Comparison of Factors Associated with Inflammation, Thrombosis, and Platelet Reactivity as well as Turnover between Patients with High versus Low CHA2DS2-VASc without Atrial Fibrillation.

BACKGROUND: The CHA2DS2-VASc score has been shown to predict systemic thromboembolism and mortality in certain groups in sinus rhythm (SR), similar to its predictive value with atrial fibrillation (AF). OBJECTIVES: To compare factors of inflammation, thrombosis, platelet reactivity, and turnover in patients with high versus low CHA2DS2-VASc score in SR. METHODS: We enrolled consecutive patients in SR and no history of AF. Blood samples were collected for neutrophil-to-lymphocyte ratio (NLR), C-reactive protein (CRP), immature platelet fraction (IPF%) and count (IPC), CD40 ligand, soluble P-selectin (sP-selectin) and E-selectin. IPF was measured by autoanalyzer and the other factors by ELISA. RESULTS: The study comprised 108 patients (age 58 ± 18 years, 63 women (58%), 28 (26%) with diabetes), In addition, 52 had high CHA2DS2-VASc score (³ 2 for male and ³ 3 for female) and 56 had low score. Patients with low scores were younger, with fewer co-morbidities, and smaller left atrial size. sP-selectin was higher in the high CHA2DS2-VASc group (45, interquartile ratio [IQR] 36-49) vs. 37 (IQR 28-46) ng/ml, P = 0.041]. Inflammatory markers were also elevated, CRP 3.1 mg/L (IQR 1.7-9.3) vs. 1.6 (IQR 0.78-5.4), P < 0.001; NLR 2.7 (IQR 2.1-3.8) vs. 2.1 (IQR 1.6-2.5), P = 0.001, respectively. There was no difference in E-selectin, CD40 ligand, IPC, or IPF% between the groups. CONCLUSIONS: Patients in SR with high CHA2DS2-VASc score have higher inflammatory markers and sP-selectin. These findings may explain the higher rate of adverse cardiovascular events associated with elevated CHA2DS2-VASc score.

Immature platelet fraction over time and clinical outcomes in patients with acute myocardial infarction.

BACKGROUND: Immature platelets in the circulation can be measured as immature platelet fraction (IPF). Limited data exist regarding IPF during the course of an acute myocardial infarction (AMI), the association between IPF and extent of cardiac damage, and the long-term prognostic implications of IPF in patients with AMI. AIMS: To examine the temporal course of IPF during the first month after AMI, the association between IPF and extent of cardiac damage, and the long-term prognostic effect of IPF in AMI patients. METHODS: Patients with AMI treated with percutaneous coronary intervention (PCI) were examined. IPF was evaluated by a Sysmex XN-3000 autoanalyzer, at 4 time points: baseline; one day post-PCI; 3 days post-PCI, and 30 days post-PCI. The association between peak troponin-T levels and IPF was evaluated. One-year clinical outcomes (cardiac hospitalization, urgent revascularization, or death) were assessed. RESULTS: One hundred patients were included, mean age was 59.5 ± 11.3 years, 82 were men, 27 had diabetes, and 54 were hospitalized with ST-segment elevation myocardial infarction (STEMI) and 46 with non-ST segment elevation myocardial infarction (NSTEMI). The levels of IPF modestly decreased a day after PCI but did not change in subsequent measurements. Peak troponin-T level was significantly associated with the levels of IPF at all 4 time points. IPF levels three days post-PCI were associated with the composite clinical outcome at 1 year. CONCLUSIONS: The levels of IPF following AMI remain relatively stable over a one-month period. Higher levels of IPF during the acute phase of AMI appear to be associated with worse cardiac outcomes at 1 year.

Difference in left atrial appendage remodeling between diabetic and nondiabetic patients with atrial fibrillation.

BACKGROUND: Diabetes mellitus (DM) is a common and increasingly prevalent condition in patients with atrial fibrillation (AFib). The left atrium appendage (LAA), a small outpouch from the LA, is the most common location for thrombus formation in patients with AFib. HYPOTHESIS: In this study, we examined LAA remodeling differences between diabetic and nondiabetic patients with AFib. METHODS: This retrospective study analyzed data from 242 subjects subdivided into two subgroups of 122 with DM (diabetic group) and 120 without DM (nondiabetic group). The study group underwent real-time 3-dimensional transesophageal echocardiography (RT3DTEE) for AFib ablation, cardioversion, or LAA device closure. The LAA dimensions were measured using the "Yosefy rotational 3DTEE method." RESULTS: The RT3DTEE analysis revealed that diabetic patients display larger LAA diameters, D1-lengh (2.09 ± 0.50 vs 1.88 ± 0.54 cm, P = .003), D2-width (1.70 ± 0.48 vs 1.55 ± 0.55 cm, P = .024), D3-depth (2.21 ± 0.75 vs 1.99 ± 0.65 cm, P = .017), larger orifice areas (2.8 ± 1.35 and 2.3 ± 1.49 cm2 , P = .004), and diminished orifice flow velocity (37.3 ± 17.6 and 43.7 ± 19.5 cm/sec, P = .008). CONCLUSIONS: Adverse LAA remodeling in DM patients with AFib is characterized by significantly LAA orifice enlargement and reduced orifice flow velocity. Analysis of LAA geometry and hemodynamics may have clinical implications in thrombotic risk assessment and treatment of DM patients with AFib.

Impact of the Change in ESC Guidelines on Clinical Characteristics and Outcomes of Cardiogenic Shock Patients Receiving IABP Therapy.

BACKGROUND: Intra-aortic balloon pump (IABP) counterpulsation provides mechanical support for patients with cardiogenic shock. The aim of the study is to evaluate the clinical characteristics and outcomes of patients with cardiogenic shock receiving IABP before and after the European Society of Cardiology (ESC) downgraded the use of IABP from a class I to a class IIb in 2012. METHODS: Data was obtained from the Acute Coronary Syndrome Israeli Survey (ACSIS) registry, a prospective observational national survey conducted once every two years. From a total of 15,200 patients with acute coronary syndrome (ACS), 524 patients were identified with acute myocardial infarction (AMI)-complicated with cardiogenic shock. The groups were further subdivided based on whether the IABP was implanted before or after the change in guideline recommendation. RESULTS: The study indicates a 24% reduction in IABP use since 2002. Until 2012, a reduction in clinical outcomes including 7-days, 30-days and in-hospital mortality, was observed in patients with IABP compared to the patients with conventional therapy. Conversely, after the ESC changed the guidelines, the clinical outcomes were not improved by IABP treatment. Additionally, the conventional therapy group presented with higher baseline ejection fraction, received less effective treatment, reperfusion and/or pharmacological therapy than patients with IABP. CONCLUSION: The use of IABP as management for cardiogenic shock has diminished over time since the guidelines were modified. After the change in guidelines, the use of IABP is restricted to high-risk, severely compromised and hemodynamically deteriorated patients hence limiting beneficial outcomes.

Comparison of Clinical Characteristics and Prognosis in Patients with Right- and Left-sided Infective Endocarditis.

OBJECTIVE: Right-sided endocarditis (RSE) accounts for 5%-10% of all cases of infective endocarditis (IE) and frequently has different etiological, pathogenetic, and clinical presentations compared with left-sided endocarditis (LSE). The aims of this study were to evaluate the epidemiologic and clinical characteristics and prognosis of RSE patients and to compare them with those of LSE patients. This study's importance relates to the local understanding of RSE and LSE, since Israeli demographics are different compared to the Unites States and Europe with regard to intravenous drug abuse and rheumatic valvular disease prevalence. MATERIAL AND METHODS: A retrospective cohort study of 215 patients with infective endocarditis was performed. The primary outcome was in-hospital mortality. The secondary outcomes were duration of hospitalization, recurrent hospitalization, recurrent infective endocarditis, and one-year mortality. RESULTS: Of the 215 patients in the study, 176 had LSE and 39 had RSE. The RSE patients were younger than the LSE patients (48.1±18.9 years versus 61.8±17.0 years, P<0.001). The most common pathogen in both groups was Staphylococcus aureus, which occurred more in the RSE group (51%) versus the LSE group (19%). In-hospital mortality was lower among patients with RSE (2.6% versus 17%, P<0.037). CONCLUSIONS: Our study demonstrated an increasing percentage of RSE compared to LSE among patients with IE. Pacemaker lead infection has become the leading cause of RSE in intravenous drug users (IVDU), although less common in Southern Israel. The etiological and clinical differences between RSE and LSE are noteworthy. Patients with RSE have a better prognosis than those with LSE.

Developing a risk score to predict mortality in the first year after implantable cardioverter defibrillator implantation: Data from the Israeli ICD Registry.

INTRODUCTION: Life expectancy of less than 1 year is usually a contraindication for implantable cardioverter defibrillator (ICD) implantation. The aim was to identify patients at risk of death during the first year after implantation. METHODS AND RESULTS: Data were derived from a prospective Israeli ICD Registry. Two groups of patients were compared, those who died and those who were alive 1 year after ICD implantation. Factors associated with 1-year mortality were identified on a derivation cohort. A risk score was established and validated. A total of 2617 patients have completed 1 year of follow-up after ICD or cardiac resynchronization therapy defibrillator (CRT-D) implantation. Age greater than 75 years (hazard ratio [HR], 2.7; 95% confidence interval [95% CI], 1.6 to 4.4), atrial fibrillation (AF; HR, 1.9; 95% CI, 1.12 to 3.17), chronic lung disease (HR, 2.0; 95% CI, 1.1 to 3.76), anemia (HR, 2.3; 95% CI, 1.3 to 3.93) and chronic renal failure (CRF; HR, 3.4; 95% CI, 1.74 to 6.6) were independent risk factors for 1-year mortality. We propose a simple AAACC ("triple A double C") score for prediction of 1-year mortality after ICD implantation: Age greater than 75 years (3 points(pts)), anemia (2 pts), AF (1 pt), CRF (3 pts) and chronic lung disease (1 pt). Mortality risk increased with rising number of points (from 1% with 0 pts to 12.5% with >4 pts). The risk score was evaluated with receiver operating characteristic curve and the area under the curve of the validation curve is 0.71 (95% CI, 0.66 to 0.76). CONCLUSIONS: Age greater than 75, AF, chronic lung disease, anemia, and CRF were independent risk factors for 1-year mortality. AAACC risk score identifies patients at high risk of death during 1 year after ICD implantation.

Gender-Related Differences in Outcomes of Patients with Cardiac Resynchronization Therapy.

BACKGROUND: Gender-related differences (GRD) exist in the outcome of patients with cardiac resynchronization therapy (CRT). OBJECTIVES: To assess GRD in patients who underwent CRT. METHODS: A retrospective cohort of 178 patients who were implanted with a CRT in a tertiary center 2005-2009 was analyzed. Primary outcome was 1 year mortality. Secondary endpoints were readmission and complication rates. RESULTS: No statistically significant difference was found in 1 year mortality rates (14.6% males vs. 11.8% females, P = 0.7) or in readmission rate (50.7% vs. 41.2%, P = 0.3). The complication rate was only numerically higher in women (14.7% vs. 5.6%, P = 0.09). Men more often had CRT-defibrillator (CRT-D) implants (63.2% vs. 35.3%, P = 0.003) and had a higher rate of ischemic cardiomyopathy (79.2% vs. 38.2%, P < 0.001). There was a trend to higher incidence of ventricular fibrillation/ventricular tachycardia in men before CRT implantation (29.9% vs. 14.7%, P = 0.07%). A higher proportion of men upgraded from implantable cardioverter defibrillator (ICD) to CRT-D, 20.8% vs. 8.8%, P = 0.047. On multivariate model, chronic renal failure was an independent predictor of 1 year mortality (hazard ratio [HR] 3.6; 95% confidence interval [95%CI] 1.4-9.5), CRT-D had a protective effect compared to CRT-pacemaker (HR 0.3, 95%CI 0.12-0.81). CONCLUSIONS: No GRD was found in 1 year mortality or readmission rates in patients treated with CRT. There was a trend toward a higher complication rate in females. Men were implanted more often with CRT-D and more frequently underwent upgrading of ICD to CRT-D.

Effectiveness of Inferior Vena Cava Filters without Anticoagulation Therapy for Prophylaxis of Recurrent Pulmonary Embolism.

OBJECTIVE: The optimal treatment of deep vein thrombosis (DVT) is anticoagulation therapy. Inferior vena cava filter (IVC) placement is another option for the prevention of pulmonary embolism (PE) in patients with deep vein thrombosis. This is used mostly in patients with a contraindication to anticoagulant therapy. The purpose of the present study was to compare the two options. METHODS: A retrospective cohort study of two groups of patients with DVT: patients who received an IVC filter and did not receive anticoagulation due to contraindications; and patients with DVT and similar burden of comorbidity treated with anticoagulation without IVC insertion. To adjust for a potential misbalance in baseline characteristics between the two groups, we performed matching for age, gender, and Charlson's index, which is used to compute the burden of comorbid conditions. The primary outcome was an occurrence of a PE. RESULTS: We studied 1,742 patients hospitalized with the diagnosis of DVT in our hospital;93 patients from this population received IVC filters. Charlson's score index was significantly higher in the IVC filter group compared with the anticoagulation group. After matching of the groups of patients according to Charlson's score index there were no significant differences in primary outcomes. CONCLUSION: Inferior vena cava filter without anticoagulation may be an alternative option for prevention of PE in patients with contraindications to anticoagulant therapy.

Endothelial nitric oxide synthase polymorphism and prognosis in systolic heart failure patients.

BACKGROUND: The endothelial nitric oxide synthase (eNOS) gene single nucleotide polymorphism G894T is associated with thrombotic vascular diseases. However, its functional significance is controversial and data are scarce concerning its influence in heart failure (HF). METHODS: We studied 215 patients with chronic systolic HF. DNA was analyzed for eNOS gene G894T polymorphism using PCR and DNA sequencing. Evaluation of clinical characteristics and analysis of factors associated with 2-year mortality were performed for the homozygous G-allele G894T variant (GG), relative to the TT and GT variants. RESULTS: The genotype distributions of eNOS G894T alleles were: GG 135 patients (63%) and TT/GT 80 (37%). Two-year mortality was significantly higher in the GG variant (48%) than the combined TT/GT group (32%). The usage of nitrates was associated with increased 2-year mortality (HR 2.0, 95% CI 1.28-3.17; p = 0.003), which was most significant in the GG group treated with nitrates (73.5%) in comparison to the TT/GT group not treated with nitrates (34%); HR 2.75, 95% CI 1.57-4.79, P < 0.001. CONCLUSIONS: Homozygosity for the G allele of the eNOS G894T polymorphism was associated with worse survival in systolic HF patients, especially in those treated with nitrates. ENOS polymorphism may result in different mechanistic interactions in HF than in thrombotic vascular diseases, suggesting that overexpression of NO may be associated with deleterious effects in systolic HF.

Transoesophageal echocardiography of aortic atherosclerosis: the additive value of three-dimensional over two-dimensional imaging.

AIMS: Complex aortic atherosclerotic plaques (AAPs) carry a significant risk of embolism. Currently, two-dimensional (2D) transoesophageal echocardiography (TOE) is the principal diagnostic tool of AAPs. However, we hypothesized that the data obtained from three-dimensional (3D) imaging may improve AAPs' spatial assessment. METHODS AND RESULTS: The study included 67 patients (aged 70 ± 15 years, 35 men), who had routine TEE studies. The thoracic aorta was studied from arch to distal descending aorta, using the x-plane mode (simultaneous short- and long-axis views). If focal intimal thickening (suggestive of AAP) was detected, the 3D zoom algorithm was exercised on the specific site with further post-processing on a Q-lab workstation to measure its thickness in the X, Y, and Z dimensions. The AAP contour was defined qualitatively as regular or irregular in each mode. A total of 100 AAPs were investigated. The AAP thickness estimation was significantly greater in the 3D mode than in the 2D mode (0.51 ± 0.33 vs. 0.28 ± 0.20 cm, P < 0.001). The rate of complex AAPs (defined by AAP thickness of ≥4 mm) was two-fold higher with 3D imaging than with 2D imaging (27% with 2D imaging alone vs. 53% with the addition of 3D imaging). The rate of irregular AAPs increased from 29 to 65% when assessed with 3D imaging compared with 2D imaging. CONCLUSION: This study has shown a significant difference in the estimation of AAPs between 2D and 3D TEE. The significant shift to a more complex AAPs profile may suggest that 3D imaging is preferable for the assessment of aortic atherosclerosis burden.

[Differences in clinical characteristics and outcomes of diabetic ketoacidosis (DKA) in Jewish and Bedouin patients].

BACKGROUND: The aim of this study was to compare clinical characteristics and outcomes of diabetic ketoacidosis (DKA) in the Jewish and Bedouin populations. METHODS: A retrospective analysis was conducted of hospital admissions for diabetic ketoacidosis in adult patients between 2003 and 2010. The clinical and biochemical characteristics and outcomes of diabetic ketoacidosis patients of Jewish origin were compared with those of Bedouin origin. The primary outcome was in-hospital all-cause mortality. RESULTS: The study cohort included 220 consecutive patients for whom the admission diagnosis was diabetic ketoacidosis. The cohort was categorized according to Jewish and Bedouin origin as follows: 177 (80.5%) Jewish and 43 (19.5%) Bedouin patients. The Jewish patients were significantly older than the Bedouin patients (45.8 +/- 18.9 vs. 32.9 +/- 15.3, p < 0.001). The majority of the patients with diabetic ketoacidosis in both the Jewish and Bedouin groups had type 1 diabetes mellitus. No differences were found for in-hospital mortality, 30 days mortality or complication rates in groups of Jewish and Bedouin patients. The Length of hospital stay was significantly Longer in the Jewish compared to the Bedouin groups of patients (median 4 days (IQR 2; 6 days) vs. median 3 days (IQR 2; 4 days) respectively, p = 0.05). CONCLUSIONS: We did not find significant differences in the outcomes between Bedouin and Jewish patients with diabetic ketoacidosis. The Bedouin patients in the present study were younger compared to Jewish patients and the Length of the hospital stay was shorter in the Bedouin compared to the Jewish group. Advanced age, mechanical ventilation and bed-ridden state were independent predictors of 30-day mortality in both ethnic groups.

Prognostic value of left ventricular dyssynchrony by myocardial perfusion-gated SPECT in patients with normal and abnormal left ventricular functions.

BACKGROUND: Left ventricular (LV) dyssynchrony by phase analysis has been studied by myocardial perfusion imaging (MPI)-gated SPECT in patients with LV dysfunction in various clinical settings. We aimed to investigate the routine use of phase analysis with gated SPECT for predicting cardiac outcome. METHODS: Patients referred to a tertiary medical center in 2010-2011 prospectively underwent a gated SPECT and phase analysis, and follow-up for cardiac events. The values of clinical variables, MPI, LV function, and LV dyssynchrony in predicting cardiac events were tested by univariate and multivariate analyses. RESULTS: The study group included 787 patients (66.5 ± 11 years, 81% men) followed for a mean duration of 18.3 ± 6.2 months. There were 45 (6%) cardiac events defined as composite endpoint; cardiac death occurred in 26 patients, and the rest had new-onset or worsening heart failure and life-threatening arrhythmias. In multivariate analysis, it was shown that NYHA class, diabetes mellitus, and LVEF <50% were the independent predictors for composite endpoint. However, the independent predictors for cardiac mortality were NYHA class (for each increment in class) and phase standard deviation (SD) (for each 10° increment). CONCLUSION: Gated SPECT with phase analysis for the assessment of LV dyssynchrony can successfully predict cardiac death together with NYHA class, in patients with LV dysfunction.

Pacemaker implantation after transcatheter aortic valve implantation.

Thirty- to 35% of patients after transcatheter aortic valve implantation undergo implantation of a permanent pacemaker (PPM) because of development of atrioventricular block (AVB) or development of a condition with high risk of progression to AVB. There are insufficient data regarding long-term follow-up on pacing dependency. From February 2009 to July 2011, 191 transcatheter aortic valve implantation procedures were performed at the Rabin Medical Center (125 CoreValve and 66 Edwards SAPIEN). Thirty-two patients (16.7%) received a PPM (30 with CoreValve and 2 with Edwards SAPIEN). Data from the pacemaker clinic follow-up was available in 27 patients. After a mean follow-up of 52 weeks (range, 22 to 103), only 8 (29%) of 27 patients were pacing dependent. The indication of PPM in these 8 patients was complete AVB. In conclusion, in our center, the rate of PPM implantation was 16%, which is lower than that reported in the published works. Only 29% of those patients implanted with PPM were pacemaker dependent. Further studies are necessary to define reliable predictors for long-term pacing.

Cardiac resynchronization therapy in patients with atrial fibrillation: a 2-year follow-up study.

INTRODUCTION: Atrial fibrillation (AF) is the most common arrhythmia in patients with heart failure (HF) and represents an important comorbidity in these patients. Cardiac resynchronization therapy (CRT) has been shown to be beneficial in patients with HF. Whether patients with AF benefit similarly from CRT as their counterparts in sinus rhythm is controversial. METHODS AND RESULTS: We conducted a cohort analysis of 175 patients (138 men; age range 57-79 years) who underwent CRT implantation during 2004-2008 in our institution. AF was documented in 66 patients (37.7% of patients, 52 men). There were no differences in 1- or 2-year mortality between patients with and without AF (13.6% vs 11.79%, P = 0.7; 25.8% vs 16.9%, P = 0.2, respectively). There were no differences between the groups in the rate of complications after CRT implantation or in the rate of appropriate electrical shocks. In the subgroup of AF patients with cardiac resynchronization therapy defibrillator (CRT-D) (n = 32, 48.5%), the 1-year mortality was 3.1% as compared to 23.5% in AF patients with cardiac resynchronization therapy pacemaker (P = 0.03). This difference was no longer evident after 2 years (25.0% vs 26.5%, P = 0.8, respectively). Ten patients (15.2%) with AF underwent atrioventricular (AV) node ablation. The 2-year mortality of these patients was 10.0% as compared to 28.6% in AF patients who did not undergo AV-node ablation (P = 0.4). CONCLUSIONS: In this study, no difference in mortality appears to exist between patients with or without AF and who undergo CRT implantation. Our findings of the beneficial effects of AV-node ablation and CRT-D in AF patients deserve further investigation.

Comparison of diabetic ketoacidosis in patients with type-1 and type-2 diabetes mellitus.

BACKGROUND: Diabetic ketoacidosis (DKA) occurs most often in patients with type 1 diabetes, however patients with type 2 diabetes are also susceptible to DKA under stressful conditions. The aims of our study were to evaluate and compare the clinical and biochemical characteristics and outcomes of type 1 versus type 2 diabetes mellitus (DM) patients with DKA. METHODS: A retrospective cohort study of adult patients hospitalized with DKA between January 1, 2003, and January 1, 2010. The clinical and biochemical characteristics of DKA patients with type-1 DM were compared with those of patients with type-2 DM. The primary outcome was in-hospital all-cause mortality. RESULTS: The study cohort included 201 consecutive patients for whom the admission diagnosis was DKA: 166 patients (82.6%) with type-1 DM and 35 patients (17.4%) with type-2 DM. The patients with DKA and type-2 DM were significantly older than patients with type-1 DM (64.3 versus 37.3, P < 0.001). Significantly more patients with severe forms of DKA were seen in the group with type-2 DM (25.7% versus 9.0%, P = 0.018). The total in-hospital mortality rate of patients with DKA was 4.5%. The primary outcome was significantly worse in the group of patients with type-2 DM. CONCLUSIONS: DKA in patients with type-2 DM is a more severe disease with worse outcomes compared with type-1 DM. Advanced age, mechanical ventilation and bed-ridden state were independent predictors of 30-day mortality.

Clinical profile and outcome of patients with severe aortic stenosis at high surgical risk: single-center prospective evaluation according to treatment assignment.

BACKGROUND: The study sought to assess the clinical profile, outcome, and predictors for mortality of "real-world" high-risk severe aortic stenosis patients according to the mode of treatment assigned. METHODS: Patients were referred to a dedicated clinic for meticulous screening and multidisciplinary team assessment and 343 were finally assigned treatment (age 81.3 ± 7.2 years, 42.3% men): transcatheter aortic valve replacement (TAVR) with the Edwards SAPIEN or CoreValve device, 100 (29.2%); surgical aortic valve replacement (SAVR), 61 (17.8%); balloon valvuloplasty (as definitive therapy), 27 (7.9%); medication only, 155 (45.2%). No patient was lost to follow-up. RESULTS: The balloon valvuloplasty group had a significantly higher 1-month mortality rate (18.5%) than the TAVR group (3%, P = 0.006) and medical therapy group (3.9%; P = 0.004), without significant difference from the SAVR group (11.5%, P = 0.5). One-year cumulative survival was significantly higher in the TAVR group (92%) than in the other groups (SAVR 71%, balloon valvuloplasty 61.5%, medication 65%; all P < 0.001). Among survivors, 1-year rates of high functional class (NYHA I/II) were as follows: TAVR, 84.6%; SAVR, 63.3%; balloon valvuloplasty, 18.2%; medication, 21.4% (TAVR vs. SAVR, P = 0.04; SAVR vs. balloon valvuloplasty or medical therapy, P = 0.01). On multivariate regression analysis, renal failure (hazard ratio [HR] = 5.3, P < 0.001), not performing TAVR (HR = 4.9, P < 0.001), and pulmonary pressure (10 mm Hg, HR = 1.2, P = 0.02) were independent predictors of 1-year mortality. CONCLUSIONS: TAVR, performed in carefully selected high-risk patients, is associated with an excellent survival rate and high functional class. Patients treated with another of the available modalities, including SAVR, had a worse outcome, regardless of which alternative treatment they receive.

Implantable cardioverter defibrillator with and without defibrillation threshold testing.

BACKGROUND: Defibrillation threshold (DFT) testing at the time of implantable cardioverter defibrillator (ICD) insertion is performed routinely. This practice is being reconsidered due to doubts about its ability to improve ICD efficacy and evidence that survival may not be affected by the test. OBJECTIVES: To compare the outcome of ICD recipients who underwent DFT testing and those who did not. METHODS: A total of 213 eligible patients were implanted with an ICD between 2004 and 2009. DFT testing was performed in 80 of them. We compared total mortality, appropriate and inappropriate ICD shocks, and anti-tachycardia pacing (ATP) events between DFT and non-DFT patients during a follow-up of 2 years. RESULTS: On comparing the DFT and non-DFT groups, we found a 2 year mortality rate of 7.5% versus 8.3%, respectively (P = 0.8). Furthermore, 20.7% of patients in the DFT group and 12.4% in the non-DFT group had at least one episode of ICD shock (P = 0.15). With regard to ICD treatment (ICD shocks or ATP events), 57.7% in the DFT group and 64.2% in the non-DFT group received appropriate treatments (P = 0.78). CONCLUSIONS: No significant differences in the incidence of 2 year mortality or percentage of ICD treatment emerged between the DFT and non-DFT groups.

Diabetic ketoacidosis: clinical characteristics, precipitating factors and outcomes of care.

BACKGROUND: Diabetic ketoacidosis (DKA) is a common and serious complication of diabetes mellitus (DM). OBJECTIVES: To evaluate the clinical characteristics, hospital management and outcomes of patients with DKA. METHODS: We performed a retrospective cohort study of patients hospitalized with DKA during the period 1 January 2003 to 1 January 2010. Three groups were compared: patients with mild DKA, with moderate DKA, and with severe DKA. The primary outcome was in-hospital all-cause mortality. The secondary outcomes were 30 days all-cause mortality, length of hospital stay, and complication rate. RESULTS: The study population comprised 220 patients with DKA. In the mild (78 patients) and moderate (116 patients) groups there was a higher proportion of patients with type 1 DM (75.6%, 79.3%) compared with 57.7% in the severe group (26 patients, P = 0.08). HbA1c levels prior to admission were high in all three groups, without significant difference (10.9 +/- 2.2, 10.7 +/- 1.9, and 10.6 +/- 2.4 respectively, P = 0.9). In all groups the most frequent precipitating factors were related to insulin therapy and infections. The patients with severe DKA had more electrolyte abnormalities (hypokalemia, hypomagnesemia, hypophosphatemia) compared with the mild and moderate forms of the disease. While 72.7% of the entire cohort was hospitalized in the general medical ward, 80.8% of those with severe DKA were admitted to the intensive care unit. The in-hospital mortality rate for the entire cohort was 4.1%, comparable with previous data from experienced centers. Advanced age, mechanical ventilation and bedridden state were independent predictors associated with 30 day mortality: hazard ratio (HR) 1.1, 95% confidence interval (CI) 1.02-1.11; HR 6.8, 95% CI 2.03-23.1; and HR 3.8, 95% CI 1.13-12.7, respectively. CONCLUSIONS: Patients with DKA in our study were generally poorly controlled prior to their admission, as reflected by high HbA1c levels. Type 2 DM is frequently associated with DKA including the severe form of the disease. The most common precipitating factors for the development of DKA were related to insulin therapy and infections. Advanced age, mechanical ventilation and bedridden state wer independent predictors of 30 day mortality.