Intraoperative Subcortical Electrical Mapping of the Optic Tract in Awake Surgery Using a Virtual Reality Headset.

BACKGROUND: Brain mapping during awake craniotomy is a well-known technique to preserve neurological functions, especially the language. It is still challenging to map the optic radiations due to the difficulty to test the visual field intraoperatively. To assess the visual field during awake craniotomy, we developed the Functions' Explorer based on a virtual reality headset (FEX-VRH). METHODS: The impaired visual field of 10 patients was tested with automated perimetry (the gold standard examination) and the FEX-VRH. The proof-of-concept test was done during the surgery performed on a patient who was blind in his right eye and presenting with a left parietotemporal glioblastoma. The FEX-VRH was used intraoperatively, simultaneously with direct subcortical electrostimulation, allowing identification and preservation of the optic radiations. RESULTS: The FEX-VRH detected 9 of the 10 visual field defects found by automated perimetry. The patient who underwent an awake craniotomy with intraoperative mapping of the optic tract using the FEX-VRH had no permanent postoperative visual field defect. CONCLUSION: Intraoperative visual field assessment with the FEX-VRH during direct subcortical electrostimulation is a promising approach to mapping the optical radiations and preventing a permanent visual field defect during awake surgery for epilepsy or tumor.

Mode of admission and its effect on adherence to reperfusion therapy guidelines in Belgian STEMI patients.

OBJECTIVES: Emergency medical services play a key role in the recognition and treatment of ST-segment elevation myocardial infarction (STEMI). This study evaluates the effect of emergency medical services use on adherence to reperfusion therapy guidelines in Belgian STEMI patients and on in-hospital mortality. METHODS: The mode of admission with against without emergency medical services was associated with baseline risk profile, reperfusion modalities and in-hospital mortality in 5692 consecutive STEMI patients from 2012 to 2014. RESULTS: A total of 3896 STEMI patients (68%) were transported to the hospital by emergency medical services, and 1796 patients (32%) arrived at the hospital using their own transport (self-referral). Emergency medical services patients were older than self-referral patients (64 vs. 62 years) and more frequently presented with cardiac arrest (14% vs. 5%) and with cardiogenic shock (10% vs. 4%). Emergency medical services patients received primary percutaneous coronary intervention more often (95% vs. 91%, P<0.0001) and more frequently within 90 minutes (72% vs. 65%, P<0.001). Moreover, the time interval between symptom onset and reperfusion therapy was shorter in the emergency medical services group (median of 195 vs. 255 minutes, P<0.001). Crude in-hospital mortality was higher in the emergency medical services group (7.7% vs. 3.8%, P<0.0001) and was mainly driven by the high prevalence of cardiogenic shock and cardiac arrest in the emergency medical services group. After adjustment, the impact on mortality was no longer significantly different. CONCLUSION: Emergency medical services are used by two-thirds of Belgian STEMI patients and are associated with a better adherence to STEMI reperfusion guidelines. These data favour the use of emergency medical services as the preferred transfer system for patients with chest pain suspicious for STEMI.

Gender, TIMI risk score and in-hospital mortality in STEMI patients undergoing primary PCI: results from the Belgian STEMI registry.

AIMS: The relationship between the predictive performance of the TIMI risk score for STEMI and gender has not been evaluated in the setting of primary PCI (pPCI). Here, we compared in-hospital mortality and predictive performance of the TIMI risk score between Belgian women and men undergoing pPCI. METHODS AND RESULTS: In-hospital mortality was analysed in 8,073 (1,920 [23.8%] female and 6,153 [76.2%] male patients) consecutive pPCI-treated STEMI patients, included in the prospective, observational Belgian STEMI registry (January 2007 to February 2011). A multivariable logistic regression model, including TIMI risk score variables and gender, evaluated differences in in-hospital mortality between men and women. The predictive performance of the TIMI risk score according to gender was evaluated in terms of discrimination and calibration. Mortality rates for TIMI scores in women and men were compared. Female patients were older, had more comorbidities and longer ischaemic times. Crude in-hospital mortality was 10.1% in women vs. 4.9% in men (OR 2.2; 95% CI: 1.82-2.66, p<0.001). When adjusting for TIMI risk score variables, mortality remained higher in women (OR 1.47, 95% CI: 1.15-1.87, p=0.002). The TIMI risk score provided a good predictive discrimination and calibration in women as well as in men (c-statistic=0.84 [95% CI: 0.809-0.866], goodness-of-fit p=0.53 and c-statistic=0.89 [95% CI: 0.873-0.907], goodness-of-fit p=0.13, respectively), but mortality prediction for TIMI scores was better in men (p=0.02 for TIMI score x gender interaction). CONCLUSIONS: In the Belgian STEMI registry, pPCI-treated women had a higher in-hospital mortality rate even after correcting for TIMI risk score variables. The TIMI risk score was effective in predicting in-hospital mortality but performed slightly better in men. The database was registered with clinicaltrials.gov (NCT00727623).

Reperfusion therapy and mortality in octogenarian STEMI patients: results from the Belgian STEMI registry.

BACKGROUND: Treatment strategies and outcome of ST-elevation myocardial infarction (STEMI) have been mainly studied in middle-aged patients. With increasing lifetime expectancy, the proportion of octogenarians will substantially increase. We aimed to evaluate whether the benefit of currently recommended reperfusion strategies is maintained in octogenarians. METHODS: Reperfusion therapy and in-hospital mortality were evaluated in 1,092 octogenarians and compared with 7,984 STEMI patients <80 years old based on data from the prospective Belgian STEMI registry. RESULTS: The octogenarian STEMI group had more cardiovascular comorbidities, contained more female patients and presented more frequently with cardiac failure (Killip class >1, 40 vs. 20 %) compared with their younger counterparts (all p < 0.05). Although the rate of thrombolysis was similar (9.2 vs. 9.9 %) between both groups, a conservative approach was chosen more frequently (13.8 vs. 4.7 %), while PCI was performed less frequently (76.9 vs. 85.4 %) in octogenarians (p < 0.001). Moreover, ischemic time and door-to-needle/balloon time were longer for octogenarians. In-hospital mortality for octogenarians was 17.8 vs. 5.5 % in the younger group [adjusted OR 2.43(1.92-3.08)]. In haemodynamically stable octogenarians, PCI seemed to improve outcome compared with thrombolysis or conservative treatment (5.7 vs. 12.7 vs. 8.5 %, p = 0.09). In octogenarians with cardiac failure, in-hospital mortality was extremely high independent of the chosen reperfusion therapy (34.6 vs. 31.6 vs. 36.3 %, p = 0.88). CONCLUSIONS: In-hospital mortality in octogenarian STEMI patients was high and related to a high prevalence of cardiac failure. Less PCI was performed in the octogenarian group compared with the younger patients, although mortality benefit of PCI was maintained in haemodynamically stable octogenarians.

Inter-hospital variation in length of hospital stay after ST-elevation myocardial infarction: results from the Belgian STEMI registry.

OBJECTIVE: The aim of this paper was to assess the determinants of and variations in length of hospital stay (LOS) in Belgium after ST-elevation myocardial infarction (STEMI). METHODS AND RESULTS: Data on LOS were collected from 2079 STEMI patients who were discharged alive from 33 Belgian hospitals (21 with PCI facilities) during 2010-201 1. Early discharge was defined as hospital discharge within 4 days after admission, and the hospitals were clustered according to their LOS for low-risk patients. Determinants of LOS were calculated by means of a negative binomial regression model. LOS was, on average, 6.5 days with a median of 5 days (IQR 4). Baseline risk profiles and reperfusion treatment explained only 13% of the LOS variation. Additional analysis revealed major in-hospital variations independent of the case mix of patients. For comparable baseline risk profiles, the average LOS in a cluster of 11 hospitals with short discharge policies was 5.3 + 5.6 days, with an early discharge rate of 58%, while in the cluster of 11 hospitals with long discharge policies, the average LOS was 7.9 + 8.5 days with an early discharge rate of 22% (P <0.0001). Among the clustered hospitals, there were no differences with regard to logistics (PCI facility, academic affiliation) or volume of STEMI patients. The 1-month mortality rate was less than 0.5% in the different clusters of hospitals (p = NS). CONCLUSIONS: Length of hospital stay is not only determined by baseline risk profiles of patients but is also highly dependent on hospital discharge policy, which seems to be unrelated to medical or logistical factors.

Renal dysfunction in STEMI-patients undergoing primary angioplasty: higher prevalence but equal prognostic impact in female patients; an observational cohort study from the Belgian STEMI registry.

BACKGROUND: Mortality in female patients with ST-segment elevation myocardial infarction (STEMI) undergoing primary angioplasty (pPCI) is higher than in men. We examined gender differences in the prevalence and prognostic performance of renal dysfunction at admission in this setting. METHODS: A multicenter retrospective sub-analysis of the Belgian STEMI-registry identified 1,638 patients (20.6% women, 79.4% men) treated with pPCI in 8 tertiary care hospitals (January 2007-February 2011). The estimated glomerular filtration rate (eGFR) was calculated using the CKD-EPI equation. Main outcome measure was in-hospital mortality. RESULTS: More women than men suffered from renal dysfunction at admission (42.3% vs. 25.3%, p < 0.001). Mortality in women was doubled as compared to men (9.5 vs. 4.7%, OR (95% CI) = 2.12 (1.36-3.32), p<0.001). In-hospital mortality for men and women with vs. without renal dysfunction was much higher (10.7 and 15.3 vs. 2.3 and 2.4%, p < 0.001). In a multivariable regression analysis, adjusting for age, gender, peripheral artery disease (PAD), coronary artery disease (CAD), hypertension, diabetes and low body weight (<67 kg), female gender was associated with renal dysfunction at admission (OR (95% CI) 1.65 (1.20-2.25), p = 0.002). In a multivariable model including TIMI risk score and renal dysfunction, renal dysfunction was an independent predictor of in-hospital mortality in both men (OR (95% CI) = 2.39 (1.27-4.51), p = 0.007) and women (OR (95% CI) = 4.03 (1.26-12.92), p = 0.02), with a comparable impact for men and women (p for interaction = 0.69). CONCLUSIONS: Female gender was independently associated with renal dysfunction at admission in pPCI treated patients. Renal dysfunction was equally associated with higher in-hospital mortality in both men and women.

Acute myocardial infarction in early postpartum.

We present a case of acute anterior myocardial infarction in a breastfeeding woman, 10 days after delivery. The presumed cause was proximal left anterior artery vasospasm, induced by a combination of smoking a first cigarette in the early morning and salbutamol inhalation, in the particular context of peripartum. We discuss briefly the epidemiology, pathophysiology, risk factors, diagnosis, treatment and prognosis of myocardial infarction related to pregnancy and the postpartum period.

STEMI mortality in community hospitals versus PCI-capable hospitals: results from a nationwide STEMI network programme.

AIMS: Reports examining local ST elevation myocardial infarction (STEMI) networks focused mainly on percutaneous coronary intervention (PCI)-related time issues and outcomes. To validate the concept of STEMI networks in a real-world context, more data are needed on management and outcome of an unselected community based STEMI population. METHODS AND RESULTS: The current study evaluated reperfusion strategies and in-hospital mortality in 8500 unselected STEMI patients admitted to 47 community hospitals (n=3053) and 25 PCI-capable hospitals (n=5447) in the context of a nationwide STEMI network programme that started in 2007 in Belgium. The distance between the hub and spoke hospitals ranged from 2.2 to 47 km (median 15 km). A propensity score was used to adjust for differences in baseline characteristics. Reperfusion strategy was significantly different with a predominant use of primary PCI (pPCI) in PCI-capable hospitals (93%), compared to a mixed use of pPCI (71%) and thrombolysis (20%) in community hospitals. A door-to-balloon time <120 min was achieved in 83% of community hospitals and in 91% of PCI-capable hospitals (p<0.0001). In-hospital mortality was 7.0% in community hospitals versus 6.7% in PCI-capable hospitals with an adjusted odds ratio of 1.1 (95% confidence interval: 0.8-1.4). Between the periods 2007-2008 and 2009-2010, the pPCI rate in community hospitals increased from 60% to 80%, whereas the proportion of conservatively managed patients decreased from 11.1% to 7.9%. CONCLUSION: In a STEMI network with >70% use of pPCI, in-hospital mortality was comparable between community hospitals and PCI-capable hospitals. Participation in the STEMI network programme was associated with an increased adherence to reperfusion guidelines over time.

Contemporary mortality differences between primary percutaneous coronary intervention and thrombolysis in ST-segment elevation myocardial infarction.

BACKGROUND: Current ST-segment elevation myocardial infarction guidelines regarding reperfusion strategy are based on trials conducted before the application of routine invasive evaluation after thrombolysis. Modern thrombolysis may affect the previously observed mortality difference between primary percutaneous coronary intervention (PPCI) and thrombolysis. METHODS: In-hospital mortality was prospectively assessed in 5295 patients with ST-segment elevation myocardial infarction admitted to 73 Belgian hospitals from July 1, 2007, through December 31, 2009. A total of 4574 patients (86.4%) were treated with PPCI and 721 (13.6%) received thrombolysis; of these thrombolysis patients, 603 (83.6%) underwent subsequent invasive evaluation. The Thrombolysis in Myocardial Infarction risk score was used to stratify the study population by low (n = 1934), intermediate (n = 2382), and high (n = 979) risk. RESULTS: In-hospital mortality in the PPCI patients was 5.9% vs 6.6% in the thrombolysis patients. After adjustment for differences in baseline risk profile, a significant mortality benefit was only present in the high-risk groups: 23.7% in the PPCI patients vs 30.6% in the thrombolysis patients. For patients not at high risk, the mortality difference was marginal. For low-risk patients, mortality was 0.3% in the PPCI patients vs 0.4% in the thrombolysis patients. For intermediate-risk patients, mortality was 2.9% in the PPCI patients vs 3.1% in the thrombolysis patients. Subgroup analysis revealed that the mortality benefit of PPCI compared with early thrombolysis (door-to-needle time <30 minutes) was offset if the door-to-balloon time exceeded 60 minutes. CONCLUSIONS: Modern thrombolytic strategies have substantially attenuated the absolute mortality benefit of PPCI over thrombolysis, particularly in patients not at high risk. Our study findings suggest that target door-to-balloon time should be less than 60 minutes to maintain the lowest mortality rates.

Fulminant myocarditis with dramatic response to corticoids.

A 47-year-old healthy man developed acute fulminant coxsackie BI myocarditis with cardiogenic shock and extreme elevation of NT-pro-BNP (82585 pg/ml). He had a dramatic and rapid improvement within the following days after administration of corticoids on top of dobutamine and classic treatment.

Relation of ECG changes to neurological outcome in patients with aneurysmal subarachnoid hemorrhage.

BACKGROUND: Electrocardiographic (ECG) alterations occurring during the course of subarachnoid hemorrhage (SAH) have been described frequently, but the incidence, patterns, and prognostic significance are not well defined. This study was designed to investigate these features. METHODS: All patients admitted to a 31-bed department of intensive care between 1993 and 2000 with acute aneurysmal SAH documented by cerebral angiography or autopsy were included. Patient charts were reviewed retrospectively, and an observer blinded to the patients' clinical course and outcome reviewed the ECGs. In-hospital mortality and outcome as assessed by the Glasgow outcome score were noted. RESULTS: Of 159 patients (49.6 years [range: 20-75]) with acute SAH, 106 (66.7%) had abnormal ECGs (classified by an observer blinded to the patients' clinical course and outcome. Conduction abnormalities were present in 7.5%. Arrhythmias occurred in 30.2%. By univariate analysis, the presence of ST depression was related to outcome as assessed by the Glasgow Outcome Scale (GOS) (15% poor outcome [GOS 4-5] vs. 1% good outcome [GOS 1-3], p<0.05). However, by multivariate analysis, none of the ECG alterations was related to outcome. ST depression was related to the APACHE II score, Hunt and Hess scale, and the WFNS score. ECG abnormalities were not related to the development of vasospasm or increased intracranial pressure. CONCLUSIONS: In patients with acute aneurysmal SAH, repolarization abnormalities are the commonest ECG alterations, and ST depression is more common in patients with poor outcome. However, ECG alterations are not independently related to outcome.

C-reactive protein increase in acute myocardial infarction.

OBJECTIVE: Considering acute myocardial infarctions (AMI), data demonstrate that C-reactive protein (CRP) levels reflect the severity of myocardial damage and that high CRP level is associated with a worse outcome. This study evaluates the prognostic value of CRP and the determinants of its increase during AMI. METHODS AND RESULTS: A retrospective observational study of 126 patients with a ST-segment elevation myocardial infarction (STEMI); 101 patients had reperfusion therapy (93 thrombolysis, 8 PTCA). Peak CRP (median: 3.5 mg/dl) was achieved the third day. A correlation existed between this peak and age (r = 0.1838; p = 0.0408). Diabetic patients not requiring insulin showed peaks double those of other patients (10.4 versus 6.1 mg/dl; p = 0.0165). The peak was higher in anterior infarctions (anterior: 8.4, lateral: 6.9, inferior: 6.4, posterior: 3.9 mg/dl; p = 0.0206) and for those showing a Q-wave (7.5 versus 3.9 mg/dl; p = 0.0020). It was correlated with the CK (r = 0.246; p = 0.0188) and troponin Ic (r = 0.242; p = 0.0224) peaks among thrombolysed patients. There was an increasing relationship between the occurrence of cardiac failure and the magnitude of the CRP peak. An inverse linear relationship existed between the ejection fraction of the left ventricle and the CRP peak (r = -0.4187; p = 0.0000). CRP peak was lower with statins (3.8 versus 7.0 mg/dl; p = 0.0446). Fibrates were only associated with lower CRP levels at admission (0.6 versus 0.9 mg/dl; p = 0.0010). CONCLUSIONS: CRP is an indicator of the severity of STEMI. It is also an indicator for the occurrence of complications during hospitalization. The effect of statins and fibrates on CRP levels in AMI should be studied further.

Peripheral sympathetic control during dobutamine infusion: effects of aging and heart failure.

OBJECTIVES: We assessed the effects of beta-adrenergic agonism on muscle sympathetic nerve activity (MSNA) in patients with congestive heart failure (CHF) and young and matched controls. BACKGROUND: Myocardial response to beta-adrenergic stimulation decreases with aging and with CHF. METHODS: In CHF patients, we measured cardiac hemodynamics and MSNA (microneurography) before, with short-term (n = 5), and after 48-h (n = 9) of dobutamine infusion (10 microg/kg/min). In eight young controls and nine controls matched to the CHF patients, we measured cardiac hemodynamics and MSNA during randomized short-term dobutamine (10 microg/kg/min) and placebo infusions. RESULTS: In CHF patients, short-term dobutamine infusion did not modify mean blood pressure (MBP), MSNA, or heart rate (HR). Moreover, 48-h dobutamine infusion increased cardiac index (3.1 +/- 0.2 vs. 2.2 +/- 0.2 l/min/m(2), p = 0.006), decreased mean pulmonary pressure (28 +/- 7 vs. 38 +/- 7 mm Hg, p = 0.0001) and peripheral resistance (1,099 +/- 112 vs. 1,759 +/- 263, p = 0.03), but did not change MBP, HR, or MSNA in the patients. In matched controls, dobutamine increased HR (87 +/- 5 vs. 65 +/- 2 beats/min, p = 0.0009) but did not change MBP or MSNA. In young controls, dobutamine increased MBP (102 +/- 2 vs. 90 +/- 2 mm Hg, p = 0.0003) and decreased MSNA (28 +/- 5 vs. 35 +/- 3 bursts/min, p = 0.03) but did not change HR (p = 0.054). In the controls, the largest increases in MBP with dobutamine were associated with the most marked reductions in MSNA (r = -0.49, p = 0.04) and the smallest increases in HR (r = -0.70, p = 0.001). CONCLUSIONS: Arterial baroreceptor activation during increases in MBP inhibits MSNA and limits the HR response to dobutamine in controls. This mechanism, together with peripheral vasodilation, probably contributes to the absence of peripheral sympathetic withdrawal despite substantial hemodynamic improvements in CHF patients.