Emmanuel Akintoye

Colorectal endoscopic submucosal dissection: a systematic review and meta-analysis.

Background and study aims: Endoscopic submucosal dissection (ESD) is an advanced endoscopic technique that allows en-bloc resection of gastrointestinal tumor. We systematically review the medical literature in order to evaluate the safety and efficacy of colorectal ESD. Patients and methods: We performed a comprehensive literature search of MEDLINE, EMBASE, Ovid, CINAHL, and Cochrane for studies reporting on the clinical efficacy and safety profile of colorectal ESD. Results: Included in this study were 13833 tumors in 13603 patients (42 % female) who underwent colorectal ESD between 1998 and 2014. The R0 resection rate was 83 % (95 % CI, 80 – 86 %) with significant between-study heterogeneity (P < 0.001) which was partly explained by difference in continent (P = 0.004), study design (P = 0.04), duration of the procedure (P = 0.009), and, marginally, by average tumor size (P = 0.09). Endoscopic en bloc and curative resection rates were 92 % (95 % CI, 90 – 94 %) and 86 % (95 % CI, 80 – 90 %), respectively. The rates of immediate and delayed perforation were 4.2 % (95 % CI, 3.5 – 5.0 %) and 0.22 % (95 % CI, 0.11 – 0.46 %), respectively, while rates of immediate and delayed major bleeding were 0.75 % (95 % CI, 0.31 – 1.8 %) and 2.1 % (95 % CI, 1.6 – 2.6 %). After an average postoperative follow up of 19 months, the rate of tumor recurrence was 0.04 % (95 % CI, 0.01 – 0.31) among those with R0 resection and 3.6 % (95 % CI, 1.4 – 8.8 %) among those without R0 resection. Overall, irrespective of the resection status, recurrence rate was 1.0 % (95 % CI, 0.42 – 2.1 %). Conclusions: Our meta-analysis, the largest and most comprehensive assessment of colorectal ESD to date, showed that colorectal ESD is safe and effective for colorectal tumors and warrants consideration as first-line therapy when an expert operator is available.

Incidence and survival after in-hospital cardiopulmonary resuscitation in nonelderly adults

Background— Survival trends after in-hospital cardiopulmonary resuscitation (ICPR) for cardiac arrest in nonelderly adults is not well known. Influence of cardiopulmonary resuscitation guidelines on nationwide survival after ICPR is yet to be well elucidated. Methods and Results— We examined survival trends and factors associated with survival after ICPR in nonelderly adults aged 18 to 64 years, using Healthcare Utilization Project Nationwide Inpatient Sample Database from 2007 through 2012 in the United States. Furthermore, we studied the impact of 2010 American Heart Association cardiopulmonary resuscitation guidelines on survival. We identified 235 959 patients who underwent ICPR after cardiac arrest. Overall, 30.4% patients survived to hospital discharge. Survival improved from 27.4% in 2007 to 32.8% in 2012 (Ptrend<0.001). Shockable arrest rhythms were noted in 23.3% of patients. Incidence of ICPR increased from 1.81 per 1000 hospitalizations in 2007 to 2.37 per 1000 hospitalizations in 2012 (Ptrend<0.001). There was no statistically significant change in survival trends before and after 2010 cardiopulmonary resuscitation guidelines. Female sex and shockable rhythms were associated with higher adjusted odds of survival, whereas black race, lack of health insurance, age, and weekend admission were associated with lower adjusted odds of survival. Conclusions— Among nonelderly adults, survival after ICPR improved significantly from 2007 through 2012, with an overall survival rate of 30.4%. Incidence of ICPR increased significantly during the study period. There was no statistically significant change in survival before and after 2010 cardiopulmonary resuscitation guidelines. Female sex and black race were associated with higher and lower odds of survival, respectively.

Cardiopulmonary exercise test in adults with prior Fontan operation: The prognostic value of serial testing

BACKGROUND The purpose of the study was to determine the role of cardiopulmonary exercise test (CPET) indices in predicting cardiovascular adverse events (CAEs) in patients with Fontan palliation. CAE was defined as death or cardiac surgery. METHODS Retrospective review of adult Fontan patients who had treadmill CPET at Mayo Clinic, 1994-2013. Patients with loss of follow-up defined as ≥2years without clinical follow-up were excluded. The results of serial CPETs were reviewed, and patients with CPETs meeting the following criteria were selected for analysis: maximum effort on serial CPETs, minimum of 3-year interval between CPETs, and absence of CAE between CPETs. RESULTS A total of 145 patients met inclusion criteria for the study; age at baseline CPET was 24±3years; age at Fontan operation was 11±5years; and 91 (63%) were males. Baseline peak oxygen consumption (VO2) was 22.7±5.4ml/kg/min (63±11% predicted), peak heart rate was 135±31beats per minute, and oxygen saturation at peak exercise was 86±7%. Serial CPETs were performed in 71/145 patients (49%); mean duration between CPETs was 3.8±0.3years. The % predicted peak VO2 decreased by 1.7±0.9 percentage points/year. CAE (deaths n=22; cardiac surgery n=45) occurred in 54/145 patients (37%) within 8±3years. Decline in % predicted peak VO2≥3 percentage points/year was the only predictor of 5-year risk of CAE (HR 1.86, 95% CI 1.11-3.48, P=0.02). CONCLUSIONS Serial CPET is prognostic of CAE in the adult Fontan population, and can be used to risk stratify these patients.

Factors associated with postoperative atrial fibrillation and other adverse events after cardiac surgery

Objective The study objective was to evaluate the impact of various surgical characteristics and practices on the risk of postoperative atrial fibrillation and other adverse outcomes after cardiac surgery. Methods By using the prospectively collected data of patients who underwent cardiac surgery in 28 centers across the United States, Italy, and Argentina, the details of surgery characteristics were collected for each patient and the outcomes, including postoperative atrial fibrillation, major adverse cardiovascular events, and mortality. These were evaluated via multivariable‐adjusted models. Results In 1462 patients, a total of 460 cases of postoperative atrial fibrillation, 33 major adverse cardiovascular events, 23 cases of 30‐day mortality, and 46 cases of 1‐year mortality occurred. We found that type of surgery and cardiopulmonary bypass use predicted the occurrence of postoperative atrial fibrillation. Compared with coronary artery bypass grafting alone, there was a higher risk of postoperative atrial fibrillation with valvular surgery alone (odds ratio, 1.4; 95% confidence interval, 1.1‐1.9), and the risk was even higher with concomitant valvular and coronary artery bypass grafting surgery (odds ratio, 1.8; 95% confidence interval, 1.2‐2.7). Compared with no bypass, use of cardiopulmonary bypass was associated with higher risk of postoperative atrial fibrillation (odds ratio, 2.4; 95% confidence interval, 1.7‐3.5), but there were significant age and sex differences of the impact of bypass use among patients undergoing coronary artery bypass grafting (P for interaction = .04). In addition, compared with spontaneous return of rhythm, ventricular pacing was associated with a higher risk of major adverse cardiovascular events (odds ratio, 5.0; 95% confidence interval, 1.4‐18), whereas concomitant coronary artery bypass grafting and valvular surgery was associated with a higher risk of 30‐day mortality (hazard ratio, 4.3; 95% confidence interval, 1.2‐14) compared with coronary artery bypass grafting alone. Occurrence of postoperative atrial fibrillation was associated with greater length of stay and 1‐year mortality (hazard ratio, 2.2; 95% confidence interval, 1.2‐3.9). Conclusions In this multicenter trial, we identified specific adverse outcomes that are associated with concomitant valvular and coronary artery bypass graft surgery, cardiopulmonary bypass, ventricular pacing, and occurrence of postoperative atrial fibrillation.

Prevalence and predictors of intracranial aneurysms in patients with bicuspid aortic valve

Objective To determine the prevalence and outcomes of intracranial aneurysm (IA) in patients with bicuspid aortic valve (BAV). Methods Retrospective review of patients with BAV who underwent brain MR angiography at the Mayo Clinic from 1994 to 2013. Results There were 678 patients included in this study—mean age 57±13 years, men 480 (71%), mean follow-up 10±3 years (5913 patient-years). Coarctation of aorta (COA) was present in 154 (23%) patients. There were 59 IAs identified in 52 of 678 patients (7.7%). IA was present in 20/154 patients (12.9%) with COA and 32/524 patients (5.7%) without COA (p<0.001). For the patients without COA, female gender and right–left cusp fusion were risks factors for IA in women after adjustment for all potential variables (HR 1.76, CI 1.31 to 2.68, p=0.03). There was no significant trend in the risk for IA across age tertiles: age ≤40 years versus 41–60 years (HR 1.19, p=0.34), and age 41–60 years versus 61–80 years (HR 1.06, p=0.56). Among the 52 patients with IA, enlargement occurred in three patients (6%), rupture in two patients (4%) and four patients (8%) underwent coil embolisation. For the 626 patients without IA at baseline, no patient developed IA over 7±2 years of imaging follow-up. Conclusions BAV is associated with a higher prevalence of IA compared to the general population, and this risk is higher in patients with COA, right–left cusp fusion and female gender.

Regional Variation in Mortality, Length of Stay, Cost, and Discharge Disposition Among Patients Admitted for Heart Failure in the United States

The objective of the study was to provide contemporary evidence on regional variation in hospitalization outcomes in patients with heart failure (HF) in the United States. Using the National Inpatient Sample, we compared hospitalization outcomes among primary HF admissions (2013 to 2014) among the 4 Census regions of the United States. Overall, an estimated 1.9 million HF hospitalizations occurred in the United States over the study period. Mortality rate was 3%, the mean length of stay was 5.3 days, the median cost of hospitalization was US

National Trends in Admission and In-Hospital Mortality of Patients With Heart Failure in the United States (2001–2014)

7,248, and the rate of routine home discharge was 51%. There was a significant regional variation for all end points (p <0.001); for example, compared with other regions of the country, the risk-adjusted rate of in-hospital mortality was highest in the Northeast (3.2%) and lowest in the Midwest (2.7%); and within each region, these mortalities were higher in the rural locations (range: 3.0% to 3.8%) than in the urban locations (range: 2.7% to 3.1%). In addition, the Northeast region had the longest length of stay (mean: 5.9 days) and the lowest risk-adjusted rate of routine home discharge (42%). However, the cost of hospitalization was highest in the West (median: US

Transcatheter aortic valve implantation in the United States: Predictors of early hospital discharge

8,898) and lowest in the South (US

Novel biomarkers with potential for cardiovascular risk reclassification.

6,366). A similar pattern of variation was found in subgroup analysis except that the risk-adjusted rate of in-hospital mortality was highest in the West among patients <65 years (1.7% vs 1.2% [lowest] in the Midwest), male gender (3.2% vs 2.8% in the Midwest), and rural location (3.8% vs 3% in the Midwest). In conclusion, HF hospitalization outcomes tend to be worse in the Northeast compared with other regions of the country. In addition, the in-hospital mortality rate was higher in rural locations than in urban locations.

Burden of arrhythmias in peripartum cardiomyopathy: Analysis of 9841 hospitalizations

Background To investigate heart failure (HF) hospitalization trends in the United States and change in trends after publication of management guidelines. Methods and Results Using data from the National Inpatient Sample and the US Census Bureau, annual national estimates in HF admissions and in‐hospital mortality were estimated for years 2001 to 2014, during which an estimated 57.4 million HF‐associated admissions occurred. Rates (95% confidence intervals) of admissions and in‐hospital mortality among primary HF hospitalizations declined by an average annual rate of 3% (2.5%–3.5%) and 3.5% (2.9%–4.0%), respectively. Compared with 2001 to 2005, the average annual rate of decline in primary HF admissions was more in 2006 to 2009 (ie, 3.4% versus 1.1%; P=0.02). In 2010 to 2014, primary HF admission continued to decline by an average annual rate of 4.3% (95% confidence interval, 3.9%–5.1%), but this was not significantly different from 2006 to 2009 (P=0.14). In contrast, there was no further decline in in‐hospital mortality trend after the guideline‐release years. For hospitalizations with HF as the secondary diagnosis, there was an upward trend in admissions in 2001 to 2005. However, the trend began to decline in 2006 to 2009, with an average annual rate of 2.4% (95% confidence interval, 0.8%–4%). Meanwhile, there was a consistent decline in in‐hospital mortality by an average annual rate of 3.7% (95% confidence interval, 3.3%–4.2%) during the study period, but the decline was more in 2006 to 2009 compared with 2001 to 2005 (ie, 5.4% versus 3.4%; P<0.001). Beyond 2009, admission and in‐hospital mortality rates continued to decline, although this was not significantly better than the preceding interval. Conclusions From 2001 to 2014, HF admission and in‐hospital mortality rates declined significantly in the United States; the greatest improvements coincided with the publication of the 2005 American College of Cardiology/American Heart Association HF guidelines.