A novel, comprehensive tool for predicting 30-day mortality after surgical aortic valve replacement

OBJECTIVES: We sought to develop and validate a novel risk assessment tool for the prediction of 30-day mortality after surgical aortic valve replacement incorporating a patient's frailty. METHODS: Overall, 4718 patients from the multicentre study OBSERVANT was divided into derivation (n=3539) and validation (n=1179) cohorts. A stepwise logistic regression procedure and a criterion based on Akaike information criteria index were used to select variables associated with 30-day mortality. The performance of the regression model was compared with that of European System for Cardiac Operative Risk Evaluation (EuroSCORE) II. RESULTS: At 30 days, 90 (2.54%) and 35 (2.97%) patients died in the development and validation data sets, respectively. Age, chronic obstructive pulmonary disease, concomitant coronary revascularization, frailty stratified according to the Geriatric Status Scale, urgent procedure and estimated glomerular filtration rate were independent predictors of 30-day mortality. The estimated OBS AVR score showed higher discrimination (area under curve 0.76 vs 0.70, P CONCLUSIONS: The OBS AVR risk score showed high discrimination and calibration abilities in predicting 30-day mortality after surgical aortic valve replacement. The addition of a simplified frailty assessment into the model seems to contribute to an improved predictive ability over the EuroSCORE II. The OBS AVR risk score showed a significant association with long-term mortality.Peer reviewe

Nanofat 2.0: experimental evidence for a fat grafting rich in mesenchymal stem cells.

Different strategies have been developed in the last decade to obtain fat grafts as rich as possible of mesenchymal stem cells, so exploiting their regenerative potential. Recently, a new kind of fat grafting, called "nanofat", has been obtained after several steps of fat emulsification and filtration. The final liquid suspension, virtually devoid of mature adipocytes, would improve tissue repair because of the presence of adipose mesenchymal stem cells (ASCs). However, since it is probable that many ASCs may be lost in the numerous phases of this procedure, we describe here a novel version of fat grafting, which we call "nanofat 2.0", likely richer in ASCs, obtained avoiding the final phases of the nanofat protocol. The viability, the density and proliferation rate of ASCs in nanofat 2.0 sample were compared with samples of nanofat and simple lipoaspirate. Although the density of ASCs was initially higher in lipoaspirate sample, the higher proliferation rate of cells in nanofat 2.0 virtually filled the gap within 8 days. By contrast, the density of ASCs in nanofat sample was the poorest at any time. Results show that nanofat 2.0 emulsion is considerably rich in stem cells, featuring a marked proliferation capability

Relativistic hydrodynamics on spacelike and null surfaces: Formalism and computations of spherically symmetric spacetimes

We introduce a formulation of Eulerian general relativistic hydrodynamics which is applicable for (perfect) fluid data prescribed on either spacelike or null hypersurfaces. Simple explicit expressions for the characteristic speeds and fields are derived in the general case. A complete implementation of the formalism is developed in the case of spherical symmetry. The algorithm is tested in a number of different situations, predisposing for a range of possible applications. We consider the Riemann problem for a polytropic gas, with initial data given on a retarded/advanced time slice of Minkowski spacetime. We compute perfect fluid accretion onto a Schwarzschild black hole spacetime using ingoing null Eddington-Finkelstein coordinates. Tests of fluid evolution on dynamic background include constant density and TOV stars sliced along the radial null cones. Finally, we consider the accretion of self-gravitating matter onto a central black hole and the ensuing increase in the mass of the black hole horizon.Comment: 23 pages, 13 figures, submitted to Phys. Rev.

Future Boundary Conditions in De Sitter Space

We consider asymptotically future de Sitter spacetimes endowed with an eternal observatory. In the conventional descriptions, the conformal metric at the future boundary I^+ is deformed by the flux of gravitational radiation. We however impose an unconventional future "Dirichlet" boundary condition requiring that the conformal metric is flat everywhere except at the conformal point where the observatory arrives at I^+. This boundary condition violates conventional causality, but we argue the causality violations cannot be detected by any experiment in the observatory. We show that the bulk-to-bulk two-point functions obeying this future boundary condition are not realizable as operator correlation functions in any de Sitter invariant vacuum, but they do agree with those obtained by double analytic continuation from anti-de Sitter space.Comment: 16 page

A General Definition of "Conserved Quantities" in General Relativity and Other Theories of Gravity

In general relativity, the notion of mass and other conserved quantities at spatial infinity can be defined in a natural way via the Hamiltonian framework: Each conserved quantity is associated with an asymptotic symmetry and the value of the conserved quantity is defined to be the value of the Hamiltonian which generates the canonical transformation on phase space corresponding to this symmetry. However, such an approach cannot be employed to define `conserved quantities' in a situation where symplectic current can be radiated away (such as occurs at null infinity in general relativity) because there does not, in general, exist a Hamiltonian which generates the given asymptotic symmetry. (This fact is closely related to the fact that the desired `conserved quantities' are not, in general, conserved!) In this paper we give a prescription for defining `conserved quantities' by proposing a modification of the equation that must be satisfied by a Hamiltonian. Our prescription is a very general one, and is applicable to a very general class of asymptotic conditions in arbitrary diffeomorphism covariant theories of gravity derivable from a Lagrangian, although we have not investigated existence and uniqueness issues in the most general contexts. In the case of general relativity with the standard asymptotic conditions at null infinity, our prescription agrees with the one proposed by Dray and Streubel from entirely different considerations.Comment: 39 pages, no figure

Exact Solutions for the Intrinsic Geometry of Black Hole Coalescence

We describe the null geometry of a multiple black hole event horizon in terms of a conformal rescaling of a flat space null hypersurface. For the prolate spheroidal case, we show that the method reproduces the pair-of-pants shaped horizon found in the numerical simulation of the head-on-collision of black holes. For the oblate case, it reproduces the initially toroidal event horizon found in the numerical simulation of collapse of a rotating cluster. The analytic nature of the approach makes further conclusions possible, such as a bearing on the hoop conjecture. From a time reversed point of view, the approach yields a description of the past event horizon of a fissioning white hole, which can be used as null data for the characteristic evolution of the exterior space-time.Comment: 21 pages, 6 figures, revtex, to appear in Phys. Rev.

Scalar field induced oscillations of neutron stars and gravitational collapse

We study the interaction of massless scalar fields with self-gravitating neutron stars by means of fully dynamic numerical simulations of the Einstein-Klein-Gordon perfect fluid system. Our investigation is restricted to spherical symmetry and the neutron stars are approximated by relativistic polytropes. Studying the nonlinear dynamics of isolated neutron stars is very effectively performed within the characteristic formulation of general relativity, in which the spacetime is foliated by a family of outgoing light cones. We are able to compactify the entire spacetime on a computational grid and simultaneously impose natural radiative boundary conditions and extract accurate radiative signals. We study the transfer of energy from the scalar field to the fluid star. We find, in particular, that depending on the compactness of the neutron star model, the scalar wave forces the neutron star either to oscillate in its radial modes of pulsation or to undergo gravitational collapse to a black hole on a dynamical timescale. The radiative signal, read off at future null infinity, shows quasi-normal oscillations before the setting of a late time power-law tail.Comment: 12 pages, 13 figures, submitted to Phys. Rev.

Quasi-Local Gravitational Energy

A dynamically preferred quasi-local definition of gravitational energy is given in terms of the Hamiltonian of a `2+2' formulation of general relativity. The energy is well-defined for any compact orientable spatial 2-surface, and depends on the fundamental forms only. The energy is zero for any surface in flat spacetime, and reduces to the Hawking mass in the absence of shear and twist. For asymptotically flat spacetimes, the energy tends to the Bondi mass at null infinity and the \ADM mass at spatial infinity, taking the limit along a foliation parametrised by area radius. The energy is calculated for the Schwarzschild, Reissner-Nordstr\"om and Robertson-Walker solutions, and for plane waves and colliding plane waves. Energy inequalities are discussed, and for static black holes the irreducible mass is obtained on the horizon. Criteria for an adequate definition of quasi-local energy are discussed.Comment: 16 page

Prespecified Risk Criteria Facilitate Adequate Discharge and Long-Term Outcomes After Transfemoral Transcatheter Aortic Valve Implantation

Background Despite the availability of guidelines for the performance of transcatheter aortic valve implantation (TAVI), current treatment pathways vary between countries and institutions, which impact on the mean duration of postprocedure hospitalization. Methods and Results This was a prospective, multicenter registry of 502 patients to validate the appropriateness of discharge timing after transfemoral TAVI, using prespecified risk criteria from FAST-TAVI (Feasibility and Safety of Early Discharge After Transfemoral [TF] Transcatheter Aortic Valve Implantation), based on hospital events within 1-year after discharge. The end point-a composite of all-cause mortality, vascular access-related complications, permanent pacemaker implantation, stroke, cardiac rehospitalization, kidney failure, and major bleeding-was reached in 27.0% of patients (95% CI, 23.3-31.2) within 1 year after intervention; 7.5% (95% CI, 5.5-10.2) had in-hospital complications before discharge and 19.6% (95% CI, 16.3-23.4) within 1 year after discharge. Overall mortality within 1 year after discharge was 7.3% and rates of cardiac rehospitalization 13.5%, permanent pacemaker implantation 4.2%, any stroke 1.8%, vascular-access-related complications 0.7%, life-threatening bleeding 0.7%, and kidney failure 0.4%. Composite events within 1 year after discharge were observed in 18.8% and 24.3% of patients with low risk of complications/early (≤3 days) discharge and high risk and discharged late (>3 days) (concordant discharge), respectively. Event rate in patients with discordant discharge was 14.3% with low risk but discharged late and increased to 50.0% in patients with high risk but discharged in ≤3 days. Conclusions The FAST-TAVI risk assessment provides a tool for appropriate, risk-based discharge that was validated with the 1-year event rate after transfemoral TAVI. Registration URL: https://www.ClinicalTrials.gov; Unique identifier: NCT02404467