Impact of Fontan Fenestration on Adverse Cardiovascular Outcomes: A Multicentre Study.

BACKGROUND: Fenestrating a Fontan baffle has been associated with improved perioperative outcomes in patients with univentricular hearts. However, longer-term potential adverse effects remain debated. We sought to assess the impact of a fenestrated Fontan baffle on adverse cardiovascular events including all-cause mortality, cardiac transplantation, atrial arrhythmias, and thromboemboli. METHODS: A multicentre North American retrospective cohort study was conducted on patients with total cavopulmonary connection Fontan baffle, with and without fenestration. All components of the composite outcome were independently adjudicated. Potential static and time-varying confounders were taken into consideration, along with competing risks. RESULTS: A total of 407 patients were followed for 10.4 (7.1-14.4) years; 70.0% had fenestration of their Fontan baffle. The fenestration spontaneously closed or was deliberately sealed in 79.9% of patients a median of 2.0 years after Fontan completion. In multivariable analysis in which a persistent fenestration was modelled as a time-dependent variable, an open fenestration did not confer a higher risk of the composite outcome (hazard ratio, 1.18; 95% confidence interval, 0.71-1.97; P = 0.521). In secondary analyses, an open fenestration was not significantly associated with components of the primary outcome: that is, mortality or transplantation, atrial arrhythmias, or thromboemboli. However, sensitivity analyses to assess the possible range of error resulting from imprecise dates for spontaneous fenestration closures could not rule out significant associations between an open fenestration and atrial arrhythmias or thromboemboli. CONCLUSIONS: In this multicentre study, no significant association was identified between an open fenestration in the Fontan baffle and major adverse cardiovascular events.

Clinical Heart fAilure Management Program: Changing the practice by partnering primary care and specialists (CHAMP-HF).

Background: While significant gains were made in the management of heart failure (HF), most patients are still diagnosed when they are acutely ill in hospital, often with advanced disease. Earlier diagnosis in the community could lead to improved outcomes. Whether a partnership and an educational program for primary care providers (PCP) increase HF awareness and management is unknown. Methods: We conducted an observational study between March 2019 and June 2020 during which HF specialists gave monthly HF conferences to PCP. Using a pre-post design, medical charts and administrative databases were reviewed and a questionnaire was completed by participating PCP. Primary and secondary endpoints included: 1) the number of patients diagnosed with HF, 2) implementation of GDMT for patients with HFrEF; 3) PCPs' experience and confidence. Results: Six PCP agreed to participate. Amongst the 11,909 patients of the clinic, 70 (0.59 %) patients met the criteria for HF. This number increased by 28.6 % (n = 90) after intervention. Increased use of GDMT for HFrEF patients at baseline (n = 35) was observed for all class of agents, with doubling of patients on triple therapies, from 8 (22.9 %) to 16 (45.7 %), p = 0.0047. Self-confidence on HF management was low (1, 16.7 %) but increased after the educational intervention of physicians (3, 50 %). Conclusion: An educational and collaborative approach between HF specialists and community PCP increased the number of new HF cases diagnosed, enhanced implementation of GDMT in patients with HFrEF and increase PCPs' confidence in treating HF, despite being conducted during the COVID-19 pandemic.

A Dyadic Analysis of Sexual Assertiveness and Sexual Outcomes in Adolescent Romantic Relationships.

Amid adolescence, youth are developing the relational skills necessary to form and maintain positive intimate relationships. Sexual assertiveness is a key skill that could be related to couples' sexual outcomes (i.e. sexual satisfaction, sexual concerns, and sexual function). However, dyadic studies are lacking, and associations between sexual assertiveness and adolescents' sexual health and well-being remain underexplored. This cross-sectional dyadic study examined associations between dimensions of sexual assertiveness and sexual outcomes in adolescent romantic relationships. The Actor-Partner Interdependence Model guided analyses of self-reported questionnaires from 110 romantic dyads (aged 14-19 years; M = 16.51). Participants' gender was considered in the models, and gender differences emerged in the associations between study variables. Path analyses revealed that sexual needs and desires communication, refusal of unwanted sex, sexual intimacy initiation, and comfort talking about sex have significant actor and partner effects on adolescents' sexual outcomes in mixed-gender dyads. These findings suggest that authentically expressing one's own sexual needs, desires, and limits in adolescence may influence not only one's own sexual satisfaction, sexual concerns, and sexual function, but also their partner's. The aforementioned dimensions of sexual assertiveness could be important targets for research-based interventions to promote sexual health and well-being in adolescent romantic relationships.

"I Just Want to Feel Good Without Making You Feel Bad": Sexual Assertiveness Negotiation in Adolescent Romantic Relationships.

Sexual assertiveness is often conceptualized as an individual's ability to express one's own sexual needs, desires, and limits. Given that sexual assertiveness is embedded in interactions and can affect not only both partners' sexual well-being but also relationship satisfaction, dyadic approaches are needed to investigate sexual assertiveness negotiation within adolescent romantic relationships. This qualitative study aimed to document adolescents' ability to negotiate their sexual needs, desires, and limits with their partners during interactions where they discussed their sexual concerns. A directed content analysis, based on the life positions of the transactional analysis theory, was conducted on the interactions of 40 adolescent romantic dyads aged 14-19 years (M = 16.65; SD = 1.49). The results revealed four categories of strategies: (1) mutual assertiveness: negotiation of one's own sexual needs, desires, and limits with those of the partner; (2) singular passiveness: repression of one's own sexual needs, desires, and limits to privilege those of the partner; (3) singular aggressiveness: prioritization of one's own sexual needs, desires, and limits over those of the partner; and (4) mutual lack of negotiation skills: neglecting both partners' sexual needs, desires, and limits. Among other things, adolescents' ability to be sexually assertive was hindered by anticipations, including assumptions leading to disregarding one's own sexual needs, desires, and limits or fearing to ignore the partner's. To promote mutually rewarding sexual activities and prevent sexual violence, sexual education initiatives should support adolescents' ability to assertively negotiate their sexuality with their partner and avoid passiveness, aggressiveness, and lack of negotiation.

Reproductive Coercion by Intimate Partners: Prevalence and Correlates in Canadian Individuals with the Capacity to be Pregnant.

OBJECTIVES: Despite the large body of research on violence against women, violence that specifically targets women's reproductive autonomy and control over their reproductive health, called reproductive coercion (RC), is poorly documented in Canada. The purpose of this study is to determine the prevalence of RC behaviors in an adult Canadian community sample and to explore associated factors. STUDY DESIGN: A self-report online questionnaire was administered from September 2020 to April 2021 in Quebec and Ontario, Canada. Participants were recruited via social media, sexual and reproductive health clinics, community-based anti-violence organizations, and the project's partner organizations. The questionnaire contained validated RC questionnaire items and new items drawn from previous qualitative work. The sample comprised 427 participants, mostly self-identified as women (92%), aged 18 to 55 years (M = 29.01; SD = 6.64). Descriptive analyses and binary logistic regressions were conducted using SPSS 27. RESULTS: The results of this study show that 63.9% of participants reported at least one lifetime experience of RC. According to our data, contraceptive sabotage was the most common form (62.8%). Of the participants who had been pregnant, 9.8% reported control of pregnancy outcomes. Each RC category shows a different pattern of correlates. The findings also reveal that intimate partner violence (IPV) increases the likelihood of contraceptive sabotage. Moreover, the study suggests that low education level and IPV increase the risk for control of pregnancy outcomes. CONCLUSION: These findings underscore the importance of RC in the lives of many Canadian individuals with the capacity to be pregnant, and they highlight certain factors that place individuals at greater risk for RC. This knowledge can inform the development of prevention efforts and clinical interventions.

Single Functional Group Platform for Multistimuli Responsivities: Tertiary Amine for CO2/pH/ROS-Triggered Cargo Release in Nanocarriers.

The design of multistimuli-responsive soft nanoparticles (NPs) often presents synthetic complexities and limited breadth in exploiting changes surrounding physiological environments. Nanocarriers that could collectively take advantage of several endogenous stimuli can offer a powerful tool in nanomedicine. Herein, we have capitalized on the chemical versatility of a single tertiary amine to construct miktoarm polymer-based nanocarriers that respond to dissolved CO2, varied pH, reactive oxygen species (ROS), and ROS + CO2. Curcumin (Cur), an anti-inflammatory phytopharmaceutic, was loaded into micelles, and we validated the sensitivity of the tertiary amine in tuning Cur release. An in vitro evaluation indicated that Cur encapsulation strongly suppressed its toxicity at high concentrations, significantly inhibited nigericin-induced secretion of interleukin-1ß by THP-1 macrophages, and the proportion of M2/M1 (anti-inflammatory/pro-inflammatory macrophages) was higher for Cur-loaded NPs than for free Cur. Our approach highlights the potential of a simple-by-design strategy in expanding the scope of polymeric NPs in drug delivery.

Canadian service providers' perspectives on reproductive coercion and abuse: a participatory action research to address their needs and support their actions.

Reproductive coercion and abuse (RCA) is a form of violence that affects sexual and reproductive health. Women and individuals who experienced RCA in an intimate relationship frequently consult service providers (SPs), such as health professionals or violence counselors. The objective of this article, which is the result of a participative action research project targeting RCA perpetrated by in an intimate partner, is twofold: (1) to better understand the practices as well as the barriers and facilitators encountered by SPs and (2) to develop information and awareness tools with them that meet their needs. To this end, we first held focus groups with 31 SPs. The use of thematic analysis revealed intervention strategies that focus on caring and listening, identifying signs of RCA, and creating a safe environment for disclosure. Their practices also focused on harm-reduction strategies and effective referrals. Despite the importance they gave to this issue, lack of time, inappropriate settings, and inadequate training hindered them from intervening effectively with individuals who were victims of RCA. They also indicated the need for easy-to-follow practice guidelines and patient education tools. Based on these findings and the best practices identified in the grey and scientific literature, we developed a practice guide for SPs and a booklet on RCA. The development of these guide and booklets involved a lot of back and forth to meet the needs expressed by the community and health professionals.

Prolonged cardiovascular pharmacological support and fluid management after cardiac surgery.

OBJECTIVE: To identify potentially modifiable risk factors related to prolonged cardiovascular pharmacological support after weaning from cardiopulmonary bypass (CPB). METHODS: This is a secondary analysis of two prospective cohort study in a specialized cardiac surgery institution in adult patients undergoing cardiac surgery with the use of CPB between August 2016 and July 2017. Prolonged cardiovascular pharmacological support was defined by the need for at least one vasopressor or one inotropic agent 24 hours after separation from CPB. Risk factors were identified among baseline characteristics and peri-operative events through multivariable logistic regression. RESULTS: A total of 247 patients were included and 98 (39.7%) developed prolonged pharmacological support. In multivariable analysis, left ventricular ejection fraction ≤ 30% (OR 9.52, 95% confidence interval (CI) 1.14; 79.25), elevated systolic pulmonary artery pressure (sPAP) > 30 and ≤ 55 mmHg (moderate) (OR 2.52, CI 1.15; 5.52) and sPAP > 55 mmHg (severe) (OR 8.12, CI 2.54; 26.03), as well as cumulative fluid balance in the first 24 hours after surgery (OR 1.76, CI 1.32; 2.33) were independently associated with the development of prolonged pharmacological support. CONCLUSIONS: Prolonged cardiovascular pharmacological support is frequent after cardiac surgery on CPB. Severe LV systolic dysfunction, preoperative pulmonary hypertension and postoperative fluid overload are risk factors. Further studies are required to explore if those risk factors could be modified or not.

Pharmacogenetics-guided dalcetrapib therapy after an acute coronary syndrome: the dal-GenE trial.

AIMS: In a retrospective analysis of dal-Outcomes, the effect of dalcetrapib on cardiovascular events was influenced by an adenylate cyclase type 9 (ADCY9) gene polymorphism. The dal-GenE study was conducted to test this pharmacogenetic hypothesis. METHODS AND RESULTS: dal-GenE was a double-blind trial in patients with an acute coronary syndrome within 1-3 months and the AA genotype at variant rs1967309 in the ADCY9 gene. A total of 6147 patients were randomly assigned to receive dalcetrapib 600 mg or placebo daily. The primary endpoint was the time from randomization to first occurrence of cardiovascular death, resuscitated cardiac arrest, non-fatal myocardial infarction, or non-fatal stroke. After a median follow-up of 39.9 months, the primary endpoint occurred in 292 (9.5%) of 3071 patients in the dalcetrapib group and 327 (10.6%) of 3076 patients in the placebo group [hazard ratio 0.88; 95% confidence interval (CI) 0.75-1.03; P = 0.12]. The hazard ratios for the components of the primary endpoint were 0.79 (95% CI 0.65-0.96) for myocardial infarction, 0.92 (95% CI 0.64-1.33) for stroke, 1.21 (95% CI 0.91-1.60) for death from cardiovascular causes, and 2.33 (95% CI 0.60-9.02) for resuscitated cardiac arrest. In a pre-specified on-treatment sensitivity analysis, the primary endpoint event rate was 7.8% (236/3015) in the dalcetrapib group and 9.3% (282/3031) in the placebo group (hazard ratio 0.83; 95% CI 0.70-0.98). CONCLUSION: Dalcetrapib did not significantly reduce the risk of occurrence of the primary endpoint of ischaemic cardiovascular events at end of study. A new trial would be needed to test the pharmacogenetic hypothesis that dalcetrapib improves the prognosis of patients with the AA genotype. CLINICAL TRIAL REGISTRATION: Trial registration dal-GenE ClinicalTrials.gov Identifier: NCT02525939.

Portrayal of Domestic Violence Trajectories During the Perinatal Period.

Domestic violence during the perinatal period (DVPP) refers to the various ways that women's partners or ex-partners control and coerce them during pregnancy and the 2 years postpartum. From the descriptions of 17 women with firsthand experience of DVPP, this article reports on its manifestations and the associated contexts. The results reveal escalating violence, diverse forms of violence, and exacerbated consequences over the perinatal period. The contexts that pose additional challenges for the women include financial precariousness and the partner's substance abuse, and to a lesser extent the residential situation.

Colchicine for community-treated patients with COVID-19 (COLCORONA): a phase 3, randomised, double-blinded, adaptive, placebo-controlled, multicentre trial.

BACKGROUND: Evidence suggests a role for excessive inflammation in COVID-19 complications. Colchicine is an oral anti-inflammatory medication beneficial in gout, pericarditis, and coronary disease. We aimed to investigate the effect of colchicine on the composite of COVID-19-related death or hospital admission. METHODS: The present study is a phase 3, randomised, double-blind, adaptive, placebo-controlled, multicentre trial. The study was done in Brazil, Canada, Greece, South Africa, Spain, and the USA, and was led by the Montreal Heart Institute. Patients with COVID-19 diagnosed by PCR testing or clinical criteria who were not being treated in hospital were eligible if they were at least 40 years old and had at least one high-risk characteristic. The randomisation list was computer-generated by an unmasked biostatistician, and masked randomisation was centralised and done electronically through an automated interactive web-response system. The allocation sequence was unstratified and used a 1:1 ratio with a blocking schema and block sizes of six. Patients were randomly assigned to receive orally administered colchicine (0·5 mg twice per day for 3 days and then once per day for 27 days thereafter) or matching placebo. The primary efficacy endpoint was the composite of death or hospital admission for COVID-19. Vital status at the end of the study was available for 97·9% of patients. The analyses were done according to the intention-to-treat principle. The COLCORONA trial is registered with ClinicalTrials.gov (NCT04322682) and is now closed to new participants. FINDINGS: Trial enrolment began in March 23, 2020, and was completed in Dec 22, 2020. A total of 4488 patients (53·9% women; median age 54·0 years, IQR 47·0-61·0) were enrolled and 2235 patients were randomly assigned to colchicine and 2253 to placebo. The primary endpoint occurred in 104 (4·7%) of 2235 patients in the colchicine group and 131 (5·8%) of 2253 patients in the placebo group (odds ratio [OR] 0·79, 95·1% CI 0·61-1·03; p=0·081). Among the 4159 patients with PCR-confirmed COVID-19, the primary endpoint occurred in 96 (4·6%) of 2075 patients in the colchicine group and 126 (6·0%) of 2084 patients in the placebo group (OR 0·75, 0·57-0·99; p=0·042). Serious adverse events were reported in 108 (4·9%) of 2195 patients in the colchicine group and 139 (6·3%) of 2217 patients in the placebo group (p=0·051); pneumonia occurred in 63 (2·9%) of 2195 patients in the colchicine group and 92 (4·1%) of 2217 patients in the placebo group (p=0·021). Diarrhoea was reported in 300 (13·7%) of 2195 patients in the colchicine group and 161 (7·3%) of 2217 patients in the placebo group (p<0·0001). INTERPRETATION: In community-treated patients including those without a mandatory diagnostic test, the effect of colchicine on COVID-19-related clinical events was not statistically significant. Among patients with PCR-confirmed COVID-19, colchicine led to a lower rate of the composite of death or hospital admission than placebo. Given the absence of orally administered therapies to prevent COVID-19 complications in community-treated patients and the benefit of colchicine in patients with PCR-proven COVID-19, this safe and inexpensive anti-inflammatory agent could be considered for use in those at risk of complications. Notwithstanding these considerations, replication in other studies of PCR-positive community-treated patients is recommended. FUNDING: The Government of Quebec, the Bill & Melinda Gates Foundation, the National Heart, Lung, and Blood Institute of the US National Institutes of Health, the Montreal Heart Institute Foundation, the NYU Grossman School of Medicine, the Rudin Family Foundation, and philanthropist Sophie Desmarais.

To Use or Not to Use the Term "Obstetric Violence": Commentary on the Article by Swartz and Lappeman.

Based on the article by Swartz and Lappeman, we propose in this commentary to reflect on three central components linked to the concept of obstetric violence: the withdrawal of intentionality as a founding element of its recognition, the preponderant place given to the perspective of women and those affected by it, as well as the recognition of its sexist, gendered, and systemic character. We also discuss the epistemic injustice associated with obstetric violence. We stress the importance of including both health workers and health systems in the equation, even though they may be offended by the use of the term. We conclude by recalling that significant leadership must be exercised by health care workers and institutions to put an end to this form of violence.

Radial-to-femoral pressure gradient quantification in cardiac surgery.

Background: A radial-to-femoral pressure gradient (RFPG) can occur in roughly one-third of cardiac surgical patients. Such a gradient has been associated with smaller stature and potentially smaller radial artery diameter. We hypothesized that preoperative radial artery diameter could be a predictor of RFPG. We also investigated the clinical impact of using a femoral versus a radial arterial catheter in terms of vasoactive support. Methods: Using ultrasound, we measured the bilateral radial artery diameters of 160 cardiac surgical patients. All arterial pressure values were continuously recorded. Significant RFPG was defined as ≥25 mm Hg in systolic and/or ≥10 mm Hg in mean arterial pressure. One hundred and forty-nine additional patients were used to validate the impact of our observations. Results: Using 78,013 pressure datapoints in 129 patients, 34.8% of patients had an RFPG with a mean duration of 54 ± 48 minutes. Patients with a radial artery diameter <1.8 mm were more likely to have an RFPG (n = 14 [48.3%] vs 12 [22.2%]; P = .042). Patients with only a radial catheter received more phenylephrine (P = .016) despite undergoing shorter and less complex procedures. In the validation cohort, similar observations were made, and patients with a radial artery catheter received a longer duration of vasoactive support in the intensive care unit. Conclusions: A significant RFPG occurs in one-third of cardiac surgical patients and in 48% of those with a radial artery diameter <1.8 mm. The use of a single radial arterial catheter instead of dual radial and femoral catheters was associated with greater vasopressor requirements in the operating room and in the intensive care unit. We do not recommend the use of a single radial artery catheter in cardiac surgery.

Influence of the Relational Context on Reproductive Coercion and the Associated Consequences.

Reproductive coercion (RC) refers to behaviors that interfere with contraception use or pregnancy and that limit reproductive autonomy. This article presents the results of a qualitative exploratory study of 21 young women in Canada who experienced RC perpetrated by an intimate partner along with the associated consequences. Results reveal that nonconsensual condom removal occurred more often in uncommitted relationships without violence, whereas pressure to become pregnant and pregnancy coercion occurred more often in committed relationships where other forms of violence were also present. Participants reported numerous repercussions on their psychological, sexual, and reproductive health and on their emotional and relational well-being.

How Adolescents, Mothers, and Fathers Qualitatively Describe Their Experiences of Co-Occurrent Problems: Intimate Partner Violence, Mental Health, and Substance Use.

This qualitative study examines the perceptions of mothers, fathers, and adolescents on the relations they see between intimate partner violence, mental health and substances use parental problems that co-occur in their family, and the mothers' and fathers' associated parenting challenges. The sample was composed of 43 people (15 mothers, 16 fathers, and 12 adolescents) who were directly affected by the co-occurrence of intimate partner violence and mental health or substances use parental problems. The participants were recruited with the collaboration of public and community organizations in the Province of Québec (Canada). The data were collected through semi-structured interviews and combined with a table detailing the specific problems identified by the participants. A thematic content analysis method was employed to do the coding, and a summary of the results was returned to some participants who agreed to collaborate with the validation of the results. The analysis revealed numerous and diverse relations between the interviewees' co-occurring problems, but two principal patterns emerged. The first one was chiefly observed in the comments made by mothers and adolescents who saw the co-occurring problems as being the consequence of the intimate partner violence on the mother. The second pattern was largely observed in the fathers' comments, who explained that the substance use problems came before the intimate partner violence and acted as an aggravating factor. The co-occurrence of intimate partner violence with other parental problems strongly affected the mothers' and fathers' parenting, making it more difficult to meet the children's needs. Considering the complexity and diversity of the experiences and needs of the mothers, fathers, and children in co-occurring situations, future studies should evaluate the services provided to these families and the coordination between the different concerned organizations.

Young Women's Acknowledgment of Reproductive Coercion: A Qualitative Analysis.

Reproductive coercion (RC) is a form of violence perpetuated against women. It occurs when male partners adopt behaviors meant to control a woman's birth control or pregnancy despite her wishes. This amounts to interference with a woman's autonomy in reproductive decisions. The three main forms of RC are birth control sabotage (including nonconsensual condom removal), pregnancy coercion, and controlling the outcome of a pregnancy. This qualitative exploratory study examines issues in the acknowledgment of RC. Participants were 21 young women in Québec (Canada), who had experienced this form of violence. Results of individual semi-directed interviews reveal that RC can be difficult to acknowledge. A thematic analysis demonstrates that awareness is modulated by the manifestations of RC and by the emotional bond with the perpetrator. Acknowledgment of RC behavior varies according to the form that is experienced: Nonconsensual condom removal is the most readily identified, whereas acknowledgment of pregnancy pressure and pregnancy coercion takes longer, requiring repeated incidents before it is identified as a form of violence. In addition, acknowledgment is facilitated when relationships are casual and uncommitted compared with romantic and committed. Moreover, reading about the issue, confiding in a friend or acquaintance, and finding a new partner who respects one's reproductive rights facilitate RC acknowledgment. In contrast, not self-identifying as a victim, assuming responsibility for the incident, having a limited understanding of sexual violence, and experiencing other forms of violence with an intimate partner contribute to impede RC acknowledgment. Results are discussed in terms of practical implications for young adults and health care professionals.

Pulmonary Vein Stenosis After Atrial Fibrillation Ablation: Insights From the ADVICE Trial.

BACKGROUND: Pulmonary vein (PV) stenosis is a complication of atrial fibrillation (AF) ablation. The incidence of PV stenosis after routine post-ablation imaging remains unclear and is limited to single-centre studies. Our objective was to determine the incidence and predictors of PV stenosis following circumferential radiofrequency ablation in the multicentre Adenosine Following Pulmonary Vein Isolation to Target Dormant Conduction Elimination (ADVICE) trial. METHODS: Patients with symptomatic AF underwent circumferential radiofrequency ablation in one of 13 trial centres. Computed tomographic (CTA) or magnetic resonance (MRA) angiography was performed before ablation and 90 days after ablation. Two blinded reviewers measured PV diameters and areas. PVs with stenosis were classified as severe (> 70%), moderate (50%-70%), or mild (< 50%). Predictors of PV stenosis were identified by means of multivariable logistic regression. RESULTS: A total of 197 patients (median age 59.5 years, 29.4% women) were included in this substudy. PV stenosis was identified in 41 patients (20.8%) and 47 (8.2%) of 573 ablated PVs. PV stenosis was classified as mild in 42 PVs (7.3%) and moderate in 5 PVs (0.9%). No PVs had severe stenosis. Both cross-sectional area and diameter yielded similar classifications for severity of PV stenosis. Diabetes was associated with a statistically significant increased risk of PV stenosis (OR 4.91, 95% CI 1.45-16.66). CONCLUSIONS: In the first systematic multicentre evaluation of post-ablation PV stenosis, no patient acquired severe PV stenosis. Although the results are encouraging for the safety of AF ablation, 20.8% of patients had mild or moderate PV stenosis, in which the long-term effects are unknown.

Quality of Life and Health Care Utilization in the CIRCA-DOSE Study.

OBJECTIVES: This study evaluated the impact of contact force-guided radiofrequency ablation versus cryoballoon ablation on quality of life and health care utilization. BACKGROUND: Traditional outcome parameters, such as arrhythmia-free survival, are insufficient to evaluate the clinical impact of atrial fibrillation (AF), as it fails to the capture patient- and health system-level differences in treatment approaches. METHODS: The CIRCA-DOSE (Cryoballoon Vs. Contact-Force Atrial Fibrillation Ablation) study randomly assigned 346 patients with drug-refractory paroxysmal AF to contact force-guided radiofrequency or cryoballoon ablation. Health-related quality-of-life (HRQOL) was assessed at baseline, and at 6 and 12 months post-ablation using a disease-specific and generic HRQOL instruments. Health care utilization (hospitalization, emergency department visits, and cardioversion) and antiarrhythmic drug use for the 12 months preceding ablation was compared with the 12 months following ablation. RESULTS: Disease-specific and generic HRQOL was moderately to severely impaired at baseline and improved significantly at 6 and 12 months of follow-up (median improvement in AFEQT [Atrial Fibrillation Effect on QualiTy of Life] score 32.4 [interquartile range: 17.7 to 48.9]). When compared with the 12 months pre-ablation, the proportion and absolute number of cardioversions decreased significantly (41.1% vs. 10.1% of patients, 137 vs. 35 events; p < 0.0001). Similar significant reductions in emergency department visits (66.7% vs. 25.1% of patients, 224 vs. 87 events; p < 0.0001), and hospitalizations (25.5% vs. 14.5% of patients, 86 vs. 50 events; p < 0.001) were observed. There were no significant differences between randomized groups. CONCLUSIONS: In this multicenter randomized trial, catheter ablation with advanced-generation technologies resulted in a significant improvement in HRQOL and a significant reduction in health care utilization in the year following AF ablation. (Cryoballoon vs. Irrigated Radiofrequency Catheter Ablation [CIRCA-DOSE]; NCT01913522).

Preoperative Diaphragm Function Is Associated With Postoperative Pulmonary Complications After Cardiac Surgery.

OBJECTIVES: Postoperative pulmonary complications increase mortality, length, and cost of hospitalization. A better diaphragmatic strength may help face an increased work of breathing postoperatively. We, therefore, sought to determine if a low preoperative diaphragm thickening fraction (TFdi) determined by ultrasonography helped predict the occurrence of postoperative pulmonary complications after cardiac surgery independently of indicators of frailty, sarcopenia, and pulmonary function. DESIGN: Prospective observational cohort study. SETTING: Montreal Heart Institute, an academic cardiac surgery center in Canada. PATIENTS: Adults undergoing nonemergency cardiac surgery. INTERVENTIONS: We measured the preoperative thickness of the right and left hemidiaphragms at their zone of apposition at end-expiration (Tdi,ee) and peak-inspiration (Tdi,ei) with ultrasonography. Maximal thickening fraction of the diaphragm during inspiration (TFdi,max) was calculated using the following formula: TFdi,max = (Tdi,ei-Tdi,ee)/Tdi,ee. We also evaluated other potential risk factors including demographic parameters, comorbidities, Clinical Frailty Scale, grip strength, 5-meter walk test, and pulmonary function tests. We repeated TFdi,max measurements within 24 hours of extubation. The primary composite outcome of this study was the occurrence of postoperative pulmonary complications, defined as pneumonia, clinically significant atelectasis, or prolonged mechanical ventilation (> 24 hr). MEASUREMENT AND MAIN RESULTS: Of the 115 patients included, 34 (29.6%) developed postoperative pulmonary complications, including two with pneumonia, four with prolonged mechanical ventilation, and 32 with clinically significant atelectasis. Those with postoperative pulmonary complications had prolonged ICU and hospital length of stays. They had a lower TFdi,max (37% [interquartile range, 31-45%] vs 44% [interquartile range, 33-58%]; p = 0.03). In multiple logistic regression, a TFdi,max less than 38.1% was associated with postoperative pulmonary complications (odds ratio, 4.9; 95% CI, 1.81-13.50; p = 0.002). All patients who developed pneumonia or prolonged mechanical ventilation had a TFdi,max less than 38.1%. Respiratory rate and diabetes were also independently associated with postoperative pulmonary complications, while pulmonary function tests and the assessed indicators of frailty and sarcopenia were not. CONCLUSIONS: A low preoperative TFdi,max can help to identify patients at increased risk of postoperative pulmonary complications after cardiac surgery.

Acute Right Ventricular Failure in Cardiac Surgery During Cardiopulmonary Bypass Separation: A Retrospective Case Series of 12 Years' Experience With Intratracheal Milrinone Administration.

OBJECTIVE: To report the authors' 12 years of experience with intratracheal milrinone administration and to assess the efficacy and limitations of intratracheal milrinone bolus administration for the treatment of unexpected acute right ventricular (RV) failure in patients undergoing cardiac surgery. DESIGN: Retrospective analysis. SETTING: Single-center university hospital. PARTICIPANTS: One hundred seventy-six patients (4.6%) undergoing on-pump cardiac surgery. INTERVENTIONS: Endotracheal tube administration of milrinone (5-mg bolus) after unexpected acute RV failure during separation from cardiopulmonary bypass (CPB) weaning. RV failure was defined as the simultaneous presence of all of the following criteria: (1) hemodynamic instability or difficult separation from CPB with associated elevated central venous pressure or abnormal RV pressure waveform, (2) >20% reduction of RV fractional area change from baseline evaluated by transesophageal echocardiography, and (3) anatomical visualization of impaired or absent RV wall motion by direct intraoperative visual inspection. MEASUREMENTS AND MAIN RESULTS: Intratracheal milrinone administration was found to improve RV failure in 109 patients (61.9%) whereas RV failure persisted in 67 patients (38.1%). Using a multiple logistic regression model, severely decreased left ventricular ejection fraction (<35% v >50%) (adjusted odds ratio [OR] 3.72; 95% confidence interval [CI] 1.2-11.3; p = 0.012), longer CPB time (adjusted OR 1.014; CI 1.01-1.02; p = 0.001) and elevated postoperative fluid balance (adjusted OR 1.39; CI 1.1-1.8; p = 0.02) were found to be significant predictors of persistent RV failure. CONCLUSION: Intratracheal instillation of milrinone was associated with clinical improvement of RV failure occurring during separation from CPB in almost two-thirds of patients. Factors limiting its therapeutic efficacy include severe left ventricular dysfunction, increased fluid balance, and long CPB time.