ERS/ESICM/ESCMID/ALAT guidelines for the management of severe community-acquired pneumonia.

BACKGROUND: Severe community-acquired pneumonia (sCAP) is associated with high morbidity and mortality, and while European and non-European guidelines are available for community-acquired pneumonia, there are no specific guidelines for sCAP. MATERIALS AND METHODOLOGY: The European Respiratory Society (ERS), European Society of Intensive Care Medicine (ESICM), European Society of Clinical Microbiology and Infectious Diseases (ESCMID) and Latin American Thoracic Association (ALAT) launched a task force to develop the first international guidelines for sCAP. The panel comprised a total of 18 European and four non-European experts, as well as two methodologists. Eight clinical questions for sCAP diagnosis and treatment were chosen to be addressed. Systematic literature searches were performed in several databases. Meta-analyses were performed for evidence synthesis, whenever possible. The quality of evidence was assessed with GRADE (Grading of Recommendations, Assessment, Development and Evaluation). Evidence to Decision frameworks were used to decide on the direction and strength of recommendations. RESULTS: Recommendations issued were related to diagnosis, antibiotics, organ support, biomarkers and co-adjuvant therapy. After considering the confidence in effect estimates, the importance of outcomes studied, desirable and undesirable consequences of treatment, cost, feasibility, acceptability of the intervention and implications to health equity, recommendations were made for or against specific treatment interventions. CONCLUSIONS: In these international guidelines, ERS, ESICM, ESCMID and ALAT provide evidence-based clinical practice recommendations for diagnosis, empirical treatment and antibiotic therapy for sCAP, following the GRADE approach. Furthermore, current knowledge gaps have been highlighted and recommendations for future research have been made.

Enhanced THz radiation through a thick plasmonic electrode grating photoconductive antenna with tight photocarrier confinement.

We propose the design of a photoconductive antenna (PCA) emitter with a plasmonic grating featuring a very high plasmonic Au electrode with a thickness of 170 nm. As we show numerically, the increase in h significantly changes the electric field distribution, owing to the excitation of higher-order plasmon guided modes in the Au slit waveguides, leading to an additional increase in the emitted THz power. We develop the plasmonic grating geometry with respect to maximal transmission of the incident optical light, so as to expect the excitation of higher-order plasmon guided Au modes. The fabricated PCA can efficiently work with low-power laser excitation, demonstrating an overall THz power of 5.3 µW over an ∼4.0 THz bandwidth, corresponding to a conversion efficiency of 0.2%. We believe that our design can be used to meet the demands of modern THz spectroscopic and high-speed imaging applications.

Anti-vascular endothelial growth factor for proliferative diabetic retinopathy.

BACKGROUND: Proliferative diabetic retinopathy (PDR) is an advanced complication of diabetic retinopathy that can cause blindness. It consists of the presence of new vessels in the retina and vitreous haemorrhage. Although panretinal photocoagulation (PRP) is the treatment of choice for PDR, it has secondary effects that can affect vision. Anti-vascular endothelial growth factor (anti-VEGF), which produces an inhibition of vascular proliferation, could improve the vision of people with PDR. OBJECTIVES: To assess the effectiveness and safety of anti-VEGFs for PDR and summarise any relevant economic evaluations of their use. SEARCH METHODS: We searched CENTRAL (which contains the Cochrane Eyes and Vision Trials Register; 2022, Issue 6); Ovid MEDLINE; Ovid Embase; the ISRCTN registry; ClinicalTrials.gov, and the WHO ICTRP. We did not use any date or language restrictions. We last searched the electronic databases on 1 June 2022. SELECTION CRITERIA: We included randomised controlled trials (RCTs) comparing anti-VEGFs to another active treatment, sham treatment, or no treatment for people with PDR. We also included studies that assessed the combination of anti-VEGFs with other treatments. We excluded studies that used anti-VEGFs in people undergoing vitrectomy. DATA COLLECTION AND ANALYSIS: Two review authors independently selected studies for inclusion, extracted data, and assessed the risk of bias (RoB) for all included trials. We calculated the risk ratio (RR) or the mean difference (MD), and 95% confidence intervals (CI). We used GRADE to assess the certainty of evidence. MAIN RESULTS: We included 15 new studies in this update, bringing the total to 23 RCTs with 1755 participants (2334 eyes). Forty-five per cent of participants were women and 55% were men, with a mean age of 56 years (range 48 to 77 years). The mean glycosylated haemoglobin (Hb1Ac) was 8.45% for the PRP group and 8.25% for people receiving anti-VEGFs alone or in combination. Twelve studies included people with PDR, and participants in 11 studies had high-risk PDR (HRPDR). Twelve studies were of bevacizumab, seven of ranibizumab, one of conbercept, two of pegaptanib, and one of aflibercept. The mean number of participants per RCT was 76 (ranging from 15 to 305). Most studies had an unclear or high RoB, mainly in the blinding of interventions and outcome assessors. A few studies had selective reporting and attrition bias. No study reported loss or gain of 3 or more lines of visual acuity (VA) at 12 months. Anti-VEGFs ± PRP probably increase VA compared with PRP alone (mean difference (MD) -0.08 logMAR, 95% CI -0.12 to -0.04; I2 = 28%; 10 RCTS, 1172 eyes; moderate-certainty evidence). Anti-VEGFs ± PRP may increase regression of new vessels (MD -4.14 mm2, 95% CI -6.84 to -1.43; I2 = 75%; 4 RCTS, 189 eyes; low-certainty evidence) and probably increase a complete regression of new vessels (RR 1.63, 95% CI 1.19 to 2.24; I2 = 46%; 5 RCTS, 405 eyes; moderate-certainty evidence). Anti-VEGFs ± PRP probably reduce vitreous haemorrhage (RR 0.72, 95% CI 0.57 to 0.90; I2 = 0%; 6 RCTS, 1008 eyes; moderate-certainty evidence). Anti-VEGFs ± PRP may reduce the need for vitrectomy compared with eyes that received PRP alone (RR 0.67, 95% CI 0.49 to 0.93; I2 = 43%; 8 RCTs, 1248 eyes; low-certainty evidence). Anti-VEGFs ± PRP may result in little to no difference in the quality of life compared with PRP alone (MD 0.62, 95% CI -3.99 to 5.23; I2 = 0%; 2 RCTs, 382 participants; low-certainty evidence). We do not know if anti-VEGFs ± PRP compared with PRP alone had an impact on adverse events (very low-certainty evidence). We did not find differences in visual acuity in subgroup analyses comparing the type of anti-VEGFs, the severity of the disease (PDR versus HRPDR), time to follow-up (< 12 months versus 12 or more months), and treatment with anti-VEGFs + PRP versus anti-VEGFs alone. The main reasons for downgrading the certainty of evidence included a high RoB, imprecision, and inconsistency of effect estimates. AUTHORS' CONCLUSIONS: Anti-VEGFs ± PRP compared with PRP alone probably increase visual acuity, but the degree of improvement is not clinically meaningful. Regarding secondary outcomes, anti-VEGFs ± PRP produce a regression of new vessels, reduce vitreous haemorrhage, and may reduce the need for vitrectomy compared with eyes that received PRP alone. We do not know if anti-VEGFs ± PRP have an impact on the incidence of adverse events and they may have little or no effect on patients' quality of life. Carefully designed and conducted clinical trials are required, assessing the optimal schedule of anti-VEGFs alone compared with PRP, and with a longer follow-up.

Feasibility of concomitant left atrial appendage closure and percutaneous coronary intervention in patients with acute coronary syndrome and atrial fibrillation: a randomized pilot study.

The optimal approach for prevention of cardiovascular events and reduction of bleeding in patients with acute coronary syndrome (ACS) and atrial fibrillation (AF) is still controversial. The aim of our study is to asses our single-center experience with concomitant left atrial appendage occlusion (LAAO) and percutaneous coronary intervention (PCI). 50 patients with ACS without ST elevation and history of AF were randomized after successful PCI to LAAO or conventional medical therapy. The primary endpoints were safety and length of hospitalization. The follow-up period was 30 days. The mean procedural times were 113 ± 23 min PCI + LAAO implantation and 39 ± 19 min of PCI only (p < 0.001), while mean fluoroscopy times were 18 ± 8 min and 12 ± 8 min (p < 0.001), respectively. No procedure-related complications were observed. There was no difference observed for length of hospitalization between two groups. LAAO in patients with ACS and AF undergoing PCI appears safe.

Myocardial protection with phosphocreatine in high-risk cardiac surgery patients: a randomized trial.

BACKGROUND: This study was conducted to test the hypothesis that phosphocreatine (PCr), administered intravenously and as cardioplegia adjuvant in patients undergoing cardiac surgery with prolonged aortic cross clamping and cardiopulmonary bypass (CPB) time, would decrease troponin I concentration after surgery. METHODS: In this randomized, double-blind, placebo-controlled pilot study we included 120 patients undergoing double/triple valve repair/replacement under cardiopulmonary bypass in the cardiac surgery department of a tertiary hospital. The treatment group received: intravenous administration of 2 g of PCr after anesthesia induction; 2.5 g of PCr in every 1 L of cardioplegic solution (concentration = 10 mmol/L); intravenous administration of 2 g of PCr immediately after heart recovery following aorta declamping; 4 g of PCr at intensive care unit admission. The control group received an equivolume dose of normosaline. RESULTS: The primary endpoint was peak concentration of troponin I after surgery. Secondary endpoints included peak concentration of serum creatinine, need for, and dosage of inotropic support, number of defibrillations after aortic declamping, incidence of arrhythmias, duration of Intensive Care Unit (ICU) stay, length of hospitalization. There was no difference in peak troponin I concentration after surgery (PCr, 10,508 pg/ml [IQR 6,838-19,034]; placebo, 11,328 pg/ml [IQR 7.660-22.894]; p = 0.24). There were also no differences in median peak serum creatinine (PCr, 100 µmol/L [IQR 85.0-117.0]; placebo, 99.5 µmol/L [IQR 90.0-117.0]; p = 0.87), the number of patients on vasopressor/inotropic agents (PCr, 49 [88%]; placebo, 57 [91%]; p = 0.60), the inotropic score on postoperative day 1 (PCr, 4.0 (0-7); placebo, 4.0 (0-10); p = 0.47), mean SOFA score on postoperative day 1 (PCr, 5.25 ± 2.33; placebo, 5,45 ± 2,65; p = 0.83), need for defibrillation after declamping of aorta (PCr, 22 [39%]; placebo, 25 [40%]; p = 0.9),, duration of ICU stay and length of hospitalization as well as 30-day mortality (PCr, 0 (0%); placebo,1 (4.3%); p = 0.4). CONCLUSION: PCr administration to patients undergoing double/triple valve surgery under cardiopulmonary bypass is safe but is not associated with a decrease in troponin I concentration. Phosphocreatine had no beneficial effect on clinical outcomes after surgery. TRIAL REGISTRATION: The study is registered at ClinicalTrials.gov with the Identifier: NCT02757443. First posted (published): 02/05/2016.

Volatile Anesthetics versus Total Intravenous Anesthesia for Cardiac Surgery.

BACKGROUND: Volatile (inhaled) anesthetic agents have cardioprotective effects, which might improve clinical outcomes in patients undergoing coronary-artery bypass grafting (CABG). METHODS: We conducted a pragmatic, multicenter, single-blind, controlled trial at 36 centers in 13 countries. Patients scheduled to undergo elective CABG were randomly assigned to an intraoperative anesthetic regimen that included a volatile anesthetic (desflurane, isoflurane, or sevoflurane) or to total intravenous anesthesia. The primary outcome was death from any cause at 1 year. RESULTS: A total of 5400 patients were randomly assigned: 2709 to the volatile anesthetics group and 2691 to the total intravenous anesthesia group. On-pump CABG was performed in 64% of patients, with a mean duration of cardiopulmonary bypass of 79 minutes. The two groups were similar with respect to demographic and clinical characteristics at baseline, the duration of cardiopulmonary bypass, and the number of grafts. At the time of the second interim analysis, the data and safety monitoring board advised that the trial should be stopped for futility. No significant difference between the groups with respect to deaths from any cause was seen at 1 year (2.8% in the volatile anesthetics group and 3.0% in the total intravenous anesthesia group; relative risk, 0.94; 95% confidence interval [CI], 0.69 to 1.29; P = 0.71), with data available for 5353 patients (99.1%), or at 30 days (1.4% and 1.3%, respectively; relative risk, 1.11; 95% CI, 0.70 to 1.76), with data available for 5398 patients (99.9%). There were no significant differences between the groups in any of the secondary outcomes or in the incidence of prespecified adverse events, including myocardial infarction. CONCLUSIONS: Among patients undergoing elective CABG, anesthesia with a volatile agent did not result in significantly fewer deaths at 1 year than total intravenous anesthesia. (Funded by the Italian Ministry of Health; MYRIAD ClinicalTrials.gov number, NCT02105610.).

Effect of Volatile Anesthetics on Myocardial Infarction After Coronary Artery Surgery: A Post Hoc Analysis of a Randomized Trial.

OBJECTIVE: To investigate the effect of volatile anesthetics on the rates of postoperative myocardial infarction (MI) and cardiac death after coronary artery bypass graft (CABG). DESIGN: A post hoc analysis of a randomized trial. SETTING: Cardiac surgical operating rooms. PARTICIPANTS: Patients undergoing elective, isolated CABG. INTERVENTIONS: Patients were randomized to receive a volatile anesthetic (desflurane, isoflurane, or sevoflurane) or total intravenous anesthesia (TIVA). The primary outcome was hemodynamically relevant MI (MI requiring high-dose inotropic support or prolonged intensive care unit stay) occurring within 48 hours from surgery. The secondary outcome was 1-year death due to cardiac causes. MEASUREMENTS AND MAIN RESULTS: A total of 5,400 patients were enrolled between April 2014 and September 2017 (2,709 patients randomized to the volatile anesthetics group and 2,691 to TIVA). The mean age was 62 ± 8.4 years, and the median baseline ejection fraction was 57% (50-67), without differences between the 2 groups. Patients in the volatile group had a lower incidence of MI with hemodynamic complications both in the per-protocol (14 of 2,530 [0.6%] v 27 of 2,501 [1.1%] in the TIVA group; p = 0.038) and as-treated analyses (16 of 2,708 [0.6%] v 29 of 2,617 [1.1%] in the TIVA group; p = 0.039), but not in the intention-to-treat analysis (17 of 2,663 [0.6%] v 28 of 2,667 [1.0%] in the TIVA group; p = 0.10). Overall, deaths due to cardiac causes were lower in the volatile group (23 of 2,685 [0.9%] v 40 of 2,668 [1.5%] than in the TIVA group; p = 0.03). CONCLUSIONS: An anesthetic regimen, including volatile agents, may be associated with a lower rate of postoperative MI with hemodynamic complication in patients undergoing CABG. Furthermore, it may reduce long-term cardiac mortality.

HgCdTe-based quantum cascade lasers operating in the GaAs phonon Reststrahlen band predicted by the balance equation method.

The lack of radiation sources in the frequency range of 7-10 THz is associated with strong absorption of the THz waves on optical phonons within the GaAs Reststrahlen band. To avoid such absorption, we propose to use HgCdTe as an alternative material for THz quantum cascade lasers thanks to a lower phonon energy than in III-V semiconductors. In this work, HgCdTe-based quantum cascade lasers operating in the GaAs phonon Reststrahlen band with a target frequency of 8.3 THz have been theoretically investigated using the balance equation method. The optimized active region designs, which are based on three and two quantum wells, exhibit the peak gain exceeding 100 cm-1 at 150 K. We have analyzed the temperature dependence of the peak gain and predicted the maximum operating temperatures of 170 K and 225 K for three- and two-well designs, respectively. At temperatures exceeding 120 K, the better temperature performance has been obtained for the two-well design, which is associated with a larger spatial overlap of weakly localized lasing wavefunctions, as well as, a higher population inversion. We believe that the findings of this work can open a pathway towards the development of THz quantum cascade lasers featuring a high level of optical gain due to the low electron effective mass in HgCdTe.

Plasmonic nanojet: an experimental demonstration: publisher's note.

This publisher's note contains corrections to Opt. Lett.45, 3244 (2020)OPLEDP0146-959210.1364/OL.391861.

Plasmonic nanojet: an experimental demonstration.

We propose and study a microstructure based on a dielectric cuboid placed on a thin metal film that can act as an efficient plasmonic lens allowing the focusing of surface plasmons at the subwavelength scale. Using numerical simulations of surface plasmon polariton (SPP) field intensity distributions, we observe high-intensity subwavelength spots and formation of the plasmonic nanojet (PJ) at the telecommunication wavelength of 1530 nm. The fabricated microstructure was characterized using amplitude and phase-resolved scattering-type scanning near-field optical microscopy. We show the first experimental observation of the PJ effect for the SPP waves. Such a novel, to the best of our knowledge, and simple platform can provide new pathways for plasmonics, high-resolution imaging, and biophotonics, as well as optical data storage.

Lung Ultrasonography and Cardiac Surgery: A Narrative Review.

Pulmonary complications are common after cardiac surgery and are closely related to postoperative heart failure and adverse outcomes. Lung ultrasonography (LUS) is currently a widely accepted diagnostic approach with well-established methodology, nomenclature, accuracy, and prognostic value in numerous clinical conditions. The advantages of LUS are universally recognized and include bedside applicability, high diagnostic sensitivity and reproducibility, no radiation exposure, and low cost. However, routine perioperative ultrasonography during cardiac surgery generally is limited to echocardiography, diagnosis of pleural effusion, and as a diagnostic tool for postoperative complications in different organs, and few studies have explored the clinical outcomes in relation to LUS among cardiac patients. This narrative review presents the clinical evidence regarding LUS application in intensive care and during the perioperative period for cardiac surgery. Furthermore, this review describes the methodology and the diagnostic and prognostic accuracies of LUS. A summary of ongoing clinical trials evaluating the clinical outcomes related to LUS also is provided. Finally, this review discusses the rationale for upcoming clinical research regarding whether routine use of LUS can modify current intensive care practice and potentially affect the clinical outcomes after cardiac surgery.

Effect of Renal Denervation and Catheter Ablation vs Catheter Ablation Alone on Atrial Fibrillation Recurrence Among Patients With Paroxysmal Atrial Fibrillation and Hypertension: The ERADICATE-AF Randomized Clinical Trial.

Importance: Renal denervation can reduce cardiac sympathetic activity that may result in an antiarrhythmic effect on atrial fibrillation. Objective: To determine whether renal denervation when added to pulmonary vein isolation enhances long-term antiarrhythmic efficacy. Design, Setting, and Participants: The Evaluate Renal Denervation in Addition to Catheter Ablation to Eliminate Atrial Fibrillation (ERADICATE-AF) trial was an investigator-initiated, multicenter, single-blind, randomized clinical trial conducted at 5 referral centers for catheter ablation of atrial fibrillation in the Russian Federation, Poland, and Germany. A total of 302 patients with hypertension despite taking at least 1 antihypertensive medication, paroxysmal atrial fibrillation, and plans for ablation were enrolled from April 2013 to March 2018. Follow-up concluded in March 2019. Interventions: Patients were randomized to either pulmonary vein isolation alone (n = 148) or pulmonary vein isolation plus renal denervation (n = 154). Complete pulmonary vein isolation to v an end point of elimination of all pulmonary vein potentials; renal denervation using an irrigated-tip ablation catheter delivering radiofrequency energy to discrete sites in a spiral pattern from distal to proximal in both renal arteries. Main Outcomes and Measures: The primary end point was freedom from atrial fibrillation, atrial flutter, or atrial tachycardia at 12 months. Secondary end points included procedural complications within 30 days and blood pressure control at 6 and 12 months. Results: Of the 302 randomized patients (median age, 60 years [interquartile range, 55-65 years]; 182 men [60.3%]), 283 (93.7%) completed the trial. All successfully underwent their assigned procedures. Freedom from atrial fibrillation, flutter, or tachycardia at 12 months was observed in 84 of 148 (56.5%) of those undergoing pulmonary vein isolation alone and in 111 of 154 (72.1%) of those undergoing pulmonary vein isolation plus renal denervation (hazard ratio, 0.57; 95% CI, 0.38 to 0.85; P = .006). Of 5 prespecified secondary end points, 4 are reported and 3 differed between groups. Mean systolic blood pressure from baseline to 12 months decreased from 151 mm Hg to 147 mm Hg in the isolation-only group and from 150 mm Hg to 135 mm Hg in the renal denervation group (between-group difference, -13 mm Hg; 95% CI, -15 to -11 mm Hg; P < .001). Procedural complications occurred in 7 patients (4.7%) in the isolation-only group and 7 (4.5%) of the renal denervation group. Conclusions and Relevance: Among patients with paroxysmal atrial fibrillation and hypertension, renal denervation added to catheter ablation, compared with catheter ablation alone, significantly increased the likelihood of freedom from atrial fibrillation at 12 months. The lack of a formal sham-control renal denervation procedure should be considered in interpreting the results of this trial. Trial Registration: ClinicalTrials.gov Identifier: NCT01873352.

Effect of Intraoperative Dexamethasone on Major Complications and Mortality Among Infants Undergoing Cardiac Surgery: The DECISION Randomized Clinical Trial.

Importance: Corticosteroids are widely used in pediatric cardiac surgery to blunt systemic inflammatory response and to reduce complications; nevertheless, their clinical efficacy is uncertain. Objective: To determine whether intraoperative administration of dexamethasone is more effective than placebo for reducing major complications and mortality during pediatric cardiac surgery. Design, Setting, and Participants: The Intraoperative Dexamethasone in Pediatric Cardiac Surgery was an investigator-initiated, double-blind, multicenter randomized trial that involved 4 centers in China, Brazil, and Russia. A total of 394 infants younger than 12 months, undergoing cardiac surgery with cardiopulmonary bypass were enrolled from December 2015 to October 2018, with follow-up completed in November 2018. Interventions: The dexamethasone group (n = 194) received 1 mg/kg of dexamethasone; the control group (n = 200) received an equivolume of 0.9% sodium chloride intravenously after anesthesia induction. Main Outcomes and Measures: The primary end point was a composite of death, nonfatal myocardial infarction, need for extracorporeal membrane oxygenation, need for cardiopulmonary resuscitation, acute kidney injury, prolonged mechanical ventilation, or neurological complications within 30 days after surgery. There were 17 secondary end points, including the individual components of the primary end point, and duration of mechanical ventilation, inotropic index, intensive care unit stay, readmission to intensive care unit, and length of hospitalization. Results: All of the 394 patients randomized (median age, 6 months; 47.2% boys) completed the trial. The primary end point occurred in 74 patients (38.1%) in the dexamethasone group vs 91 patients (45.5%) in the control group (absolute risk reduction, 7.4%; 95% CI, -0.8% to 15.3%; hazard ratio, 0.82; 95% CI, 0.60 to 1.10; P = .20). Of the 17 prespecified secondary end points, none showed a statistically significant difference between groups. Infections occurred in 4 patients (2.0%) in the dexamethasone group vs 3 patients (1.5%) in the control group. Conclusions and Relevance: Among infants younger than 12 months undergoing cardiac surgery with cardiopulmonary bypass, intraoperative administration of dexamethasone, compared with placebo, did not significantly reduce major complications and mortality at 30 days. However, the study may have been underpowered to detect a clinically important difference. Trial Registration: ClinicalTrials.gov Identifier: NCT02615262.

Spinor-Helicity Formalism for Massless Fields in AdS_{4}.

In this Letter, we suggest a natural spinor-helicity formalism for massless fields in four-dimensional anti-de Sitter space (AdS_{4}). It is based on the standard realization of the AdS_{4} isometry algebra so(3,2) in terms of differential operators acting on sl(2,C) spinor variables. We start by deriving the anti-de Sitter counterpart of plane waves in flat space and then use them to evaluate simple scattering amplitudes. Finally, based on symmetry arguments, we classify all three-point amplitudes involving massless spinning fields. As in flat space, we find that the spinor-helicity formalism allows us to construct additional consistent interactions as compared to approaches employing Lorentz tensors.

Mikhail Kucherov: "The Experiment Confirmed my Hypothesis".

Named reactions are key points in the development of chemistry. Any competent chemist easily identifies the reaction named after Wittig, or Grignard, Diels-Alder, or Friedel-Crafts, Michael, or Favorsky. But how much do we can say about scientist who discovered it? This Essay is devoted to the transition-metal-catalyzed hydration of acetylenic hydrocarbons discovered by Russian chemist Mikhail Kucherov. This reaction is one of the most straightforward methods for the synthesis of carbonyl compounds. With it, in industry for a long time acetaldehyde was essentially manufactured from accessible unsaturated raw material-acetylene. This reaction is one of the first steps in the establishment of homogenous metal complex catalysis in organic synthesis. Herein, we described the history of this discovery and the role of many scientists in the development of research in this field. We would also like to show the life of Russian scientists in the latter half of the 19th century.

Prophylactic pulmonary vein isolation during isthmus ablation for atrial flutter: Three-year outcomes of the PREVENT AF I study.

INTRODUCTION: The PREVENT AF I study demonstrated that prophylactic pulmonary vein isolation (PVI) in patients with pure typical atrial flutter (AFL) resulted in substantial reduction of new-onset atrial fibrillation (AF) during 1-year follow-up as assessed by continuous implantable cardiac monitor (ICM). The objective of this study was to assess 3-year outcomes. METHODS AND RESULTS: Fifty patients with documented AFL were randomized to either cavotricuspid isthmus (CTI) ablation alone (n = 25) or CTI with concomitant PVI (n = 25). The primary endpoint of the study was the occurrence of any atrial tachyarrhythmia with the monthly burden exceeding 0.5% on the ICM. At the end of 3 years, freedom from any atrial tachyarrhythmia was 48% (95% confidence interval [CI]: 32-72%) in the CTI plus PVI group as compared to 20% (95% CI: 9-44%) in the CTI-only group (P = 0.01). Freedom from redo procedures was also higher: 92% (95% CI: 82-100%) versus 68% (95% CI: 52-89%), respectively (P = 0.027). The 3-year AF burden favored the combined ablation group: 6.2% versus 16.8% (P = 0.03). In the CTI-only group, 12 (48%) patients were hospitalized compared to 4 (16%) in the PVI + CTI group (P = 0.03). Two patients in the CTI-only group developed stroke with no serious adverse events in the PVI + CTI group. CONCLUSION: Prophylactic PVI in patients with only typical AFL resulted in a significant reduction of new-onset AF and burden during long-term follow-up as assessed by ICM, with consequent reduction in hospitalizations and need to perform repeat ablation for AF.

Incidence of atrial fibrillation detected by continuous rhythm monitoring after acute myocardial infarction in patients with preserved left ventricular ejection fraction: results of the ARREST study.

Aims: Cardiac arrhythmias following acute myocardial infarction (AMI) can be associated with major adverse cardiovascular events. Data on the "real incidence" of post-MI arrhythmias are limited. We aimed to determine the rate and burden of cardiac arrhythmias by the use of insertable cardiac monitors (ICM) in patients with preserved left ventricular ejection fraction (LVEF) after AMI. Methods and results: In this prospective observational study, patients with LVEF ≥40% who underwent PCI within 7 days following AMI were enrolled to receive an ICM. Primary outcome was the incidence of new-onset atrial fibrillation (AF) measured by the ICM during a follow-up of 2 years; results: Of 165 consecutive patients with AMI, 50 (30.3%) eligible patients were recruited (mean age 57.8 ± 8.3, 88% male). During follow-up, AF was the most frequently detected arrhythmia. Twenty-nine (58%, 95% CI: 42-70%) patients developed new-onset AF, with a cumulative rate of all detected arrhythmias of 65%. Median time to the first detected AF episode was 4.8 months and the peak cumulative AF burden was detected between 3 and 6 months. Twenty-seven (93%) out of 29 patients with AF were asymptomatic. Cox regression analysis found that baseline troponin level (hazard ratio [HR] for 1 ng/mL increment: 1.03, 95% CI: 1.01-1.06, P = 0.01) and CHA2DS2-VASc score of 4 (HR: 11.42, 95% CI: 1.01-129.06, P = 0.04) were independent risk factors of new-onset AF post-AMI. Conclusion: AF is a frequent but largely underestimated cardiac arrhythmia after AMI. More rigorous monitoring strategies resulting in crucial medical interventions (e.g. implementation of oral anti-coagulation) are needed. Clinical Trial Registration: http://www.clinicaltrials.gov. Unique identifier: NCT02492243.

Chronic Lung Disease and Mortality after Cardiac Surgery: A Prospective Cohort Study.

OBJECTIVE: To investigate the 1-year survival in cardiac surgical patients with lung disease, including previously undiagnosed cases. DESIGN: Prospective cohort study. SETTING: Tertiary hospital. PARTICIPANTS: Patients scheduled for elective coronary artery bypass graft (CABG) surgery. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Pulmonary function tests (PFTs) were performed in 454 patients before surgery. Abnormal respiratory patterns were defined as follows: obstructive (forced expiratory volume in 1 second/forced vital capacity <0.70), restrictive (forced expiratory volume in 1 second/forced vital capacity ≥0.70 and forced vital capacity <80% of predicted), and mixed. Overall 1-year mortality was 3.3%. Among 31 patients with documented chronic obstructive pulmonary disease (COPD), mortality was 9.6%, hazard ratio (HR) 1.28, 95% confidence interval (CI) 1.02-12.80, p = 0.04. Of 423 patients without history of COPD, 57 obstructive, 46 restrictive, and 4 mixed abnormal patterns were identified. Of a total of 72 with obstructive lung disease confirmed by PFT (ie, 15 of COPD patients and 57 newly identified cases), 6.9% died, HR 2.75, 95% CI 0.98-8.07, p = 0.06. When combined with cases of COPD where a respiratory abnormality was confirmed (26 patients), newly diagnosed obstructive lung disease (57 patients) was significantly associated with 1-year mortality, HR 4.13, 95% CI 1.50-11.42, p = 0.006. The adjustment for EuroSCORE II did not change the results. CONCLUSIONS: Combination of confirmed preexisting lung disease and newly diagnosed cases provides a clear link to mid-term mortality.

Prevalence and Implications of Abnormal Respiratory Patterns in Cardiac Surgery: A Prospective Cohort Study.

OBJECTIVE: To investigate the prevalence and impact of abnormal respiratory patterns in cardiac surgery patients. DESIGN: Prospective cohort study. SETTING: Tertiary hospital. PARTICIPANTS: Patients scheduled for elective coronary artery bypass graft surgery. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Pulmonary function tests were performed in 454 patients before surgery. Abnormal respiratory patterns were defined as follows: obstructive (forced expiratory volume in 1 s [FEV1]/forced vital capacity [FVC]<0.70), restrictive (FEV1/FVC≥0.70 and FVC<80% of predicted), and mixed (FEV1/FVC<0.70 and both FEV1 and FVC<80% of predicted). Of the 31 patients with a history of chronic obstructive pulmonary disease, no abnormal respiratory pattern was confirmed in 5. Of the 423 patients without a history of lung disease, the authors newly identified 57 obstructive, 46 restrictive, and 4 mixed patterns. Therefore, lung disease was reclassified in 24.7% of cases. Independent predictors of obstructive pattern were age, male sex, history of smoking, and chronic obstructive pulmonary disease. Obstructive lung disease was associated with 16 hours or longer ventilation. A reduced FEV1 was associated with a likelihood of atrial fibrillation (1-L decrement, odds ratio: 1.38, 95% confidence interval: 1.01-to-1.90, p = 0.04) and hospitalization time (regression coefficient: 1.23, 95% confidence interval: 0.54-to-1.91, p<0.001). CONCLUSIONS: Abnormal respiratory patterns are common and often underdiagnosed in the cardiac surgery setting. Pulmonary function tests help reveal patients at risk of complications and may provide an opportunity for intervention.