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Low rates of bystander cardiopulmonary resuscitation (CPR) were identified as a shortcoming in the “chain of survival” for out-of-hospital cardiac arrest (OHCA) care in the Korean city of Ansan. This study sought to evaluate the effect of an initiative to increase bystander CPR and quality of out-of-hospital resuscitation on outcome from OHCA. The post-intervention data were used to determine the next quality improvement (QI) target as part of the “Plan-Do-Study-Act” (PDSA) model for QI.
The study hypothesis was that bystander CPR, return of spontaneous circulation (ROSC), and survival to discharge after OHCA would increase in the post-intervention period.
This was a retrospective pre/post study. The data from the pre-intervention period were abstracted from 2008–2011 and the post-intervention period from 2012–2013. The effect of the intervention on the odds of ROSC and survival to hospital discharge was determined using a generalized estimating equation to account for confounders and the effect of clustering within medical centers. The analysis was then used to identify other factors associated with outcomes to determine the next targets for intervention in the chain of survival for cardiac arrest in this community.
Rates of documented bystander CPR increased from 13% in the pre-intervention period to 37% in the post-intervention period. The overall rate of ROSC decreased from 18.4% to 14.3% (risk difference −4.1%; 95% CI, −7.1%–1.0%), whereas survival to hospital discharge increased from 3.9% to 5.0% (risk difference 1.1%; 95% CI, −1.8%–3.8%), and survival with good neurologic outcome increased from 0.8% to 1.6% (risk difference 0.8%; 95% CI, −0.8%–2.4%). In multivariable analyses, there was no association between the intervention and the rate of ROSC or survival to hospital discharge. The designated level of the treating hospital was a significant predictor of both survival and ROSC.
In this case study, there were no observed improvements in outcomes from OHCA after the targeted intervention to improve out-of-hospital CPR. However, utilizing the PDSA model for QI, the designated level of the treating hospital was found to be a significant predictor of survival in the post-period, identifying the next target for intervention.
This chapter reviews the incidence, presentation and types of atrial septal defects. The pathophysiology and hemodynamic effects of atrial septal defects are discussed. The surgical and catheter-based interventions are reviewed in relation to the anesthetic considerations.
This chapter reviews the basics of truncus arteriosus. The authors review the signs and symptoms as well as the anatomic classifications for truncus arteriosus. The associated congenital anomalies are presented in addition to the anesthetic concerns of caring for patients with truncus arteriosus defects.
Intercoronary communications are a very rare congenital coronary artery anomalies. We report a case of a man who underwent elective coronary angiography that showed a bidirectional direct intercoronary communication between right coronary and left circumflex arteries.
An 11-year-old male was presented with exertional chest pain and was diagnosed with atresia of the left main coronary artery. A stress nuclear perfusion imaging was negative at initial presentation, and a vasodilator stress cardiac MRI was again negative 5 years later. The patient has fully participated in competitive sports for 6 years with no occurrence of cardiac events.
Abnormal small fistulous flows in the pulmonary artery were detected on routine transthoracic echocardiography in asymptomatic patients by colour Doppler echocardiography. The most likely diagnosis is small coronary artery-pulmonary artery fistulas. We evaluated the clinical, echocardiographic, and follow-up findings of 101 patients. The mean age at first echocardiographic evaluation was 4.3 ± 4.2 years. In 79 (78.2%) of the patients, fistula flow in the pulmonary artery was diagnosed at the first presentation and the remaining 22 patients (21.8%) were diagnosed between the 2nd and 10th examination. The echocardiography indication was cardiac murmur in 42 (41.6%), routine cardiac control in 30 (29.7%), additional CHD in 14 (13.8%), non-specific chest pain in 11 (10.9%), suspicion of inflammatory heart disease in 2 (2%), and syncope in 2 (2%) patients. In 70 (69.3%) patients, fistulous flow was located in the anterior aspect of the main pulmonary artery, in 23 (22.8%) patients on the aortic side of the pulmonary artery and in 8 (7.9%) patients on the right pulmonary artery. Additional cardiac anomalies were ventricular septal defect in 8, patent ductus arteriosus in 6, atrial septal defect in 5, mitral valve prolapse in 4, coarctation of aorta in 4, bicuspid aortic valve in 3, and Kawasaki syndrome in 1 patient. Sixty-four patients (63.3%) were followed during a mean of 52.6 ± 43.7 months. Spontaneous closure was detected in only three patients; the others remained almost unchanged during the follow-up. Since the fistulas are thin and hemodynamically insignificant, echocardiography is an appropriate method to monitor these patients without performing any invasive diagnostic procedures for the fistula source.
Malnutrition and acute kidney injury (AKI) are common complications in hospitalized patients, and both increase mortality; however, the relationship between them is unknown. This is a retrospective propensity score matching study enrolling 46,549 inpatients, aimed to investigate the association between Nutritional Risk Screening 2002 (NRS-2002) and AKI, and to assess the ability of NRS-2002 and AKI in predicting prognosis. In total, 37,190 (80%) and 9,359 (20%) patients had NRS-2002 scores < 3 and ≥ 3, respectively. Patients with NRS-2002 scores ≥ 3 had longer lengths of stay (12.6±7.8 days vs. 10.4±6.2 days, P < 0.05), higher mortality rates (9.6% vs. 2.5%, P<0.05), and higher incidence of AKI (28% vs. 16%, P < 0.05) than normal nutritional patients. The NRS-2002 showed a strong association with AKI, that is, the risk of AKI changed in parallel with the score of the NRS-2002. In short- and long-term survival, patients with a lower NRS-2002 score or who did not have AKI achieved a significantly lower risk of mortality than those with a high NRS-2002 score or AKI. Univariate Cox regression analyses indicated that both the NRS-2002 and AKI were strongly related to long-term survival (area under the curve (AUC) 0.79 and 0.71) and that the combination of the two showed better accuracy (AUC 0.80) than the individual variables. In conclusion, malnutrition can increase the risk of AKI, and both AKI and malnutrition can worsen the prognosis, that the undernourished patients who develop AKI yield far worse prognosis than normal nutritional patients.
Carbon monoxide (CO) poisoning is the most common cause of death and injury among all poisonings. Myocardial injury is detected in one-third of CO poisonings. In this Case Report, a previously healthy 41-year-old man was referred for CO poisoning. The initial electrocardiogram (ECG) showed 1mm ST segment elevation in leads DII, DIII, and aVF. As the patient did not describe chest pain and had no cardiac symptoms, ECG was repeated 10 minutes later and it was seen that ST segment elevation disappeared. As the patient had a transient ST segment elevation and elevated high-sensitive Tn-T (HsTn-T), the patient was transferred to the coronary angiography laboratory. The patient’s left coronary system was normal, but a thrombus image narrowing the lumen by approximately 60% was observed in the right coronary artery. Intravenous tirofiban was administered for 48 hours. Control coronary angiography showed continuing thrombus formation and a bare metal stent was successfully implanted. This is the first reported case with transient ST segment elevation associated with acute coronary thrombus caused by CO poisoning. It may be recommended that patients with CO poisoning should be followed-up with a 12-lead ECG monitor or 24-hour ECG Holter monitoring, even if they show no cardiac symptoms and echocardiography shows no wall motion abnormality. Early coronary angiography upon detection of such dynamic ECG changes in these recordings as ST segment elevation can reduce the risk of myocardial infarction (MI) and mortality in these patients.
A child undergoing routine transcatheter patent arterial duct closure developed severe transient ischemic changes in the electrocardiogram (Pardee waves) while the aortic retention skirt of the Amplatzer™ Duct Occluder was pulled against the duct orifice. The occluder was then released, and the delivery system was pulled back to inferior caval vein which led to electrocardiogram normalisation. Aortic root angiography showed a single coronary artery originating from the right sinus of Valsalva with the left coronary stem wedged behind the posterior aspect of the right ventricular outflow tract. We believe that the left coronary artery was compressed while applying tension on the occluder delivery system.
Coronary artery complications are the main reason for early mortality after an arterial switch operation. Late complications are relatively rare, and there is no consensus regarding the need or indications for routine follow-up coronary artery evaluations or the best first-line assessment modality. The aim of this study was to present the long-term post-operative frequency of coronary abnormalities in asymptomatic patients with transposition of the great arteries discovered by coronary CT angiography and potential “red flags” revealed by other examinations.
Patients and methods:
A group of 50 consecutive asymptomatic patients who underwent routine long-term coronary artery evaluation after an arterial switch operation according to our institutional protocol were qualified for this study. This routine in-hospital visit included a detailed medical interview, electrocardiography, echocardiography, Holter electrocardiography examinations, and laboratory and cardiopulmonary exercise tests. Patients who showed significant abnormalities were qualified for perfusion scintigraphy.
Unfavourable coronary abnormalities were detected in 30 patients (60%) and included ostial stenosis, muscular bridge, coronary fistula, interarterial course, proximal kinking, high ellipticity index, proximal acute angulation (<30 degree) of the left coronary artery, and proximal acute angulation of the right coronary artery. These features could not be predicted based on the medical interviews, surgical reports, or non-invasive screening test results.
Complex coronary configurations with potentially dangerous coronary features are common in patients with transposition after an arterial switch operation. Such high-risk patients cannot be identified indirectly, and coronary CT angiography provides accurate information that is useful for post-operative management.
We present two patients, one 10 years old and another 43 years old, who both had successful transcatheter closure of left main coronary artery to right atrium fistulas. The older patient had a larger fistula as well as more symptoms and a complicated post-procedure course. Closure of medium or large coronary artery fistulas should be considered at younger ages to minimise future complications.
We report an extremely rare case of a 14-month-old girl who was diagnosed with a single right coronary artery with coronary artery fistula communicating with the right ventricle and congenital absence of left coronary artery. Angiography showed a dilated and tortuous single right coronary artery draining into the right ventricle, absence of left coronary system, and left ventricular coronary circulation supplied via collateral vessels.
This chapter is devoted to the macroscopic and microscopic appearance of myocardial ischaemia and includes discussion of regional myocardial infarction and of papillary muscle rupture. Coronary atherosclerosis can occur, albeit rarely, in the child, and this is discussed particularly in relation to hypercholesterolaemia. Antiphospholipid syndrome and haemolytic-uraemic syndrome are also discussed.
No data exist on the associations of dietary tomato and lycopene consumption with total and cause-specific mortality. Using the National Health and Nutrition Examination Surveys (NHANES) 1999-2010, we evaluted the long-term impact of tomato and lycopene intake on total and cause-specific (coronary heart disease [CHD] and cerebrovascular disease) mortality. We also assessed the changes in cardio-metabolic risk factors according to tomato and lycopene intake. Vital status through December 31, 2011 was ascertained. Cox proportional hazard regression models (followed by propensity score-matching) were used to investigate the link between tomato and lycopene consumption total, CHD and cerebrovascular mortality. Among the 23,935 participants included (mean age = 47.6 years, 48.8% men), 3403 deaths occurred during 76.4 months of follow-up. Tomato intake was inversely associated with total (risk ratio (RR):0.86, 95% confidence interval (CI):0.81-0.92), CHD (0.76, 95%CI: 0.70-0.85) and cerebrovascular (0.70, 95%CI: 0.62-0.81) mortality. Similar inverse associations were found between lycopene consumption, total (0.76, 95%CI: 0.72-0.81), CHD (0.73, 95%CI: 0.65-0.83) and cerebrovascular (0.71, 95%CI: 0.65-0.78) mortality; these associations were independent of anthropometric, clinical and nutritional parameters. Age and obesity did not affect the associations of tomato and lycopene consumption with total, CHD and cerebrovascular mortality. C-reactive protein significantly moderated the link between lycopene and tomato intake with total, CHD and cerebrovascular mortality. Analysis of co-variance showed that participants with a higher tomato and lycopene consumption had a more cardio-protective profile compared with those with a lower intake. Our results highlighted the favorable effect of tomato and lycopene intake on total and cause-specific mortality as well as to cardio-metabolic risk factors. These findings should be taken into consideration for public health strategies.
A brief introduction on demographics is followed by a section on the aims of investigation of sudden cardiac death. Specific cardiac causes are dealt with in turn: congenital heart disease, coronary artery anomalies, cardiomyopathy, myocarditis and metabolic disease. A section is then devoted to cases where there is no morphological abnormality and death is due to ion channelopathy. There is a separate discussion of sudden infant death syndrome as a possible sudden cardiac death. The chapter closes with a brief discussion of commotio cordis.
This study was performed to evaluate the effects of vitamin D and n-3 fatty acids’ co-supplementation on markers of cardiometabolic risk in diabetic patients with CHD. This randomised, double-blinded, placebo-controlled trial was conducted among sixty-one vitamin D-deficient diabetic patients with CHD. At baseline, the range of serum 25-hydroxyvitamin D levels in study participants was 6·3–19·9 ng/ml. Subjects were randomly assigned into two groups either taking 50 000 IU vitamin D supplements every 2 weeks plus 2× 1000 mg/d n-3 fatty acids from flaxseed oil (n 30) or placebo (n 31) for 6 months. Vitamin D and n-3 fatty acids’ co-supplementation significantly reduced mean (P = 0·01) and maximum levels of left carotid intima–media thickness (CIMT) (P = 0·004), and mean (P = 0·02) and maximum levels of right CIMT (P = 0·003) compared with the placebo. In addition, co-supplementation led to a significant reduction in fasting plasma glucose (β −0·40 mmol/l; 95 % CI −0·77, −0·03; P = 0·03), insulin (β −1·66 μIU/ml; 95 % CI −2·43, −0·89; P < 0·001), insulin resistance (β −0·49; 95 % CI −0·72, −0·25; P < 0·001) and LDL-cholesterol (β −0·21 mmol/l; 95 % CI −0·41, −0·01; P = 0·04), and a significant increase in insulin sensitivity (β +0·008; 95 % CI 0·004, 0·01; P = 0·001) and HDL-cholesterol (β +0·09 mmol/l; 95 % CI 0·01, 0·17; P = 0·02) compared with the placebo. Additionally, high-sensitivity C-reactive protein (β −1·56 mg/l; 95 % CI −2·65, −0·48; P = 0·005) was reduced in the supplemented group compared with the placebo group. Overall, vitamin D and n-3 fatty acids’ co-supplementation had beneficial effects on markers of cardiometabolic risk.
Anomalous single coronary artery from pulmonary artery is a very rare congenital heart anomaly. Anomalous single coronary artery from pulmonary artery has high mortality rates and poor surgical outcome despite advanced surgical techniques. We report a 4-month-old infant presented by congestive heart failure findings and diagnosed with anomalous single trunk coronary arteries arising from right pulmonary artery.
Coronary ostial atresia seen with pulmonary atresia and coronary-cameral fistulae or, more rarely, in isolation manifested as left main coronary artery atresia, is well described. We describe the clinical course and post-mortem findings in a neonate who suffered a fatal cardiac arrest and was found to have congenital absence of both coronary ostia in a single/common coronary system.
Kawasaki disease is an acute vasculitis of childhood and is the leading cause of acquired heart disease in the developed countries.
Data from hospital discharge records were obtained from the National Kids Inpatient Database for years 2009 and 2012. Hospitalisations by months, hospital regions, timing of admission, insurance types, and ethnicity were analysed. Length of stay and total charges were also analysed.
There were 10,486 cases of Kawasaki disease from 12,678,005 children hospitalisation. Kawasaki disease was more common between 0 and 5 years old, in male, and in Asian. The January–March quarter had the highest rate compared to the lowest in the July–September quarter (OR=1.62, p < 0.001). Admissions on the weekend had longer length of stay [4.1 days (95 % CI: 3.97–4.31)] as compared to admissions on a weekday [3.72 days (95 % CI: 3.64–3.80), p < 0.001]. Blacks had the longest length of stay and whites had the shortest [4.33 days (95 % CI: 4.12–4.54 days) versus 3.60 days (95 % CI: 3.48–3.72 days), p < 0.001]. Coronary artery aneurysm was identified in 2.7 % of all patients with Kawasaki disease. Children with coronary artery aneurysm were hospitalised longer and had higher hospital charge. Age, admission during weekend, and the presence of coronary artery aneurysm had significant effect on the length of stay.
This report provides the most updated epidemiological information on Kawasaki disease hospitalisation. Age, admissions during weekend, and the presence of coronary artery aneurysm are significant contributors to the length of stay.