Coronary-Artery Bypass Surgery in Patients with Ischemic Cardiomyopathy.

BACKGROUND: The survival benefit of a strategy of coronary-artery bypass grafting (CABG) added to guideline-directed medical therapy, as compared with medical therapy alone, in patients with coronary artery disease, heart failure, and severe left ventricular systolic dysfunction remains unclear. METHODS: From July 2002 to May 2007, a total of 1212 patients with an ejection fraction of 35% or less and coronary artery disease amenable to CABG were randomly assigned to undergo CABG plus medical therapy (CABG group, 610 patients) or medical therapy alone (medical-therapy group, 602 patients). The primary outcome was death from any cause. Major secondary outcomes included death from cardiovascular causes and death from any cause or hospitalization for cardiovascular causes. The median duration of follow-up, including the current extended-follow-up study, was 9.8 years. RESULTS: A primary outcome event occurred in 359 patients (58.9%) in the CABG group and in 398 patients (66.1%) in the medical-therapy group (hazard ratio with CABG vs. medical therapy, 0.84; 95% confidence interval [CI], 0.73 to 0.97; P=0.02 by log-rank test). A total of 247 patients (40.5%) in the CABG group and 297 patients (49.3%) in the medical-therapy group died from cardiovascular causes (hazard ratio, 0.79; 95% CI, 0.66 to 0.93; P=0.006 by log-rank test). Death from any cause or hospitalization for cardiovascular causes occurred in 467 patients (76.6%) in the CABG group and in 524 patients (87.0%) in the medical-therapy group (hazard ratio, 0.72; 95% CI, 0.64 to 0.82; P<0.001 by log-rank test). CONCLUSIONS: In a cohort of patients with ischemic cardiomyopathy, the rates of death from any cause, death from cardiovascular causes, and death from any cause or hospitalization for cardiovascular causes were significantly lower over 10 years among patients who underwent CABG in addition to receiving medical therapy than among those who received medical therapy alone. (Funded by the National Institutes of Health; STICH [and STICHES] ClinicalTrials.gov number, NCT00023595.).

Ten-Year Outcomes After Coronary Artery Bypass Grafting According to Age in Patients With Heart Failure and Left Ventricular Systolic Dysfunction: An Analysis of the Extended Follow-Up of the STICH Trial (Surgical Treatment for Ischemic Heart Failure).

BACKGROUND: Advancing age is associated with a greater prevalence of coronary artery disease in heart failure with reduced ejection fraction and with a higher risk of complications after coronary artery bypass grafting (CABG). Whether the efficacy of CABG compared with medical therapy (MED) in patients with heart failure caused by ischemic cardiomyopathy is the same in patients of different ages is unknown. METHODS: A total of 1212 patients (median follow-up, 9.8 years) with ejection fraction ≤35% and coronary disease amenable to CABG were randomized to CABG or MED in the STICH trial (Surgical Treatment for Ischemic Heart Failure). RESULTS: Mean age at trial entry was 60 years; 12% were women; 36% were nonwhite; and the baseline ejection fraction was 28%. For the present analyses, patients were categorized by age quartiles: quartile 1, ≤54 years; quartile, 2 >54 and ≤60 years; quartile 3, >60 and ≤67 years; and quartile 4, >67 years. Older versus younger patients had more comorbidities. All-cause mortality was higher in older compared with younger patients assigned to MED (79% versus 60% for quartiles 4 and 1, respectively; log-rank P=0.005) and CABG (68% versus 48% for quartiles 4 and 1, respectively; log-rank P<0.001). In contrast, cardiovascular mortality was not statistically significantly different across the spectrum of age in the MED group (53% versus 49% for quartiles 4 and 1, respectively; log-rank P=0.388) or CABG group (39% versus 35% for quartiles 4 and 1, respectively; log-rank P=0.103). Cardiovascular deaths accounted for a greater proportion of deaths in the youngest versus oldest quartile (79% versus 62%). The effect of CABG versus MED on all-cause mortality tended to diminish with increasing age (Pinteraction=0.062), whereas the benefit of CABG on cardiovascular mortality was consistent over all ages (Pinteraction=0.307). There was a greater reduction in all-cause mortality or cardiovascular hospitalization with CABG versus MED in younger compared with older patients (Pinteraction=0.004). In the CABG group, cardiopulmonary bypass time or days in intensive care did not differ for older versus younger patients. CONCLUSIONS: CABG added to MED has a more substantial benefit on all-cause mortality and the combination of all-cause mortality and cardiovascular hospitalization in younger compared with older patients. CABG added to MED has a consistent beneficial effect on cardiovascular mortality regardless of age. CLINICAL TRIAL REGISTRATION: URL: http://www.clinicaltrials.gov. Unique identifier: NCT00023595.

Determining the Role of Thiamine Deficiency in Systolic Heart Failure: A Meta-Analysis and Systematic Review.

BACKGROUND: Approximately 5.7 million Americans carry the diagnosis of systolic heart failure (HF), a major health care burden. HF is a known manifestation of thiamine deficiency (TD). HF patients are at unique risk for developing TD, which may contribute to further altered cardiac function and symptoms. METHODS AND RESULTS: We performed a systematic review of the literature and a meta-analysis to evaluate the prevalence of TD in HF patients, risk factors for and mechanisms of development of TD in HF population, and outcomes of thiamine supplementation in HF patients. We found 54 studies that met our selection criteria, 9 of which were suitable for meta-analysis. TD is more common in HF patients than control subjects (odds ratio 2.53, 95% confidence interval 1.65-3.87). Diuretic use, changes in dietary habits, and altered thiamine absorption and metabolism were identified as possible mechanisms of TD in HF patients. Small observational studies and randomized control trials suggest that thiamine supplementation in HF population may improve ejection fraction and reduce symptoms. CONCLUSIONS: Thiamine deficiency is more prevalent in the HF population, and its supplementation may be beneficial. The therapeutic role of thiamine in HF warrants further study.

Optical coherence tomography imaging of the patent ductus arteriosus: first known uses in congenital heart disease.

BACKGROUND: Angiography is used to assess ductal morphology and caliber during interventional closure of the ductus arteriosus. We are evaluating the use of optical coherence tomography (OCT) to evaluate ductal anatomy given the potential benefit of superior resolution and lower radiation. METHODS: Standard angiograms were performed on two patients with patent ductus arteriosus prior to device occlusion. OCT was then used to obtain high-resolution three-dimensional vessel reconstructions. Devices were chosen based on angiographic measurements. RESULTS: OCT resulted in excellent three-dimensional anatomic definition, with elliptical narrowest lumenal measurements of 2.2 × 3.1 mm and 1.6 × 2.3 mm, respectively, compared with angiographic measurements of 2.6 and 1.4 mm. CONCLUSIONS: To our knowledge, this is the first reported use of OCT use in pediatric patients outside the coronaries, and in patients with congenital heart disease. We found OCT imaging of the PDA to be feasible, and only used a small amount of additional radiation and contrast. The three-dimensional OCT reconstructions provided additional anatomic information that could potentially improve device selection, and in both cases may have led to choosing larger devices than what was chosen based on angiography. In addition, once the technique is perfected, little or no angiography or fluoroscopy will be required to perform imaging runs, and only a small injection of contrast appears to be sufficient for vessel imaging. However, there are certain limitations to OCT imaging that are unlikely to make it the method of choice specifically for imaging the patent ductus arteriosus, but we have shown its ability to provide high resolution imaging in a relatively simple fashion which may prove useful for other purposes. © 2014 Wiley Periodicals, Inc.

Helex device closure of multiple atrial septal defects.

OBJECTIVES: To describe the effectiveness of the Helex Septal Occluder (HSO) to close multiple atrial septal defects (mASDs). Background : Limited information is available describing closure of mASDs with the HSO. METHODS: A total of 28 patients who underwent closure of mASDs with the HSO were identified by retrospective review of our catheterization database between 2001 and 2012. Procedural details and follow up information were collected. RESULTS: Median age was 19.2 years, median weight 48 kg, with 10 (36%) patients weighing <25 kg. Indication for closure was RV enlargement (RVE) in all patients and additionally neurologic events occurred in 3/28 (11%). Median stop-flow diameter for the largest ASD was 14 (4-23) mm. One HSO was implanted in 21/28 (75%), 2 in 6/28 (21%), and 3 in 1/28 (4%). One embolization and one transient arrhythmia occurred with no sequelae. Immediate residual shunt was absent in 5/28 (18%), trivial in 15/28 (54%), small in 6/28 (21%), and moderate in 2/28 (7%). Of the 25 patients with ≥6 months follow-up (median 53 months), residual shunt was absent in 13/25 (52%), trivial in 5/25 (20%), and small in 7/25 (28%). RVE resolved in all but one patient with no other associated lesions and ≥6 months of follow-up. No patient with prior neurological event had recurrence at last follow-up. CONCLUSIONS: We conclude that closure of mASDs with ≥1 HSO is effective with a low complication rate. The ability of HSO devices to overlap or sandwich each other may facilitate safe implantation of multiple devices in smaller patients.

Standardizing radiation dose reporting in the pediatric cardiac catheterization laboratory-a multicenter study by the CCISC (Congenital Cardiovascular Interventional Study Consortium).

OBJECTIVES: We examine normalized air Kerma area product (PKA ) by body weight (PKA /BW) as a reference value of radiation dose and benchmark PKA /BW in pediatric laboratories using a multicenter registry database. BACKGROUND: Reduction of radiation dose is an important quality improvement task in pediatric cardiac catheterization laboratories. Physicians need to agree on a standard method of reporting radiation dose that would allow comparisons to be made between operators and institutions. METHODS: This was a multicenter observational study of radiation dose in pediatric laboratories. Patient demographic, procedural and radiation data including fluoroscopic time and PKA (µGy m(2) ) were analyzed. PKA /BW was obtained by indexing PKA to body weight. RESULTS: A total of 8,267 pediatric catheterization procedures (age <18 years) were included from 16 institutions. The procedures consisted of diagnostic (n = 2,827), transplant right ventricular (RV) biopsy (n = 1,172), and interventional catheterizations (n = 4268). PKA correlated with body weight better than with age and best correlated with weight-fluoroscopic time product. PKA /BW showed consistent values across pediatric ages. Interventional catheterizations had the highest PKA /BW (50th, 75th, and 90th percentiles: 72, 151, and 281 µGy m(2) /kg), followed by diagnostic (59, 105, and 175 µGy m(2) /kg) and transplant RV biopsy (27, 79, and 114 µGy m(2) /kg). CONCLUSION: PKA /BW appeared to be the most reliable standard to report radiation dose across all procedure types and patient age. We recommend PKA /BW to be used as the standard unit in documenting radiation usage in pediatric laboratories and can be used to evaluate strategies to lower radiation dosage in pediatric patients undergoing cardiac catheterizations. © 2014 Wiley Periodicals, Inc.

Drug-eluting stents may not reduce target lesion revascularization in cardiac allograft vasculopathy.

OBJECTIVE: Although drug-eluting stent (DES) compared with bare metal stent (BMS) use reduces in-stent restenosis (ISR) in traditional coronary artery disease, its efficacy in cardiac allograft vasculopathy (CAV) has not been clearly established. BACKGROUND: CAV is a leading cause of mortality after the first year following cardiac transplantation. CAV treatment options are limited, and DES use has increased significantly in this population. METHODS: In a retrospective study of heart transplant patients at our institution who underwent percutaneous coronary intervention with a BMS or DES for CAV, we compared baseline characteristics, clinical outcomes, ISR, and target lesion revascularization (TLR). The primary end-point was angiographic ISR assessed by quantitative coronary angiography analyzed as both a binary (≤50% vs. >50%) and continuous variable (follow-up minimal luminal area [MLA]/baseline MLA). Secondary outcomes included TLR and a composite of death, myocardial infarction, heart failure, and retransplantation. RESULTS: In 45 patients with DES, BMS, or both, ISR assessed as a continuous variable was statistically different between the 2 stent groups (follow-up MLA/baseline MLA = 0.796 DES vs. 0.481 BMS; P = 0.0037). There was also a significant difference in ISR (10.8% for DES versus 30.7% for BMS) when assessed as a binary variable. There was no statistically significant difference in TLR or composite cardiovascular outcomes between groups when adjusted for traditional cardiovascular risk factors. CONCLUSIONS: ISR assessed as a continuous variable was significantly different between stent groups. However, this did not lead to a difference in TLR or cardiovascular outcomes. This hypothesis-generating finding suggests that patients with CAV may not necessarily need treatment with DES, which can be more costly and carries more potential risk than BMS.

Coronary bypass surgery with or without surgical ventricular reconstruction.

BACKGROUND: Surgical ventricular reconstruction is a specific procedure designed to reduce left ventricular volume in patients with heart failure caused by coronary artery disease. We conducted a trial to address the question of whether surgical ventricular reconstruction added to coronary-artery bypass grafting (CABG) would decrease the rate of death or hospitalization for cardiac causes, as compared with CABG alone. METHODS: Between September 2002 and January 2006, a total of 1000 patients with an ejection fraction of 35% or less, coronary artery disease that was amenable to CABG, and dominant anterior left ventricular dysfunction that was amenable to surgical ventricular reconstruction were randomly assigned to undergo either CABG alone (499 patients) or CABG with surgical ventricular reconstruction (501 patients). The primary outcome was a composite of death from any cause and hospitalization for cardiac causes. The median follow-up was 48 months. RESULTS: Surgical ventricular reconstruction reduced the end-systolic volume index by 19%, as compared with a reduction of 6% with CABG alone. Cardiac symptoms and exercise tolerance improved from baseline to a similar degree in the two study groups. However, no significant difference was observed in the primary outcome, which occurred in 292 patients (59%) who were assigned to undergo CABG alone and in 289 patients (58%) who were assigned to undergo CABG with surgical ventricular reconstruction (hazard ratio for the combined approach, 0.99; 95% confidence interval, 0.84 to 1.17; P=0.90). CONCLUSIONS: Adding surgical ventricular reconstruction to CABG reduced the left ventricular volume, as compared with CABG alone. However, this anatomical change was not associated with a greater improvement in symptoms or exercise tolerance or with a reduction in the rate of death or hospitalization for cardiac causes. (ClinicalTrials.gov number, NCT00023595.)

Acute ST changes during anesthesia induction 10 months after Norwood procedure.

After the Norwood procedure for palliation of hypoplastic left heart syndrome, there is still significant interstage and late mortality with often unclear etiology. An important, but possibly under-recognized complication of the Norwood operation is the potential for coronary insufficiency from pre-coronary stenosis due to kinking or scarring at the anastomosis between the native and neo-aorta. We report a case of a clinically thriving 10-month old infant status post bidirectional Glenn who had acute ischemic changes on electrocardiogram (ECG) during induction of anesthesia for elective bilateral herniorrhaphy. A discrete narrowing in the native aorta to neo-aorta anastomosis was identified. A stent was placed emergently to restore adequate coronary blood flow after failure of simple angioplasty to adequately improve the stenosis.

Oxygen pulse kinetics in Fontan patients during treadmill ramp protocol cardiopulmonary exercise testing.

After single-ventricle palliation, patients have variable long-term functional outcomes. Cardiopulmonary exercise testing (CPET) is an assessment tool used to quantify functional outcome. Oxygen pulse kinetics during CPET, which can be an important indicator of dynamic changes in stroke volume reserve, has not been systematically studied in this population. This study aimed to analyze oxygen pulse kinetics during a treadmill ramp protocol among patients with Fontan physiology compared with that of normal subjects and to explore the ability of oxygen pulse kinetics to define functional status further. Peak oxygen pulse and change in oxygen pulse during ramp treadmill CPET were retrospectively collected and compared between 44 Fontan patients and 85 age- and sex-matched control subjects. The peak oxygen pulse was significantly lower in the Fontan group (9.80 ± 4.11 ml/beat) than in the control group (13.62 ± 4.7 ml/beat) (p ≤ 0.001). The resting oxygen pulse did not differ between the two groups (3.13 ± 1.23 vs. 3.09 ± 1.33 ml/beat; p = 0.88). The oxygen pulse was higher in the patients with chronotropic insufficiency, but the difference was not statistically significant (11.11 ± 4.97 vs. 9.25 ± 3.63 ml/beat; p = 0.17). Regression analysis showed a significant difference in the slope of the oxygen pulse-to-workload relationship. The Fontan group showed no relation between degree of reduction in the oxygen pulse from peak to end of exercise and the underlying defect, peak heart rate, peak oxygen consumption, ventilatory anaerobic threshold (VAT), expired volume (VE)/carbon dioxide output (VCO(2)) at the VAT, maximum heart rate, or minimum oxygen saturation. Analysis of oxygen pulse kinetics in Fontan patients suggests that there is an early and progressive limitation in stroke volume compared with control subjects. This limitation may be partially masked by increased oxygen extraction. In patients with chronotropic insufficiency, absolute or body surface area-indexed oxygen pulse may be higher than in those with a normal heart rate response. A composite assessment of the oxygen pulse and oxygen pulse kinetics, including the oxygen pulse slope and the percentage of reduction in oxygen pulse from peak to end of exercise, may allow a more comprehensive assessment of the degree of cardiac limitation in this group of patients.

Renal function and coronary bypass surgery in patients with ischemic heart failure.

OBJECTIVE: Chronic kidney disease is a known risk factor in cardiovascular disease, but its influence on treatment effect of bypass surgery remains unclear. We assessed the influence of chronic kidney disease on 10-year mortality and cardiovascular outcomes in patients with ischemic heart failure treated with medical therapy (medical treatment) with or without coronary artery bypass grafting. METHODS: We calculated the baseline estimated glomerular filtration rate (Chronic Kidney Disease Epidemiology Collaboration formula, chronic kidney disease stages 1-5) from 1209 patients randomized to medical treatment or coronary artery bypass grafting in the Surgical Treatment for IsChemic Heart failure trial and assessed its effect on outcome. RESULTS: In the overall Surgical Treatment for IsChemic Heart failure cohort, patients with chronic kidney disease stages 3 to 5 were older than those with stages 1 and 2 (66-71 years vs 54-59 years) and had more comorbidities. Multivariable modeling revealed an inverse association between estimated glomerular filtration rate and risk of death, cardiovascular death, or cardiovascular rehospitalization (all P < .001, but not for stroke, P = .697). Baseline characteristics of the 2 treatment arms were equal for each chronic kidney disease stage. There were significant improvements in death or cardiovascular rehospitalization with coronary artery bypass grafting (stage 1: hazard ratio, 0.71; confidence interval, 0.53-0.96, P = .02; stage 2: hazard ratio, 0.71; confidence interval, 0.59-0.84, P < .0001; stage 3: hazard ratio, 0.76; confidence interval, 0.53-0.96, P = .03). These data were inconclusive in stages 4 and 5 for insufficient patient numbers (N = 28). There was no significant interaction of estimated glomerular filtration rate with the treatment effect of coronary artery bypass grafting (P = .25 for death and P = .54 for death or cardiovascular rehospitalization). CONCLUSIONS: Chronic kidney disease is an independent risk factor for mortality in patients with ischemic heart failure with or without coronary artery bypass grafting. However, mild to moderate chronic kidney disease does not appear to influence long-term treatment effects of coronary artery bypass grafting.

FcMBL magnetic bead-based MALDI-TOF MS rapidly identifies paediatric blood stream infections from positive blood cultures.

Rapid identification of potentially life-threatening blood stream infections (BSI) improves clinical outcomes, yet conventional blood culture (BC) identification methods require ~24-72 hours of liquid culture, plus 24-48 hours to generate single colonies on solid media suitable for identification by mass spectrometry (MS). Newer rapid centrifugation techniques, such as the Bruker MBT-Sepsityper® IVD, replace culturing on solid media and expedite the diagnosis of BCs but frequently demonstrate reduced sensitivity for identifying clinically significant Gram-positive bacterial or fungal infections. This study introduces a protocol that utilises the broad-range binding properties of an engineered version of mannose-binding lectin linked to the Fc portion of immunoglobulin (FcMBL) to capture and enrich pathogens combined with matrix-assisted laser desorption-ionisation time-of-flight (MALDI-TOF) MS for enhanced infection identification in BCs. The FcMBL method identified 94.1% (64 of 68) of clinical BCs processed, with a high sensitivity for both Gram-negative and Gram-positive bacteria (94.7 and 93.2%, respectively). The FcMBL method identified more patient positive BCs than the Sepsityper® (25 of 25 vs 17 of 25), notably with 100% (3/3) sensitivity for clinical candidemia, compared to only 33% (1/3) for the Sepsityper®. Additionally, during inoculation experiments, the FcMBL method demonstrated a greater sensitivity, identifying 100% (24/24) of candida to genus level and 9/24 (37.5%) top species level compared to 70.8% (17/24) to genus and 6/24 to species (25%) using the Sepsityper®. This study demonstrates that capture and enrichment of samples using magnetic FcMBL-conjugated beads is superior to rapid centrifugation methods for identification of BCs by MALDI-TOF MS. Deploying the FcMBL method therefore offers potential clinical benefits in sensitivity and reduced turnaround times for BC diagnosis compared to the standard Sepsityper® kit, especially for fungal diagnosis.

ProteomeCommons.org collaborative annotation and project management resource integrated with the Tranche repository.

ProteomeCommons.org has implemented a resource that incorporates concepts of Web 2.0 social networking for collaborative annotation of data sets placed in the Tranche repository. The annotation tools are part of a project management resource that is effective for individual laboratories or large distributed groups. The creation of the resource was motivated by the need for a way to encourage annotation of data sets with high accuracy and compliance rates. The system is designed to respond to the dynamic nature of research in an easy-to-use fashion through the use of a dynamic data model that does not inhibit the innovation that is important for basic research. Placing the annotation tool within a project manager allows annotation to occur over the life of the project and provides the security and monitoring capabilities needed for large or small collaborative projects. The resource effectively supports distributed groups of investigators working on common data sets and is available immediately at https://ProteomeCommons.org . In addition, a silver compliant data resource based on ProteomeCommons.org has been developed for cancer Biomedical Informatics Grid (caBIG) to allow much broader access to the annotations describing data sets in the Tranche repository.

Systolic blood pressure, heart rate, and outcomes in patients with coronary disease and heart failure.

AIMS: Data regarding the optimal systolic blood pressure (SBP) and heart rate (HR) for coronary artery disease (CAD) patients with hypertension and a history of heart failure (HF) are limited. Accordingly, using data from a large clinical trial, we investigated the association between SBP and heart rate and subsequent adverse outcomes in CAD patients with a history of HF, and we aimed to better understand how pre-existing HF impacts outcomes among patients with CAD. METHODS AND RESULTS: Among 22 576 CAD patients enrolled in the INternational VErapamil SR-Trandolapril STudy (INVEST), 1256 were identified with a history of physician-diagnosed HF New York Heart Association (NYHA) Class 1-3 at entry. The primary outcome was the first occurrence of all-cause death, myocardial infarction (MI), or stroke. Cox proportional-hazards models adjusted for pre-specified covariates were constructed to estimate risk among the HF cohort compared with a case-matched sample from the non-HF cohort. At a mean 2.5 years' follow-up, those with prior HF had a higher risk of the primary outcome (hazard ratio (HR) 2.55, 95% confidence interval 2.30-2.83, P < 0.0001). Among those with history of HF, a low (<120 mmHg) or high (>140 mmHg) SBP and heart rate ≥ 85 b.p.m. were associated with increased risk for adverse outcomes, which persisted after covariate adjustment. CONCLUSIONS: In patients with CAD, a physician diagnosis of HF at baseline portended a higher risk for death, MI, or stroke than in those without an HF history. Achieving SBP of 120-140 mmHg and heart rate < 85 b.p.m. was associated with a better outcome in patients with known HF and CAD.

Standardizing care for acute decompensated heart failure in a large megatrial: the approach for the Acute Studies of Clinical Effectiveness of Nesiritide in Subjects with Decompensated Heart Failure (ASCEND-HF).

Acute decompensated heart failure (ADHF) is a major public health issue and remains a heterogeneous, complex, and difficult condition to manage. Although novel acute therapies are being tested in large randomized clinical trials, opportunities exist to improve the standard of care by ensuring optimal adherence to currently established evidence-based interventions for HF. Consideration of the goals of therapy and practical application of current methods to assess for clinical improvement may lead to improved patient management and possibly improved outcomes for patients with ADHF. This review provides key practical information regarding the current standard of care for patients with ADHF including the goals of therapy, management of acute and chronic medications, and discharge/transition of care planning.

Does prior coronary angioplasty affect outcomes of surgical coronary revascularization? Insights from the STICH trial.

BACKGROUND: The STICH trial showed superiority of coronary artery bypass plus medical treatment (CABG) over medical treatment alone (MED) in patients with left ventricular ejection fraction (LVEF) ≤35%. In previous publications, percutaneous coronary intervention (PCI) prior to CABG was associated with worse prognosis. OBJECTIVES: The main purpose of this study was to analyse if prior PCI influenced outcomes in STICH. METHODS AND RESULTS: Patients in the STICH trial (n = 1212), followed for a median time of 9.8 years, were included in the present analyses. In the total population, 156 had a prior PCI (74 and 82, respectively, in the MED and CABG groups). In those with vs. without prior PCI, the adjusted hazard-ratios (aHRs) were 0.92 (95% CI = 0.74-1.15) for all-cause mortality, 0.85 (95% CI = 0.64-1.11) for CV mortality, and 1.43 (95% CI = 1.15-1.77) for CV hospitalization. In the group randomized to CABG without prior PCI, the aHRs were 0.82 (95% CI = 0.70-0.95) for all-cause mortality, 0.75 (95% CI = 0.62-0.90) for CV mortality and 0.67 (95% CI = 0.56-0.80) for CV hospitalization. In the group randomized to CABG with prior PCI, the aHRs were 0.76 (95% CI = 0.50-1.15) for all-cause mortality, 0.81 (95% CI = 0.49-1.36) for CV mortality and 0.61 (95% CI = 0.41-0.90) for CV hospitalization. There was no evidence of interaction between randomized treatment and prior PCI for any endpoint (all adjusted p > 0.05). CONCLUSION: In the STICH trial, prior PCI did not affect the outcomes of patients whether they were treated medically or surgically, and the superiority of CABG over MED remained unchanged regardless of prior PCI. CLINICAL TRIAL REGISTRATION: Clinicaltrials.gov; Identifier: NCT00023595.

Proteomics FASTA archive and reference resource.

A FASTA file archive and reference resource has been added to ProteomeCommons.org. Motivation for this new functionality derives from two primary sources. The first is the recent FASTA standardization work done by the Human Proteome Organization's Proteomics Standards Initiative (HUPO-PSI). Second is the general lack of a uniform mechanism to properly cite FASTA files used in a study, and to publicly access such FASTA files post-publication. An extension to the Tranche data sharing network has been developed that includes web-pages, documentation, and tools for facilitating the use of FASTA files. These include conversion to the new HUPO-PSI format, and provisions for both citing and publicly archiving FASTA files. This new resource is available immediately, free of charge, and can be accessed at http://www.proteomecommons.org/data/fasta/. Source-code for related tools is also freely available under the BSD license.

Incidence, predictors, and outcomes of cardiac pacing after cardiac transplantation: an 11-year retrospective analysis.

More than 20% of cardiac transplant patients go on to require permanent pacing. We sought to determine the incidence of cardiac pacing in our cardiac transplant population and identify characteristics that may predict which patients will require permanent pacing. We reviewed medical records of cardiac transplant recipients and compared baseline characteristics of patients who received pacemakers with those of patients who did not receive pacemakers. Of 292 patients included in this analysis, 71 (24%) required permanent posttransplant pacing. Use of amiodarone before transplant was associated with a nonsignificant trend toward needing a pacemaker after transplant (P=0.08). Patients undergoing biatrial anastomosis were more likely to require permanent pacing than patients undergoing bicaval anastomosis (P<0.001). Approximately one fourth of cardiac transplant patients require permanent pacing. Surgical technique is a major predictor of who will require permanent pacing after cardiac transplantation.

Role of heart failure etiology on arterial wave reflection in heart transplant recipients: relation with C-reactive protein.

OBJECTIVES: Aortic augmentation index (AIa), a measure of arterial pressure wave reflection related to central and peripheral arterial stiffness, is elevated in many heart transplant recipients. We investigated whether the increase in wave reflection observed in some heart transplant recipients is influenced by the etiology of antecedent heart failure and circulating pro-inflammatory proteins early in the post-transplantation period. METHODS: Two months after heart transplantation, 20 heart transplant recipients underwent noninvasive measurement of aortic pressure and wave reflection properties and measurement of plasma pro-inflammatory proteins. RESULTS: AIa adjusted to a heart rate of 75 beats/min (AIaHR75) was higher in heart transplant recipients with ischemic (n = 12) compared with nonischemic (n = 8) heart failure (P < 0.01). Similarly, circulating C-reactive protein, a marker of systemic inflammation and an independent predictor of allograft vasculopathy and death in heart transplant recipients, was higher in heart transplant recipients with ischemic than with nonischemic heart failure (log-transformed, P < 0.05). Moreover, there was a significant relation between log C-reactive protein and AIaHR75 (r = 0.68, P < 0.05), augmented pressure (r = 0.60, P < 0.01), roundtrip time of the reflected wave to the peripheral reflecting sites and back (r = -0.62; P < 0.01), and left ventricular wasted energy (r = 0.55, P < 0.01). Multiple regression analysis revealed that log C-reactive protein explained 43% of the variance in AIaHR75 and the difference in AIaHR75 between groups was abolished when adjusted for log C-reactive protein. CONCLUSIONS: Heart transplant recipients with antecedent ischemic heart failure demonstrated increased AIaHR75 compared with nonischemic heart transplant recipients and AIaHR75 was associated with higher circulating C-reactive protein concentration. Whether elevated arterial wave reflection and associated systemic low-grade inflammation early after transplantation have clinical implications in ischemic heart transplant recipients requires further investigation.