- 作者列表："Kundi H","Noseworthy PA","Valsdottir LR","Shen C","Yao X","Yeh RW","Kramer DB
:Catheter ablation for atrial fibrillation (AF) improves outcomes compared with medical treatment alone. Risk stratification for outcomes following AF ablation remains an important area of uncertainty. This analysis evaluated the association between frailty and outcomes following AF ablation. We evaluated US inpatients receiving AF ablation between January 1, 2016 and December 1, 2016 using Medicare fee-for-service billing codes. Diagnosis codes were used to calculate patients' Hospital Frailty Risk Score, with the cohort divided according to established cut-points of low (<5), intermediate (5 to 15), and high (>15) risk for frailty. The primary outcome was survival. Among 5,070 in patients treated with catheter ablation (mean age 74.9 ± 6.8 years, 51.1% female), 38.6% were defined as frail with a Hospital Frailty Risk Score >5, including 8.3% at high risk. Mortality rates (up to 630 days) were 5.8% in the low-risk group, 23.4% in the intermediate-risk group, and 42.2% in the high-risk group (log-rank p values <0.001 for comparison between categories). In restricted cubic spline regression analysis, the adjusted hazard ratios for long-term mortality monotonically increased with increasing values of the Hospital Frailty Risk Score (adjusted hazard ratio 1.065, 95% confidence interval 1.054 to 1.077). In secondary end points, frailty was independently associated with length of stay, postprocedure 30-day mortality, 30-day readmission and postdischarge 30-day mortality rates. In conclusion, frailty as assessed by a claims-based score is common in inpatient recipients of AF ablation, and provides risk stratification for mortality and other key clinical outcomes.
: 导管消融治疗心房颤动 (AF) 与单独药物治疗相比改善预后。房颤消融术后结局的风险分层仍然是一个重要的不确定性领域。该分析评估了虚弱与AF消融后结果之间的相关性。我们使用Medicare收费服务账单代码评估了2016年1月1日至20 16年12月1日期间接受AF消融的美国住院患者。诊断代码用于计算患者的医院虚弱风险评分，队列根据确定的虚弱风险的低 (<5) 、中 (5至15) 和高 (>15) 切点进行划分。主要结局是生存。在接受导管消融治疗的5,070例患者 (平均年龄74.9 ± 6.8岁，51.1% 为女性) 中，38.6% 被定义为医院虚弱风险评分> 5的虚弱者，包括8.3% 的高风险者。低危组的死亡率 (高达630天) 为5.8%，中危组为23.4%，高危组为42.2% (类别间比较的对数秩p值 <0.001).在限制性三次样条回归分析中，调整后的长期死亡率风险比随着医院虚弱风险评分值的增加而单调增加 (调整后的风险比为1.065，95% 置信区间为1.054 ~ 1.077).在次要终点中，虚弱与住院时间、术后30天死亡率、30天再入院和出院后30天死亡率独立相关。总之，通过基于索赔的评分评估的虚弱在房颤消融的住院患者中很常见，并为死亡率和其他关键临床结局提供了风险分层.
METHODS:BACKGROUND AND PURPOSE:The current left atrial appendage (LAA) classification system (cLAA-CS) categorizes it into 4 morphologies: chicken wing (CW), windsock, cactus, and cauliflower, though there is limited data on either reliability or associations between different morphologies and stroke risk. We aimed to develop a simplified LAA classification system and to determine its relationship to embolic stroke subtypes. METHODS:Consecutive patients with ischemic stroke from a prospective stroke registry who previously underwent a clinically-indicated chest CT were included. Stroke subtype was determined and LAA morphology was classified using the traditional system (in which CW = low risk) and a new system (LAA-H/L, in which low risk morphology (LAA-L) was defined as an acute angle bend or fold from the proximal/middle portion of the LAA and high risk morphology (LAA-H) was defined as all others). As a proof of concept study, we determined reliability for the two classification systems, and we assessed the associations between both classification systems with stroke subtypes in our cohort and previous studies. RESULTS:We identified 329 ischemic stroke patients with a qualifying chest CT (126 cardioembolic subtype, 116 embolic stroke of undetermined source (ESUS), and 87 non-cardioembolic subtypes). Intra- and inter-rater agreements improved using the LAA-H/L (0.95 and 0.85, respectively) vs. cLAA-CS (0.50 and 0.40). The LAA-H/L led to classifying 69 LAA morphologies that met criteria for CW as LAA-H. In fully adjusted models, LAA-H was associated with cardioembolic stroke (OR 5.4, 95%CI 2.1-13.7) and ESUS (OR 2.8 95% CI 1.2-6.4). Non-CW morphology was also associated with embolic stroke subtypes, but the effect size was much less pronounced. Studies using the cLAA-CS yielded mixed results for inter- and intra-rater agreements but most showed an association between a non-CW morphology and stroke with no difference among the three non-CW subtypes. CONCLUSION:The LAA-H/L classification system is simple, has excellent intra and inter-rater agreements, and may help risk identify patients with cardioembolic stroke subtypes. Larger studies are needed to validate these findings.
METHODS:PURPOSE:Low-molecular-weight heparins are currently the recommended antithrombotic therapy for treatment and prevention of malignancy-related venous thromboembolism. Currently, the evidence evaluating direct oral anticoagulants versus low-molecular-weight heparins or a vitamin K antagonist in cancer patients with hematologic malignancies is limited. We evaluated the safety and efficacy of direct oral anticoagulants for venous thromboembolism treatment or stroke prevention for non-valvular atrial fibrillation in patients with hematologic malignancies. METHODS:This was a retrospective evaluation of adult patients with hematologic malignancies who received at least one dose of the Food and Drug Administration-approved direct oral anticoagulant for venous thromboembolism treatment or stroke prevention. We determined the frequency of major bleeding events, non-major bleeding events, stroke, systemic embolism, appropriateness of initial direct oral anticoagulant doses, holding practices prior to procedures, and the rate of all-cause mortality. An analysis was also performed to compare the incidence of bleeding between patients with a history of hematopoietic stem cell transplant to non-transplant patients. RESULTS:A total of 103 patients were identified, with the majority of patients receiving rivaroxaban for venous thromboembolism treatment. Major bleeding events occurred in four patients and no fatal bleeding events occurred. Non-major bleeding occurred in 29 patients, most commonly epistaxis and bruising. Two patients experienced a systemic embolism while on direct oral anticoagulant therapy. CONCLUSION:Direct oral anticoagulants may be a safe and effective alternative for anticoagulation therapy in patients with hematologic malignancies. However, larger prospective studies comparing direct oral anticoagulants to low-molecular-weight heparins or vitamin K antagonists are warranted to compare efficacy and safety outcomes in this patient population.
METHODS::It has been over two decades since the very first robotic cardiac surgery was performed. Over the years, there has been an increase in the demand for less invasive cardiac surgical techniques. Developments in technology and engineering have provided an opportunity for robotic surgery to be applied to a variety of cardiac procedures, including coronary revascularisation, mitral valve surgery, atrial fibrillation ablation, and others. In coronary revascularisation, it is becoming more widely used in single vessel, as well as hybrid coronary artery approaches. Currently, several international centres are specialising in a totally endoscopic coronary artery bypass surgery involving multiple vessels. Mitral valve and other intracardiac pathologies such as atrial septal defect and intracardiac tumour are also increasingly being addressed robotically. Even though some studies have shown good results with robot-assisted cardiac surgery, there are still concerns about safety, cost and clinical efficacy. There are also limitations and additional challenges with the management of cardiopulmonary bypass and myocardial protection during robotic surgery. Implementing novel strategies to manage these challenges, together with careful patient selection can go a long way to producing satisfactory results. This review examines the current evidence behind robotic surgery in various aspects of cardiac surgery.