Acute Care Physical and Occupational Therapy Early Intervention Pathway After Transcatheter Aortic Valve Replacement: A Retrospective Study

Purpose: Transcatheter aortic valve replacement (tAVR) has emerged as a less-invasive alternative to traditional surgical aortic valve replacement. The purpose of this study was to examine the effect of a novel clinical pathway with an emphasis on early physical therapy and occupational therapy on patients undergoing tAVR in the acute care setting. Methods: A retrospective study was conducted involving 189 patients who underwent tAVR. The control group (n = 74) included patients who underwent tAVR prior to the implementation of the pathway. The intervention group (n = 115) included patients who underwent tAVR following the implementation of the pathway. Inpatient length of stay and discharge disposition were measured. Results: No differences in demographics or clinical variables were found; for example, mean age was 79.5 ± 11.2 years, with 57% male in the control group versus 81.6 ± 8.4 years and 59% male in the intervention group. Length of stay was significantly lower in the intervention group (control 6.9 ± 5.4 days, intervention 4.8 ± 5.4 days,P = .009) and significantly shorter length of stay postprocedure (control 4.8 ± 2.9 days, intervention 3.5 ± 4.0, P= .015). The incidence of the patient\u27s discharge disposition to home increased from 77% of patients in the control group to 86% of patients in the intervention group but was not statistically significant (P = .118). Conclusions: A clinical pathway specific to patients post-tAVR provided early mobility, targeted education, individualized functional goals, and discharge disposition recommendations. Patients in the intervention group experienced reduced hospital length of stay

Caval-Aortic Access to Allow Transcatheter Aortic Valve Replacement in Otherwise Ineligible Patients Initial Human Experience

ObjectivesThis study describes the first use of caval-aortic access and closure to enable transcatheter aortic valve replacement (TAVR) in patients who lacked other access options. Caval-aortic access refers to percutaneous entry into the abdominal aorta from the femoral vein through the adjoining inferior vena cava.BackgroundTAVR is attractive in high-risk or inoperable patients with severe aortic stenosis. Available transcatheter valves require large introducer sheaths, which are a risk for major vascular complications or preclude TAVR altogether. Caval-aortic access has been successful in animals.MethodsWe performed a single-center retrospective review of procedural and 30-day outcomes of prohibitive-risk patients who underwent TAVR via caval-aortic access.ResultsBetween July 2013 and January 2014, 19 patients underwent TAVR via caval-aortic access; 79% were women. Caval-aortic access and tract closure were successful in all 19 patients; TAVR was successful in 17 patients. Six patients experienced modified VARC-2 major vascular complications, 2 (11%) of whom required intervention. Most (79%) required blood transfusion. There were no deaths attributable to caval-aortic access. Throughout the 111 (range 39 to 229) days of follow up, there were no post-discharge complications related to tract creation or closure. All patients had persistent aorto-caval flow immediately post-procedure. Of the 16 patients who underwent repeat imaging after the first week, 15 (94%) had complete closure of the residual aorto-caval tract.ConclusionsPercutaneous transcaval venous access to the aorta allows TAVR in otherwise ineligible patients, and may offer a new access strategy for other applications requiring large transcatheter implants

Strategies for a Successful PhD Program: Words of Wisdom From the \u3cem\u3eWJNR\u3c/em\u3e Editorial Board

Nursing doctoral programs prepare students for research-focused careers within academic settings. The purpose of this Editorial Board Special Article is to provide PhD students and advisors with suggestions for making the most of their doctoral experience. Editorial Board members provide their individual insights on the skills and attributes students must acquire during the course of their doctoral education in order to succeed. The authors provide practical tips and advice on how to excel in a PhD program, including how to select an advisor and a dissertation committee, the importance of attending conferences to increase visibility and develop a network of colleagues, presenting and publishing research while still a student, and balancing work and personal life. Students who take full advantage of the opportunities available to them during the course of their doctoral programs will graduate well prepared to take on the multiple responsibilities of research, teaching, and leadership

Procedural and Mid-Term Outcomes of Coronary Protection During Transcatheter Aortic Valve Replacement in Patients at Risk of Coronary Occlusion: Insight From a Single-Centre Retrospective Analysis

BACKGROUND: Detailed procedural analysis and long-term data is limited for coronary protection (CP) during transcatheter aortic valve replacement (TAVR) for patients with high anatomical risk for coronary occlusion (CO). We aim to assess the procedural and mid-term outcomes of CP during TAVR. METHODS: We retrospectively analyzed patients who underwent TAVR at Henry Ford Hospital, USA from January 2015 to August 2019 and identified those considered at risk of CO and underwent pre-emptive CP with or without subsequent chimney stenting (i.e. coronary stenting with intentional protrusion into the aorta). Procedural features, immediate and mid-term clinical outcomes were reviewed. RESULTS: Twenty-five out of 1166 (2.1%) patients underwent TAVR with CP, including 10 (40%) valve-in-valve procedures. Twenty-eight coronary arteries (Left: n = 11, Right: n = 11; Left + Right: n = 3) were protected. Eleven coronaries (39.3%) were electively chimney -stented due to angiographic evidence of coronary impingement (63.6%), tactile resistance while withdrawing stent (27.3%) and electrocardiogram change (9.1%). Twenty-four patients (24/25, 96%) had successful TAVR without CO. Procedure-related complications included stent-balloon entrapment (n = 1), stent entrapment (n = 1) and occlusive distal stent edge dissection (n = 1). After a mean follow-up of 19.1 months, there was 1 cardiac death but no target vessel re-intervention or myocardial infarction. CONCLUSIONS: Our study found that angiographic evidence of coronary impingement (63.6%) was the most common reason for stent deployment during TAVR with CP. The mid-term clinical outcome of CP with TAVR was favorable

INITIAL EXPERIENCE WITH LITHOTRIPSY FOR MITRAL BALLOON VALVULOPLASTY

Background: Mitral annular calcification (MAC) causes degeneration of the mitral valve function. Since these patients are poor surgical candidates, options are limited to percutaneous solutions. Use of balloon lithotripsy (BL) to augment mitral balloon valvuloplasty (MBV) is a novel technique for treatment of MAC-related mitral stenosis (MS). Methods: Single-center retrospective review of 35 consecutive MBV for MAC cases at Henry Ford from 3/2013 to 4/2021. Outcome variables are reported as median and interquartile ranges (IQR). Chi-squared and Wilcoxon-signed rank tests were used to compare categorical and continuous variables respectively using 95% confidence intervals for statistical significance. Procedural success was defined as a final mitral valve area ≥1.5 cm2 or ≥50% reduction in gradient. Results: Of 35 MBV cases done for MAC, 5 utilized lithotripsy balloons to augment valvuloplasty results (Table). Mean baseline gradients were similar and right ventricular systolic pressures trended higher for BL cases. Cases utilizing lithotripsy were longer and utilized more fluoroscopy time but the final invasive gradient trended lower (non-BL 7mmHg [4, 9] vs. BL 1 mmHg [0,5] p=0.113), therefore, higher rates of procedural success were seen (non-BL 47% vs. BL 80%, p=0.2). Survival analysis was hampered due to loss of follow-up in the BL group. Conclusion: BL appears to augment immediate valvuloplasty results. Further studies regarding the durable impact of balloon lithotripsy on MBV are warranted

SURVIVAL OF PATIENTS WITH RHEUMATIC AND NON-RHEUMATIC MITRAL VALVE STENOSIS AFTER VALVULOPLASTY

Background: Non-rheumatic (NR) mitral stenosis (MS) due to mitral annular calcification (MAC) presents in elderly patients and is difficult to treat due elevated surgical risk. In search for alternative treatments, mitral balloon valvuloplasty (MBV) has been performed in non-rheumatic mitral stenosis but no outcomes have been described in this cohort. Methods: Single center retrospective review of 85 consecutive MBV cases at Henry Ford from 3/2013 to 4/2021. Clinical and procedural outcome variables are reported as median and interquartile ranges (IQR). Kaplan-Meier method was used to estimate survival. Chi-squared and Wilcoxon-signed rank tests were used to compare categorical and continuous variables respectively using 95% confidence intervals for statistical significance. Results: Of 85 MBV cases, 50 and 35 were performed for rheumatic (R) and NR MS respectively. NR patients tended to be older and were more likely to have hypertension, diabetes, coronary artery disease, chronic kidney disease, aortic valve procedures. Rates of ≥moderate-severe mitral regurgitation (MR) (R 18% vs. NR 12% p=0.4) and procedure success (R 57% vs NR 42.9% p=0.2) were similar. Median follow up for the entire cohort was 0.5 yrs [0.1, 2.1]. Survival was significantly better for rheumatic cases (Figure). Conclusion: Survival of NR MS post-valvuloplasty is significantly attenuated as compared to those with R MS. Larger prospective studies are necessary in understanding optimal bridging therapies for patients with MAC

Finishing the euchromatic sequence of the human genome

The sequence of the human genome encodes the genetic instructions for human physiology, as well as rich information about human evolution. In 2001, the International Human Genome Sequencing Consortium reported a draft sequence of the euchromatic portion of the human genome. Since then, the international collaboration has worked to convert this draft into a genome sequence with high accuracy and nearly complete coverage. Here, we report the result of this finishing process. The current genome sequence (Build 35) contains 2.85 billion nucleotides interrupted by only 341 gaps. It covers ∼99% of the euchromatic genome and is accurate to an error rate of ∼1 event per 100,000 bases. Many of the remaining euchromatic gaps are associated with segmental duplications and will require focused work with new methods. The near-complete sequence, the first for a vertebrate, greatly improves the precision of biological analyses of the human genome including studies of gene number, birth and death. Notably, the human enome seems to encode only 20,000-25,000 protein-coding genes. The genome sequence reported here should serve as a firm foundation for biomedical research in the decades ahead

Rates of anticoagulation following transcatheter aortic valve replacement in patients with atrial fibrillation

Background: Late strokes have been observed to occur in high rates post-transcatheter aortic valve replacement (TAVR). Atrial fibrillation (AF) is a common co-morbidity in TAVR patients, but anticoagulation is problematic due to age or frailty in this population. Our aim was to assess the quality of anticoagulation in TAVR patients with atrial fibrillation. Methods: In a single center retrospective study, we analyzed 500 patients who underwent TAVR. Patient characteristics and discharge medications were evaluated in the TAVR cohort with AF. Results: A signifcant portion of patients who underwent TAVR had atrial fibrillation (36.8%), with a mean CHADS2VASC of 5.8 + 1.2 and HAS-BLED of 3.4 + 0.1. Patient demographics (Table 1) were well matched aside from a higher rate of prior CABG in the AF cohort. Discharge anticoagulant medication regimen post-TAVR (Table 2) noted higher rates of warfarin prescriptions in AF patients, however only 50.2% of TAVR patients with AF were discharged on oral anticoagulation. The rates of anticoagulation were not related to bleeding risk according to HAS-BLED scores (p=NS). Conclusion: Atrial fibrillation is a common problem in patients undergoing TAVR. In our population, approximately half of patients with AF were not discharged on anticoagulation post-TAVR and rates of anticoagulation were not related to risk of bleeding. Barriers to prescribing oral anticoagulation thromboprophylaxis for atrial fibrillation in TAVR patients should be further investigated

Long-term outcomes of transcatheter mitral valve replacement using a balloon expandable valve

Background Transcatheter mitral valve replacement (TMVR) using commercially available balloon expandable valves via a percutaneous, transseptal access has previously been reported but only short-term outcomes have been discussed. Long-term outcomes of this percutaneous strategy should be elucidated. Methods From 1/2013-12/2018, retrospective review of all percutaneous TMVR using the Edwards Lifesciences, Sapien family of valves was reviewed. Clinical characteristics, procedure outcomes, and ambulatory clinic interactions were abstracted. Survival according to procedure type (valve-in-valve (ViV), valve-in-ring (ViR) and valve-in-mitral annuluar calcification (ViMAC)) was calculated using the Kaplan-Meier (KM) method. Results A total of 65 TMVR cases were performed between 2013-2018, some as part of the MITRAL trial. Using KM analysis, the 2 year survival approximates 50% and by 5 years, almost all of the patients have died (p=0.2579). Conclusion Despite the relatively lower risk of ViV procedures, this population did exhibit survival advantages compared to ViR and ViMAC. The TMVR population is a sick elderly cohort and this series bears the limitations of retrospective research and observations of the early learning curve of performing a complex procedure. Further investigation is warranted to better select patients

Death penalty: the political foundations of the global trend toward abolition

The death penalty is like no other punishment. Its continued existence in many countries of the world creates political tensions within these countries and between governments of retentionist and abolitionist countries. After the Second World War, more and more countries have abolished the death penalty. This article argues that the major determinants of this global trend toward abolition are political, a claim which receives support in a quantitative cross-national analysis from 1950 to 2002. Democracy, democratization, international political pressure on retentionist countries and peer group effects in relatively abolitionist regions all raise the likelihood of abolition. There is also a partisan effect as abolition becomes more likely if the chief executive’s party is left-wing oriented. Cultural, social and economic determinants receive only limited support. The global trend toward abolition will go on if democracy continues to spread around the world and abolitionist countries stand by their commitment to press for abolition all over the world.