Commissural fusion as etiology of bioprosthetic mitral stenosis in a patient with rheumatic heart disease.

We report commissural fusion as a unique morphologic etiology of early bioprosthetic mitral valve failure in a woman with a history of rheumatic mitral stenosis. She had undergone mitral valve replacement with a 25-mm Edwards Magna Ease bovine pericardial bioprosthesis 3 years earlier and presented with progressive dyspnea. Transesophageal echocardiography revealed severe bioprosthetic stenosis due to commissural fusion. She underwent percutaneous valve-in-valve implantation with a 26-mm Edwards Sapien 3 prosthesis. Marked symptomatic improvement was noted postprocedurally. We speculate that commissural fusion may be a unique pathologic feature of failing bioprosthetic valves in patients with prior rheumatic mitral valve disease.

Prevalence and Significance of Patient Prosthesis Mismatch Following Edwards SAPIEN XT and SAPIEN 3 Transcatheter Aortic Valve Replacement.

Background Severe patient prosthesis mismatch (sPPM) after surgical aortic valve replacement is associated with worse outcomes. Limited data exists on the impact of sPPM on outcomes after transcatheter aortic valve replacement (TAVR), especially regarding the newer generation valves. The aim of this study was to evaluate the incidence, determinants, and outcomes of sPPM in patients undergoing TAVR with Edwards SAPIEN XT (ES XT) and Edwards SAPIEN 3 (ES3) valves (Edwards Lifesciences, Irvine, CA, USA). Methods We retrospectively reviewed 366 patients who underwent TAVR with ES XT (n = 114) or ES3 (n = 252) valves between July 2012 and June 2018. sPPM was defined as indexed effective orifice area (iEOA) <0.65 cm2/m2. Kaplan-Meier survival estimates were used to determine outcomes. Results Multivariate linear regression analysis was utilized to determine potential independent effects of PPM on outcomes. sPPM was present in 40 (11%) of the patients [8 (7%) ES XT and 32 (13%) ES3] and was associated with female sex, smaller left ventricular outflow tract (LVOT) diameter and aortic valve annular area, absence of prior coronary artery bypass graft (CABG) surgery, shorter height, higher body mass index, and smaller pre-TAVR valve area (all p < 0.05). Among those with ES3 valves, the incidence of sPPM was inversely proportional to the valve size (50%, 25%, 5% and 3% for 20-, 23-, 26- and 29-mm valve sizes, respectively; p < 0.001). At a mean follow-up period of 3.5 ± 1.5 years, there was no difference in all-cause mortality (22.5% vs. 25.6%, p = 0.89) or a composite endpoint of heart failure, arrhythmias, stroke, and myocardial infarction (30% vs. 34%, p = 0.24) in those with or without sPPM. Conclusion ES3 was associated with a higher incidence of sPPM, particularly with smaller valve sizes. However, the presence of sPPM as defined by iEOA was not an independent predictor of adverse outcomes in patients undergoing TAVR within an intermediate follow-up period.

Low Risk of Hypertrophic Cardiomyopathy With Contemporary Management Strategies Implemented in Non-Referral Regional Community-Based Practices.

Major advances in diagnosis and treatment have emerged for hypertrophic cardiomyopathy (HCM), largely in major tertiary referral centers dedicated to this disease. Whether these therapeutic benefits are confined to patients in such highly selected cohorts, or can be implemented effectively in independent regional or community-based populations is not generally appreciated. We assessed management and clinical outcomes in a non-referral HCM center (n = 214 patients) in Eastern Pennsylvania. Over a 6.0 ± 3.2-year follow-up, the HCM-related mortality rate was 0.1% per year attributed to a single disease-related death, in a 49-year-old man with end-stage heart failure, ineligible for heart transplant. Fifteen patients (7%) with prophylactically placed implantable cardioverter-defibrillators (ICDs) experienced appropriate therapy terminating life-threatening ventricular tachyarrhythmias. In 23 other patients (11%; 5%/year), heart failure due to left ventricular outflow obstruction was reversed by surgical septal myectomy (n = 20) or percutaneous alcohol septal ablation (n = 3). This regional HCM cohort was similar to a comparison tertiary center referral population in terms of HCM-mortality: 0.1%/year vs 0.3%/year (p = 0.3) and ICD therapy (31% vs 16% of primary prevention implants), although more frequently with uncomplicated benign clinical course (62% vs 46%; p <0.01). In conclusion, effective contemporary HCM management strategies and outcomes in referral-based HCM centers can be successfully replicated in regional and/or non-referral settings. Therefore, HCM is now a highly treatable disease compatible with normal longevity when assessed in a variety of clinical venues not limited to tertiary centers.

Comparative analysis of risk-adjusted bypass surgery stratification models in a community hospital.

BACKGROUND: Quality improvement in health care, which relies on appropriate strategies to evaluate and compare provider performance, has spawned the propagation of many public report cards or provider profiles for cardiac surgery. These risk-adjusted prediction models allow for the computation of a provider's expected outcome event rate compared with observed outcome events. The aim of this study was to assess the accuracy and reliability of 5 risk-adjusted predictive models for mortality in an independent population of patients in a community hospital who underwent coronary artery bypass graft surgery. METHODS: Five nonproprietary models were selected for evaluation (Parsonnet, Canadian, Cleveland, New York, and the Northern New England). RESULTS: The C-statistic for the 5 models was 0.752, 0.693, 0.748, 0.735, and 0.722 for the Parsonnet, Canadian, Cleveland, New York, and Northern New England models respectively. The H-L c2 calibration statistics were 4.948, P =.763; 1.616, P =.899; 11.96, P =.035; 10.23, P =.249; and c2 = 12.14, P =.145 for the Parsonnet, Canadian, Cleveland, New York, and Northern New England models respectively. CONCLUSIONS: Comparing hospital-specific or surgeon-specific mortality/morbidity rates will remain a challenge. This analysis reaffirms the concept of risk-adjusting outcomes and emphasizes the importance of the risk-adjustment process for CABG surgery in a community hospital.

Off the shelf or recalibrate? customizing a risk index for assessing mortality.

BACKGROUND: Public "report cards" for cardiac surgery have been freely available from a variety of sources. These risk-adjusted indices serve as a means of benchmarking outcomes performances, allowing comparisons of outcomes between surgical programs, and quantifying quality improvement programs. We examined two alternative strategies for using previously developed risk-adjusted mortality models in a community hospital: (1) using the model "off the shelf" (OTS) and (2) recalibrating the existing model (RM) to fit the institution-specific population. METHODS: Six OTS models were used: Parsonnet (PA), Canadian (CA), Cleveland (CL), Northern New England (NNE), New York (NY), and New Jersey (NJ). The RM models were created by each model's independent variables and definitions and adjusting the weighting with logistic regression methods. The accuracy, the C statistic, and the precision of each model were assessed for in-hospital mortality. We compared the OTS version of each model to the RM version with methods detailed by Hanley and McNeil. RESULTS: The RM C statistic was improved for all risk-adjusted models, most notably in the statistical improvement seen in the PA (0.053 improvement) and NJ (0.052 improvement) indices. Statistical gains in precision were also seen in the RM models for the PA, CL, and NNE indices. Conversely, one model, the CA model, was more poorly calibrated in the RM model compared with the OTS model, despite an improved C statistic (0.062). CONCLUSIONS: The RM strategy provides institution-explicit models that demonstrate a higher degree of accuracy and precision than the OTS models.

Surgical treatment of an amniotic fluid embolism with cardiopulmonary collapse.

Amniotic fluid embolism is a rare but devastating condition associated with a very high rate of morbidity and mortality. The treatment has traditionally been aggressive supportive care. We report a case of a term pregnant woman with complete cardiovascular collapse secondary to a paradoxical amniotic fluid embolism. The embolism was seen on transesophageal echocardiogram during an emergency Cesarean section as a free-floating interatrial clot through a patent foramen ovale. She was subsequently and successfully treated with immediate cardiopulmonary bypass, thromboembolectomy, and closure of the patent foramen ovale.

Amniotic fluid embolism complicated by paradoxical embolism and disseminated intravascular coagulation.

Amniotic fluid embolism is a rare syndrome with potentially lethal outcomes. Complications include cardiorespiratory failure, disseminated intra-vascular coagulation, seizures, neurological deficits, and death. A 34-year-old woman had amniotic fluid embolism complicated by paradoxical embolism and disseminated intravascular coagulation. Emergency cesarean section followed by cardiopulmonary bypass with removal of the clot from the atria and closure of the patent foramen ovale was performed, resulting in a good outcome for both the mother and the baby. Subsequent treatment with anticoagulants for 6 months was recommended. A literature review revealed that this clinical scenario is rare but can be successfully managed by cardiopulmonary bypass and thromboembolectomy. Data on guidelines for the use of anticoagulation in this situation are limited.

Impact of aprotinin on adverse clinical outcomes and mortality up to 12 years in a registry of 3,337 patients.

BACKGROUND: Recent studies have suggested increased renal complications and long-term mortality with aprotinin use in coronary artery bypass grafting (CABG) patients. However, these studies have been criticized for including multiple centers and different dosing strategies. We analyzed prospectively collected registry data from a single center hospital utilizing a full-dose aprotinin regimen to evaluate if aprotinin was associated with increased mortality and adverse outcomes compared with Amicar. METHODS: Data were prospectively collected from 1994 to 2006 at a teaching hospital. Long-term mortality was collected from a Social Security database. To account for differences between aprotinin and Amicar-treated patients, a propensity score was generated and propensity-stratified multivariate model for mortality were performed. RESULTS: Compared with Amicar-treated patients (n = 1,830), aprotinin-treated patients (n = 1,507) were older, more often female, had lower creatinine clearance, and more baseline risk factors. Blood loss was lower in aprotinin-treated patients (median 715 mL vs 918 mL, p < 0.001). Postoperative renal failure was significantly higher in aprotinin patients (6.2% vs 2.7%, p < 0.001). At median 5.4-year follow-up (up to 12.2 years), aprotinin-treated patients had higher mortality versus Amicar-treated patients (Kaplan-Meier failure rates 43.5% vs 23.7% at 8 years, p < 0.0001). In a propensity-stratified model with multivariate adjustment, aprotinin remained associated with increased mortality (hazard ratio 1.62, 95% CI 1.39 to 1.90, p < 0.001). There was a stepwise relationship between weight-based aprotinin dose and mortality (p-trend < 0.001). CONCLUSIONS: Among patients undergoing CABG in this registry, aprotinin use was associated with increased renal failure and higher mortality through 12 years in a propensity-stratified analysis. The increased mortality may be related to higher concentrations of aprotinin received.

Impact of saphenous vein graft radiographic markers on clinical events and angiographic parameters.

BACKGROUND: Use of saphenous vein graft (SVG) radiographic markers has been associated with shorter cardiac catheterization procedure times and reduced contrast agent volume for postoperative coronary artery bypass graft (CABG) catheterizations. Use of such markers is varied and often operator-dependent, as the effect of SVG markers has not been fully evaluated. The goal of the present analysis was to evaluate the association of SVG markers with clinical outcomes and graft patency. METHODS: Data were drawn from the Project of Ex-vivo Vein Graft Engineering via Transfection (PREVENT) IV trial of patients undergoing CABG at 107 hospitals across the United States. Repeat angiography was performed within 12 to 18 months after CABG. The SVG markers were used at the discretion of the surgeon and were identified on the follow-up angiogram as any device used to mark the ostium, regardless of shape. RESULTS: The SVG markers were present in 51.2% of evaluable patients (910 of 1,778) and 52.3% of SVGs (2,228 of 4,240). Among patients with totally occluded SVGs (n = 911), visual identification of the SVG was obtained more frequently in those with an SVG marker (90.7% vs 72.1%, p < 0.001). The SVG stenosis 70% or greater at follow-up did not differ by use of markers (25.8% with marker vs 24.4% without marker, p = not significant). These findings were also consistent in ostial lesions (n = 942). Long-term death or myocardial infarction (MI) was similar by use of marker. The perioperative CABG MI was higher in patients with SVG markers (10.1% vs 5.5%, odds ratio adjusted 1.86, p = 0.021). CONCLUSIONS: Saphenous vein graft radiographic markers were associated with higher rates of direct visualization of totally occluded SVGs without an adverse effect on graft patency or long-term clinical outcomes, but the association of SVG markers with increased perioperative CABG MI warrants further examination.

Personal exposures to inorganic and organic dust in manual harvest of California citrus and table grapes.

The aim of this study was to determine characteristics of personal exposure to inorganic and organic dust during manual harvest operations of California citrus and table grapes. Personal exposures to inhalable dust and respirable dust were measured five times over a 4-month period of harvesting season. We analyzed components of the dust samples for mineralogy, respirable quartz, endotoxin, and total and culturable microorganisms. Workers manually harvesting were exposed to a complex mixture of inorganic and organic dust. Exposures for citrus harvest had geometric means of 39.7 mg/m(3) for inhalable dust and 1.14 mg/m(3) for respirable dust. These exposures were significantly higher than those for table grape operations and exceeded the threshold limit value for inhalable dust and respirable quartz. Exposures for table grape operations were lower than the threshold limit value, except inhalable dust exposure during leaf pulling. Considered independently, exposures to inhalable dust and respirable quartz in citrus harvest may be high enough to cause respiratory health effects. The degree of vigorous contact with foliage appeared to be a significant determining factor of exposures in manual harvesting.

Is chronic airway obstruction from cotton dust exposure reversible?

BACKGROUND: Exposure to cotton dust is known to cause chronic airway obstruction, but there is little information on whether the obstructive impairment is reversible after the exposure stops. METHODS: Longitudinal changes in lung function were evaluated among 429 cotton textile workers and 449 silk workers in Shanghai, China, beginning in 1981. Both active and retired workers were tested every 4 to 6 years for 15 years. RESULTS: Overall, cotton workers had greater annual declines in forced expiratory volume in 1 second (FEV1) and forced vital capacity (FVC). Compared with active workers, retired cotton workers had lower annual loss of FEV1, although the retired workers had a greater loss during their active employment than the currently active workers. No such trends were detected in silk workers. Annual declines in FEV1 in retired cotton workers were smaller with increasing time since retirement. Multivariate analysis showed that retirement was a substantial contributing factor for improved FEV1 and FVC in the cotton workers, especially among those who did not smoke. Correspondingly, remission of airflow obstruction, defined as a ratio of FEV1 and FVC of less than 70%, was more common in retirees than in the active workers, and more common in nonsmokers than in smokers. CONCLUSION: Chronic airway obstruction related to long-term exposure to cotton dust may be partially reversible after the exposure ceases, although lung function does not return to the level found in unexposed workers.

Changes in humoral immunologic parameters after exposure to volcanic ash

Occupational exposure to volcanic ash from Mount St. Helens continues during the salvaging of trees in the high dust blow-down area of Washington. We studied the effects of volcanic ash exposure on the level of humoral inmune factors IgG, IgA, IgM, C3, C4, and ANA (antinuclear antibody) in a group of volcanic ash-exposed loggers shortly after the major eruption and one year later. Comparisons with similar levels in nonexposed, similarly employed, matched loggers were made. C3 and C4 levels were significantly lower at both time periods in the exposed loggers when compared to the reference group. No differences between groups were observed at either time period for the inmunoglobulin levels or ANA. The exposed loggers did show a marked decrease (not seen in the reference group) in serum IgG levels after 1 yr of exposure to the volcanic ash. They likewise showed a significant mean increase in IgA, while the reference group had a mean increase in IgM after 1 yr. These data suggest that exposure to volcanic ash may affect humoral inmunologic parameters(AU)