Long-term outcome with the automatic implantable cardioverter-defibrillator

AbstractThe automatic implantable cardioverter-defibrillator was implanted in 270 patients because of life-threatening arrhythmias over a 7 year period. There was a history of sustained ventricular tachycardia or fibrillation, or both, in 96% of these patients, 80% had one or more prior cardiac arrests and 78% had coronary artery disease as their underlying diagnosis. The average ejection fraction was 34%, and 96% of these patients had had an average of 3.4 antiarrhythmic drug failures per patient before defibrillator implantation. There were four perioperative deaths and eight patients had generator infection or generator erosion, or both, during the perioperative period or during long-term follow-up. Concomitant antiarrhythmic drug therapy was given to 69% of patients.Shocks from the device were given to 58% of patients, and 20% received “problematic” shocks. The device was removed from 16 patients during long-term follow-up for a variety of reasons. There were 7 sudden cardiac deaths and 30 nonsudden cardiac deaths, 18 of which were secondary to congestive heart failure. The actuarial incidence of sudden death, total cardiac death and total mortality from all causes was 1%, 7% and 8%, respectively, at 1 year, and 4%, 24% and 26% at 5 years.The automatic implantable cardioverter-defibrillator nearly eliminates sudden death over a long-term follow-up period in a high risk group of patients. It has an acceptable rate of complications or problems, or both, and most late deaths in these patients are nonsudden and of cardiovascular origin

Effects of Once-Weekly Exenatide on Cardiovascular Outcomes in Type 2 Diabetes.

Abstract BACKGROUND: The cardiovascular effects of adding once-weekly treatment with exenatide to usual care in patients with type 2 diabetes are unknown. METHODS: We randomly assigned patients with type 2 diabetes, with or without previous cardiovascular disease, to receive subcutaneous injections of extended-release exenatide at a dose of 2 mg or matching placebo once weekly. The primary composite outcome was the first occurrence of death from cardiovascular causes, nonfatal myocardial infarction, or nonfatal stroke. The coprimary hypotheses were that exenatide, administered once weekly, would be noninferior to placebo with respect to safety and superior to placebo with respect to efficacy. RESULTS: In all, 14,752 patients (of whom 10,782 [73.1%] had previous cardiovascular disease) were followed for a median of 3.2 years (interquartile range, 2.2 to 4.4). A primary composite outcome event occurred in 839 of 7356 patients (11.4%; 3.7 events per 100 person-years) in the exenatide group and in 905 of 7396 patients (12.2%; 4.0 events per 100 person-years) in the placebo group (hazard ratio, 0.91; 95% confidence interval [CI], 0.83 to 1.00), with the intention-to-treat analysis indicating that exenatide, administered once weekly, was noninferior to placebo with respect to safety (P<0.001 for noninferiority) but was not superior to placebo with respect to efficacy (P=0.06 for superiority). The rates of death from cardiovascular causes, fatal or nonfatal myocardial infarction, fatal or nonfatal stroke, hospitalization for heart failure, and hospitalization for acute coronary syndrome, and the incidence of acute pancreatitis, pancreatic cancer, medullary thyroid carcinoma, and serious adverse events did not differ significantly between the two groups. CONCLUSIONS: Among patients with type 2 diabetes with or without previous cardiovascular disease, the incidence of major adverse cardiovascular events did not differ significantly between patients who received exenatide and those who received placebo. (Funded by Amylin Pharmaceuticals; EXSCEL ClinicalTrials.gov number, NCT01144338 .)

Transvenous catheter ablation of extranodal accessory pathways

AbstractTwelve patients with an accessory pathway and recurrent symptomatic reciprocating tachycardia or atrial fibrillation, or both, underwent attempted transvenous catheter ablation of the accessory pathway. In one patient with a small right coronary artery, the pathway was along the right free wall. In 11 patients, the pathway was located at or within 15 mm of the coronary sinus os. For these patients, a quadripolar electrode catheter was placed in the coronary sinus and positioned, if possible, so that the proximal pair of electrodes straddled the pathway. For those patients with a pathway > 5 mm within the coronary sinus, the most proximal electrode was placed at the os. This proximal pair of electrodes was connected to the cathodal output of a defibrillator with an anterior chest wall patch serving as the current sink. Two shocks were then delivered for a cumulative energy of 500 to 600 J (stored energy).Among the eight patients with a pathway at or within 5 mm of the coronary sinus os, conduction over the pathway was abolished in five and modified in one. Among the four patients with a pathway farther from the os (10 to 15 mm) and along the right free wall, pathway conduction was modified only in two. Rupture of the coronary sinus did not occur in any patient. There were no serious complications. Minor damage surrounding the area of ablation was seen at the time of surgical division of the accessory pathway in two of five patients with unsuccessful ablation who subsequently underwent surgery.Transvenous catheter ablation of accessory pathways appears to be a safe and reasonably effective alternative to surgery for those patients with a pathway at or near the coronary sinus os, but not for those with a pathway farther from the septum. Although subsequent intraoperative mapping was more difficult because of the loss of large, discrete atrial electrograms, surgical division was successful in all five patients after unsuccessful catheter ablation

Upper-Extremity Injuries Have the Poorest Return to Play and Most Time Lost in Professional Baseball: A Systematic Review of Injuries in Major League Baseball

PURPOSE: To summarize the incidence of injuries occurring in professional baseball and compare player outcomes reported in the literature. METHODS: We conducted a systematic review using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines across 3 databases (PubMed, MEDLINE, Embase). Inclusion criteria were studies of injury incidences and/or injury outcomes on active Major League Baseball (MLB) athletes and studies published in the English language. Exclusion criteria were non-MLB players, case series and case report studies with a cohort of ≤3 players, and/or review articles. RESULTS: A total of 477 articles were identified from the initial search of 3 databases, with 105 studies meeting inclusion criteria. Among these articles, the most common injuries studied were elbow (38%), shoulder (14%), hip/groin (11%), hand/wrist (7%), head/face (7%), knee (7%), spine (5%), and foot/ankle (3%). Injuries with the greatest incidence included hand/wrist (150.3 per year), hamstring (7.8-73.5 per year), ulnar collateral ligament (UCL) tears (0.23-26.8 per year), gastrocnemius strains (24.2 per year), and concussions (3.6-20.5 per year). Lowest rates of return to play were seen following shoulder labral tears (40%-72.5%), rotator cuff tears (33.3%-87%), and UCL tears (51%-87.9%). The injuries leading to most time away from sport included elbow UCL tears (average 90.3 days treated nonoperatively to 622.8 days following revision reconstruction), shoulder labral tears (average 315-492 days), and anterior cruciate ligament (ACL) tears (average 156.2-417.5 days). Following ACL tears, rotator cuff tears, shoulder labral tears, and hip femoroacetabular impingement requiring arthroscopy, athletes had a significantly lower workloads compared with before injury upon return to play. CONCLUSIONS: Most published investigations focus on elbow injuries of the UCL, with variable return to play and mixed performance following surgery. UCL tears, shoulder labral tears, and ACL tears result in the most missed time. Upper-extremity injury such as shoulder labral tears, rotator cuff tears, and UCL tears had the poorest return to play rates. Workload was most affected following ACL reconstruction, rotator cuff repair, shoulder labral repair, and hip arthroscopy for femoroacetabular impingement. LEVEL OF EVIDENCE: IV, systematic review of level II-IV studies

Autologous pericardium versus a xenograft substitute in myocardial wound healing

This study compared repair of myocardial wounds covered with autologous pericardium to healing of wounds covered with gluteraldehyde-preserved bovine pericardium in an experimental canine model. Right (RV) and left (LV) full thickness ventriculotomies were made and closed. In the control group (n = 12), the pericardium was closed over the wound; in the experimental group (n = 12), wounds were covered with bovine pericardium. Animals were sacrificed at 14, 21, 28, and 42 days. After excising the pericardium, 6 mm punch biopies of normal RV, RV wound, normal LV, and LV wound were assayed for hydroxyproline (HPro). Both autologous and bovine pericardium became densely adherent to the wounds. Bovine pericardium was mildly adherent over unwounded areas, while autologous pericardium was usually free. Normal RV contained more than twice as much HPro as normal LV (5.4 ± 0.57 μg/mg vs 1.7 ± 0.35 μg/mg, P \u3c 0.0002). A gradual rise in HPro over time was seen in both groups, but this increase was statistically significant only at 42 days (P \u3c 0.05). There was no significant difference in HPro between wounds covered with autologous pericardium and those covered with bovine grafts (P = 0.13) at any of the sample times in this study. In this experimental canine model, the pericardium does not appear to play a prominent role in myocardial wound healing by contributing collagen-producing fibroblasts. Furthermore, the bovine pericardial xenograft becomes densely adherent to LV and RV incisions. In the clinical setting, such may make reoperation more hazardous when the heart has been previously incised or coronary bypass grafts have been constructed. © 1986