Higher Incidence Of In-hospital Complications Research Articles

Comparison of Guillain-Barre Syndrome Cases during and Prior to the COVID-19 Pandemic: A Multicentric Study.

Guillain-Barre syndrome (GBS) is one of the most common neurological manifestations associated with severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infection. Although data for a strong causal association is lacking, anecdotal reports, case series and systematic reviews linking the two have emerged in the literature. This prompted us to compare the clinical features, electrophysiology, and outcomes of GBS cases presenting during the pandemic with cases reported during a similar time period prior to the pandemic. Prospective data of GBS cases diagnosed as per the National Institute of Neurological Disorders and Stroke (NINDS) criteria was collected for a 6-month period (July-December 2021) at three tertiary care teaching hospitals during the coronavirus pandemic and compared with retrospective records-based data of cases prior to the pandemic (January-July 2019). A total of 40 cases were included in the cases, out of which 17 were in the prepandemic and 23 in the postpandemic period. A total of three cases temporally related to coronavirus disease 2019 (COVID-19) infection and four cases following COVID-19 vaccination were seen in the pandemic cohort. The clinical features, electrophysiological features, and outcomes were comparable during both periods. A slightly higher rate of in-hospital complications and single mortality was reported in the postpandemic period. The number of GBS hospital admissions, clinical presentation, electrodiagnostic features, and short-term outcomes did not differ significantly between the prepandemic and postpandemic periods; a slightly higher incidence of in-hospital complications was observed during the pandemic period. How to cite this article: Panicker P, R D, V AG, et al. Comparison of Guillain-Barre Syndrome Cases during and Prior to the COVID-19 Pandemic: A Multicentric Study. J Assoc Physicians India 2023;71(9):69-71.

Is Tocilizumab An Effective Therapy For Severe Covid-19: A Single Center Study.

The quest for effective therapies in Covid-19 continues. We compared the outcome of severe COVID-19 patients treated with and without Tocilizumab, an IL-6 inhibitor. This is a prospective cohort study on the clinical characteristics and outcomes of patients with Covid-19 patients admitted at The Indus Hospital and Health Network, Karachi between 24th March and 19th June 2020. Adult patients who received TCZ were compared with respect to mortality and days of hospitalization with those who did not. A total of 88 patients including 41 patients in the TCZ group and 47 in non-TCZ group were recruited. Baseline demographic characteristics were comparable. TCZ group patients presented with worse clinical features including median SpO2 82% vs 88%, p<0.05 and CRP 193 vs 133.9 mg/L, p<0.05. Approximately, 85.4% were admitted in ICU compared to 69.8% in non-TCZ group, p>0.05. Mortality was not different among the groups (46% in TCZ group vs 51.1% in non-TCZ group, p>0.05). Median length of hospital stays, days of intubation, use of inotropic agents, and use of invasive ventilation or in-hospital complications were similar between the groups. Sub-group analysis revealed that mortality within TCZ group was associated with high IL-6 levels (173 vs 69.66 pg/ml, p<0.05), ICU admission (100% vs 72%, p<0.05), need for mechanical ventilation (100% vs 13.6%, p<0.05) and higher incidence of in-hospital complications, p<0.05. TCZ failed to demonstrate any mortality benefit in our patients. Non-survivors within the TCZ group were more critical compared to survivors and developed more in hospital complications.

Sex Difference in Outcomes Following Transcatheter Aortic Valve Replacement in Bicuspid Aortic Stenosis.

It is unknown whether the sex difference whereby female transcatheter aortic valve replacement (TAVR) candidates had a lower risk profile, a higher incidence of in-hospital complications, but more favorable short-and long-term survival observed in tricuspid cohorts undergoing TAVR would persist in patients with bicuspid aortic valves(BAVs). The aim of this study was to reexamine the impact of sex on outcomes following TAVR in patients withBAVs. In this single-center study, patients with BAVs undergoing TAVR for severe aortic stenosis from 2012 to 2021were retrospectively included. Baseline characteristics, aortic root anatomy, and in-hospital and 1-year valve hemodynamic status and survival were compared between sexes. A total of 510 patients with BAVs were included. At baseline, women presented with fewer comorbidities. Men had a greater proportion of Sievers type 1 BAV, higher calcium volumes (549.2 ± 408.4mm3 vs 920.8 ± 654.3mm3; P< 0.001), and larger aortic root structures. Women experienced more vascular complications (12.9% vs 4.9%; P=0.002) and bleeding (11.1% vs 5.3%; P=0.019) and higher residual gradients (16.9 ± 7.7mmHg vs 13.2±6.4mmHg; P< 0.001), while men were more likely to undergo second valve implantations during index TAVR (6.3%vs15.9%; P=0.001). Death at 1 year was not significantly different between sexes (HR: 1.15; 95%CI: 0.56-2.35; P=0.70). Bleeding (adjusted HR: 4.62; 95%CI: 1.51-14.12; P=0.007) was the single independent predictor of 1-year death for women. In patients with BAVs undergoing TAVR, women presented with fewer comorbidities, while men had a greater proportion of type 1 BAV, more calcification, and larger aortic roots. In-hospital outcomes favored men, with fewer complications except for the need for second valve implantation, but 1-year survival was comparable between sexes.

Influence of polyvascular disease on clinical outcome in patients undergoing transcatheter aortic valve implantation via transfemoral access.

BackgroundThe influence of polyvascular disease (PVD) on the short- and long-term clinical outcomes of patients undergoing transcatheter aortic valve implantation via trans-femoral access (TF-TAVI) has not been fully elucidated.MethodsA total of 2167 patients from the Optimized CathEter vAlvular iNtervention-TAVI (OCEAN-TAVI) registry who underwent TF-TAVI was studied. PVD was defined as the presence of at least two of the following vascular bed (VB) diseases: concomitant coronary artery disease (CAD), cerebrovascular disease (CVD), and peripheral artery disease (PAD).ResultsPatients with PVD (288 patients, 13.3%) had a higher incidence of in-hospital complications, such as AKI (16.3% vs. 7.0%, p<0.01) and disabling stroke (3.5% vs. 1.2%, p<0.01) than patients without PVD. These complications caused higher rates of procedural mortality (4.5% vs. 2.0%, p<0.01). PVD increased the risk of the 2-year rate of cardiovascular death (adjusted hazard ratio [HR], 1.61; 95% confidence interval [CI], 1.04–2.50; p<0.05); however, non-cardiovascular death, myocardial infarction, or ischemic stroke was not associated with PVD. Worsening heart failure (4.6% vs. 1.1%, p<0.01) was the main cause of cardiovascular death among patients with PVD. In a sub-analysis, compared with patients with AS alone, those with 2 VB diseases (CAD+PAD; adjusted HR, 1.93; 95% CI, 1.06–3.53; p<0.05) and 3 VB diseases (CAD+CVD+PAD; adjusted HR, 2.61; 95% CI, 1.21–5.62; p<0.05) had a higher risk of 2-year cardiovascular death.ConclusionsThe increased prevalence of concomitant atherosclerotic VB diseases before TF-TAVI may increase the rates of in-hospital complications and 2-year cardiovascular death. Given the higher rate of mortality in patients with PVD undergoing TF-TAVI, future studies focusing on medical therapy are needed to reduce long-term cardiovascular events in this high-risk subset.

Relation of Pain-to-Balloon Time and Mortality in Patients With ST-Segment Elevation Myocardial Infarction Undergoing Primary Percutaneous Coronary Intervention

Limited and inconsistent data are present regarding the importance of the time delay between symptom onset and balloon inflation in ST-segment elevation myocardial infarction (STEMI) patients. We aimed to investigate the possible influence of prolonging pain-to-balloon times (PBT) on in-hospital outcomes and mortality in a large cohort of patients with STEMI undergoing primary percutaneous coronary intervention. We retrospectively studied 2,345 STEMI patients (age 61 ± 13 years, 82% men) who underwent primary percutaneous coronary intervention. Patients were stratified according to PBT into 3 groups: ≤120 minutes, 121 to 360 minutes, and >360 minutes. Patients' records were assessed for the occurrence of in-hospital complications, 30-day, and 1-year mortality. Of the 2,345 study patients, 36% had PBT time ≤120 minutes, 40% had PBT of 121 to 360 minutes and 24% had PBT time >360 minutes. The major part of the total PBT (average 358 minutes) was caused by the time interval from symptom onset to hospital arrival, namely, pain-to-door time (average 312 minutes) in all 3 groups. Longer PBT was associated with a lower left ventricular ejection fraction, higher incidence of in-hospital complications, and higher 30-day mortality. In 2 multivariate cox regression models, a per-hour increase in PBT (hazard ratio 1.03 [95% confidence interval 1.00 to 1.06], p=0.039) as well as PBT >360 minutes (hazard ratio 1.6 [95% confidence interval 1.1 to 2.5], p=0.04) were both independently associated with an increased risk for 1-year mortality. In conclusion, PBT may be an accurate and independent marker for adverse events, pointing to the importance of coronary reperfusion as early as possible based on the onset of pain.

Anemia Is Associated With Poor Clinical Outcomes in Hospitalized Patients With Takotsubo Cardiomyopathy.

The association between anemia and Takotsubo cardiomyopathy (TCM) has not been well studied. To assess the effect of anemia on patients hospitalized with TCM, we identified 4733 patients with a primary diagnosis of TCM from the 2016 to 2018 National Inpatient Sample (NIS) database (the United States) using the International Classification of Diseases, 10th edition, Clinical Modification (ICD-10-CM) code. Of these, 603 (12.7%) patients had a comorbidity of anemia and 4130 did not. After propensity score matching, we compared the in-hospital outcomes between the 2 groups (anemia vs nonanemia, n = 594 vs 1137). Patients with TCM with anemia had significantly higher rates of in-hospital complications, including cardiogenic shock (11.4% vs 4.0%, P < .001), ventricular arrhythmia (6.6% vs 3.6%, P = .008), acute kidney injury (22.7% vs 13.1%, P < .001), acute respiratory failure (22.6% vs 13.1%, P < .001), longer length of hospital stay (5.6 ± 5.8 days vs 3.6 ± 3.6 days, P < .001), and higher total charges (US$79 586 ± 10 2436 vs US$50 711 ± 42 639, P < .001). In conclusion, patients with anemia who were admitted for TCM were associated with a higher incidence of in-hospital complications compared with those without anemia.

Hepatectomy for Breast Cancer Metastasis and Sarcoma are more likely to have Adverse Outcomes than Hepatectomy for Primary Hepatocellular Cancer or for Colorectal Metastasis

Outcomes for hepatectomy for breast cancer metastasis and sarcomatous disease processes are not well defined in literature. We sought to use a national database to identify outcomes in these patients compared to subset of patients more well studied in literature - primary Hepatocellular cancer patients and patients with colorectal metastasis. We identified patients undergoing major hepatectomy (≥ 3 segments) for primary hepatocellular cancer (HCC), sarcoma metastasis, breast cancer metastasis, and colorectal metastasis using NSQIP database. The Primary outcome measure was 30-day mortality. Secondary outcome measures were 30-day readmission and complication rates. A total of 5580 patients underwent major hepatectomy during the study period. Patients who underwent hepatectomy for breast cancer metastasis had higher incidence of in-hospital complications (37%) compared to sarcoma (29%), colon (26%), and HCC patients (24%) and 30-days readmission rate (37% vs. 29% - sarcoma vs. 26% - colon vs. 25% HCC). There was no difference in 30-days mortality among the groups. Patients undergoing major hepatectomies for breast cancer metastasis and sarcoma are more likely to have adverse outcomes than compared to their counterparts. This difference highlights the lack of experience in managing breast cancer and sarcoma with metastatic disease to the liver. This also highlights the difference in tumor biology among all the lesions we studied. An extensive discussion should take place when dealing with breast and sarcoma lesions in the liver because of these outcomes.

Understanding a woman's heart: Lessons from 14 177 women with acute coronary syndrome

IntroductionCoronary artery disease is becoming the leading cause of death in women in Western society. However, the available data shows that women are still underdiagnosed and undertreated with guideline-recommended secondary prevention therapy, leading to a significantly higher rate of in-hospital complications and in-hospital mortality. ObjectiveThe main objective of this work is to assess the approach to acute coronary syndrome (ACS) in Portugal, including form of presentation, in-hospital treatment and in-hospital complications, according to gender and in three different periods. MethodsWe performed an observational study with retrospective analysis of all patients included between 2002 and 2019 in the Portuguese Registry of Acute Coronary Syndromes (ProACS), a voluntary, observational, prospective, continuous registry of the Portuguese Society of Cardiology and the National Center for Data Collection in Cardiology. ResultsA total of 49 113 patients (34 936 men and 14 177 women) were included. Obesity, hypertension, diabetes (p<0.001 for all) and dyslipidemia (p=0.022) were all more prevalent in women, who were more frequently admitted for non-ST segment elevation ACS (p<0.001), and more frequently presented with atypical symptoms. Women had more time until needle and until reperfusion, which is less accessible to this gender (p<0.001). During hospitalization, women had a significantly higher risk of in-hospital mortality (OR 1.94 [1.78-2.12], p<0.001), major bleeding (OR 1.53 [1.30-1.80], p<0.001), heart failure (OR 1.87 [1.78-1.97], p<0.001), atrial fibrillation (OR 1.55 [1.36-1.77], p<0.001), mechanical complications (OR 2.12 [1.78-2.53], p<0.001), cardiogenic shock (OR 1.71 [1.57-1.87], p<0.001) and stroke (OR 2.15 [1.76-2.62], p<0.001). Women were more likely to have a normal coronary angiogram or coronary lesions with <50% luminal stenosis (p<0.001 for both), and thus a final diagnosis other than ACS. Both during hospitalization and at hospital discharge, women were less likely to receive guideline-recommended secondary prevention therapy. ConclusionIn women admitted for ACS, revascularization strategies are still underused, as is guideline-recommended secondary prevention therapy, which may explain their higher incidence of in-hospital complications and higher unadjusted mortality.

Retrospective analysis of complications and survival in patients with acute inferior myocardial infarction accompanied by right ventricular myocardial infarction

Summary Right ventricular myocardial infarction (RVMI) accompanies about 30–50% of inferior wall myocardial infarction. RVMI is associated with higher rates of cardiogenic shock, atrioventricular block, atrial fibrillation, increased mortality rates. The topic requires a scientific update, as only a few studies have been made on RVMI during the past decade. We aimed to analyse the impact of RVMI on inferior myocardial infarction. Design and methods: Retrospective study included 310 patients with documented inferior myocardial infarction (with and without RVMI) between January 2013 and January 2014. Data on baseline characteristics, mortality, in-hospital complications: cardiogenic shock and rhythm and conduction disorders was collected. Results: In 102 (32.9%) patients with inferior myocardial infarction, RVMI was present and 208 (67.1%) cases were without RVMI involvement. RVMI patients had higher rate of rhythm and conduction disturbances than patients without RVMI involvement: atrioventricular block (OR 3.8, 95% CI 2.0–7.1, p &lt; 0.001), atrial fibrillation (OR 1.6, 95% CI 0.9–2.9, p = 0.001), also higher incidence of cardiogenic shock (OR 2.6, 95% CI 1.7–3.9, p &lt; 0.001). Mortality rates after 24 months were higher in RVMI group (OR 1.8, 95% CI 1.2–3.8, p = 0.034). No significant difference was found on in-hospital mortality. Conclusions: Right ventricular involvement complicates the long-term mortality and outcomes after inferior myocardial infarction. It is related to a higher incidence of in-hospital complications, especially I–III degree AV block and atrial fibrillation. However, influence on long-term mortality needs further investigation.

Sex Differences in Cardiac Arrhythmias: Clinical and Research Implications.

Sex differences have the potential to impact diagnostic and therapeutic interventions in a wide variety of medical conditions, and cardiac arrhythmias are no exception.1 Studies evaluating pathophysiology, disease course, and therapeutic options for cardiac arrhythmias have been performed predominantly in male patients. However, catheter and device-based therapies coupled with landmark clinical trials have contributed to an improved understanding of this important aspect. The objective of this review is to present the current state of knowledge on sex differences in cardiac arrhythmias with a focus on clinical management, while highlighting gaps in knowledge that would benefit from future investigation. ### Atrial Fibrillation and Atrial Flutter #### Disease Burden Atrial fibrillation (AF) and atrial flutter (AFL) are the most commonly encountered tachyarrhythmias in clinical practice, with significant implications for public health and healthcare costs. Stroke, hospitalization, and loss of productivity are the major consequences of AF.2 The incidence of AF (per 1000 person-years) is reported to be between 1.6 and 2.7 in women and between 3.8 and 4.7 in men.2 The age-adjusted incidence and prevalence of AF is lower in women compared with that in men, and accordingly, the lifetime risk of AF from the Framingham Heart Study at 40 years of age was higher in men (26.0% for men versus 23.0% for women).3 Another analysis from the Framingham Heart Study demonstrated no significant sex differences in the risk of developing AFL.4 The prevalence of AF continues to rise among both men and women. In a study investigating the global burden of disease from 1980 to 2010, there was not only an increase in overall burden, incidence, and prevalence of AF, but most importantly an increase in AF-associated mortality in both men and women (Figure 1).5 The age-adjusted mortality for women was consistently higher compared with that for men from 1990 to 2010 (Figure …

Invited commentary

This study by Hicks et al interrogated the Vascular Quality Initiative database to examine the effect of being lost to follow-up (LTF) on survival after endovascular aneurysm repair (EVAR). Medicare data had suggested that a lack of imaging after EVAR did not confer a survival disadvantage.1Garg T. Baker L.C. Mell M.W. Postoperative surveillance and long-term outcomes after endovascular aneurysm repair among Medicare beneficiaries.JAMA Surg. 2015; 150: 957-963Crossref PubMed Scopus (51) Google Scholar In the Vascular Quality Initiative EVAR population, only 49.9% of elective patients had a follow-up visit recorded in the database (an astonishing low number). Of this group, ∼11% each had phone follow-up or were LTF. The LTF group was older, had more comorbid conditions, and had larger aneurysms. The LTF group (and the phone follow-up group) had significantly lower survival compared with those with in-person follow-up. A coarsened exact matching on 30 preoperative and perioperative variables demonstrated that those LTF still had reduced survival (vs in person follow-up), although the differences compared with the multivariate analysis with in-person follow-up, were considerably smaller. Phone follow-up patients had fewer imaging studies, and survival outcomes were equivalent to the LTF group. The authors conclude that EVAR patients with more comorbidities and a higher incidence of in-hospital complications tend to be more frequently LTF and ultimately have worse survival outcomes. This study's conclusions differ from a study of EVAR Medicare patients that used a propensity-matched study design.1Garg T. Baker L.C. Mell M.W. Postoperative surveillance and long-term outcomes after endovascular aneurysm repair among Medicare beneficiaries.JAMA Surg. 2015; 150: 957-963Crossref PubMed Scopus (51) Google Scholar The patients with incomplete postoperative EVAR surveillance had few ruptured abdominal aortic aneurysms postoperatively, fewer reinterventions, and no reduction in aneurysm-related survival. Nonadherence to Society for Vascular Surgery suggested guidelines for postoperative EVAR was surprisingly not associated with poorer outcomes. Other population-derived data published suggest that regular imaging after EVAR is associated with reduced mortality that becomes more pronounced as the length of follow-up increases.2de Mestral C. Croxford R. Roche-Nagle G. PC036. Ten years of endovascular aortic aneurysm repair: a population-based evaluation of postoperative imaging and mortality [Abstract].J Vasc Surg. 2016; 6: 163S-164SAbstract Full Text Full Text PDF Google Scholar All of these data demonstrate a failure to achieve the Society for Vascular Surgery EVAR follow-up guidelines. The preponderance of data, in my opinion, demonstrates those who are LTF have worse long-term outcomes and mortality than those with imaging and in-person follow-up. Key barriers to complete follow-up include patient factors (age, choice to come for follow-up, and comorbidities), provider factors (databases and coordinators dedicated to ensuring imaging and follow-up), and the lack of patient-specific follow-up guidelines that take into account the presence or absence of endoleaks at the first follow-up, anatomic considerations (short or angulated aortic necks or common iliac landing zones), sac shrinkage, and other factors. Database software dedicated to EVAR patient-specific follow-up should assist providers to improve follow-up compliance and determine whether this improves aneurysm-related mortality. Vascular surgeons need to ensure careful EVAR follow-up or risk compromising its promise of comparable outcomes to open repair.3Patel R. Sweeting M.J. Powell J.T. Greenhaugh R.M. EVAR trial investigatorsEndovascular versus open repair of abdominal aortic aneurysm in 15-years' follow-up of the UK endovascular aneurysm repair trial 1 (EVAR trial 1): a randomised controlled trial.Lancet. 2016; 388: 2366-2374Abstract Full Text Full Text PDF PubMed Scopus (606) Google Scholar Endovascular aneurysm repair patients who are lost to follow-up have worse outcomesJournal of Vascular SurgeryVol. 65Issue 6PreviewSociety for Vascular Surgery practice guidelines recommend 1- and 12-month follow-up with computed tomography imaging for the year after endovascular aneurysm repair (EVAR). We describe the incidence, risk factors, and outcomes of EVAR patients who are lost to follow-up (LTF). Full-Text PDF Open Archive

Endovascular aneurysm repair patients who are lost to follow-up have worse outcomes

BackgroundSociety for Vascular Surgery practice guidelines recommend 1- and 12-month follow-up with computed tomography imaging for the year after endovascular aneurysm repair (EVAR). We describe the incidence, risk factors, and outcomes of EVAR patients who are lost to follow-up (LTF). MethodsAll patients undergoing elective EVAR in the Vascular Quality Initiative (VQI) data set (January 2003-December 2015) were stratified according to long-term follow-up method (in-person vs phone call vs LTF). Mortality was captured for all patients by linkage with the Social Security Death Index. Univariable statistics, Kaplan-Meier estimated survival curves, and Cox proportional hazard modeling were used to compare groups. Coarsened exact matching analysis was then performed to refine the association between LTF and risk of post-EVAR death. ResultsDuring the study period, 11,309 patients underwent elective EVAR (78% in-person follow-up, 11% phone call follow-up, 11% LTF). On univariable analysis, LTF patients had larger baseline aneurysms, higher American Society of Anesthesiologists scores, more comorbidities, and worse baseline functional status compared to patients with in-person or phone call follow-up (P ≤ .05). Procedural factors (contrast material volume, blood transfusions, postoperative vasopressor use) were higher in the LTF group, as was the incidence of postoperative complications (P ≤ .05). Accordingly, LTF patients had longer postoperative lengths of stay and were less frequently discharged to home (P < .001). Five-year survival was lower for LTF vs phone call follow-up vs in-person follow-up (62% vs 68% vs 84%; P < .001). On multivariable analysis correcting for baseline differences between groups, there was a significantly higher risk of death for both the LTF group (hazard ratio, 6.45; 95% confidence interval, 4.89-8.51) and phone call follow-up group (hazard ratio, 3.48; 95% confidence interval, 2.66-4.57) compared with patients who followed up in person (P < .001). After coarsened exact matching on 30 preoperative and perioperative variables, 5-year survival after EVAR for LTF vs phone call follow-up vs in-person follow-up was 84.9% vs 84.8% vs 91.9%, respectively (log-rank, P < .001). Notably, patients with phone call follow-up had a lower prevalence of documented postoperative imaging compared with patients with in-person follow-up (56.1% vs 85.1%; P < .001). ConclusionsEVAR patients with more comorbidities and a higher incidence of in-hospital complications tend to be more frequently LTF and ultimately have worse survival outcomes. In-person follow-up is associated with better post-EVAR survival and a higher rate of postoperative imaging. Phone follow-up confers a mortality risk equivalent to lack of follow-up, possibly as a result of inadequate postoperative imaging. Surgeons should stress the importance of office-based postoperative follow-up to all EVAR patients, particularly those with poor baseline health and functional status and more complicated perioperative courses.

Impact of diabetes on prognosis in patients with a first acute myocardial infarction

ObjectiveDiabetic patients with acute myocardial infarction (AMI) have poor prognosis. The aim of this study was to compare the influence of diabetes on prognosis after AMI by serial changes of...

Higher Incidence of In-Hospital Complications in Patients With Clipped Versus Coiled Ruptured Intracranial Aneurysms

After aneurysmal subarachnoid hemorrhage (SAH), patients with clipped aneurysms have a higher incidence of neurocognitive deficits and seizures compared with patients with coiled aneurysms. It remains unknown if patients with clipped aneurysms also have a higher incidence of other in-hospital complications. We used data from the Registry of the Canadian Stroke Network on consecutive patients admitted to hospital with aneurysmal SAH. Patients who died within 2 days after admission were excluded. Baseline characteristics, incidence of various in-hospital complications within 30 days after admission, length of stay, poor functional outcome (modified Rankin Scale score at discharge of ≥3), and mortality were compared between patients with clipped versus coiled aneurysms. Of the 931 patients, 548 (59%) were clipped and 383 (41%) coiled. Baseline characteristics were similar. Compared with patients with coiled aneurysms, patients with clipped aneurysms had a higher incidence of in-hospital complications (37.2% versus 24.5% of patients; P<0.0001), poor functional outcome at discharge (69.4% versus 51.4%; P<0.0001), mortality (at discharge: 14.6% versus 9.1%; P=0.01), and a longer length of stay (17 [interquartile range, 11 to 29] versus 13 [interquartile range, 7 to 22] days; P<0.0001). Higher incidences were observed for urinary tract infection (P=0.02), pneumonia (P=0.01), cardiac/respiratory arrest (P=0.007), seizure (P=0.01), and decubitus ulcer (P=0.02). Urinary tract infection, pneumonia, cardiac/respiratory arrest, and seizure were independent predictors of poor functional outcome. Patients with clipped aneurysms have a higher incidence of in-hospital complications than patients with coiled aneurysms, which attributes to a higher risk of poor functional outcome and death and an increased length of stay.

Acid–base imbalance in uncomplicated ST-elevation myocardial infarction: the clinical role of tissue acidosis

Little information is available on acid-base imbalance in uncomplicated ST-elevation myocardial infarction (STEMI) submitted to primary percutaneous intervention (PCI). We therefore assessed acid-base imbalance in 257 consecutive uncomplicated STEMI patients submitted to PCI to determine whether its evaluation could help in identifying patients at higher risk for in-hospital complications (acute pulmonary edema and dysrhythmias). A basic metabolic profile was performed at hospital admission, that is before PCI. After PCI, we measured: creatinine, uric acid and NT-pro BNP and serum electrolytes. Peak troponin I was also considered. Acidemia was present in 11 patients (4.2%), HCO(3) < 22 in 62 (24.1%). Base excess < -3 was detectable in 70 patients (27.2%), anion gap > 12 in 13 (5.1%), Cl/Na < 0.79 in 93 patients (38.5%). Patients with a Cl/Na < 0.79 had a lower LVEF (p = 0.042) and higher values of NT-pro-BNP (p = 0.019) and of latency (p = 0.029) together with a higher length of stay (p = 0.017) and a higher incidence of in-hospital complications (p = 0.017). At backward stepwise regression analysis, the following variables resulted independent predictors of in-hospital complications: base excess OR 1.47 (95% CI 1.04-2.10) p = 0.031; Cl/Na ratio O.R. 1.85 (95% CI 1.05-3.27) p = 0.035. In STEMI patients submitted to mechanical revascularization the evaluation of acid-base status and, in particular the detection of even mild degrees of acidosis may help in risk stratification for in-hospital complications. A Cl/Na < 0.79 ratio and a base excess are independent predictors for in-hospital complications.

The Role of False Lumen Size in Prediction of In-Hospital Complications After Acute Type B Aortic Dissection

The aim of this study was to determine whether false lumen size predicts in-hospital complications for acute type B aortic dissection. The incidence of complications developing in patients with acute type B aortic dissection has been high. However, methods for recognizing high-risk patients have not been well-studied. We used quantitative analysis by computed tomography (CT) to predict the occurrence of in-hospital complications. Fifty-five consecutive patients with acute type B aortic dissection documented by CT imaging were analyzed. They were divided into groups, with and without in-hospital complications, and compared regarding maximal aortic diameter (MAD), maximal false lumen area (MFLA), minimal true lumen area (MTLA), branch-vessel involvement (BVI), and longitudinal length (LL) of aortic dissection. There were 31 patients with a stable course (group 1) and 24 patients who developed complications (group 2). The MFLA of group 2 was significantly larger than that of group 1 (group 1 vs. group 2=577.7+/-273.2 mm2 vs. 1,899.3+/-1,642.4 mm2, p<0.001). The BVI number was also higher in group 2 (group 1 vs. group 2=1.0+/-1.1 vs. 3.3+/-2.0, p<0.001). On multivariate analysis, only MFLA and BVI number were independent predictors of in-hospital complications. Patients with initial MFLA>or=922 mm2 or BVI number>or=2 showed a significantly higher incidence of in-hospital complications than the other patients (p<0.001). A large MFLA and a higher BVI number are powerful predictors of in-hospital complications after acute type B aortic dissection.

Clinical Significance of Coronary Flow to the Infarct Zone Before Successful Primary Percutaneous Transluminal Coronary Angioplasty in Acute Myocardial Infarction

To assess the effect of coronary flow to the infarct zone before primary coronary angioplasty on hospital complications in patients with acute myocardial infarction (MI). Consecutive case series analysis. Coronary-care unit in a university hospital. Two hundred sixty-four consecutive patients with ST-elevation acute MIs who had successful primary percutaneous transluminal coronary angioplasty. Coronary angiography on hospital admission and serial echocardiography. The status of infarct-related artery flow before primary angioplasty was evaluated on hospital admission. Left ventricular wall motion and pericardial effusions were studied by echocardiography. One hundred ninety patients had total occlusions (Thrombolysis in Myocardial Infarction [TIMI] flow grade, 0 to 1) in the infarct-related artery (group 1), and 74 patients had antegrade flow (TIMI flow grade, 2 to 3) [group 2] before undergoing primary angioplasty procedures. When group 1 was subdivided into two groups (for the presence and absence of collateral flow), the patients with total occlusions and no collateral flow had a higher incidence of left ventricular aneurysmal wall motion (11% vs 1%, respectively; p = 0.03) and pericardial friction rub (15% vs 3%, respectively; p = 0.03) than did those in group 2. Moreover, those patients with total occlusions and no collateral flow had higher incidences of pericardial effusion (34% vs 17%, respectively; p = 0.02; and 34% vs 9%, respectively; p < 0.01) and in-hospital mortality (8% vs 1%, respectively; p = 0.04; and 8% vs 1%, respectively; p = 0.06) than did those patients in the other two groups. Despite successful primary angioplasty, the absence of antegrade flow in the infarct-related artery and collateral flow to the infarct zone before angioplasty resulted in a higher incidence of in-hospital complications.

Creatine kinase-MB fraction elevation after percutaneous coronary intervention in patients with chronic renal failure

We evaluated the short- and long-term clinical outcomes of 326 consecutive patients with chronic renal failure, not on dialysis, who had creatine kinase (CK)-myocardial band (MB) fraction elevation after successful percutaneous coronary intervention in a native coronary artery. Based on peak CK-MB levels measured after intervention, patients were divided into 3 groups: no elevation (group 1, n = 184), 1 to 3 × upper normal levels (group 2, n = 72), and >3 × upper normal levels (group 3, n = 70). Baseline clinical and angiographic characteristics were similar among the 3 groups. Angiographic success was similar among the 3 groups, although there was a significantly higher use of intra-aortic balloon pump in patients who had postprocedural CK-MB >3 × normal values and a higher rate of in-hospital complications, i.e., repeat catheterization, repeat target lesion intervention, pulmonary edema, renal function deterioration, emergency dialysis, and major bleeding complications. At 1-year follow-up, mortality rates were significantly higher in these patients (35.4% vs 22.0% for patients with CK-MB 1 to 3 × normal values and 16.7% for patients without CK-MB elevation, p = 0.007). Multivariate analysis showed that CK-MB >3 × normal (odds ratio 3.04; 95% confidence interval 1.41 to 6.57, p = 0.005) and intra-aortic balloon pump (odds ratio 1.49; confidence interval 1.15 to 1.93, p = 0.002) were independent predictors of late mortality. Therefore, patients with chronic renal failure who had CK-MB elevation >3 × the upper normal limit after a successful percutaneous coronary intervention had a higher incidence of in-hospital complications and a significantly higher mortality rate at 1-year follow-up than patients without CK-MB elevation or with <3 × normal CK-MB elevation.