Impact of On-Site Cardiac Surgery on Clinical Outcomes After Transfemoral Transcatheter Aortic Valve Replacement.

OBJECTIVES: This study sought to investigate the outcome of high-risk and inoperable patients with severe symptomatic aortic stenosis undergoing transfemoral transcatheter aortic valve replacement (TAVR) in hospitals with (iOSCS) versus without institutional on-site cardiac surgery (no-iOSCS). BACKGROUND: Current guidelines recommend the use of TAVR only in institutions with a department for cardiac surgery on site. METHODS: In this analysis of the prospective multicenter Austrian TAVI registry, 1,822 consecutive high-risk patients with severe symptomatic aortic stenosis undergoing transfemoral TAVR were evaluated. A total of 290 (15.9%) underwent TAVR at no-iOSCS centers (no-iOSCS group), whereas the remaining 1,532 patients (84.1%) were treated in iOSCS centers (iOSCS group). RESULTS: Patients of the no-iOSCS group had a higher perioperative risk defined by the logistic EuroSCORE (20.9% vs. 14.2%; p < 0.001) compared with patients treated in hospitals with iOSCS. Procedural survival was 96.9% in no-iOSCS centers and 98.6% in iOSCS centers (p = 0.034), whereas 30-day survival was 93.1% versus 96.0% (p = 0.039) and 1-year survival was 80.9% versus 86.1% (p = 0.017), respectively. After propensity score matching for confounders procedural survival was 96.9% versus 98.6% (p = 0.162), 93.1% versus 93.8% (p = 0.719) at 30 days, and 80.9% versus 83.4% (p = 0.402) at 1 year. CONCLUSIONS: Patients undergoing transfemoral TAVR in hospitals without iOSCS had a significantly higher baseline risk profile. After propensity score matching short- and long-term mortality was similar between centers with and without iOSCS.

Radial versus femoral access site for percutaneous coronary intervention in patients suffering acute myocardial infarction : A randomized prospective multicenter trial.

BACKGROUND: Transradial access (TRA) in percutaneous coronary intervention (PCI) is a widely used standard technique with lower complication rates compared to transfemoral access (TFA). The aim of this study was to evaluate the impact of TRA versus TFA for PCI on clinically significant vascular access complications in the setting of acute myocardial infarction (AMI). METHODS: This multicenter study randomly assigned 250 patients in a 1:1 fashion (TRA vs. TFA) admitted with or without ST-segment elevation AMI undergoing immediate PCI. The primary endpoint was defined as the occurrence of hematoma, pseudo-aneurysm or local bleeding at the access site requiring any further intervention and/or prolonged hospital stay. Radiation exposure to the patient and operator was also investigated. RESULTS: In the study cohort (N = 250 patients, mean age 62 ± 12.7 years, 76% males) 5 patients (2%) achieved the primary endpoint without a significant difference between groups, 4 out of 125 (3.2%) in the TFA group and 1 out of 125 (0.8%) in the TRA group (p = 0.17). Access site hematoma was significantly more frequent in the TFA group compared to the TRA group (24.8% vs. 8.8%, respectively; p < 0.0007). Local bleeding was only seen in the TFA group (3.2% vs. 0%, p = 0.04). Time intervals from admission to catheter laboratory to first balloon inflation were longer in the TRA compared to the TFA group (34 ± 17 min vs 29.5 ± 13 min, respectively; p = 0.018). Radiation exposure to the patient and operator was identical. CONCLUSION: The use of TRA was accompanied by lower rates of access site complications; however, the need for subsequent treatment or prolonged hospital stays was not observed using either of the two access approaches.

Life-threatening heat stroke presenting with ST elevations: a report of consecutive cases during the heat wave in Austria in July 2013.

Heat stroke is a life-threatening condition due to an acute thermoregulatory failure during exposure to high environmental temperatures. We report a series of four cases (three exertional, one classic heat stroke) during the heat wave of July 2013 in Austria. All of them presented with a core temperature > 41 °C, central nervous dysfunction, acute respiratory and renal failure, disseminated intravascular coagulation, rhabdomyolysis, and severe electrocardiographic changes, two cases even mimicking ST-elevation myocardial infarction. The patients were cooled to normal temperature with the "Arctic sun" external cooling system within hours. Electrocardiographic changes resolved quickly. All patients primarily recovered from multiple organ dysfunction and could be discharged from intensive care unit. Unfortunately, the two elder patients died 1 week and 5 weeks later because of late complications.

Climate change impacts on streamflow and subbasin-scale hydrology in the Upper Colorado River Basin.

In the Upper Colorado River Basin (UCRB), the principal source of water in the southwestern U.S., demand exceeds supply in most years, and will likely continue to rise. While General Circulation Models (GCMs) project surface temperature warming by 3.5 to 5.6°C for the area, precipitation projections are variable, with no wetter or drier consensus. We assess the impacts of projected 21(st) century climatic changes on subbasins in the UCRB using the Soil and Water Assessment Tool, for all hydrologic components (snowmelt, evapotranspiration, surface runoff, subsurface runoff, and streamflow), and for 16 GCMs under the A2 emission scenario. Over the GCM ensemble, our simulations project median Spring streamflow declines of 36% by the end of the 21(st) century, with increases more likely at higher elevations, and an overall range of -100 to +68%. Additionally, our results indicated Summer streamflow declines with median decreases of 46%, and an overall range of -100 to +22%. Analysis of hydrologic components indicates large spatial and temporal changes throughout the UCRB, with large snowmelt declines and temporal shifts in most hydrologic components. Warmer temperatures increase average annual evapotranspiration by ∼23%, with shifting seasonal soil moisture availability driving these increases in late Winter and early Spring. For the high-elevation water-generating regions, modest precipitation decreases result in an even greater water yield decrease with less available snowmelt. Precipitation increases with modest warming do not translate into the same magnitude of water-yield increases due to slight decreases in snowmelt and increases in evapotranspiration. For these basins, whether modest warming is associated with precipitation decreases or increases, continued rising temperatures may make drier futures. Subsequently, many subbasins are projected to turn from semi-arid to arid conditions by the 2080 s. In conclusion, water availability in the UCRB could significantly decline with adverse consequences for water supplies, agriculture, and ecosystem health.

Projecting water withdrawal and supply for future decades in the U.S. under climate change scenarios.

The sustainability of water resources in future decades is likely to be affected by increases in water demand due to population growth, increases in power generation, and climate change. This study presents water withdrawal projections in the United States (U.S.) in 2050 as a result of projected population increases and power generation at the county level as well as the availability of local renewable water supplies. The growth scenario assumes the per capita water use rate for municipal withdrawals to remain at 2005 levels and the water use rates for new thermoelectric plants at levels in modern closed-loop cooling systems. In projecting renewable water supply in future years, median projected monthly precipitation and temperature by sixteen climate models were used to derive available precipitation in 2050 (averaged over 2040-2059). Withdrawals and available precipitation were compared to identify regions that use a large fraction of their renewable local water supply. A water supply sustainability risk index that takes into account additional attributes such as susceptibility to drought, growth in water withdrawal, increased need for storage, and groundwater use was developed to evaluate areas at greater risk. Based on the ranking by the index, high risk areas can be assessed in more mechanistic detail in future work.

Validation of a brachial cuff-based method for estimating central systolic blood pressure.

The prognostic value of central systolic blood pressure has been established recently. At present, its noninvasive assessment is limited by the need of dedicated equipment and trained operators. Moreover, ambulatory and home blood pressure monitoring of central pressures are not feasible. An algorithm enabling conventional automated oscillometric blood pressure monitors to assess central systolic pressure could be of value. We compared central systolic pressure, calculated with a transfer-function like method (ARCSolver algorithm), using waveforms recorded with a regular oscillometric cuff suitable for ambulatory measurements, with simultaneous high-fidelity invasive recordings, and with noninvasive estimations using a validated device, operating with radial tonometry and a generalized transfer function. Both studies revealed a good agreement between the oscillometric cuff-based central systolic pressure and the comparator. In the invasive study, composed of 30 patients, mean difference between oscillometric cuff/ARCSolver-based and invasive central systolic pressures was 3.0 mm Hg (SD: 6.0 mm Hg) with invasive calibration of brachial waveforms and -3.0 mm Hg (SD: 9.5 mm Hg) with noninvasive calibration of brachial waveforms. Results were similar when the reference method (radial tonometry/transfer function) was compared with invasive measurements. In the noninvasive study, composed of 111 patients, mean difference between oscillometric cuff/ARCSolver-derived and radial tonometry/transfer function-derived central systolic pressures was -0.5 mm Hg (SD: 4.7 mm Hg). In conclusion, a novel transfer function-like algorithm, using brachial cuff-based waveform recordings, is suited to provide a realistic estimation of central systolic pressure.

Applied climate-change analysis: the climate wizard tool.

BACKGROUND: Although the message of "global climate change" is catalyzing international action, it is local and regional changes that directly affect people and ecosystems and are of immediate concern to scientists, managers, and policy makers. A major barrier preventing informed climate-change adaptation planning is the difficulty accessing, analyzing, and interpreting climate-change information. To address this problem, we developed a powerful, yet easy to use, web-based tool called Climate Wizard (http://ClimateWizard.org) that provides non-climate specialists with simple analyses and innovative graphical depictions for conveying how climate has and is projected to change within specific geographic areas throughout the world. METHODOLOGY/PRINCIPAL FINDINGS: To demonstrate the Climate Wizard, we explored historic trends and future departures (anomalies) in temperature and precipitation globally, and within specific latitudinal zones and countries. We found the greatest temperature increases during 1951-2002 occurred in northern hemisphere countries (especially during January-April), but the latitude of greatest temperature change varied throughout the year, sinusoidally ranging from approximately 50 degrees N during February-March to 10 degrees N during August-September. Precipitation decreases occurred most commonly in countries between 0-20 degrees N, and increases mostly occurred outside of this latitudinal region. Similarly, a quantile ensemble analysis based on projections from 16 General Circulation Models (GCMs) for 2070-2099 identified the median projected change within countries, which showed both latitudinal and regional patterns in projected temperature and precipitation change. CONCLUSIONS/SIGNIFICANCE: The results of these analyses are consistent with those reported by the Intergovernmental Panel on Climate Change, but at the same time, they provide examples of how Climate Wizard can be used to explore regionally- and temporally-specific analyses of climate change. Moreover, Climate Wizard is not a static product, but rather a data analysis framework designed to be used for climate change impact and adaption planning, which can be expanded to include other information, such as downscaled future projections of hydrology, soil moisture, wildfire, vegetation, marine conditions, disease, and agricultural productivity.

Projected climate-induced faunal change in the Western Hemisphere.

Climate change is predicted to be one of the greatest drivers of ecological change in the coming century. Increases in temperature over the last century have clearly been linked to shifts in species distributions. Given the magnitude of projected future climatic changes, we can expect even larger range shifts in the coming century. These changes will, in turn, alter ecological communities and the functioning of ecosystems. Despite the seriousness of predicted climate change, the uncertainty in climate-change projections makes it difficult for conservation managers and planners to proactively respond to climate stresses. To address one aspect of this uncertainty, we identified predictions of faunal change for which a high level of consensus was exhibited by different climate models. Specifically, we assessed the potential effects of 30 coupled atmosphere-ocean general circulation model (AOGCM) future-climate simulations on the geographic ranges of 2954 species of birds, mammals, and amphibians in the Western Hemisphere. Eighty percent of the climate projections based on a relatively low greenhouse-gas emissions scenario result in the local loss of at least 10% of the vertebrate fauna over much of North and South America. The largest changes in fauna are predicted for the tundra, Central America, and the Andes Mountains where, assuming no dispersal constraints, specific areas are likely to experience over 90% turnover, so that faunal distributions in the future will bear little resemblance to those of today.

Ability of neuron-specific enolase to predict survival to hospital discharge after successful cardiopulmonary resuscitation.

BACKGROUND: Accurate prediction of survival to hospital discharge in patients who achieve return of spontaneous circulation after cardiopulmonary resuscitation (CPR) has significant ethical and socioeconomic implications. We investigated the prognostic performance of serum neuron-specific enolase (NSE), a biochemical marker of ischemic brain injury, after successful CPR. METHODS: In-hospital or out-of-hospital patients with nontraumatic normothermic cardiac arrest who achieved return of spontaneous circulation (ROSC) following at least 5 minutes of CPR were eligible. Neuron-specific enolase levels were assessed immediately, 6 hours, 12 hours and 2 days after ROSC. Subjects were followed to death or hospital discharge. RESULTS: Seventeen patients (7 men, 10 women) were enrolled during a 1-year period. Median (range) NSE levels in survivors and non-survivors respectively were as follows: immediately after ROSC: 14.0 microg/L (9.1-51.4 microg/L) versus 25.9 microg/L (10.2-57.5 microg/L); 6 hours after ROSC: 15.2 microg/L (9.7-30.8 microg/L) versus 25.6 microg/L (12.7-38.2 microg/L); 12 hours after ROSC: 14.0 microg/L (8.6-32.4 microg/L) versus 28.5 microg/L (11.0-50.7 microg/L); and 48 hours after ROSC: 13.1 microg/L (7.8-29.5 microg/L) versus 52.0 microg/L (29.1-254.0 microg/L). Non-survivors had significantly higher NSE levels 48 hours after ROSC than surivors (p = 0.04) and showed a trend toward higher values during the entire time course following ROSC. An NSE concentration of >30 microg/L 48 hours after ROSC predicted death with a high specificity (100%: 95% confidence interval [CI] 85%-100%), and a level of 29 microg/L or less at 48 hours predicted survival with a high specificity (100%: 95% CI 83%-100%). CONCLUSIONS: Serum NSE levels may have clinical utility for the prediction of survival to hospital discharge in patients after ROSC following CPR over 5 minutes in duration. This study is small, and our results are limited by wide confidence intervals. Further research on ability of NSE to facilitate prediction and clinical decision-making after cardiac arrest is warranted.

Emissions pathways, climate change, and impacts on California.

The magnitude of future climate change depends substantially on the greenhouse gas emission pathways we choose. Here we explore the implications of the highest and lowest Intergovernmental Panel on Climate Change emissions pathways for climate change and associated impacts in California. Based on climate projections from two state-of-the-art climate models with low and medium sensitivity (Parallel Climate Model and Hadley Centre Climate Model, version 3, respectively), we find that annual temperature increases nearly double from the lower B1 to the higher A1fi emissions scenario before 2100. Three of four simulations also show greater increases in summer temperatures as compared with winter. Extreme heat and the associated impacts on a range of temperature-sensitive sectors are substantially greater under the higher emissions scenario, with some interscenario differences apparent before midcentury. By the end of the century under the B1 scenario, heatwaves and extreme heat in Los Angeles quadruple in frequency while heat-related mortality increases two to three times; alpine/subalpine forests are reduced by 50-75%; and Sierra snowpack is reduced 30-70%. Under A1fi, heatwaves in Los Angeles are six to eight times more frequent, with heat-related excess mortality increasing five to seven times; alpine/subalpine forests are reduced by 75-90%; and snowpack declines 73-90%, with cascading impacts on runoff and streamflow that, combined with projected modest declines in winter precipitation, could fundamentally disrupt California's water rights system. Although interscenario differences in climate impacts and costs of adaptation emerge mainly in the second half of the century, they are strongly dependent on emissions from preceding decades.

[Platelet glycoprotein IIb/IIIa inhibitors in coronary artery disease]. / Thrombozytäre Glykoprotein-IIb/IIIa-Rezeptor-Blocker in der Behandlung der koronaren Herzkrankheit.

BACKGROUND: Inhibition of platelet activity at the injured coronary plaque is a target for novel therapeutic strategies. One of these mechanisms is the blockade of the platelet surface membrane glycoprotein (GP) IIb/IIIa receptor, which binds circulating fibrinogen or von Willebrand factor and crosslinks platelets as the final common pathway to platelet aggregation. Intravenous agents directed against this receptor include the chimeric monoclonal antibody fragment abciximab, the peptide inhibitor eptifibatide and nonpeptide mimetics tirofiban and lamifiban. RESULTS: During percutaneous coronary intervention, an absolute reduction of 1.5-6.5% in the 30-day risk of death, myocardial infarction or repeat urgent revascularization has been observed, with some variability in treatment effect among the agents tested. Treatment effect is achieved early with every modality of revascularization and maintained over the long-term up to 3 years. Increased bleeding risk may be minimized by reduction and weight adjustment of concomitant heparin dosing. In the acute coronary syndromes without ST segment elevation, absolute 1.5-3.2% reductions in 30-day rates of death or myocardial infarction have been achieved with 2- to 4-day courses of eptifibatide or tirofiban. Clinical benefit accrues during the period of drug infusion and is durable. Treatment effect may be enhanced among patients undergoing early coronary revascularization, with evidence of stabilization before intervention and suppression of postprocedural ischemic events. CONCLUSION: Thus, blockade of the platelet GP IIb/IIIa receptor reduces ischemic complications when used as an adjunct to percutaneous coronary intervention or the management of acute ischemic syndromes.

Clinical and angiographic outcome after cutting balloon angioplasty.

The cutting balloon is a new device for coronary angioplasty, that, by the combination of incision and dilatation of the plaque, is believed to be promising for treatment of in-stent restenosis. The purpose of the study was to evaluate the safety and efficacy of CBA. We reviewed the immediate and 6-month follow-up angiographic and clinical outcome of 147 patients (109 men and 38 women) with a mean age of 67.3 +/- 10 undergoing this procedure at eight interventional centers in Austria. The target lesions treated with CBA were in-stent restenosis in 61% of patients, stenosis after balloon angioplasty in 8% of patients, and native lesions in 33% of patients. Sixty-five percent of the patients included had multivessel disease. Lesion type was A in 18% of patients, B1 in 31% of patients, B2 in 39% of patients, and C in 12% of patients. The degree of stenosis was 87% +/- 9%, the length of the target lesion treated with CBA was 8.8 +/- 5.1 mm. Target vessel was left circumflex artery in 22 cases, right coronary artery in 36 cases, and left anterior descending artery in 89 cases. The overall procedural success rate was 90.5%. "Stand-alone" CBA was performed in 63% of patients, the procedure was combined with coronary stenting in 16% of patients, and with balloon angioplasty in 21% of patients. Coronary complications occurred in eight cases (5.4%) with coronary dissection in seven (total dissection rate of 4.7%) and urgent bypass surgery in one case (0.7%). No further complications such as death, occlusion, or perforation of coronary arteries, embolization, or thrombosis were observed. Six-month clinical follow-up revealed q-wave myocardial infarction in 2.7% of patients, aortocoronary bypass surgery in 8.5% of patients, and repeated percutaneous coronary intervention in 17% of patients (11.5% with stenting). Six-month angiographic follow-up of patients with recurrent angina showed target lesion restenosis (> 50% diameter stenosis) in 14% of patients, late lumen loss with < or = 50% diameter stenosis in 6% of patients and progression of "other than target" lesions with > 50% diameter stenosis in 14% of patients. This series demonstrates the safety and feasibility of cutting balloon angioplasty in patients with complex coronary artery disease and in-stent restenosis.

[Angiographic results of "atypical" chest pain]. / Ergebnisse koronarangiographischer Untersuchungen bei Patienten mit "atypischem" Thoraxschmerz.

BACKGROUND AND AIMS: Coronary angiography permits evaluation of coronary artery morphology and coronary pathology. It represents an accurate method of defining stenotic coronary lesions. Chest pain may be caused by coronary artery disease as well as by other cardiac and noncardiac disorders. However, sensitivity of clinical evaluation and noninvasive diagnostic assessment in detection of coronary artery disease is limited. Noninvasive diagnostic strategies give inconsistent results in about 10-30%. Here coronary angiography is regarded as an accurate method for appropriate diagnosis. Ist sophisticated apparatus, cost, and invasiveness necessitate well-considered application of this procedure. Therefore, it appears important to analyze coronary angiograms in patients with the referral diagnosis of "atypical" chest pain with inconsistent noninvasive testing or impossibility to perform noninvasive assessment. PATIENTS AND METHODS: We analyzed records of 1,000 consecutive patients (625 men, 375 women, mean age 63.1 years), who underwent coronary angiography at our institution from January 5, 1998 to May 5, 1998. RESULTS: 49 patients (17 women, 32 men; mean age 59 years) were referred due to "atypical" chest pain. 21 (42.9%, nine women, twelve men) of these 49 patients had normal coronary arteries at angiography. 21 (42.9%) patients showed coronary artery disease with a diameter stenosis > 50%. In seven (14.2%) patients, coronary sclerosis with a diameter stenosis < 50% could be observed. Only five (29.4%) of the 17 women but 16 of the 32 men (50%) had coronary artery disease with a diameter stenosis > 50% (p < 0.01). CONCLUSIONS: In unselected patients referred for coronary angiography due to "atypical" chest pain and inconsistent noninvasive testing or impossibility to perform noninvasive assessment. 42.9% had coronary artery disease with a diameter stenosis > 50%. Angiographic evaluation of symptomatic patients with "atypical" signs and symptoms and inconsistent noninvasive testing seems to be appropriate.