Lower Risk Of Early Mortality Research Articles

The highly educated live longer: The role of time preference, cognitive ability, and educational plans.

Using Swedish data on a cohort born in 1953, interviewed in 1966 (age 13), and followed with register data until 2018 (age 65), this study shows that one more year of schooling predicts a 17% lower risk of early mortality. Addressing concerns of potential selection bias, the mortality inequality by educational attainment persists when extensive controls are included in the regression. Adding information on background health, gender, socioeconomic variables, as well as adolescents' early educational plans, cognitive ability, and time preferences, only result in a 2-percentage point change in the mortality risk by years of education. Even when adolescents' applications to upper-secondary school and years 6 and 9 grades are controlled for, completion of upper-secondary and university education remain strong predictors of future health. Yet, the study also finds that the measure of future health matters for the stability of the results.

Early mortality after inpatient versus outpatient catheter ablation in patients with atrial fibrillation

Rates of early mortality and complications after catheter ablation (CA) of atrial fibrillation (AF) vary across health care settings. The purpose of this study was to identify the rate and predictors of early mortality (within 30 days) after CA in the inpatient and outpatient settings. Using the Medicare Fee for Service database, we analyzed 122,289 patients who underwent CA for treatment of AF between 2016 and 2019 to define 30-day mortality in both inpatients and outpatients. Odds of adjusted mortality were assessed with several methods, including inverse probability of treatment weighting. Mean age was 71.9 ± 6.7 years, 44% were women, and mean CHA2DS2-VASc score was 3.2 ± 1.7. Overall, 82% underwent AF ablation as an outpatient. Mortality rate 30 days after CA was 0.6%, with inpatients accounting for 71.5% of deaths (P <.001). Early mortality rates were 0.2% for outpatient procedures and 2.4% for inpatient procedures. The prevalence of comorbidities was significantly higher in patients with early mortality. Patients with early mortality had significantly higher rates of postprocedural complications. After adjustment, inpatient ablation was significantly associated with early mortality (adjusted odds ratio [aOR] 3.81; 95% confidence interval [CI] 2.87-5.08; P <.001). Hospitals with high overall ablation volume had 31% lower odds of early mortality (highest vs lowest tertile: aOR 0.69; 95% CI 0.56-0.86; P <.001). AF ablation conducted in the inpatient setting is associated with a higher rate of early mortality compared with outpatient AF ablation. Comorbidities are associated with enhanced risk of early mortality. High overall ablation volume is associated with a lower risk of early mortality.

Heart Rate Variability Impairment Is Associated with Right Ventricular Overload and Early Mortality Risk in Patients with Acute Pulmonary Embolism.

The association between heart rate variability (HRV) and mortality risk of acute pulmonary embolism (APE), as well as its association with right ventricular (RV) overload is not well established. We performed an observational study on consecutive patients with confirmed APE. In the first 48 h after admission, 24 h Holter monitoring with assessment of time-domain HRV, echocardiography and NT-proBNP (N-terminal pro-B-type natriuretic peptide) measurement were performed in all participants. We pre-examined 166 patients: 32 (20%) with low risk of early mortality, 65 (40%) with intermediate-low, 65 (40%) with intermediate-high, and 4 (0.02%) in the high risk category. The last group was excluded from further analysis due to sample size, and finally, 162 patients aged 56.3 ± 18.5 years were examined. We observed significant correlations between HRV parameters and echocardiographic signs of RV overload. SDNN (standard deviation of intervals of all normal beats) correlated with echocardiography-derived RVSP (right ventricular systolic pressure; r = -0.31, p = 0.001), TAPSE (tricuspid annulus plane systolic excursion; r = 0.21, p = 0.033), IVC (inferior vena cava diameter; r = -0.27, p = 0.002) and also with NT-proBNP concentration (r = -0.30, p = 0.004). HRV indices were also associated with APE risk stratification, especially in the low-risk category (r = 0.30, p = 0.004 for SDNN). Univariate and multivariate analyses confirmed that SDNN values were associated with signs of RV overload. In conclusion, we observed a significant association between time-domain HRV parameters and echocardiographic and biochemical signs of RV overload. Impaired HRV parameters were also associated with worse a clinical risk status of APE.

Infective endocarditis of mitral valve, valve replacement or repair?- a meta-analysis of 10,965 patients

Abstract Background Being characterized by high mortality and recurrence rates, native mitral valve infective endocarditis (IE) constitutes a burden on both patients and surgeons from its poor prognosis and debatable interventions. Mitral valve repair (MVRr) and mitral valve replacement (MVRp) are two main surgical methods. Nevertheless, which of them carries an outweigh benefit over the other is still controversial. Thus, in our meta-analysis we aimed to further investigate the efficacy of each technique on both short term and long-term outcomes. Methods Our search strategy was applied on several databases including the PubMed, Scopus, Web of science, and Cochrane literature databases to compare MVP and MVR, with data extracted for baseline characteristics, mortality, survival, recurrent endocarditis, and valve reoperation. Risk and hazard ratio (RR and HR) and 95% confidence interval (CI) were pooled and analyzed using RevMan 5.0. Results A total of 22 relevant publications with a total population of 10,965 patients, with 3,557 patients having undergone MVRr and 7,408 patients having undergone MVRp, respectively, were analyzed. Patients who underwent MVP may benefit from a lower risk of early mortality (RR 0.44; 95% CI, 0.38–0.51; p&amp;lt;0.00001; I2=0%), a higher long-term survival rate (HR 0.56; 95% CI, 0.36–0.76; p&amp;lt;0.001; I2=0%), and a lower risk of recurrence (RR 0.66; 95% CI, 0.40–0.93; p=0.05; I2=0%). Although the risk of reoperation was observed lower for MVRr, it was not statistically significant (RR, 0.86; 95% CI, 0.36–1.36; p=0.76; I2=37%). Conclusion Our results suggests that MVRr showed superiority in the terms of in hospital mortality and long-term survival. Furthermore, it has lower risk of recurrence and valve reoperation. Therefore, MVRr is an appropriate as a primary treatment choice and should be considered whenever possible in most IE patients. Conclusion Our results suggests that MVRr showed superiority in the terms of in hospital mortality and long-term survival. Furthermore, it has lower risk of recurrence and valve reoperation. Therefore, MVRr is an appropriate as a primary treatment choice and should be considered whenever possible in most IE patients. Funding Acknowledgement Type of funding sources: None.

Valve replacement or repair in native mitral valve infective endocarditis-Which is better? A meta-analysis and systematic review.

Native mitral valve infective endocarditis (IE) plagues patients and surgeons alike because of its high mortality and recurrence rates as well as poor prognosis. Mitral valve repair (MVP) and mitral valve replacement (MVR) are two main surgical methods. However, the question of which benefits patients more remains controversial. Thus, we conducted a meta-analysis to systematically review the two approaches, focusing on the early survival rate and long-term outcomes. A meta-analysis and systematic review were conducted using studies sourced from the PubMed, Embase, and Cochrane literature databases to compare MVP and MVR, with data extracted for baseline characteristics, mortality, survival, recurrent endocarditis, and valve reoperation. Risk ratio (RR) or hazard ratio (HR) values were calculated, and publication bias was tested. A total of 17 relevant publications with a total population of 3759 patients, with 1180 patients having undergone MVP and 2579 patients having undergone MVR, respectively, were analyzed. Patients who underwent MVP may benefit from a lower risk of early mortality (RR, 0.51; 95% confidence interval [CI], 0.39-0.66; p < .00001), a higher long-term survival rate (HR, 0.69; 95% CI, 0.58-0.81; p < .001; I2 = 0%), and a lower risk of recurrence (RR, 0.66; 95% CI, 0.40-1.09; p = .10; I2 = 0%). However, a similar risk of reoperation was observed for both groups (RR, 1.02; 95% CI, 0.36-2.91; p = .96; I2 = 43%). This meta-analysis suggests that MVP may lead to better outcomes compared to MVR. Among patients with mitral valve IE, MVP can reduce in-hospital mortality, improve long-term survival, and has a lower risk of recurrent endocarditis. As a result, MVP may be suitable as a primary treatment choice and should be considered whenever possible in most IE patients.

Comparison of in-hospital outcomes and 30-days readmissions between type 1 and type 2 myocardial infarction patients: a study of the nationwide readmissions database

Abstract Introduction Traditionally Type- 1 myocardial infarction (T1-MI) results from a plaque erosion, rupture, or fissure. In contrast, Type- 2 myocardial infarction (T2-MI) is a consequence of severe supply and demand mismatch. Despite the different mechanisms, both T1-MI and T2-MI can be associated with severe morbidity and mortality. Yet there is sparse data analyzing in-hospital outcomes and readmission rates comparing patients who present with T1-MI and T2-MI. Purpose We aimed to compare the outcome data of patients with T1-MI and T2-MI derived from the Nationwide Readmissions Database, a large national database of hospital readmissions. Method We utilized the 2018 Nationwide Readmissions Database to identify all index hospital admissions with a primary diagnosis of “acute MI” (AMI) using ICD-10 diagnosis codes. All AMI admissions were further categorized into ST-elevation myocardial infarction (STEMI), no-ST-elevation myocardial infarction (NSTEMI), or T2-MI. Primary outcomes analyzed included 30-days major adverse cardiovascular events (MACE) (defined as re-infarction, repeat revascularization and death within 30 days of admission), short term mortality and readmission rates. Results Among 556,816 total admissions for AMI, 28,250 (5.1%) were T2-MI. Table 1 compares baseline variables and short-term outcomes for patients with T1-MI vs T2-MI. Compared to patients with T1-MI patients with T2-MI were older, more likely to be female, and had a higher burden of comorbidities. Additionally, T2-MI patients were less likely to receive coronary revascularization during the index admission. The mean length of stay for T2-MI patients was 4.7±0.6 days, which is longer than the length of stay for STEMI patient (4.1±0.4 days) but slightly shorter than NSTEMI patient (4.9±0.4 days). T2-MI patients had a higher rate of all-cause 30-days readmissions but a lower rate of 30-days MACE. Early mortality rate (within 30 days of index admission) in T2-MI patients was comparable to NSTEMI patients but was lower than STEMI patients. Cox proportional-hazards model adjusting for age, sex, comorbidities and type of hospital setting demonstrated that T2-MI was associated with a lower 30-day MACE risk (T2-MI vs STEMI: [HR 0.33 (95% CI 0.31–0.36)]; T2-MI vs NSTEMI [HR 0.70 (95% CI 0.64–0.75)]) and a lower risk of early mortality (T2-MI vs STEMI: [HR 0.29 (95% CI 0.26–0.32)]; T2-MI vs NSTEMI [HR 0.71 (95% CI 0.65–0.79)]). The adjusted HR for 30-days all-cause readmissions was higher with T2-MI, (T2-MI vs STEMI: [HR 1.16 (95% CI 1.10–1.23)]; T2-MI vs NSTEMI: [HR 1.11 (95% CI 1.06–1.16)]). Conclusion T2-MI patients are older and have a higher burden of comorbidities. After adjusting for baseline comorbidities, all-cause readmission risk is higher in T2-MI but short-term MACE and mortality is lower with T2-MI. Funding Acknowledgement Type of funding sources: None.

Epidemiology and Analysis of Early Mortality of Patients with Multiple Myeloma in Russia According to the Kirov Regional Population-Based Database

Multiple myeloma (MM) is a heterogeneous disease with the survival ranges from a few months to 10 years and more. The prevalence of MM varies according to ethnicity and geographical backgrounds. The real incidence of this disease in Russia is poorly understood. Available data are limited. Although the survival of MM patients has increased over the past 10-15 years, there is still a proportion of patients who die within a few months during induction therapy. The aim of this study was to examine the incidence of MM in Russia, describe characteristics of newly diagnosed MM patients, and assess patient survival, using the data from a population-based primary care database. Moreover we identified the clinical and laboratory features that are associated with early death within the first 12 months after initiation of antimyeloma therapy.Methods. Patients with new diagnosed MM were identified in the Kirov regional population-based primary care database (dates of diagnosis ranged from 01 Jan 1994 to 31 Dec 2016). Demographic and clinical characteristics were described at time of diagnosis. Median overall survival (OS) was estimated using Kaplan-Meier methods using individual patient level data from diagnosis date to date of death or end of follow-up. Survival rates were stratified by 5-year periods by calendar year of diagnosis: 1994-1999, 2000-2005, 2006-2011 and 2012-Dec 2016.Results. The five hundred and sixty seven patients with new diagnosed MM (male - 215, female - 352) were included in this study. Median age of the patients was 64 years (range, 29-90 years). The age-standardized incidence of MM was 1.8 cases per 100.000/year. During research period (23 years) we have the positive trend of the incidence and prevalence of MM and negative tendency of mortality every year. Our prognosis of the intensive incidence is 2.2-2.3 cases per 100.000 in 2017-2019 years. The 5-year OS rate was 18% (1994-1999); 24% (2000-2005) and 36% (2006-2011) respectively (Fig. 1). The median OS was 28; 26 and 38 months respectively. The median OS for patients who diagnosed in the period 2012-2016 was not achieved.The incidence of early mortality was different in selected observation periods. In particular it was 45% between 1994 and 1999, 43% in 2000-2005, 36% in 2006-2011 and 11% between 2012 and 2016. These frequencies differed from each other (X-squared = 22.125, df = 3, p-value = 6.143e-05). The impact of age, hemoglobin and platelets levels, serum creatinine, LDH, albumin, B2-microglobulin, plasma cells in bone marrow, immature plasma cells in bone marrow, Durie-Salmon stage, IgA type and treatment by proteasome inhibitors (bortezomib) were estimated as predictors of a short survival rate. Based on the results of univariate analysis age, Durie-Salmon stage III, bortezomib treatment, hemoglobin level, B2-microglobulinum, serum creatinine and albumin were found to be significant (p<0.05). These factors were evaluated in multivariate analysis. In multivariate analysis the strongest predictors of death within <12 months were hemoglobin level (HR: 0.97, 95% CI: 0.94-0.99, p=0.04), B2-microglobulin (HR: 1.09, 95% CI: 1.03-1.15, p=0.002) and using bortezomib in treatment (HR: 0.17, 95% CI: 0.05-0.45, p=0.0007). According analysis the using bortezomib in treatment of MM patients reduce risk of early mortality in 5.9 times. The odds ratio for dying in the first year was 0.13 (CI: 0.07-0.25) for patients receiving a bortezomib compared to the rest.Conclusion. The age-standardized incidence of MM in Kirov region (Russia) was 1.8 cases per 100.000/year. 5y-OS was 18% (1994-1999); 24% (2000-2005) and 36% (2006-2011). In newly diagnosed MM low hemoglobin level and high B2-microglobulin levels were associated with high risk of early mortality (<12 months after initiation of antimyeloma therapy). In 2006-2016 recent years a novel agents (bortezomib, lenalidomide) for treating MM have been introduced, which according to our database is associated good outcome and low risk of early mortality. [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

A Meta-Analysis of the Prognostic Accuracy of Clinical Prediction Rules for Post-Pulmonary Embolism Mortality in Patients with Cancer

Introduction: Pulmonary embolism (PE) is a common complication of cancer and its treatments; it is a leading cause of morbidity and mortality in patients with malignancy. While extensive work has been done in evaluating PE risk of patients with cancer, there are limited data on the prognostication of adverse outcomes when these patients do experience an event. Guidelines recommend the use of clinical prediction rules to help clinicians identify patients at low- and higher-risk for adverse outcomes and guide the appropriate level of care. However, no single clinical prediction rule has been shown to be superior in stratifying these patients. Thus, we sought to determine the accuracy of clinical prediction rules for identifying patients with cancer and acute PE at low risk for mortality.Methods: A systematic literature search of Medline and Scopus from January 1, 2000 through July 1, 2017 was performed, along with a manual search of references. Studies deriving/validating at least one clinical prediction rule for early post-PE all-cause mortality in patients with cancer and providing mortality data over at least the index PE hospitalization but not longer than 90 days were included. Only full-text, English-language articles were included. A bivariate model was used to pool sensitivity and specificity estimates for each clinical prediction rule using a random-effects approach. Traditional random effects meta-analysis was performed to estimate the weighted proportion of patients deemed at low risk for early mortality and their odds ratios for death compared with high-risk patients. Statistical heterogeneity was assessed with the I2 statistic with values >50% deemed as high.Results: We identified 1,104 non-duplicate citations from our literature search. Eight studies evaluating ten clinical prediction rules in 3,974 (range 124 to 1,075) unique patients were ultimately included in our meta-analysis (Table). Mean/median patient age ranged from 59 to 71 years. The majority of included patients were receiving chemotherapy and/or radiotherapy (50 to 75% of patients), and metastatic disease was observed in 49% to 74% of patients. The Hestia and EPIPHANY index rules displayed the highest sensitivities (98.1% [95% CI = 75.6% to 99.9%] and 97.4% [95% CI = 93.2% to 99.0%], respectively) with the remaining rules' sensitivities ranging from 0.88 to 0.97; only the GPS tool had a sensitivity of 0.60. Of the six clinical prediction rules with sensitivities ≥95%, none had specificities >33%. Traditional random-effects meta-analysis suggested anywhere from 6.6% to 51.6% of cancer patients with PE were at low risk and that low-risk patients had a 43% to 94% lower odds of death compared with those at high risk.Conclusions: There is a limited total body of evidence on the ten clinical prediction rules included in our meta-analysis. As such, the results of clinical prediction rules as well as other patient-specific clinical factors should continue to be used in identifying appropriate treatment for patients with cancer experiencing an acute PE. [Display omitted] DisclosuresColeman:Bayer AG: Consultancy, Honoraria, Research Funding; Janssen Pharmaceuticals: Consultancy, Honoraria, Research Funding; Boehringer Ingelheim: Consultancy, Honoraria.

Non-O blood group is associated with lower risk of in-hospital mortality in non-surgically managed patients with type A aortic dissection

BackgroundThe association between different ABO blood groups and mortality of aortic dissection (AD) remains controversial. This study aimed to examine whether different ABO blood groups affect the prognosis of AD.MethodsDemographic and clinical data were collected from 877 patients diagnosed with AD from 2015 to 2019 in the First Affiliated Hospital of Shantou University Medical College. The association between in-hospital mortality of AD patients and ABO blood group was analyzed using Cox proportional hazards regression models.ResultsThis retrograde cohort study demonstrated that for 877 patients, male gender, non-O blood group, Stanford type B AD (TBAD), higher presenting systolic and diastolic blood pressure, and being a recipient of aortic arch replacement surgery (surgery) or endovascular stent-graft implantation (stent-graft) were associated with decreased in-hospital mortality of AD. In Cox proportional hazards models, non-O blood group was associated with lower risk of early mortality regardless of adjustment (HR = 0.668, 95% confidence interval [CI] 0.473–0.944 before adjustment, HR = 0.662, 95% CI 0.468–0.935 after adjustment for age and sex, and HR = 0.641, 95% CI 0.453–0.906 after adjustment for AD types, SBP and surgery). Further analyses revealed that for patients diagnosed with type A AD (TAAD), non-O blood group renders a significant 34.3% decrease in the risk of in-hospital mortality compared with blood group O. Specifically, this difference in mortality risk was found among TAAD patients who did not undergo surgery (HR = 0.579, 95% CI 0.377–0.889), rather than those who did. There was no significant difference in early mortality for patients with TBAD, whether or not stent-grafts were implanted.ConclusionsNon-O blood type decreases the risk of in-hospital mortality, especially for TAAD, in AD patients without surgical intervention. More attention must be paid to blood type O TAAD patients without surgical interventions, and early surgical intervention may be an effective means to decrease in-hospital mortality of TAAD.

Outcomes following self-expanding transcatheter or surgical aortic valve implantation in patients at low operative risk stratified by need for revascularization

Abstract Background Self-expanding transcatheter aortic valve implantation (TAVI) was non-inferior to surgical aortic valve replacement (SAVR) in a randomized clinical trial of patients with severe aortic stenosis at low operative risk. Randomization was stratified by the need for revascularization, but it remains unclear how this has impacted the results of TAVI and SAVR. Purpose To compare TAVI and SAVR outcomes in a prespecified analysis according to the need for revascularization. Methods A total of 1403 patients underwent attempted TAVI (n=725) or SAVR (n=678) at 87 centres worldwide. Patients were deemed at low risk of early mortality (&amp;lt;3%) confirmed by a national screening committee. Patients were stratified by site and need for revascularization based on heart team assessment. The trial used a Bayesian study design for the 2-year primary analysis and an interim analysis was performed when 850 patients had reached 1-year follow-up. Results There were 85/725 (11.7%) TAVI patients and 79/678 (11.7%) SAVR patients identified as needing revascularization. Previous CABG had occurred in 3 (1.8%) patients and previous PCI had been performed in 31 (18.9%) patients. The baseline characteristics for the TAVI and SAVR cohorts are shown in the table. In the TAVI revascularization group, 44 of 85 (51.8%) received PCI concomitant or staged with TAVI and 6 of 639 (0.9%) received PCI in the no revascularization group. In the SAVR revascularization group, 65 of 79 (82.3%) underwent concomitant CABG and 27 of the 599 (4.5%) patients in the no revascularization group had concomitant CABG. Kaplan-Meier estimates of 1-year all-cause mortality or disabling stroke at the time of the interim analysis are provided for TAVI and SAVR patients by need for revascularization (Table). Conclusions The proportion of low-risk patients needing revascularization was small in this low risk population. The complete 1-year follow-up for the entire 1403 patient cohort will be available for presentation in August. Funding Acknowledgement Type of funding source: Private company. Main funding source(s): Medtronic, plc

The Tricuspid Valve in Single-Ventricle Patients: Forgotten, Unforgivable, and Indispensable

The Tricuspid Valve in Single-Ventricle Patients: Forgotten, Unforgivable, and Indispensable

Short-term survival prediction scale in patients with metastatic brain disease caused by lung and breast cancer

To develop a prognostic scale suitable for distinguishing a group of poor prognosis with low survival prior to deciding on the appropriateness of radiotherapy. We analyzed only those patients with reliably known date of death after previous WBRT to determine objective criteria allowing WBRT abandonment. WBRT was carried out in 100 patients with non-small cell lung cancer (n=49) and breast cancer (n=51) and confirmed metastatic brain disease. All procedures have been conducted at the radiotherapy department of the Herzen Moscow Oncology Research Institute since January 2014. The prescribed dose of 3 Gy was ensured in all patients. Total focal dose of 30 Gy delivered in 10 fractions was achieved in 77 cases, 36 Gy delivered in 12 fractions - in 23 cases. Death date was recorded in all patients (n=100) by January 2020. In the electronic SPSS database, death information was digitized for each patient up to 2-24 months, respectively. We identified eight the most significant factors by using of correlation analysis: primary tumor (controlled (0), uncontrolled (1)), number of brain metastases (<17 (0), ≥17 (1)), volume of brain metastases (<48 cm3 (0) ≥48 cm3 (1)), extracranial control (no metastases (0), metastases with positive dynamics after chemotherapy (1), continued growth after chemotherapy (2)), metastatic lesion of liver and lungs, respectively (no (0), yes (1)), functional status (≥ 70% (0), ≤ 60% (1)), carcinomatosis of the meninges (no (0), yes (1)). A simple summation of digital variables for factors 1-8 in each patient resulted a prognostic scale. Low risk of early mortality after WBRT was determined by 0-3 scores, intermediate risk - 4-5 scores, high risk - 6-9 scores. According to univariate analysis (log-rank 0.000), median survival rate varied in these groups: low risk - 15.5 months (11.4-19.7), intermediate risk - 5.26 months (4.6-6.0), high risk - only 1.35 months (0.9-1.8). Only 1 out of 15 high-risk patients (6-9 scores) survived 3 months (3.25 months). Inclusion of all eight factors into multivariate analysis revealed significant impact of only risk group on short-term survival. A 3-month survival in the high-risk group was 20.6 times lower (p=0.002) compared to the low and intermediate risk groups. High significance of prognostic model and low informative value of each of the included factors emphasize the advisability of determining risk groups for short-term survival according to the suggested scale for each patient scheduled for WBRT. A simple assessment of separate predictors is pointless to decide whether WBRT is necessary.

The relationship between platelet-to-lymphocyte ratio and pulmonary embolism severity in acute pulmonary embolism.

The aim of this study was to determine the level of platelet-to-lymphocyte ratio (PLR) and neutrophil-to-lymphocyte ratio (NLR) in patients with acute pulmonary embolism (APE) according to high and low risk for early mortality based on simplified Pulmonary Embolism Severity Index (sPESI). In addition, it was investigated the relationship between PLR and NLR with systolic pulmonary artery pressure (sPAP), cardiac markers, disease severity and hospital, 1th month, 3th month and 3-month total mortality. Our hospital's electronic patient database was searched for the patients with APE during last year and eighty-two patients retrospectively evaluated. Plasma D-dimer, troponin I (TnI), brain natriuretic peptide (BNP), hemogram values, sPAP from echocardiographic findings were recorded from database system. Hospital mortality was determined from files of cases and 1th, 3th month mortality and survival information were determined by phone calls with the patient and/or relatives. A percentage of 67.1% (55) of APE cases had sPESI≥1. There was no significant difference for age and sex between high and low risk patients according to sPESI (P>0.05). The mean serum BNP, TnI, sPAP, neutrophil counts, platelet counts, PLR and NLR was statistically increased and lymphocyte counts was statistically decreased in high risk patients according to sPESI compared with low risk patients (P<0.01 for BNP, PLR and NLR; P<0.05 for TnI, sPAP, neutrophil and platelet; P<0.01 for lymphocyte). There was no significantly difference for hospital and total 3-month mortality between high and low risk patients (P>0.05). When the cut-off value of PLO was taken as ≥156 by ROC analysis for the predicting of high sPESI, PLR had an area under the curve (AUC) in the receiver operating characteristic (ROC) curve of 0.704 (0.591-0.816; 95% CI; P<0.01) and the cut-off value of NLR was taken as ≥3.56 by ROC analysis for the predicting of high sPESI, NLR had an area under the curve (AUC) in the receiver operating characteristic (ROC) curve of 0.675 (0.556-0.794; 95% CI; P<0.05). An NLR level of 3.56 was taken as the cut-off between high and low risk patients according to sPESI, NLR had a sensitivity of 66% and specificity of 53%. When the cases were evaluated as two groups according to the cut-off value of 156; total 3-month mortality was statistically increased (χ2=6.896, P<0.01) and when the cases were evaluated as two groups according to the based NLR cut-off value of 3.56; hospital mortality, 3th month mortality and total 3-month mortality was statistically increased (χ2=4.771, P<0.05; χ2=4.383, P<0.05; χ2=9.101, P<0.01 respectively). PLR and NLR increased in patients with high risk, and PLR may have predicting value for 3-month mortality while NLR may have predicting value for hospital mortality, 3th month mortality and total 3-month mortality in patients with APE.

Clinical prediction rules for mortality in patients with pulmonary embolism and cancer to guide outpatient management: a meta‐analysis

Background Cancer treatment is commonly complicated by pulmonary embolism (PE), which remains a leading cause of morbidity and mortality in these patients. Some guidelines recommend the use of clinical prediction rules (CPRs) to help clinicians identify patients at low risk of mortality and therefore guide care. Objective To determine and compare the accuracy of available CPRs for identifying cancer patients with PE at low risk of mortality. Methods A literature search of Medline and Scopus (January 2000 to August 2017) was performed. Studies deriving/validating ≥1 CPR for early post-PE all-cause mortality were included. A bivariate, random-effects model was used to pool sensitivity and specificity estimates for each CPR. Traditional random-effects meta-analysis was performed to estimate the weighted proportion of patients deemed at low risk of early mortality, mortality in low risk patients and odds ratios for death compared with higher-risk patients. Results Eight studies evaluating 10 CPRs were included. The highest sensitivities were observed with Hestia (98.1%, 95% confidence interval [CI]=75.6-99.9%) and the EPIPHANY index (97.4%, 95% CI=93.2-99.0%); sensitivities of remaining rules ranged from 59.9 to 96.6%. Of the six CPRs with sensitivities ≥95%, none had specificities >33%. Random-effects meta-analysis suggested that 6.6-51.6% of cancer patients with PE were at low risk of mortality, 0-14.3% of low-risk patients died and low-risk patients had a 43-94% lower odds of death compared with those at higher risk. Conclusions Because of the limited total body of evidence regarding CPRs, their results, in conjunction with other pertinent patient-specific clinical factors, should continue to be used in identifying appropriate management for PE in patients with cancer.

Early and Midterm Results of the Arterial Switch Operation: A 9-Year, Single-Center Experience.

The arterial switch operation (ASO) has become the surgical approach of choice for transposition of the great arteries. The aim of this paper was to describe the outcomes in patients who underwent arterial switch operation and to analyze the predictors of in-hospital mortality and further need for reoperation at a single-center institution. We reviewed our 9-year experience with arterial switch operation (ASO) for transposition of the great arteries (TGA) or Taussig-Bing anomaly (TBA) to assess the early and midterm outcomes. Between January 2007 and May 2016, 34 consecutive patients who underwent ASO for TGA with IVS; and TGA with ventricular septal defect (VSD); and double outlet right ventricle (DORV) with subpulmonary VSD at our institution were included in this retrospective study. The same surgeons operated on all patients. Patients' charts, surgical reports, and echocardiograms were retrospectively reviewed. Median follow-up time ranged from 1 to 9 years, 54.2 (0.4-108) months. There were 2 (5%) in-hospital deaths. Late death occurred in 1 (2.9%) of 32 survivors. One patient (2.9%) required reintervention. The freedom from reintervention rate was 95.9 ± 1.8% at 9 years. Two patients (3.9%) developed moderate neoaortic regurgitation during the follow-up and one patient underwent reoperation mainly for neopulmonary artery stenosis. The analysis showed that weight, cross-clamp (CC) time, cardiopulmonary bypass (CPB) time, and age of operation are strong predictors for mortality. ASO remains the procedure of choice for the treatment of various forms of TGA with acceptable early and midterm outcome, and can also be performed with a low risk of early mortality and satisfactory midterm outcomes even in a small-volume center. Early and midterm survival is excellent after arterial switch operation.

External validation of a claims-based and clinical approach for predicting post-pulmonary embolism outcomes among United States veterans.

The In-hospital Mortality for PulmonAry embolism using Claims daTa (IMPACT) rule can accurately identify pulmonary embolism (PE) patients at low risk of early complications using claims data. We sought to externally validate the IMPACT and simplified Pulmonary Embolism Severity Index (sPESI) tools for predicting all-cause mortality and readmission. We used Veteran Health Administration data (10/1/2010-9/30/2015) to identify adults with ≥1 inpatient diagnosis code for acute PE, ≥12months continuous medical and pharmacy benefits prior to the index PE, ≥90days of post-event follow-up (unless death occurred) and ≥1 claim for an anticoagulant during the index PE stay. Prognostic accuracies of IMPACT and sPESI for 30- and 90-day all-cause mortality and 90-day readmission were estimated. Of 6,746 PE patients, 7.5 and 12.6% died at 30 and 90days. Within 90days, 20.1% were readmitted for any reason. Hospitalization for recurrent VTE and major bleeding occurred in 5.6 and 1.7% of patients. IMPACT classified 15.2% as low risk, while 28.4% were low risk per sPESI. Both tools displayed sensitivity >90% and negative predictive values (NPVs) >97% for 30-day mortality, but low specificity (range 16.2-30.0) and positive predictive values (PPVs) (range 8.7-9.5); with similar results observed for 90-day mortality. IMPACT's sensitivity for all-cause readmission was numerically higher than sPESI (88.2 vs. 79.0%), but both had comparable NPVs (85.1 vs. 84.2%). Similar trends were observed for VTE or major bleeding readmissions. IMPACT classified patients for post-PE outcomes with similar accuracy as sPESI. IMPACT appears useful for identifying PE patients at low risk for early mortality or readmission in claims-based studies.

External Validation of the Hestia Criteria for Identifying Acute Pulmonary Embolism Patients at Low Risk of Early Mortality.

There are limited studies evaluating the ability of the Hestia criteria to accurately identify patients with acute pulmonary embolism (PE) at low risk of early mortality. We sought to externally validate the Hestia criteria for predicting in-hospital and 30-day post-PE mortality. We retrospectively identified consecutive, adult, objectively confirmed PE patients presenting to the emergency department at our institution from November 21, 2010, to January 31, 2014. We ascertained the total number of Hestia criteria met for each patient, calculated the proportion of patients categorized as low risk (ie, no Hestia criteria met), and determined the accuracy of the Hestia criteria for predicting in-hospital and 30-day all-cause mortality. Mortality was determined through Social Security Death Index searches. A total of 577 patients with PE were included, of which 19 (3.3%) and 35 (6.6%) died in hospital or within 30 days of presentation. Both in-hospital and 30-day case fatality rates rose as the number of Hestia criteria increased. One-hundred forty nine (25.8%) patients were classified as low risk for early mortality, and none of these patients died within 30 days (negative predictive values of 100%). The Hestia criteria had excellent sensitivity (100%, 95% confidence interval [CI] = 79.1%-100% and 100%, 95% CI = 87.7%-100%) for predicting in-hospital and 30-day mortality but low specificity (<27.5% for both). The c-statistics for in-hospital and 30-day mortality were 83.5%, 95% CI = 77.1%-89.9% and 78.5%, 95% CI = 71.9%-85.1%. The predictive accuracy of the Hestia criteria remained acceptable in patients >80 years of age, with active cancer or chronic cardiopulmonary disease. The Hestia criteria have an acceptable predictive accuracy to identify patients with PE at low risk for in-hospital or 30-day mortality.

On-pump beating-heart technique is associated with lower morbidity and mortality following coronary artery bypass grafting: a meta-analysis.

A hybrid procedure of beating-heart coronary artery bypass grafting (CABG) with the concomitant use of cardiopulmonary bypass termed on-pump beating-heart CABG (ON-BH CABG) has emerged as an alternative for high-risk patient populations. Although several studies have reported the advantage of ON-BH CABG in high-risk patients, the clinical benefit of ON-BH CABG is still under discussion. Here, we performed a meta-analysis of the data derived from published studies comparing the clinical outcomes of ON-BH CABG with that of conventional arrested heart CABG. Medline, Embase and Scopus databases were searched for relevant publications up to March 2015. A systematic review of the published literature identified 14 published studies incorporating 2040 patients (884 ON-BH CABG and 1156 conventional CABG). Odds ratios (ORs) for binary variables or weighted mean difference for continuous variables were combined using the inverse variance method in a fixed-effects model. Study heterogeneity was tested using Cochran's Q test and the publication bias was assessed using Begg's and Egger's tests. The fixed-effects meta-analysis for early mortality showed that ON-BH CABG provided a 45% lower risk of early mortality compared with conventional CABG (OR 0.553; 95% confidence interval [CI] 0.376-0.815; P = 0.003). There was minimal heterogeneity in the included studies (P = 0.29) and no evidence of significant publication bias. A sensitivity analysis, including a random-effects meta-analysis (OR 0.552; 95% CI 0.356-0.856; P = 0.008) and a one-study-removed meta-analysis, supported the validity of the primary analysis for early mortality. There was significantly lower perioperative morbidity associated with ON-BH CABG, including myocardial infarction (OR 0.294; 95% CI 0.141-0.613; P = 0.001), renal failure (OR 0.362; 95% CI 0.209-0.626; P < 0. 001) and low output syndrome (OR 0.330; 95% CI 0.197-0.551; P < 0.001) with no significant heterogeneity. In conclusion, current evidence from comparative studies indicates that ON-BH CABG is associated with significantly lower early morbidity and mortality. The ON-BH CABG could be an attractive planned alternative for high-risk patient populations.

Current expectations of the arterial switch operation in a small volume center: a 20-year, single-center experience.

BackgroundWe reviewed our 20-year experience with arterial switch operation (ASO) for transposition of the great arteries (TGA) or double outlet right ventricle with subpulmonary ventricular septal defect (Taussig-Bing anomaly) to assess the early and long-term outcomes.MethodsBetween January 1995 and December 2014, 139 consecutive patients who underwent ASO for TGA or Taussig-Bing anomaly were included in this retrospective study. The median age at the operation was 9 (0–485) days, and 97 patients (70 %) underwent ASO less than 2 weeks. The median weight was 3.3 (2.1-10.3) kg. The patients were divided into three groups; simple TGA (n = 78) included patients with TGA with intact ventricular septum, complex TGA (n = 46) included those who had TGA with ventricular septal defect or other anomalies, and Taussig-Bing anomaly (n = 15). Median follow-up duration was 72.5 (0.4-230) months.ResultsThere were 3(2.2 %) in-hospital deaths. One patient (0.7 %) underwent early reoperation due to coronary insufficiency. Late deaths occurred in 3 (2.2 %) of 136 survivors. The Kaplan-Meier’s survival rate was 97.6 ± 1.4 % at 15 years. Twenty-three patients (16.9 %) required 26 reintervention. The freedom from reintervention rates were 82.5 ± 3.7 % at 5 years and 75.8 ± 4.7 % at 10 years, respectively. Median interval between ASO and first reintervention was 22.8 (6.4-89.2) months. The multivariate analysis showed that diagnosis of Taussig-Bing anomaly (hazard ratio, 7.09; P < 0.001) and side by side great artery relationship (hazard ratio, 7.98; P = 0.001) were independent risk factors for reoperation. Five patients (3.9 %) had developed at least moderate neo-aortic regurgitation during the follow-up and one patient underwent reoperation mainly for neo-aortic regurgitation. By multivariate analysis, Taussig-Bing anomaly was the risk factor for at least moderate neo-aortic regurgitation (P = 0.035).ConclusionsASO can be performed with a low risk of early mortality and satisfactory long-term outcomes even in a small volume center. Close long-term surveillance is mandatory to detect structural or hemodynamic changes.

Prognostic Accuracy of Clinical Prediction Rules for Early Post-Pulmonary Embolism All-Cause Mortality: A Bivariate Meta-analysis

BACKGROUND: Studies suggest outpatient treatment or early discharge of patients with acute pulmonary embolism (aPE) is reasonable for those deemed to be at low risk of early mortality. We sought to determine clinical prediction rule accuracy for identifying patients with aPE at low risk for mortality.METHODS: We performed a literature search of Medline and Embase from January 2000 to March 2014, along with a manual search of references. We included studies deriving/validating a clinical prediction rule for early post-aPE all-cause mortality and providing mortality data over at least the index aPE hospitalization but ≤ 90 days. A bivariate model was used to pool sensitivity and specificity estimates using a random-effects approach. Traditional random-effects meta-analysis was performed to estimate the weighted proportion of patients deemed at low risk for early mortality and their ORs for death compared with high-risk patients.RESULTS: Forty studies (52 cohort-clinical prediction rule analyses) reporting on 11 clinical prediction rules were included. The highest sensitivities were observed with the Global Registry of Acute Coronary Events (0.99, 95% CI = 0.89-1.00), Aujesky 2006 (0.97, 95% CI = 0.95-0.99), simplified Pulmonary Embolism Severity Index (0.92, 95% CI = 0.89-0.94), Pulmonary Embolism Severity Index (0.89, 95% CI = 0.87-0.90), and European Society of Cardiology (0.88, 95% CI = 0.77-0.94) tools, with remaining clinical prediction rule sensitivities ranging from 0.41 to 0.82. Of these five clinical prediction rules with the highest sensitivities, none had a specificity > 0.48. They suggested anywhere from 22% to 45% of patients with aPE were at low risk and that low-risk patients had a 77% to 97% lower odds of death compared with those at high risk.CONCLUSIONS: Numerous clinical prediction rules for prognosticating early mortality in patients with aPE are available, but not all demonstrate the high sensitivity needed to reassure clinicians.