Patient Selection For Intervention Research Articles

Variability in healthcare delivery: It is never a good thing.

In medicine, wide variations in healthcare delivery or outcomes are a sign of missing information and beg for more information in a timely resolution. While differences in patient selection for intervention in out-of-hospital-cardiac-arrest in Wales and England might seem regional, there is little reason to assume this is not true across many other geographical areas.

Artificial intelligence for the detection, prediction, and management of atrial fibrillation.

The present article reviews the state of the art of machine learning algorithms for the detection, prediction, and management of atrial fibrillation (AF), as well as of the development and evaluation of artificial intelligence (AI) in cardiology and beyond. Today, AI detects AF with a high accuracy using 12-lead or single-lead electrocardiograms or photoplethysmography. The prediction of paroxysmal or future AF currently operates at a level of precision that is too low for clinical use. Further studies are needed to determine whether patient selection for interventions may be possible with machine learning.

National trends in admissions, repair, and mortality for thoracic aortic aneurysm and type B dissection in the National Inpatient Sample

ObjectiveThe advent of endovascular repair for both thoracic aortic aneurysm and type B dissection has transformed the management of these disease processes. This study was undertaken to better define, compare, and contrast the national trends in hospital admissions, invasive treatments, and inpatient mortality of patients with thoracic aortic aneurysm and type B dissection in the National Inpatient Sample. MethodsThe cohort was derived from International Classification of Diseases, Ninth Revision diagnosis codes for thoracic aortic dissection and thoracic aortic or thoracoabdominal aortic aneurysm. Patients receiving type A dissection or ascending aortic repair during their index admission were excluded using International Classification of Diseases, Ninth Revision procedure codes. A total of 155,187 patients were available for analysis from 2000 to 2012. ResultsAdmissions for thoracic aortic aneurysm outnumbered the admissions for type B dissection (69.8% vs 30.2%; P < .001), and the number of admissions for aneurysm grew more rapidly during this time (132% vs 63%; P < .001). Thoracic endovascular aortic repair (TEVAR) for aneurysm experienced an increase in 2005, concordant with Food and Drug Administration approval of TEVAR for thoracic aortic aneurysm indication, then superseded open repair for thoracic aortic aneurysm from 2006 onward. Despite this, the rate of thoracic aortic aneurysm repair has remained relatively stable over time. TEVAR for dissection increased in 2006, superseded open repair in 2010, and continues to account for 50.5% of all dissection repairs. Overall, the number of type B dissection repairs has increased (P < .001), over and above the increase in number of admissions for type B dissection. Despite the increased trends of utilization of TEVAR for both aneurysm and type B dissection, the overall in-hospital mortality rate among patients admitted for either disease state has decreased steadily over time (P < .001). ConclusionsWhereas admissions for thoracic aortic aneurysm disease have increased over time, the rate of aneurysm repair has been stable, although TEVAR has supplanted a proportion of open repairs. In contrast, whereas admissions for type B dissection have experienced a more modest increase, there has been a disproportionate increase in type B dissection repair, largely due to increased use of TEVAR. These results show embracing of endovascular technology for dissection through expansion of indication. Despite the increase in rate of repair for type B dissection, inpatient mortality rate was reduced in both aneurysm and dissection patients, influenced by appropriate selection of patients for intervention.

Abstract TP46: The Probability of an Endovascular Intervention Target Independent of Time From Last Known Well

Introduction: Selection of patients based on treatment-related targets has been especially important for endovascular therapy. Recently presented trial evidence has demonstrated that cases with an eligible arterial occlusion and a target PWI-DWI mismatch were able to successfully receive treatment beyond the 6 hour window. Method: The LESION Study is a prospective cohort study of the baseline MR imaging (&lt;24 hrs from onset and prior to treatment) of 1,092 consecutive ischemic stroke presentations with admission NIHSS ≥4. Multiple therapeutic targets were assessed. Endovascular intervention target was defined as the presence of ischemia on MRA in the ICA or MCA-M1 arterial branches. Presence of PWI-DWI mismatch was qualitatively determined by vascular neurologists. Multivariate logistic regression was used to test for association of time from onset with presence of an endovascular target, while examining the roles of presentation and imaging characteristics. Results: Probability of an endovascular target decreases over the first 24 hours (OR=0.96; p=0.004). However, stratification or adjustment for a PWI-DWI mismatch signal and/or admission NIHSS confounds the effect of occlusion target over time. Stratification by mismatch demonstrates a consistently higher proportion of endovascular target presence in those with a concurrent target mismatch. For cases with a target mismatch, presentation within the 6 hour window is associated with just a 17% greater likelihood of endovascular target relative to those beyond 6 hours (OR=1.17; p &gt; 0.05). In multivariate modeling: NIHSS, mismatch, and sex were all identified as independent risk factors for presence of an endovascular target (all p &lt; 0.01), while time was not significantly associated with target presence. Discussion: While the presence of an arterial occlusion in territories relevant to endovascular intervention appear to be related to time from onset, stratified and adjusted analyses show that this relationship is not maintained when limited to cases with and without a target mismatch identified. This finding has clinical and methodological implications for selection of patients for intervention at varying time intervals.

Advanced Imaging of Intracranial Atherosclerosis: Lessons from Interventional Cardiology.

Intracranial atherosclerosis is a major cause of ischemic stroke. Patients with a high degree of stenosis have a significant rate of stroke despite medical therapy. Two randomized trials of stenting have failed to show benefit. Improving periprocedural complication rates and patient selection may improve stenting outcomes. Fractional flow reserve (FFR), intravascular ultrasound (IVUS), and optical coherence tomography (OCT) are intravascular imaging techniques employed to improve patient selection and stent placement in interventional cardiology. FFR has been shown to improve cardiovascular outcomes when used in patient selection for intervention. Studies of FFR in intracranial atherosclerosis show that the measure may predict which plaques lead to stroke. IVUS is used in cardiology to quantify stenosis and assist with stent placement. Comparisons with histology show that it can reliably characterize plaques. Several case reports of IVUS in intracranial arteries show the technique to be feasible and indicate it may improve stent placement. Plaque characteristics on IVUS may help identify vulnerable plaques. In interventional cardiology, OCT provides excellent visualization of vessel geometry and is useful periprocedurally. Images reliably identify thin-capped fibroatheromas and other plaque features. Case reports indicate that OCT is safe for use in intracranial arteries. OCT can be used to identify perforator vessels and so may be useful in avoiding perforator strokes, a common complication of stenting. Plaque characteristics on OCT may be useful in patient selection.

Evaluation and Management of Fetal Cardiac Function and Heart Failure

Two-dimensional (2D) and Doppler echocardiography has become both an essential component in the assessment of anatomic anomalies of the fetal heart and an important tool in the assessment of fetal cardiac function. Various techniques for assessing fetal cardiovascular function exist and can be used to characterize systolic and diastolic ventricular function and estimate fetal cardiac output. These techniques can be utilized to assess fetuses with cardiovascular compromise due to a number of cardiac and non-cardiac conditions, including twin-twin transfusion syndrome, high-cardiac output lesions such as fetal tumors and vascular malformations, and primary fetal cardiomyopathy. As many of these conditions can now be treated by a variety of fetal therapeutic techniques, it is now important to be able to understand and identify fetal cardiac dysfunction. Characterization of fetal cardiac dysfunction now has the potential to provide clinicians with the means to better select patients for intervention, predict outcome, and perform follow-up following fetal interventional procedures.

Angioplastie rénale : état des lieux en 2014

Atherosclerotic renal artery stenosis can cause ischaemic nephropathy and arterial hypertension. Renal artery stenosis (RAS) continues to be a problem for clinicians, with no clear consensus on how to investigate and assess the clinical significance of stenotic lesions and manage the findings. RAS caused by fibromuscular dysplasia is probably commoner than previously appreciated, should be actively looked for in younger hypertensive patients and can be managed successfully with angioplasty. Atheromatous RAS is associated with increased incidence of cardiovascular events and increased cardiovascular mortality, and is likely to be seen with increasing frequency. Many patients with RAS may be managed effectively with medical therapy for several years without endovascular stenting, as demonstrated by randomized, prospective trials including the cardiovascular outcomes in Renal Atherosclerotic Lesions (CORAL) trial, the Angioplasty and Stenting for Renal Artery Lesions (ASTRAL) trial. These trials share the limitation of excluding subsets of patients with high-risk clinical presentations, including episodic pulmonary edema and rapidly progressing renal failure and hypertension. Blood pressure control and medication adjustment may become more difficult with declining renal function and may prevent the use of angiotensin receptor blocker and angiotensin-converting enzyme inhibitors. The objective of this review is to evaluate the current management of RAS for cardiologists in the context of recent randomized clinical trials. There is now interest in looking more closely at patient selection for intervention, with focus on intervening only in patients with the highest-risk presentations such as flash pulmonary edema, rapidly declining renal function and severe resistant hypertension.

Abstract 309: Vasovasorum Volume Can Be Measured by Contrast-Enhanced 3D Carotid Duplex Ultrasound: Concept and Design of a Novel Method for Predicting Stroke Risk in Patients With Carotid Artery Stenosis

Introduction: Stroke remains a leading cause of death and disability. The reliance on the occurrence of symptoms and degree of stenosis for selecting patients with carotid stenosis for intervention is not ideal because it is often seen that patients with severe stenosis remain asymptomatic while many patients with moderate stenosis experience stroke. Furthermore, the majority of patients are asymptomatic until they experience stroke. It is known that intimal neovascularization flourishes as atherosclerotic disease progresses; however no technique in current use adequately correlates neovascularization to stroke risk. Objective: With seed grant support from the Society for Vascular Surgery Foundation we are executing a study based on our hypothesis that Vasovasorum Volume (VVV) measured using CE-3DCDU as a valid tool for mapping stroke risk. Method: We are recruiting symptomatic and asymptomatic patients adjudged to have &gt;50% and &gt;70% stenosis respectively on routine duplex ultrasound. Vasovasorum volume is measured using CE-3DCDU in patients who are eligible for carotid endarterectomy. Plaque removed during surgery is marked, decalcified and immunostained with CD34. Thereafter, VVV is measured in the excised plaque using 3D reconstruction histometry. We then evaluate the reliability and accuracy of CE-3DCDU in relation to the histopathology and compare VVV in symptomatic and asymptomatic patients. Results: The preliminary study included six patients and the results show that VVV measurement in carotid ultrasound and histopathology is feasible and reproducible (Figures 1 and 2). Conclusion: Vasovasorum volume is a promising predictor of stroke risk. By identifying patients who are truly at high risk for stroke, VVV measured by CE-3DCDU will aid precise patient selection for intervention, thus prevent stroke, save lives, limit disability and expend health care resources in an informed manner. The next phase of this project involves the establishment of efficacy and a population based multi-center clinical trial to generate evidence required to incorporate VVV measured using CE-3DCDU into clinical practice.

Renal artery stenosis-when to screen, what to stent?

Renal artery stensosis (RAS) continues to be a problem for clinicians, with no clear consensus on how to investigate and assess the clinical significance of stenotic lesions and manage the findings. RAS caused by fibromuscular dysplasia is probably commoner than previously appreciated, should be actively looked for in younger hypertensive patients and can be managed successfully with angioplasty. Atheromatous RAS is associated with increased incidence of cardiovascular events and increased cardiovascular mortality, and is likely to be seen with increasing frequency. Evidence from large clinical trials has led clinicians away from recommending interventional revascularisation towards aggressive medical management. There is now interest in looking more closely at patient selection for intervention, with focus on intervening only in patients with the highest-risk presentations such as flash pulmonary oedema, rapidly declining renal function and severe resistant hypertension. The potential benefits in terms of improving hard cardiovascular outcomes may outweigh the risks of intervention in this group, and further research is needed.

Performance of the preterm prevention clinic at heart of England NHS Trust

IntroductionPreterm birth remains the major cause of neonatal mortality, in developed countries, despite major improvements in neonatal care. Appropriate antenatal intervention helped in prolonging gestation and reducing mortality and morbidity.This...

Cardiovascular magnetic resonance with late gadolinium enhancement improves mortality prediction beyond echocardiography: a comparative effectiveness study

Summary Adding information from CMR with LGE to ejection fraction measured by echocardiography significantly improves the prediction for all cause mortality and better classifies individuals at risk. Background We tested the hypotheses that 1) ejection fraction (EF) assessed by cardiovascular magnetic resonance (CMR) is a stronger predictor of all cause mortality than EF assessed by echocardiography; and 2) CMR with late gadolinium enhancement (LGE) improves risk stratification over echocardiography EF in Cox regression models as determined by net reclassification improvement (NRI). Echocardiography with EF measurement remains the initial noninvasive imaging modality for evaluation of patients, and it is used to individualize medical, surgical, and device-based therapy. Yet, if CMR with LGE improves risk stratification compared to echocardiography, then CMR would demonstrate a potential to optimize care through improved patient selection for interventions and more efficient allocation of healthcare resources.

Computed tomography perfusion–based selection of patients for endovascular recanalization

Intravenous and intraarterial recombinant tissue plasminogen activator remains underutilized in the treatment of acute ischemic stroke, largely due to strict adherence to the concept of the therapeutic time window for administration. Recent efforts to expand the number of patients eligible for thrombolysis have been mirrored by an evolution in endovascular recanalization technology and techniques. As a result, there is a growing need to establish efficient and reliable means by which to select candidates for endovascular intervention beyond the traditional criteria of time from symptom onset. Perfusion imaging techniques, particularly CT perfusion used in combination with CT angiography, represent an increasingly recognized means by which to identify those patients who stand to benefit most from endovascular recanalization. Additionally, CT perfusion and CT angiography appear to provide sufficient data by which to exclude patients in whom there is little chance of neurological recovery or a substantial risk of postprocedure symptomatic intracranial hemorrhage. The authors review the current literature as it pertains to the limitations of time-based selection of patients for intervention, the increasing utilization of endovascular therapy, and the development of a CT perfusion-based selection of acute stroke patients for endovascular recanalization. Future endeavors must prospectively evaluate the utility and safety of CT perfusion-based selection of candidates for endovascular intervention.

Left renal vein transposition for nutcracker syndrome

Nutcracker syndrome, caused by compression of the left renal vein (LRV) between the superior mesenteric artery and the aorta, results in left renal and gonadal venous hypertension. Several treatment options have been described to relieve associated symptoms. The purpose of this study was to evaluate late results of LRV transposition and identify risk factors affecting outcomes. Clinical data from 23 consecutive patients diagnosed with nutcracker syndrome from January 1996 to October 2007 were retrospectively reviewed. There were 10 males and 13 females (median age 22 years; range, 14-67) with radiologic evidence of LRV compression. On ultrasound evaluation (15/23 patients), the mean ratio of LRV peak systolic velocity measured at the site of compression and the renal hilum was 7.3 (range, 2.5-12). On venography (14/23 patients), the mean renocaval pressure gradient was 4 mm Hg (range, 2-6 mm Hg). Twelve patients with atypical abdominal pain (n = 4), hematuria (n = 5), and varicocele (n = 6) were managed expectantly. Eleven patients underwent LRV transposition through a transperitoneal exposure. Symptoms in these patients included left flank pain (n = 10), hematuria (n = 7), and varicocele (n = 3). In 2/11 patients, the LRV was found to be occluded at operation. There were no early postoperative complications. Most conservatively managed patients remained stable or improved over a mean follow-up period of 26 months (range, 0.2-59 months). Two patients were lost to follow-up at our institution and ultimately underwent intervention with LRV stenting and autotransplantation elsewhere. One patient was diagnosed with thin basement membrane disease on renal biopsy. Five patients with varicocele remained asymptomatic; 1 underwent local repair. Over a mean follow-up of 39 months (range, 0.13-144 months) in surgically managed patients, symptoms of flank pain and hematuria resolved or improved in 8/10 and 7/7, respectively. Varicoceles recurred in 2/3 patients in spite of resolution of flank pain. Both preoperatively occluded LRVs rethrombosed; one underwent thrombolysis with stenting, the other reimplantation of the left gonadal vein into the IVC. Evaluation of the clinical significance of radiologic LRV compression remains challenging, as does selection of patients for intervention. LRV transposition is a safe, effective procedure in selected patients with persistent, severe symptoms. Patients with progression to occlusion of the LRV should be considered for alternative therapeutic procedures. Varicoceles, in the setting of nutcracker syndrome, may need independent repair.

A review of 58 patients with periorbital haemangiomas to determine appropriate cases for intervention

Periorbital haemangiomas cause severe effects on visual development. They can be treated with some success, but there is currently no literature on the selection of patients for intervention. Our study aims to review all periorbital haemangioma cases in Edinburgh over the past 20 years, to set more stringent guidelines regarding the appropriate selection of patients for treatment and determine prognostic indicators of visual outcome. A review of 58 patients since 1980 with significant lesions, seen by ophthalmologists and/or plastic surgeons. 82% of those presenting were female. The mean age of presentation was 4 months and 2 months in more serious cases. Mean follow up was for 5.6 (range 0-15) years. Loss of visual field was the most sensitive prediction of the development of visual complications (67%), but least specific (76%). Pressure on the globe and pupillary obstruction were more specific (77-100%), but less sensitive (33-50%). Loss of visual field, partial/complete pupillary obstruction and pressure exerted on the globe are all valuable prognostic indicators. The size and position of the lesion are also relevant, but are probably due to these factors. Based on these results we recommend specific guidelines for the selection of patients for intervention.

Early identification of patients at risk for significant left ventricular dilation one year after myocardial infarction

We prospectively investigated criteria to identify patients in the early phase of acute myocardial infarction at risk for significant left ventricular (LV) dilation 1 year after myocardial infarction. In 54 patients receiving thrombolysis within 4 hours after onset of symptoms, the end-diastolic volume index (EDVI) and the end-systolic volume index were assessed by two-dimensional echocardiography initially (within 23 +/- 21 hours) and 1 year after myocardial infarction. After 1 year, LV dilation occurred in 51 patients (94%) and was significant (> mean normal value + 2 SDs) in 14 patients (26%). Significant univariate predictors (p < 0.05) for LV dilation were age, anterior myocardial infarction, initial EDVI and end-systolic volume index, enzymatic infarct size, LV end-diastolic pressure, and mitral regurgitation. No other variables obtained from clinical information, two-dimensional echocardiography, or angiography, including residual coronary perfusion or stenosis, had predictive value. The optimal multivariate predictive model was the combination of the initial EDVI and the enzymatic infarct size, which correctly predicted significant LV dilation in 12 of 14 patients and falsely in eight of 39 patients (sensitivity 86%; specificity 79%). Patients at risk for significant LV dilation 1 year after myocardial infarction were identified adequately 3 days after myocardial infarction by the combination of the initial echocardiographic assessment of EDVI and the enzymatic infarct size. Thus a simple method could facilitate the selection of patients for intervention after acute myocardial infarction.

708-1 Defect Size with IV Dipyridamole Tc-99m Sestamibi SPECT Imaging Predicts Both Future Cardiac Events and Other Cardiac Hospitalizations

Optimal management of patients with coronary artery disease requires identification of those at greatest risk of future adverse cardiac events. The relationship between defect size after IV dipyridamole with Tc-99m Sestamibi SPECT imaging and cardiac events (death, MI) or need for other cardiac hospitalizations for CHF, unstable angina (UA) or late revascularization (REV) (&gt;6 months after imaging) was evaluated in 512 pts followed for 12.8 ± 9.8 months. Defects were classified as small (Sml), moderate (Mod) or large (Lrg). Of 216 pts with normal scans, there were 3 cardiac events and 11 other cardiac hospitalizations. Of the 296 pts with abnormal scans, there were 22 cardiac events (Sml 1.5%, Mod 6.9%, Lrg 12.5%) and 51 other cardiac hospitalizations (Sml 6%, Mod 12%, Lrg 20%). An abnormal scan was a significant and independent predictor of these events when compared with clinical variables. Multiple logistic regression analysis compared to normal scans (normal = 1.0) demonstrated that the defect size predicted a progressively increased likelihood of cardiac events as well as need for other cardiac hospitalizations (Figure). There was a low event rate with small defects (similar to normal scans) while the highest event rates occurred in patients with large defects. Defect size with IV dipyridamole Tc99m Sestamibi SPECT myocardial perfusion imaging is an independent predictor of future cardiac events (death, Ml) and other cardiac hospitalizations. This information may have important implications regarding the selection of patients for interventions.

Quantification of myocardial ischemic injury.

Quantitative assessment of infarct size is becoming increasingly important, particularly since this parameter appears to be a major determinant of prognosis. Morphologic, radioisotopic and electrophysiological techniques for assessing the extent of irreversible ischemic injury entail certain unavoidable limitations. Experimental and preliminary clinical findings suggest that estimation of the extent of infarction from biochemical markers in serum is practical and useful. Furthermore, prediction of infarct size during its early evolution may improve selection of patients for interventions designed to protect ischemic myocardium and may contribute to objective assessment of their efficacy.