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Whether to repair nonsevere tricuspid regurgitation (TR) during surgery for ischemic mitral valve regurgitation (IMR) remains uncertain.The goal of this study was to investigate the incidence, predictors, and clinical significance of TR progression and presence of ≥moderate TR after IMR surgery.Patients (n = 492) with untreated nonsevere TR within 2 prospectively randomized IMR trials were included. Key outcomes were TR progression (either progression by ≥2 grades, surgery for TR, or severe TR at 2 years) and presence of ≥moderate TR at 2 years.Patients' mean age was 66 ± 10 years (67% male), and TR distribution was 60% ≤trace, 31% mild, and 9% moderate. Among 2-year survivors, TR progression occurred in 20 (6%) of 325 patients. Baseline tricuspid annular diameter (TAD) was not predictive of TR progression. At 2 years, 37 (11%) of 323 patients had ≥moderate TR. Baseline TR grade, indexed TAD, and surgical ablation for atrial fibrillation were independent predictors of ≥moderate TR. However, TAD alone had poor discrimination (area under the curve, ≤0.65). Presence of ≥moderate TR at 2 years was higher in patients with MR recurrence (20% vs. 9%; p = 0.02) and a permanent pacemaker/defibrillator (19% vs. 9%; p = 0.01). Clinical event rates (composite of ≥1 New York Heart Association functional class increase, heart failure hospitalization, mitral valve surgery, and stroke) were higher in patients with TR progression (55% vs. 23%; p = 0.003) and ≥moderate TR at 2 years (38% vs. 22%; p = 0.04).After IMR surgery, progression of unrepaired nonsevere TR is uncommon. Baseline TAD is not predictive of TR progression and is poorly discriminative of ≥moderate TR at 2 years. TR progression and presence of ≥moderate TR are associated with clinical events. (Comparing the Effectiveness of a Mitral Valve Repair Procedure in Combination With Coronary Artery Bypass Grafting [CABG] Versus CABG Alone in People With Moderate Ischemic Mitral Regurgitation, NCT00806988; Comparing the Effectiveness of Repairing Versus Replacing the Heart's Mitral Valve in People With Severe Chronic Ischemic Mitral Regurgitation, NCT00807040).

To determine the frequency and risk factors for non-home discharge (NHD) and its association with clinical outcomes and quality of life (QOL) at 1 year following cardiac surgery in patients with ischemic mitral regurgitation (IMR).Discharge disposition was evaluated in 552 patients enrolled in trials of severe or moderate IMR. Patient and in-hospital factors associated with NHD were identified using logistic regression. Subsequently, association of NHD with 1-year mortality, serious adverse events (SAEs), and QOL was assessed.NHD was observed in 30% (154/522) with 25% (n = 71/289) in moderate and 36% (n = 83/233) in patients with severe IMR (unadjusted P = .006), a difference not significant after including age (5-year change: adjusted odds ratio [adjOR], 1.52; 95% confidence interval [CI], 1.35-1.72; P .001), diabetes (adjOR, 1.94; 95% CI, 1.27-2.94; P = .002), and previous heart failure (adjOR, 1.64; 95% CI, 1.06-2.52; P = .03). Odds of NHD were increased for patients with postoperative SAEs (adjOR, 1.85; 95% CI, 1.19-2.86; P = .01) but not based on type of cardiac surgery. Greater rates of death and SAEs were observed in NHD patients at 1 year: adjusted hazard ratio, 4.29 (95% CI, 2.14-8.59; P .001) and adjusted rate ratio, 1.45 (95% CI, 1.03-2.02; P = .03), respectively. QOL did not differ significantly between groups.NHD is common following surgery for IMR, influenced by older age, diabetes, previous heart failure, and postoperative SAEs. These patients may be at greater risk of death and subsequent SAEs after discharge. Discussion of NHD with patients may have important implications for decision-making and guiding expectations following cardiac surgery.

Background The incidence of permanent pacemaker (PPM) implantation is higher following mitral valve surgery (MVS) with ablation for atrial fibrillation (AF) compared with MVS alone. Objectives This study identified risk factors and outcomes associated with PPM implantation in a randomized trial that evaluated ablation for AF in patients who underwent MVS. Methods A total of 243 patients with AF and without previous PPM placement were randomly assigned to MVS alone (n = 117) or MVS + ablation (n = 126). Patients in the ablation group were further randomized to pulmonary vein isolation (PVI) (n = 62) or the biatrial maze procedure (n = 64). Using competing risk models, this study examined the association among PPM and baseline and operative risk factors, and the effect of PPM on time to discharge, readmissions, and 1-year mortality. Results Thirty-five patients received a PPM within the first year (14.4%), 29 (83%) underwent implantation during the index hospitalization. The frequency of PPM implantation was 7.7% in patients randomized to MVS alone, 16.1% in MVS + PVI, and 25% in MVS + biatrial maze. The indications for PPM were similar among patients who underwent MVS with and without ablation. Ablation, multivalve surgery, and New York Heart Association functional (NYHA) functional class III/IV were independent risk factors for PPM implantation. Length of stay post-surgery was longer in patients who received PPMs, but it was not significant when adjusted for randomization assignment (MVS vs. ablation) and age (hazard ratio [HR]: 0.81; 95% confidence interval [CI]: 0.61 to 1.08; p = 0.14). PPM implantation did not increase 30-day readmission rate (HR: 1.43; 95% CI: 0.50 to 4.05; p = 0.50). The need for PPM was associated with a higher risk of 1-year mortality (HR: 3.21; 95% CI: 1.01 to 10.17; p = 0.05) after adjustment for randomization assignment, age, and NYHA functional class. Conclusions AF ablation, multivalve surgery, and NYHA functional class III/IV were associated with an increased risk for permanent pacing. PPM implantation following MVS was associated with a significant increase in 1-year mortality. (Surgical Ablation Versus No Surgical Ablation for Patients With Atrial Fibrillation Undergoing Mitral Valve Surgery; NCT00903370)

Congenital Morgagni hernia (CMH) is a rare congenital anomaly is typically diagnosed in childhood and on occasions in adults during work up of unexplained respiratory infections or gastrointestinal symptoms. The average age of laparoscopic repair of CMH was 3.3 years. We describe a newborn with fetal aberrant ductus venosus with progressive right ventricular dilation prompting early delivery. Post-natally, the baby had frequent episodes of cyanosis. Echocardiogram during distress showed compression of the inferior vena cava and of the right heart, with significant right to left shunt through patent foramen ovale. Infant underwent successful laparoscopic diaphragmatic hernia repair with resolution in her episodes of cyanosis. Keywords: Morgagni diaphragmatic hernia, Neonate, Cyanosis, Tamponade

Objective Fetal tachyarrhythmias complicate 0.5% of pregnancies, with high morbidity and mortality. We hypothesized that maternal factors may predispose to fetal supraventricular tachycardia (SVT). Study Design We reviewed medical records of all 124 mothers who presented to the Vanderbilt Fetal Cardiology Clinic from 2004 to 2010 for fetal arrhythmias, excluding heart block. Maternal factors were compared between 28 fetuses with SVT and a control group of 112 fetuses screened for noncardiac conditions. The proportions were analyzed using chi-square or Fisher exact test for categorical variables and Wilcoxon rank sum test for continuous variables. Results Of maternal factors, thyroid disease was statistically significant compared with controls. Among mothers whose fetuses had SVT, 21% had thyroid disease (83% hypothyroidism) compared with 3% of controls ( p Conclusion In this cohort, the maternal thyroid disease was more common in fetuses with SVT compared with controls (odds ratio = 9.8, 95% confidence interval 2.3–42.3), suggesting closer screening for fetal arrhythmias and SVT in mothers with thyroid disease. Also, routine screening of thyroid functions and thyroid autoantibodies may be warranted in mothers of fetuses with SVT.

More patients in the ablation group than in the control group were free from atrial fibrillation at both 6 and 12 months (63.2% vs. 29.4%, P

Supraventricular tachycardia (SVT) is the most common arrhythmia in the pediatric population. Despite its commonality, presentation of SVT can be nonspecific and varies based upon age with infants demonstrating fussiness or irritability and older children reporting vague perceptions of tachycardia or palpitations. Furthermore, SVT may manifest as self-limited paroxysms or with prolonged runs of SVT with subsequent development of cardiac dysfunction, heart failure, and multiorgan shock. Clinicians must maintain high levels of suspicion for SVT given the potentially dire consequences of untreated SVT. When diagnosed, there are effective acute and chronic treatments for SVT, with potential for spontaneous resolution in many infants. [ Pediatr Ann . 2014;43(11):456–460.]

In this study we investigated whether the addition of peak oxygen consumption (VO(2)) improves the predictive accuracy of the Seattle Heart Failure Model (SHFM). The SHFM is a validated multivariate risk model that uses NYHA classification to assess functional capacity rather than peak oxygen consumption (VO(2)).Outpatients (n = 1,240) evaluated for transplant at three centers had their SHFM score calculated and peak VO(2) measured. The outcomes assessed were death/LVAD/urgent transplant with censoring at the time of elective transplant.Over the course of 4.0 (mean) years of observation, there were 571 events. Both the SHFM score (χ(2) = 227) and peak VO(2) (χ(2) = 88, both p0.0001) were highly predictive of outcomes. The SHFM and peak VO(2) were modestly correlated (r = 0.39, p0.0001). In a multivariate Cox model, peak VO(2) added to the SHFM with a hazard ratio of 0.949 (p0.0001) for each 1-ml/kg/min increase. Peak VO(2) improved both the net reclassification improvement and integrated discrimination index (both p ≤ 0.0002). Peak VO(2) provided additive prognostic information within each SHFM score (p0.05). The 1-year areas under the receiver-operating characteristic curve were obtained for peak VO(2) (0.645, 95% CI 0.606 to 0.684), SHFM (0.758, 95% CI 0.721 to 0.795) and SHFM with peak VO(2) (0.766, 95% CI 0.731 to 0.802). The SHFM-predicted vs actual survival free of LVAD/UNOS Status 1 transplant at 1 year (86% vs 83%) and 4 years (63% vs 63%) were similar.The multivariate SHFM is a powerful predictor of death/LVAD/urgent transplant. Peak VO(2) adds prognostic information across the spectrum of the SHFM, but changes in decision regarding transplant listing occur mainly in moderate-risk patients.

Summary Background Understanding of adolescent-onset asthma remains limited. We sought to characterise this state and identify associated factors within a longitudinal birth cohort study. Methods The Isle of Wight Whole Population Birth Cohort was recruited in 1989 ( N =1456) and characterised at 1, 2, 4, 10 and 18-years. "Adolescent-onset asthma" was defined as asthma at age 18 without prior history of asthma, "persistent-adolescent asthma" as asthma at both 10 and 18 and "never-asthma" as those without asthma at any assessment. Results Adolescent-onset asthma accounted for 28.3% of asthma at 18-years and was of similar severity to persistent-adolescent asthma. Adolescent-onset asthmatics showed elevated bronchial hyper-responsiveness (BHR) and atopy at 10 and 18 years. BHR in this group at 10 was intermediate to that of never-asthmatics and persistent-adolescent asthma. By 18 their BHR, bronchodilator reversibility and sputum eosinophilia was greater than never-asthmatics and comparable to persistent-adolescent asthma. At 10, males who later developed adolescent-onset asthma had reduced FEV 1 and FEF 25–75 , while females had normal lung function but then developed impaired FEV 1 and FEF 25–75 in parallel with adolescent asthma. Factors independently associated with adolescent-onset asthma included atopy at 10 (OR=2.35; 95% CI=1.08–5.09), BHR at 10 (3.42; 1.55–7.59), rhinitis at 10 (2.35; 1.11–5.01) and paracetamol use at 18-years (1.10; 1.01–1.19). Conclusions Adolescent-onset asthma is associated with significant morbidity. Predisposing factors are atopy, rhinitis and BHR at age 10 while adolescent paracetamol use is also associated with this state. Awareness of potentially modifiable influences may offer avenues for mitigating this disease state.

The Heart Failure Survival Score (HFSS) risk-stratifies patients with chronic heart failure (CHF) referred for heart transplantation using 7 parameters, including peak VO₂. The Seattle Heart Failure Model (SHFM) is a 20-variable model that combines clinical, laboratory and therapeutic data. Although both models have excellent accuracy, only the HFSS was derived and validated in patients referred for transplantation, and the HFSS and SHFM have not been directly compared.We tested the accuracy of the SHFM and compared the HFSS and SHFM in 715 patients referred for heart transplantation.Over a follow-up of 962 ± 912 days, 354 patients died or received an urgent heart transplantation or a ventricular assist device. One-year event-free survival was 89%, 72% and 60%, respectively, for the low-, medium- and high-risk HFSS strata, and 93%, 76%, and 58%, respectively, for the low-, medium- and high-risk SHFM strata. The HFSS and SHFM were modestly correlated (R = -0.48, p0.001). In receiver operating characteristic curve analysis, areas under the curves (AUCs) for the HFSS and SHFM were comparable (1 year: 0.72 vs 0.73; 2-year: 0.70 vs 0.74, respectively) and incremental to New York Heart Association class. The 1- and 2-year combined HFSS+SHFM AUCs were 0.77 and 0.76, respectively, significantly better than the HFSS or SHFM alone.The HFSS and SHFM provide accurate and comparable risk stratification in CHF patients referred for transplantation. Combining the HFSS and SHFM improves predictive ability.

Objective To use novel statistical methods for analyzing the effect of lesion set on (long-standing) persistent atrial fibrillation (AF) in the Cardiothoracic Surgical Trials Network trial of surgical ablation during mitral valve surgery (MVS). Methods Two hundred sixty such patients were randomized to MVS + surgical ablation or MVS alone. Ablation was randomized between pulmonary vein isolation and biatrial maze. During 12 months postsurgery, 228 patients (88%) submitted 7949 transtelephonic monitoring (TTM) recordings, analyzed for AF, atrial flutter (AFL), or atrial tachycardia (AT). As previously reported, more ablation than MVS-alone patients were free of AF or AF/AFL at 6 and 12 months (63% vs 29%; P Results Estimated freedom from AF/AFL/AT on any transmission trended higher after biatrial maze than pulmonary vein isolation (odds ratio, 2.31; 95% confidence interval, 0.95-5.65; P = .07) 3 to 12 months postsurgery; estimated AF/AFL/AT load (ie, proportion of TTM strips recording AF/AFL/AT) was similar (odds ratio, 0.90; 95% confidence interval, 0.57-1.43; P = .6). Within 12 months, estimated prevalence of AF/AFL/AT by TTM was 58% after MVS alone, and 36% versus 23% after pulmonary vein isolation versus biatrial maze (P Conclusions Statistical modeling using TTM recordings after MVS in patients with (long-standing) persistent AF suggests that a biatrial maze is associated with lower AF/AFL/AT prevalence, but not a lower load, compared with pulmonary vein isolation. The discrepancy between AF/AFL/AT prevalence assessed at 2 time points by Holter monitoring versus weekly TTM suggests the need for a confirmatory trial, reassessment of definitions for failure after ablation, and validation of statistical methods for assessing atrial rhythms longitudinally.

Peak oxygen consumption (VO(2) ) during cardiopulmonary exercise testing (CPET) is a powerful predictor of survival, providing an indirect assessment of cardiac output (CO). Noninvasive indices of CO derived from bioreactance methodology would add significantly to peak VO(2) as a means of risk-stratifying patients with heart failure. In this study, 127 patients (53 ± 14 years of age, 66% male) with heart failure and an average ejection fraction of 31% ± 15% underwent symptom-limited CPET using a bicycle ergometer while measuring CO noninvasively by a bioreactance technique. Peak cardiac power was derived from the product of the peak mean arterial blood pressure and CO divided by 451. Follow-up averaged 404 ± 179 days (median, 366 days) to assess endpoints including death (n=3), heart transplant (n=10), or left ventricular assisted device implantation (n=2). Peak VO(2) and peak power had similar areas under the curve (0.77 and 0.76), which increased to 0.83 when combined. Kaplan-Meier cumulative survival curves demonstrated different outcomes in the subgroup with a VO(2)

Peak oxygen consumption (Vo(2)) is a powerful prognostic predictor of survival in patients with chronic heart failure (CHF) because it provides an indirect assessment of a patient's ability to increase cardiac output (CO). However, many patients with CHF who undergo cardiopulmonary exercise testing are unable to perform maximal exercise. New metabolic carts coupled with the inert gas rebreathing technique provide a noninvasive measurement of CO. Whether the noninvasive measurement of CO at a fixed submaximal workload can predict outcome is unknown. This study's population comprised 259 patients (mean age 54 +/- 14 years, mean left ventricular ejection fraction 27 +/- 14%) with CHF who underwent symptom-limited incremental cardiopulmonary exercise testing. Vo(2) and CO were measured at rest, at 25 W, and at peak exercise. Submaximal exercise was defined as80% peak Vo(2). Among 259 patients, 145 had Vo(2) at 25 W80% of peak. Vo(2) at 25 W averaged 9.3 +/- 1.8 ml/kg/min. This Vo(2) represented 62 +/- 11% of peak Vo(2), which averaged 15.4 +/- 4.4 ml/kg/min. Prospective follow-up averaged 521 +/- 337 days. In this cohort, there were 15 outcome events (death, urgent heart transplantation, or implantation of a left ventricular assist device as a bridge to transplantation). On univariate Cox hazard analysis, CO at 25 W (hazard ratio 0.64, 95% confidence interval 0.48 to 0.84, p = 0.002) was found to be significant predictor of events of outcome. In conclusion, CO at 25 W measured noninvasively during submaximal exercise may have potential value as a predictor of outcomes in patients with CHF.

Atrial flutter (AFL) is the second most common type of tachyarrhythmia in the fetus and neonate. An atrial rate of 240 to 360 beats per minute, 2:1 atrioventricular conduction, and a “saw tooth” appearance on electrocardiogram (ECG) are characteristic. On echocardiogram, bilateral atrial dilatation is the most common finding. Treatment is dependent on the severity of symptoms; delivery is usually indicated in the case of fetal heart failure or hydrops fetalis, whereas postnatal AFL is most commonly treated with direct current cardioversion (DCC). This article presents an illustrative case in which the patient presented antenatally via abnormal nonstress testing and subsequent fetal echocardiogram that was concerning for AFL. Postnatal ECG confirmed this diagnosis and the patient received DCC on the day of birth, followed by digoxin and propranolol as maintenance therapy. [ Pediatr Ann . 2015;44(10):e247–e250.]

Critical congenital heart disease (CCHD) is defined as a ductal-dependent congenital heart defect requiring surgical or percutaneous intervention via cardiac catheterization before 1 year of age. Most cases of CCHD can be diagnosed with prenatal ultrasound or fetal echocardiogram. If not prenatally diagnosed, CCHD can be stable in the newborn nursery due to persistent ductal patency, and the patient may only be diagnosed after ductal closure and development of cardiac symptoms at home. In this case, a 6-day-old female presented to the emergency department (ED) floppy with agonal respirations, poor capillary refill, and absent femoral pulses. On the day of presentation, the patient became increasingly fussy, refused feeding, and began to gasp. The patient was transported to the ED for evaluation, where a bedside echocardiogram revealed interrupted aortic arch (IAA), ventricular septal defect, minimal flow through a thread-like ductus arteriosus, and severely depressed cardiac function. IAA is very rare, with an incidence of three cases per 1 million live births. Patients require neonatal supportive care, continuous prostaglandin E1 infusion, and urgent referral for neonatal surgical repair in the first days to weeks of life. To reduce the volume of undiagnosed CCHD in the immediate newborn period, the U.S. Department of Health and Human Services Secretary’s Advisory Committee on Heritable Diseases in Newborns and Children (SACHDNC) recommended that CCHD screening via pulse oximetry be added to the recommended uniform screening panel. A positive screen results in an immediate referral for an echocardiogram. Fetal diagnosis, newborn screening, and/or careful clinical examination may have resulted in detection of IAA in our patient prior to ductal closure.

Three years of intervention to improve the language skills of children with severe intellectual disability are reported. Family based teaching, therapy and counselling programs were used as the basis of the interventions. Repeated language measures (norm referenced) were used to assess the effects of the interventions. Comparison with other language intervention studies are made. The distinct features of the effective behaviourally oriented teaching program are identified.

Background Hemodynamic responses to exercise were assessed in patients with varying degrees of chronic heart failure (CHF) to determine the feasibility of using bioreactance during exercise testing in multicenter studies of CHF. Methods and Results A total of 210 symptomatic CHF patients and 22 subjects without heart failure were subjected to symptom-limited exercise testing on a bicycle (105) or treadmill (127) while measuring gas exchange for VO 2 , cardiac output (CO) noninvasively by a bioreactance technique, heart rate, and blood pressure. Peak CO (pCO) and VO 2 (pVO 2 ) during exercise were lower in patients with higher New York Heart Association (NYHA) class, in females and in older patients. Multiple linear regression analysis showed that pCO (L/min)=19.6+4·M –2.1·NYHA+1.9·G –0.09·Age, where M=1 for treadmill and 0 for bicycle and G=1 for males and 0 for females. Similarly, pVO 2 (mL/kg/min)=24+2.1·M –2.9·NYHA+1.26·G –0.08·Age. VO 2 and CO were also highly correlated to each other: pCO (mL/kg/min)=0.059+0.007·pVO 2 +0.036·M –0.025·G. Similar correlations were determined for other parameters of exercise, including left ventricular power, and the ratio of peak/resting VO 2 (cardiovascular reserve), the ratio of peak/resting CO (cardiac reserve), and total peripheral vascular resistance. Conclusion Bioreactance-based noninvasive measurements of CO at rest and during exertion identified abnormalities of cardiovascular function consistent with those identified by pVO 2 and in prior studies using invasive CO measurements. This technique might therefore be useful for indexing disease severity, prognostication, and for tracking responses to treatment in clinical practice and in clinical trials.

Hybrid coronary revascularization (HCR), an emerging treatment paradigm, combines minimally invasive internal mammary artery (IMA) to left anterior descending artery (LAD) revascularization with percutaneous coronary intervention (PCI) to treat multi–vessel coronary artery disease (CAD) that