RESUMO
Objective: The effect of mitral valve (MV) surgery on the natural history of ventricular arrhythmia (VA) in patients with arrhythmic MV prolapse remains unknown. We sought to evaluate the cumulative incidence of VA at 1 year after surgical mitral repair. Methods: A retrospective review of progressively captured data identified 204 consecutive patients who underwent elective MV repair for significant degenerative mitral regurgitation as a first-time cardiovascular intervention in a quaternary reference center between January 2018 and December 2020. A subset of 62 consecutive patients with diagnosed arrhythmic MV prolapse was further evaluated for recurrent VA after MV repair. Results: The median age was 62 years (range, 27-77 years) and 26 of 62 (41.9%) were female. The median time from initial mitral regurgitation/MV prolaspe diagnosis-to-referral was 13.8 years (interquartile range [IQR], 5.4-25) and from VA diagnosis-to-referral was 8 years (IQR, 3-10.6). Using the Lown-Wolf classification, complex VA (Lown grade ≥3) was identified in 36 of 62 patients (58%) at baseline, whereas 8 of 62 (13%) had a cardioverter/defibrillator implanted for primary (4/8) or secondary (4/8) prevention. Left ventricular myocardial scar was confirmed in 23 of 34 (68%) of patients scanned at baseline. The prevailing valve phenotype was bileaflet Barlow (59/62; 95.2%). All patients underwent surgical MV repair by the same team. Surgical repair was stabilized with an annuloplasty prosthesis (median size 36 mm [IQR, 34-38]). Concomitant procedures included tricuspid valve repair (51/62; 82.3%), cryo-maze ± left atrial appendage exclusion (14/62, 23%), and endocardial cryoablation of VA ectopy (4/62; 6.5%). The 30-day and 1-year freedom from recurrent VA were 98.4% and 75.9%, respectively. Absent VA after mitral repair was uniformly observed in patients with minor VA at baseline. Absent VA after mitral repair was uniformly observed in patients with minor VA preoperatively. Complex baseline VA was the strongest predictor of recurrent VA (hazard ratio, 10.8; 95% confidence interval, 1.4-84.2; P = .024), irrespective of myocardial fibrosis. Conclusions: In a series of 62 consecutive patients operated electively for arrhythmic mitral prolapse, VA remained undetected in 75.9% of patients at 1 year. Freedom from recurrent VA was greater among patients without complex VA preoperatively, whereas baseline Lown grade ≥3 was the strongest independent risk factor for recurrent VA at 1 year. These findings attest to the importance of early recognition and prompt referral of patients with mitral prolapse and progressive VA to specialty interdisciplinary care.
RESUMO
PURPOSE: Pulmonary hypertension (PH) is a common cause of postoperative mortality in cardiac surgery that is commonly treated with conventional inhaled therapies, specifically nitric oxide and prostacyclin. Alternative therapies include inhaled milrinone and levosimendan, which are receiving more research interest and are increasing in clinical use as they may cut costs while allowing for easier administration. We sought to conduct a scoping review to appraise the evidence base for the use of these two novel inhaled vasodilators as an intervention for PH in cardiac surgery. SOURCE: We searched Embase and MEDLINE for relevant articles from 1947 to 2022. PRINCIPAL FINDINGS: We identified 17 studies including 969 patients. The included studies show that inhaled milrinone and levosimendan are selective pulmonary vasodilators with potential benefits ranging from ease of weaning from cardiopulmonary bypass to reduction in ventricular dysfunction. Nevertheless, high-quality data are limited, and study design and comparators are extremely heterogeneous, limiting the potential validity and generalizability of findings. CONCLUSION: The findings of this scoping review suggest that milrinone and levosimendan may be effective alternatives to current inhaled therapies for cardiac dysfunction in the setting of PH. Nevertheless, randomized trials have focused on specific agents and consistent outcome measures are needed to better validate the early-stage promise of these agents. STUDY REGISTRATION: Open Science Framework ( https://osf.io/z3k6f/ ); first posted 21 July 2022.
RéSUMé: OBJECTIF: L'hypertension pulmonaire (HTP) est une cause fréquente de mortalité postopératoire en chirurgie cardiaque généralement traitée par des thérapies inhalées conventionnelles, en particulier le monoxyde d'azote et la prostacycline. Les thérapies alternatives comprennent la milrinone et le lévosimendan inhalés, qui suscitent de plus en plus d'intérêt dans la recherche et sont de plus en plus utilisés en clinique car ils peuvent réduire les coûts tout en permettant une administration plus facile. Nous avons cherché à réaliser une étude de portée afin d'évaluer la base de données probantes concernant l'utilisation de ces deux nouveaux vasodilatateurs inhalés comme intervention pour l'HTP en chirurgie cardiaque. SOURCES: Nous avons cherché des articles pertinents dans Embase et MEDLINE de 1947 à 2022. CONSTATATIONS PRINCIPALES: Nous avons identifié 17 études incluant 969 patient·es. Les études incluses montrent que la milrinone et le lévosimendan inhalés sont des vasodilatateurs pulmonaires sélectifs possédant des avantages potentiels allant de la facilité de sevrage de la circulation extracorporelle à la réduction de la dysfonction ventriculaire. Néanmoins, les données de haute qualité sont limitées, et la conception des études et les comparateurs sont extrêmement hétérogènes, ce qui limite la validité potentielle et la généralisabilité des résultats. CONCLUSION: Les résultats de cette étude de portée suggèrent que la milrinone et le lévosimendan pourraient être des solutions de rechange efficaces aux traitements inhalés actuels pour le dysfonctionnement cardiaque dans un contexte d'HTP. Néanmoins, les études randomisées se sont concentrées sur des agents spécifiques et des mesures cohérentes des résultats sont nécessaires pour mieux valider les promesses de ces agents à un stade précoce. ENREGISTREMENT DE L'éTUDE: Open Science Framework ( https://osf.io/z3k6f/ ); première publication le 21 juillet 2022.
Assuntos
Procedimentos Cirúrgicos Cardíacos , Hipertensão Pulmonar , Milrinona , Simendana , Vasodilatadores , Humanos , Vasodilatadores/administração & dosagem , Vasodilatadores/uso terapêutico , Administração por Inalação , Procedimentos Cirúrgicos Cardíacos/métodos , Milrinona/administração & dosagem , Milrinona/uso terapêutico , Hipertensão Pulmonar/tratamento farmacológico , Simendana/administração & dosagem , Simendana/uso terapêutico , Simendana/farmacologia , Adulto , Complicações Pós-Operatórias/tratamento farmacológicoRESUMO
BACKGROUND: Though 15% of hospitalized patients have a documented penicillin (PCN) allergy, fewer than 1% have an IgE-mediated reaction that necessitates avoidance of ß-lactam antibiotics. OBJECTIVE: Our interdisciplinary team of medical and nursing students led and executed a two-pronged quality improvement intervention to reduce prescribing of non-ß-lactam antibiotics (NBLs) for patients with reported PCN allergies. To the best of our knowledge, this is the first multidisciplinary student-led intervention aimed at educating providers on low-risk penicillin allergy and encouraging best antibiotic prescribing practices. DESIGN AND PARTICIPANTS: The intervention took place from June 2021 to February 2022. We developed and provided clinician education modules, including peer-to-peer information sharing and in-person small group discussions, as well as clinical decision support (CDS) strategies through the electronic medical record (EMR). The target population was attendings, residents, nurse practitioners, and physician assistants on the hospital medicine service at a large urban academic tertiary care center. We followed the SQUIRE 2.0 guidelines for reporting on quality improvement. MAIN MEASURES: Primary outcome measures included number of NBL prescriptions and use of nonspecific descriptors (e.g., "other" or "unknown") for PCN allergy reaction type, and were compared with a pre-intervention period. KEY RESULTS: The percent of ß-lactam prescriptions for patients with a PCN allergy after the intervention increased from 19 to 23% (p = 0.006). For patients with a low severity PCN allergy, the percent of ß-lactam prescriptions increased from 20 to 28% (p = 0.001). There was a significant decrease in nonspecific PCN allergy reaction type from 23% in the pre-intervention period to 20% post-intervention (p = 0.012). CONCLUSIONS: An intervention focused on educating prescribers and CDS strategies delivered through the EMR increased appropriate ß-lactam prescribing for patients with a documented low-risk PCN allergy and reduced the use of nonspecific PCN allergy reaction type in EMR documentation.
Assuntos
Hipersensibilidade a Drogas , Hipersensibilidade , Humanos , Antibacterianos/efeitos adversos , Penicilinas/efeitos adversos , beta-Lactamas , Hipersensibilidade/tratamento farmacológico , Hipersensibilidade a Drogas/prevenção & controle , Hipersensibilidade a Drogas/tratamento farmacológico , Hipersensibilidade a Drogas/epidemiologia , EstudantesRESUMO
Advances in hypervalent iodine chemistry have put the field on the precipice of a second golden age; the first being pioneered in the 1990s. During that period, C-C bond forming reactions would be published but rarely with the intended goal of developing a C-C bond forming methodology. More recently, the development of hypervalent iodine-guided electrophilic substitution, arylations using hypervalent iodine, and photoredox reactions with hypervalent iodine have shown great progress in the area of C-C bond formation.