Predictability and durability of mitral valve repair in patients with severe degenerative mitral regurgitation in medium sized centres.

INTRODUCTION: Mitral valve repair (MVr) is now the treatment of choice to correct severe degenerative mitral regurgitation (MR). Repair rates vary greatly from centre to centre, and the concept of heart valve centres of excellence has been established. OBJECTIVE: The purpose of this study was to see whether large international centre repair rates, and outcomes, are transferrable to medium-sized centres with an interest in mitral repair. METHODS: Between 2011 and 2018, a total of 346 patients underwent mitral valve surgery by a single surgeon. Of these, 238 consecutive patients had repairs, or attempted repairs for degenerative MR, and are included in this study. RESULTS: The study sample consisted of 71% male patients and had a mean age of 64.4 ± 12.3 years; 66% of the study population had concomitant procedures. The overall repair rate in this cohort is 99%. Mean follow up was 3.7 ± 1.9 years. At 5 years, the freedom from MR ≥ 3+ was 95.9 ± 1.9% and at 7 years 91.1 ± 3.8%. Freedom from reoperation at 5 years was 92.9 ± 3.7%, while the 5 years actuarial survival was 89.1 ± 3.7%. On a multivariate analysis, predischarge echo grade was associated with higher risk of future reoperation (odds ratio (OR) = 21.82, p = 0.05). Only age (OR = 1.3, p = 0.03) was predictive of long-term survival. CONCLUSIONS: In specialised medium-sized heart centres, where the surgical team have undergone specialist mitral training, favourable short- and long-term outcomes are achievable with mitral repair rates similar to those from large international centres of excellence. In these heart centres, early surgery should be considered for all patients with severe degenerative MR.

Heart rate awareness in patients with chronic stable heart failure. A multi-center observational study.

AIMS: We assessed adherence to European Society of Cardiology heart rate guidelines (i.e. heart rates less than 70 bpm) in patients with chronic stable heart failure. We also investigated the percent of patients on target doses of rate controlling drugs. METHODS: Multicenter study involving 549 patients from 12 heart failure centers in the Republic of Ireland. Patients in sinus rhythm with stabilized heart failure treatment and without recent cardiac events were included. Resting heart rates, demographics, co-morbidities and heart failure therapies were recorded. RESULTS: Heart rates ≥ 70 bpm were noted in 176 (32.1%) patients with 117 (21.3%) having rates > 75 bpm. Non-achievement of target heart rates were unrelated to age, gender or most cardiovascular risk factors. However, 42% of patients with diabetes (p<0.01), 56% of those with COPD (p<0.0001) and 46% of those with NYHA Class 3 (p<0.05) did not achieve target heart rates. Fifty eight (11%) subjects were not on beta-blockers and of these forty subjects (69%) (p<0001) did not achieve target heart rates. Of those on beta-blockers only 25% were at target dose. However, beta-blocker dosage was unrelated to achieving target heart rates. Ivabradine was used in 11% of patients with 10% at target dosage. CONCLUSION: This study highlights that a third of "stabilized" chronic heart failure patients have not reached recommended target heart rates. Respiratory problems, diabetes and marked dyspnea were associated with poorer rate control. Guideline unawareness, inadequate beta-blocker titration and under use of ivabradine may prevent patients gaining the proven benefits of heart rate control.

Sudden cardiac death in the young: a 1-year post-mortem analysis in the Republic of Ireland.

AIMS: A retrospective post-mortem analysis was undertaken to determine the aetiology of sudden cardiac death (SCD) amongst individuals aged

B-type natriuretic peptide levels are not a surrogate marker for invasive hemodynamics during management of patients with severe heart failure.

BACKGROUND: We sought to assess the utility of serial BNP measurements in patients with severe heart failure and attempted to correlate values with invasively derived data. METHODS: In a retrospective study, we analyzed serial BNP levels in patients receiving hemodynamically guided therapy for severe heart failure and sought correlation with invasively derived data. RESULTS: Thirty-nine patients with New York Heart Association Class III-IV, with an ejection fraction of 35% or less, who had a pulmonary artery catheter inserted for hemodynamically tailored heart failure therapy, were identified and serial BNP measurements reviewed. BNP was estimated on admission, at 12 and 36 hours. Normally distributed variables are expressed as mean +/- SD and otherwise as median +/- interquartile range. Mean ejection fraction was 16% +/- 6%. Mean pulmonary artery occlusion pressures (PAOP) fell with therapy and were 25 +/- 7 mmHg, 18 +/- 7 mmHg and 19 +/- 7 mmHg at admission, 12 hours and 36 hours respectively ( P < 0.05). Median BNP levels fell from 1200 +/- 641 to 771 +/- 803 at 12 hours and to 805 +/- 771 at 36 hours (P < .001). There was no correlation between BNP and any hemodynamically derived variable. A change in BNP was not associated with a change in PAOP in any individual patient. Only 42% remained alive on medical therapy at 30 days. CONCLUSIONS: In patients with severe heart failure, BNP levels do not accurately predict serial hemodynamic changes and do not obviate the need for pulmonary artery catheterization.

Immunosuppression for cardiac transplantation--the past, present and future.

The field of cardiac transplant immunosuppression is rapidly developing and has evolved over the past 35 years. Anecdote, experience and registry based practice is giving way to an increasing bounty of well designed, randomized controlled trials which will guide future therapy. Current therapy is based on triple therapy with corticosteroids, a calcineurin inhibitor and an antimetabolite, but these regimens may be replaced by substitution or addition of newer antiproliferative agents. The true nemesis is coronary graft vasculopathy, which affects 50% of patients at 5 years and until recently had very few preventive therapeutic options. Renal toxicity remains among the most challenging adverse effects of immunosuppression to be overcome.

Emergency management of atrial fibrillation.

Atrial fibrillation is the most common cardiac arrhythmia managed by emergency and acute general physicians. There is increasing evidence that selected patients with acute atrial fibrillation can be safely managed in the emergency department without the need for hospital admission. Meanwhile, there is significant variation in the current emergency management of acute atrial fibrillation. This review discusses evidence based emergency management of atrial fibrillation. The principles of emergency management of acute atrial fibrillation and the subset of patients who may not need hospital admission are reviewed. Finally, the need for evidence based guidelines before emergency department based clinical pathways for the management of acute atrial fibrillation becomes routine clinical practice is highlighted.

The management of acute myocardial infarction--practical problems in implementing the evidence.

Cardiovascular disease is the leading cause of death in Europe. Acute myocardial infarction (AMI) is among the most common of its manifestations. Women and older patients are under-represented in most trials of treatment for AMI, as are those with significant co-morbidities. These patients also have a worse long term outcome after AMI. We sought to evaluate the management of AMI in a small non-academic general hospital. A review was performed of cases of AMI during 2000. Ninety-two cases were analysed, 69% were male. The mean age was 70 years. In-hospital mortality was 12%; 30-day mortality was 14%. There was no gender or age difference in mortality. Of thirty eligible patients, twenty-eight were thrombolysed (93%). Aspirin (81%) and beta-blocker (41%) prescription on discharge were below published European and American rates. Females were significantly less likely to receive aspirin or beta-blockers on discharge. Those aged 70 years or more were less likely to receive beta-blockers, statins or ACE inhibitors on discharge. Those with co-morbidities were less likely to receive beta-blockers or statins on discharge. This study highlights the difficulty in realising evidence based guidelines optimal management of AMI in clinical practice. While the outcome with regard to mortality is similar to national figures, there is a need to enhance care, with particular emphasis on secondary pharmacological measures prescribed on discharge.