Prognostic significance of preoperative left ventricular ejection fraction and valve lesion in patients with aortic valve replacement

After aortic valve replacement, depressed left ventricular function, as assessed from the preoperative left ventricular ejection fraction, has been reported to improve significantly in patients with aortic stenosis, but to improve little or to a lesser degree In patients with aortic regurgitation. Accordingly, the effect of preoperative left ventricular ejection fraction and other variables on postoperative survival was examined in 229 patients after aortic valve replacement. The preoperative left ventricular ejection fraction, cardiac index and left ventricular end-diastolic pressure were found not to affect the 3 year postoperative survival rate in patients with aortic stenosis and mixed aortic valve disease. However, patients with aortic regurgitation and a left ventricular ejection fraction of less than 0.50 had a significantly poorer 3 year survival rate (64 ± 10 percent) than patients with aortic regurgitation and an ejection fraction of 0.50 or more (91 ± 8 percent) (p <0.02). The 3 year postoperative survival rate in patients with a reduced cardiac index (less than 2.5 liters/min per m²) and aortic regurgitation was also significantly lower (63 ± 10 percent) than the rate in patients with aortic regurgitation and a normal cardiac index (p <0.02). There was less significance in the difference between the 3 year postoperative survival rate of patients with aortic regurgitation whose left ventricular end-diastolic pressure was 15 mm Hg or less and those whose pressure was greater than 15 mm Hg (p <0.05). Thus, it may be advisable to monitor left ventricular ejection fraction noninvasively in patients with aortic regurgitation and to advise aortic valve replacement before the ejection fraction becomes severely depressed.     

Symptomatic, electrocardiographic, metabolic, and hemodynamic alterations during pacing-induced myocardial ischemia

Atrial pacing has been used to assess the physiologic impact of coronary artery disease (CAD). Several variables have served as markers of pacing-induced myocardial ischemia, but their specificities and sensitivities are unknown. Accordingly, in 28 patients, incremental atrial pacing was performed. Of the 28, 10 had no CAD. The left ventricular ejection fraction (LVEF) (by gated equilibrium blood pool scintigraphy) increased in this group (0.60 ± 0.11 [mean ± standard deviation] before pacing to 0.67 ± 0.13 at peak-pacing, p = 0.002). In no patient did left ventricular end-diastolic pressure increase by > 5 mm Hg. No patient had lactate production, and 2 (20%) had electrocardiographic S-T segment depression ≥0.1 mV. Four (40%) had chest pain with atrial pacing. In the remaining 18 patients with CAD, atrial pacing caused a decrease in LVEF ≥0.05 (0.46 ± 0.10 to 0.33 ± 0.09, p < 0.001) and new segmental wall motion abnormalities in all, indicating pacing-induced myocardial ischemia. Only 8 (44%) had an increase in left ventricular end-diastolic pressure of > 5 mm Hg, and only 9 (50%) had lactate production. Ten (56%) had ischemic electrocardiographic changes, and 12 (67%) had chest pain. Thus, the electrocardiographic, metabolic, and hemodynamic alterations that may accompany pacing-induced ischemia are specific but relatively insensitive markers of ischemia. In contrast, chest pain during atrial pacing is a nonspecific occurrence, appearing with similar frequency in normal subjects and patients with CAD and pacing-induced ischemia.     

Risk factors for perioperative adverse events in children with myotonic dystrophy

Background:  This study was conducted to identify patient-related, surgical, and anesthetic factors that would help predict adverse events and allow for better planning of perioperative care in children with myotonic dystrophy.
Methods:  This is a retrospective chart review from a large tertiary pediatric hospital. Data were collected on demographics, disease severity, surgical procedure, and anesthetic technique. Perioperative adverse events were recorded.
Results:  Records on 27 patients having 78 anesthetics over a 17.5-year period were reviewed. The overall frequency of postoperative respiratory complications was 10%. Significant risk factors were high muscular impairment rating scale (MIRS) grade ( P  = 0.007), at least 2300 cytosine, thymine, guanine (CTG) repeats on the protein kinase gene of chromosome 19q ( P  = 0.009), a longer duration of surgery (RR = 14.0 for surgery lasting at least 1 h; P  = 0.002), perioperative morphine use (RR = 7.7, 95% CI 2.2–12.8; P  = 0.005), intubation ( P  = 0.02), and the use of muscle relaxant without reversal (RR = 15.5, P  = 0.0002). Using a multivariate risk model, only MIRS grade and the use of muscle relaxant without reversal were shown to be significant independent risk factors (RR = 24.9, P  < 0.0001).
Conclusions:  The MIRS is a statistically significant and clinically useful tool for predicting high perioperative risk. Patients with a high MIRS grade should therefore be considered for postoperative intensive care. The use of muscle relaxant without reversal was also shown to be a significant risk factor. Patients who require morphine infusions postoperatively might also be most safely managed in a high dependency unit.     

Zero‐contrast percutaneous coronary intervention on calcified lesions facilitated by rotational atherectomy

Percutaneous coronary intervention (PCI) in patients with advanced chronic kidney disease (CKD) is challenging due to frequent presence of complex calcified lesions and the very high risk of contrast‐induced nephropathy (CIN). We report a strategy of “zero contrast” PCI, guided by intravascular imaging and physiology, performed in three patients with advanced CKD in whom severe calcification necessitated rotational atherectomy (RA) to facilitate and optimize PCI. This approach resulted in safe and successful PCI while preserving renal function. © 2017 Wiley Periodicals, Inc.     

A randomized comparison of the magnetic navigation system versus conventional percutaneous coronary intervention

Objective : A randomized comparison of the magnetic navigation system (MNS) to conventional guidewire techniques in percutaneous coronary interventions. Background : The MNS precisely directs a magnetized guidewire in vivo through two permanent external magnets. Methods : A total of 111 consecutive patients were enrolled. Crossing success, crossing‐/fluoroscopy times, and contrast usage were directly compared. Lesions were classified according to the AHA/ACC criteria. Three tertiles of vessel/lesion complexity [low (<5), medium (6–10) and high (>10)] were defined using 3D reconstructions and angiographic information. Results : The crossing success for magnetic and the conventional wires were 93.3and 95.6%, respectively. Crossing and fluoroscopy times were longer with the magnetic wires (72.9 ± 50.3 sec vs. 58.1 ± 47.2 sec, P < 0.001 and 66.2 ± 44.1 sec vs. 55.2 ± 44.4 sec, P = 0.03, respectively). In vessels with low and medium complexity the magnetic wires had significantly longer times (P < 0.001) but for those with high scores (>10) a trend towards shorter times was observed. The MNS resulted in a small but significant reduction in contrast usage (2.3 ± 3.5 ml vs. 4.5 ± 4.4 ml, P < 0.001). Moreover by superimposing a virtual roadmap of the vessel on the live fluoroscopy image 48% of the lesions were crossed without requiring contrast agents with the MNS. Conclusion : The MNS has comparable crossing success to conventional PCI. It is relatively slower but there is a trend to support a potential advantage in more complex vessels. By simultaneously employing a virtual roadmap there is a small but significant reduction in contrast usage. © 2008 Wiley‐Liss, Inc.     

Clinical outcomes following bioresorbable scaffold implantation for bifurcation lesions: Overall outcomes and comparison between provisional and planned double stenting strategy

The aim of this study was to investigate clinical outcomes of patients treated with a provisional stenting (PS) versus a double stenting (DS) strategy for coronary bifurcation lesions with bioresorbable scaffolds (BRS). There are limited data available with regards to outcomes following BRS implantation for bifurcation lesions. A total of 132 bifurcation lesions treated with BRS between 2012 and 2014 were analyzed. Of the total of 132 bifurcation lesions, 10 lesions were treated without crossover stenting. 99 lesions (81%) were treated with a PS strategy and 23 lesions (19%) with a DS strategy. The DS group consisted of patients with a greater number of true bifurcation lesions (PS 52.0% vs. DS 91.3%: P < 0.001). In the PS group, seven lesions (7.1%) were crossed‐over to T‐stenting. In the DS group, 13 lesions (57%) were treated with BRS to the side branch (SB). A hybrid stenting technique [BRS to the main branch, and metallic drug‐eluting stent (DES) to the SB] was utilized in 10 (43%) lesions. Target lesion revascularization (TLR) rates were 5.5% for PS and 11.2% for DS (P = 0.49) at 1‐year follow‐up. Definite scaffold thrombosis did not occur at the site of any bifurcation lesion. These findings suggest that BRS implantation for bifurcation lesions is technically feasible. The rates of TLR tended to be higher in the DS group compared to when a PS strategy was employed. Larger studies are eagerly awaited to determine longer‐term follow‐up of this treatment strategy. © 2015 Wiley Periodicals, Inc.     

Quality of life of adolescents with cerebral palsy: perspectives of adolescents and parents

Quality of life (QOL) has emerged over the past 20 years as an outcome for measuring the effectiveness of health‐improvement interventions. The Cerebral Palsy Quality of Life Questionnaire for Children (CPQOL‐Child) is well regarded and now integrated into research internationally. We describe the results of qualitative research, using grounded research in which we aimed to identify domains of QOL for adolescents with cerebral palsy (CP) from adolescent and parent perspectives to guide the development of an adolescent version. Seventeen adolescents (nine males, eight females) aged 13 to 18 years (mean=15.53 SD=1.74), with varying levels of impairment (Gross Motor Function Classification System levels I n=5, II n=2, III n=6, IV n=4, and V n=6) and their parents (n=23) participated in semi‐structured interviews. Questions included: ‘What do you think is important to your (child’s) QOL?’ and ‘How does CP impact on your (child’s) life?’ Fifteen themes were identified, including domains related to health issues in adolescence, participation, education, specific CP‐related issues (pain and discomfort, communication), family issues, practical issues (financial resources), and changes associated with adolescence (sexuality, independence). The composition of these QOL domains reflects the developmental concerns of adolescents with CP, adding to the views of children, and strongly supports adolescent participation in the development of self‐reported well‐being and QOL measures. Many of the domains are consistent with child reports of QOL and thus it appears feasible and valid to develop a measure that will be transferable across childhood and adolescence.     

Efficacy, dose-response, and adverse effects of droperidol for prevention of postoperative nausea and vomiting

PURPOSE: To estimate the efficacy and harm produced by droperidol in the prevention of postoperative nausea and vomiting (PONV). METHODS: Systematic search (MEDLINE, EMBASE, Cochrane library, hand-searching, bibliographies, all languages, up to May 1999) for randomised comparisons of droperidol with placebo in surgical patients. Relevant end points were prevention of early PONV (up to six hours postoperatively), and late PONV (24 hr), and adverse effects. Combined data were analysed using relative risk and NNT. RESULTS: In 76 trials, 5,351 patients received 24 different regimens of droperidol. The average incidence of early and late PONV in controls was 34% and 51%, respectively. Droperidol was more efficacious than placebo in preventing PONV. In adults, the anti-nausea effect was short-lived, and there was no dose-responsiveness; with 0.25 to 0.30 mg the number-needed-to-treat (NNT) to prevent early nausea was 5. For both early and late anti-vomiting efficacy there was dose-responsiveness; best efficacy was with 1.5 mg to 2.5 mg (NNT, 7). In children, there was dose-responsiveness; best efficacy was with 75 microg x kg(-1) (NNT to prevent early and late vomiting, 4). Two children had extrapyramidal symptoms with droperidol (NNT in children, 91; in any patient, 408). There was dose-responsiveness for sedation and drowsiness (with 2.5 mg the NNT was 7.8). Droperidol prevented postoperative headache (NNT, -25). CONCLUSIONS: Droperidol is anti-emetic in the surgical setting. The effect on nausea is short-lived but more pronounced than the effect on vomiting. Sedation and drowsiness are dose-dependent, extrapyramidal symptoms are rare, and there is a protective effect against headache.