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Background: Optimal patient recovery from open-heart surgery relies on effective discharge planning and education. However, the nature of the discharge experience has not been clearly described. Objective: The study purpose is to explore patients' and nurses' narrative accounts of the facilitators and barriers of heart surgery discharge. Methods: A qualitative study was employed using a narrative methodology that elicited and analyzed stories. This research was conducted in a large, urban hospital in Ontario, Canada. A total of 17 patients and nurses were recruited. Five female and 5 male patients were recruited from a preoperative clinic. Ages ranged from 37 to 80 years. Seven nurses were recruited from inpatient cardiovascular units. They had 2 to 19 years of cardiovascular nursing experience. Semistructured, narrative-based interviews were conducted. Two interviews were conducted with each patient at 1 week after discharge and at 4 to 6 weeks. One interview was conducted with each nurse. Results: Findings indicate that although the preoperative period was identified as an effective time for discharge preparation, the patient's cognitive capacity was limited during the postoperative phase of surgery. Both nurses and patients also found that insufficient time impeded the discharge process and limited individualized discussions. The structured and standardized delivery of discharge information affected patients' capacity to apply it to the particularities in their own lives and homes. The fostering of therapeutic relationships created a space where patients felt comfortable sharing their concerns and nurses learned more about patients and thus could better tailor the discharge approach. Conclusions: Study recommendations include group and scenario-based education in which patients and nurses brainstorm about how to apply the discharge information to the particularities of patients' lives and homes. Provision of support needs to be bolstered during the home period, where patients have timely opportunities to discuss their concerns and questions with practitioners or possibly peers. [ABSTRACT FROM AUTHOR]

In mechanically ventilated patients, head of bed (HOB) elevation above 30° decreases the risk of ventilator-associated pneumonia. The research team studied (a) compliance with proper HOB elevation in their cardiac surgical intensive care unit, (b) the accuracy of HOB angles recorded in the electronic medical record (EMR), and (c) the effect of bed type on (a) and (b). Nurses were polled to discover how HOB angles were measured in practice. HOB angles were compliant in 80% of observations. Compliance was more frequent in beds with side-of-bed angle indicators (SBI) than beds with under-bed angle indicators (UBI; 88% vs 77%, P = .04). Charting in the EMR was accurate in 50% of SBI bed observations but only 20% of UBI bed observations (P < .0001). Sixty-seven percent of nurses used the SBI; 27% used the UBI; 6% used estimation alone. Though compliance was suboptimal, compliance and EMR accuracy were significantly associated with bed type. Bedside indicators are underutilized. [ABSTRACT FROM AUTHOR]

Sleep deprivation is common in intensive care unit (ICU) patients. The criterion standard for sleep monitoring, polysomnography, is impractical in ICU. Actigraphy (a wrist watch indicating amount of sleep) proved to be a good alternative in non-ICU patients, but not in prolonged mechanically ventilated patients, probably due to ICU-acquired weakness. Short-stay ICU patients do not suffer from ICU-acquired weakness. However, the accuracy of actigraphy is unknown in these patients. Therefore, we compared actigraphy to polysomnography in short-stay ICU patients. Sleep measurements were conducted in 7 postcardiothoracic surgery patients. The sensitivity (percentage of actigraphy data that agreed with sleep determined using polysomnography) and specificity (percentage of actigraphy data that agreed with awake determined using polysonmography) were calculated. The result showed that actigraphy underestimated the amount of wake time and overestimated the amount of sleep. The median specificity for actigraphy was always less than 19% and sensitivity more than 94%. Therefore, actigraphy is not reliable for sleep monitoring in short-stay ICU patients. [ABSTRACT FROM AUTHOR]

Background--Contemporary ventricular assist device therapy results in a high rate of successful heart transplantation but is associated with bleeding, infections, and other complications. Further reductions in pump size, centrifugal design, and intrapericardial positioning may reduce complications and improve outcomes. Methods and Results--We studied a small, intrapericardially positioned, continuous-flow centrifugal pump in patients requiring an implanted ventricular assist device as a bridge to heart transplantation. The course of investigational pump recipients was compared with that of patients implanted contemporaneously with commercially available devices. The primary outcome, success, was defined as survival on the originally implanted device, transplantation, or explantation for ventricular recovery at 180 days and was evaluated for both noninferiority and superiority. Secondary outcomes included a comparison of survival between groups and functional and quality-of-life outcomes and adverse events in the investigational device group. A total of 140 patients received the investigational pump, and 499 patients received a commercially available pump implanted contemporaneously. Success occurred in 90.7% of investigational pump patients and 90.1% of controls, establishing the noninferiority of the investigational pump (P<0.001; 15% noninferiority margin). At 6 months, median 6-minute walk distance improved by 128.5 m, and both disease-specific and global quality-of-life scores improved significantly. Conclusions--A small, intrapericardially positioned, continuous-flow, centrifugal pump was noninferior to contemporaneously implanted, commercially available ventricular assist devices. Functional capacity and quality of life improved markedly, and the adverse event profile was favorable. [ABSTRACT FROM AUTHOR]

Background: Sleep is a vital and restorative human function However, it has been reported that up to 50% of heart surgery patients experience sleep disturbance during hospitalization and after discharge. Purpose: This study describes sleep patterns in adults over the recovery course after heart surgery and works to identify potential interventions. Researchers analyzed and synthesized studies of sleep patterns and sleep-related factors in heart surgery patients. Methods: Observational studies describing sleep through the course of recovery from heart surgery were searched from databases of PubMed, MEDLINE, Cumulative Index to Nursing and Allied Health Literature, Current Contents, and Chinese Electronic Periodicals Service from 1966 to 2011. Only studies that used polysomnography, actigraphy, or self-report sleep questionnaires to measure sleep were recruited in this review. Results of sleep patterns and sleep quality were pooled from homogeneity studies. Results: Eight studies that investigated sleep patterns in heart surgery patient and nine studies that examined factors associated with sleep disturbances in this patient group were analyzed and synthesized. Serious problems including low sleep efficiency and difficulty in maintaining sleep often happened during the first postoperative week. It took 2 months for sleep to recover to preoperational levels. Although sleep quality improved over time, sleep disturbances still persisted through 6 months of recovery. Physical factors, including pain, dyspnea, nocturia, and cardiac function, and environmental factors, including noise, light, and procedures on patients, were associated with sleep disturbances during hospitalization. Psychological factors, including anxiety and depression, affected sleep during the first -6 months after discharge. Individual factors of age and gender affected sleep through the entire recovery course. Conclusions/Implication for Practice: Sleep disturbances persist over the course of recovery in heart surgery patients, and sleep disturbance is associated with individual, physiological, psychological, and environmental factors. Findings suggest that management of major symptoms and control of the patient's sleeping environment during hospitalization and at early recovery stage as well as mental healthcare after discharge may improve sleep quality and recovery in heart surgery patients. [ABSTRACT FROM AUTHOR]

The article presents a study on the role of the 4q25 chromosomal locus in the prediction of atrial fibrillation (AF) after coronary artery bypass graft surgery. Multivariate predictors of postoperative AF were identified by genotyping 45 single-nucleotide polymorphisms (SNPs) including the 4q25 area. Results show that the genetic variations in the 4q25 chromosomal region were associated with postoperative AF after bypass graft surgery.

Background: The prognostic value of echocardiographic indices of right ventricular dysfunction(RVD) in left sided valve surgery has not been well described. The main objective of this study is to evaluate preoperative RV echocardiographic parameters associated with adverse outcomes after left sided valve surgery. Methods: Pre-operative echocardiographic data, perioperative adverse outcomes(POAO) and 30-day mortality were retrospectively analyzed in a total of 359 patients who underwent left sided valve surgery (198 aortic and 161 mitral respectively) at a single academic medical center from 2006 to 2014. RVD was defined as 2 or more abnormal RV echocardiographic parameters: RV fractional area change, RV dp/dt, TAPSE, tissue doppler S' and RIMP(Tei index). Results: 359 patients with left sided valvular surgery (average age: 67 ±15, 60.6 % male). The most common POAO were atrial fibrillation and prolonged ventilation time as shown in Figure. After adjustment for age, sex, ejection fraction and admission with heart failure, patients with preexisting RVD undergoing aortic valve surgery were associated with 30-day composite outcome(POAO) [adjusted odds ratio(OR): 2.92, 95 % confidence interval(CI): 1.46 to 5.8; P< 0.05]. Patients with preexisting RVD undergoing mitral valve surgery were also observed to have 30-day composite outcome(POAO) [OR: 2.2, 95 % CI: 1.08 to 4.6; P<0.05]. Pre and post echocardiographic parameters which significantly changed after surgery are listed in Table. Conclusion: Preoperative RVD is associated with increased peri-operative complications after left sided valve surgery. A comprehensive assessment of RV function with multiple echocardiographic parameters can help with better estimation of surgical risk. [ABSTRACT FROM AUTHOR]

Introduction: Among asymptomatic patients, the value of stress imaging at 1 year following successful CABG for predicting long-term adverse outcomes has not been shown. Hypothesis: Among patients enrolled in a VA cooperative study to detect graft patency at 1-year post-CABG, SPECT-MPI predicts long-term risk of adverse cardiovascular events. Methods: At a single center participating in a VA Cooperative Study on long-term graft patency, enrolled patients underwent both coronary angiography and stress imaging at 1-year following CABG. Stress imaging was performed on the same day as the coronary angiogram and interpretation was blinded to the coronary angiogram. SPECT results were categorized according to the size of the perfusion defect, and graded as none, small or moderate to large. Results of the graft studies were categorized as either none or 1 or more grafts with a significant stenosis. Long-term adverse end-points include the composite of death and new diagnosis of heart failure. Results: Eighty-four participants underwent SPECT-MPI and coronary angiogram at one-year post-CABG. Graft disease was identified in 39 patients involving 56 of 251 potential graft sites (22%) and compared to those individuals with no graft disease, did not predict long-term adverse outcomes (31% vs 38% p=0.51). Those individuals with a poor long-term outcome failed to increase their LVEF at 1-year compared with pre-CABG (Figure 1). In addition, a moderate or larger sized defect on SPECT (N=18) was associated with a significant increased risk of adverse outcomes compared with those individuals with either no defect (N=57) or a small defect (N=27) (56% Versus 30%; Odds Ratio = 1.8, P<0.05) (Figure 2). Conclusions: Among asymptomatic patients at 1-year following CABG, assessment of LVEF and defect size with SPECT-MPI was a predictor of long-term risk of death and heart failure. Use of stress imaging, as a means of risk-stratification following bypass surgery, even among those patients without clinical symptoms, may have value. [ABSTRACT FROM AUTHOR]

Introduction: Significant variability in morbidity and mortality persists for children with single ventricle congenital heart disease (SV-CHD) despite standardization in medical and surgical care. Multiple risk factors for poor outcomes have been described, but they only explain a fraction of the disparity in outcomes. The Developmental Origins of Health and Disease (DOHaD) theory proposes that fetal adaptation to an adverse in utero environment alters the ability to respond to post-natal stressors and may explain additional risk for poor outcomes. This study assessed maternal risk factor association with disparate outcomes following SV palliation. Hypothesis: Maternal factors related to weight, diabetes, hypertension, and smoking may be associated with an increased risk of poor outcomes in children with SV-CHD. Methods: This retrospective observational cohort study included all term maternal-infant pairs with a diagnosis of SV-CHD who underwent surgical palliation from 2006-2015 at Primary Children's Hospital. Pairs lacking maternal variables of interest or infant follow-up data up to 1 year were excluded. The association of death or transplant with maternal risk factors [abnormal pre-pregnancy BMI, abnormal weight gain during pregnancy (≤ 7 kg or ≥ 20 kg), any type of hypertension or diabetes and smoking] was analyzed using a multivariable logistic regression model. Results: Of 190 infants who qualified, 135 (71%) maternal-infant dyads had complete data for inclusion. Systemic right ventricular morphology was present in 69% and 31% had systemic left ventricular morphology. Death or transplant occurred in 48 infants (36%) during an average follow-up of 2.2 years (0.1-11.7 years). Abnormal weight gain during pregnancy was present in 34 (25%) mothers, of which 24 had excessive (>20 kg) and 10 had inadequate (<7 kg) weight gain. Prevalence of other risk factors was 53% with an abnormal pre-pregnancy BMI, 10% for diabetes, 6% for hypertension and 8% for smoking. Abnormal weight gain during pregnancy was associated with an increased risk of death or transplant in offspring with SV-CHD. (OR=2.55, 95%CI:1.11-5.84, p=0.027). Conclusions: Abnormal maternal weight gain (excessive or inadequate) during pregnancy is a novel risk factor that may contribute to worse outcomes in SV-CHD. [ABSTRACT FROM AUTHOR]

Introduction: Partial leaflet resection followed by ring annuloplasty is a reliable and reproducible mitral valve (MV) repair technique for the treatment of severe mitral regurgitation (MR) due to posterior chordal rupture. Hypothesis: We have developed a novel computational virtual MV repair strategy to predict the biomechanical and physiologic characteristics of post-repair MV dynamics to help with optimal surgical planning. Methods: Computational MV models were created using pre- and post-repair 3D echocardiographic data of a patient having posterior chordal rupture and severe MR. Virtual resection was designed by removing a pre-defined triangle-shaped leaflet portion in the P2 scallop and merging the excised leaflet edges. Virtual ring annuloplasty with the same ring size as the post-repair MV was performed following the triangular leaflet resection. Computational simulations of MV function (pre-repair, virtual repair, and post-repair) were performed using dynamic finite element methods. Leaflet coaptation across the MVs were quantitatively determined and compared. Results: The pre-repair MV with P2 chordal rupture showed severe P2 prolapse and leaflet malcoaptation. The post-repair MV demonstrated markedly reduced prolapse and sufficiently restored leaflet coaptation. The virtually repaired MV revealed a similar coaptation ratio as the post-repair MV indicating effective restoration of normal MV function. Both virtual repair and post-repair MVs showed improved coaptation not only in the P2 region but also in the A1-P1 and A3-P3 regions. Conclusions: We have quantitatively evaluated patient-specific MV function before and after potential MV repair using a novel virtual MV repair protocol. Both virtual repair and post-repair MVs decreased posterior leaflet prolapse and restored normal coaptation. This virtual MV repair strategy has the potential for improved pre-surgical planning to predict and optimize post-repair MV function. [ABSTRACT FROM AUTHOR]

Introduction: Dysregulation of endothelial nitric oxide synthase (eNOS) and generation of nitric oxide (NO) are critical early indicators for diabetes-induced endothelial dysfunction and cardiovascular complications. We hypothesize that levels of NO production and eNOS expression by endothelial cells are decreased in DM subjects when compared to non-DM subjects. Methods: The study cohort consisted of 9 non-DM subjects and 6 DM subjects undergoing myocardial biopsy at the time of coronary artery bypass grafting surgery. The non-myocyte cell suspensions from the left ventricle (LV), right atrial appendages (RAA), and skeletal muscle (SKM) tissue were analyzed by flow cytometry to measure production of nitric oxide in subpopulations of endothelial and non-endothelial cells. Cells in suspension were incubated with DAF-2DA in the presence or absence of NO synthase inhibitor, L-NAME. Flow cytometry was used to determine production of NO in subpopulations of endothelial and non-endothelial cells from biopsies. Measurements of eNOS and phospho-eNOS (ser1177) were performed using western blot. Results: Basal Nitric oxide production was measurable in non-diabetic subjects \ in 55%, 80% and 65% of unstimulated endothelial cells obtained from RAA, LV and SKM biopsies, compared to 40%, 40%, and 66%, respectively in diabetic subjects (P < 0.02, DM vs Non-DM). No differences were found in the number of NO-producing non-endothelial cells between DM and non-DM subjects. The level of eNOS showed a trend towards decreased protein expression in DM subjects compared to non-DM. Conclusions: Generation of NO by endothelial cells and level of eNOS expression are decreased in left ventricular endothelial cells of DM patients compared to non-DM. Left ventricular biopsies can be used safely for assessment of NO dysregulation and endothelial dysfunction, and whether these can be improved with interventions targeting diabetic cardiovascular disease. [ABSTRACT FROM AUTHOR]

Introduction: Neochordoplasty is an important repair technique, though the optimal anchoring position is unknown. While typically anchored at papillary muscles, new percutaneous devices anchor the chordae at or near the ventricular apex, which we hypothesize will result in significantly higher forces on the chordae and neochord. Methods: Porcine mitral valves were dissected (n=3) and mounted in a custom 3D printed left heart simulator generating physiological pressure and flow. Hemodynamic and echocardiographic data were collected, and chordal forces were measured using Fiber Bragg Grating (FBG) strain gauge sensors. Isolated MR was induced by cutting P2 primary chordae resulting in prolapse. Regurgitant valves were then repaired with a PTFE neochord with transapical fixation, followed by papillary fixation for comparison. In both cases, the neochord was anchored to a customized force-sensing post positioned to mimic in vivo placement (Fig. A). Results: Hemodynamic and echocardiographic data confirmed that both techniques resulted in elimination of MR in all valves and restoration of physiologic hemodynamics. Peak forces on the chordae and neochord were lower for papillary than the transapical fixation (p=0.04). Force tracings were compiled for each class of chordae at baseline, after prolapse, and after both repair techniques (Fig. B). The maximum dF/dt for the neochord suture was 30.6 N/s with the papillary fixation and 51.7 N/s with the transapical fixation. These may translate into increased stress on the mitral valve apparatus. Conclusions: Transapical fixation results in higher peak forces on the chordae and noechord suture as well as an increased rate of loading on the neochord when compared to the papillary muscle fixation and may influence repair durability. [ABSTRACT FROM AUTHOR]

Background: The use of contemporary advanced cardiovascular interventions (ACI) has dramatically increased. Concurrently, survivorship from cancer continues to improve, and cardiovascular disease (CVD) is quickly becoming a leading cause of death. Hypothesis: There is underutilization of ACIs among patients with cancer compared to general population. Methods: Hospitalizations were identified by querying the National Inpatient Sample from 2003-2015. Hospitalizations included were adults with diagnosis of acute coronary syndrome (dx1), heart failure (dx1) or diagnosis of valve disease (dx1-30). ACI was defined as percutaneous coronary intervention (PCI), coronary artery bypass grafting (CABG), cardiac valvular surgeries and percutaneous interventions (valves) and cardiac implanted electronic devices (combination of defibrillator, resynchronization therapy and pacemaker, CIED). Metastatic cancer was excluded from analysis. Trends of ACI and in-hospital mortality were plotted across time and compared using Rao-White Chi-Square test. Adjusted analysis was performed with age < 65 years, white race, Medicare insurance and Elixhauser's comorbidity (ELI) <= 2. Results: Over the 13 years considered there were 7,889,166 ACIs (50.8% PCI, 17.5% CABG, 16.7% valves and 15% CIED), of which 631,293 (8.8%, table) were performed in cancer patients. Overall, cancer patients were older, and more often male, smokers, had Medicare insurance. The performance of ACIs is lower in those with cancer compared to those without in the whole cohort with increasing trend of utilization of ACI (p-trend <0.0001, figure 1). Further, cancer cohort has a lower rate of in-hospital mortality following an ACI compared to those who are free of cancer (2.6% vs 2.9%, 1.6% vs 1.9% (adjusted), p<0.0001 for both) with overall decreasing in-hospital mortality in non-cancer cohort (figure 2, p-trends <0.0001) and no change in in-hospital mortality trends in cancer cohort (p-trend not significant, figure 2). Conclusions: Cancer patients have experienced a disproportionate lower but increasing use of ACI. In-hospital mortality is has not changed in the last 13 years and is lower compared to the non-cancer patients. [ABSTRACT FROM AUTHOR]

Introduction: Elevated wall stress (WS) from chamber dilatation and wall thinning drive cause congestive heart failure(CHF) after a myocardial infarction(MI). Reducing WS by reshaping the left ventricle (LV) could decelerate or halt CHF progression, delaying need for ventricular assist devices or transplantation. In this study, we sought to investigate if a transventricular reshaping device (TRD - Fig 1A,B) can preserve cardiac function and inhibit adverse remodeling in a rodent model of chronic ischemic cardiomyopathy. Hypothesis: Reducing left ventricular WS and sphericity index (SI) can preserve cardiac function and inhibit adverse remodeling in ischemic cardiomyopathy. Methods: Rats (n=18) were induced with an MI by left coronary artery ligation. 3 weeks post-MI, TRD was implanted on a beating heart in 9 rats (MI+TRD) (Fig 2A-C) and no surgery in others (MI only).TRD was tightened with echo, for 25% reduction in end-diastolic diameter and in WS. All rats were survived for another 3 weeks, with echo at 0, 2, 4, 6 weeks post-MI, and invasive hemodynamics at termination. Tissue was snap frozen for RNA-seq analysis. Results: Cardiac dysfunction were confirmed in both groups prior to TRD implantation (%EF in MI+TRD: 77.4±1.2vs. 59.6±2.1; p<0.0001; %EF in MI: 74.7±1.8 vs. 57.0±3.3; p=0.0002). TRD implantation and tightening, reduced LVEDD from 8.7±0.2mm to 6.7±0.2mm (23% change, p <0.0001), reduced sphericity index from 0.74±0.04 to 0.54±0.05 (27% reduction, p<0.0001), and WS from 19.9±2.0 to 14.5±1.7 (27% decrease, p=0.0662) (Fig 3A-B). At termination, EDV and ESV were significantly reduced in MI+TRD compared to MI alone (EDV: 647.5±39.0μl vs 500.1±14.4μl; p=0.0032; 317.5±16.9 μl vs 218.1±14.7 μl; p=0.0021), indicating halted adverse remodeling with TRD (Fig 4A-B). Infarct border zone wall thickness was preserved in MI+TRD, but significantly reduced/thinned in MI (Fig 5A), containing infarct expansion. Pre-load adjusted LV dp/dt(max), was significantly higher in MI+TRD compared to MI only ( Fig 5B ). Conclusions: Reshaping and reducing the ischemic LV with the transventricular restraint, improves cardiac contractility, preserves ventricular wall thickness and inhibits infarct expansion in this chronic rodent model of cardiomyopathy. [ABSTRACT FROM AUTHOR]

Introduction: Durable ventricular assist device (VAD) therapy is a highly specialized surgical treatment that has experienced rapid growth. To date, there is limited understanding of its dissemination and use compared to heart transplantation. Hypothesis: Use of durable VAD therapy varies by geography and race in patterns that are distinct from heart transplantation. Methods: Durable VAD implant volume was assessed from 2008 to 2014 using data compiled from INTERMACS and Medicare to maximize capture of VADs. State-level U.S. Census data consisting of population estimates stratified by age (>20 years) and race (white vs. minority) were obtained from the Center for Disease Control WONDER database. Implant rates (using implant volume) and heart transplant rates (using data from 2008-2014 from the United Network for Organ Sharing, UNOS) were calculated using the stratified census population data. Results: Overall, 16,607 patients received a VAD implant. The total number of VAD implants increased over time (1,159 in 2008 to 3,390 in 2014). The rate of VAD implants (per 1M) increased for whites from 4.5 in 2008 to 12.2 in 2014 and for minorities from 8.3 in 2008 to 22.79 in 2014. Per capita implant rates varied by UNOS region with relative increases for minorities greatest in UNOS regions 7, 11, 8 and 2 (FIG). Modest increases in transplant rates (<5%) were observed in most UNOS regions for whites and were accompanied by only modest rate increases in VAD implants (<10%). In contrast, most UNOS regions demonstrated a large increase in minority VAD implant rates (>10%) with only modest increases in transplantation rates (<5%). Conclusion: Rates of VAD use increased appreciably over time and varied by race and geography in patterns distinct from rates of heart transplantation. While the reasons underlying a higher rate of VAD use in minority populations are unclear, our findings have implication for ensuring equitable dissemination of this therapy. [ABSTRACT FROM AUTHOR]

Introduction: Purpura fulminans (PF) is a hematologic emergency that can occur in the setting of severe septic shock. It is an uncommon and severe manifestation of disseminated intravascular coagulation (DIC) in which multiple coagulation factors are consumed, including the endogenous inhibitors antithrombin and protein C (PC). Case: A 30-year-old female with a history of treatment-naïve Hepatitis C and intravenous drug abuse that was complicated by methicillin-resistant Staphylococcus aureus (MRSA) tricuspid valve (TV) endocarditis status post bioprosthetic TV replacement presented with altered mental status. She was febrile, hypotensive, and tachycardic on presentation. Admission blood cultures grew MRSA. Electrocardiogram revealed sinus tachycardia with rightward axis deviation and right atrial enlargement. Transesophageal echocardiogram demonstrated severely thickened TV leaflets with severe stenosis and a large mobile echodensity consistent with vegetation. Chest CT demonstrated subpleural nodules. She stabilized however subsequently developed large purpuric plaques with central bulla formation throughout her distal extremities. Further work-up noted depressed function of PC, Protein S, and antithrombin. This constellation of findings was consistent with DIC and PF. Intravenous human PC concentrate was initiated and her purpuric plaques rapidly resolved (Figure). Operative findings noted an obstructive vegetation involving all three TV leaflets with an abscess cavity around the annulus. She underwent a bioprosthetic TV replacement and was discharged to a skilled nursing facility after completion of ceftaroline for six weeks. Conclusion: In this case report, we describe the first patient with PF secondary to MRSA endocarditis who was successfully treated with PC concentrate and surgical valve replacement. Future studies to determine whether administration of PC concentrate can reduce mortality in this setting are indicated. [ABSTRACT FROM AUTHOR]

Background: Septal atrial tachycardia (AT) can occur in patients without structural heart disease and in patients with previous catheter ablation of atrial fibrillation. We aimed to assess septal AT that occurs after open-heart surgery., Methods and Results: This study comprised 20 consecutive patients undergoing catheter ablation of macroreentrant AT after open-heart surgery. Relevance to surgical approach, mechanisms, anatomic and electrophysiological characteristics, and outcomes were assessed. Septal AT was identified in 7 patients who had all undergone mitral valve surgery. All septal ATs were localized in the left atrial septum, whereas 10 of 13 nonseptal ATs originated from the right atrium. Patients with left septal AT had a thicker fossa ovalis (median, 4.0; 25th-75th percentile, 3.6-4.2 versus 2.3; 1.6-2.6 mm; P=0.006) and broader area of low voltage (<0.3 mV) in the septum than patients with nonseptal AT (82; 76-89 versus 31; 28%-36%; P=0.02). Repeated gradual prolongations of the tachycardia cycle length without change of the septal circuit were observed in all patients with septal AT (70; 63-100 versus 15; 10-40 ms; P=0.0008). Although ablation terminated all ATs, recurrence of targeted ATs was more frequent in patients with left septal AT during 30-month follow-up (71 versus 0%; P=0.001)., Conclusions: Left septal AT after open-heart surgery was characterized by a thicker septum, more scar burden in the septum, and repeated prolongations of the tachycardia cycle length during ablation. Such an arrhythmogenic substrate may interfere with transmural lesion formation by ablation and may account for higher likelihood of recurrence of left septal AT., (© 2014 American Heart Association, Inc.)

The article comments on the paper "Immune globulin G treatment of postcardiac surgery patients with score-identified severe systemic inflammatory response syndrome (SIRS): The ESSICS study," by K. Werdan and colleagues. According to the authors, the paper reports the results of a phase III multicenter trial that intravenous immunoglobulin G administration does not affect postoperative morbidity at day 5 or mortality at 28 days in cardiac surgery patients with SIRS.