The majority (89%) of left ventricular assist device (LVAD) patients have an implantable cardioverter-defibrillator (ICD) in place. Due to the advances of modern-day LVAD therapy, more patients are ...on support for longer. This inevitably leads to more LVAD patients facing ICD generator battery depletion. Until now, there are insufficient data regarding periprocedural risks of generator replacements in a high-risk group like the LVAD cohort.
A retrospective, single-center analysis of pocket-related outcomes of all ICD generator replacements in LVAD and Non-LVAD patients between January 2014 and December 2018. The primary outcome was the combined endpoint of clinically significant pocket hematoma and/or cardiac implantable electronic device (CIED) infection in the first 6 months after ICD generator exchange. The clinically significant hematoma was defined as hematoma requiring reoperation, prolongation of hospitalization, or interruption of anticoagulation. The cumulative incidence function was calculated for the primary endpoint.
Two hundred seventy-seven patients underwent ICD generator exchange in our clinic in this time. Of these, 251 patients had a complete 6-month follow-up regarding clinically significant pocket hematomas and pocket infections. One hundred ninety patients had no LVAD, and 61 patients were on LVAD support. The rate of the primary combined endpoint clinically significant pocket hematoma and/or CIED infection was 3.5 times higher in LVAD patients compared to the non-LVAD cohort (event rate 39.14 vs 11.07 per 100 patient-years, p = 0.048). Clinically significant pocket hematomas necessitating revision occurred nearly 4 times more often in the LVAD group (p = 0.042). Pocket device infection rates were around 16 times higher in LVAD patients compared to non-LVAD patients (p = 0.002).
Compared to Non-LVAD patients, LVAD patients exhibit a relevant higher rate of clinically significant pocket hematoma and CIED infection after ICD generator exchange. This information should additionally be considered in the decision-making process regarding the indication for ICD generator exchange.
Anxiety and limited patient comprehension may pose significant barriers when informing elderly patients about complex procedures such as transcatheter aortic valve implantation (TAVI).
We aimed to ...evaluate the utility of medical graphics to improve the patient informed consent (IC) before TAVI.
In this prospective, randomized dual center study, 301 patients were assigned to a patient brochure containing medical graphics (Comic group, n = 153) or sham information (Control group, n = 148) on top of usual IC. Primary outcomes were patient understanding of central IC-related aspects and periprocedural anxiety assessed by the validated Spielberger State Trait Anxiety Inventory (STAI), both analyzed by cognitive status according to the Montreal Cognitive Assessment (MoCA).
Patient understanding was significantly higher in the Comic group mean number of correct answers 12.8 (SD 1.2) vs. 11.3 (1.8); mean difference 1.5 (95% CI 1.2-1.8); p < 0.001. This effect was more pronounced in the presence of cognitive dysfunction (MoCA < 26) 12.6 (1.2) in the Comic vs. 10.9 (1.6) in the Control group; mean difference 1.8 (1.4-2.2), p < 0.001. Mean STAI score declined by 5.7 (95% CI 5.1-6.3; p < 0.001) in the Comic and 0.8 points (0.2-1.4; p = 0.015) in the Control group. Finally, mean STAI score decreased in the Comic group by 4.7 (3.8-5.6) in cognitively impaired patients and by 6.6 (95% CI 5.8 to 7.5) in patients with normal cognitive function (p < 0.001 each).
Our results prove beneficial effects for using medical graphics to inform elderly patients about TAVI by improving patient understanding and reducing periprocedural anxiety (DRKS00021661; 23/Oct/2020). Medical graphics entailed significant beneficial effects on the primary endpoints, patient understanding and periprocedural anxiety, compared to the usual patient informed consent (IC) procedure. Patient understanding of IC-related aspects was significantly higher in the Comic group, with a more pronounced benefit in patients with cognitive impairment (p for IC method and cognitive status < 0.001, respectively; p for IC method x MoCA category interaction = 0.017). There further was a significant decline of periprocedural anxiety in patients with and without cognitive impairment (p for IC method x measuring time point < 0.001; p for IC method x MoCA category x measuring time point interaction = 0.018).
There is no established strategy of how and when to treat coronary artery disease (CAD) in patients referred for transcatheter aortic valve implantation (TAVI). Simultaneous, single-stage treatment ...of both pathologies is a possible solution. We report our initial results of simultaneously performed transapical TAVI and elective percutaneous coronary interventions (PCI) in high-risk patients with severe aortic valve stenosis. Between April 2008 and July 2011, a total of 419 patients underwent transapical TAVI. Combined elective PCI and TAVI were performed in 46 (11%) patients. Only the most significant coronary lesion or lesions were treated. Technical success of the combined approach was 100%. The mean count of implanted stents per patient was 1.6 ± 1.0 (range, 1-5 stents). The 30-day mortality rates in the PCI and TAVI group was 4.3%. Survival at 12, 24 and 36 months of the PCI and TAVI group 87.1 ± 5.5, 69.7 ± 10.3 and 69.7 ± 10.3%, respectively. The results showed that the single-stage approach with combined elective PCI and TAVI is feasible and safe. It has become our primary choice for treatment of high-risk patients with severe aortic valve stenosis and CAD.
Transapical aortic valve implantation (TAVI) is a new method that might reduce the surgical risk of conventional surgical aortic valve replacement in very high-risk patients. Increased downstream ...microembolization is expected in transapical aortic valve implantation. However, whether it usually occurs, how often, and its clinical relevance are not known. We report the results of ultrasound microembolic signal detection in the middle cerebral artery during the procedure.
Fifty patients (mean age: 80 ± 5 years; mean EuroSCORE: 36 ± 13 %) underwent transapical aortic valve implantation. Intraoperative transcranial Doppler (TCD) sound examination of both middle cerebral arteries (MCA) was used to identify high-intensity transient signals (HITS) and microembolic signals (MES) during seven phases of the procedure. Pre- and postoperative computed tomography of the brain and clinical neurological examinations were performed preoperatively and daily during the first postoperative week.
During the procedure, HITS right MCA: 435 ± 922 (range 9-5765); left MCA: 471 ± 996 (range 24-6432) and MES right MCA: 78 ± 172 (range 1-955); left MCA: 62 ± 190 (range 2-1553) were detected in all patients. Most of the MES were recorded during valvuloplasty right MCA: 3 ± 5.6 (range 0-31); left MCA: 2 ± 4.9 (range 0-30) and positioning of the prosthetic valve in the aortic position right MCA: 6 ± 5 (range 0-22); left MCA: 2 ± 6.9 (range 0-38). Postoperatively, there were no clinical signs of new cerebral embolism.
Cerebral microemboli were detected by intraoperative transcranial Doppler sound examinations in all patients during transapical aortic valve implantation. Most of the signals were detected during balloon valvuloplasty and delivery of the prosthetic valve.
The Cherenkov Telescope Array and the KM3NeT neutrino telescopes are major upcoming facilities in the fields of
γ
-ray and neutrino astronomy, respectively. Possible simultaneous production of
γ
rays ...and neutrinos in astrophysical accelerators of cosmic-ray nuclei motivates a combination of their data. We assess the potential of a combined analysis of CTA and KM3NeT data to determine the contribution of hadronic emission processes in known Galactic
γ
-ray emitters, comparing this result to the cases of two separate analyses. In doing so, we demonstrate the capability of
Gammapy
, an open-source software package for the analysis of
γ
-ray data, to also process data from neutrino telescopes. For a selection of prototypical
γ
-ray sources within our Galaxy, we obtain models for primary proton and electron spectra in the hadronic and leptonic emission scenario, respectively, by fitting published
γ
-ray spectra. Using these models and instrument response functions for both detectors, we employ the
Gammapy
package to generate pseudo data sets, where we assume 200 h of CTA observations and 10 years of KM3NeT detector operation. We then apply a three-dimensional binned likelihood analysis to these data sets, separately for each instrument and jointly for both. We find that the largest benefit of the combined analysis lies in the possibility of a consistent modelling of the
γ
-ray and neutrino emission. Assuming a purely leptonic scenario as input, we obtain, for the most favourable source, an average expected 68% credible interval that constrains the contribution of hadronic processes to the observed
γ
-ray emission to below 15%.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
Abstract
Background
The impact of pre-existing mild cognitive disorder (MCD) on patient-reported outcome measures (PROMs) after transcatheter aortic valve implantation (TAVI) remains unclear.
Purpose
...To investigate functional and symptomatic outcomes after TAVI in patients with or without MCD at two German tertiary care centers as part of a randomised controlled trial (TAVI-COMIC study).
Methods
Adult patients undergoing elective TAVI were enrolled. MCD was defined by the Montreal Cognitive Assessment (MoCA) <26 points. PROMs were assessed at 90 days after TAVI.
Results
Of 199 patients, 109 (54.8%) showed MCD. Female patients had significantly more often MCD (49.5% vs. 34.4%, p=0.046). Prior to TAVI, 21.6% reported dyspnea (NYHA class III-IV), 35.1% angina (CCS class II-IV), 41.2% dizziness and 12.6% syncope. Both patient groups reported similar improvements in general health status after TAVI: "marginally or significantly better" health status in 73.5% with MCD vs. 68.9% without MCD (p=n.s.). In multivariable logistic regression models, the number of patients reporting a "good, very good or excellent" general health status after TAVI was similar in both patient groups (p=n.s.) (Table). Similarly, post-TAVI symptoms of dyspnea, angina, dizziness or syncope were similar between both groups (each p=n.s.). Procuration and walking ability without difficulties as well as functional independence were 54% 95% Confidence Interval (CI) 0.23-0.92 (p=0.028), 55% 95% CI 0.22-0.89 (p=0.023) and 52% 95% CI 0.24-0.94 (p=0.035) less frequently reported by patients with MCD compared to patients without MCD, respectively. Of note, delirium was more frequently observed in patients with MCD within 3 days after TAVI (8.3% vs. 1.1%, p=0.049).
Conclusions
TAVI appeared to result in similar improvements in general health status and symptomatic PROMs in patients with and without MCD. Though, patients with MCD reported impaired functional PROMs after TAVI. More careful post-procedural care should be taken for patients with MCD to enhance functional independence in this vulnerable patient group.
Objetivos El implante de prótesis aórticas transapicales (TAVI) es una nueva alternativa terapéutica para los pacientes con estenosis aórtica y elevado riesgo quirúrgico. Analizamos nuestra ...experiencia inicial. Métodos Desde abril de 2008, 672 pacientes (edad 79 ± 8 años; rango 28–99) han sido tratados mediante implante de TAVI. El EuroSCORE logístico medio fue de 38 ± 21% y el score Society of Thoracic Surgeons (STS) 18 ± 15%; 25 pacientes (6,1%) presentaban shock cardiogénico. Se realizaron los siguientes procedimientos concomitantes: stent coronario electivo (46), cirugía de revascularización coronaria (4), reparación tricuspídea (3), cierre de comunicación interauricular (CIA) (1), dilatación de válvula pulmonar (1) y sustitución valvular mitral (1). Resultados El implante se llevó a cabo con éxito en el 99,5%. La supervivencia a los 30 días, 1, 2 y 3 años fue del 95,2 ± 1,1%, 83,0 ± 2,1%, 68,3 ± 3,5%, y 63,7 ± 4,5%, respectivamente. En el análisis multivariante se observaron como factores predictores de supervivencia el sexo femenino, ausencia de insuficiencia renal previa, arteriopatía periférica y shock cardiogénico. Conclusiones El implante de TAVI es factible en pacientes con riesgo prohibitivo para cirugía convencional. Dado que nuestros resultados son excelentes, incluso a medio plazo, consideramos que esta técnica cambiará el futuro de la cirugía cardíaca, abriendo un nuevo camino hacia la cirugía híbrida.
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