Outcome of mild periprosthetic regurgitation detected by intraoperative transesophageal echocardiography.

OBJECTIVES: The goal of this study was to determine the outcome of trivial or mild periprosthetic regurgitation (PPR) identified by intraoperative transesophageal echocardiography (TEE). BACKGROUND: The clinical significance, natural history and correlates of trivial or mild PPR detected early after surgery are unknown. METHODS: Between 1992 and 1997, 608 consecutive patients underwent isolated aortic valve replacement or mitral valve replacement at Dartmouth-Hitchcock Medical Center. Of these, 113 patients (18.3%) were found to have trivial or mild PPR at surgery by TEE. Follow-up transthoracic echocardiograms (early TTEs) were obtained within six weeks of surgery in 99.0% of patients and late TTEs (mean 2.1 years) in 54.3%. Clinical, intraoperative and outcome variables associated with PPR were identified using t test, chi-square and logistic regression analyses. RESULTS: By univariate analysis, compared with patients without PPR, patients with PPR were older, of smaller body surface area (BSA), had degenerative valve disease more often and were more likely to receive a bioprosthetic valve. By multivariate analysis, smaller BSA and the use of a bioprosthesis were the strongest predictors of PPR (p < 0.01). At early TTE, PPR was not observed (n = 56) or remained unchanged (n = 44) in all patients. At late TTE, four patients were found to have progression of their PPR. All four patients had bioprosthetic valves. Two of these patients had endocarditis, and one had primary valvular degeneration. The fourth patient had progressive PPR. CONCLUSIONS: Trivial or mild PPR is a frequent finding on intraoperative TEE. Smaller body size and the use of a bioprosthetic valve are significantly associated with PPR. The clinical significance and natural history of PPR is benign in most cases.

Multivariate prediction of in-hospital mortality after percutaneous coronary interventions in 1994-1996. Northern New England Cardiovascular Disease Study Group.

OBJECTIVES: Using recent data, we sought to identify risk factors associated with in-hospital mortality among patients undergoing percutaneous coronary interventions. BACKGROUND: The ability to accurately predict the risk of an adverse outcome is important in clinical decision making and for risk adjustment when assessing quality of care. Most clinical prediction rules for percutaneous coronary intervention (PCI) were developed using data collected before the broader use of new interventional devices. METHODS: Data were collected on 15,331 consecutive hospital admissions by six clinical centers. Logistic regression analysis was used to predict the risk of in-hospital mortality. RESULTS: Variables associated with an increased risk of in-hospital mortality included older age, congestive heart failure, peripheral or cerebrovascular disease, increased creatinine levels, lowered ejection fraction, treatment of cardiogenic shock, treatment of an acute myocardial infarction, urgent priority, emergent priority, preprocedure insertion of an intraaortic balloon pump and PCI of a type C lesion. The receiver operating characteristic area for the predicted probability of death was 0.88, indicating a good ability to discriminate. The rule was well calibrated, predicting accurately at all levels of risk. Bootstrapping demonstrated that the estimate was stable and performed well among different patient subsets. CONCLUSIONS: In the current era of interventional cardiology, accurate calculation of the risk of in-hospital mortality after a percutaneous coronary intervention is feasible and may be useful for patient counseling and for quality improvement purposes.

The relationship between operator volume and outcomes after percutaneous coronary interventions in high volume hospitals in 1994-1996: the northern New England experience. Northern New England Cardiovascular Disease Study Group.

OBJECTIVES: The purpose of this study was to examine the relationship between annual operator volume and outcomes of percutaneous coronary interventions (PCIs) using contemporaneous data. BACKGROUND: The 1997 American College of Cardiology (ACC)/American Heart Association task force based their recommendation that interventionists perform > or = 75 procedures per year to maintain competency in PCI on data collected largely in the early 1990s. The practice of interventional cardiology has since changed with the availability of new devices and drugs. METHODS: Data were collected from 1994 through 1996 on 15,080 PCIs performed during 14,498 hospitalizations by 47 interventional cardiologists practicing at the five high volume (>600 procedures per hospital per year) hospitals in northern New England and one Massachusetts-based institution that support these procedures. Operators were categorized into terciles based on their annualized volume of procedures. Multivariate regression analysis was used to control for case-mix. In-hospital outcomes included death, emergency coronary artery bypass graft surgery (eCABG), non-emergency CABG (non-eCABG), myocardial infarction (MI), death and clinical success (> or = 1 attempted lesion dilated to < 50% residual stenosis and no death, CABG or MI). RESULTS: Average annual procedure rates varied across terciles from low = 68, middle = 115 and high = 209. After adjusting for case-mix, clinical success rates were comparable across terciles (low, middle and high terciles: 90.9%, 88.8% and 90.7%, Ptrend = 0.237), as were all the adverse outcomes including death (low-risk patients = 0.45%, 0.41%, 0.71%, Ptrend = 0.086; high-risk patients = 5.68%, 5.99%, 7.23%, Ptrend = 0.324), eCABG (1.74%, 2.05%, 1.75%, Ptrend = 0.733) and MI (2.57%, 1.90%, 1.86%, Ptrend = 0.065). CONCLUSIONS: Using current data, there is no significant relationship between operator volumes averaging > or = 68 per year and outcomes at high volume hospitals. Future efforts should be directed at determining the generalizability of these results.

Results of directional coronary atherectomy in Northern New England. Northern New England Cardiovascular Disease Study Group.

The role of directional coronary atherectomy (DCA) in interventional cardiology remains uncertain. We report the Northern New England regional experience with DCA from 1991 to 1994. Data were collected on 11,178 patients having had an intervention on a single lesion in a single vessel (798 DCAs; 10,380 percutaneous transluminal angioplasties [PTCA]). The use of DCA increased from 1.8% of interventions in 1991 to 10% in 1994. Compared with PTCA, DCA patients were younger, more often men, had more 1-vessel disease and more coronary artery bypass surgery (CABG). DCA was more often used in the left anterior descending artery, in vein grafts, for restenoses, for subtotal occlusions, and with type A lesions. Angiographic success (96.7%) and clinical success (93%) were good. Adverse events were rare: mortality 0.9%, emergent CABG 2.2%, nonfatal myocardial infarction 2.8%. After adjusting for case-mix, there was no difference between DCA and PTCA for in-hospital mortality (odds ratio [OR] = 1.03, 95% confidence interval [CI] 0.44 to 2.43, p = 0.95) or need for emergent CABG (OR = 1.27, 95% CI 0.77 to 2.10, p = 0.34). Atherectomy patients were more likely to have a nonfatal myocardial infarction (OR = 2.0, 95% CI 1.26 to 3.20, p <0.01), to sustain an injury to the femoral or brachial artery (OR = 2.89, 95% CI 1.52 to 5.51, p <0.01), and to have a clinically successful procedure (OR = 1.37, 95% CI 1.01 to 1.88, p = 0.05). Our results support the relative safety and effectiveness of DCA as its use disseminated into the region.

Safety and efficacy of percutaneous coronary interventions performed immediately after diagnostic catheterization in northern new england and comparison with similar procedures performed later.

"Ad hoc" percutaneous coronary interventions (PCIs)-those performed immediately after diagnostic catheterization-have been reported in earlier studies to be safe with a suggestion of higher risk in certain subgroups. Despite increasing use of this strategy, no data are available in recent years with new device technology. We studied use of an ad hoc strategy in a large regional population to determine its use and outcomes compared with staged procedures. A database from the 6 centers performing PCIs in northern New England and 1 center in Massachusetts was analyzed. During 1997, excluding only patients requiring emergency procedures or those with a prior PCI, 4,136 PCIs were performed, 1,748 (42.3%) of these being ad hoc procedures. Patients having ad hoc procedures were less likely to have peripheral vascular disease, renal failure, prior myocardial infarction, or coronary artery bypass surgery, congestive heart failure, or poor left ventricular function, and more likely to have received preprocedural intravenous heparin or nitroglycerin or to have required an urgent procedure. Narrowings treated during ad hoc procedures were less frequently types B and C or in saphenous vein grafts. Adjusted rates of clinical success were not different between ad hoc and non-ad hoc procedures (93.7% vs 93.6%); there was no difference in the incidence of death (0.6% vs 0.5%), emergency (0. 9% vs 0.8%) or any (1.4% vs 0.8%) coronary artery bypass surgery, or myocardial infarction (2.6% vs 2.0%). As currently practiced in our region, ad hoc intervention is used selectively with outcomes similar for ad hoc and non-ad hoc procedures.

Improved in-hospital mortality in women undergoing coronary artery bypass grafting. Northern New England Cardiovascular Disease Study Group.

BACKGROUND: Few studies have examined the changes in in-hospital mortality for women over time. We describe the changing case mix and mortality for women undergoing coronary artery bypass grafting (CABG) from 1987 to 1997 in northern New England. METHODS: Data were collected on 8,029 women and 21,139 men undergoing isolated CABG. The study consisted of three time periods (1987 to 1989, 1990 to 1992, and 1993 to 1997) to account for regional efforts to improve quality of care that occurred during 1990 to 1992. RESULTS: Compared with 1987 to 1989, women undergoing CABG in 1993 to 1997 were older, had poorer ventricular function, and more often required urgent or emergency operations. The crude and adjusted mortality rates for both women and men decreased significantly over time. The absolute magnitude of the change in adjusted rates was greater for women (3.1%) than for men (1.5%). Although women represented only 28% of the study population, the decrease in their mortality accounted for 44% of the total decrease in adjusted mortality during the study period. CONCLUSIONS: Over the last decade there has been a marked decrease in CABG mortality for women, despite a worsening case mix.

Stenosis at the origin of an anomalous left main coronary artery arising from the pulmonary artery in a symptom-free adolescent girl: transesophageal echocardiographic findings.

We report an unusual finding of ostial stenosis of an anomalous left main coronary artery originating from the pulmonary artery in a symptom-free adolescent girl. Transesophageal echocardiography with Doppler color imaging correctly identified all of the salient features of this anomaly including proximal stenoses of the right and left coronary arteries. These findings were subsequently confirmed at cardiac catheterization.

Propafenone-induced drug fever in the absence of agranulocytosis.

Propafenone is an antiarrhythmic drug used in the treatment of life-threatening ventricular tachyarrhythmias. Adverse reactions necessitating discontinuation of the medication are common. Propafenone-induced drug fever has not been definitively proven. We present a case report of drug fever secondary to propafenone, confirmed with rechallenge.

The clinical utility of adenosine in difficult to diagnose tachyarrhythmias.

BACKGROUND: The use of intravenous adenosine to help differentiate the origin of tachyarrhythmias has been suggested to be beneficial. However, the benefit of this intervention to physicians with different levels of training in electrocardiographic (ECG) interpretation is unknown. HYPOTHESIS: The purpose of the study was to determine whether intravenous adenosine improved the diagnostic accuracy of difficult to diagnose tachyarrhythmias when used by physicians with different levels of training in ECG interpretation. METHODS: We studied 28 consecutive patients presenting with wide and narrow complex tachyarrhythmias, in whom adenosine was given specifically for diagnostic purposes. Two groups of physicians, attending (n = 14) and housestaff (n = 10), reviewed each ECG before and after the administration of adenosine. RESULTS: For narrow complex tachyarrhythmias, neither physician group derived diagnostic benefit from the use of adenosine. However, for wide complex tachyarrhythmias, the diagnostic accuracy of the housestaff group significantly improved with the use of adenosine (pre = 54%, post = 70%, p < 0.01), while the attending physician group had no significant improvement (pre = 61%, post = 71%, p = NS). CONCLUSION: This study suggests that adenosine provides useful diagnostic information to physicians less experienced in ECG interpretation when presented with patients having wide complex tachyarrhythmias of uncertain origin.

Redesigning nighttime care for personal care residents.

This study investigated the effects of non-disruptive nighttime care for residents in a personal care setting. The sample consisted of 18 personal care home residents in an urban, 388-bed, long-term care facility located in Winnipeg, Manitoba, Canada. The study used a quasi-experimental, single-arm design, exposing all residents to both intervention and control conditions. Independent variables were the current nighttime routine of regular rounds to turn and change residents, and a non-disruptive plan of care in which residents were checked hourly by staff and necessary care was provided when they were awake. Outcome variables included total sleep from evening bedtime to morning awakening, longest period of uninterrupted sleep at night, amount of time spent sleeping during the day, self-reported restfulness of cognitively intact residents, and skin condition. Findings suggested that the non-disruptive nighttime care routine increased total sleep by an average of 30 minutes a night for each resident. The amount of uninterrupted sleep increased by approximately 45 minutes with the new routine. No significant differences were noted in the amount of time spent sleeping during the day. There was no evidence of skin breakdown during any phase of the study. Clinical implications of this study demonstrate a need for gerontological nurses to re-evaluate nighttime care routines in personal care settings.

Rasmussen's encephalitis presenting as focal cortical dysplasia.

Rasmussen's encephalitis is a rare syndrome characterized by intractable seizures, often associated with epilepsia partialis continua and symptoms of progressive hemispheric dysfunction. Seizures are usually the hallmark of presentation, but antiepileptic drug treatment fails in most patients and is ineffective against epilepsia partialis continua, which often requires surgical intervention. Co-occurrence of focal cortical dysplasia has only rarely been described and may have implications regarding pathophysiology and management. We describe a rare case of dual pathology of Rasmussen's encephalitis presenting as a focal cortical dysplasia (FCD) and discuss the literature on this topic.

Patent ductus arteriosus evaluation by serial echocardiography in preterm infants.

BACKGROUND: Patent ductus arteriosus (PDA) is associated with morbidity and mortality in premature neonates. METHODS: The effect of serial echocardiography performed by a neonatologist and early targeted medical PDA treatment was evaluated and compared to historical controls. One hundred ninety-two infants <1,500 g were included and 45 infants had a PDA. RESULTS: Serial echocardiography allowed significantly earlier identification and treatment of PDA versus awaiting the evolution of clinical signs. Severe intraventricular haemorrhage and ventilator days were significantly decreased in the studied cohort following the introduction of echocardiography. In addition, hospital stay was also reduced in the non-PDA group and other outcomes were unchanged. CONCLUSION: Serial echocardiography for PDA evaluation, performed by a neonatologist trained in echo, may reduce morbidity in preterm infant.

Critical pathway management of unstable angina.

The critical pathway for UA is a multidisciplinary management tool designed to assist in expediting the treatment and evaluation of this frequent clinical syndrome. No critical pathway or practice guideline will meet the needs of all patients, and flexibility for patient variations and physician judgment is mandatory. Prediction tools and other facilitators cannot replace and must not impede the thoughtful assessment of complex clinical situations. Numerous factors, occasionally social or political in nature, impact on patient treatment strategies and the application of interventions. It is our hope that the Unstable Angina Critical Pathway will form a foundation for further innovation and cooperative effort toward optimizing the management of patients with acute ischemic syndromes.