Homelessness in pregnancy.

OBJECTIVES: To evaluate the association, if any, of homelessness or refuge accommodation on delivery and short term perinatal outcomes in an Irish tertiary maternity hospital. METHODS: A retrospective cohort study of 133 singleton pregnancies in women reporting to be homeless or living in refuge at their booking antenatal appointment between 2013 and 2022. Analysis compared sociodemographic characteristics and perinatal outcomes in this cohort to a reference population of 76,858 women with stable living arrangements. RESULTS: Women in the homeless/refuge population were statistically more likely to be single (75.2 % vs 39.5 %, p < 0.001), have an unplanned pregnancy (73.7 % vs 27.2 %, p < 0.001), report a history of psychiatric illness (42.9 % vs 22.4 %, p < 0.001), domestic violence (18.8 % vs 0.9 %, p < 0.001) alcohol consumption in pregnancy (3.0 % vs 0.8 %, p < 0.001) or smoking in pregnancy (41.3 % vs 9.7 %, p < 0.001). They were significantly more likely to have a preterm birth (adjusted OR 1.71 (1.01-2.87) p = 0.04). They also had a significantly lower median birth weight compared to the reference population (birthweight 3270 g vs 3420 g, p < 0.001). CONCLUSION: Women in the homeless and refuge population are more likely to experience poorer perinatal outcomes compared to women with stable living arrangements.

Perinatal and neonatal outcomes of high-risk asymptomatic women from a specialist preterm birth surveillance clinic.

OBJECTIVES: To report the perinatal outcomes of high-risk asymptomatic women who attended a specialist preterm surveillance clinic (PSC) to undergo screening for spontaneous preterm birth (PTB) in Ireland. METHODS: Single center, retrospective cohort study of asymptomatic high risk women who attended the PSC between January 2019 and December 2022. A comprehensive database of all patients who attended the clinic during the study period was constructed and analyzed. Overall outcomes were reported, and stratified per the occurrence of preterm or term birth. Iatrogenic PTBs were included in the outcome data. RESULTS: Following exclusions for loss-to-follow-up, 762 cases were analyzed, constituting 2262 PSC visits. Of those, 183 women were prescribed progesterone (24.0 %), and 100 women underwent cervical cerclage (13.1 %) to prevent spontaneous PTB. Overall, 2.4 %, 6.2 % and 18.6 % of participants gave birth prior to 30 weeks, 34 weeks, and 37 weeks, respectively. The median gestational age at birth for the entire cohort was 38.6 weeks (inter-quartile range (IQR) 37.2-39.6 weeks). Women who delivered < 37 weeks were significantly more likely to be smokers (p = 0.030), have a previous spontaneous PTB (p = 0.016), have multiple pregnancies (p < 0.001), type 1 or 2 diabetes (p = 0.044), or have a previous full dilatation caesarean section birth (p = 0.024). Infants born prior to 37 weeks were more likely to have a lower median birthweight (2270 vs 3300 g, p < 0.001), be admitted to a neonatal intensive care unit (53.8 % vs 2.3 %, p < 0.001) or experience short-term morbidity, including respiratory support (38.0 % vs 1.6 %, p < 0.001). CONCLUSIONS: Over 80% of women deemed to be at high risk of PTB gave birth at term gestations following attendance at a PSC during pregnancy. Most women can be successfully managed without interventions, instead employing a policy of serial cervical surveillance, to identify those at greatest risk of PTB.

A cross-sectional survey of women's views and preferences for preterm birth screening and treatment.

OBJECTIVES: Primary outcomes were to determine; 1) the desire for more patient information from healthcare professionals on preterm birth (PTB) prevention 2) the desire for PTB screening surveillance or participation in research or 3) the acceptability of transvaginal ultrasound (TVUS) or vaginal examinations to predict spontaneous PTB. METHODS: A 19-question, piloted, self-administered survey was completed by unselected pregnant women in a tertiary maternity hospital in Dublin, Ireland. Data was collected to include maternal socio-demographics, past obstetric history, and current pregnancy details, in addition to views and preferences on PTB screening and preventative treatments. Statistical analysis to include binary and multinomial regression was performed by IBM SPSS Statistics for Windows (Version 29.0). RESULTS: 277 women completed the study survey. 9.4% of women had attended the preterm birth surveillance clinic (PSC). 75.1% of respondents indicated a preference for more information from healthcare professionals about PTB. 65% reported that TVUS and vaginal examinations were acceptable in pregnancy. The acceptability of antenatal examinations was significantly influenced by ethnicity; white European (OR 2.58, CI 1.12-5.95, p = 0.003) and Asian (OR 3.39, CI 1.18-9.67, p = 0.02). Discomfort (25.3%) and vaginal bleeding (11.9%) were the most frequently reported concerns about TVUS. 95.7% of unselected women indicated that they would accept treatment to prevent PTB. Vaginal progesterone (53.8%) was preferred treatment compared to cervical cerclage (15.9%) or cervical pessary (16.6%). 55.6% of respondents stated they attend or wish to attend for additional appointments or research opportunities for PTB screening. Women with a previous PTB or second trimester miscarriage were more likely to attend or wish to attend for PTB screening (OR 3.23, CI 1.34-7.79, p = 0.009). CONCLUSION: PTB is an important healthcare priority for pregnant women in Ireland. However, women require more information, counselling and reassurance about the utility and safety of TVUS in PSCs.

Postoperative atrial arrhythmias: risk factors and associated adverse outcomes.

Atrial arrhythmias are the most common complication of cardiac surgical procedures today. Because of the additional hospital costs associated with these arrhythmias, owing to increased use of antiarrhythmic medications, diagnostic studies, and prolonged hospitalization, this subject continues to draw the interest of cardiac surgeons, cardiologists, insurance companies, and hospital administrators, among others. Despite many clinical studies, there is still no consensus regarding the best prevention strategy for these arrhythmias. We recently reviewed our experience with these arrhythmias, with the intent of identifying risk factors for the development of these arrhythmias and identifying any associated, potentially adverse, outcomes. We found that the incidence of postoperative atrial arrhythmias has increased to more than 35% in recent years. Risk factors for the development of postoperative atrial arrhythmias include increasing patient age, preoperative use of digoxin, history of rheumatic heart disease, chronic obstructive pulmonary disease, and increasing aortic cross-clamp (ischemic) time. Among patients with postoperative atrial arrhythmias, there was an increased rate of perioperative stroke, increased frequency of ventricular arrhythmias, increased need for the placement of a permanent pacemaker, and prolongation of the intensive care unit and total hospital length of stay.

Obesity is not a risk factor for significant adverse outcomes after cardiac surgery.

BACKGROUND: Obese patients undergoing cardiac surgery are often thought to have prohibitive perioperative risk despite the lack of sufficient data to support this assumption. METHODS AND RESULTS: To assess the significance of obesity as a risk factor in patients undergoing cardiac surgery, we analyzed data from 2299 patients undergoing procedures requiring cardiopulmonary bypass from January 1, 1991, to December 31, 1993. Obesity was defined by use of the body mass index, defined as weight in kilograms divided by height in meters squared. Potential adverse outcomes analyzed included operative mortality, deep sternal wound infection, superficial sternal wound infection, infection at the saphenous vein harvest site, stroke, renal failure, adult respiratory distress syndrome, prolonged mechanical ventilation, pneumonia, sepsis, atrial arrhythmias, pulmonary embolism, need for early reexploration for bleeding, and ventricular arrhythmias. To control for the confounding effects of other risk factors, we performed a multivariate logistic regression analysis. Potential covariates considered in the logistic model included age, sex, race, history of reoperation, congestive heart failure, prior myocardial infarction, renal failure, diabetes, hypertension, chronic obstructive pulmonary disease or stroke, and cardiopulmonary bypass and aortic cross-clamp time. Twenty-five percent of patients (567/2299) were classified as obese. The results of the multivariate regression demonstrated that obesity was a risk factor only for superficial sternal wound infection (P < .001; odds ratio, 2.3), leg infections (P = .005; odds ratio, 1.8), and atrial dysrhythmias (P = .04; odds ratio, 1.2). Notably, obesity did not predispose toward increased pulmonary complications or deep sternal wound infection (P = .65). CONCLUSIONS: With the exception of superficial wound complications and atrial dysrhythmias, obesity is not a significant multivariate risk factor for adverse outcomes. The results indicate that obese patients may safely undergo cardiac surgery with due attention to technical considerations designed to minimize wound complications.

Reexploration for bleeding is a risk factor for adverse outcomes after cardiac operations.

OBJECTIVE: Although previous studies have included early reexploration for bleeding as a risk factor in analyzing adverse outcomes after cardiac operations, reexploration for bleeding has not been systematically examined as a multivariate risk factor for increased morbidity and mortality after cardiac surgery. Furthermore, multivariate predictors of the need for reexploration have not been identified. Accordingly, we performed a retrospective analysis of 6100 patients requiring cardiopulmonary bypass from January 1, 1986, to December 31, 1993. METHODS: Eighty-five patients who had ventricular assist devices were excluded from further analysis because of the prevalence of bleeding and the significant morbidity and mortality associated with placement of a ventricular assist device, unrelated to reexploration. In the remaining 6015 patients, potential adverse outcomes analyzed included operative mortality, mediastinitis, stroke, renal failure, adult respiratory distress syndrome, prolonged mechanical ventilation, sepsis, atrial arrhythmias, and ventricular arrhythmias. To control for the confounding effects of other risk factors, we performed a multivariate logistic regression analysis. Potential covariates considered in the logistic model included age, sex, race, history of reoperation, urgency of the operation, congestive heart failure, prior myocardial infarction, renal failure, diabetes, hypertension, chronic obstructive pulmonary disease or stroke, and the bypass and crossclamp time. RESULTS: The overall incidence of reexploration was 4.2% (253/6015). Four independent risk factors--increased patient age (p < 0.001), preoperative renal insufficiency (p = 0.02), operation other than coronary bypass (p < 0.001), and prolonged bypass time (p = 0.0.3)--were identified as predictors of the need for reexploration. The preoperative use of aspirin, heparin, or thrombolytic agents and the bleeding time were not identified as predictors. Reexploration for bleeding was identified as a strong independent risk factor for operative mortality (p = 0.005), renal failure (p < 0.0001), prolonged mechanical ventilation (p < 0.0001), adult respiratory distress syndrome (p = 0.03), sepsis (p < 0.0001), and atrial arrhythmias (p = 0.006). CONCLUSION: These data indicate that meticulous attention to surgical hemostasis and possibly application of recently developed modalities designed to facilitate perioperative correction of coagulopathy could improve outcomes after cardiac operations.

Mechanical dysfunction in the border zone of an ovine model of left ventricular aneurysm.

BACKGROUND: The pathophysiology of regional mechanical dysfunction in the border zone (BZ) region of left ventricular aneurysm was studied in an ovine model using magnetic resonance imaging tissue-tagging and regional deformation analysis. METHODS: Transmural infarcts were created in adult Dorsett sheep (n = 8) by ligation of the distal homonymous coronary artery and were allowed to mature into left ventricular aneurysms for 8 to 12 weeks. Animals were imaged subsequently using double oblique magnetic resonance imaging with radiofrequency tissue tagging. Short axis slices were selected for analysis that included predominantly the septal component of the aneurysm as well as adjacent BZ regions in the anterior and posterior ventricular walls. Dark grid patterns of magnetic presaturations were placed on the myocardium and tracked as they deformed during the diastolic, isovolumic systolic, and systolic ejection phases of the cardiac cycle. Regional ventricular wall strains were calculated in BZ regions and regions remote from the aneurysm and compared with strains measured in corresponding regions from normal control sheep (n = 6). RESULTS: Diastolic midwall circumferential strains (fiber extensions) were relatively preserved, but abnormal circumferential lengthening strains were observed in the BZ regions during isovolumic systole. Peak circumferential strains ranged from 0.04 to 0.07 in the BZ regions but averaged -0.05 in the normal hearts (p = 0.002 for the anterior BZ and p = 0.001 for the posterior BZ). Midwall end-systolic fiber strains were depressed in the anterior BZ (-0.03 to -0.09 for the BZ versus -0.11 for the normal heart, p < 0.0001) but not in the posterior BZ (p = 0.19). CONCLUSIONS: Our data support the theory that the stretching of BZ fibers during isovolumic systole contributed to a reduction in fiber shortening during systolic ejection and thus reduced the overall contribution of these fibers to forward ventricular output.

Swallowing dysfunction after cardiac operations. Associated adverse outcomes and risk factors including intraoperative transesophageal echocardiography.

The frequency, importance to patient outcomes, and independent predictors of postoperative swallowing dysfunction documented by barium cineradiography were examined in 869 patients undergoing cardiac operations over a 12-month period. Swallowing dysfunction was diagnosed in 34 patients (4% incidence) and was associated with documented pulmonary aspiration in 90% of these patients, increased frequency of pneumonia (p < 0.0001), need for tracheostomy (p = 0.0002), length of stay in the intensive care unit (p = 0.0001), and duration of hospitalization after the operation (p = 0.0001). Independent predictors of postoperative swallowing dysfunction determined by multivariate logistic regression included age (p < 0.001), length of tracheal intubation after the operation (p = 0.001), and intraoperative use of transesophageal echocardiography (p = 0.003). Dysfunctional swallowing after cardiac operations, a serious complication significantly related to postoperative respiratory morbidity and extended length of hospitalization, is more common in older patients. An association between intraoperative use of transesophageal echocardiography and swallowing dysfunction was also observed in our patients.

Revascularization after acute myocardial infarction.

BACKGROUND: The optimal timing for coronary artery bypass grafting (CABG) after acute myocardial infarction (MI) remains controversial. METHODS: We examined our experience retrospectively in 3,942 patients who underwent CABG between 1986 and 1993, including 2,296 patients after acute MI. RESULTS: The operative mortality associated with increasing time intervals between MI and CABG were 9.1%, 8.3%, 5.2%, 6.5%, and 2.9%, for less than 6 hours, 6 hours to 2 days, 2 to 14 days, 2 to 6 weeks, and more than 6 weeks, respectively. In comparison, the operative mortality was 2.5% for patients with no history of acute MI. The incidence of permanent stroke and perioperative MI were greater and the length of postoperative hospitalization was longer for patients undergoing CABG early after MI. For patients undergoing operation electively, however, the operative mortality associated with increasing time intervals between MI and CABG were less, at 0.0%, 3.6%, 2.1%, 6.4%, and 2.1% for less than 6 hours, 6 hours to 2 days, 2 to 14 days, 2 to 6 weeks, and more than 6 weeks, respectively. For patients undergoing CABG within 14 days of MI, the operative mortality was 5.3% for those receiving an intraaortic balloon pump preoperatively for postinfarction angina, but 11.8% for those who underwent urgent/emergent operation without intraaortic balloon pump support. CONCLUSIONS: Elective CABG can be accomplished with acceptable morbidity and mortality early after acute MI if an elective operation is possible. In addition, the intraaortic balloon pump should be used aggressively in patients with postinfarction angina to allow for elective rather than urgent/emergent operation.

Coronary artery disease in patients with type A aortic dissection.

The usefulness of preoperative coronary arteriography in patients with type A dissection of the aorta is controversial. To determine the prevalence of arteriosclerotic coronary artery disease in patients with type A dissection of the aorta, we reviewed our experience in 62 patients (42 with acute dissection and 20 with chronic dissection) who underwent operation between January 1, 1986, and December 31, 1993. Among 23 patients with acute dissection who underwent coronary arteriography, 8 (34.8%) had one or more coronary artery lesions causing a greater than 50% narrowing. Among 14 patients with chronic dissection who underwent coronary arteriography, 6 (42.9%) had one or more coronary artery lesions causing a greater than 50% narrowing. There were no fatal complications associated with coronary arteriography. Four patients with acute dissection and 6 patients with chronic dissection underwent coronary artery bypass grafting at the time of operative repair of the aortic dissection, with no operative deaths. On the basis of these findings and the success of combined coronary artery bypass grafting and aortic repair, we recommend that patients with an acute type A dissection who are in stable condition and all patients with a chronic type A dissection of the aorta should undergo preoperative coronary arteriography.

Potential ablation of accessory atrioventricular pathways: injection of alcohol into the atrioventricular groove.

Accessory atrioventricular (AV) pathways responsible for the Wolff-Parkinson-White syndrome have been treated successfully by surgical and radiofrequency catheter ablation techniques. In this study, we explored the feasibility of permanent chemical ablation of accessory pathways by direct injection of 100% ethanol into the canine AV groove. Right coronary artery blood flow and AV compartment pressure were measured in 5 adult mongrel dogs (part I) during injection of saline solution (10 to 15 mL) into the right AV groove. Atrioventricular groove compartment pressure increased from 1 +/- 1 to 31 +/- 12 mm Hg (p < 0.0001) and right coronary artery blood flow increased slightly from 117 +/- 17 to 138 +/- 44 mL/min (p = not significant). In 8 additional dogs (part II), 100% ethanol (10 mL) was injected into the left AV groove. After 6 weeks (n = 6) or 12 weeks (n = 2), histologic examination of the left AV groove demonstrated localized fibrous replacement of injured epicardial muscle, with only scant inflammatory infiltrate. Mild intimal fibrosis and intimal proliferation were present in the circumflex artery and its larger branches, but no significant luminal narrowing was evident. Angiograms at 12 weeks (n = 2) demonstrated no significant narrowing of the circumflex artery. In summary, injection of 100% ethanol into the AV groove is capable of locally ablating myocardial tissue, presumably including conductive tissues, while sparing the coronary arteries.

Hazards of postoperative atrial arrhythmias.

Between January 1, 1986, and December 31, 1991, 4,507 adult patients underwent cardiac surgical procedures requiring cardiopulmonary bypass. Of these patients, 3,983 patients who did not undergo operation for supraventricular tachycardia and who were in normal sinus rhythm preoperatively form the study group for the present study. Postoperatively, all patients were monitored continuously for the development of arrhythmias until the time of hospital discharge. The incidence of atrial arrhythmias requiring treatment for the most commonly performed operative procedures were as follows: coronary artery bypass grafting, 31.9%; coronary artery bypass grafting and mitral valve replacement, 63.6%; coronary artery bypass grafting and aortic valve replacement, 48.8%; and heart transplantation, 11.1%. For all patients considered collectively, the risk factors associated with an increased incidence of postoperative atrial arrhythmias (p < 0.05 by multivariate logistic regression) included increasing patient age, preoperative use of digoxin, history of rheumatic heart disease, chronic obstructive pulmonary disease, and increasing aortic cross-clamp time. Postoperative atrial fibrillation was associated with an increased incidence of postoperative stroke (3.3% versus 1.4%; p < 0.0005), increased length of hospitalization in the intensive care unit (5.7 versus 3.4 days; p = 0.001) and postoperative nursing ward (10.9 versus 7.5 days; p = 0.0001), increased incidence of postoperative ventricular tachycardia or fibrillation (9.2% versus 4.0%; p < 0.0005), and an increased need for placement of a permanent pacemaker (3.7% versus 1.6%; p < 0.0005). These data provide a basis for targeting specific patient subgroups for prospective, randomized trials of therapeutic modalities designed to decrease the incidence of postoperative atrial arrhythmias.

Intraaortic balloon counterpulsation: patterns of usage and outcome in cardiac surgery patients.

Between January 1, 1986, and May 6, 1991, 7,884 cardiac surgical procedures requiring cardiopulmonary bypass were performed at our institution, including 672 (9.8% of adult procedures) performed in 669 patients that were associated with preoperative (n = 240), intraoperative (n = 353), or postoperative (n = 79) use of an intraaortic balloon pump. The mean age of recipients was 65.3 years (range, 16 to 89 years). Intraaortic balloon pump usage increased during the study period from 6.4% of patients (83/1,298) in 1986 to 12.7% of patients (169/1,333) in 1990. The relative distribution between preoperative (mean, 35.7%), intraoperative (52.5%), and postoperative (11.8%) insertion remained nearly constant during the study period. The overall operative (30-day) mortality for patients with preoperative, intraoperative, or postoperative insertion of the intraaortic balloon pump was 19.6%, 32.3%, and 40.5%, respectively (X2 = 16.4; p less than 0.001). Although use of the intraaortic balloon pump in the intraoperative and postoperative settings is accompanied by a favorable outcome in most patients, the high associated mortality suggests the need for earlier use of the intraaortic balloon pump or other supportive measures such as the ventricular assist device.

Regional myocardial stress distribution from magnetic resonance image-based mathematical models.

The instantaneous regional stress distribution within the myocardium, which cannot be directly measured, has been estimated using improved numerical methods and nonaxisymmetric biventricular geometry. To do this, we have employed computer-aided solid mathematical modeling to generate a three-dimensional representation for an ex vivo canine biventricular unit using magnetic resonance imaging. A two-dimensional transverse section was isolated from the solid mathematical model for regional stress analysis using p-version finite element analysis. Loading conditions and material property descriptions were taken from published reports. Analyses showed the maximum principal stresses to range from -1.76 X 10(5) to 8.52 X 10(5) dynes/cm2 during systolic loading, and from -3.85 X 10(4) to 1.13 X 10(5) dynes/cm2 during diastolic loading. This study demonstrates that magnetic resonance image-based solid mathematical biventricular models are suitable for regional stress analysis using p-version finite element analysis. p-Version finite element analysis using magnetic resonance image-based cardiac representations facilitates in vivo stress-strain analyses and may allow the clinical estimation of regional myocardial stress.