Long-term results of left ventricular myotomy and myectomy for obstructive hypertrophic cardiomyopathy

AbstractA retrospective analysis of patients with hypertrophic obstructive cardiomyopathy treated by left ventricular myotomy and myectomy from 1972 to 1994 is reported. There were 158 patients (81 male and 77 female) with a mean age of 50.2 (±17.2) years (range 12 to 80 years). One hundred nine patients (69%) were 60 years of age or younger, and 49 patients (31%) were older than 60 years. The overall mean follow-up period was 6.1 (±4.8) years (range 0.1 to 19.3 years) and was 94% complete with a cumulative total of 956 patient-years. Preoperative exertional dyspnea was present in 84%, chest pain in 70%, presyncope in 54%, syncope in 31%, and cardiac arrest in 5% of patients. Preoperative cardiac catheterization was done in 150 patients, with mitral regurgitation detected in 104 patients (67%). The average maximal provocable left ventricular outflow tract gradient was 118 (±46) mm Hg (range 25 to 250 mm Hg). The average preoperative echocardiographic gradient at rest was 64 mm Hg, 20 mm Hg in the early postoperative period and 10 mm Hg in the late postoperative period. The mean septal thickness was 2.2 (±0.6) cm, 1.9 (±0.7) cm in the early postoperative period (p < 0.05 vs preoperative) and 1.7 (±0.5) cm in the late postoperative period (p < 0.05 vs preoperative). The overall 30-day operative mortality rate was 3.2% (5/158), and 0% for 109 patients 60 years of age or younger. Causes of death included myocardial infarction and left ventricular free wall rupture, myocardial failure from septal perforation, sepsis, cerebrovascular accident caused by thromboembolism, and delayed cardiac tamponade in one patient each. Concomitant coronary artery bypass grafting was performed in 22 patients (19.3% of patients ≥40 years of age) and mitral valve replacement in 5 patients (3.2%). One hundred nine patients (69%) are alive, 10 patients (6.3%) were lost to follow-up, and 39 patients died (24.7%, including operative deaths). Actuarial survivals at 1, 5, 10, and 15 years were 92.4% ±2.2%, 85.4% ±3.1%, 71.5% ±4.6%, and 46% ±9%, respectively. The overall linearized death rate for discharged patients was 1.9%/pt-yr, and for cardiac related deaths it was 1.7%/pt-yr. Thirty-nine (36%) of the 109 survivors received β-adrenergic blockers, and 30 (28%) received calcium channel blockers. Ninety-four patients had improvement in New York Heart Association functional class, 10 had improvement in symptoms but not in functional class, and 5 had no improvement in functional class or symptoms. Neither preoperative hemodynamic values nor routine echocardiographic measurements significantly correlated with quality of postoperative results. Left ventricular myotomy and myectomy is a safe and reproducibly effective operative treatment for medically refractory hypertrophic obstructive cardiomyopathy, especially for patients 60 years of age or younger. Improvement in functional class and symptoms can be expected in nearly all patients. The results of myotomy and myectomy serve as a standard for comparison with other interventions for medically refractory cardiomyopathy. (J THORAC CARDIOVASC SURG 1996;111:586-94

Characteristics of patients surviving more than ten years after cardiac transplantation

AbstractThe clinical status and quality of life of 40 patients who lived or are still alive more than 10 years after transplantation at our institution were reviewed with the use of our transplant database, prospective patient examinations, cardiac catheterization, and exercise testing. Patient-perceived health status was determined with use of the Nottingham Health Profile and General Well Being examinations. Factors associated with longevity were determined by a Cox proportional hazards model. Twenty-six patients are alive and 14 have died. The mean age at transplant was 32.4 ± 12 years and the current age (or age at death) is 46.1 ± 12.8 years. Actuarial freedom from rejection was similar to that of patients surviving less than 10 years (p = 0.8), but freedom from all types of infection was less (p = 0.005). Immunosuppressive drugs include cyclosporine (11/26 patients), azathioprine (24/26), and prednisone (26/26, mean dose 12.7 mg/day). Catheterization hemodynamic data show well-preserved graft function at a mean follow-up of 11.7 ± 3.3 years. Graft coronary artery disease prevalence is 51.0% ± 8%. Exercise test results are as follows: duration 8.7 ± 3.5 minutes (range 2 to 16 minutes), maximum heart rate/expected rate 77.3% ± 11% (50% to 92%), maximum systolic blood pressure 171 ± 23 mm Hg (140 to 208 mm Hg), and metabolic equivalents 9.2 ± 2.3 units (5.5 to 12.9 units), or about 84% of predicted. Mean score on the General Well Being examination was 75.3 ± 21.6 (normal). Nottingham Health Profile scores were nearly normal, except for in the 50- to 64-year-old age group in categories of mobility, pain, sleep quality, and energy level. Causes of death were coronary artery disease in 7 of 14, infection in 4 of 14, lymphoma in 1 of 14, and nonlymphoid cancer in 2 of 14. In the Cox regression, variables most associated with survival t > 2.0, multivariate p = 0.0005) were age at transplantation (t = 3.26), preoperative duration of illness (t = 3.57), postoperative cytomegalovirus infection ( t = 2.16), and ejection fraction at 12 months after operation (t = -2.62). We conclude that cardiac transplantation can provide patients with end-stage cardiac failure an acceptable general medical condition, functional status, and perceived quality of life well into the second decade after operation. (J T HORAC C ARDIOVASC S URG 1995;109:1103-15

Probing multiscale factors affecting the reactivity of nanoparticle-bound molecules

I. K. M., W. E., E. J. H, S. S. and E. R. K. are grateful for funding from the Leverhulme Trust [RPG-2015-042], the Engineering and Physical Sciences Research Council [EP/K016342/1], the University of St Andrews, and the EPSRC Centre for Doctoral Training in Critical Resource Catalysis (CRITICAT) [Ph.D. studentship to SS: EP/L016419/1]. D. M. and P.P thank the Italian Ministry of University Research (MIUR) for funding [RBSI14PBC6].The structures and physicochemical properties of surface-stabilizing molecules play a critical role in defining the properties, interactions, and functionality of hybrid nanomaterials such as monolayer-stabilized nanoparticles. Concurrently, the distinct surface-bound interfacial environment imposes very specific conditions on molecular reactivity and behavior in this setting. Our ability to probe hybrid nanoscale systems experimentally remains limited, yet understanding the consequences of surface confinement on molecular reactivity is crucial for enabling predictive nanoparticle synthon approaches for postsynthesis engineering of nanoparticle surface chemistry and construction of devices and materials from nanoparticle components. Here, we have undertaken an integrated experimental and computational study of the reaction kinetics for nanoparticle-bound hydrazones, which provide a prototypical platform for understanding chemical reactivity in a nanoconfined setting. Systematic variation of just one molecular-scale structural parameter—the distance between reactive site and nanoparticle surface—showed that the surface-bound reactivity is influenced by multiscale effects. Nanoparticle-bound reactions were tracked in situ using 19F NMR spectroscopy, allowing direct comparison to the reactions of analogous substrates in bulk solution. The surface-confined reactions proceed more slowly than their solution-phase counterparts, and kinetic inhibition becomes more significant for reactive sites positioned closer to the nanoparticle surface. Molecular dynamics simulations allowed us to identify distinct supramolecular architectures and unexpected dynamic features of the surface-bound molecules that underpin the experimentally observed trends in reactivity. This study allows us to draw general conclusions regarding interlinked structural and dynamical features across several length scales that influence interfacial reactivity in monolayer-confined environments.PostprintPeer reviewe

Early development of accelerated graft coronary artery disease: Risk factors and course

AbstractObjectives. This study assessed the time of first appearance of angiographic graft coronary artery disease in relation to clinical and laboratory variables and clinical events in heart transplant recipients.Background. Graft coronary artery disease is the main factor limiting long-term survival after heart transplantation, and it is important to understand its natural history.Methods. One hundred thirty-nine consecutive patients who developed angiographic coronary artery disease after heart transplantation were classified according to early (≤2 years) versus late (>2 years) posttransplantation initial detection of coronary artery disease. These subgroups were analyzed for differences in clinical and laboratory demographics, incidence of progression to ischemic events and incidence of antecedent cytomegalovirus infection.Results. The early-onset group (64 patients) had more rapid progression to ischemic events than the late-onset group (75 patients), with 59% of the late group and only 35% of the early group free from ischemic events by 5 years after initial detection (p = 0.02), but there were no significantly correlated clinical or laboratory predictors of ischemic events. The early group had a significantly higher incidence of antecedent cytomegalovirus infection.Conclusions. We conclude that 1) accelerated graft coronary artery disease develops at variable times after heart transplantation; 2) the early appearance of graft coronary artery disease may be a marker of intrinsically more aggressive disease; 3) cytomegalovirus infection is associated with earlier onset of graft coronary artery disease. Patients with early development of graft coronary artery disease should potentially be given priority for interventional strategies as they are developed

Self-management skills in adolescents with chronic rheumatic disease: A cross-sectional survey

<p>Abstract</p> <p>Background</p> <p>For adolescents with a diagnosis of lifelong chronic illness, mastery of self-management skills is a critical component of the transition to adult care. This study aims to examine self-reported medication adherence and self-care skills among adolescents with chronic rheumatic disease.</p> <p>Methods</p> <p>Cross-sectional survey of 52 adolescent patients in the Pediatric Rheumatology Clinic at UCSF. Outcome measures were self-reported medication adherence, medication regimen knowledge and independence in health care tasks. Predictors of self-management included age, disease perception, self-care agency, demographics and self-reported health status. Bivariate associations were assessed using the Student's t-test, Wilcoxon rank sum test and Fisher exact test as appropriate. Independence in self-management tasks were compared between subjects age 13-16 and 17-20 using the chi-squared test.</p> <p>Results</p> <p>Subjects were age 13-20 years (mean 15.9); 79% were female. Diagnoses included juvenile idiopathic arthritis (44%), lupus (35%), and other rheumatic conditions (21%). Mean disease duration was 5.3 years (SD 4.0). Fifty four percent reported perfect adherence to medications, 40% reported 1-2 missed doses per week, and 6% reported missing 3 or more doses. The most common reason for missing medications was forgetfulness. Among health care tasks, there was an age-related increase in ability to fill prescriptions, schedule appointments, arrange transportation, ask questions of doctors, manage insurance, and recognize symptoms of illness. Ability to take medications as directed, keep a calendar of appointments, and maintain a personal medical file did not improve with age.</p> <p>Conclusions</p> <p>This study suggests that adolescents with chronic rheumatic disease may need additional support to achieve independence in self-management.</p