Outcome of elective endovascular abdominal aortic aneurysm repair in nonagenarians

ObjectiveCompared with open repair of abdominal aortic aneurysms (AAA), endovascular repair (EVAR) is associated with decreased perioperative morbidity and mortality in a standard patient population. This study sought to determine if the advantage of EVAR extends to patients aged ≥90 years.MethodsThis was a retrospective review from a prospectively maintained computerized database. Of the 322 patients aged ≥80 treated with EVAR from January 1997 to November 2007, 24 (1.9%) were aged ≥90. Mean age was 91.5 ± 1.5 years (range, 90-95 years), and 83.3% were men. Mean aneurysm size was 6.8 cm (range, 5.2-8.7 cm).ResultsMean procedural blood loss was 490 mL (range, 100-4150 mL), and 20.8% required an intraoperative transfusion. Mean postoperative length of stay was 6.0 days, (median, 4 days; mode, 1 day; range, 1-42 days), with 33.3% of patients discharged on the first postoperative day. Amongst the 24 patients, there were 6 (25.0%) perioperative major adverse events, and 2 patients died, for a perioperative mortality rate of 8.3%. Mean follow-up was 20.5 months (range, 1-49 months). Overall, three patients (12.5%) required a secondary intervention, comprising thrombectomy, angioplasty, and proximal cuff extension. No patients required conversion to open repair. Two patients (8.3%) died of AAA rupture at 507 and 1254 days. Freedom from all-cause mortality was 83.3% at 1 year and 19.3% at 5 years. Freedom from aneurysm-related mortality was 87.5% at 1 year and 73.2% at 5 years. Endoleak occurred in five patients (20.8%), with three type I and two of indeterminate type; of these, two patients with type I endoleak underwent secondary intervention at 153 and 489 days after EVAR, of which one case was successful.ConclusionOur study supports that EVAR in nonagenarians is associated with acceptable procedural success and perioperative morbidity and mortality. The medium-term results suggest that EVAR may be of limited benefit in very carefully selected patients who are aged ≥90 years

Peripheral Determinants of Oxygen Utilization in Heart Failure With Preserved Ejection Fraction

The aim of this study was to determine the arteriovenous oxygen content difference (ΔAVO2) in adult subjects with and without heart failure with preserved ejection fraction (HFpEF) during systemic and forearm exercise. Subjects with HFpEF had reduced ΔAVO2. Forearm diffusional conductance for oxygen, a lumped conductance parameter that incorporates all impediments to the movement of oxygen from red blood cells in skeletal muscle capillaries into the mitochondria within myocytes, was estimated. Forearm diffusional conductance for oxygen was not different among adults with HFpEF, those with hypertension, and healthy control subjects; therefore, diffusional conductance cannot explain the reduced forearm ΔAVO2. Instead, adiposity was strongly associated with ΔAVO2, suggesting an active role for adipose tissue in reducing exercise capacity in patients with HFpEF

Intravitreal triamcinolone acetonide injections in the treatment of retinal vein occlusions

To report the visual acuity response after intravitreal triamcinolone injection in patients with macular edema due to retinal vein occlusions. Retrospective nonrandomized interventional series of 172 consecutive patients with macular edema due to retinal vein occlusions who were treated with intravitreal triamcinolone acetonide injection. Patients underwent Snellen visual acuity testing and ophthalmoscopic examination at baseline and 1, 3, 6, and 12 months after intravitreal triamcinolone acetonide injection. All subtypes of retinal vein occlusions showed significant improvements in mean visual acuity 1 month after injection. This improvement in visual acuity was maintained over the 12-month period for all but the central retinal vein occlusion group. Seventy-one (41.3%) of the 172 patients received more than one intravitreal triamcinolone injection for unresolved or recurrent macular edema. This study demonstrates a benefit associated with intravitreal triamcinolone acetonide injection for retinal vein occlusions that was maintained by patients with branch retinal vein occlusions and hemiretinal vein occlusions over a 12-month period. Visual acuity improvement was not maintained in patients with central retinal vein occlusions with this course of treatment

. IMPACT OF RACE AND ETHNICITY ON PROGNOSTIC MODELS OF OUTCOMES IN PRIMARY SCLEROSING CHOLANGITIS

Background: Primary sclerosing cholangitis (PSC) is a chronic cholestatic liver disease with a median time to liver transplant or death (LT/D) of approximately 20 years. The Mayo Risk Score (MRS), Amsterdam-Oxford Model (AOM), and UK-PSC scores predict LT/D in PSC but have not been validated in a racially and ethnically diverse population. We aimed to validate these models in a diverse cohort and determine if race and/or ethnicity affect their performance. Methods: Patients diagnosed with PSC, including small duct PSC and overlap with autoimmune hepatitis (PSC/AIH), alive without liver transplantation after 2008, were enrolled in the Consortium for Autoimmune Liver Diseases (CALiD) registry at 9 U.S. centers. MRS, AOM, UK-PSC (short term), and model for end-stage liver disease (MELD) were calculated from the earliest available data. Time-to-failure analysis was performed from the date of the earliest available score to either LT/D or hepatic decompensation (HD), defined as first variceal bleed, ascites, or encephalopathy. Accuracy of each model was summarized using Harrell’s C-index. The effect of race and ethnicity on each model for LT/D and HD was determined by Cox regression. Results: A total of 335 patients with a median follow up 6.4 y were analyzed including 39 (11.6%) Black(B) and 37 (11.0%) Hispanic(H) patients. Characteristics did not differ between non-Hispanic White (NHW), B, and H patients [age of diagnosis (median 40.4, IQR 24.6; p=0.52), male sex (60.3%; p=0.84), PSC type (89.0% large duct, 3.6% small duct, 7.7% PSC/AIH; p=0.57), and IBD (72.2%; p=0.14)]. All models predicted both LT/D and HD (Table). However, MELD score demonstrated poor discrimination for both LT/D and HD (C-index\u3c0.7) and MELD prediction of LT/D was significantly lower than MRS (p = 0.013). MRS, AOM, and UK-PSC had good discrimination for LT/D (C-index\u3e0.7) and did not significantly differ. C-index for HD was generally lower than for LT/D and did not significantly differ between the scores. Notably, B race compared to NHW was independently associated with an increased risk of HD in three of four models. Conclusion: Current PSC-specific models performed similarly and better than MELD in an ethnically and racially diverse patient population. Neither race nor ethnicity impacted any of the models’ performance for LT/D, but B race was an independent predictor of HD in some models. Race and ethnicity should be incorporated into new models as they are developed for clinical trials as surrogate endpoints

Quantitative proteomic analysis of diabetes mellitus in heart failure with preserved ejection fraction

Diabetes mellitus (DM) is associated with a higher risk of heart failure hospitalization and mortality in patients with heart failure with preserved ejection fraction (HFpEF). Using SomaScan assays and proteomics analysis of plasma from participants in the TOPCAT (Treatment of Preserved Cardiac Function Heart Failure with an Aldosterone Antagonist) trial and the Penn Heart Failure Study, this study identified 10 proteins with significantly different expression in patients with HFpEF and DM. Of these, apolipoprotein M was found to mediate 72% (95% CI: 36% to 100%; p < 0.001) of the association between DM and the risk of cardiovascular death, aborted cardiac arrest, and heart failure hospitalization. (C) 2021 The Authors. Published by Elsevier on behalf of the American College of Cardiology Foundation