[The arrest-related excited delirium syndrome; prevention, treatment and controversies]. / Het opwindingsdelier bij gewelddadige arrestatie: preventie, behandeling en controverses.

BACKGROUND: Patients with an acute confusional state can develop a potentially life-threatening medical emergency when arres­ted by police. This phenomenon has been named the excited delirium syndrome. Controversy regarding this topic has arisen both in the medical literature and in the civil media. AIM: To provide an overview regarding the pathophysiological, epidemiological and clinical aspects of the excited delirium syndrome, the controversy and the opportunities for prevention of a fatal outcome. METHOD: A systematic review of the literature from 1985 to 2021. RESULTS: We included 103 studies in our review. The excited delirium syndrome occurs predominantly in young, physically healthy men who are under the influence of drugs or a psychiatric illness. Several pathophysiological theories exist: the dopaminergic and catecholaminergic hypotheses and restraint asphyxia. There is controversy both in the medical scientific discourse and in the civil media regarding the existence of this syndrome and the cause of death. There are suggestions that mortality can be decreased by timely recognition, de-escalation and medical treatment. CONCLUSION: The excited delirium syndrome is a medical emergency that can arise during physical arrest of patients with a drugs intoxication or psychiatric illness. Improved collaboration between mental health care professionals and police could prevent fatal outcomes.

Mitral prolapsing volume is associated with increased cardiac dimensions in patients with mitral annular disjunction.

INTRODUCTION: In patients with mitral annular disjunction (MAD), it can be difficult to assess the severity of mitral regurgitation (MR), as they present with a prolapsing volume (i.e. volume resulting from mitral valve prolapse, blood volume shift) rather than a regurgitant jet. The influence of the mitral prolapsing volume (MPV) on cardiac dimensions is unknown. We hypothesised that the severity of MR is underestimated in these patients. Our aim was to measure MPV and to investigate its influence on cardiac dimensions in patients with MAD. METHODS: We retrospectively included 131 consecutive patients with MAD from our institution's echocardiographic database. Transthoracic echocardiography was used to assess MPV. Additionally, we established a control group of 617 consecutive patients with degenerative mitral valve disease and performed propensity score matching. RESULTS: Median MPV in the MAD group was 12 ml. MPV was an independent predictor for left ventricular end-diastolic (LVEDD) and end-systolic diameter (LVESD) and left atrial volume (all p < 0.001). In patients with large prolapsing volumes (> 15 ml), LVEDD (56 ± 6 mm vs 51 ± 6 mm, p < 0.001), LVESD [38 mm (34-41) vs 34 mm (31-39), p < 0.01] and left atrial volume [105 ml (86-159) vs 101 ml (66-123), p = 0.04] were significantly increased compared to matched patients with degenerative mitral valve disease and similarly assessed severity of MR. CONCLUSION: Due to a volume shift based on the MPV rather than an actual regurgitant jet, MR severity cannot be assessed adequately in MAD patients. Increased MPV induces ventricular and atrial enlargement. These findings warrant future studies to focus on MPV as an additional parameter for assessment of the severity of MR in MAD patients.

Determining the optimal interval for imaging surveillance of ascending aortic aneurysms.

BACKGROUND: Cardiovascular guidelines recommend (bi-)annual computed tomography (CT) or magnetic resonance imaging (MRI) for surveillance of the diameter of thoracic aortic aneurysms (TAAs). However, no previous study has demonstrated the necessity for this approach. The current study aims to provide patient-specific intervals for imaging follow-up of non-syndromic TAAs. METHODS: A total of 332 patients with non-syndromic ascending aortic aneurysms were followed over a median period of 6.7 years. Diameters were assessed using all available imaging techniques (echocardiography, CT and MRI). Growth rates were calculated from the differences between the first and last examinations. The diagnostic accuracy of follow-up protocols was calculated as the percentage of subjects requiring pre-emptive surgery in whom timely identification would have occurred. RESULTS: The mean growth rate in our population was 0.2 ± 0.4 mm/year. The highest recorded growth rate was 2.0 mm/year, while 40.6% of patients showed no diameter expansion during follow-up. Females exhibited significantly higher growth rates than men (0.3 ± 0.5 vs 0.2 ± 0.4 mm/year, p = 0.007). Conversely, a bicuspid aortic valve was not associated with more rapid aortic growth. The optimal imaging protocol comprises triennial imaging of aneurysms 40-49 mm in diameter and yearly imaging of those measuring 50-54 mm. This strategy is as accurate as annual follow-up, but reduces the number of imaging examinations by 29.9%. CONCLUSIONS: In our population of patients with non-syndromic TAAs, we found aneurysm growth rates to be lower than those previously reported. Yearly imaging does not lead to changes in the management of small aneurysms. Thus, lower imaging frequencies might be a good alternative approach.

Multidisciplinary decision-making in mitral valve disease: the mitral valve heart team.

BACKGROUND: Although decision-making using the heart-team approach is apparently intuitive and has a class I recommendation in most recent guidelines, supportive data is still lacking. The current study aims to demonstrate the individualised clinical pathway for mitral valve disease patients and to evaluate the outcome of all patients referred to the dedicated mitral valve heart team. METHODS: All patients who were evaluated for mitral valve pathology with or without concomitant cardiac disease between 1 January 2016 and 31 December 2016 were prospectively followed and included. Patients were evaluated, and a treatment strategy was determined by the dedicated mitral valve heart team. RESULTS: One hundred and fifty-eight patients were included; 67 patients were treated surgically (isolated and concomitant surgery), 20 by transcatheter interventions and 71 conservatively. Surgically treated patients had a higher 30-day mortality rate (4.4%), which decreased when specified to a dedicated surgeon (1.7%) and in primary, elective cases (0%). This was also observed for major adverse events within 30 days. Residual mitral regurgitation >grade 2 was more frequent in the catheter-based intervention group (23.5%) compared to the surgical group (4.8%). CONCLUSION: In conclusion, the implementation of a multidisciplinary heart team for mitral valve disease is a valuable approach for the selection of patients for different treatment modalities. Our research group will focus on a future comparative study using historical cohorts to prove the potential superiority of the dedicated multidisciplinary heart-team approach.