Arrhythmias and Sudden Death among Older Children and Young Adults Following Tetralogy of F allot Repair in the Current Era: Are Previously Reported Risk Factors Still Applicable?

Background Young adult patients (pts) with repaired tetralogy of F allot ( TOF ) remain at risk for arrhythmias ( A r) and sudden cardiac death ( SCD ). Based on past studies with earlier pt subsets, A r/ SCD events were associated with right ventricular ( RV ) systolic pressures >60 mm Hg, outflow tract gradients >20 mm Hg, and QRS duration >180 ms. However, there are limited recent studies to evaluate these risk factors in the current patient generation. Methods Patients with TOF followed over the past 50 years were grouped by presence of any arrhythmias (group 1), absence of arrhythmias (group 2), and presence of SCD or significant ventricular arrhythmias (group 3) and correlated with current pt age, gender, age at repair, repair types, echocardiogram, cardiac magnetic resonance imaging, electrocardiogram/ H olter, hemodynamics, and electrophysiology findings. Results Of 109 pts, 52 were male aged 17–58 years. Of these, 59 (54%) had A r, two of whom had SCD . These 59 pts were chronologically older at the time of analysis, with repair at an older age and wider QRS duration (78–240, mean 158 ms) when compared with those without A r. However, there was no correlation with surgical era, surgical repair, gender, RV pressure >60 mm Hg, right ventricular outflow tract gradient >20 mm Hg, or RV end‐diastolic volume on CMRI . Conclusions A r/ SCD risk continues to correlate with repair age and advancing pt age. QRS duration is longer in these patients but at a shorter interval (mean 158 ms) and less RV pressure (mean 43 mm Hg) than previously reported. In the current TOF patient generation, neither surgical era, type of repair, RV outflow gradient nor RV volume correlate with A r/ SCD . Electrophysiologic testing to verify and identify arrhythmias remains clinically effective.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/108615/1/chd12153.pd

Sequential intravascular ultrasound of the mechanisms of rotational atherectomy and adjunct balloon angioplasty

AbstractObjectives. The purpose of this study was to use sequential intravascular ultrasound imaging before intervention, after rotational atherectomy and after adjunct balloon angioplasty to characterize the mechanisms of lumen enlargement after each.Background. Rotational atherectomy uses a high speed, rotating, diamond-tipped elliptic burr to abrade atherosclerotic plaque to increase lumen size. In vitro studies have shown that high speed rotational atherectomy selectively abrades hard, especially calcified, plaque elements. However, rotational atherectomy procedures usually require adjunct balloon angioplasty.Methods. Forty-eight lesions in 46 patients were treated with rotational atherectomy followed by adjunct balloon angioplasty in 44. Quantitative coronary arteriographic and intravascular ultrasound measurements of the target lesion were made before intervention, after rotational atherectomy and after balloon angioplasty.Results. Before intervention, target lesion external elastic membrane area measured 17.3 ± 5.9 mm2, lumen area measured 1.8 ± 0.9 mm2and plaque plus media area measured 15.7 ± 4.1 mm2. After rotational atherectomy, lumen area increased, plaque plus media area decreased, arc of target lesion calcium decreased and 26% of the target lesions had dissection planes After adjunct balloon angioplasty, external elastic membrane area increased, lumen area increased, plaque plus media area did not change and 77% of the target lesions had dissection planes. Arterial expansion was seen in 80% of lesions. The pattern of dissection plane location, which was predominantly within calcified plaque after rotational atherectomy, became predominantly adjacent to calcified plaque after adjunct balloon angioplasty (p = 0.008).Conclusions. Sequential intravascular ultrasound imaging shows that high speed rotational atherectomy causes lumen enlargement by selective ablation of hard, especially calcific, atherosclerotic plaque with little tissue disruption and rare arterial expansion. Adjunct balloon angioplasty further increased lumen area by a combination of arterial dissection and arterial expansion, especially of compliant, noncalcified plaque elements

Influence Of A Dedicated Paediatric Cardiac Intensive Care Unit On Patient Outcomes

Background: The impact of a designated intensive care unit (ICU) for postoperative cardiac care in children is not clear. In our hospital (in the USA), we started a new Paediatric Cardiac Surgery programme 5 years ago, in September 2004. During the first 2 years of the programme, postoperative care was accomplished within the general paediatric ICU (PICU or c-ICU). Subsequently, in September 2006, a dedicated cardiac ICU (d-ICU) was established. We looked at our experience during these two periods to determine whether the designation of a separate ICU affected outcomes for these children. Design and Methods: We obtained Institutional Review Board (IRB) approval to review the medical records for all postoperative cardiac admissions to the ICU during the first 4 years of the programme (September 2004–September 2008). Variables collected included age, gender, diagnosis, type of cardiac surgery, Risk Adjustment for Congenital Cardiac Surgery, version 1 (RACHS-1) classification, ventilator use, hospital stay, invasive line infections, ventilator-related infections, wound infections, need for cardiopulmonary support, return to the operating room, re-exploration of the chest, delayed sternal closure, accidental extubations, re-intubation and mortality rates. These variables were summed and compared for the combined PICU and the dedicated paediatric cardiac ICU. Results: There were 199 cases performed in the first 2 years compared with 244 in the following 2 years. We saw a statistically insignificant increase in the number and complexity of cases during the second period (p = 0·08). However, morbidity declined as evidenced by the decrease in wound infection (p \u3c 0·001) and need for chest re-exploration (p \u3c 0·001). In addition, mortality declined from 7 of 199 (3·5%)to2of 244 (0·8%). p \u3c 0·04 and less children required resuscitation (p \u3c 0·01). Conclusions: We believe the designation of a specific area for postoperative cardiac care was instrumental in the growth and development of our cardiac programme. This rapid change accomplished several crucial elements that lead to accelerated improvement in patient care and a decline in morbidity and mortality

Finding High Risk Persons with Internet Tests to Manage Risk—A Literature Review with Policy Implications to Avoid Violent Tragedies, Save Lives and Money

The goal is to share policy implications of sensitive, specific internet-based tests in place of current approaches to lowering violence, namely fewer mass murders, suicides, homicides. When used, internet-based tests save lives and money. From 2009-2015, a Chicago field test had 324 fewer homicides (saving $2,089,848,548, ROI=6.42). In 60 yrs., conventional approaches for high risk persons (e.g.,. inappropriately releasing poor, severely mentally ill) led to unnecessary expense including yearly: (a) 300 mass murders (59$100/test, require 2-4 hrs

Finding High Risk Persons with Internet Tests to Manage Risk—A Literature Review with Policy Implications to Avoid Violent Tragedies, Save Lives and Money

The goal is to share policy implications of sensitive, specific internet-based tests in place of current approaches to lowering violence, namely fewer mass murders, suicides, homicides. When used, internet-based tests save lives and money. From 2009-2015, a Chicago field test had 324 fewer homicides (saving $2,089,848,548, ROI=6.42). In 60 yrs., conventional approaches for high risk persons (e.g.,. inappropriately releasing poor, severely mentally ill) led to unnecessary expense including yearly: (a) 300 mass murders (59$100/test, require 2-4 hrs