Acetazolamide in Decompensated Heart Failure with Volume Overload trial (ADVOR): baseline characteristics.

AIMS: To describe the baseline characteristics of participants in the Acetazolamide in Decompensated Heart Failure with Volume Overload (ADVOR) trial and compare these with other contemporary diuretic trials in acute heart failure (AHF). METHODS AND RESULTS: ADVOR recruited 519 patients with AHF, clinically evident volume overload, elevated N-terminal pro-B-type natriuretic peptide (NT-proBNP) and maintenance loop diuretic therapy prior to admission. All participants received standardized loop diuretics and were randomized towards once daily intravenous acetazolamide (500 mg) versus placebo, stratified according to study centre and left ventricular ejection fraction (LVEF) (≤40% vs. >40%). The primary endpoint was successful decongestion assessed by a dedicated score indicating no more than trace oedema and no other signs of congestion after three consecutive days of treatment without need for escalating treatment. Mean age was 78 years, 63% were men, mean LVEF was 43%, and median NT-proBNP 6173 pg/ml. The median clinical congestion score was 4 with an EuroQol-5 dimensions health utility index of 0.6. Patients with LVEF ≤40% were more often male, had more ischaemic heart disease, higher levels of NT-proBNP and less atrial fibrillation. Compared with diuretic trials in AHF, patients enrolled in ADVOR were considerably older with higher NT-proBNP levels, reflecting the real-world clinical situation. CONCLUSION: ADVOR is the largest randomized diuretic trial in AHF, investigating acetazolamide to improve decongestion on top of standardized loop diuretics. The elderly enrolled population with poor quality of life provides a good representation of the real-world AHF population. The pragmatic design will provide novel insights in the diuretic treatment of patients with AHF.

Percutaneous pulmonary valvuloplasty and atrial septal defect closure in a 69-year-old patient with Noonan's syndrome.

We present the case of a patient with Noonan syndrome who was seen for the first time at the age of 69 years with combined pulmonary valve stenosis and atrial septal defect. The patient was treated by a staged percutaneous approach. The treatment of these combined congenital heart defects remains challenging because their haemodynamics interact directly. In this case report we discuss both the underlying pathophysiology and haemodynamics.

Long-term outcome of pneumatic dilation in the treatment of achalasia.

BACKGROUND & AIMS: Achalasia is treated with pneumatic dilation or Heller myotomy, but studies suggest poor long-term outcomes. We analyzed long-term outcomes after initial pneumatic dilation and studied factors associated with failure. METHODS: A total of 209 patients (111 men; mean age, 51.2 +/- 1.4 years) with achalasia who were treated with pneumatic dilation between 1992 and 2002 were followed. Outcomes were correlated with demographics, presenting symptoms, manometric features, and treatment variables by using chi(2) and Student t tests. RESULTS: All patients were initially treated with consecutive esophageal dilations up to balloon diameters of 3.0 (26%), 3.5 (41%), or 4.0 cm (33%). After dilations, mean lower esophageal sphincter (LES) pressure had decreased from 31.3 +/- 1.3 to 14.0 +/- 0.7 mm Hg (P < .0001); dysphagia decreased from 96% to 26%; and 49% had gained an average of 4.6 +/- 0.5 kg (weight loss at presentation was 10.6 +/- 0.7 kg in 39%). During follow-up, 66% required no additional treatment, whereas 23% underwent repeat dilations after 79 +/- 8 months. Patients without recurrence were older (41.2 +/- 2.1 vs 56.6 +/- 1.6 years; P < .0001) and had lower post-treatment LES pressure (17.8 +/- 1.2 vs 12.9 +/- 0.6 mm Hg; P < .005). After 70-month follow-up, balloon dilation yielded good or excellent outcomes in 72% of patients. In nonresponders, rescue surgery yielded higher success rates than botulinum toxin therapy (84% vs 44%). Patient satisfaction ranged from good to excellent in 81% of patients. CONCLUSIONS: Treating achalasia with initial dilation and then surgery for short-term failures yielded good long-term results in more than 70% and treatment satisfaction in more than 80% of patients. Management of dilation failures is more problematic.

Risk assessment in patients with heart valve disease facing non-cardiac surgery.

Cardiac-related perioperative complications are well-known in general practice. The role of echocardiography in preoperative risk assessment before non-cardiac surgery remains unclear though. In this article we discuss recently published guidelines, articles and opinions in the domain of preoperative risk assessment of patients with valvular heart disease undergoing non-cardiac surgery. We created a risk stratification model that can be used in daily practice. This model may increase our awareness of the risks associated with heart valve disease in the perioperative period.