean age 66.1 ± 9.6 years) suffered preoperatively from LV dysfunction (defined as LV ejection fraction ≤35 %). The mean expected operative risk (EuroSCORE II) was 10.3 ± 13 %. Hospital deaths and perioperative complications were analyzed retrospectively. Outcomes were evaluated during a mean follow-up of 6.2 ± 4 years. None, one or both internal thoracic arteries (ITAs) were used in 6.3, 29 and 64.7 % of cases, respectively. There were 16 (5.3 %) hospital deaths. Prolonged invasive ventilation (17.7 %), acute kidney injury (14.7 %) and multiple blood transfusion (21.3 %) were the most frequent major postoperative complications. The 10-year non-parametric estimates of freedom from all-cause death, cardiac death, and major adverse cardiac and cerebrovascular events (MACCEs) were 47.8 [95 % confidence interval (CI) 44.1–51.5], 65.3 (95 % CI 61.4–69.2), and 42.3 % (95 % CI 38.3–46.3), respectively. Shared predictors of decreased late survival and MACCEs were old age (P < 0.04), chronic lung disease (P < 0.01), chronic dialysis (P < 0.0001) and extracardiac arteriopathy (P < 0.045). After adjustment for corresponding risk factors, freedom from cardiac death was higher when both ITAs were used but only for patients with significant increase of LV ejection fraction early after surgery (P = 0.04). In patients with LV dysfunction, CABG may be performed with acceptable hospital mortality and long-term survival. Late outcomes depend mainly on preoperative characteristics of the patients. The use of both ITAs for myocardial revascularization may give long-term survival benefits but only for patients whose LV function improves significantly early after surgery.     

Pulmonary blood flow distribution in transposition of the great arteries

Pulmonary blood flow distribution was studied by scintillation scanning of the lungs after the infusion of iodine-131-labeled macroaggregates of human albumin before and after the Mustard operation in 53 patients with transposition of the great arteries. The patients were classified as follows: Group I (24 infants with uncomplicated transposition of the great arteries); Group II (18 patients with transposition and ventricular septal defect); and Group III (11 patients with transposition, ventricular septal defect and pulmonary obstruction).Before operation, 21 patients had a normal distribution of pulmonary blood flow, 10 had preferential flow to the right lung and 2 had preferential flow to the left lung. After operation, 19 had a normal pattern of pulmonary blood flow, 21 had preferential flow to the right lung and 3 had preferential flow to the left lung. The scanning studies have proved helpful in follow-up of patients to rule out recurrence of the shunt, pulmonary or systemic venous obstruction, development of pulmonary hypertension and occlusion of a palliative systemic-pulmonary shunt.     

Functional status and quality of life after emergency revascularization for cardiogenic shock complicating acute myocardial infarction

OBJECTIVES: Our goal was to describe the functional status of cardiogenic shock survivors, identify the correlates of cardiogenic shock, and compare global quality of life and functional status of patients randomly assigned to treatment with emergency revascularization (ERV) versus initial medical stabilization (IMS). BACKGROUND: Historically, the hospital survival rate of patients with cardiogenic shock complicating acute myocardial infarction (MI) has been very low. Shock survivors are salvaged from a critically ill state, and their later functional status is not well documented. The SHould we emergently revascularize Occluded Coronaries for cardiogenic shocK (SHOCK) trial showed significantly improved one-year survival after ERV compared with IMS. METHODS: The SHOCK trial survivors completed interviews at 2 weeks after discharge and at 6 and 12 months after MI. Functional status assessment included the Multidimensional Index of Life Quality and New York Heart Association (NYHA) congestive heart failure functional class. RESULTS: Eighty-seven percent of one-year survivors of the SHOCK trial were in NYHA functional class I or II. Between two weeks after discharge and one year after MI, improvement was similar in the two treatment groups (18% overall), but fewer patients remained stable (44% vs. 71%), and more patients worsened or died (34% vs. 15%) in the IMS group compared with those assigned to ERV. Assignment to ERV was the only independent predictor of outcome at one year. CONCLUSIONS: Although one-year mortality after ERV is still high (54%), most survivors have good functional status. The ERV patients have a lower rate of deterioration than IMS patients. The level of recovery for shock patients undergoing ERV is similar to that of historical controls not in cardiogenic shock undergoing elective revascularization.     

Withholding or withdrawing of life-sustaining therapy in older adults (≥ 80 years) admitted to the intensive care unit

Purpose

To document and analyse the decision to withhold or withdraw life-sustaining treatment (LST) in a population of very old patients admitted to the ICU.

Methods

This prospective study included intensive care patients aged?≥?80 years in 309 ICUs from 21 European countries with 30-day mortality follow-up.

Results

LST limitation was identified in 1356/5021 (27.2%) of patients: 15% had a withholding decision and 12.2% a withdrawal decision (including those with a previous withholding decision). Patients with LST limitation were older, more frail, more severely ill and less frequently electively admitted. Patients with withdrawal of LST were more frequently male and had a longer ICU length of stay. The ICU and 30-day mortality were, respectively, 29.1 and 53.1% in the withholding group and 82.2% and 93.1% in the withdrawal group. LST was less frequently limited in eastern and southern European countries than in northern Europe. The patient-independent factors associated with LST limitation were: acute ICU admission (OR 5.77, 95% CI 4.32–7.7), Clinical Frailty Scale (CFS) score (OR 2.08, 95% CI 1.78–2.42), increased age (each 5 years of increase in age had a OR of 1.22 (95% CI 1.12–1.34) and SOFA score [OR of 1.07 (95% CI 1.05–1.09 per point)]. The frequency of LST limitation was higher in countries with high GDP and was lower in religious countries.

Conclusions

The most important patient variables associated with the instigation of LST limitation were acute admission, frailty, age, admission SOFA score and country.

Trial registration

ClinicalTrials.gov (ID: NTC03134807).

     

Comparing the Palliative Care Needs of Patients With Hematologic and Solid Malignancies

Context

Hematologic cancer patients use palliative care services less frequently than their solid tumor counterparts. Prior work suggests that these patients have a sizable symptom burden, but comparisons between hematologic and solid tumor patients near the end of life are limited.

Seroprevalence and molecular epidemiology of HTLV-1 isolates from HIV-1 co-infected women in Feira de Santana, Bahia, Brazil

HTLV-1/HIV-1 co-infection is associated with severe clinical manifestations, marked immunodeficiency, and opportunistic pathogenic infections, as well as risk behavior. Salvador, the capital of the State of Bahia, Brazil, has the highest HTLV-1 prevalence (1.74%) found in Brazil. Few studies exist which describe this co-infection found in Salvador and its surrounding areas, much less investigate how these viruses circulate or assess the relationship between them. To describe the epidemiological and molecular features of HTLV in HIV co-infected women. To investigate the prevalence of HTLV/HIV co-infection in surrounding areas, as well as the molecular epidemiology of HTLV, a cross sectional study was carried out involving 107 women infected with HIV-1 from the STD/HIV/AIDS Reference Center located in the neighboring City of Feira de Santana. Patient samples were submitted to ELISA, and HTLV infection was confirmed using Western Blot and Polymerase Chain Reaction (PCR). Phylogenetic analysis using Neighbor-Joining (NJ) and Maximum Likelihood (ML) was performed on HTLV LTR sequences in order to gain further insights about molecular epidemiology and the origins of this virus in Bahia. Four out of five reactive samples were confirmed to be infected with HTLV-1, and one with HTLV-2. The seroprevalence of HTLV among HIV-1 co-infected women was 4.7%. Phylogenetic analysis of the LTR region from four HTLV-1 sequences showed that all isolates were clustered into the main Latin American group within the Transcontinental subgroup of the Cosmopolitan subtype. The HTLV-2 sequence was classified as the HTLV-2c subtype. It was also observed that four HTLV/HIV-1 co-infected women exhibited risk behavior with two having parenteral exposure, while another two were sex workers. This article describes the characteristics of co-infected patients. This co-infection is known to be severe and further studies should be conducted to confirm the suggestion that HTLV-1 is spreading from Salvador to surrounding areas.