Influence of mitral valve repair versus replacement on the development of late functional tricuspid regurgitation

ObjectivesTo study the determinants of functional tricuspid regurgitation (TR) progression after surgical correction of mitral regurgitation, including the influence of mitral valve (MV) repair (MVr) versus replacement (MVR) for degenerative mitral regurgitation.MethodsFrom January 1995 to January 2006, 747 adults with MV prolapse underwent isolated MVr (n = 683) or MVR (n = 64; mechanical in 32). The mean age was 60.8 years, and 491 were men (66.0%). Moderate preoperative functional TR was present in 115 (15.4%). The MVR group had a greater likelihood of New York Heart Association class III or IV (75.0% vs 34.4%, P < .001), atrial fibrillation (20.3% vs 8.3%, P = .002), a lower left ventricular ejection fraction (61.0% vs 65.2%, P < .003), and a higher pulmonary artery pressure (50.1 vs 41.2 mm Hg, P = .001). The patients were monitored for a mean of 6.9 years (MVr) or 7.7 years (MVR; P = .075).ResultsDuring late follow-up, no difference was found between the groups in the development of moderately severe or severe TR: 1 to 5 years (3.0% vs 3.3%, P = .91) and >5 years (6.1% vs 6.5%; P = .93). The univariate predictors of severe TR after 5 years were older age (hazard ratio [HR], 1.1; P = .011), female gender (HR, 6.86; P = .005), higher pulmonary artery pressure (HR, 1.05; P = .022), and larger left atrial size (HR, 2.11; P = .035). Two patients (0.26%) who had undergone initial MVr required reoperation for late functional TR. Another 2 patients had had the tricuspid valve addressed concurrent with reoperation for MVr failure. No tricuspid reoperations were required in the MVR group.ConclusionsThe risk of TR progression was low after MVr or MVR for MV prolapse. Timely MV surgery before the development of left atrial dilatation or pulmonary hypertension could further decrease the risk of TR progression during follow-up

Gender differences in the upward mobility of black managers: Double whammy or double advantage?

This study draws upon the theory and research on intraorganizational mobility to examine gender differences in the upward mobility of black managers. Results suggest that neither the “double whammy” assumptions nor the “double advantage” assumptions are accurate descriptions of the contemporary experience of black female managers in corporate America. Upward mobility rates were nearly identical for both gender groups. Other findings and the implications of the results for future research are discussed.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/45590/1/11199_2004_Article_BF00289811.pd

Cost-effectiveness analysis of stand-alone or combined non-invasive imaging tests for the diagnosis of stable coronary artery disease: results from the EVINCI study

Aim: This study aimed at evaluating the cost-effectiveness of different non-invasive imaging-guided strategies for the diagnosis of obstructive coronary artery disease (CAD) in a European population of patients from the Evaluation of Integrated Cardiac Imaging in Ischemic Heart Disease (EVINCI) study. Methods and results: Cost-effectiveness analysis was performed in 350 patients (209 males, mean age 59 ± 9&nbsp;years) with symptoms of suspected stable CAD undergoing computed tomography coronary angiography (CTCA) and at least one cardiac imaging stress-test prior to invasive coronary angiography (ICA) and in whom imaging exams were analysed at dedicated core laboratories. Stand-alone stress-tests or combined non-invasive strategies, when the first exam was uncertain, were compared. The diagnostic end-point was obstructive CAD defined as &gt; 50% stenosis at quantitative ICA in the left main or at least one major coronary vessel. Effectiveness was defined as the percentage of correct diagnosis (cd) and costs were calculated using country-specific reimbursements. Incremental cost-effectiveness ratios (ICERs) were obtained using per-patient data and considering “no-imaging” as reference. The overall prevalence of obstructive CAD was 28%. Strategies combining CTCA followed by stress ECHO, SPECT, PET, or stress CMR followed by CTCA, were all cost-effective. ICERs values indicated cost saving from − 969€/cd for CMR-CTCA to − 1490€/cd for CTCA-PET, − 3092€/cd for CTCA-SPECT and − 3776€/cd for CTCA-ECHO. Similarly when considering early revascularization as effectiveness measure. Conclusion: In patients with suspected stable CAD and low prevalence of disease, combined non-invasive strategies with CTCA and stress-imaging are cost-effective as gatekeepers to ICA and to select candidates for early revascularization

Long-Term Implications of Atrial Fibrillation in Patients With Degenerative Mitral Regurgitation

Background: Scientific guidelines consider atrial fibrillation (AF) complicating degenerative mitral regurgitation (DMR) a debated indication for surgery. Objectives: This study analyzed the prognostic/therapeutic implications of AF at DMR diagnosis and long-term. Methods: Patients were enrolled in the MIDA (Mitral Regurgitation International Database) registry, which reported the consecutive, multicenter, international experience with DMR due to flail leaflets echocardiographically diagnosed. Results: Among 2,425 patients (age 67 \ub1 13 years; 71% male, 67% asymptomatic, ejection fraction 64 \ub1 10%), 1,646 presented at diagnosis with sinus rhythm (SR), 317 with paroxysmal AD, and 462 with persistent AF. Underlying clinical/instrumental characteristics progressively worsened from SR to paroxysmal to persistent AF. During follow-up, paroxysmal and persistent AF were associated with excess mortality (10-year survival in SR and in paroxysmal and persistent AF was 74 \ub1 1%, 59 \ub1 3%, and 46 \ub1 2%, respectively; p &lt; 0.0001), that persisted 20 years post-diagnosis and independently of all baseline characteristics (p values &lt;0.0001). Surgery (n = 1,889, repair 88%) was associated with better survival versus medical management, regardless of all baseline characteristics and rhythm (adjusted hazard ratio: 0.26; 95% confidence interval: 0.23 to 0.30; p &lt; 0.0001) but post-surgical outcome remained affected by AF (10-year post-surgical survival in SR and in paroxysmal and persistent AF was 82 \ub1 1%, 70 \ub1 4%, and 57 \ub1 3%, respectively; p &lt; 0.0001). Conclusions: AF is a frequent occurrence at DMR diagnosis. Although AF is associated with older age and more severe presentation of DMR, it is independently associated with excess mortality long-term after diagnosis. Surgery is followed by improved survival in each cardiac rhythm subset, but persistence of excess risk is observed for each type of AF. Our study indicates that detection of AF, even paroxysmal, should trigger prompt consideration for surgery

Post-stenotic aortic dilatation

Aortic stenosis is the most common valvular heart disease affecting up to 4% of the elderly population. It can be associated with dilatation of the ascending aorta and subsequent dissection. Post-stenotic dilatation is seen in patients with AS and/or aortic regurgitation, patients with a haemodynamically normal bicuspid aortic valve and following aortic valve replacement. Controversy exists as to whether to replace the aortic root and ascending aorta at the time of aortic valve replacement, an operation that potentially carries a higher morbidity and mortality. The aetiology of post-stenotic aortic dilatation remains controversial. It may be due to haemodynamic factors caused by a stenotic valve, involving high velocity and turbulent flow downstream of the stenosis, or due to intrinsic pathology of the aortic wall. This may involve an abnormality in the process of extracellular matrix remodelling in the aortic wall including inadequate synthesis, degradation and transport of extracellular matrix proteins. This article reviews the aetiology, pathology and management of patients with post-stenotic aortic dilatation

Cost-effectiveness analysis of stand-alone or combined non-invasive imaging tests for the diagnosis of stable coronary artery disease: results from the EVINCI study

Aim: This study aimed at evaluating the cost-effectiveness of different non-invasive imaging-guided strategies for the diagnosis of obstructive coronary artery disease (CAD) in a European population of patients from the Evaluation of Integrated Cardiac Imaging in Ischemic Heart Disease (EVINCI) study.Methods and results: Cost-effectiveness analysis was performed in 350 patients (209 males, mean age 59 ± 9 years) with symptoms of suspected stable CAD undergoing computed tomography coronary angiography (CTCA) and at least one cardiac imaging stress-test prior to invasive coronary angiography (ICA) and in whom imaging exams were analysed at dedicated core laboratories. Stand-alone stress-tests or combined non-invasive strategies, when the first exam was uncertain, were compared. The diagnostic end-point was obstructive CAD defined as > 50% stenosis at quantitative ICA in the left main or at least one major coronary vessel. Effectiveness was defined as the percentage of correct diagnosis (cd) and costs were calculated using country-specific reimbursements. Incremental cost-effectiveness ratios (ICERs) were obtained using per-patient data and considering “no-imaging” as reference. The overall prevalence of obstructive CAD was 28%. Strategies combining CTCA followed by stress ECHO, SPECT, PET, or stress CMR followed by CTCA, were all cost-effective. ICERs values indicated cost saving from − 969€/cd for CMR-CTCA to − 1490€/cd for CTCA-PET, − 3,09 €/cd for CTCA-SPECT and − 3776€/cd for CTCA-ECHO. Similarly when considering early revascularization as effectiveness measure.Conclusion: In patients with suspected stable CAD and low prevalence of disease, combined non-invasive strategies with CTCA and stress-imaging are cost-effective as gatekeepers to ICA and to select candidates for early revascularization.</p

Smart card initiative for South African e-governance - A study

The paper presents the feasibility of setting up a smart card based platform using free and open source that is card terminal vendor independent. This is important in accelerating smart card usage since lack of vendor independence has been a barrier to smart card adoption. The thesis also proves the feasibility of integrating free and open source technologies in enhancing e-government in the South Africa context. This is important because adopting free and open source software allows African government the opportunity to roll out online government services at lesser costs and be in full control of localization and adaptatio