Lower 1-year Mortality Research Articles

Prehospital ECG signs of acute coronary occlusion are associated with reduced one-year mortality

We wanted to evaluate predictors of direct admittance to a coronary care unit (CCU) and predictors of death in patients with suspected acute coronary syndromes (ACS). During 2004-2007, all consecutive prehospitally triaged patients with suspected ACS were prospectively included. Prehospital and emergency data were collected at point of care. Data from medical records, ECG-, echocardiography- and laboratory databases was collected retrospectively. In all, 2757 patients were included. Out of these 858 were directly admitted to the CCU or cath/lab. Predictors for direct admittance to the CCU were ST-segment elevation on the initial ECG; odds ratio (OR) 46.11, left bundle branch block; OR 3.30, ongoing symptoms; OR 2.90, current smoking; OR 2.18 and ST-segment depression; OR 2.05. Independent predictors for 1-year mortality were cardiogenic shock; OR 14.40, increasing age OR (per year) 1.08, diabetes; OR 2.09 and chronic heart failure; OR 1.67. ST-segment elevation was associated with a lower 1-year mortality rate; OR 0.52. Among patients with a suspected ACS, prehospital ECG-signs indicating an acute coronary occlusion were not only a predictor for direct admission to acute coronary care but also a predictor for increased survival. To improve future outcome in acute ischemic heart diseases we must find and treat not only the STEMI's but also the high-risk NSTEMIs that otherwise would have a poor prognosis.

Letter to the Editor: Fee-based Care is Important for Access to Prompt Treatment of Hip Fractures Among Veterans

To the Editor: As an orthopaedic surgeon who fixes hip fractures at a VA hospital, I was proud to read the study by Richardson et al., Fee-based Care is Important for Access to Prompt Treatment of Hip Fractures Among Veterans [3], showing that non-VA hospitals have a 21% lower 1-year mortality for patients with hip fractures. One may wonder why I would be proud to read a study that ostensibly shows a better performance at a Non-VA hospital. Truth be told, I was proud only when I looked closely at their data. The mean age of VA patients in their study was 76 years, versus 71 years for the non-VA group. It probably is no surprise to discover that a 76-year-old person is more likely to die than a 71-year-old—in fact, the 1-year mortality rate, 4.4%, is 57% higher that of a 71-year-old person, 2.8% [1]. As such, finding that the rates differed by only 21% show that the VA is associated with a distinctly reduced rate of mortality, when the base case risk is considered. I point this out not to be a schoolmarm or to shill for my friend, Howard Wainer, whose book, coauthored with Lawrence Hubert), A Statistical Guide for the Ethically Perplexed [2], teaches this point. I point this out particularly because in the coming years, the debate about healthcare reform no doubt will put the VA system under heightened scrutiny, as the VA does things differently compared with civilian institutions. When the VA does something better—technically speaking, “is associated with something better” for association does not imply causality—it should be celebrated.

Influence of Crossover on Mortality in a Randomized Study of Revascularization in Patients With Systolic Heart Failure and Coronary Artery Disease

To assess the influence of therapy crossovers on treatment comparisons and mortality at 5 years in patients with ischemic heart disease and heart failure randomly assigned to medical therapy alone (MED) or to MED and coronary artery bypass graft (CABG) surgery in the Surgical Treatment for Ischemic Heart Failure (STICH) trial. The influence of early crossover (within the first year after randomization) on 5-year mortality was assessed using time-dependent multivariable Cox models. CABG was performed in 65/602 patients (10.8%) assigned to MED, and 55/610 patients (9.0%) assigned to CABG received MED only. Common reasons for crossover from MED to CABG were progressive symptoms or acute decompensation. MED-assigned patients who underwent CABG had lower 5-year mortality than those who received MED only (25% vs 42%; hazard ratio, 0.50; 95% confidence interval, 0.30-0.85; P=0.008).The main reason for crossover from CABG to MED was patient/family decision. Five patients did not undergo their assigned CABG within a year but died before receiving surgery without status change. They were deemed crossover to MED. The CABG-to-MED crossover population had higher 5-year mortality compared with those treated with CABG per-protocol (59% vs 33%; hazard ratio, 2.01; 95% confidence interval, 1.36-2.96; P<0.001). CABG was associated with lower mortality compared with MED in per-protocol and several time-dependent analyses (all P<0.05). CABG reduced mortality in both the per-protocol and crossover STICH patient populations. Crossover from assigned therapy, therefore, diminished the impact of CABG on survival in STICH when analyzed by intention to treat. URL: http://www.clinicaltrials.gov. Unique identifier: NCT00023595.

Complete versus partial preservation of mitral valve apparatus during mitral valve replacement: meta-analysis and meta-regression of 1535 patients

To determine if there is any real difference between complete preservation (CP) and partial preservation (PP) of the mitral valve apparatus during mitral valve replacement (MVR) in terms of hard outcomes. MEDLINE, EMBASE, CENTRAL/CCTR, SciELO, LILACS, Google Scholar and reference lists of relevant articles were searched for clinical studies that compared outcomes [30-day mortality, postoperative low cardiac output syndrome (LCOS), 5-year mortality or left ventricle ejection fraction (LVEF) before and after surgery] between MVR-CP vs MVR-PP during MVR until July 2012. The principal summary measures were odds ratios (ORs) with 95% confidence interval (CI)--for categorical variables (30-day mortality, postoperative LCOS, 5-year mortality); difference means and standard error (SE)--for continuous variables (LVEF before and after surgery) and P values (that will be considered statistically significant when <0.05). The ORs were combined across studies using DerSimonian-Laird random effects weighted model. The same procedure was executed for continuous variables, taking into consideration the difference in means. Eight studies (2 randomized and 6 non-randomized) were identified and included a total of 1535 patients (597 for MVR-CP and 938 for MVR-PP). There was no significant difference between MVR-CP or MVR-PP groups in the risk for 30-day mortality (OR 0.870; 95% CI 0.50-1.52; P = 0.63) or postoperative LCOS (OR 0.35; 95% CI 0.11-1.08 and P = 0.07) or 5-year mortality (OR 0.70; 95% CI 0.43-1.14; P = 0.15). Taking into consideration LVEF, neither MVR-CP nor MVR-CP demonstrated a statistically significant improvement in LVEF before and after surgery, and both strategies were not different from each other. No publication bias was observed. We found evidence that argues against any superiority between both techniques of preservation (complete or partial) of mitral valve apparatus during MVR.

EComment. Cardiac venous arterialization in acute myocardial infarction

We read the article by Munz et al. with interest [1]. They aimed to investigate the benefits of cardiac venous arterialization in reducing acute myocardial infarct size and its effects on cardiac performance. This study revealed that selective cardiac venous arterialization can nourish the myocardium and is able to reduce the infarct size by more than 50%, while protecting cardiac performance. The study is successfully planned and the results are presented well — thanks to the authors for their contribution. In the absence of collateral circulation, coronary occlusion causes myocyte necrosis, the extent of which correlates directly with the speed and duration of the occlusion. Early reperfusion of an ischaemia related artery (IRA) would decrease myocardial necrosis, improve left ventricular (LV) function, and reduce mortality rates. Opening an occluded IRA, whether early or late, produces survival rates disproportionate to the amount of myocardium salvaged. A current trial clearly showed that in patients diagnosed with acute coronary syndrome, an early invasive approach is superior to a conservative approach [3]. Early reintervention may limit the extent of myocardial cellular damage compared with conservative medical strategy in patients with myocardial ischaemia due to early graft failure as well as in patients with acute myocardial infarction [4]. Myocardial reperfusion has been shown to improve both short- and long-term survival in patients who have experienced an AMI. The open artery hypothesis suggests that survival after AMI depends on improved LV remodeling and healing, electrical stability, and myocardial perfusion rather than on the reduction of the infarct size (i.e., myocardial salvage) [5]. Studies showed that late patency of an IRA, as opposed to persistent occlusion, was independently associated with better 1-year survival. In a long-term follow-up study of 505 patients who underwent percutaneous transluminal coronary angioplasty for post-MI ischaemia, 22 patients with an open IRA had a lower 5-year mortality rate than patients with a closed IRA. This held true even for patients with LVEFs <0.50. Conflict of interest: none declared

Fee-based Care is Important for Access to Prompt Treatment of Hip Fractures Among Veterans

Hip fracture is a medical emergency for which delayed treatment increases risk of disability and death. In emergencies, veterans without access to a Veterans Administration (VA) hospital may be admitted to non-VA hospitals under fee-based (NVA-FB) care paid by the VA. The affect of NVA-FB care for treatment and outcomes of hip fractures is unknown. This research seeks to answer three questions: (1) What patient characteristics determine use of VA versus NVA-FB hospitals for hip fracture? (2) Does time between admission and surgery differ by hospital (VA versus NVA-FB)? (3) Does mortality differ by hospital? Veterans admitted for hip fractures to VA (n = 9308) and NVA-FB (n = 1881) hospitals from 2003 to 2008 were identified. Primary outcomes were time to surgery and death. Logistic regression identified patient characteristics associated with NVA-FB hospital admissions; differences in time to surgery and death were evaluated using Cox proportional hazards regression, controlling for patient covariates. Patients admitted to NVA-FB hospitals were more likely to be younger, have service-connected disabilities, and live more than 50 miles from a VA hospital. Median days to surgery were less for NVA-FB admissions compared with VA admissions (1 versus 3 days, respectively). NVA-FB admissions were associated with 21% lower relative risk of death within 1 year compared with VA hospital admissions. For veterans with hip fractures, NVA-FB hospital admission was associated with shorter time to surgery and lower 1-year mortality. These findings suggest fee-based care, especially for veterans living greater distances from VA hospitals, may improve access to care and health outcomes. Level II, prognostic study. See the Guidelines for Authors for a complete description of levels of evidence.

Erratum for a missing eComment 'Left ventricular rupture after mitral valve replacement: the most dreaded complication'

Erratum for a missing eComment to ‘Preservation versus non-preservation of mitral valve apparatus during mitral valve replacement: a meta-analysis of 3835 patients’ [Interact CardioVasc Thorac Surg 2012;15:1033–1039]† The publisher regrets having failed to include the following eComment related to the article by Sa et al. [1]. We express our sincere apologies to the author of this eComment. eComment. Left ventricular rupture after mitral valve replacement: the most dreaded complication Author: Ovidio A. Garcia-Villarreal Department of Cardiac Surgery, Hospital of Cardiovascular Disease No. 34, IMSS, Monterrey, Mexico. E-mail: moc.liamtoh@vgoidivo. doi:10.1093/icvts/ivs467 © The Author 2012. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved. I have read with great interest the article by Sa et al [1]. This meta-analysis addresses a very important topic in surgery for mitral valve disease, that is, the preservation of subvalvular structures during mitral valve replacement (MVR) and its inherent consequences. As the authors note, after the analysis of 3835 patients (1918 for MVR with subvalvular preservation and 1917 for MVR with non-preservation) the odds ratio for early mortality (0.418, p <0.001), postoperative low cardiac output syndrome (0.299, p <0.001) and 5-year mortality (0.380, p <0.001) were in favour of MVR with subvalvular preservation. Unfortunately, this meta-analysis is not specific for anterior, posterior or bileaflet preservation. Many cardiac surgeons are reluctant to preserve the anterior mitral subvalvular complex due to the risk of left ventricular (LV) outflow tract obstruction. At the same time, there are no papers that conclusively prove the role of anterior subvalvular mitral structures in the concern discussed here. With regard to posterior subvalvular preservation, this is a common and easy procedure to perform in the real world. Particular care should be taken in rheumatic cases because of leaflet calcification and chordae thickening. But perhaps we have overlooked the relationship between the section of the posterior subvalvular apparatus and the LV rupture after MVR. This is a rare but dreaded and potentially lethal complication of mitral valve surgery, with an incidence of up to 1% and an associated mortality of up to 85% [2]. Treasure et al. [3] described type I and type II left ventricular ruptures as those located in the posterior atrioventricular groove, and the area overlying the papillary muscles, respectively. Type III cited by Miller et al. [4] is in an intermediate zone between the base of the papillary and the left atrioventricular sulcus, which is directly related to untethered loop hypothesis proposed by Cobbs et al. [5]. The supporting structures of the posterior LV wall form a loop. The outer portion is composed of longitudinal muscle fibres in the LV wall, and the inner portion consists of the papillary muscles with the chordae attached to the annulus of the posterior leaflet. Thus, the surgical division of the posterior leaflet chordae can seriously weaken the posterior LV wall. In rheumatic cases with advanced alteration of the valvular structures, such as chordae thickening and shortening, and leaflet thickening and calcification, preservation of the second and third order chordae tendinae of the posterior mitral leaflet may be enough to avoid this catastrophe. Conflict of interest: none declared

Preservation versus non-preservation of mitral valve apparatus during mitral valve replacement: a meta-analysis of 3835 patients

Resection of the chordopapillary apparatus during mitral valve replacement has been associated with a negative impact on survival. Mitral valve replacement with the preservation of the mitral valve apparatus has been associated with better outcomes, but surgeons remain refractory to its use. To determine if there is any real difference in preservation vs non-preservation of mitral valve apparatus during mitral valve replacement in terms of outcomes, we performed a systematic review and meta-analysis using MEDLINE, EMBASE, CENTRAL/CCTR, SciELO, LILACS, Google Scholar and reference lists of relevant articles to search for clinical studies that compared outcomes (30-day mortality, postoperative low cardiac output syndrome or 5-year mortality) between preservation vs non-preservation during mitral valve replacement from 1966 to 2011. The principal summary measures were odds ratios (ORs) with 95% confidence interval and P-values (that will be considered statistically significant when <0.05). The ORs were combined across studies using a weighted DerSimonian-Laird random-effects model. The meta-analysis was completed using the software Comprehensive Meta-Analysis version 2 (Biostat Inc., Englewood, NJ, USA). Twenty studies (3 randomized and 17 non-randomized) were identified and included a total of 3835 patients (1918 for mitral valve replacement preservation and 1917 for mitral valve replacement non-preservation). There was significant difference between mitral valve replacement preservation and mitral valve replacement non-preservation groups in the risk of 30-day mortality (OR 0.418, P<0.001), postoperative low cardiac output syndrome (OR 0.299, P<0.001) or 5-year mortality (OR 0.380, P<0.001). No publication bias or important heterogeneity of effects on any outcome was observed. In conclusion, we found evidence that argues in favour of the preservation of mitral valve apparatus during mitral valve replacement.

Abstract P28: Comparison of Short- and Long-Term Mortality Between Older Asian and White Patients with Non–ST-Elevation Myocardial Infarction: Findings from CRUSADE-CMS Database

Background: While previous studies have shown similar in-hospital mortality between Asian and White patients with non-ST elevation myocardial infarction (NSTEMI), little is known about their longer-term mortality differences. Methods: We linked Medicare claims data to detailed clinical data for 37702 NSTEMI patients ≥65 years of age from 444 CRUSADE hospitals between 2003 and 2006 to examine longitudinal outcomes. All-cause 30-day and 1-year mortality were compared between Asian and White patients by Cox proportional hazards modeling adjusting for differences in baseline patient characteristics. Results: Compared with White patients, Asians (n= 307) were younger, more frequently had hypertension, diabetes, and renal insufficiency, and less likely to have had a prior MI or coronary revascularization. There were no significant differences in rates of cardiac catheterization (60.7% vs. 58.0%, p=0.26), PCI (32.2% vs. 31.6%, p=0.73), and CABG (9.2% vs. 8.5%, p=0.62) between Whites and Asians respectively. While the difference in risk-adjusted mortality was not statistically significant between Asian and White patients at 30-days (HR 0.70, 95% CI 0.48 - 1.01), lower 1-year mortality (adjusted HR 0.62, 95% CI 0.48 - 0.79) and 1-year mortality conditional on surviving 30 days (adjusted HR 0.56, 95% CI 0.40 - 0.78) were observed among Asians (Figure). Conclusions: While short-term outcomes were similar between Asian and White NSTEMI patients ≥65 years of age, Asians had better outcomes at 1 year. Further study is needed to determine whether more complete follow-up and use of secondary prevention strategies in Asians help to explain these long-term differences in outcome.

Does the Outcome Justify an Oral-First Treatment Strategy for Management of Pulmonary Arterial Hypertension?

Guidelines for the treatment of World Health Organization (WHO) functional class (FC) III pulmonary arterial hypertension (PAH) provide for oral (PO) therapy or parenteral prostacyclins at the discretion of expert physicians. The objective of this study was to assess the appropriateness of PO-first treatment in patients with WHO FC III PAH. This study was a retrospective analysis of 79 treatment-naive adult patients with idiopathic, familial, or anorexigen-associated PAH, referred to a single pulmonary hypertension center. Forty-eight received either PO therapy with an endothelin receptor antagonist, calcium channel blocker, or phosphodiesterase inhibitor (PO group) and 31 an IV or subcutaneous (SC) prostacyclin (IV/SC group). Patients in the IV/SC group had a significantly worse baseline hemodynamic profile; however, on univariate analysis, there was no association between hemodynamics and mortality. Initial treatment with PO vs IV/SC therapy was associated with a lower overall mortality (20.8% vs 45.2%, P = .02) and a lower 5-year mortality (14.6% vs 32.3%, P = .062). Based on the National Institutes of Health equation, actual survival for patients who received PO therapy was greater than predicted at 5 years. Finally, there were similar improvements between groups in 6-min walk distance (P = .38) at 6 to 12 months after initiation of treatment. For WHO FC III PAH that is idiopathic, familial, or anorexigen associated, the clinical decision for treatment with a PO-first strategy is associated with a high survival rate when patients are appropriately risk stratified prior to initiation of therapy. The more potent prostacyclins can be reserved for high-risk patients, those with evidence of disease progression, or those with treatment failure.

Post–hip fracture use of prescribed calcium plus vitamin D or vitamin D supplements and antiosteoporotic drugs is associated with lower mortality: A nationwide study in Finland

We previously found a positive association between calcium plus vitamin D and antiosteoporotic drugs and survival among hip fracture patients. Our aim was to verify this observation using a nationwide database. A retrospective cohort of home-discharged hip fracture patients aged 50 years or older (n = 23,615) was enrolled from the national database. Primary exposure was medical treatment for osteoporosis, and the outcome was all-cause mortality. Cumulative mortalities were calculated using the Kaplan-Meier estimator. The relationship between mortality and medication purchases was modeled using Cox's proportional hazards regression with time-dependent covariates for medication use. One in 4 women and 1 in 10 men with a hip fracture were treated for osteoporosis in Finland. Unadjusted 1-year mortality was lower among patients who purchased calcium plus vitamin D or vitamin D supplements and antiosteoporotic drugs than among those who did not purchase these medications [hazard ratio (HR) = 0.74, 95% confidence interval (CI) 0.67-0.81]. The difference in unadjusted cumulative mortality remained in favor of the drug users for at least 5 years. Among men, the use of calcium plus vitamin D or vitamin D supplements was associated with lower 1-year mortality even after adjustments for observed confounders (HR = 0.74, 95% CI 0.56-0.97). Among women, the use of antiosteoporotic drugs was associated with lower mortality (HR = 0.79, 95% CI 0.67-0.93). There was a tendency to even better survival in both genders if calcium plus vitamin D or vitamin D supplements and antiosteoporotic drugs were used simultaneously, the HR being 0.72 (95% CI 0.50-1.03) in men and 0.62 (95% CI 0.50-0.76) in women.

Prehospital triage in the ambulance reduces infarct size and improves clinical outcome

We evaluated the effect of prehospital triage (PHT) in the ambulance on infarct size and clinical outcome and studied its relationship to the distance of patient's residence to the nearest percutaneous coronary intervention (PCI) center. All consecutive ST-segment elevation myocardial infarction patients who were transported to the Isala klinieken from 1998 to 2008 were registered in a dedicated database. Of these, 2,288 (45%) were referred via a spoke center and 2.840 (55%) via PHT. PHT patients were more often treated within 3 hours after symptom onset (46.2% vs 26.8%, P < .001), more often had a post-procedural thrombolysis in myocardial infarction (TIMI) 3 flow (93.0% vs 89.7%, P < .001) had a smaller infarct size (peak creatine kinase 2,188 ± 2,187 vs 2,575 ± 2,259 IU/L, P < .001) and had a lower 1-year mortality (4.9% vs 7.0%, P = .002). After multivariate analysis, PHT was independently associated with ischemic time less than 3 hours (OR 2.45, 95% CI 2.13-2.83), a peak creatine kinase less than the median value (OR 1.19, 95% CI 1.04-1.36) and a lower 1-year mortality (OR 0.67, 95% CI 0.50-0.91). The observed differences between PHT patients and the spoke group were more pronounced in the subgroup of patients living >38 km from the PCI center. PHT in the ambulance is associated with a shorter time to treatment, a smaller infarct size and a more favorable clinical outcome, especially with longer distance from the patient's residence to the nearest PCI center. Therefore, PHT in the ambulance may reduce the negative effect of living at a longer distance from the PCI center.

Computer‐assisted quantification of myocardial reperfusion after primary percutaneous coronary intervention predicts functional and contrast‐enhanced cardiovascular magnetic resonance outcomes in patients with ST‐segment elevation myocardial infarction

We investigated whether the Quantitative Blush Evaluator (QuBE) value predicts functional and contrast-enhanced cardiovascular magnetic resonance (CMR) outcomes at 4-6 months after primary percutaneous coronary intervention (PCI) inpatients with ST-segment elevation myocardial infarction (STEMI). QuBEis a computer-assisted open source program to quantify myocardial reperfusion.Although a higher QuBE value is associated with improved myocardial reperfusion measures and lower 1-year mortality, the association with intermediate functional parameters after STEMI has not yet been investigated. QuBE values were quantified retrospectively on angiograms of patients enrolled in the ancillary CMR study of the proximal embolic protection in acute myocardial infarction and resolution of ST-elevation trial. QuBE en CMR outcomes were independently assessed by reviewers blinded to clinical data. A higher QuBE value was significantly associated with a smaller left ventricular (LV) end-diastolic and end-systolic volume, a higher LV ejection fraction and systolic wall thickening in the infarct area, and a smaller final infarct size and extent of transmural segments (P ≤ 0.008). In a multivariable model, including age, gender, infarct location, time to treatment, history of myocardial infarction, and postprocedural thrombolysis in myocardial infarction flow grade,only the QuBE value and infarct location remained as independent predictors of LV ejection fraction (P 5 0.018 for QuBE value). Higher QuBE values are independently associated with improved functional and contrast-enhanced CMR outcomes including LV ejection fraction at 4-6 months after primary PCI and may therefore aid in identifying high-risk patients who benefit most from adjunctive therapies sustaining myocardial function after PCI.

Facilitated reperfusion with prehospital glycoprotein IIb/IIIa inhibition: predictors of complete ST-segment resolution before primary percutaneous coronary intervention in the On-TIME 2 trial: Correlates of reperfusion before primary PCI

Objective The objective of this study is to evaluate the incidence, predictors, and outcome of complete ST-segment resolution (STR) during transportation after pretreatment with dual or triple antiplatelet therapy in the Ongoing Tirofiban in Myocardial Infarction Evaluation (On-TIME) 2 trial. Methods Patients with ST-segment elevation myocardial infarction were randomized in the ambulance to pretreatment with high-dose tirofiban (HDT) or to a control pretreatment (placebo or no HDT) on top of 600-mg clopidogrel, 500-mg aspirin, and 5000-IU unfractionated heparin. Complete STR was defined as ≥70% STR on the electrocardiogram obtained before percutaneous coronary intervention (PCI) as compared with the inclusion electrocardiogram. Results Complete STR before PCI occurred in 16.8% (n = 188/1121) and more frequently in the HDT group (19.0% vs 14.6%, P = .05). Independent predictors for complete STR before PCI were younger age (odds ratio [OR], 0.82; 95% confidence interval [CI], 0.70-0.96, P = .01 per 10 year increase), fast diagnosis (OR, 0.97; 95% CI, 0.97-1.0, P = .004 per 15-minute increase time from symptom onset to diagnosis), longer pretreatment time (OR, 1.09; 95% CI, 1.03-1.16, P = .003 per 15-minute increase time start study medication to angiography), and randomization to HDT (OR, 1.39; 95% CI, 1.0-1.9, P = .05). Complete STR before PCI was associated with very low 30-day (0.5% vs 2.8%, P = .07) and 1-year (1.1% vs 5.0%, P = .019) mortality. Conclusions Dual or triple antiplatelet pretreatment in the ambulance results in complete STR before PCI in 17% of patients. Fast ST-segment elevation myocardial infarction diagnosis, prehospital initiation of pretreatment early after symptom onset, and HDT independently predicted STR before PCI. Complete STR is associated with improved clinical outcome.

Alternative Donor Hematopoietic Cell Transplantation In 94 Patients with Fanconi Anemia at the University of Minnesota

AbstractAbstract 3526Alternative donor hematopoietic cell transplantation (AD-HCT) for patients with Fanconi anemia (FA) is challenging. We report on the outcomes of 94 patients with FA, median age 9.0 (range 1–33) years, who underwent AD-HCT at our institution from 1999–2010, using one of three consecutive prospective phase II total body irradiation (TBI) containing clinical trials. With each trial, one change was made from the previous trial to systematically study the optimal AD-HCT approach for FA patients. In Trial 1, from 1999–2003, fludarabine (FLU) 140 mg/m2 was added to the conventional cyclophosphamide (CY), antithymocyte globulin (ATG), TBI 450 cGy preparative regimen to overcome the high risk of graft failure. In Trial 2, from 2003–2006, CT guided thymic shielding (TS) was included during TBI to improve immune reconstitution. In Trial 3, from 2006–2010, a TBI dose-de-escalation trial with TS was performed to determine the lowest possible dose of TBI required for engraftment. All patients received CY 40 mg/kg, FLU 140 mg/m2, ATG and single fraction TBI using 150, 300 or 450 cGy, with or without TS as per specific protocol. Graft-versus-host disease (GVHD) prophylaxis consisted of cyclosporin A and methylprednisolone. Graft sources included T-cell depleted bone marrow (BM; n=75), single umbilical cord blood (UCB, n=17) or double UCB (n=2). At the time of HCT, 74 patients had aplastic anemia (AA) and 16 patients demonstrated early MDS defined as refractory anemia (RA, n=8), refractory anemia with ringed sideroblasts (RARS), RA with multilineage dysplasia (RCMD, n=4) or RCMD and ringed sideroblasts (RCMD-RS, n=4). One patient had RA with excess blasts-2 (RAEB-2) and 3 patients had acute myeloid leukemia (AML). For the entire cohort of 94 patients, probabilities of neutrophil and platelet engraftment were 97% and 75%, respectively. In Trial 3, two recipients of TBI 150 cGy developed secondary graft failure and dose de-escalation was stopped at TBI 300 cGy. For all patients, probabilities of grade II-IV and grade III-IV acute GVHD were 23% and 10%. Probability of chronic GVHD was 13%. In multivariate analysis of 89 patients (excluding 3 patients with GFR <40 and 2 recipients of TBI 150), higher 3-year mortality was associated with older age (>10 years), and any transfusions prior to HCT. Lower 3-year mortality was associated with Trial 3 (Table). Of the 8 patients in Trial 3 who were <10 years of age and never received transfusions before HCT, 7 are alive and well. Immune reconstitution and infectious disease data analyses are in progress.Based on the results of the largest single center analysis of alternative donor HCT for FA patients, four findings emerge: (1) TBI 300 cGy +TS with CY-FLU-ATG is sufficient for consistent engraftment but TBI 150 cGy +TS is not adequate; (2) rates of GVHD are low with T cell depletion; (3) patients with FA and marrow failure should be referred to HCT before receiving transfusions, and (4) superior survival is associated with CY-FLU-ATG-TBI 300+TS followed by T-cell depleted AD-BM or unmanipulated UCB, potentially due to enhanced immune recovery. Longer follow-up is required to determine whether this approach is associated with reduced late effects, particularly endocrinopathies and malignancy. Disclosures:Wagner:CORD:USE: Membership on an entity's Board of Directors or advisory committees; VidaCord: Membership on an entity's Board of Directors or advisory committees.

One-year Outcome After Neurosurgery for Intracranial Tumor in Elderly Patients

The number of elderly patients proposed for brain tumor removal is increasing. Only few data on long-term functional prognosis after intracranial surgery are available. Prospective, observational study of all patients greater than 70 year of age operated for intracranial tumors. Two scales for health status evaluation were used: Karnofsky Performance Scale (KPS) and Activities of Daily Living (ADL) score. Data were expressed as medians (first to third quartiles). The primary endpoint was the probability to remain nondependant (ADL>3 and KPS≥70%) after 1 year. Between 2003 and 2007, 90 patients were included: 46 (51.1%) meningioma, 17 (18.9%) high-grade glioma, and 11 (12.2%) metastasis. At hospital admission, age was 73.50 years (71.25-76.00), American Society of Anesthesiology score 2 (2 to 3), KPS 80% (70-90), ADL 5.5 (4.5 to 6.0). Two patients died during the first 28 days, 3 others during the first year. Both KPS and ADL decreased after 1 year: KPS 80% (70 to 90; mean: 80%) at hospital admission versus 80% (60 to 90) at 1 year (mean: 70%), P=0.003; ADL 5.5 (4.5 to 6.0) at hospital admission versus 5.0 (3.25 to 5.50) at 1 year, P=0.001. In multivariate analysis, 2 preoperative parameters were associated with autonomy at 1 year: the ADL at hospital admission and meningioma as histologic type. In this series of elderly patients, intracranial tumor surgery was associated with low 1-year mortality. Meningioma was associated with a better postoperative functional outcome. Preoperative ADL score was a predictive of functional evolution 1 year after the surgery.

Physician Consultation, Multidisciplinary Care, and 1‐Year Mortality in Medicare Recipients Hospitalized with Hip and Lower Extremity Injuries

To determine whether routine surgeon consultation with medicine specialists and multidisciplinary care conferences-potentially modifiable hospital characteristics-are associated with lower 1-year mortality in older adults with hip and lower extremity injuries. Retrospective cohort study. Oregon hospitals. Two thousand five hundred thirty-eight Medicare recipients aged 67 and older hospitalized in Oregon hospitals in 2002 with hip or lower extremity injuries. Demographic, injury, comorbidity, and survival information were gathered from Medicare records for 2000 to 2003. All Oregon hospitals with a qualifying case were surveyed using a structured telephone interview to collect information about routine surgeon consultations and multidisciplinary care conferences for older adult orthopedic patients. Multivariable generalized estimating equation models were used to estimate odds ratios (ORs) and 95% confidence intervals (CIs) for the associations between hospital characteristics and mortality. After adjusting for age, injury severity, comorbid conditions, trauma center status, and hospital annual volume of patients with hip fracture, the relative odds of dying in the year after injury for inpatients treated in settings with routine surgeon consultation with medical staff was 0.69 (95% CI 0.57-0.83) compared with patients not treated in such settings. Inpatient treatment in settings with routine multidisciplinary care conferences did not significantly affect the relative odds of dying in the year after injury (OR=1.06, 95% CI=0.89-1.26). Routine consultation by attending orthopedic surgeons with medicine or primary care specialists for Medicare inpatients is associated with better survival 1 year after injury.

Drug-eluting versus bare-metal stents in ST-segment elevation myocardial infarction: a mortality analysis from the EUROTRANSFER Registry

To assess the patterns of drug-eluting stent (DES) and bare-metal stent (BMS) implantation and associated real-life outcomes in patients with ST-segment elevation myocardial infarction (STEMI) transferred for primary percutaneous coronary intervention (PCI). Data were gathered for 1,650 consecutive STEMI patients transferred for primary PCI from hospital networks in seven countries of Europe from November 2005 to January 2007. We identified 1,428 patients with ≥1 stent implanted (86.5%). DES were implanted in 382 patients (26.8%) and BMS in 1,046 patients (73.2%) of 1,428 who received stent. High variability in DES use among countries participating in the registry (range from 6.8 to 72.1%) was observed. The use of DES in STEMI declined during the fourth quarter of 2006 through the first quarter of 2007. In the assessed population, age, previous PCI, systolic and diastolic pressures on admission, clopidogrel before admission, left anterior descending artery as the infarct-related artery, and thrombus aspiration device use were identified as the independent predictors of DES implantation. Use of DES was associated with significantly lower rates of ischemic events during follow-up (1-year mortality: BMS vs. DES: 6.7% vs. 3.1%; p = 0.014), but observed difference was no longer significant after adjustment for propensity score (adjusted OR (95% CI): 0.55 (0.28-1.06); p = 0.07). In this large, prospective European registry, the presence of large geographical and temporal variation of DES utilization in STEMI in Europe was confirmed. DES in STEMI appear to be as safe as BMS, with similar mortality after adjustment for potential confounders and trend toward lower 1-year mortality in patients treated with DES.

The 1-year mortality of patients treated in a hip fracture program for elders.

Comanagement of geriatric hip fracture patients with standardized protocols has been shown to improve short-term outcomes after surgery. A standardized, patient-centered, comanaged Hip Fracture Program for Elders is examined for 1-year mortality. Patients ≥60 years of age who were treated in the Hip Fracture Program for Elders were comanaged by orthopaedic surgeons and geriatricians. Data including age, place of origin, procedure, length of stay, 1-year mortality, Charlson score, and activities of daily living (ADLs) were retrospectively collected. A total of 758 patients ≥60 years of age with hip fractures between April 15, 2005, and March 1, 2009, were included. Their data were analyzed, and the Social Security Death Index and the hospital data system were searched for mortality data. Seventy-eight percent were female, with a mean age of 84.8 years. The mean Charlson score was 3. Fifty percent were admitted from an institutional setting. The overall 1-year mortality was 21.2%. Age (odds ratio [OR] = 1.03, 95% confidence interval [CI] = 1.00-1.05; P = .02), male gender (OR = 1.55, 95% CI = 1.01-2.36; P = .04), low Parker mobility score (OR = 2.94, 95% CI = 1.31-6.57; P = .01), and a Charlson score of 4 or greater (OR = 2.15, 95% CI = 1.30-3.55; P = .002) were predictive of 1-year mortality. ADL dependence was a borderline predictor, as was medium Parker mobility score. Prefracture residence and moderate comorbidity (Charlson score of 2-3) were not independently predictive of mortality at 1 year after adjusting for other characteristics. A comprehensive comanaged hip fracture program for elders not only improves the short-term outcomes but also demonstrates a low 1-year mortality rate, particularly in patients from nursing facilities.

Pre-Hospital Triage for Primary Angioplasty: Direct Referral to the Intervention Center Versus Interhospital Transport

We sought to study the impact of direct referral to an intervention center after pre-hospital diagnosis of ST-segment elevation myocardial infarction (STEMI) on treatment intervals and outcome. Primary angioplasty has become the preferred reperfusion strategy in STEMI. Ambulance diagnosis and direct referral to an intervention center is an attractive treatment option that has not been studied extensively. Consecutive pre-hospital patients with STEMI, who were referred to our intervention center for primary angioplasty between 2005 and 2007, were studied. After pre-hospital diagnosis, patients were either directly transported to our center or referred through a nonintervention center. The catheterization laboratory was activated before transport to the intervention center. Of the 581 patients referred, 454 (78%) came with direct transport and 127 (22%) through a nonintervention center. Direct transport was associated with a higher proportion of patients treated within the 90-min time window of the STEMI guidelines: 82% versus 23% (p < 0.01). Patients directly transported had a significantly shorter median symptom-to-balloon time of 149 min (Interquartile range: 118 to 197 min) versus 219 min (interquartile range: 178 to 315 min), p < 0.01, a higher post-procedural Thrombolysis In Myocardial Infarction (TIMI) flow grade 3 rate (92% vs. 84%; p = 0.03), and a lower 1-year mortality rate (7% vs. 13%; p = 0.03). Direct transport to the intervention center was independently associated with the symptom-to-balloon time, which in turn was an independent predictor of post-procedural TIMI flow grade 3, a strong prognosticator of outcome. After ambulance-based diagnosis of STEMI, direct transport to an intervention center with pre-hospital notification of the catheterization laboratory more than triples the proportion of patients treated within the time window of the guidelines. Time to balloon was an independent predictor of post-procedural TIMI flow grade 3, which underscores the need to reduce treatment delays.