Anesthetic Management for Transcatheter Aortic Valve Replacement: A National Anesthesia Clinical Outcomes Registry Analysis

Background: General anesthesia has traditionally been used in transcatheter aortic valve replacement; however, there has been increasing interest and momentum in alternative anesthetic techniques. Aims: To perform a descriptive study of anesthetic management options in transcatheter aortic valve replacements in the United States, comparing trends in use of monitored anesthesia care versus general anesthesia. Settings and Design: Data evaluated from the American Society of Anesthesiologists� (ASA) Anesthesia Quality Institute抯 National Anesthesia Clinical Outcomes Registry. Materials and Methods: Multivariable logistic regression was used to identify predictors associated with use of monitored anesthesia care compared to general anesthesia. Results: The use of monitored anesthesia care has increased from 1.8% of cases in 2013 to 25.2% in 2017 (p = 0.0001). Patients were more likely ages 80+ (66% vs. 61%; p = 0.0001), male (54% vs. 52%; p = 0.0001), ASA physical status > III (86% vs. 80%; p = 0.0001), cared for in the Northeast (38% vs. 22%; p = 0.0001), and residents in zip codes with higher median income ($63,382 vs. $55,311; p = 0.0001). Multivariable analysis revealed each one-year increase in age, every 50 procedures performed annually at a practice, and being male were associated with 3% (p = 0.0001), 33% (p = 0.012), and 16% (p = 0.026) increased odds of monitored anesthesia care, respectively. Centers in the Northeast were more likely to use monitored anesthesia care (all p < 0.005). Patients who underwent approaches other than percutaneous femoral arterial were less likely to receive monitored anesthesia care (adjusted odds ratios all < 0.51; all p = 0.0001). Conclusion: Anesthetic type for transcatheter aortic valve replacements in the United States varies with age, sex, geography, volume of cases performed at a center, and procedural approach.

HIV related stigma, perceived social support and risk of premature atherosclerosis in South Asians

Objective This study sought to determine the association between social support and stigma experienced by HIV-positive patients and presence of subclinical cardiovascular disease. Methods We implemented a cross sectional study in 67 HIV-positive patients and 52 controls from a community health care center in central India. The participants underwent an in-depth survey and a clinical and laboratory assessment of cardiovascular risk. Carotid-intimal thickness (CIMT) was used as a marker of subclinical cardiovascular disease. Results On comparing the HIV and age and sex-matched control population, HIV patients had lower body weight (P=<0.001), and lower systolic blood pressures (P = 0.002). Despite the lack of higher cardiac risk factor prevalence and lower lipid abnormalities, HIV patients had higher right, left and average CIMT values than controls (P < 0.001 for all). HIV patients also showed higher prevalence of abnormal CIMT (≥ 0.9 mm) than controls (32% vs. 0%, P < 0.001). HIV patients with increased CIMT (n = 37) in comparison with those with normal CIMT (n = 30) were more frequently males (P = 0.023), had higher systolic blood pressures (P = 0.002), lower CD4 counts (P = 0.033) and experienced higher enacted stigma (P = 0.044). On multivariable stepwise logistic regression, systolic blood pressure (odds ratio:1.06, P = 0.002) and stigma score > 25th percentile value (odds ratio:3.84, P = 0.037) were independent predictors of the abnormal CIMT. Conclusions HIV-positive patients from central India have a higher prevalence of abnormal CIMT as a marker of subclinical cardiovascular disease than the general population. This predisposition to increased cardiovascular risk may be related to complex interactions between HIV disease and stigma-related healthcare inequalities.

¿Deberíamos preocuparnos por la durabilidad de lasválvulas aórticas percutáneas? / Should we be concerned about the durability of percutaneous aortic valves?

El reemplazo de válvulas aórticas transcatéter es una opción de tratamiento excelente para pacientes con estenosis aórtica severa sintomática y riesgo alto o intermedio para cirugía. Con base en evidencia científica sólida en reemplazo de válvulas aórticas transcatéter, obtenida de estudios clínicos aleatorios y con ya cerca de ocho años de experiencia comercial, ¿por qué importaría pensar en la durabilidad de estas válvulas y por qué esta duda acaba de salir a la luz pública? La durabilidad a largo plazo de las válvulas utilizadas en reemplazo de válvulas aórticas transcatéter, ha sido motivo de interés como respuesta a diferentes factores: El desarrollo continuo de la tecnología reduce los riesgos del procedimiento y mejora la expectativa de vida. Cada vez el reemplazo de válvulas aórticas transcatéter se utiliza con más frecuencia en pacientes jóvenes, aun con patología congénita como la válvula aórtica bivalva, y en aquellas más complejas incluidas las bioprótesis disfuncionales, con estenosis regurgitación severa, procedimiento que se conoce como válvula en válvula1), (2. Sin embargo, pese a la penetración cada vez mayor de la técnica, una gran población con estenosis aórtica severa sintomática, que podría ser potencial candidata a reemplazo de válvulas aórticas transcatéter en un futuro, permanece sin diagnóstico y sin tratamiento.

Tissue Doppler echocardiography: principles and applications.

Tissue velocity imaging is an important development in the field of cardiac ultrasound that provides quantitative information for analysis of myocardial motion independent of the quality of gray-scale 2-D echocardiography data. It holds promise to reduce inter- and intraobserver variability in regional wall motion interpretation and is likely to improve the accuracy and reproducibility of stress echocardiography and myocardial viability assessment. It also enables regional diastolic function assessment independent of the loading conditions and offers a practical clinical tool to differentiate pathologic from physiologic myocardial hypertrophy, restrictive cardiomyopathy from constrictive pericarditis and for monitoring and selecting therapies in patients with advanced heart failure. The use of tissue velocity data for myocardial strain and strain rate imaging is likely to circumvent the limitations of tissue velocity in differentiating active and passive motion of a myocardial segment. However, its incremental utility and exact role in improving the diagnostic yield and clinical outcome needs to be addressed in future studies.

Left ventricle dynamics during pulsus alternans: insights from tissue velocity imaging.

A 34-year-old female patient with idiopathic dilated cardiomyopathy presented with hemodynamic pulsus alternans. Mitral annular tissue Doppler velocities showed reciprocal beat-to-beat alterations during systolic ejection and diastolic filling periods. Tissue velocity waves were unaltered during the isovolumic relaxation and contraction periods.

Chlamydia pneumoniae infection and nonspecific aortoarteritis: search for a link with a nonatherosclerotic inflammatory arterial disease.

BACKGROUND: The association between Chlamydia pneumoniae infection and atherosclerosis has gained recognition. However, the nature of this association is controversial. The infective link may not be specific for atherosclerosis and may also exist in other nonatherosclerotic arterial diseases. We investigated patients with nonspecific aortoarteritis for serological evidence of prior Chlamydia pneumoniae infection. METHODS AND RESULTS: Fifty patients each of nonspecific aortoarteritis and coronary artery disease with angiographic evidence of significant (>70%) coronary artery lesions were tested for the presence of IgG antibodies against Chlamydia pneumoniae by micro-immunofluorescence assay and compared with 50 age- and sex-matched normal healthy controls. The number of patients with nonspecific aortoarteritis who tested positive for Chlamydia pneumoniae antibodies (IgG) was not significantly different from controls (8 v. 7, p=ns). The mean titer amongst positive subjects in the two groups was also similar (1:40+/-40 v. 1:50+/-25; p=ns). Patients with coronary artery disease were significantly older than patients with nonspecific aortoarteritis and controls (53.2+/-5.8 v. 21.2+/-9.9 years and 24.5+/-5.2 years, p<0.01 for both) and showed a higher seroprevalence of prior Chlamydia pneumoniae infection (18 v. 8 and 7, p < 0.05 for both). The mean IgG titers of patients with coronary artery disease who tested positive were also significantly higher than the other two groups (1:98+/-34 v. 1:40+/-40, p<0.001 and 1:98+/-34 v. 1:50+/-25, p<0.01, respectively). CONCLUSIONS: In patients with nonspecific aortoarteritis, the seroprevalence of prior Chlamydia pneumnoniae infection is not more than that in healthy individuals of the same age group, but is significantly lesser than that in patients with coronary artery disease. Thus Chlamydia pneumoniae infection may not be associated with all forms of chronic inflammatory arterial lesions.