Cord prolapse, associated factors and fetal outcome: a report of 47 cases from the Yaounde Central Hospital, Cameroon.

Cord prolapse is a condition in which the umbilical cord comes ahead of the presenting part. Fetal demise occurs as a consequence of the compression of the cord by the presenting part. We conducted this study to determine profile of pregnancy and its outcome at the Central Hospital Yaounde, Cameroon. This was an observational, descriptive and retrospective study of deliveries complicated by cord prolapse between January 2003 and December 2006 at the Central Maternity of the Central Hospital Yaounde. Data was retrieved from patient’s files, operation room registers and admission registers. During this period, there were a total of 6924 deliveries amongst which 47 were complicated by umbilical cord prolapse (2.8 per 1000 deliveries). Among the women with cord prolapse, 62.2% were delivered by emergency caesarean section. Fetal demise was reported in 32 % of the women upon admission. An abnormal pelvis was seen in 25.5% of the women. Artificial rupture of membranes was carried out in 40.4%. This study shows that cord prolapse is associated with severe fetal consequences in our unit. A good knowledge of the risk factors, prompt diagnosis and rapid intervention by medical staff are required.KEY WORDS: Cord prolapsed - Perinatal morbidity and mortality - Caesarean section - Vaginal delivery

A systematic review and meta-analysis of carotid artery stenting using the transcervical approach

Introduction: Carotid artery stenting (CAS) via a transcarotid revascularization (TCAR) approach has emerged as an alternative when carotid endarterectomy or conventional CAS is contraindicated. The present study was conducted to assess the feasibility and safety of TCAR in patients with carotid artery stenosis. Evidence acquisition: A systematic review of the literature was performed, according to PRISMA guidelines (Preferred Reporting Items for Systematic reviews and Meta-Analyses), using PubMed, EMBASE and CENTRAL databases. The primary outcomes included technical success, perioperative neurological event, myocardial ischemic events, death and their composite. Operational duration, flow reversal time and any local procedure related complication (carotid dissection and cranial nerve injury) were also recorded. Evidence synthesis: Twenty-three studies were included, reporting on 3130 patients, undergoing TCAR. Thirty-five per cent of them were symptomatic. Technical success was 98% (95% CI: 0.97-0.99; P=0.11, I2=32%). Early (30-day) new neurological event rate was estimated at 2% (95% CI: 0.01-0.02; P=1.0, I2=0%, respectively) while early death rate was 1% (95% CI: 0.00-0.01; P=1.0, I2=0%). Myocardial ischemic (MI) event rate was 1% (95% CI, 0.00-0.01, P=0.97, I2=6.6%). The composite outcome of neurological event/MI/death at 30-day follow-up was 2% (95% CI: 0.01-0.02, P=0.79, I2=14%). Carotid dissection rate during the intervention was 2% (95% CI: 0.01-0.03, P=0.58, I2=2.9%) while the post-operatively detected cranial nerve injury rate was 1% (95% CI, 0.00-0.01, P=1.0, I2=0%). Regarding the technical aspects of the procedures, operational and flow reversal time were at 73.8 min and 13.7 min, respectively (95% CI: 68.2-79.3, P=0.18, I2=37.6% and 95% CI: 11.3-16.1, P=0.48, I2=0%, respectively). Conclusions: TCAR is feasible with high technical success rate. The procedure presents low incidence of local complications, neurological events, myocardial complications and mortality during the early postoperative period and should be considered an acceptable alternative for patients treated for carotid artery stenosis. © 2020 EDIZIONI MINERVA MEDIC

Transesophageal echocardiography during endovascular procedures for thoracic aorta diseases: Sensitivity and specificity analysis

INTRODUCTION: The widespread use of endovascular repair in thoracic aorta (TEVAR) pathologies has ameliorated postoperative outcomes. This meta-analysis was designed to investigate the intra-operative use of transesophageal echocardiography (TEE) compared to angiography in patients undergoing TEVAR. EVIDENCEACQUISITION: The meta-analysis was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analysis statement (PRISMA) guidelines. Adata search of the English literature was conducted, using PubMed, EMBASEand CENTRALdatabases, until November 30, 2019. The Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach was used to evaluate the quality of evidence and the summary of findings for each of the included outcomes. EVIDENCE SYNTHESIS: The final analysis included 7 articles (183 patients). All patients underwent TEVAR using intra-operative TEE and angiography. The sensitivity and specificity rates of entry points were 0.624 (95% CI: 0.145-0.97) and 0.377 (95% CI: 0.029-0.856), respectively. Regarding the detection of adequate guidewire advancement, the sensitivity was 0.778 (95% CI: 0.288-939) and specifity 0.346 (95% CI: 0.019-0.844). TEE could detect endograft incomplete deployment within acceptable rates of sensitivity and specifity, estimated at 0.616 (95% CI: 0.141-0.971) and 0.365 (95% CI: 0.028-0.845), respectively. The intra-operative detection of endoleaks presented a sensitivity estimated at 0.875 (0.51-0.998) and specificity at 0.698 (95% CI: 0.284-0.904). CONCLUSIONS: Despite the limitations of this analysis, TEEmay be evaluated in the current endovascular era, as a useful tool, providing adequate information, on graft deployment and early endoleaks. © 2021 Edizioni Minerva Medica. All rights reserved

Association between loop diuretic dose changes and outcomes in chronic heart failure: observations from the ESC-EORP Heart Failure Long-Term Registry

Aims: Guidelines recommend down-titration of loop diuretics (LD) once euvolaemia is achieved. In outpatients with heart failure (HF), we investigated LD dose changes in daily cardiology practice, agreement with guideline recommendations, predictors of successful LD down-titration and association between dose changes and outcomes. Methods and results: We included 8130 HF patients from the ESC-EORP Heart Failure Long-Term Registry. Among patients who had dose decreased, successful decrease was defined as the decrease not followed by death, HF hospitalization, New York Heart Association class deterioration, or subsequent increase in LD dose. Mean age was 66 ± 13 years, 71% men, 62% HF with reduced ejection fraction, 19% HF with mid-range ejection fraction, 19% HF with preserved ejection fraction. Median [interquartile range (IQR)] LD dose was 40 (25–80) mg. LD dose was increased in 16%, decreased in 8.3% and unchanged in 76%. Median (IQR) follow-up was 372 (363–419) days. Diuretic dose increase (vs. no change) was associated with HF death [hazard ratio (HR) 1.53, 95% confidence interval (CI) 1.12–2.08; P = 0.008] and nominally with cardiovascular death (HR 1.25, 95% CI 0.96–1.63; P = 0.103). Decrease of diuretic dose (vs. no change) was associated with nominally lower HF (HR 0.59, 95% CI 0.33–1.07; P = 0.083) and cardiovascular mortality (HR 0.62,. 95% CI 0.38–1.00; P = 0.052). Among patients who had LD dose decreased, systolic blood pressure [odds ratio (OR) 1.11 per 10 mmHg increase, 95% CI 1.01–1.22; P = 0.032], and absence of (i) sleep apnoea (OR 0.24, 95% CI 0.09–0.69; P = 0.008), (ii) peripheral congestion (OR 0.48, 95% CI 0.29–0.80; P = 0.005), and (iii) moderate/severe mitral regurgitation (OR 0.57, 95% CI 0.37–0.87; P = 0.008) were independently associated with successful decrease. Conclusion: Diuretic dose was unchanged in 76% and decreased in 8.3% of outpatients with chronic HF. LD dose increase was associated with worse outcomes, while the LD dose decrease group showed a trend for better outcomes compared with the no-change group. Higher systolic blood pressure, and absence of (i) sleep apnoea, (ii) peripheral congestion, and (iii) moderate/severe mitral regurgitation were independently associated with successful dose decrease. © 2020 European Society of Cardiolog

Acute heart failure congestion and perfusion status – impact of the clinical classification on in-hospital and long-term outcomes; insights from the ESC-EORP-HFA Heart Failure Long-Term Registry

Aims: Classification of acute heart failure (AHF) patients into four clinical profiles defined by evidence of congestion and perfusion is advocated by the 2016 European Society of Cardiology (ESC)guidelines. Based on the ESC-EORP-HFA Heart Failure Long-Term Registry, we compared differences in baseline characteristics, in-hospital management and outcomes among congestion/perfusion profiles using this classification. Methods and results: We included 7865 AHF patients classified at admission as: ‘dry-warm’ (9.9%), ‘wet-warm’ (69.9%), ‘wet-cold’ (19.8%) and ‘dry-cold’ (0.4%). These groups differed significantly in terms of baseline characteristics, in-hospital management and outcomes. In-hospital mortality was 2.0% in ‘dry-warm’, 3.8% in ‘wet-warm’, 9.1% in ‘dry-cold’ and 12.1% in ‘wet-cold’ patients. Based on clinical classification at admission, the adjusted hazard ratios (95% confidence interval) for 1-year mortality were: ‘wet-warm’ vs. ‘dry-warm’ 1.78 (1.43–2.21) and ‘wet-cold’ vs. ‘wet-warm’ 1.33 (1.19–1.48). For profiles resulting from discharge classification, the adjusted hazard ratios (95% confidence interval) for 1-year mortality were: ‘wet-warm’ vs. ‘dry-warm’ 1.46 (1.31–1.63) and ‘wet-cold’ vs. ‘wet-warm’ 2.20 (1.89–2.56). Among patients discharged alive, 30.9% had residual congestion, and these patients had higher 1-year mortality compared to patients discharged without congestion (28.0 vs. 18.5%). Tricuspid regurgitation, diabetes, anaemia and high New York Heart Association class were independently associated with higher risk of congestion at discharge, while beta-blockers at admission, de novo heart failure, or any cardiovascular procedure during hospitalization were associated with lower risk of residual congestion. Conclusion: Classification based on congestion/perfusion status provides clinically relevant information at hospital admission and discharge. A better understanding of the clinical course of the two entities could play an important role towards the implementation of targeted strategies that may improve outcomes. © 2019 The Authors. European Journal of Heart Failure © 2019 European Society of Cardiolog

Performance of Prognostic Risk Scores in Chronic Heart Failure Patients Enrolled in the European Society of Cardiology Heart Failure Long-Term Registry

Objectives: This study compared the performance of major heart failure (HF) risk models in predicting mortality and examined their utilization using data from a contemporary multinational registry. Background: Several prognostic risk scores have been developed for ambulatory HF patients, but their precision is still inadequate and their use limited. Methods: This registry enrolled patients with HF seen in participating European centers between May 2011 and April 2013. The following scores designed to estimate 1- to 2-year all-cause mortality were calculated in each participant: CHARM (Candesartan in Heart Failure-Assessment of Reduction in Mortality), GISSI-HF (Gruppo Italiano per lo Studio della Streptochinasi nell'Infarto Miocardico-Heart Failure), MAGGIC (Meta-analysis Global Group in Chronic Heart Failure), and SHFM (Seattle Heart Failure Model). Patients with hospitalized HF (n = 6,920) and ambulatory HF patients missing any variable needed to estimate each score (n = 3,267) were excluded, leaving a final sample of 6,161 patients. Results: At 1-year follow-up, 5,653 of 6,161 patients (91.8%) were alive. The observed-to-predicted survival ratios (CHARM: 1.10, GISSI-HF: 1.08, MAGGIC: 1.03, and SHFM: 0.98) suggested some overestimation of mortality by all scores except the SHFM. Overprediction occurred steadily across levels of risk using both the CHARM and the GISSI-HF, whereas the SHFM underpredicted mortality in all risk groups except the highest. The MAGGIC showed the best overall accuracy (area under the curve [AUC] = 0.743), similar to the GISSI-HF (AUC = 0.739; p = 0.419) but better than the CHARM (AUC = 0.729; p = 0.068) and particularly better than the SHFM (AUC = 0.714; p = 0.018). Less than 1% of patients received a prognostic estimate from their enrolling physician. Conclusions: Performance of prognostic risk scores is still limited and physicians are reluctant to use them in daily practice. The need for contemporary, more precise prognostic tools should be considered