The Value of Claims-Based Nontraditional Risk Factors in Predicting Long-term Mortality After MitraClip Procedure

Background

We sought to identify nontraditional risk factors coded in administrative claims data and evaluate their ability to improve prediction of long-term mortality in patients undergoing percutaneous mitral valve repair.

Blood loss and bank blood requirement in coronary bypass surgery.

With the use of nonblood prime and refinement in perfusion and surgical techniques, blood requirement for coronary bypass operations has been reduced to a minimum. Of 240 patients (average number of bypasses, 3.07; average pump time, two hours and 22 minutes), no blood was used in pump prime or before perfusion. During perfusion, 29 patients (12%) received 34 units of blood in the pump-oxygenator, and after bypass 64 patients (27%) received 65 units of blood in the operating room (average intraoperative use, 203 ml per patient). For the total hospital stay, the blood requirement was 728 ml per patient. For the last 60 patients operated on, the figure was 328 ml. There were no surgical deaths, and only 1 reexploration for postoperative hemorrhage (0.4%). Discharge hemoglobin level averaged 11.8 gm, whereas the admission hemoglobin level had averaged 13.8 gm. Autotransfusion, avoidance of entry into the pleural space, shorter perfusion time, postoperative platelet count of more than 150,000, and normal partial thromboplastin time tend to reduce blood requirement, but not to a striking degree. Bank blood requirement for the coronary bypass program accounted for 3.7% of the hospital need and 2% of the community need.     

Sodium nitroprusside as a coronary vasodilator in man. I. Effect of intracoronary sodium nitroprusside on coronary arteries, angina pectoris, and coronary blood flow.

The effect of the intra-arterial injection of 5 to 10 microng of sodium nitroprusside on the caliber of normal and diseased coronary arteries was evaluated in 21 patients during diagnostic cardiac catheterization. In addition, the effect of intra-graft injection of 5 microng of the same agent on the blood flow in aorta-right coronary artery saphenous vein bypass grafts was also evaluated intra-operatively in two patients. The compound induced an increase in the caliber of both normal and stenosed coronary arteries as well as an increase of flow in the grafts. Consistent with measurements of coronary flow response to sodium nitroprusside, angina pectoris which developed in four patients during cardiac catheterization was immediately relieved and the ischemic ST-segment depression significantly reversed after injection of 5 to 10 microng of the drug into the left main coronary artery. Within the dose range used, the drug caused no significant effect on systemic blood pressure or apparently deleterious electrophysiologic changes. No side effects were observed. We conclude that the primary direct action of sodium nitroprusside in the human coronary artery is vasodilatory.     

Early furosemide therapy in premature infants (less than or equal to 2000 gm) with respiratory distress syndrome: a randomized controlled trial

Pulmonary edema has been demonstrated in the early stages of respiratory distress syndrome in premature infants. To evaluate whether early furosemide therapy (0 to 8 hours after birth) would affect the electrolyte balance, pulmonary status, and outcome, 57 infants (less than or equal to 2000 gm) with respiratory distress syndrome who required mechanical ventilation shortly after birth were randomized into two groups: 29 given furosemide (1 mg/kg/day intravenously for three doses) and 27 control. The clinical, biochemical, and laboratory characteristics of the groups were comparable before entry into the study. Administration of furosemide significantly enhanced the urinary excretion of Na and Cl at 0 to 24, 24 to 48 and 48 to 72 hours and of Ca at 24 to 48 and 48 to 72 hours after drug administration. There was no significant difference between the groups in urinary excretion of K and in serum Na, Cl, K, and Ca values. A spontaneous increase in urine output occurred in the control group at 48 to 72 hours after the initiation of the study (mean +/- SD 7.0 +/- 3.5 hours postnatal age), along with a decrease in mean airway pressure for mechanical ventilation. The use of furosemide (7.3 +/- 3.5 hours postnatal age) enhanced urine output at 24 to 48 and 48 to 72 hours after medication, resulting in further decrease in mean airway pressure and facilitating extubation. There was, however, no significant difference between the groups with respect to incidence of patent ductus arteriosus, morbidity from bronchopulmonary dysplasia, and mortality.     

Urinary excretion of desmosine in patients with severe burns

Urinary excretion of total desmosine was measured by a radioimmunoassay in severely burned adult males, as well as in normal adult males. Total urinary desmosine was significantly elevated in all the samples in the burned patients, who had injuries involving more than 19% of total body surface area. The values of 24-hr urinary desmosine for the burned patients ranged from 250–1,411 nmoles, as compared with 82–142 nmoles for normal controls. These were equivalent to 14–78 mg of elastin degraded for the burned patients and 5–8 mg for normal controls. Urinary desmosine values expressed as nmoles per g of creatinine were also higher than the corresponding normal values, ranging from 110–768 nmoles versus 63 ± 6 nmoles for normal controls. Urinary excretion of total hydroxyproline in the burned patients was also higher than in normal controls, ranging from 56–471 mg per 24 hrs, or 36 to 413 mg per g of creatinine, vs. 31 ± 6 mg per 24 hr, or 23 ± 2 mg per g of creatinine, in burned patients and normal controls, respectively. These values of hydroxyproline were equivalent to 413–3,623 mg of collagen and 238 mg of collagen, respectively. In the burned patients, both urinary desmosine and hydroxyproline values were elevated from day 1 post-burn, and reached peak levels in days 2–12, declining thereafter but remaining higher than values for normal controls through day 60. The metabolism of elastin and collagen in skin of burned patients was probably highly accelerated for a long time, at least through day 60 post-burn.     

Y-grafts and sequential grafts in coronary bypass surgery: a critical evaluation of patency rates.

In a series of 584 patients undergoing coronary bypass, 425 patients received Y-grafts, sequential grafts, or a combination of the two. The saphenous veins from the legs frequently had Y- or double Y-branches suitable for bypasses. As many as 5 grafts have been served satisfactorily by a single proximal anastomosis. Simultaneous procedures included 45 left ventricular aneurysmectomies, 18 valve replacements, 7 carotid endarterectomies, repairs of a ventricular septal defect, an acute dissection, and coronary arteriovenous fistulas, with a total surgical mortality of 6 (1.4%). Restudy to determine graft patency was undertaken only in the 59 patients with unsatisfactory surgical results. These patients represent the worst 10% of the series in terms of surgical results. The patency rate for proximal anastomoses was 93%; Y-branchings, 93%; distal end-to-side anastomoses, 89%; and distal side-to-side anastomoses, 89%. Fifty-eight patients (98%) had at least 1 patient graft, and in 47 patients (80%) all anastomoses were patent up to six years after operation. Six patients underwent reoperation without any deaths.