Citations

Background: Troponin-T (TnT) elevation is common in severe sepsis and septic shock, but the impact on mortality and other clinical outcomes remains uncertain. Methods: This was a retrospective review of adult patients with severe sepsis and septic shock admitted to all the intensive care units (ICU) at Mayo Clinic, Rochester from January 2012 to December 2014. Patients with congenital heart disease or pre-existing moderate or greater valvular disease were excluded. TnT elevation was defined as initial TnT ≥0.1 ng/mL or rise in 3- and 6-hour TnT ≥0.03 ng/mL. Primary outcomes included ICU, hospital, 28-day and 1-year mortality and secondary outcomes were need for and duration of non-invasive ventilation or invasive mechanical ventilation, ICU readmission, and ICU and hospital length of stay. Two-tailed p <0.05 was considered statistically significant. Results: During this three-year period, TnT was measured in 372/765 patients (49%) with septic shock with TnT elevation noted in 329/372 (88%) patients. In patients with and without TnT elevation, initial TnT was 0.14±0.26 vs. 0.14±0.02 ng/mL, p =0.57 and peak TnT was 0.20±0.36 vs. 0.08±0.11 ng/mL, p <0.001. Severity of illness scores, laboratory values, vasopressor use, clinical parameters and medications were similar between patients with and without TnT elevation, except that patients with TnT elevation were older and had more frequent history of coronary atherosclerosis, chronic kidney disease, heart failure and atrial fibrillation (all p <0.05). There was no significant difference in ICU mortality [43 (13%) vs. 8 (19%), p =0.34] and hospital mortality [75 (23%) vs. 12 (28%), p =0.45] between patients with and without TnT elevation. Long-term follow-up of 220/329 (67%) patients showed no significant difference in 28-day mortality [97/216 (45%) vs. 1/4 (25%); p =0.63] or 1-year mortality [163/216 (75%) vs. 4/4 (100%); p =0.58]. There was no significant difference in any of the secondary outcomes between patients with and without elevated TnT (all p >0.05). There was no difference in mortality with increasing quartiles of peak TnT. Conclusions: Troponin elevation is associated with older age and higher comorbidity burden, but does not predict mortality in patients with severe sepsis and septic shock.

Introduction: Limited data is available regarding the incidence of new-onset diabetes mellitus (NODM) after heart transplantation and it`s impact on patient survival. Hypothesis: Methods: From the United Network of Organ Sharing database (January 2004 to September 2014), we identified 13,353 patients without pre-operative diabetes mellitus undergoing heart transplantation. Multivariable Cox regression was implemented to determine predictors for the development of NODM. A matched cohort of New-onset Diabetes mellitus (NODM (+)) and NODM (-) was generated by 1:1 nearest neighbor propensity-matching. The association of NODM with long-term survival was then estimated with robust Cox regression. Results are presented at the 95% Confidence level; all tests are two-tailed. Results: During the study period, 1,921 of 13,353 (14%) developed NODM. Estimated freedom from NODM was 97% (96-98%) & 77% (76 - 78%) at the end of 1 and 5 years respectively. Predictors for the development of NODM were recipient age > 50 years (HR 1.2 95% CI1.05, 1.3; p < 0.01), recipient BMI > 30 (HR 1.4 95% CI1.2, 1.6; p < 0.01) and race (African American vs Caucasian (HR 1.3 95% CI1.2, 1.5; p < 0.01)). Cox-regression of a propensity-matched cohort of 1921 NODM+ve and NODM-ve recipient-pairs demonstrates that NODM is associated with poorer survival (HR for mortality: 1.3 95% CI 1.1, 1.5; p < 0.001). Conclusions: More than one in ten heart transplant recipients develop NODM post heart transplantation. Obesity, older age, and African American race patients to be at higher risk for NODM. New onset diabetes was independently associated with an almost 30% reduced long-term survival. More than one in ten heart transplant recipients develop NODM post heart transplantation. Obesity, older age, and African American race patients to be at higher risk for NODM. New onset diabetes was independently associated with an almost 30% reduced long-term survival.

Background: Left ventricle assist device (LVAD) support, a well established therapy in advanced CHF, improves renal function assessed by creatinine. While renal function in large numbers of continuous flow (CF) LVADs vs pulsatile flow (PF) LVADs has been evaluated at 3 mo., long term studies are needed with large numbers of CF vs PF devices. To date longer term analysis comparing renal function in CF vs PF devices have relied on a small number of CF devices. We evaluated renal function assessed by creatinine in a large number of CF (HM II) (n=119) devices and compared this to renal function in a group of subjects treated with PF devices (HM XVE) (n=8) at 6 mo. post implant. Our aim was to evaluate change in creatinine between 3 and 6 months in these groups. Methods and Results: Plasma creatinine was evaluated at 3 and 6 months in two groups: subjects with CF HM II (n=119) and PF LVAD (HM XVE, n=8). The data were collected from two centers in patients undergoing implant for destination or bridge to transplant therapy. Baseline creatinine was higher in the HM XVE group at baseline (BL), and decreased at 3 mo. (1.7 [1.1-2.1] vs 1.1 [0.8-1.5] mg/dL, p<0.05). BL creatine in the HM II group decreased at 3 mo as well (1.2 [1-1.5] vs 1.1 [0.9-1.3] mg/dL, p,0.05). Between 3 and 6 months there was no difference in degree of creatinine change in CF vs PF, however both groups had an increase in Creatinine in this time frame: PF (1.1 [0.8-1.5] vs 1.35 [1.05-1.9] mg/dL, p<0.05); CF (1.1 [0.9-1.3] vs 1.2 [0.92-1.4] mg/dL, p<0.05). Conclusion: This is the first study to demonstrate with large numbers of CF LVAD that creatinine does not incrementally increase between 3 and 6 mo. in comparison to PF LVAD. Further studies are required with large numbers of continuos flow LVADs evaluating the comparative effect of long term continuous flow vs pulsatile flow. Additionally, it remains important to identify surrogates of pulsatility in subjects with continuous flow devices and evaluate prognostic impact on renal function long term.

Introduction: In patients with coronary artery disease (CAD), mortality risk increases directly with central obesity (waist circumference [WC] or waist-hip ratio [WHR]) and inversely with BMI (“obesity paradox”). We hypothesized that CAD patients with normal BMI but centrally obese would have increased risk of death compared to other patterns of adiposity. Methods: We studied 15,923 subjects with established CAD who were part of 5 studies from 3 continents. We excluded 373 participants with BMI <18.5 Kg/m 2 and 3863 without either WC or WHR data. Subjects were divided in 6 categories based on BMI (normal, overweight or obese) and either WC or WHR (normal or high). Multivariate Cox-proportional hazard models adjusted for age, sex, BMI, hypertension, diabetes, smoking, heart failure, creatinine level and use of aspirin, beta-blockers, and inhibitors of the renin-angiotensin system assessed mortality risk according to different patterns of adiposity, using subjects with normal BMI and normal WC or WHR as reference. Results: Mean age was 65.7±11.0 yr, and 55% were men. There were 4699 deaths, median follow-up 4.7 years (IQR: 0.5 - 7.6 years). Results are summarized in the Table. Subjects with normal BMI but centrally obese had the worst long-term survival when compared to subjects with other patterns of adiposity. Furthermore, normal weight centrally obese subjects had 1.92 higher risk of dying than individuals with overweight BMI but normal WHR, and 1.63 higher mortality risk than subjects with obese BMI but normal WHR ( P <0.002 for both). Conclusions: Normal weight with central obesity, a body morphology pattern often clinically dismissed, is associated with the highest mortality in patients with CAD, especially when compared to individuals considered overweight or obese but without central obesity. An adverse metabolic milieu or less attention to risk assessment/modification in the setting of normal weight central obesity may explain these findings.

Device infection is associated with increased mortality in cardiovascular implantable electronic device (CIED) recipients. However, published data regarding clinical predictors of mortality in patients with CIED infection are limited. In current investigation, we sought to identify patient and device-related factors associated with mortality in CIED infection cases. We performed a retrospective review of all cases of CIED infection admitted to Mayo Clinic Rochester from 1991 to 2008. Survival data were obtained from hospital medical records and United Sates Social Security Index. Key data regarding patient demographics, device features, comorbid conditions, clinical presentation, echocardiographic findings and management strategies were abstracted. Potential risk factors for short (30-day) and long-term mortality were analyzed using univariate and multivariable logistic and Cox proportional hazards regression models, respectively. 415 cases of CIED infection were identified from the institutional database. The mean duration of follow-up for the 243 patients who were alive at last follow-up was 6.9 years. In multivariable model, congestive heart failure (CHF, Odds ratio 9.31, 95% CI 2.08-41.67), chronic corticosteroid use (OR 4.04, 1.40-11.60) and presentation with CIED-related infective endocarditis (CIED-IE), (OR 5.6, 2.25-13.92) were associated with increased odds of short-term mortality. Independent predictors of long-term mortality on multivariable model included patients' age (hazard ratio for 10-year increase 1.2, 95% CI 1.06-1.36), CHF (HR 2.01, 1.42-2.86), metastatic malignancy (HR 5.99, 1.67-21.53), corticosteroid use (HR 1.97, 1.22-3.18), renal failure (HR 1.94, 1.37-2.74) and CIED-IE (HR 1.68, 1.17-2.41). Our investigation provides some novel insights into predictors of short- and long-term mortality in CIED infection cases. While comorbid conditions and immunocompromised host status were primary determinants of both short- and long-term mortality, complicated device infection (CIED-IE) is the only predictor that presents an opportunity for intervention where mortality may be reduced by early diagnosis and expedited device removal.

Thais Coutinho, 2011 Finalist and Presenting Author

Introduction: Long QT Syndrome (LQTS) is a potentially lethal, but highly treatable cardiac channelopathy. Current treatment options include pharmacotherapy (mostly beta blockers), device therapy (mostly implantable cardioverter defibrillators (ICDs)), and/or left cardiac sympathetic denervation (LCSD) with the majority of patients requiring only beta blocker therapy. However, beta blockers are not without side effects and beta blocker intolerance can have a profoundly negative effect on a patient's quality of life. Heretofore, a prophylactic ICD has been utilized for the patient with LQTS who can not tolerate high dose beta blocker therapy. Here we examined the role of a prophylactic LCSD rather than an ICD for the LQTS patient with beta blocker intolerance. Methods: In this IRB-approved study, we retrospectively reviewed the electronic medical record for 58 patients (28 male (48%), mean age at diagnosis 9.6 ± 9 years (yrs), mean baseline QTc 524 ± 73 ms, 93% genotype positive) with LQTS who underwent LCSD at our institution from November 2005 through May 2011 (mean age at LCSD 14.0 ± 9.8 yrs). Results: Out of 58, 19 patients (33%; 15 female (79%) had LCSD as primary prevention because of beta blocker intolerance and were older at LQTS diagnosis (15.1 ± 8 vs 7.0 ± 9 yrs;.p=0.001), older at LCSD (20.5 ± 8 vs 10.9 ± 9 yrs; p<0.001), and had a shorter baseline QTc (493 ± 32 vs 539 ± 82 ms; p = 0.004) compared to the other 38 patients. Post-LCSD, 5/19 (26 %) had QTc-shortening of >30ms. With an average follow-up of 1.3 ± 0.8 yrs, none of these patients have experienced a post-LCSD cardiac event even though 7/19 (37%) had at least 1 LQTS-associated cardiac event. Qualitatively, there has been a dramatic improvement in quality of life following LCSD with subsequent decrease in beta blocker dose in 13 or discontinuation of beta blockers altogether in 5. Conclusions: Prophylactic LCSD may provide a beta blocker-reducing or even sparing strategy without increasing risk in carefully selected patients. However, LCSD should not be viewed as curative or an ICD-alternative for high-risk patients. Among appropriately selected patients who are failing to tolerate beta blocker therapy, LCSD may be an acceptable, quality of life improving alternative to an ICD and its associated comorbidities.

AbstractUse of magnetic resonance (MR) imaging in radiation therapy has increased substantially in recent years as more radiotherapy centers are having MR simulators installed, requesting more time on clinical diagnostic MR systems, or even treating with combination MR linear accelerator (MR‐linac) systems. With this increased use, to ensure the most accurate integration of images into radiotherapy (RT), RT immobilization devices and accessories must be able to be used safely in the MR environment and produce minimal perturbations. The determination of the safety profile and considerations often falls to the medical physicist or other support staff members who at a minimum should be a Level 2 personnel as per the ACR. The purpose of this guidance document will be to help guide the user in making determinations on MR Safety labeling (i.e., MR Safe, Conditional, or Unsafe) including standard testing, and verification of image quality, when using RT immobilization devices and accessories in an MR environment.

AbstractThis joint ASGE-ESGE guideline provides an evidence-based summary and recommendations regarding the role of endoscopic bariatric and metabolic therapies (EBMTs) in the management of obesity. The document was developed using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) framework. It evaluates the efficacy and safety of EBMT devices and procedures that currently have CE mark or FDA-clearance/approval, or that had been approved within five years of document development. The guideline suggests the use of EBMTs plus lifestyle modification in patients with a BMI of ≥30 kg/m2, or with a BMI of 27.0–29.9 kg/m2 with at least 1 obesity-related comorbidity. Furthermore, it suggests the utilization of intragastric balloons and devices for endoscopic gastric remodeling (EGR) in conjunction with lifestyle modification for this patient population.