Is degree of chronic illness management in heart transplant centers associated with better patient survival? Findings from the intercontinental BRIGHT study.

PURPOSE: To explore the association between the degree of Chronic illness management and survival rates at 1-, 3-, 5-years post heart transplantation. METHODS: Exploratory secondary analysis of a cross-sectional, international study (Building Research Initiative Group study). Latent profile analysis was performed to classify 36 heart transplant centers according to the degree of chronic illness management. RESULTS: The analysis resulted in 2 classes with 29 centers classified as "low-degree chronic illness management" and 7 centers as "high-degree chronic illness management". After 1-year posttransplantation, the high-degree chronic illness management class had a significantly greater mean survival rate compared to the low-degree chronic illness management class (88.4% vs 84.2%, p = 0.045) and the difference had a medium effect size (η2 = .06). No difference in survival for the other time points was observed. Patients in high-degree chronic illness management centers had 52% lower odds of moderate to severe drinking (95% confidence interval .30-.78, p = 0.003). No significant associations between degree of chronic illness management and the other recommended health behaviors were observed. CONCLUSIONS: The findings from this exploratory study offer preliminary insight into a system-level pathway (chronic illness management) for improving outcomes for heart transplant recipients. The signals observed in our data support further investigation into the effectiveness of chronic illness management-based interventions in heart transplant follow-up care.

Multilevel factors are associated with immunosuppressant nonadherence in heart transplant recipients: The international BRIGHT study.

Factors at the level of family/healthcare worker, organization, and system are neglected in medication nonadherence research in heart transplantation (HTx). The 4-continent, 11-country cross-sectional Building Research Initiative Group: Chronic Illness Management and Adherence in Transplantation (BRIGHT) study used multistaged sampling to examine 36 HTx centers, including 36 HTx directors, 100 clinicians, and 1397 patients. Nonadherence to immunosuppressants-defined as any deviation in taking or timing adherence and/or dose reduction-was assessed using the Basel Assessment of Adherence to Immunosuppressive Medications Scale© (BAASIS© ) interview. Guided by the Integrative Model of Behavioral Prediction and Bronfenbrenner's ecological model, we analyzed factors at these multiple levels using sequential logistic regression analysis (6 blocks). The nonadherence prevalence was 34.1%. Six multilevel factors were associated independently (either positively or negatively) with nonadherence: patient level: barriers to taking immunosuppressants (odds ratio [OR]: 11.48); smoking (OR: 2.19); family/healthcare provider level: frequency of having someone to help patients read health-related materials (OR: 0.85); organization level: clinicians reporting nonadherent patients were targeted with adherence interventions (OR: 0.66); pickup of medications at physician's office (OR: 2.31); and policy level: monthly out-of-pocket costs for medication (OR: 1.16). Factors associated with nonadherence are evident at multiple levels. Improving medication nonadherence requires addressing not only the patient, but also family/healthcare provider, organization, and policy levels.

Prenatal diagnosis of isolated total anomalous systemic venous connection to the left atrium.

We report the prenatal diagnosis and the neonatal follow-up of a patient with isolated total abnormal systemic venous connection to the left atrium. Right-sided and left-sided superior caval veins and the inferior caval vein were all connected to the left atrium. Pulmonary venous return was normal. This was associated with some right ventricular underdevelopment. To our knowledge, this is the first fetal description of this very rare congenital cardiac malformation.

Heart transplantation using a donor with partial anomalous pulmonary venous connection and atrial septal defect.

Over the last decade, the shortage of donors has led to increased waiting time prior to transplantation and its related mortality. Therefore, extended criteria for donor hearts have been proposed. In this report, we describe a successful transplantation despite a diagnosis of partial abnormal pulmonary venous return associated with an atrial septal defect sinus venosus and persisting left-sided superior vena cava. Knowledge in congenital cardiac disease can broaden the definition of 'marginal' donor hearts and allow their use without increasing the risk of transplantation.

Off-pump revascularization in a 2-year-old girl after neonatal arterial switch.

One drawback of the arterial switch operation for treating transposition of the great arteries is the occurrence of coronary lesions, found during follow-up in about 5% of (a)symptomatic children. The established corrective procedures include coronary artery proximal patch arterioplasty or coronary artery bypass grafting (CABG). To avoid aortic manipulations and extracorporeal circulation, off-pump coronary artery bypass (OPCAB) has become increasingly used in the adult population. We report a case of OPCAB revascularization in a symptomatic 2-year-old child.

Mediastinal teratoma with coexisting parenchymal pulmonary cystic lesion.

A double-located mediastinal and intrapulmonary cystic teratoma is a rare condition to be considered by thoracic surgeons. Clinical or radiologic diagnosis of a ruptured mediastinal teratoma into adjacent structures may be highly suggestive. An atypical presentation may indicate cautiousness for complete surgical excision. We report the case of a 14-year-old girl presenting with chronic chest pain. The radiologic work-up showed a large cystic mediastinal tumor and a heterogeneous intrapulmonary left upper-lobe lesion. We discuss the radiologic differential diagnosis of this atypical double-located thoracic tumor and the surgical strategy for complete excision.

Levosimendan in congenital cardiac surgery: a randomized, double-blind clinical trial.

OBJECTIVE: In this study, the authors used a continuous infusion of either levosimendan or milrinone as inotropic support after corrective congenital cardiac surgery. The hemodynamic and biochemical parameters were compared. DESIGN: A prospective, randomized, double-blind clinical study. SETTING: A university hospital. PARTICIPANTS: Forty-one patients between 0 and 5 years old requiring inotropic support for corrective congenital heart surgery under cardiopulmonary bypass (CPB) were enrolled in this trial. Thirty-six patients completed the study. INTERVENTIONS: Patients were randomized in a double-blind fashion to a continuous infusion of either levosimendan at 0.05 µg/kg/min or milrinone at 0.4 µg/kg/min started at the onset of CPB. Epinephrine was started at 0.02 µg/kg/min after aortic cross-clamp release in both groups. MEASUREMENTS AND MAIN RESULTS: There was no significant difference between serum lactate levels of groups. The rate-pressure index (the product of heart rate and systolic blood pressure), which is an indicator of myocardial oxygen demand, was significantly lower at 24 hours and 48 hours postoperatively in the levosimendan group (p < 0.001) in comparison to the milrinone group. Although not significantly different, the troponin values in the levosimendan group were less at 1 hour (median [P(25)-P(75)]: 20.7 [15.3- 48.3] v 34.6 [23.8- 64.5] ng/mL and 4 hours postoperatively: 30.4 [17.3-59.9] v 33.3 [25.5-76.7] ng/mL). CONCLUSION: Levosimendan is at least as efficacious as milrinone after corrective congenital cardiac surgery in neonates and infants.

Subjective and objective assessment of quality of life after chest wall resection.

OBJECTIVE: To date, quality of life (QoL) after extensive chest wall resection is not known. This study analyses QoL in long-term survivors after extensive resection. METHODS: Retrospective analysis of 51 patients operated for non-small-cell lung cancer (NSCLC)/mediastinal tumour invading the chest wall, primary/secondary chest wall tumours. QoL and functional status of long-term survivors (>36 months) were studied using Borg scale, Mahler dyspnoea index, Functional Autonomy Measuring System (SMAF) and 36-item Short Form Health Survey (SF-36) questionnaire. Out of the 51 patients, pulmonary function tests were available before and after resection in 24 patients and were subjected to analysis. RESULTS: Five-year survival was 50%, 26 patients survived>36 months. At follow-up, 22/28 deaths were cancer related. Compared to baseline, the reduction of flow expiratory volume in 1s (FEV1) and forced vital capacity (FVC) were 18% and 15%, respectively (p<0.001). The QoL study included 23 long-term survivors. A moderate/severe dyspnoea was present in 5/23 patients (21%). The SF-36 questionnaire revealed that, compared to controls, patients with chest wall resection experienced impaired QoL in physical functioning, in role physical, in body pain, in social functioning and in mental health. Objective measurements of pulmonary function correlated poorly with QoL, whereas subjective assessment of dyspnoea was significantly associated with QoL. CONCLUSIONS: This study shows that long-term survivors after extensive chest wall resection experienced moderate impairments in several QoL subscales. As previously reported in patients after pulmonary resection, subjective assessment such as dyspnoea correlated well with patient-perceived QoL.

Algorithm for primary closure in sternal wound infection: a single institution 10-year experience.

OBJECTIVES: To evaluate a simple treatment algorithm in sternal wound infection (SWI) allowing for primary closure and to describe the different surgical techniques and their associated morbidity and mortality. METHODS: A retrospective analysis of all patients operated on between 1996 and 2004 in a single tertiary care institution. All epidemiological and surgical data were prospectively collected in our database. Univariate and multivariate analysis were used to determine preoperative and perioperative risks factors for 90-day and long-term mortality. RESULTS: Out of 5905 procedures, 146 sternal wound infections were documented (2.4%). The respective incidence of SWI for CABG, isolated valve, or combined procedures were 2.8%, 1.1%, and 3.2%. Pathogens involved were S. epidermidis (44.5%), S. aureus (31.5%), and gram-negative rods (19.2%). Re-operation was required in 131/146 patients. Mean time to the first re-operation was 17.3+/-12 days. Modalities of treatment consisted of drainage alone (44 patients), rewiring (25 patients), debridement, rewiring and mediastinal lavage (52 patients), and partial/complete sternal resection (10 patients). Additional procedures were required in 49 patients (37.7%). The 90-day mortality for uninfected patients and patients with superficial SWI were 4.4% and 2.8% (p=0.78) whereas for patients with deep SWI, 90-day mortality was 14.5% (DSWI vs others, p<0.0001). CONCLUSIONS: Deep sternal wound infection (DSWI) remains a dreadful complication in contemporary cardiac surgery while risk factors are currently well defined. Using a simple approach of primary closure together with liberal use of vascularized flaps has allowed us to achieve satisfactory short-term outcome in this subset of patients.

Prognostic factors for long-term survival in patients with thoracic metastatic disease: a 10-year experience.

OBJECTIVE: To compare survival results after resection in patients with thoracic parenchymal metastatic disease versus non-parenchymal metastatic disease and to identify prognostic factors for survival. METHODS: From 1990 to 2002, we retrospectively studied 134 procedures performed on 93 patients (3-84 years old). There were 73 patients with parenchymal resection and 20 patients with non-parenchymal resection. Tumor histology was epithelial in 62 patients, sarcoma in 21 patients, and teratomas and melanoma in 6 and 4 patients, respectively. Sixty-five patients underwent a metastasectomy once, whereas 28 had their metastatic disease repeatedly resected. RESULTS: Follow-up was 100% complete with a mean time of 43 months (range 1-169). In-hospital mortality was 2.2% (3/134 procedures) and major morbidity 5.5%. Median survival was 39 months (95% CI: 21-56 months). Overall, the actuarial survival at 1, 3, and 5 years were 84%, 55%, and 44%, respectively. For the entire group, by univariate analysis, among the 13 predictor variables selected, only the number of metastases (Hazard Ratio (HR)=3.4 [95% CI: 1.9-6.1]) and completeness of resection (HR=2.3 [95% CI: 1.3-4.2]) were found to be significant for death whereas repeated metastasectomy was found to be a significant predictor for survival (HR=0.25 [95% CI: 0.12-0.55]). In the group of parenchymal metastatic disease, a size greater than 3cm was a predictor for death (HR=2 [95% CI: 1.1-3.7]). In the subgroup of patients with colorectal metastasis, bilateral disease was also found to be a significant predictor for death (HR=3.6, [95% CI: 1.2-11.1]). CONCLUSION: This study supports our current aggressive approach to metastatic thoracic disease. Indeed, patient's survival is improved while a low mortality and morbidity is achieved. The most beneficial impact on long-term survival is correlated to the completeness of the surgery whereas the increasing number and size of the metastasis inversely correlate with survival.

Paracardiac opacity following inferior- and middle-lobe resection for bronchogenic carcinoma: unsuspected diagnosis.

We report the case of a patient who had benefited initially from a right middle and lower lobectomy for bronchogenic carcinoma and who had an extensive radiologic workup in an outside hospital in the early postoperative period. Based on CT scan findings, this patient was referred back with a diagnosis that conveys both medical and medicolegal issues: a gossypiboma (or retained surgical sponge). We describe herein the unexpected operative findings that highlight the difficulty in accurately diagnosing intrathoracic foreign bodies.