Discordance in Grading Methods of Aortic Stenosis by Pre-Cardiopulmonary Bypass Transesophageal Echocardiography.

BACKGROUND: Current guidelines define severe aortic valve stenosis (AS) as an aortic valve area (AVA) ≤1.0 cm by the continuity equation and mean gradient (ΔPm) ≥ 40 mm Hg. However, these measurements can be discordant when classifying AS severity. Approximately one-third of patients with normal ejection fraction and severe AS by AVA have nonsevere AS by ΔPm when measured by preoperative transthoracic echocardiography (TTE). Given the use of positive pressure ventilation and general anesthesia in the pre-cardiopulmonary bypass (pre-CPB) period, we hypothesized that discordance between ΔPm and AVA during pre-CPB transesophageal echocardiography (TEE) would be higher than previously reported by TTE. METHODS: We retrospectively examined pre-CPB TEE data for patients who had aortic valve replacement, with or without coronary artery bypass grafting, from 2000 to 2012. Patients were excluded if they had ejection fraction <55%, emergency surgery, repeat sternotomy, moderate or severe mitral regurgitation, or severe aortic regurgitation. Only patients with both pre-CPB AVA and ΔPm measurements were included. Patients were grouped according to severity (mild, moderate, and severe) by AVA or ΔPm. Discordance was defined as disagreement between severities based on either parameter. RESULTS: A total of 277 patients met inclusion criteria. There were 227 patients with AVA ≤ 1.0 cm. The proportion of these patients with a ΔPm < 40 mm Hg was 54% (95% confidence interval, 47%-61%). The rate of discordance was significantly higher than the rate (37%; P < 0.001) found in previously reported analyses using TTE. Of the patients with a ΔPm ≥ 40 mm Hg, only 8% (n = 9/113) had a discordant AVA. In contrast, of the patients with ΔPm < 40 mm Hg, 80% (n = 131/164) had a discordant AVA. CONCLUSIONS: We confirmed our hypothesis that grading AS by ΔPm and AVA during pre-CPB TEE exhibits higher discordance than reported for TTE by others. It remains unclear whether these discrepancies reflect the effect of general anesthesia, imaging modality (TTE versus TEE) differences, inaccuracies in AS grading cutoffs when applied to pre-CPB TEE, or selection bias of the surgical population.

Anatomy of the patent foramen ovale for the interventionalist.

BACKGROUND: Patent foramen ovale (PFO) is an interatrial communication whose management is controversial. Several manufacturers have submitted protocols for Food and Drug Administration (FDA) approval of their PFO closure device. The purpose of this study was to define anatomy relevant to percutaneous PFO closure, validate the clinical observation that most PFOs contain little tissue rim at the aorta, comment on proposed closure guidelines, and to discuss approaches to PFO closure. METHODS: From the Mayo Clinic Tissue Registry, five normal hearts with PFO were selected from each sex from the first 10 decades of life (n = 100). Measurements (mm) included PFO length, diameter, and distance from FO-superior vena cava (SVC) and FO-aortic annulus (AoAn). Patient age, weight, and height were obtained from autopsy reports, and body surface area (BSA) was calculated. RESULTS: PFO length and diameter increased with age (P = 0.029 and 0.001, respectively), and FO-SVC and FO-AoAn increased with BSA (P

How well do headache patients remember? A comparison of self-report measures of headache frequency and severity in patients with migraine.

OBJECTIVE: To compare patient recall of migraine headache frequency and severity over 4 weeks prior to a return visit as reported in an interval questionnaire vs a daily diary. BACKGROUND: Many therapeutic decisions in the management of migraine patients are based on patient recall of response to treatment. As consistent completion of a daily headache diary is problematic, we have assessed the reliability of patient recall in a 1-time questionnaire. METHODS: Headache frequency and average severity (0 to 3-point scale) were reported in an interval questionnaire by 209 patients who had also maintained a daily diary over the same 4-week period. RESULTS: Headache frequency over the previous 4 weeks as reported in interval questionnaires (14.7) was not different from that documented in diaries (15.1), P = .056. However, reported average headache severity on a 0 to 3 scale as reported in the questionnaire (1.84) was worse than that documented in the diaries (1.63), P < .001. CONCLUSIONS: In the management of individual patients, the daily diary is still preferable when available. Aggregate assessment of headache frequency in groups of patients based on recall of the prior 4 weeks is equally as reliable as a diary. Headache severity reported in questionnaires tends to be greater than that documented in daily diaries and may be less reliable.

Surgical correction of childhood intermittent exotropia and the risk of developing mental illness.

PURPOSE: To assess whether successful surgical intervention for intermittent exotropia, or the timing of intervention, has any effect on the development of mental illness. DESIGN: Retrospective, observational case series. METHODS: All patients (<19 years of age) diagnosed with intermittent exotropia in Olmsted County, Minnesota, from January 1, 1975, through December 31, 1994, were reviewed retrospectively. Potential cases were identified using the resources of the Rochester Epidemiology Project, a medical records database designed to capture data on any patient-physician encounter in Olmsted County, Minnesota. The main outcome measures were the occurrence and severity of mental illness among those who underwent strabismus surgery compared with those who did not. RESULTS: Ninety-six (52%) of the 184 children identified were diagnosed with a mental illness at a mean age of 23.3 years (range, 6 to 41 years). Thirty-five (36%) of the 96 children in whom mental illness developed underwent strabismus surgery. Success at surgery (<10 prism diopters) was not associated with a decreased occurrence of mental illness (P = .30). Of the 88 patients in whom mental illness did not develop, strabismus surgery was not more commonly performed (P = .54), nor was it performed at a younger age (P = 1.0), when compared with the 96 patients in whom mental illness developed later. CONCLUSIONS: Strabismus surgery for children with intermittent exotropia, regardless of success or age at surgery, did not alter the development of mental illness by early adulthood.

Prevalence and sex differences of psychiatric disorders in young adults who had intermittent exotropia as children.

OBJECTIVE: To evaluate the prevalence and sex differences of mental disorders diagnosed among young adults who had intermittent exotropia (IXT) as children. METHODS: The medical records of all children (<19 years) diagnosed as having IXT as residents of Olmsted County, Minnesota, from January 1, 1975, through December 31, 1994, and their randomly selected nonstrabismic birth- and sex-matched controls (1:1) were retrospectively reviewed. RESULTS: A mental health disorder was diagnosed in 97 (53.0%) of the 183 patients with childhood IXT followed to a mean age of 22 years compared with 55 (30.1%) controls (P < .001). Patients with IXT were 2.7 (95% confidence interval, 1.7-4.1) times more likely to develop a psychiatric illness than controls. A mental health disorder was diagnosed in 63% (41 of 65) and 47% (56 of 118) of males and females with IXT, respectively, compared with 33% (22 of 66) and 28% (33 of 117) of male and female controls, respectively. Additionally, males with IXT had a greater use of psychotropic medication (P = .003), psychiatric emergency department visits (P < .001), psychiatric hospital admissions (P = .04), suicide attempts (P = .004), and suicidal ideation (P = .002) than controls, and females with IXT had more suicidal ideation (P = .02) than controls. CONCLUSIONS: Children diagnosed as having IXT, especially males, are more likely to develop mental illness by the third decade of life compared with children without strabismus.

Mental illness in young adults who had strabismus as children.

OBJECTIVE: We investigated the prevalence and types of psychiatric disorders diagnosed by early adulthood among patients who had common forms of strabismus as children. METHODS: The medical records of children (<19 years) who were diagnosed as having esotropia (N = 266) or exotropia (N = 141) while residents of Olmsted County, Minnesota, between January 1, 1985, and December 31, 1994, were reviewed retrospectively for psychiatric disease diagnoses. Each case subject was compared with a randomly selected, individually birth- and gender-matched, control subject from the same population. RESULTS: A mental health disorder was diagnosed for 168 (41.3%) of the 407 patients with a history of childhood strabismus, who were monitored to a mean age of 17.4 years, compared with 125 control subjects (30.7%). Children with exotropia were 3.1 times more likely to develop a psychiatric disorder than were control subjects when monitored to a mean age of 20.3 years. Children with esotropia were no more likely to develop mental illness than were control subjects when monitored for similar periods. Patients with intermittent exotropia also were significantly more likely to have greater numbers of mental health disorders, mental health emergency department visits, and mental health hospitalizations and to have suicidal or homicidal ideation. CONCLUSIONS: Children diagnosed as having strabismus in this population, especially those with exotropia, were at increased risk for developing mental illness by early adulthood. Patients with intermittent exotropia seemed to be particularly prone to developing significant psychiatric diseases by the third decade of life.