Factors associated with safe early discharge after transcatheter aortic valve implantation

  Background: As transcatheter aortic valve implantation (TAVI) becomes more straightforward, a larger proportion of patients will be well enough to be discharged early. This study sought to charac­terise the clinical features that allowed patients to be discharged early after TAVI and to evaluate the safety of an early discharge policy. Methods: All patients undergoing TAVI at the above cited center from August 2007 to March 2015 were included in this study. Baseline characteristics, in-hospital outcomes, re-admissions and mortality were compared. Results: Three hundred thirty-seven TAVIs were performed during the study period, and 18 died in-hospital (18/337, 5.3%). Of the remaining patients, 56 were discharged within 3 days of the index procedure (‘early discharge group’ 56/319, 17.5%). There was no difference between the early discharge and late discharge group in terms of Valve Academic Research Consortium-2 (VARC-2) criteria out­comes, all-cause re-admission rates and the need for permanent pacemaker implantation. Mortality at 1 year was better among the early discharge group (3.6% vs. 15.6%, p = 0.014); a reflection of baseline clinical differences. Conclusion: Early discharge of clinically selected TAVI patients is safe and appropriate. Lower logistic EuroSCORE, smaller delta creatinine and not developing any complications are factors associated with early discharge. (Cardiol J 2018; 25, 1: 14–23

Unusual tumours of the heart: diagnostic and prognostic implications

Metastases to the heart are extremely uncommon. We describe three unusual cases along with their management. A review of the current literature concerning cardiac secondaries is included

Intra-abdominal pectus bar migration – a rare clinical entity: case report

We present the case of a 20-year-old male who underwent successful surgical correction of pectus excavatum with the Highly Modified Ravitch Repair (HMRR). At 29 months the attempted operative removal of the Ravitch bar was unsuccessful despite the impression of adequate bar location on chest x-ray. Subsequent imaging with computed tomography was unclear in determining whether the bar was supra or infra-diaphragmatic due to the tissue distortion subsequent to initial surgery. Video assisted thoracoscopic surgery (VATS) successfully retrieved the bar and revealed that it was not in the thorax, but had migrated to the intra-abdominal bare area of the liver, with no evidence of associated diaphragmatic defect or hernia. Intra-abdominal pectus bar migration is a rare clinical entity, and safe removal can be facilitated by the use of the VATS technique

Calculated plasma volume status predicts outcomes after transcatheter aortic valve implantation

Objectives: Congestion can worsen outcomes after transcatheter aortic valve implantation (TAVI), but can be difficult to quantify non-invasively. We hypothesised that preprocedural plasma volume status (PVS), estimated using a validated formula that enumerates percentage change from ideal PV, would provide prognostic utility post-TAVI. Methods: This retrospective cohort study identified patients who underwent TAVI (2007–2017) from a prospectively collected database. Actual ([1-haematocrit] × [a + (b × weight (Kg))] and ideal (c × weight (Kg)) PV were quantified from equations where a, b and c are sex-dependent constants. Calculated PVS was then derived (100% x [(actual – ideal PV)/ideal PV]). Results: In 564 patients (mean age 82±7 years, 49% male), mean PVS was −2.7±10.2%, with PV expansion (PVS >0%) evident in 39%. Only logistic European System for Cardiac Operative Risk Evaluation (EuroSCORE) independently predicted a PVS >0% (OR 1.85, p=0.002). On Cox analyses, a PVS >0% was associated with greater mortality at 3 (HR 2.29, 95% CI 1.11 to 4.74, p=0.03) and 12 months (HR 2.00, 95% CI 1.23 to 3.26, p=0.006) after TAVI, independently of, and incremental to, the EuroSCORE and New York Heart Association class. A PVS >0% was also independently associated with more days in intensive care (coefficient: 0.41, 95% CI 0.04 to 0.78, p=0.03) and in hospital (coefficient: 1.95, 95% CI 0.48 to 3.41, p=0.009). Conclusion: Higher PVS values, calculated simply from weight and haematocrit, are associated with greater mortality and longer hospitalisation post-TAVI. PVS could help refine risk stratification and further investigations into the utility of PVS-guided management in TAVI patients is warranted

Photocatalytic behavior of Ba(Sb/Ta)2O6 perovskite for reduction of organic pollutants: Experimental and DFT correlation

We have synthesized closely packed hexagonal 2D plates and clustered nanoparticle morphologies of Ba(Sb/Ta)2O6 (BSTO) perovskite via the polymerizable complex method for photocatalytic dye degradation activities. The BSTO crystallized in a hexagonal structure. The presence of Ba2+, Sb5+, Ta5+, and O2− chemical states identified from XPS confirmed the formation of mixed Ba(Sb/Ta)2O6 phase accompanied with a minor amount of TaOx. Furthermore, BSTO showed excellent photocatalytic activity for the degradation of various organic dyes. The kinetic studies revealed 65.9%, 77.3%, 89.8%, and 84.2%, of Crystal Violet (CV), Methylene Blue (MB), Rhodamine blue (RhB), and Methylene Orange (MO), respectively, after irradiation of 180 min without using a cocatalyst. The formation of and OH−surface radicals, which are believed to facilitate the degradation of the dyes, are unveiled through first-principles Density Functional Theory (DFT) calculations and scavenging studies. Our results suggest that BSTO holds promise as an excellent photocatalyst with better degradation efficiency for various organic dyes

Arterial stiffness is a predictor for acute kidney injury following coronary artery bypass graft surgery

Cardiac surgery-associated acute kidney injury (CSA-AKI) is a serious postoperative complication of cardiac surgery, an episode of which impacts on patient morbidity and mortality. Pulse wave velocity (PWV; a non-invasive measurement tool to assess arterial stiffness) has been shown to predict kidney disease progression, and cardiovascular and all-cause mortality in patients with chronic kidney disease. We hypothesised that PWV would also predict acute kidney injury in subjects who have undergone non-valve repair elective coronary artery bypass graft (CABG) surgery

Minithoracotomy vs Conventional Sternotomy for Mitral Valve Repair: A Randomized Clinical Trial

Importance: The safety and effectiveness of mitral valve repair via thoracoscopically-guided minithoracotomy (minithoracotomy) compared with median sternotomy (sternotomy) in patients with degenerative mitral valve regurgitation is uncertain. Objective: To compare the safety and effectiveness of minithoracotomy vs sternotomy mitral valve repair in a randomized trial. Design, Setting, and Participants: A pragmatic, multicenter, superiority, randomized clinical trial in 10 tertiary care institutions in the UK. Participants were adults with degenerative mitral regurgitation undergoing mitral valve repair surgery. Interventions: Participants were randomized 1:1 with concealed allocation to receive either minithoracotomy or sternotomy mitral valve repair performed by an expert surgeon. Main Outcomes and Measures: The primary outcome was physical functioning and associated return to usual activities measured by change from baseline in the 36-Item Short Form Health Survey (SF-36) version 2 physical functioning scale 12 weeks after the index surgery, assessed by an independent researcher masked to the intervention. Secondary outcomes included recurrent mitral regurgitation grade, physical activity, and quality of life. The prespecified safety outcomes included death, repeat mitral valve surgery, or heart failure hospitalization up to 1 year. Results: Between November 2016 and January 2021, 330 participants were randomized (mean age, 67 years, 100 female [30%]); 166 were allocated to minithoracotomy and 164 allocated to sternotomy, of whom 309 underwent surgery and 294 reported the primary outcome. At 12 weeks, the mean between-group difference in the change in the SF-36 physical function T score was 0.68 (95% CI, −1.89 to 3.26). Valve repair rates (≈ 96%) were similar in both groups. Echocardiography demonstrated mitral regurgitation severity as none or mild for 92% of participants at 1 year with no difference between groups. The composite safety outcome occurred in 5.4% (9 of 166) of patients undergoing minithoracotomy and 6.1% (10 of 163) undergoing sternotomy at 1 year. Conclusions and relevance: Minithoracotomy is not superior to sternotomy in recovery of physical function at 12 weeks. Minithoracotomy achieves high rates and quality of valve repair and has similar safety outcomes at 1 year to sternotomy. The results provide evidence to inform shared decision-making and treatment guidelines. Trial Registration: isrctn.org Identifier: ISRCTN1393045

132 Impact of hospital census and ICU throughput on hospital length of stay

Introduction: High acuity hospitals often experience delays in transferring patients from one care unit to another within the facility. One strategy to increase inpatient ward capacity and improve throughput is to delay transfer of appropriate patients from intensive care units (ICU’s) to inpatient wards. The practice of boarding “floor” patients in the ICU when there is a lack of inpatient floor beds assumes that patients will receive the appropriate care necessary to progress toward hospital discharge.Hypothesis: We hypothesized that the care provided in an inpatient ward and an ICU boarding a “floor” patient were not equivalent in terms of ancillary services and appropriate resources to prepare patients for eventual discharge from the hospital. This difference has the potential to impact length of stay and further degrade hospital throughput.Methods: We conducted a retrospective analysis of patients admitted to the Weinberg Intensive Care Unit (WICU) between July 1, 2011 and June 30, 2012. Patients were divided into two group based on whether patients remained in the ICU after critical care services were no longer deemed necessary. Suitability for ICU discharge was reached by consensus between the patients’ primary surgeon and an intensive care physician. Our control group consisted of patients that left the ICU within 24 hours of being deemed appropriate for transfer. The floor group consisted of patients that remained in the ICU for greater than 24 hours after meeting clinical discharge criteria. Our primary outcome measure was length of hospital stay.Results: During the study period there were 1518 patients qualified for our control group and 129 patients met criteria for our boarding group. Using a linear regression model we determined that there were no significant differences between the groups in terms of age, sex, APR severity, admitting service, and mortality. Patients in the floor group had a statistically significant increase in the mean length of stay when compared to the standard group (13.0 days vs. 10.6 days p \u3c 0.05).Conclusions: These results suggest that boarding patients in an ICU when critical care services are no longer needed is associated with increased hospital length of stay in otherwise similar patients. It is possible that this increase is due to bias in selection of patients, exposure to pathogens in the ICU environment, or delays in progression of care along normal pathways of recovery. Further study will need to prospectively address the finding that delayed discharge of patients from the ICU increases hospital LOS

A Theoretical study of electronic and vibrational properties of neutral, cationic, and anionic B\u3csub\u3e24\u3c/sub\u3e clusters

The equilibrium geometries, electronic and vibrational properties, and static polarizability of B24, B-24, and B+24 clusters are reported here. First‐principles calculations based on density functional theory predict the staggered double‐ring configuration to be the ground state for B24, B-24, and B+24, in contrast to the quasi‐planar structure observed in small neutral and ionized Bn clusters with n ≤ 15. Furthermore, the (4 × B6) tubular structure is found to be relatively stable in comparison to the 3D cage structure. The presence of delocalized π and multicentered σ bonds appears to be the cause of the stability of the double‐ring and tubular isomers. For the ground state of B24, the lower and upper bound of the electron affinity is 2.67 and 2.81 eV, respectively, and the vertical ionization potential is 6.88 eV. Analysis of the frequency spectrum of the double‐ring and tubular isomers reveals the characteristic vibrational modes typically observed in carbon nanotubes. The corresponding IR spectrum also reflects the presence of some of these characteristic modes in the neutral and ionized B24, suggesting that double‐ring and tubular structures can be considered as the building blocks of boron nanotubes