Prognostic Value of the 6-Min Walk Test After Open-Heart Valve Surgery: EXPERIENCE OF A CARDIOVASCULAR REHABILITATION PROGRAM

PURPOSE: This single-center retrospective analysis aimed to evaluate the prognostic relevance of 6-min walk test (6MWT) in patients admitted to an in-hospital cardiovascular rehabilitation program after open-heart valve surgery. METHODS: One hundred one patients able to perform a 6MWT within the first week of admission (time after surgery: 16 ± 8 d) were included (age 68 ± 11 y; 55% female; median left ventricular ejection fraction 55% [interquartile range: 50-60]; 51% after aortic valve surgery). Study endpoints were cardiovascular death and the combined outcome of cardiovascular death/cardiac hospitalization. Univariate and multivariate analyses were performed to analyze predictive value of the 6MWT. RESULTS: After a median follow-up of 27 mo, cardiovascular mortality was 9.9% while combined endpoint occurrence was 33%. Patients experiencing study endpoints had lower left ventricular ejection fraction, higher N-terminal prohormone of brain natriuretic peptide serum levels, and longer in-hospital stay (all P < .05). The 6MWT distance was a significant predictor of cardiovascular death (hazard ratio [HR] = 0.89, 95% CI: 0.81-0.97, P = .007) and cardiac hospitalizations (HR = 0.95, 95% CI: 0.90-0.99, P = .02). Even after adjusting for the relevant confounding variables of cardiovascular death and cardiac hospitalization, the adjusted HR = 0.88, 95% CI: 0.75-0.98, P = .028 and adjusted HR = 0.95, 95% CI: 0.90-0.99, P = .05, respectively. CONCLUSIONS: In patients admitted to an in-hospital cardiovascular rehabilitation program after open-heart valve surgery, 6MWT proved to be an independent prognostic tool, potentially allowing identification of high-risk patients for whom a more intensive and tailored in-hospital cardiovascular rehabilitation program should be designed and implemented in order to avoid unfavorable cardiovascular events

Giant left atrial myxoma causing acute ischemic stroke

Atrial myxomas are primary cardiac tumors which may cause ischemic stroke. The authors present a case of a 51-year-old man admitted to the emergency department with right-sided hemiplegia and aphasia caused by ischemic stroke. 2D and 3D transesophageal echocardiography showed an atrial myxoma described as a large mass in the left atrium attached to the interatrial septum. In the end, surgical excision of the myxoma was performed 48 h after diagnosis. Nowadays, specific guidelines concerning the correct time for surgical excision of the myxoma are lacking. The authors highlight the utmost role of echocardiography to promptly characterize a cardiac mass and the importance of discuss about the timing of cardiac surgery. Plain language summary Atrial myxoma is a rare cardiac tumor that is often located in the left atrium of the heart. Patients with myxoma can have no symptoms, or they can present signs of systemic embolization, where fragments of the tumor have been released into the blood stream and are circulating to different areas of the body. Indeed, if a fragment reaches the brain, it can cause a cerebral acute ischemic stroke, which is a sudden loss of blood circulation to an area of the brain, resulting in a loss of neurologic function. Transesophageal echocardiography, an ultrasound test that produces real-time and detailed images of the heart, is a useful tool that allows physicians to diagnose the presence of an atrial myxoma. In this case report, the authors stress the role of echocardiography in diagnosing patients presenting with sudden neurological symptoms, because it can show a potential mass inside the heart. Once identified, the tumor can be removed surgically as soon as possible to avoid further complications, such as a new stroke. Tweetable abstract The authors describe a case of an ischemic stroke caused by a large atrial myxoma, which was surgically removed 48 h after diagnosis

Treatment Decision-Making Capacity in Forensic vs Non-forensic Psychiatric Patients: A European Comparison

Background: Consent to treatment is a cornerstone of medical ethics and law. Nevertheless, very little empirical evidence is available to inform clinicians and policymakers regarding the capacities of forensic patients with schizophrenia spectrum disorders (SSDs) to make decisions about their treatment, with the risk of clinical and legal inertia, silent coercion, stigmatization, or ill-conceived reforms. Study Design: In this multinational study, we assessed and compared with treatment-related decisional capacities in forensic and non-forensic patients with SSD. 160 forensic and 139 non-forensic patients were used in Austria, Germany, Italy, Poland, and England. Their capacity to consent to treatment was assessed by means of the MacArthur Competence Assessment Tool for Treatment (MacCAT-T). Multiple generalized linear regression models were used to identify the socio-demographic and clinical variables associated with MacCAT-T scores. Study Results: In total, 55 forensic (34.4%) and 58 non-forensic patients (41.7%) showed high treatment-related decisional capacity, defned as scoring ≥75% of the maximum scores for the understanding, appreciation and reasoning, and 2 for expressing a choice. Forensic patients showed differences in their capacity to consent to treatment across countries. Of all socio-demographic and clinical variables, only “social support” was directly relevant to policy. Conclusions: Forensic patients have treatmentrelated decisional capacities comparable with their non-forensic counterparts. Social contacts might provide a substantial contribution towards enhancing the decisional autonomy of both forensic and non-forensic patients, hence improving the overall quality and legitimacy of mental health care