A retrospective comparative study of three data modelling techniques in anticoagulation therapy.

Three types of data modelling technique are applied retrospectively to individual patients’ anticoagulation therapy data to predict their future levels of anticoagulation. The results of the different models are compared and discussed relative to each other and previous similar studies. The conclusions of earlier papers are reinforced here using an extensive data set and continuously-updating neural network models are shown to predict future INR measurements best of the models presented here

Warfarin versus dabigatran etexilate: an assessment of efficacy and safety in patients with atrial fibrillation

dabigatran etexilate, warfarin, oral anticoagulation, atrial fibrillation, efficacy, safety.Introduction Oral anticoagulation is the mainstay for stroke and thromboembolic events prevention in patients with atrial fibrillation (AF). Given limitations of warfarin therapy non-vitamin K oral anticoagulants have been developed, including direct thrombin inhibitors (i.e. dabigatran etexilate). Dabigatran etexilate has been tested thoroughly in terms of efficacy and safety in clinical trials and studies, involving 'real world' cohorts. In this review currently available evidence in patients with non-valvular AF is discussed. Areas covered The pharmacology, efficacy and safety, and current aspects of use of dabigatran etexilate in patients with non-valvular AF are reviewed in comparative manner to warfarin both for chronic anticoagulation and in different clinical settings. Expert opinion Dabigatran etexilate appeared to have several pharmacokinetic and pharmacodynamic advantages over warfarin as well as a favourable efficacy and safety profile being at least non-inferior and often superior to warfarin in patients with non-valvular AF. The latter was shown in the clinical trials, meta-analyses and studies with 'real world' data. Currently ongoing trials will expand the body of evidence on warfarin and will aid decision-making in currently controversial areas. Important limitations of dabigatran etexilate include contraindications for its use in patients with prosthetic heart valves and end-stage chronic kidney disease

AFICILL: a single-cohort, retrospective study on Atrial Fibrillation In Critically ILL patients admitted to a medical sub-intensive care unit: implications for clinical management, outcomes and elaboration of new data-driven models

Introduction: atrial fibrillation (AF) is common among critically-ill patients, who are considered at increased cardioembolic and haemorragic risk. Consequently, anticoagulant therapy might be ineffective or harmful for an excess of haemorragic events which could not be counterbalanced by an adequate reduction of cardioembolic occurrences. Aims: main outcome (MO) was the composite of death or intensive care unit (ICU) transfer in a population of critically-ill subjects admitted to a medical subintensive care unit (sICU); we assessed (i) thromboembolic events (TEE) and major haemorrhages (MH); (ii) current guidelines (GL) adherence and related outcomes; (iii) performance of validated risk scores for TEE and MH; we engineered (iv) new scores adopting machine learning (ML) predicting MO, TEE, MH. Patients and Methods: single-center, retrospective study enrolling all the consecutive AF-affected patients admitted to a sICU for critical illness. Demographic, clinical, therapeutic and laboratoristic data were collected. Performance of CHA2DS2-VASc and HAS-BLED scores was evaluated. GL-adherence and its relationship with outcomes was studied. ML was used to engineer new predictive models. Results: we enrolled 1430 subjects; CHA2DS2-VASc (AUC:0.516;95%CI:0.472-0.560) and HAS-BLED (AUC:0.493;95%CI:0.443-0.543) did not predict TEE or MH; in-hospital warfarin use was associated to increased MO risk (OR:1.73;95%CI:1.06-2.83; p<0.05); low-molecular-weight-heparin use was not associated to an increased MO risk; antiplatelet drugs use was associated to MO risk reduction (OR:0.51;95%CI:0.34-0.78;p<0.002). GL-adherent treatment was associated to TEE risk reduction and MH and MO risk increase; ML identified specific features for MO, TEE, MH: ML-based classifiers outperformed CHA2DS2-VASc (AUC: from 0.516 to 0.90, p<0.0001) and HAS-BLED (AUC: from 0.493 to 0.82, p<0.0001). Discussion: AF-related outcomes cannot be predicted in critically-ill patients with currently validated methods. GL-adherence is associated to a significant TEE reduction, but also to MH and MO increase. ML algorithms can identify the most important features and shape specific scores able to outperform the classical models

Comparison of congenital cardiac surgery techniques through the development of national and international cohorts

Plusieurs avancées exceptionnelles ont permis à un nombre grandissant d’enfants avec pathologies cardiaques complexes d’atteindre l’âge adulte. Ainsi, plus de patients développent maintenant des complications en lien avec leur maladie ou leurs antécédents chirurgicaux. Malheureusement, en raison de nombreux obstacles limitant la recherche en cardiopathie congénitale adulte, un écart de savoir perdure et freine l’optimisation des soins. En attendant le couplage de grands registres pédiatriques et adultes facilitant l’accès aux données existantes, les projets multicentriques indépendants demeurent essentiels. Cette thèse présente deux études multicentriques de cohorte comparant des techniques opératoires couramment utilisées dans le traitement de pathologies congénitales cardiaques complexes dans le but de promouvoir la santé des patients à long terme. La première étude visait à évaluer l’impact chronique du type de procédure de Fontan sur le risque thromboembolique. Pour ce projet nord-américain, 522 patients avec connexion atriopulmonaire (21.4%), tunnel latéral (41.8%) ou conduit extracardiaque (36.8%) ont été recrutés. À l’aide d’analyses multivariées contrôlant pour la décennie opératoire et les effets variables dans le temps de l’arythmie et de la thromboprophylaxie, l’étude a conclu à un plus faible risque de complications thromboemboliques systémiques (rapport des risques instantanés [RRI] : 0.20 ; intervalle de confiance [IC] à 95% : 0.04-0.97) et combinées (RRI : 0.34 ; IC à 95% : 0.13-0.91) avec le conduit extracardiaque. Ces résultats remettent en question la croyance populaire selon laquelle cette technique serait plus thrombogène en raison d’un grand contact avec du matériel synthétique et d’un débit limité par le calibre fixe du greffon. La deuxième étude avait pour but d’investiguer, auprès de patients avec tétralogie de Fallot ou sténose pulmonaire corrigée nécessitant une implantation de valve pulmonaire, l’efficacité immédiate et l’innocuité d’une intervention concomitante sur la valve tricuspide. Pour ce projet pancanadien, 542 patients ayant subi un remplacement isolé de la valve pulmonaire (66.8%) ou une chirurgie combinée des valves pulmonaire et tricuspide (33.2%) ont été enrôlés. À l’aide d’analyses multivariées, cette étude a révélé que la chirurgie combinée était associée à une plus grande réduction du grade de régurgitation tricuspidienne qu’un remplacement isolé de la valve pulmonaire (rapport de cotes [RC] : 0.44 ; IC à 95% : 0.25-0.77) sans une augmentation des complications périopératoires (RC : 0.85 ; IC à 95% : 0.46-1.57) ou du temps d’hospitalisation (ratio du taux d’incidence : 1.17 ; IC à 95% : 0.93-1.46). Ces résultats questionnent la pertinence d’une gestion conservatrice de l’insuffisance tricuspide sévère. De plus, ils confirment qu’une procédure ciblée peut améliorer de façon sécuritaire la fuite modérée au-delà de l’effet produit par la décharge du ventricule – une stratégie potentiellement avantageuse auprès de jeunes patients déjà à haut risque de défaillance cardiaque droite. En conclusion, avec une puissance statistique plus élevée que les études précédemment publiées, ces travaux ont permis une comparaison valide et pertinente de techniques opératoires couramment utilisées en chirurgie cardiaque congénitale, ce qui influencera possiblement la pratique. Ultimement, cette thèse souligne l’importance de promouvoir la collaboration afin de répondre aux besoins émergents des patients avec pathologies congénitales cardiaques complexes.Outstanding technical advances have made possible for a growing number of infants with complex heart disease to survive into adulthood. Consequently, more patients are now living long enough to experience late complications related to their underlying pathology or sequelae from past interventions. However, due to the inherent challenges of carrying research in adult congenital heart disease, important knowledge gaps prevent further optimization of care. Waiting on broad linkage of pediatric and adult databases to facilitate access to data, stand-alone multicenter research initiatives remain essential. The current body of work presents two multicenter cohort studies which were designed to help improving the long-term health of patients with complex heart disease through a comparison of common operative techniques. The first study sought to evaluate the chronic impact of Fontan surgery type on the thromboembolic risk. This North American cohort enrolled 522 patients with univentricular palliation consisting of an atriopulmonary connection (21.4%), lateral tunnel (41.8%) or extracardiac conduit (36.8%). In multivariable analyses stratified by surgical decade and controlling for the time-varying effects of atrial arrhythmias and thromboprophylaxis, extracardiac conduits were independently associated with a lower risk of systemic (hazard ratio [HR]: 0.20 vs. lateral tunnel; 95% confidence interval [CI]: 0.04-0.97) and combined (HR: 0.34 vs. lateral tunnel; 95% CI: 0.13-0.91) thromboembolic events. These results cast doubt on the widely held notion that extracardiac conduits are potentially more thrombogenic than lateral tunnels by virtue of greater exposure to synthetic material and relative flow restriction through a fixed pathway. The second study investigated, in patients with repaired tetralogy of Fallot or equivalent disease undergoing a first pulmonary valve implant, the early effectiveness and safety of concomitant tricuspid valve intervention. This pan-Canadian cohort included 542 patients who underwent isolated pulmonary valve replacement (66.8%) or combined pulmonary and tricuspid valve surgery (33.2%). In multivariable analyses, combined surgery was associated with a greater reduction in tricuspid regurgitation grade than isolated pulmonary valve replacement (odds ratio [OR]: 0.44; 95% CI: 0.25-0.77) without an increase in early adverse events (OR: 0.85; 95% CI: 0.46-1.57) or hospitalization time (incidence rate ratio: 1.17; 95% CI: 0.93-1.46). These results strongly question the appropriateness of conservative management of severe tricuspid regurgitation at the time of pulmonary reintervention. Furthermore, they confirm that concomitant tricuspid valve intervention can safely improve moderate insufficiency beyond the effect of right ventricular offloading – a strategy likely worthwhile to adopt in a population of young adults already at high risk of right heart failure. In conclusion, with higher statistical power than previously published studies, the presented body of work allowed for a valid comparison of common surgical techniques used in congenital cardiac care, which will likely impact current practices. Ultimately, this thesis underlines the importance of fostering collaboration in order to meet the emerging health needs of patients with complex heart disease

Cost-effectiveness analysis of Left Ventricular Assist Devices (LVAD): a preliminary study on the interventions carried out at the Cardiac Surgery Department of the Padua University Hospital

openIl lavoro di tesi punta ad un'analisi di costo efficacia dei dispositivi LVAD (Left Ventricular Assist Device) a partire da dati su pazienti trattati con terapia VAD presso la Cardiochirurgia dell'Azienda Ospedale-Università di Padova. Lo studio preliminare coinvolge 20 pazienti impiantati a Padova presso il reparto di Cardiochirurgia, tra il 2016 e il 2023, con particolare attenzione al timing del referral

Left atrial function after atrial fibrillation cryoablation concomitant to minimally invasive mitral valve repair: A pilot study on long-term results and clinical implications

Background and Objectives: Surgical atrial fibrillation (AF) ablation concomitant to minimally invasive mitral valve repair has been proven to offer improved short- and long-term sinus rhythm (SR) maintenance compared to mitral valve surgery only. The objective of the present study was to explore, by thorough echocardiographic assessment, long-term morphological and functional left atrial (LA) outcomes after this combined surgical procedure. Materials and Methods: From October 2006 to November 2015, 48 patients underwent minimally invasive mitral valve repair and concomitant surgical AF cryoablation. Results: After 3.8 &plusmn; 2.2 years, 30 (71.4%) of those completing the follow-up (n = 42, 87.5%) presented SR. During follow-up, four (9.5%) patients suffered from cerebrovascular accidents and two of these subjects had a long-standing persistent AF relapse and were in AF at the time of the event, while the other two were in SR. An echocardiographic study focused on LA characteristics was performed in 29 patients (69.0%). Atrial morphology and function (e.g., maximal LA volume indexed to body surface area and total LA emptying fraction derived from volumes) in patients with stable SR (60.6 &plusmn; 13.1 mL/mq and 25.1 &plusmn; 7.3%) were significantly better than in those with AF relapses (76.8 &plusmn; 16.2 mL/mq and 17.5 &plusmn; 7.4%; respectively, p = 0.008 and p = 0.015). At follow-up, patients who suffered from ischemic cerebral events had maximal LA volume indexed to body surface area 61 &plusmn; 17.8 mL/mq, with total LA emptying fraction derived from volumes 23.6 &plusmn; 13.7%; patients with strokes in SR showed very enlarged LA volume (&gt;70 mL/mq). Conclusions: AF cryoablation concomitant with minimally invasive mitral valve repair provides a high rate of SR maintenance and this relates to improved long-term morphological and functional LA outcomes. Further prospective studies are needed to define the cut-off values determining an increase in the risk for thromboembolic complications in patients with restored stable SR

American College of Veterinary Emergency and Critical Care (ACVECC) Consensus on the Rational use of Antithrombotics in Veterinary Critical Care (CURATIVE) Guidelines: Small Animal

Objectives To systematically review available evidence and establish guidelines related to the risk of developing thrombosis and the management of small animals with antithrombotics. Design Standardized, systematic evaluation of the literature (identified by searching Medline via PubMed and CAB abstracts) was carried out in 5 domains (Defining populations at risk; Defining rational therapeutic use; Defining evidence‐based protocols; Refining and monitoring antithrombotic therapies; and Discontinuing antithrombotic therapies). Evidence evaluation was carried out using Population, Intervention, Comparison, Outcome generated within each domain questions to address specific aims. This was followed by categorization of relevant articles according to level of evidence and quality (Good, Fair, or Poor). Synthesis of these data led to the development of a series of statements. Consensus on the final guidelines was achieved via Delphi‐style surveys. Draft recommendations were presented at 2 international veterinary conferences and made available for community assessment, review, and comment prior to final revisions and publication. Settings Academic and referral veterinary medical centers. Results Over 500 studies were reviewed in detail. Worksheets from all 5 domains generated 59 statements with 83 guideline recommendations that were refined during 3 rounds of Delphi surveys. A high degree of consensus was reached across all guideline recommendations. Conclusions Overall, systematic evidence evaluations yielded more than 80 recommendations for the treatment of small animals with or at risk of developing thrombosis. Numerous significant knowledge gaps were highlighted by the evidence reviews undertaken, indicating the need for substantial additional research in this field