Coronavirus disease 2019 (COVID-19) is a growing pandemic that confers augmented risk for right ventricular (RV) dysfunction and dilation; the prognostic utility of adverse RV remodeling in COVID-19 ...patients is uncertain.
The purpose of this study was to test whether adverse RV remodeling (dysfunction/dilation) predicts COVID-19 prognosis independent of clinical and biomarker risk stratification.
Consecutive COVID-19 inpatients undergoing clinical transthoracic echocardiography at 3 New York City hospitals were studied; images were analyzed by a central core laboratory blinded to clinical and biomarker data.
In total, 510 patients (age 64 ± 14 years, 66% men) were studied; RV dilation and dysfunction were present in 35% and 15%, respectively. RV dysfunction increased stepwise in relation to RV chamber size (p = 0.007). During inpatient follow-up (median 20 days), 77% of patients had a study-related endpoint (death 32%, discharge 45%). RV dysfunction (hazard ratio HR: 2.57; 95% confidence interval CI: 1.49 to 4.43; p = 0.001) and dilation (HR: 1.43; 95% CI: 1.05 to 1.96; p = 0.02) each independently conferred mortality risk. Patients without adverse RV remodeling were more likely to survive to hospital discharge (HR: 1.39; 95% CI: 1.01 to 1.90; p = 0.041). RV indices provided additional risk stratification beyond biomarker strata; risk for death was greatest among patients with adverse RV remodeling and positive biomarkers and was lesser among patients with isolated biomarker elevations (p ≤ 0.001). In multivariate analysis, adverse RV remodeling conferred a >2-fold increase in mortality risk, which remained significant (p < 0.01) when controlling for age and biomarker elevations; the predictive value of adverse RV remodeling was similar irrespective of whether analyses were performed using troponin, D-dimer, or ferritin.
Adverse RV remodeling predicts mortality in COVID-19 independent of standard clinical and biomarker-based assessment.
Approximately 15% of all clinically recognized pregnancies in patients with infertility result in spontaneous abortion. However, despite its potential to have a profound and lasting effect on ...physical and emotional well-being, the natural history of spontaneous abortion in women with infertility has not been described. Although vaginal bleeding is a common symptom in pregnancies conceived via reproductive technologies, its prognostic value is not well understood.
This study aimed to evaluate the combination of early pregnancy bleeding and first-trimester ultrasound measurements to determine spontaneous abortion risk.
This was a retrospective cohort study of patients with infertility who underwent autologous embryo transfer resulting in singleton intrauterine pregnancy confirmed by ultrasound from January 1, 2017, to December 31, 2019. Early pregnancy symptoms of bleeding occurring before gestational week 8 and measurements of crown-rump length and fetal heart rate from ultrasounds performed during gestational week 6 (6 0/7 to 6 6/7 weeks of gestation) and gestational week 7 (7 0/7 to 7 6/7 weeks of gestation) were recorded. Modified Poisson regression with robust error variance was adjusted a priori for patient age, embryo transfer day, and transfer of a preimplantation genetic-tested embryo to estimate the relative risk and 95% confidence interval of spontaneous abortion for dichotomous variables. The relative risks and positive predictive values for early pregnancy bleeding combined with ultrasound measurements on the occurrence of spontaneous abortion were calculated for patients who had an ultrasound performed during gestational week 6 and separately for patients who had an ultrasound performed during gestational week 7. The primary outcome was spontaneous abortion in the setting of vaginal bleeding with normal ultrasound parameters. The secondary outcomes were spontaneous abortion with vaginal bleeding and (1) abnormal crown-rump length, (2) abnormal fetal heart rate, and (3) both abnormal crown-rump length and abnormal fetal heart rate.
Of the 1858 patients who were included (359 cases resulted in abortions and 1499 resulted in live births), 315 patients (17.0%) reported vaginal bleeding. When combined with ultrasound measurements from gestational week 6, bleeding was significantly associated with increased spontaneous abortion only when accompanied by absent fetal heart rate (relative risk, 5.36; 95% confidence interval, 3.36-8.55) or both absent fetal heart rate and absent fetal pole (relative risk, 9.67; 95% confidence interval, 7.45-12.56). Similarly, when combined with ultrasound measurements from gestational week 7, bleeding was significantly associated with increased spontaneous abortion only when accompanied by an abnormal assessment of fetal heart rate or crown-rump length (relative risk, 5.09; 95% confidence interval, 1.83-14.19) or both fetal heart rate and crown-rump length (relative risk, 14.82; 95% confidence interval, 10.54-20.83). With normal ultrasound measurements, bleeding was not associated with increased spontaneous abortion risk (relative risk: 1.05 95% confidence interval, 0.61-1.78 in gestational week 6 and 0.80 95% confidence interval, 0.36-1.74 in gestational week 7), and the live birth rate was comparable with that in patients with normal ultrasound measurements and no bleeding.
Patients with a history of infertility who present after embryo transfer with symptoms of vaginal bleeding should be evaluated with a pregnancy ultrasound to accurately assess spontaneous abortion risk. In the setting of normal ultrasound measurements, patients can be reassured that their risk of spontaneous abortion is not increased and that their live birth rate is not decreased.
COVID-19 is associated with cardiac dysfunction. This study tested the relative prognostic role of left (LV), right and bi- (BiV) ventricular dysfunction on mortality in a large multicenter cohort of ...patients during and after acute COVID-19 hospitalization.
All hospitalized COVID-19 patients who underwent clinically indicated transthoracic echocardiography within 30 days of admission at four NYC hospitals between March 2020 and January 2021 were studied. Images were re-analyzed by a central core lab blinded to clinical data. Nine hundred patients were studied (28% Hispanic, 16% African-American), and LV, RV and BiV dysfunction were observed in 50%, 38% and 17%, respectively. Within the overall cohort, 194 patients had TTEs prior to COVID-19 diagnosis, among whom LV, RV, BiV dysfunction prevalence increased following acute infection (p<0.001). Cardiac dysfunction was linked to biomarker-evidenced myocardial injury, with higher prevalence of troponin elevation in patients with LV (14%), RV (16%) and BiV (21%) dysfunction compared to those with normal BiV function (8%, all p<0.05). During in- and out-patient follow-up, 290 patients died (32%), among whom 230 died in the hospital and 60 post-discharge. Unadjusted mortality risk was greatest among patients with BiV (41%), followed by RV (39%) and LV dysfunction (37%), compared to patients without dysfunction (27%, all p<0.01). In multivariable analysis, any RV dysfunction, but not LV dysfunction, was independently associated with increased mortality risk (p<0.01).
LV, RV and BiV function declines during acute COVID-19 infection with each contributing to increased in- and out-patient mortality risk. RV dysfunction independently increases mortality risk.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
BACKGROUNDNo randomized controlled trials have compared implant and flap reconstruction. Recently, worse longitudinal outcomes have been suggested for flap reconstruction. The authors compared ...long-term oncologic outcomes of postmastectomy breast reconstruction using propensity score matching. METHODSA retrospective study of postmastectomy reconstruction was achieved using the Weill Cornell Breast Cancer Registry between 1998 and 2019. Patients were matched using propensity scores based on demographic, clinical, and surgical characteristics. Kaplan-Meier estimates, Cox-regression models, and restricted mean survival times (RMST) were used to evaluate patient outcomes. RESULTSBefore matching, 1395 implant and 586 flap patients were analyzed. No difference in overall survival and recurrence were observed. Multivariable models showed decreased survival for Medicare/Medicaid hazard ratio (HR), 3.09; 95% CI, 1.63 to 5.87; P < 0.001, pathologic stage II (HR, 2.98; 95% CI, 1.12 to 7.90; P = 0.028), stage III (HR, 4.88; 95% CI, 1.54 to 15.5; P = 0.007), 11 to 20 lymph nodes positive (HR, 3.66; 95% CI, 1.31 to 10.2; P = 0.013), more than 20 lymph nodes positive (HR, 6.41; 95% CI, 1.49 to 27.6; P = 0.013). RMST at 10 years after flap reconstruction showed 2 months of decreased survival time compared with implants (9.56 versus 9.74 years; 95% CI, -0.339 to -0.024; P = 0.024). After matching, 563 implant and 563 flap patients were compared. Reconstruction was not associated with overall survival and recurrence. RMST between implant and flap reconstruction showed no difference in each 5-year interval over 20 years. CONCLUSIONPostmastectomy breast reconstruction was not associated with a difference in long-term oncologic outcomes over a 20-year period. CLINICAL QUESTION/LEVEL OF EVIDENCETherapeutic, III.
No randomized controlled trials have compared implant and flap reconstruction. Recently, worse longitudinal outcomes have been suggested for flap reconstruction. We compared long-term oncologic ...outcomes of post-mastectomy breast reconstruction using propensity score matching.
A retrospective study of post-mastectomy reconstruction was achieved using the Weill Cornell Breast Cancer Registry between 1998 and 2019. Patients were matched using propensity scores based on demographic, clinical, and surgical characteristics. Kaplan-Meier estimates, Cox-regression models, and restricted mean survival times (RMST) were used to evaluate patient outcomes.
Before matching, 1395 implant and 586 flap patients were analyzed. No difference in overall survival and recurrence were observed. Multivariable models showed decreased survival for Medicare/Medicaid (HR: 3.09; 95% CI: 1.63, 5.87; P <.001), pathological stage II (HR: 2.98; 95% CI: 1.12, 7.90; P = .028), stage III (HR: 4.88; 95% CI: 1.54, 15.5; P = .007), 11 to 20 lymph nodes positive (HR: 3.66; 95% CI: 1.31, 10.2; P = .013), >20 lymph nodes positive (HR: 6.41; 95% CI: 1.49, 27.6; P = .013). RMST at 10 years post-flap reconstruction showed 2 months of decreased survival time compared to implants (9.56 vs 9.74 years; 95% CI: -.339, -.024; P = .024). After matching, 563 implant and 563 flap patients were compared. Reconstruction was not associated with overall survival and recurrence. RMST between implant and flap reconstruction showed no difference in each 5-year interval over 20 years.
Post-mastectomy breast reconstruction was not associated with a difference in long-term oncologic outcomes over a twenty-year period.
While all echo functional indices were lower (p<0.001) in RVdys pts, CMR RVEF correlated best with 3D echo (r=0.89) - a 2 fold increment vs 2D indices (r=0.39-0.49; p<0.001): In ROC analysis, 3D ...diagnostic performance for RVdys was higher (AUC: 0.97) than strain (0.94) or 2D indices (0.75-0.77) Figure, corresponding to high sensitivity (89%) and specificity (95%). Conclusion Among iMR pts, 3D echo yields incremental utility for RVdys vs 2D linear parameters and strain, paralleling high 3D correlation with CMR-quantified RV chamber remodeling.
Ischemic mitral regurgitation (iMR) augments risk for right ventricular dysfunction (RV
DYS
). Right and left ventricular (LV) function are linked via common coronary perfusion, but data is lacking ...regarding impact of LV ischemia and infarct transmurality—as well as altered preload and afterload—on RV performance. In this prospective multimodality imaging study, stress CMR and 3-dimensional echo (3D-echo) were performed concomitantly in patients with iMR. CMR provided a reference for RV
DYS
(RVEF < 50%), as well as LV function/remodeling, ischemia and infarction. Echo was used to test multiple RV performance indices, including linear (TAPSE, S′), strain (GLS), and volumetric (3D-echo) approaches. 90 iMR patients were studied; 32% had RV
DYS
. RV
DYS
patients had greater iMR, lower LVEF, larger global ischemic burden and inferior infarct size (all p < 0.05). Regarding injury pattern, RV
DYS
was associated with LV inferior ischemia and infarction (both p < 0.05); 80% of affected patients had substantial viable myocardium (< 50% infarct thickness) in ischemic inferior segments. Regarding RV function, CMR RVEF similarly correlated with 3D-echo and GLS (r = 0.81–0.87): GLS yielded high overall performance for CMR-evidenced RV
DYS
(AUC: 0.94), nearly equivalent to that of 3D-echo (AUC: 0.95). In multivariable regression, GLS was independently associated with RV volumetric dilation on CMR (OR − 0.90 CI − 1.19 to − 0.61, p < 0.001) and 3D echo (OR − 0.43 CI − 0.84 to − 0.02, p = 0.04). Among patients with iMR, RV
DYS
is associated with potentially reversible processes, including LV inferior ischemic but predominantly viable myocardium and strongly impacted by volumetric loading conditions.
Background
Myocardial strain provides a novel means of quantifying subtle alterations in contractile function; incremental utility post‐MI is unknown.
Objectives
To test longitudinal—quantified by ...postprocessing routine echo—for assessment of MI size measured by cardiac magnetic resonance (CMR) and conventional methods, and assess regional and global strain (GLS) as markers of LV thrombus.
Methods
The population comprised of patients with anterior ST‐segment MI who underwent echo and CMR prospectively. Preexisting echoes were retrieved, re‐analyzed for strain, and compared to conventional MI markers as well as CMR‐evidenced MI, function, and thrombus.
Results
Seventy‐four patients underwent echo and CMR 4 ± 1 weeks post‐MI; 72% had abnormal GLS. CMR‐quantified MI size was 2.5‐fold larger and EF lower among patients with abnormal GLS, paralleling 2.6–3.1 fold differences in Q‐wave size and CPK (all P ≤ .002). GLS correlated with CMR‐quantified MI (r = .66), CPK (r = .52) and Q‐wave area (r = .44; all P ≤ .001): Regional strain was lower in the base, mid, and apical LV among patients with CMR‐defined transmural MI in each territory (P < .05) and correlated with cine‐CMR regional EF (r = .53–.71; P < .001) and echo wall motion (r = .45–.71; P < .001). GLS and apical strain were ~2‐fold lower among patients with LV thrombus (P ≤ .002): Apical strain yielded higher diagnostic performance for thrombus (AUC: 0.83 0.72–0.93, P = .001) than wall motion (0.73 0.58–0.88, P = .02), as did global strain (0.78 0.65–0.90, P = .005) compared to LVEF (0.58 0.45–0.72, P = .41).
Conclusions
Echo‐quantified longitudinal strain provides a marker of MI size and improves stratification for post‐MI LV thrombus beyond conventional indices.
IntroductionCOVID-19 is a growing pandemic that confers augmented risk for RV dysfunction and dilation; prognostic utility of adverse RV remodeling in COVID-19 patients is uncertain.HypothesisTo test ...whether adverse RV remodeling (dysfunction/dilation) predicts COVID-19 prognosis independent of clinical and biomarker risk stratification.MethodsConsecutive adult COVID-19 patients undergoing clinical transthoracic echo at three NYC hospitals were studied; images were analyzed by a central core lab blinded to clinical and biomarker data.ResultsOf 510 patients (64±14 years, 66% male) studied, RV dilation and dysfunction were present in 35% and 15%, respectively. RV dysfunction increased stepwise in relation to RV chamber size (p=0.015). During inpatient follow-up (median 20 days), there were 165 deaths (32%) and 229 discharges (45%). RV dysfunction (HR 2.25 CI 1.26-3.98; p=0.006) and dilation (HR 1.82 CI 1.11-2.97; p=0.02) each independently conferred mortality risk. Patients without adverse RV remodeling were more likely to survive to hospital discharge (HR 1.39 CI 1.01-1.90; p=0.04). Figure 1A demonstrates prognostic utility for each echo-quantified RV parameter (p<0.05) in relation to all-cause mortality. Figure 1B shows RV indices to provide risk stratification beyond biomarker strata, as evidenced by greatest risk for death among patients with both adverse RV remodeling and positive biomarkers, and lesser risk among patients with isolated biomarker elevations. RV remodeling conferred over a 2-fold increase in mortality risk (HR 2.68 CI 1.70-4.23; p<0.001), which remained significant when controlling for biomarker elevations, irrespective of whether analyses were performed using troponin, D-dimer, or ferritin. (p<0.01).ConclusionsAdverse RV remodeling predicts mortality in COVID-19 independent of standard clinical and biomarker-based assessment.
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