Worldwide Survey of COVID-19-Associated Arrhythmias.

[Figure: see text].

Repeat Revascularization for Severe Recurrent Coronary Artery Disease in a Young Woman With Takayasu Arteritis.

A young woman with Takayasu arteritis presented with an acute coronary syndrome with ostial left main coronary artery stenosis. She underwent urgent coronary artery bypass surgery but developed recurrent symptoms 6 months later owing to graft failure. She was treated with percutaneous coronary intervention with resolution of her symptoms. (Level of Difficulty: Beginner.).

Comparison of Percutaneous and Surgical Right Ventricular Assist Device Support After Durable Left Ventricular Assist Device Insertion.

BACKGROUND: Early right ventricular (RV) failure after left ventricular assist device (LVAD) implantation increases morbidity and mortality. Percutaneous right ventricular assist device (pRVAD) support is an alternative to more invasive surgical RVAD (sRVAD). METHODS AND RESULTS: We retrospectively reviewed patients receiving isolated pRVAD or sRVAD after durable LVAD at our center in the years 2007-2018. Hemodynamic parameters before and after implantation and survival outcomes were compared among groups. Nineteen patients received pRVAD and 21 sRVAD. Hemodynamic parameters improved immediately with the use of pRVAD; central venous pressure decreased (from 15.9 ± 2.4 to 12.3 ± 3.2 mm Hg; P<.001) and cardiac index increased (from 2.4 ± 0.5 to 3.5 ± 0.8 L·min-1·m-2; P<.001). These were sustained after device removal and were similar to those with the use of sRVAD. Patients with pRVAD required fewer blood transfusions and mechanically ventilated days than those with sRVAD. Among survivors, intensive care unit and hospital days were fewer with the use of pRVAD: 21 (16-27) versus 34 (27-46) ICU days (P = .01); 43.5 (30-66) versus 91 (62-111) hospital days (P = .03). There was no significant difference in 30-day mortality with the use of pRVAD compared with sRVAD (21.1% vs 42.9%; P = .14), but there was a trend toward a higher rate of discharge free from hemodialysis (73.7% vs 47.6%; P = .09). CONCLUSIONS: Novel pRVAD systems for RV failure provide hemodynamic benefits similar to sRVAD, are associated with less morbidity, and should be considered as an alternative to sRVAD.

Preoperative Proteinuria and Reduced Glomerular Filtration Rate Predicts Renal Replacement Therapy in Patients Supported With Continuous-Flow Left Ventricular Assist Devices.

BACKGROUND: Renal failure requiring renal replacement therapy (RRT) has detrimental effects on quality of life and survival of patients with continuous-flow left ventricular assist devices (CF-LVADs). Current guidelines do not offer a decision-making algorithm for CF-LVAD candidates with poor baseline renal function. Objective of this study was to identify risk factors associated with RRT after CF-LVAD implantation. METHODS AND RESULTS: Three hundred and eighty-nine consecutive patients underwent contemporary CF-LVAD implantation at the Columbia University Medical Center between January 2004 and August 2015. Baseline demographics, comorbid conditions, clinical risk scores, and renal function were analyzed in patients with or without RRT after CF-LVAD implantation. Time-dependent receiver-operating characteristic curve analysis was performed to define optimal cutoffs for continuous risk factors. Forty-four patients (11.6%) required RRT during a median follow-up of 9.9 months. Patients requiring RRT had significantly worse renal function, lower hemoglobin, and increased proteinuria at baseline. Low estimated glomerular filtration rate (<40 mL/min/1.73 m2) and proteinuria (urine protein to creatinine ratio ≥0.55 mg/mg) were significant predictors of RRT after CF-LVAD support. Dipstick proteinuria was also a significant predictor of RRT after CF-LVAD implantation. Patients with both low estimated glomerular filtration rate and proteinuria had highest risk of RRT (63.6%) compared with those with either low estimated glomerular filtration rate or proteinuria (18.7%) and those with neither of these risk factors (2.7%) at 1-year follow-up (log-rank P<0.001). CONCLUSIONS: Estimated glomerular filtration rate and proteinuria are predictors RRT after CF-LVAD implantation and should be routinely assessed in CF-LVAD candidates to guide decision making.

Axillary evaluation and lymphedema in women with ductal carcinoma in situ.

Axillary evaluation in women with ductal carcinoma in situ (DCIS) is increasing; however, this may introduce additional morbidity with unclear benefit. Our objective was to examine the morbidity and mortality associated with axillary evaluation in DCIS. We conducted a retrospective cohort study of 10,504 women aged 65-90 years with DCIS who underwent breast conserving surgery between 2002 and 2012 using SEER-Medicare database. Patients were categorized by receipt of axillary evaluation with either sentinel lymph node biopsy (SLNB) or axillary node dissection (ALND). We determined the incidence of lymphedema treatment as defined by diagnostic and procedural codes, as well as 10-year breast cancer-specific and all-cause mortality. 18.3 % of those treated with BCS and 69.4 % of those treated with mastectomy had an axillary evaluation. One year after treatment, 8.2 % of women who had an axillary evaluation developed lymphedema, compared to 5.9 % of those who did not. In a multivariable Cox proportional hazard model, the incidence of lymphedema was higher among those who underwent axillary evaluation (HR 1.22, 95 % CI 1.04-1.45). Overall 10-year breast cancer-specific survival was similar between both groups (HR 0.83, 95 % CI 0.40-1.74). Only 44 (0.40 %) women died of breast cancer; receipt of axillary evaluation did not alter overall survival. Axillary evaluation is commonly performed in women with DCIS, especially those undergoing mastectomy. However, women who receive an axillary evaluation have higher rates of lymphedema, without breast cancer-specific or overall survival benefit. Efforts should be made to determine the population of women with DCIS who benefit from this procedure.

The Influence of Hospital and Surgeon Factors on the Prevalence of Axillary Lymph Node Evaluation in Ductal Carcinoma In Situ.

IMPORTANCE: Although axillary lymph node evaluation is standard of care in the surgical management of invasive breast cancer, a benefit has not been demonstrated in ductal carcinoma in situ (DCIS). Despite uncertainty regarding the efficacy, axillary evaluation is often performed in women with DCIS. OBJECTIVE: To determine the incidence of axillary evaluation in women with DCIS and identify clinical, hospital, and surgeon-related factors associated with axillary evaluation. DESIGN, SETTING, AND PARTICIPANTS: Cross-sectional analysis conducted from January 2006 through December 2012 of medical records contained in the Perspective database for women with DCIS who underwent breast-conserving surgery (BCS) or mastectomy. A total of 35,591 women aged 18 to 90 years were included in the analysis. MAIN OUTCOMES AND MEASURES: Receipt or nonreceipt of surgical axillary evaluation, categorized as sentinel lymph node biopsy (SLNB), axillary lymph node dissection (ALND), or none. Analyses were stratified by surgery type, and multivariable regression analysis was used to identify factors associated with axillary evaluation. RESULTS: Of women identified with DCIS, 26,580 (74.7%) underwent BCS while 9011 (25.3%) underwent mastectomy; 17.7% undergoing BCS and 63.0% undergoing mastectomy had an axillary evaluation. Rates of axillary evaluation increased over time with mastectomy (2006, 56.6%; 2012, 67.4%) and were relatively stable with BCS (2006, 18.5%; 2012, 16.2%). Rates of ALND decreased in women undergoing mastectomy (2006, 20.0%; 2012, 10.7%) and BCS (2006, 1.2%; 2012, 0.3%), with increasing use of SLNB. In a multivariable analysis, hospital factors including nonteaching hospital (risk ratio [RR], 1.17; 95% CI, 1.05-1.30) and urban location (RR, 1.15; 95% CI, 1.03-1.29) influenced axillary evaluation with mastectomy. Surgeon volume was the most significant predictor of axillary evaluation among women undergoing BCS (mid vs low volume: RR, 0.87; 95% CI, 0.70-0.94; high vs low volume: RR, 0.54; 95% CI, 0.44-0.65). CONCLUSIONS AND RELEVANCE: Despite guidelines recommending against axillary lymph node evaluation in women with DCIS undergoing BCS and uncertainty regarding its use with mastectomy, SLNB or ALND is performed frequently. Given the additional morbidity and cost of these procedures, alternative surgical approaches or prospective evaluation of the clinical benefit of axillary evaluation in women with DCIS is needed.

Household net worth, racial disparities, and hormonal therapy adherence among women with early-stage breast cancer.

PURPOSE: Nonadherence to adjuvant hormonal therapy is common and is associated with increased prescription copayment amount and black race. Studies suggest that household wealth may partly explain racial disparities. We investigated the impact of net worth on disparities in adherence and discontinuation. PATIENTS AND METHODS: We used the OptumInsight insurance claims database to identify women older than age 50 years diagnosed with early breast cancer, from January 1, 2007, to December 31, 2011, who were using hormonal therapy. Nonadherence was defined as a medication possession ratio of ≤ 80% of eligible days over a 2-year period. We evaluated the association of demographic and clinical characteristics, annual household income, household net worth (< $250,000, $250,000 to $750,000, or > $750,000), insurance type, and copayments (< $10, $10 to $20, or > $20) with adherence to hormonal therapy. Logistic regression analyses were conducted by sequentially adding sociodemographic and financial variables to race. RESULTS: We identified 10,302 patients; 2,473 (24%) were nonadherent. In the unadjusted analyses, adherence was negatively associated with black race (odds ratio [OR], 0.76; P < .001), advanced age, comorbidity, and Medicare insurance. Adherence was positively associated with medium (OR, 1.33; P < .001) and high (OR, 1.66; P < .001) compared with low net worth. The negative association of black race with adherence (OR, 0.76) was reduced by adding net worth to the model (OR, 0.84; P < .05). Correcting for other variables had a minimal impact on the association between race and adherence (OR, 0.87; P = .08). The interaction between net worth and race was significant (P < .01). CONCLUSION: We found that net worth partially explains racial disparities in hormonal therapy adherence. These results suggest that economic factors may contribute to disparities in the quality of care.