Abstract Objectives The study sought to examine the risk of ischemic events and bleeding episodes associated with differing antithrombotic strategies in patients undergoing transcatheter aortic valve ...replacement (TAVR) with concomitant atrial fibrillation (AF). Background Guidelines recommend antiplatelet therapy (APT) post-TAVR to reduce the risk of stroke. However, data on the efficacy and safety of this recommendation in the setting of a concomitant indication for oral anticoagulation (due to atrial fibrillation AF) with a vitamin K antagonist (VKA) are scarce. Methods A multicenter evaluation comprising 621 patients with AF undergoing TAVR was undertaken. Post-TAVR prescriptions were used to determine the antithrombotic regimen used according to the following 2 groups: monotherapy (MT) with VKA (n = 101) or multiple antithrombotic therapy (MAT) with VKA plus 1 or 2 antiplatelet agents (aspirin or clopidogrel; n = 520). Endpoint definitions were in accordance with Valve Academic Research Consortium-2 criteria. The rate of stroke, major adverse cardiovascular events (stroke, myocardial infarction, or cardiovascular death), major or life-threatening bleeding events, and death were assessed by a Cox multivariate model regression survival analysis according to the antithrombotic regime used. Results During a median follow-up of 13 months (interquartile range: 3 to 31 months) there were no differences between groups in the rate of stroke (MT: 5%, MAT: 5.2%; adjusted hazard ratio HR: 1.25; 95% confidence interval CI: 0.45 to 3.48; p = 0.67), major adverse cardiovascular events (MT: 13.9%, MAT: 16.3%; adjusted HR: 1.33; 95% CI: 0.75 to 2.36; p = 0.33), and death (MT 22.8%, MAT: 19.2%; adjusted HR: 0.93; 95% CI: 0.58 to 1.50; p = 0.76). A higher risk of major or life-threatening bleeding was found in the MAT group (MT: 14.9%, MAT: 24.4%; adjusted HR: 1.85; 95% CI: 1.05 to 3.28; p = 0.04). These results remained similar when patients receiving VKA plus only 1 antiplatelet agent (n = 463) were evaluated. Conclusions In TAVR recipients prescribed VKA therapy for AF, concomitant antiplatelet therapy use appears not to reduce the incidence of stroke, major adverse cardiovascular events, or death, while increasing the risk of major or life-threatening bleeding.
Abstract Background Scarce data exist on the incidence of and factors associated with valve hemodynamic deterioration (VHD) after transcatheter aortic valve replacement (TAVR). Objectives This study ...sought to determine the incidence, timing, and predictors of VHD in a large cohort of patients undergoing TAVR. Methods This multicenter registry included 1,521 patients (48% male; 80 ± 7 years of age) who underwent TAVR. Mean echocardiographic follow-up was 20 ± 13 months (minimum: 6 months). Echocardiographic examinations were performed at discharge, at 6 to 12 months, and yearly thereafter. Annualized changes in mean gradient (mm Hg/year) were calculated by dividing the difference between the mean gradient at last follow-up and the gradient at discharge by the time between examinations. VHD was defined as a ≥10 mm Hg increase in transprosthetic mean gradient during follow-up compared with discharge assessment. Results The overall mean annualized rate of transprosthetic gradient progression during follow-up was 0.30 ± 4.99 mm Hg/year. A total of 68 patients met criteria of VHD (incidence: 4.5% during follow-up). The absence of anticoagulation therapy at hospital discharge (p = 0.002), a valve-in-valve (TAVR in a surgical valve) procedure (p = 0.032), the use of a 23-mm valve (p = 0.016), and a greater body mass index (p = 0.001) were independent predictors of VHD. Conclusions There was a mild but significant increase in transvalvular gradients over time after TAVR. The lack of anticoagulation therapy, a valve-in-valve procedure, a greater body mass index, and the use of a 23-mm transcatheter valve were associated with higher rates of VHD post-TAVR. Further prospective studies are required to determine whether a specific antithrombotic therapy post-TAVR may reduce the risk of VHD.
Abstract Context A tool to quantify agitation severity and sedation level in patients with advanced cancer is needed. Objectives To test the appropriateness and reliability of the Richmond ...Agitation-Sedation Scale (RASS) in Spanish patients with advanced cancer. Methods The original RASS was translated into Spanish according to the standard guidelines. Face validity was assessed by members of the palliative care team, and interrater reliability was assessed, using a weighted kappa, from observations of patients admitted to the palliative care unit. The association between scores of the RASS, Ramsay Sedation Scale, and Glasgow Coma Scale was evaluated using Spearman's ρ. Results Three hundred twenty-two observations were performed in 156 patients: 116 observations were performed for delirious patients, 76 observations for sedated patients, and 130 observations for patients admitted for other symptom control. The weighted kappa values were practically equal to or greater than 0.90 between nurses and nurses and physicians. The agreement level between observers for each RASS score was roughly 90%. The correlation between the RASS and the Ramsay and Glasgow Scale values was analyzed for 196 observations recorded in 80 patients. The sedation scale of the RASS had a strong correlation with both the Ramsay (Spearman's ρ , −0.89; P < 0.001) and the Glasgow Coma Scales (Spearman's ρ , 0.85; P < 0.001). Conclusion These data support the use of the RASS in Spanish patients with advanced cancer.
Abstract Objectives The aim of this study was to determine the impact of the degree of residual aortic regurgitation (AR) and acuteness of presentation of AR after transcatheter aortic valve ...replacement (TAVR) on outcomes. Background The degree of residual AR after TAVR leading to excess mortality remains controversial, and little evidence exists on the impact of the acuteness of presentation of AR. Methods A total of 1,735 patients undergoing TAVR with balloon-expandable or self-expanding valves were included. The presence and degree of AR were evaluated by transthoracic echocardiography; acute AR was defined as an increase in AR severity of ≥1 degree compared with pre-procedural echocardiography. Results Residual AR was classified as mild in 761 patients (43.9%) and moderate to severe in 247 patients (14.2%). The presence of moderate to severe AR was an independent predictor of mortality at a mean follow-up of 21 ± 17 months compared with none to trace (adjusted hazard ratio HR: 1.81, 95% confidence interval CI: 1.32 to 2.48; p < 0.001) and mild AR (adjusted HR: 1.68, 95% CI: 1.27 to 2.24; p < 0.001) groups. There was no increased risk in patients with mild AR compared with those with none to trace AR (p = 0.393). In patients with moderate to severe AR, acute AR was observed in 161 patients (65%) and chronic AR in 86 patients (35%). Acute moderate to severe AR was independently associated with increased risk of mortality compared with none/trace/mild AR (adjusted HR: 2.37, 95% CI: 1.53 to 3.66; p < 0.001) and chronic moderate to severe AR (adjusted HR: 2.24, 95% CI: 1.17 to 4.30; p = 0.015). No differences in survival rate were observed between patients with chronic moderate to severe and none/trace/mild AR (p > 0.50). Conclusions AR occurred very frequently after TAVR, but an increased risk of mortality at ∼2-year follow-up was observed only in patients with acute moderate to severe AR.
In-hospital infection (IHI) after transcatheter aortic valve implantation (TAVI) has received little attention, although it may have a significant effect on outcomes and costs because of prolonged ...hospital stay. Therefore, the aim of this study was to determine the incidence, type, predictors, and prognostic effects of IHI after TAVI. This study included 298 consecutive patients from 2 centers who underwent TAVI from November 2005 to November 2011. IHI during the hospital stay was defined on the basis of symptoms and signs assessed by the attending physician in the cardiac care unit or medium care unit in combination with all technical examinations performed to confirm infection. IHI after TAVI was observed in 58 patients (19.5%): urinary tract infections in 25 patients (43.1%), pneumonia in 12 patients (20.7%), and access-site infections in 7 patients (12.1%). In 12 patients (20.7%), the site of infection could not be determined, and 2 patients (3.4%) had multiple infection sites. Multivariate analysis revealed that surgical access through the femoral artery was the most important determinant of infection (odds ratio OR 4.18, 95% confidence interval CI 1.02 to 17.19), followed by perioperative major stroke (OR 3.21, 95% CI 1.01 to 9.52) and overweight (body mass index ≥25 kg/m2 ; OR 2.27, 95% CI 1.12 to 4.59). The length of hospital stay in patients with IHIs was 15.0 days (interquartile range 8.0 to 22.0) compared with 7.0 days (interquartile range 4.0 to 10.0) in patients without infections (p <0.0001). Kaplan-Meier estimates of survival at 1 year were 76.6% and 74.4% (log-rank, p = 0.61), respectively. Unadjusted and adjusted OR analysis revealed that IHI did not predict mortality at 30 days (OR 1.27, 95% CI 0.49 to 3.30) or at 1 year (hazard ratio 1.24, 95% CI 0.68 to 2.25). In conclusion, IHI occurred in 19.5% of the patients. Patient-related and, more important, procedure-related variables play a role in the occurrence of infection, indicating that improvements in the execution of TAVI may lead to a reduction of this complication.
Etiology of liver cirrhosis in Mexico Méndez-Sánchez, Nahum; Aguilar-Ramírez, Juan R; Reyes, Angel ...
Annals of hepatology,
2004 Jan-Mar, 2004-01-00, 2004-01-01, Letnik:
3, Številka:
1
Journal Article
Recenzirano
Odprti dostop
In the last decades it has been suggested that the main cause of liver cirrhosis in Mexico is alcohol. Currently in Western countries hepatitis C virus stage liver disease and liver transplantation. ...In Mexico, we have no data relative to the etiology of liver cirrhosis. The aim of this study was to investigate the main causes of liver cirrhosis in Mexico.
Eight hospitals located in different areas of the country were invited to participate in this study. Those hospitals provide health care to different social classes of the country. The inclusion criteria were the presence of either an histological or a clinical and biochemical diagnosis of liver cirrhosis.
A total 1,486 cases were included in this study. The etiology of liver cirrhosis was alcohol in 587 (39.5%), HCV 544 (36.6%), cryptogenic 154 (10.4%), PBC 84 (5.7%), HBV 75 (5.0%) and other 42 (2.8%). There was no statistical difference between alcohol and HCV.
We conclude that the main causes of liver cirrhosis in Mexico are alcohol and HCV.
Highlights • MTAP in revascularization procedures provides good histologic results. • PRP in revascularization procedures provides good histologic results. • MTAP and PRP improves the success rate of ...the revascularization procedure.
To evaluate the safety and efficacy of intracorneal ring segments (ICRS) for high astigmatism after penetrating keratoplasty (PKP).
Department of Ocular Surface and Inflammation, Ophthalmology, ...Hospital Clínico San Carlos, Complutense University, Madrid, Spain.
This retrospective noncomparative study comprised eyes with high post-PKP astigmatism (>4.00 diopters D), contact lens intolerance, and a minimum follow-up of 24 months who had ICRS (Kerarings) implantation by mechanical stromal dissection. Corrected distance visual acuity (CDVA), refractive astigmatism, spherical equivalent (SE), surgically induced astigmatism (SIA), central corneal curvature, topographic corneal astigmatism, average corneal power, and complications were assessed.
The mean CDVA was statistically significantly better postoperatively (0.23 +/- 0.21) than preoperatively (0.98 +/- 0.27) (P = .007); no eye lost CDVA. The mean refractive astigmatism decreased from 6.17 +/- 1.12 D to 4.04 +/- 1.67 D (P = .068) and the mean SE from -3.17 +/- 5.48 D to -0.12 +/- 2.40 D (P = .34). The mean SIA was 4.55 +/- 2.83 D. The mean central corneal curvature decreased from 46.28 +/- 1.73 D to 42.09 +/- 3.20 D (P<.01); the mean topographic corneal astigmatism, from 7.07 +/- 2.52 D to 4.48 +/- 2.00 D (P<.05) and the mean average corneal power from 45.92 +/- 1.59 D to 41.88 +/- 3.37 D (P<.01); all decreases were statistically significant. One patient developed deep vascularization in the lower temporal stromal channel that resolved after ICRS removal. One patient reported significant night halos.
Implantation of ICRS for high post-PKP astigmatism reduced corneal curvature and topographic astigmatism, significantly improving CDVA.
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