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1.
Anesthesiology ; 130(5): 756-766, 2019 05.
Artigo em Inglês | MEDLINE | ID: mdl-30870165

RESUMO

BACKGROUND: Perioperative hypotension is associated with cardiovascular events in patients having noncardiac surgery. It is unknown if the severity of preexisting coronary artery disease determines susceptibility to the cardiovascular risks of perioperative hypotension. METHODS: In this retrospective exploratory analysis of a substudy of an international prospective blinded cohort study, 955 patients 45 yr of age or older with history or risk factors for coronary artery disease underwent coronary computed tomographic angiography before elective inpatient noncardiac surgery. The authors evaluated the potential interaction between angiographic findings and perioperative hypotension (defined as systolic blood pressure less than 90 mmHg for a total of 10 min or more during surgery or for any duration after surgery and for which intervention was initiated) on the composite outcome of time to myocardial infarction or cardiovascular death up to 30 days after surgery. Angiography assessors were blinded to study outcomes; patients, treating clinicians, and outcome assessors were blinded to angiography findings. RESULTS: Cardiovascular events (myocardial infarction or cardiovascular death within 30 days after surgery) occurred in 7.7% of patients (74/955), including in 2.7% (8/293) without obstructive coronary disease or hypotension compared to 6.7% (21/314) with obstructive coronary disease but no hypotension (hazard ratio, 2.51; 95% CI, 1.11 to 5.66; P = 0.027), 8.8% (14/159) in patients with hypotension but without obstructive coronary disease (hazard ratio, 3.85; 95% CI, 1.62 to 9.19; P = 0.002), and 16.4% (31/189) with obstructive coronary disease and hypotension (hazard ratio, 7.34; 95% CI, 3.37 to 15.96; P < 0.001). Hypotension was independently associated with cardiovascular events (hazard ratio, 3.17; 95% CI, 1.99 to 5.06; P < 0.001). This association remained in patients without obstructive disease and did not differ significantly across degrees of coronary disease (P value for interaction, 0.599). CONCLUSIONS: In patients having noncardiac surgery, perioperative hypotension was associated with cardiovascular events regardless of the degree of coronary artery disease on preoperative coronary computed tomographic angiography.

2.
Can J Cardiol ; 35(1): 61-67, 2019 01.
Artigo em Inglês | MEDLINE | ID: mdl-30595184

RESUMO

BACKGROUND: Cardiac surgery waitlist recommendations, which were developed based on expert opinion, poorly predict preoperative mortality. Studies reporting risk factors for waitlist mortality have not evaluated the risks including nonadherence to waitlist benchmarks. METHODS: In patients who underwent cardiac surgery or died on the waitlist between 2005 and 2015, we used a Fine and Gray competing risk model to identify independent predictors of waitlist mortality in 12,106 patients scheduled for urgent, semiurgent, or nonurgent surgery. The predictive variables were compared with Canadian Cardiovascular Society (CCS) waitlist recommendations using the Akaike information criterion. RESULTS: A total of 101 (0.8%) patients died awaiting surgery. The median wait times and frequency waitlist deaths among emergent, urgent, semi-urgent, and nonurgent surgery were 0.6, 7.4, 69.0, 55.5 days (P < 0.001) and 6.3%, 0.8%, 0.3%, 0.6% (P < 0.001), respectively. Adherence to CCS waitlist recommendations was higher in patients who died on the waitlist (51.6% vs 70.8%, P = 0.001) and was not predictive of waitlist mortality (hazard ratio 1.48, 95% confidence interval 0.62-0.56). Independent predictors of waitlist mortality were age, aortic surgery, ejection fraction < 35%, urgent surgery, prior myocardial infarction, haemodynamic instability during cardiac catheterization, hypertension, and dyslipidemia. These variables were superior to current CCS guidelines (Akaike information criterion 1251 vs 1317, likelihood ratio test P < 0.001). CONCLUSIONS: CCS waitlist recommendations were poorly predictive of waitlist mortality and the majority of waitlist deaths occur within recommended benchmarks. We identified variables associated with waitlist mortality with improved clinical performance. Our findings suggest a need to re-evaluate cardiac surgical triage criteria using evidence-based data.


Assuntos
Procedimentos Cirúrgicos Cardíacos , Doença das Coronárias/cirurgia , Fidelidade a Diretrizes , Vigilância da População , Medição de Risco/métodos , Triagem/métodos , Listas de Espera/mortalidade , Idoso , Alberta/epidemiologia , Doença das Coronárias/mortalidade , Bases de Dados Factuais , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Fatores de Risco , Taxa de Sobrevida/tendências , Fatores de Tempo
3.
Echocardiography ; 35(11): 1746-1754, 2018 11.
Artigo em Inglês | MEDLINE | ID: mdl-30376596

RESUMO

AIM: Limited data exist on the impact of contrast-enhanced echocardiography on treatment decisions in heart failure patients that require specific left ventricular ejection fraction (LVEF) criteria. This study assessed accuracy of contrast-enhanced echocardiography in identifying patients with LVEF >35% vs ≤35% with cardiac magnetic resonance (CMR) used as reference method. METHODS AND RESULTS: Fifty-five patients from prospective Alberta HEART cohort with LVEF ≤50% on CMR were included. All patients had echocardiography performed within 2 weeks of CMR. Contrast agent was used when ≥2 contiguous LV endocardial segments were poorly visualized on echocardiography. LVEF was computed by Simpson's biplane method using non-contrast echocardiography and contrast-enhanced echocardiography and by outlining the endocardial contours in short-axis cine CMR images. Strong agreement in LV volumes and LVEF was seen between CMR and echocardiography with and without contrast (intra-class correlation coefficients >0.8) with less underestimation of LV volumes by contrast-enhanced echocardiography. Good agreement in LVEF ≤35% vs >35% was seen between CMR and non-contrast echocardiography with optimal images (κ 0.862) and contrast echocardiography (κ 0.769) while it was moderate for non-contrast echocardiography with suboptimal images (κ 0.491). The use of LV contrast in patients with suboptimal images (n = 39) resulted in correctly upgrading LVEF from ≤35% to >35% in 5 (13%) patients and downgrading LVEF from >35% to ≤35% in 2 (5%) patients using CMR as reference. CONCLUSIONS: Contrast-enhanced echocardiography in heart failure patients with suboptimal images helps to more accurately assess eligibility for specific therapies and avoid need for further testing, therefore should be considered routine part of echocardiographic assessment.

4.
Atherosclerosis ; 275: 74-79, 2018 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-29864608

RESUMO

BACKGROUND AND AIMS: Epicardial adipose tissue (EAT) volume derived from contrast enhanced (CE) computed tomography (CT) scans is not well validated. We aim to establish a reliable threshold to accurately quantify EAT volume from CE datasets. METHODS: We analyzed EAT volume on paired non-contrast (NC) and CE datasets from 25 patients to derive appropriate Hounsfield (HU) cutpoints to equalize two EAT volume estimates. The gold standard threshold (-190HU, -30HU) was used to assess EAT volume on NC datasets. For CE datasets, EAT volumes were estimated using three previously reported thresholds: (-190HU, -30HU), (-190HU, -15HU), (-175HU, -15HU) and were analyzed by a semi-automated 3D Fat analysis software. Subsequently, we applied a threshold correction to (-190HU, -30HU) based on mean differences in radiodensity between NC and CE images (ΔEATrd = CE radiodensity - NC radiodensity). We then validated our findings on EAT threshold in 21 additional patients with paired CT datasets. RESULTS: EAT volume from CE datasets using previously published thresholds consistently underestimated EAT volume from NC dataset standard by a magnitude of 8.2%-19.1%. Using our corrected threshold (-190HU, -3HU) in CE datasets yielded statistically identical EAT volume to NC EAT volume in the validation cohort (186.1 ±â€¯80.3 vs. 185.5 ±â€¯80.1 cm3, Δ = 0.6 cm3, 0.3%, p = 0.374). CONCLUSIONS: Estimating EAT volume from contrast enhanced CT scans using a corrected threshold of -190HU, -3HU provided excellent agreement with EAT volume from non-contrast CT scans using a standard threshold of -190HU, -30HU.

5.
Clin Exp Optom ; 101(6): 771-777, 2018 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-29895093

RESUMO

BACKGROUND: The use of patient simulators in ophthalmic education appears limited. This study examines the effects of the addition of the 'Virtual Refractor' patient simulator learning activity into a short unit preparing students to determine the power of the spectacle lenses required by patients in a clinic. METHODS: Twenty-four year one optometry students were randomly assigned to either the simulator-intervention group (n = 12) or the non-intervention group. All students attended tutorials on refraction and the use of a refractor-head. Simulator-intervention students additionally attended a tutorial on the Virtual Refractor. All answered a questionnaire concerning time spent studying, perceived knowledge and confidence. Twenty-four short-sighted patients were recruited. Two refractions per student were timed and the accuracy compared with that of an experienced optometrist. RESULTS: Ten students from each group completed the study. Students who used the simulator were significantly (p < 0.05) more accurate at a clinical level (within 0.22 ± 0.22 DS, 95 per cent CI 0.12-0.32) than those who did not (within 0.60 ± 0.67 DS, 95 per cent CI 0.29-0.92) and 13 per cent quicker (4.7 minutes, p < 0.05). Students who used the simulator felt more knowledgeable (p < 0.05) and confident (p < 0.05), but had spent more time reading about refraction and practised on the Virtual Refractor at home for 5.7 ± 1.3 hours. CONCLUSION: The Virtual Refractor has many features of high-fidelity medical simulation known to lead to effective learning and it also offers flexible independent learning without a concomitant increase in the student time-burden. The improved accuracy and speed on first patient encounters found in this study validates the use of this patient simulator as a useful bridge for students early in training to successfully transfer theoretical knowledge prior to entering the consulting room. The translational benefits resulting from compulsory learning activities on a patient simulator can lead to reduced demands on infrastructure and clinical supervision.

6.
SAGE Open Med Case Rep ; 5: 2050313X17695719, 2017.
Artigo em Inglês | MEDLINE | ID: mdl-28321308

RESUMO

Anomalous origin of the left coronary artery from the pulmonary artery is rare congenital abnormality that most commonly presents in childhood and is associated with a high mortality. In the elderly, patients may present acutely with arrhythmias or signs of ischemia or with vague chronic presentations of shortness of breath and fatigue. In the high-risk elderly population, it is unclear as to whether conservative surgical management by means of suture ligation of the left coronary artery is associated with positive long-term outcomes. We present a case of a 69-year-old patient diagnosed with anomalous origin of the left coronary artery from the pulmonary artery, which was treated with conservative surgical management and followed up for 15 years with cardiovascular magnetic resonance imaging, with positive outcomes.

7.
Ann Thorac Surg ; 102(3): e211-e213, 2016 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-27549545

RESUMO

Transcatheter aortic valve replacement (TAVR) by valve-in-valve (VIV) implantation is an alternative treatment for high-risk patients with a degenerating aortic bioprosthesis. We present a case of transapical TAVR VIV with a 29-mm Edwards SAPIEN XT (ESV) (Edwards Lifesciences, Irvine, CA) into a 29-mm Medtronic Freestyle stentless bioprosthesis (Medtronic Inc, Minneapolis, MN) in which unanticipated dilatation of the Freestyle bioprosthesis resulted in intraprocedural embolization of the TAVR valve, necessitating urgent conversion to a conventional surgical aortic valve replacement (AVR). Our experience suggests that TAVR VIV with the 29-mm ESV in the setting of a degenerated 29-mm Freestyle stentless bioprosthesis must be undertaken with caution.


Assuntos
Estenose da Valva Aórtica/cirurgia , Bioprótese , Estenose Coronária/cirurgia , Complicações Intraoperatórias/cirurgia , Toracotomia/métodos , Substituição da Valva Aórtica Transcateter/métodos , Idoso de 80 Anos ou mais , Estenose da Valva Aórtica/complicações , Estenose da Valva Aórtica/diagnóstico por imagem , Ponte de Artéria Coronária/métodos , Estenose Coronária/complicações , Estenose Coronária/diagnóstico por imagem , Ecocardiografia Transesofagiana/métodos , Seguimentos , Humanos , Complicações Intraoperatórias/diagnóstico por imagem , Imagem Cinética por Ressonância Magnética/métodos , Masculino , Medição de Risco , Índice de Gravidade de Doença , Resultado do Tratamento
8.
J Bone Joint Surg Am ; 98(10): e40, 2016 May 18.
Artigo em Inglês | MEDLINE | ID: mdl-27194502

RESUMO

As health care increasingly emphasizes high value, the terms "population health" and "patient-centered care" have become common, but their application is less clear. Patient-centered care encourages using data to optimize care for an individual. Population health offers a framework to consider how to efficiently and effectively manage a condition for a population, how prevention affects large groups, and the specific distribution of a given disorder. Integrating both concepts into practice can facilitate required outcome-measure reporting and potentially improve patient outcomes. Clinical practice guidelines and appropriate use criteria are examples of reconciliation of these topics. By embracing attempts to decrease variation in treating musculoskeletal disorders while personalizing delivery to individual patients, surgeons may benefit from the improvement of both efficiency and patient experience.


Assuntos
Assistência à Saúde , Ortopedia , Assistência Centrada no Paciente , Saúde Pública , Humanos , Prática Profissional
9.
J Heart Lung Transplant ; 34(5): 643-50, 2015 May.
Artigo em Inglês | MEDLINE | ID: mdl-25934478

RESUMO

BACKGROUND: Endomyocardial biopsy (EMB) is the current gold standard to screen for heart transplant rejection but has important risks and limitations. Cardiovascular magnetic resonance imaging (CMRI) is increasingly used to characterize cardiac function and myocardial tissue. We evaluated the diagnostic accuracy of CMRI compared with EMB and clinically diagnosed heart transplant rejection. METHODS: Comprehensive CMRI scans were performed on adult heart transplant recipients within 24 hours of EMB (routine or clinically indicated), before initiation of any anti-rejection therapy, and blinded to EMB results. Multivariable analysis was used to create CMRI diagnostic criteria for comparison with a positive EMB (Grade ≥ 2R or antibody-mediated rejection) and clinical rejection (change in medical therapy to treat rejection). RESULTS: Sixty participants (75% male; mean age, 51 ± 14 years) were recruited, providing 73 comparisons between CMRI and EMB for the diagnosis of rejection. Multivariable logistic regression identified myocardial edema (T2 relaxation time) and right ventricular end-diastolic volume index as independent predictors of a positive EMB. Combining threshold right ventricular end-diastolic volume index and edema values predicted a positive EMB with very good accuracy: sensitivity, 93%; specificity, 78%; positive predictive value, 52%; and negative predictive valve, 98%. CMRI was more sensitive than EMB at predicting clinical rejection (sensitivity of 67% vs 58%). CONCLUSIONS: CMRI has high sensitivity and high negative predictive value in predicting biopsy-positive heart transplant rejection and may be useful as a screening test before routine EMB. CMRI also has better sensitivity for clinically diagnosed heart transplant rejection and could be helpful in cases of negative rejection on the biopsy specimen.


Assuntos
Biópsia , Rejeição de Enxerto/patologia , Transplante de Coração , Imagem Cinética por Ressonância Magnética/métodos , Miocárdio/patologia , Adulto , Alberta/epidemiologia , Cateterismo Cardíaco , Diagnóstico Diferencial , Feminino , Seguimentos , Rejeição de Enxerto/epidemiologia , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Reprodutibilidade dos Testes , Estudos Retrospectivos
10.
BMJ ; 350: h1907, 2015 Apr 22.
Artigo em Inglês | MEDLINE | ID: mdl-25902738

RESUMO

OBJECTIVES: To determine if coronary computed tomographic angiography enhances prediction of perioperative risk in patients before non-cardiac surgery and to assess the preoperative coronary anatomy in patients who experience a myocardial infarction after non-cardiac surgery. DESIGN: Prospective cohort study. SETTING: 12 centers in eight countries. PARTICIPANTS: 955 patients with, or at risk of, atherosclerotic disease who underwent non-cardiac surgery. INTERVENTIONS: Coronary computed tomographic angiography was performed preoperatively; clinicians were blinded to the results unless left main disease was suspected. Results were classified as normal, non-obstructive (<50% stenosis), obstructive (one or two vessels with ≥ 50% stenosis), or extensive obstructive (≥ 50% stenosis in two vessels including the proximal left anterior descending artery, three vessels, or left main). MAIN OUTCOME MEASURE: Composite of cardiovascular death and non-fatal myocardial infarction within 30 days after surgery (primary outcome). This was the dependent variable in Cox regression. The independent variables were scores on the revised cardiac risk index and findings on coronary computed tomographic angiography. RESULTS: The primary outcome occurred in 74 patients (8%). The model that included both scores on the revised cardiac risk index and findings on coronary computed tomographic angiography showed that coronary computed tomographic angiography provided independent prognostic information (P=0.014; C index=0.66). The adjusted hazard ratios were 1.51 (95% confidence interval 0.45 to 5.10) for non-obstructive disease; 2.05 (0.62 to 6.74) for obstructive disease; and 3.76 (1.12 to 12.62) for extensive obstructive disease. For the model with coronary computed tomographic angiography compared with the model based on the revised cardiac risk index alone, with 30 day risk categories of <5%, 5-15%, and >15% for the primary outcome, the results of risk reclassification indicate that in a sample of 1000 patients that coronary computed tomographic angiography would have resulted appropriately in 17 net patients receiving a higher risk estimation among the 77 patients who would have experienced the primary outcome (P<0.001). Coronary computed tomographic angiography, however, would have resulted inappropriately in 98 net patients receiving a higher risk estimation, among the 923 patients who would not have experienced the primary outcome (P<0.001). Among patients who had a perioperative myocardial infarction, preoperative coronary anatomy showed extensive obstructive disease in 31% (22/71), obstructive disease in 41% (29/71), non-obstructive disease in 24% (17/71), and normal findings in 4% (3/71). CONCLUSIONS: Though findings on coronary computed tomographic angiography can improve estimation of risk for patients who will experience perioperative cardiovascular death or myocardial infarction, findings are more than five times as likely to lead to an inappropriate overestimation of risk among patients who will not experience these outcomes. Perioperative myocardial infarction occurs across the spectrum of coronary artery disease, suggesting that there could be several pathophysiologic mechanisms.


Assuntos
Angiografia Coronária , Morte Súbita Cardíaca/prevenção & controle , Infarto do Miocárdio/prevenção & controle , Complicações Pós-Operatórias/prevenção & controle , Cuidados Pré-Operatórios , Procedimentos Cirúrgicos Operatórios , Idoso , Estudos de Coortes , Morte Súbita Cardíaca/etiologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/etiologia , Complicações Pós-Operatórias/etiologia , Guias de Prática Clínica como Assunto , Valor Preditivo dos Testes , Prognóstico , Estudos Prospectivos , Medição de Risco , Fatores de Risco
12.
Can J Cardiol ; 29(9): 1076-83, 2013 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-23380296

RESUMO

BACKGROUND: Heart transplant recipients (HTRs) experience multiple cardiac complications, many of which might produce myocardial fibrosis. Cardiovascular magnetic resonance imaging (CMR) can image myocardial fibrosis using late gadolinium enhancement (LGE) imaging. We hypothesized that the presence and volume of LGE in heart transplant recipients correlates with left ventricular (LV) functional parameters and clinical outcomes. METHODS: Thirty-eight stable HTRs underwent a CMR study and clinical follow-up. RESULTS: In 38 stable HTRs, LGE was seen in 19 patients (50%), of which 15 (79%) had a nonischemic pattern and 4 (21%) had an ischemic pattern. LGE volume was associated with reduced LV ejection fraction (EF) (R(2) = 0.57; P = 0.001) and increased LV end-diastolic volume (R(2) = 0.59; P = 0.001). The presence of LGE was associated with cardiovascular death or hospitalization within the next year (P = 0.04), and patients who died or were hospitalized had more LGE than those that were not hospitalized (15 g vs 7 g; P = 0.03). CONCLUSIONS: LGE is common in HTR and is associated with adverse ventricular remodelling and adverse clinical outcomes. LGE might be a useful noninvasive approach to monitor graft disease in asymptomatic patients after heart transplant.


Assuntos
Meios de Contraste/efeitos adversos , Gadolínio DTPA/efeitos adversos , Transplante de Coração , Imagem por Ressonância Magnética/métodos , Miocárdio/patologia , Disfunção Ventricular Esquerda/induzido quimicamente , Adulto , Idoso , Morte , Feminino , Fibrose , Seguimentos , Hospitalização/estatística & dados numéricos , Humanos , Aumento da Imagem/métodos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias , Prognóstico , Volume Sistólico/efeitos dos fármacos , Disfunção Ventricular Esquerda/fisiopatologia , Remodelação Ventricular/efeitos dos fármacos
14.
Clin Orthop Relat Res ; 471(6): 1809-17, 2013 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-23229427

RESUMO

BACKGROUND: The relationships between physicians and hospitals are viewed as central to the proposition of delivering high-quality health care at a sustainable cost. Over the last two decades, major changes in the scope, breadth, and complexities of these relationships have emerged. Despite understanding the need for physician-hospital alignment, identification and understanding the incentives and drivers of alignment prove challenging. QUESTIONS/PURPOSES: Our review identifies the primary drivers of physician alignment with hospitals from both the physician and hospital perspectives. Further, we assess the drivers more specific to motivating orthopaedic surgeons to align with hospitals. METHODS: We performed a comprehensive literature review from 1992 to March 2012 to evaluate published studies and opinions on the issues surrounding physician-hospital alignment. Literature searches were performed in both MEDLINE(®) and Health Business™ Elite. RESULTS: Available literature identifies economic and regulatory shifts in health care and cultural factors as primary drivers of physician-hospital alignment. Specific to orthopaedics, factors driving alignment include the profitability of orthopaedic service lines, the expense of implants, and issues surrounding ambulatory surgery centers and other ancillary services. CONCLUSIONS: Evolving healthcare delivery and payment reforms promote increased collaboration between physicians and hospitals. While economic incentives and increasing regulatory demands provide the strongest drivers, cultural changes including physician leadership and changing expectations of work-life balance must be considered when pursuing successful alignment models. Physicians and hospitals view each other as critical to achieving lower-cost, higher-quality health care.


Assuntos
Comportamento Cooperativo , Prestação Integrada de Cuidados de Saúde/organização & administração , Relações Hospital-Médico , Ortopedia/organização & administração , Administração de Linha de Produção , Bases de Dados Factuais , Prestação Integrada de Cuidados de Saúde/economia , Reforma dos Serviços de Saúde , Humanos , MEDLINE , Cultura Organizacional , Ortopedia/economia
15.
BMJ Open ; 2(4)2012.
Artigo em Inglês | MEDLINE | ID: mdl-22855630

RESUMO

INTRODUCTION: At present, physicians have a limited ability to predict major cardiovascular complications after non-cardiac surgery and little is known about the anatomy of coronary arteries associated with perioperative myocardial infarction. We have initiated the Coronary CT Angiography (CTA) VISION Study to (1) establish the predictive value of coronary CTA for perioperative myocardial infarction and death and (2) describe the coronary anatomy of patients that have a perioperative myocardial infarction. METHODS AND ANALYSIS: The Coronary CTA VISION Study is prospective observational study. Preoperative coronary CTA will be performed in 1000-1500 patients with a history of vascular disease or at least three cardiovascular risk factors who are undergoing major elective non-cardiac surgery. Serial troponin will be measured 6-12 h after surgery and daily for the first 3 days after surgery. Major vascular outcomes at 30 days and 1 year after surgery will be independently adjudicated. ETHICS AND DISSEMINATION: Coronary CTA results in a measurable radiation exposure that is similar to a nuclear perfusion scan (10-12 mSV). Treating physicians will be blinded to the CTA results until 30 days after surgery in order to provide the most unbiased assessment of its prognostic capabilities. The only exception will be the presence of a left main stenosis >50%. This approach is supported by best available current evidence that, excluding left main disease, prophylatic revascularisation prior to non-cardiac surgery does not improve outcomes. An external safety and monitoring committee is overseeing the study and will review outcome data at regular intervals. Publications describing the results of the study will be submitted to major peer-reviewed journals and presented at international medical conferences.

16.
Heart Fail Rev ; 17(4-5): 615-33, 2012 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-22258830

RESUMO

Dilated cardiomyopathy (DCM) is a common debilitating condition with limited therapeutic options besides heart transplantation or palliation. It is characterized by maladaptive remodeling of cardiomyocytes, extracellular collagen matrix (ECCM) and left ventricular (LV) geometry which contributes to further dysfunction. LV assist devices (LVADs) can reverse adverse remodeling in end-stage DCM. However, there is a disconnect between the benefits of prolonged unloading with LVAD at molecular and cellular levels and the low rate of bridge to recovery (BTR). Potential explanations for this paradox include insufficient reverse ECCM remodeling and/or excessive reverse cardiomyocyte remodeling with atrophy. LVAD therapy is associated with decreased collagen turnover and cross-linking and increased tissue angiotensin II (AngII), whereas LVAD combined with angiotensin-converting enzyme inhibition results in decreased tissue AngII and collagen cross-linking, normalizes LV end-diastolic pressure volume relationships and is associated with modestly higher rates of BTR. Much remains to be learned about ventricular reverse remodeling after LVAD. This can be facilitated through systematic collection and comparison of recovered and unrecovered myocardium. Importantly, vigilant monitoring for ventricular recovery among LVAD patients is needed, particularly in older patients receiving LVAD for destination therapy. In addition, prospective multicenter trials are needed to clarify the potential benefit of concomitant heart failure therapy with selective ß2 agonism on ventricular recovery.


Assuntos
Cardiomiopatia Dilatada/fisiopatologia , Insuficiência Cardíaca/fisiopatologia , Ventrículos do Coração/fisiopatologia , Coração Auxiliar/efeitos adversos , Remodelação Ventricular/fisiologia , Idoso , Cardiomiopatia Dilatada/cirurgia , Matriz Extracelular , Humanos
17.
Heart Fail Rev ; 17(4-5): 663-9, 2012 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-22237460

RESUMO

End-stage systolic heart failure is an increasingly common problem in elderly patients and is associated with high cost, poor quality of life, and poor outcomes. Mechanical circulatory support is a promising therapy as both a bridge to transplantation and destination therapy. Elderly patients are frequently ineligible for heart transplantation because of their age and comorbidities, and the application of mechanical circulatory support for destination therapy in this population is not well defined. A review of the literature was undertaken to better characterize our experience to date with mechanical circulatory support in older heart failure populations. Mechanical circulatory support is being employed increasingly for destination therapy indications in older patients. The newer continuous flow devices appear to have disproportionate advantage in elderly patients, which has translated into marked improvement in 1- and 2-year survival. The rational implementation of MCS devices in elderly heart failure patients needs to focus on (1) continuous flow devices that appear to have particular benefit in this population, (2) extensive pre-MCS assessment including variables relating to frailty, and (3) intervening before these patients develop cardiogenic shock. More data are needed on the cost-benefit analysis of routine use of CF devices as destination therapy in elderly patients with heart failure.


Assuntos
Envelhecimento/fisiologia , Insuficiência Cardíaca/terapia , Coração Auxiliar , Idoso , Gerenciamento Clínico , Insuficiência Cardíaca/mortalidade , Humanos
18.
Clin Orthop Relat Res ; 470(4): 1017-26, 2012 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-21952744

RESUMO

BACKGROUND: Public reporting of patient health outcomes offers the potential to incentivize quality improvement by fostering increased accountability among providers. Voluntary reporting of risk-adjusted outcomes in cardiac surgery, for example, is viewed as a "watershed event" in healthcare accountability. However, public reporting of outcomes, cost, and quality information in orthopaedic surgery remains limited by comparison, attributable in part to the lack of standard assessment methods and metrics, provider fear of inadequate adjustment of health outcomes for patient characteristics (risk adjustment), and historically weak market demand for this type of information. QUESTIONS/PURPOSES: We review the origins of public reporting of outcomes in surgical care, identify existing initiatives specific to orthopaedics, outline the challenges and opportunities, and propose recommendations for public reporting of orthopaedic outcomes. METHODS: We performed a comprehensive review of the literature through a bibliographic search of MEDLINE and Google Scholar databases from January 1990 to December 2010 to identify articles related to public reporting of surgical outcomes. RESULTS: Orthopaedic-specific quality reporting efforts include the early FDA adverse event reporting MedWatch program and the involvement of surgeons in the Physician Quality Reporting Initiative. Issues that require more work include balancing different stakeholder perspectives on quality reporting measures and methods, defining accountability and attribution for outcomes, and appropriately risk-adjusting outcomes. CONCLUSIONS: Given the current limitations associated with public reporting of quality and cost in orthopaedic surgery, valuable contributions can be made in developing specialty-specific evidence-based performance measures. We believe through leadership and involvement in policy formulation and development, orthopaedic surgeons are best equipped to accurately and comprehensively inform the quality reporting process and its application to improve the delivery and outcomes of orthopaedic care.


Assuntos
Custos de Cuidados de Saúde , Procedimentos Ortopédicos/economia , Avaliação de Resultados (Cuidados de Saúde)/economia , Acesso à Informação , Medicina Baseada em Evidências , Humanos , Estados Unidos
19.
AJR Am J Roentgenol ; 197(3): 614-22, 2011 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-21862803

RESUMO

OBJECTIVE: We evaluated the precision of helical MDCT for the quantification of mitral valve stenosis (MVS) compared with transthoracic echocardiography (TTE) and cardiac catheterization. MATERIALS AND METHODS: A total of 28 patients with MVS of differing severity underwent an ECG-gated contrast-enhanced MDCT scan. The mitral valve area (MVA) was determined planimetrically by MDCT and was compared with Doppler TTE using the pressure half-time method and with cardiac catheterization using the Gorlin formula. RESULTS: Planimetry of the MVA with MDCT was feasible in all cases. The MVA on MDCT (1.88 ± 0.76 cm(2)) was significantly larger than that seen with TTE (1.74 ± 0.75 cm(2); p = 0.039) or cardiac catheterization (1.72 ± 0.67 cm(2); p = 0.037). The correlation between MDCT and TTE (r = 0.90; p < 0.001; limits of agreement, ± 0.65 cm(2)) and that between MDCT and cardiac catheterization (r = 0.86; p < 0.001; limits of agreement, ± 0.76 cm(2)) were good and similar to the correlation between TTE and cardiac catheterization (r = 0.88; p < 0.001; limits of agreement, ± 0.71 cm(2)). The best cutoff level for detecting moderate-to-severe stenosis at MDCT was an MVA of 1.70 cm(2), resulting in a sensitivity, specificity, accuracy, positive predictive value, and negative predictive value of 73%, 88%, 82%, 80%, and 83%, respectively, with two false-positive and three false-negative results. CONCLUSION: The MVA planimetrically determined by MDCT is systematically larger than those calculated by Doppler TTE and cardiac catheterization. However, because of a good correlation between methods and adjustment for the systematic bias, MDCT may allow reliable quantification of MVS and effectual discrimination among severity grades, although discrepancies between methods remain in individual cases.


Assuntos
Cateterismo Cardíaco , Ecocardiografia Doppler , Estenose da Valva Mitral/diagnóstico por imagem , Tomografia Computadorizada Espiral/métodos , Idoso , Idoso de 80 Anos ou mais , Técnicas de Imagem de Sincronização Cardíaca , Meios de Contraste , Feminino , Humanos , Iohexol/análogos & derivados , Iopamidol/análogos & derivados , Modelos Lineares , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Sensibilidade e Especificidade , Estatísticas não Paramétricas
20.
Eur Radiol ; 21(5): 925-35, 2011 May.
Artigo em Inglês | MEDLINE | ID: mdl-20963443

RESUMO

OBJECTIVE: To assess active myocardial inflammation by cardiovascular magnetic resonance (CMR) and endomyocardial biopsy (EMB) amongst adult patients with dilated cardiomyopathy (DCM). METHODS: We evaluated 23 adults with chronic DCM, who had successfully undergone both CMR and EMB within 3.5 ± 2.6 days. EMB was considered the gold standard. CMR assessment of myocardial inflammation used the following parameters as recommended by the recently published "Lake Louise Criteria": global myocardial oedema, global relative enhancement (RE), and late gadolinium enhancement (LGE). According to "Lake Louise Criteria", myocardial inflammation was diagnosed if two or more of the three above-mentioned parameters were positive. RESULTS: Myocardial inflammation was confirmed by immunohistology in 12 patients (52.2%). Sensitivity, specificity, and diagnostic accuracy of CMR to detect immunohistologically confirmed myocardial inflammation were 75.0%, 72.7%, and 73.9%, respectively. Sensitivity, specificity, and diagnostic accuracy of the individual CMR parameters to detect myocardial inflammation were as follows: global myocardial oedema, 91.7%, 81.8%, and 87.0%, respectively; global RE, 58.3%, 63.6%, and 60.9%, respectively; LGE, 58.3%, 45.4%, and 52.2%, respectively. CONCLUSION: Global myocardial oedema was identified as a promising CMR parameter for assessment of myocardial inflammation in patients with DCM. In these patients, global myocardial oedema yielded superior diagnostic performance compared to "Lake Louise Criteria".


Assuntos
Cardiomiopatia Dilatada/patologia , Imagem por Ressonância Magnética/métodos , Miocardite/patologia , Miocárdio/patologia , Adulto , Biópsia , Ecocardiografia/métodos , Edema/patologia , Feminino , Gadolínio/farmacologia , Humanos , Inflamação , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Sensibilidade e Especificidade
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