Revista de gastroenterologia del Peru : organo oficial de la Sociedad de Gastroenterologia del Peru, Apr 1, 2009
D2 gastrectomy has been regarded as an inconvenient procedure with high morbidity and no survival... more D2 gastrectomy has been regarded as an inconvenient procedure with high morbidity and no survival benefit in the West. Recent studies, however, have shown low mortality and a survival benefit of D2 gastrectomy. In the Instituto de Enfermedades Neoplasicas (INEN) of Lima Peru D2 gastrectomy is performed since 1990 after training of some of the authors in the NCC of Tokyo Japan. Distal Pancreatectomy was performed only if the pancreas was involved.The aim of this study was to evaluate the peri operative mortality and survival in a group of patients who had a standard D2 lymphadenectomy according to the rules of the Japanese Research Society for Gastric Cancer. Data were collected prospectively, and patients were followed for more than 7 years. Between 1990 and 1999, 938 patients with localized gastric cancer were registered at INEN. Of these, 801 patients underwent curative resection with extended lymphadenectomy (D2). Postoperative morbidity/mortality, type of gastrectomy, mean of lymph nodes removed, pTNM stages and Survival Time and were analyzed. Sub total distal gastrectomy was performed in 511 patients and total gastrectomy in 290 patients. The mean number of lymph nodes removed was 46.48 per patient (54.91 nodes for total and 41.69 for sub total distal gastrectomy). Hospital mortality was 2.9%. 11% were Stage (TNM) IA, 9.4% stage IB, 19% stage II, 24.6% stage IIIA, 13.1% stage IIIB and 23% stage IV. Five-year actuarial survival was 47.5%. Five-year survival of patients with TNM stages IA, IB, II, IIIA, IIIB and IV were 85.8%, 79.4%, 60%, 46.7% 33% and 14.3% respectively. Gastrectomy with D2 lymphadenectomy may be performed with low morbidity and mortality if the operation is performed in specialized centers with a strict quality control system, and without removing the pancreas during total gastrectomy unless it is suspected to be involved. This procedure could provide a good probability of long-term survival, even for patients with invaded regional lymph nodes.
Revista de gastroenterologia del Peru : organo oficial de la Sociedad de Gastroenterologia del Peru, Jul 1, 2007
To evaluate the short and long term outcome of liver resections for hepatocellular carcinoma a re... more To evaluate the short and long term outcome of liver resections for hepatocellular carcinoma a retrospective analysis was performed on 232 consecutive patients with hepatocellular carcinoma resected between January 1990 and December 2006 at the Department of Abdomen of the Instituto de Enfermedades Neoplasicas of Lima Peru. Disease-free survival (DFS) and overall survival (OS) were determined by Kaplan-Meier method, Prognostic factors were evaluated using univariate and multivariate analysis The median age was 36 years. 44.2% were associated with hepatitis B, only 16.3% had cirrhosis. The median size of the tumors was 15 cm. The median value of AFP was 5,467 ng/ml. The majority of patients underwent a major hepatectomy (74.2 % had four or more segments resected)Overall morbidity and mortality were 13.7% and 5.3% respectively. After a median follow-up of 40 months, tumour recurrence appeared in 53.3% of the patients. The 1, 3, and 5 year overall survival rates were 66.5%, 38.7% and 26.7%respectively. The 1, 3, and 5 year disease-free survival rates were 53.7%, 27.6%, and 19.9%. On multivariate analysis, presence of multiple nodules (p<0.000), cirrhosis (p=0.001), and macroscopic vascular invasion (p=0.001) were found to be independent prognostic factors related to a worse long-term survival. Surgical resection is the optimal therapy for large HCC and can be safely performed with a reasonable long-term survival.
<jats:p>Background: Patients with cardiac arrest associated with STEMI are routinely exclud... more <jats:p>Background: Patients with cardiac arrest associated with STEMI are routinely excluded from clinical trials and therefore, almost no data exist regarding their outcomes with primary PCI. Patients with out of hospital cardiac arrest (OOHCA) are a particularly high-risk cohort and the appropriate reperfusion strategy for these patients is controversial.</jats:p> <jats:p> Methods/Results: We determined the outcomes of patients who sustained a cardiac arrest prior to primary PCI in 1,500 consecutive patients with STEMI admitted to or transferred to a regional PCI center. Overall 159(10.6%) STEMI patients sustained a cardiac arrest prior to PCI, including 47 (3.1%) with OOHCA. The in-hospital, 30-day and 1-year mortality for patients without cardiac arrest, cardiac arrest excluding OOHCA and patients with OOHCA are included in table <jats:xref ref-type="table" /> . 53.3% of the deaths in OOHCA were related to anoxic brain injury compared to 9.1% of the deaths in patients with in-hospital cardiac arrest (p&lt;0.003). Thirty-six percent of patients with OOHCA underwent a cooling protocol (return of spontaneous circulation and persistent neurologic impairment) with a 41% in-hospital mortality. </jats:p> <jats:p>Conclusions: Cardiac arrest prior to PCI (including both OOHCA and in-hospital) in patients with STEMI is a major predictor for in-hospital mortality. Patients with cardiac arrest who survive to discharge subsequently do well. OOHCA has a higher mortality than in-hospital cardiac arrest and the majority of deaths are due to anoxic brain injury. Still, nearly 70% of OOHCA survived to discharge without neurological impairment.</jats:p> <jats:p> <jats:table-wrap orientation="portrait" position="anchor"> <jats:graphic xmlns:xlink="http://www.w3.org/1999/xlink" orientation="portrait" position="float" xlink:href="2227T1.jpeg" /> </jats:table-wrap> </jats:p>
Circulation: Cardiovascular Quality and Outcomes, 2014
Background: Approximately 15% of Medicare patients who undergo percutaneous coronary intervention... more Background: Approximately 15% of Medicare patients who undergo percutaneous coronary intervention (PCI) are readmitted to the hospital within 30 days of discharge. A risk prediction algorithm which accurately identifies PCI patients’ risk for readmission may provide an opportunity to implement strategies to optimize care transitions to reduce inpatient readmissions and hospitalization costs in higher risk patients. Methods: We retrospectively applied a published validated 30-day readmission risk prediction algorithm to all PCI cases across three high volume centers within a single health care system between July 1, 2009 and September 30, 2013. Readmission risk scores were calculated and cases were grouped by low- (<6), intermediate- (6-10) and high-risk (≥11). Inpatient readmissions were compared between groups. Based on 4.25-year historical data and mean total variable costs per inpatient readmission, we assessed the impact of reducing the readmission rate by 50% in high-risk pa...
Introduction: The preferred access site for cardiac catheterization in patients with prior corona... more Introduction: The preferred access site for cardiac catheterization in patients with prior coronary artery bypass surgery (CABG) continues to be debated. Methods: We performed a systematic review and meta-analysis of two randomized trials and eighteen observational studies, including 58,237 patients with prior CABG (27,063 in the radial group; 31,174 in the femoral group) that underwent cardiac catheterization with or without intervention. Outcomes included (1) access-site complications rate; (2) crossover rate to a different vascular access; (3) procedure time; and (4) contrast volume. Data were extracted by two independent authors; using a random effects model, standardized mean differences (SMD) and 95% confidence interval (CI) were calculated for continuous outcomes, whereas odds ratio (OR) and 95% CI were calculated for binary outcomes. Results: Among randomized trials, the crossover rate (OR:12.63; 95% CI: 1.57,101.62; p=0.021) was higher in the radial group, while contrast vo...
Journal of the American College of Cardiology, 2020
Background: Recurrent drug-eluting stent restenosis (DES ISR) can be challenging to treat. Vascul... more Background: Recurrent drug-eluting stent restenosis (DES ISR) can be challenging to treat. Vascular brachytherapy (VBT) has been used with encouraging results. Methods: We report the long-term outcomes of patients with recurrent DES ISR treated with VBT from January 2014 to September 2018 [target lesion failure (TLF), defined as the composite of clinically driven target lesion revascularization (TLR), myocardial infarction (MI) and cardiac death]. We performed a Cox proportional analysis to identify factors associated with recurrent TLF. We examined the impact of intravascular ultrasound (IVUS) use on long-term outcomes. Results: 116 patients (143 lesions) underwent VBT. During a median follow-up of 24.7 (14.5-35.4) months, the incidence of TLF, TLR, target lesion MI, and cardiac death related to the target lesion were 35.7%, 32.2%, 11.2%, and 0%, respectively. Initial presentation with acute coronary syndrome (ACS) was independently associated with TLF (hazard ratio [HR] 1.975, 95% CI 1.120-3.485, p=0.019). Lesions treated with IVUS guidance had a lower incidence of TLR (14.3% vs. 39.6%, log-rank p=0.038), and a trend towards a lower incidence of TLF (19% vs. 42.6%, log-rank p=0.086). Conclusion: VBT can improve the treatment of recurrent DES-ISR, but target lesion failure occurs in one-third of patients at two years. Initial presentation with ACS was associated with higher TLF and the use of intravascular ultrasound with a trend for a lower incidence of TLF.
Catheterization and Cardiovascular Interventions, 2020
To examine the outcomes of vascular brachytherapy (VBT) for recurrent drug‐eluting stents (DES) i... more To examine the outcomes of vascular brachytherapy (VBT) for recurrent drug‐eluting stents (DES) in‐stent restenosis (ISR).
e16096Background: Modulation of immune system has demonstrated tumor response in Gastric Cancer. ... more e16096Background: Modulation of immune system has demonstrated tumor response in Gastric Cancer. Tumor infiltrating lymphocytes and microsatellite instability are predictive biomarkers for response...
Aim: To correlate levels of tumor-infiltrating lymphocytes (TIL) evaluated using the Internationa... more Aim: To correlate levels of tumor-infiltrating lymphocytes (TIL) evaluated using the International Immuno-Oncology Biomarker Working Group methodology, and both density of tumor-infiltrating immune cell and clinicopathological features in different malignancies. Methods: 209 pathological samples from gastric cancer, cervical cancer (CC), non-small-lung cancer, cutaneous melanoma (CM) and glioblastoma were tested for TIL in hematoxylin eosin, and density of CD3+, CD4+, CD8+, CD20+, CD68+ and CD163+ cells by digital analysis. Results: TIL levels were higher in invasive margin compartments (IMC). TIL in IMC, intratumoral and stromal compartments predicted survival. CC and gastric cancer had higher TIL in intratumoral; CC and CM had higher TIL in stromal compartment and IMC. CM had the highest density of lymphocyte and macrophage populations. CD20 density was associated with survival in the whole series. Conclusion: Standardized evaluation of TIL levels may provide valuable prognostic i...
Journal of the American College of Cardiology, 2018
Background: The burden and impact of sleep deprivation in cardiology has received limited study. ... more Background: The burden and impact of sleep deprivation in cardiology has received limited study. Methods: Multidisciplinary, online-based survey on sleep health pattern and potential impact of sleep deprivation involving 44 closed-ended questions distributed via email list to cardiovascular providers, involving physicians, nurses, and technicians. Results: Of 239 respondents, 75% were men and 66% were interventional cardiologists. Nearly all (90%) had call responsibilities with 43% doing ≥7-call nights/month. For those sleep deprived, 19% could go home early the following day. Sleep disorders were reported in 21%, with 23% using sleep-inducing medications (7% used regularly). Main factors diminishing the quality and/or quantity of sleep were related to: a) work (68%), b) family and/or personal activities (58%), and c) staying up late at night writing or studying (49%). Coffee consumption and use of energy drinks or supplements was reported by 79% and 24% respectively. Digital devices were used often (42%) at bedtime. Sleep deprivation was associated with difficulty concentrating (59%), lack of motivation (55%), and irritability (69%). Work performance was felt to be hindered by 45% of participants and 8.4% reported a complication and/or negative patient outcome likely related to sleep deprivation. Many (56%) felt burnout and 86% opined that policies should exist that allows sleep-deprived individuals to go home early post-call. Most respondents (67%) felt that disclosure of sleep deprivation was not routinely required; yet 47% felt that disclosure should happen there is very limited time for sleep. Conclusion: Cardiologists are prone to sleep deprivation, mainly because of frequent call coverage responsibilities. Our survey elucidates several potential contributing factors; such as underlying sleep disorders, use of digital devices, and caffeinated products. Work-related and/or academic responsibilities are felt to diminish the quality and/or quantity of sleep. Sleep deprivation may impact work performance, with >8% reporting such to be associated with complications. More study is required to identify measures to attenuate the burden and impact of sleep deprivation.
long-term outcomes were compared for patients who received gemcitabine versus either 5-FU or cape... more long-term outcomes were compared for patients who received gemcitabine versus either 5-FU or capecitabine. Results: A total of 57 patients were included for analysis. Thirty patients received gemcitabine, 23 received capecitabine, and 4 received 5-FU infusion. Full results are detailed in Table 1. The 5-FU/capecitabine and gemcitabine groups were comparable with regard to age, gender, and carbohydrate antigen 19-9 levels. There were no significant differences in peri-operative complication or readmission rates. There were more node positive resections in the 5FU/ capecitabine group (59 vs 20%, p = 0.006), while other pathologic outcomes were comparable. Median disease-free survival was 15.5 months in the 5-FU/capecitabine group versus 14.3 months in the gemcitabine group (p = 0.61); overall survival was 29.2 versus 26.5 months (p = 0.61). Conclusion: Neoadjuvant chemoradiation with gemcitabine demonstrated an advantage over 5-FU or capecitabine in BRPC, with more node negative resections. This improvement in pathology did not translate to a survival benefit in this study.
Objective To evaluate perceptions toward pharmacogenetic testing of patients undergoing percutane... more Objective To evaluate perceptions toward pharmacogenetic testing of patients undergoing percutaneous coronary intervention (PCI) who are prescribed dual antiplatelet therapy (DAPT) and whether geographical differences in these perceptions exist. Participants and methods TAILOR-PCI is the largest genotype-based cardiovascular clinical trial randomizing participants to conventional DAPT or prospective genotyping-guided DAPT. Enrolled patients completed surveys before and 6 months after randomization. Results A total of 1327 patients completed baseline surveys of whom 28, 29, and 43% were from Korea, Canada and the USA, respectively. Most patients (77%) valued identifying pharmacogenetic variants; however, fewer Koreans (44%) as compared with Canadians (91%) and USA (89%) patients identified pharmacogenetics as being important (P < 0.001). After adjusting for age, sex, and country, those who were confident in their ability to understand genetic information were significantly more likely to value identifying pharmacogenetic variants (odds ratio: 30.0; 95% confidence interval: 20.5-43.8). Only 21% of Koreans, as opposed to 86 and 77% of patients in Canada and USA, respectively, were confident in their ability to understand genetic information (P < 0.001). Conclusion Although genetically mediated clopidogrel resistance is more prevalent amongst Asians, Koreans undergoing PCI identified pharmacogenetic variants as less important to their healthcare, likely related to their lack of confidence in their ability to understand genetic information. To enable successful implementation of pharmacogenetic testing on a global scale, the possibility of international population differences in perceptions should be considered.
We sought to examine the impact of coronary chronic total occlusion (CTO) percutaneous coronary i... more We sought to examine the impact of coronary chronic total occlusion (CTO) percutaneous coronary intervention (PCI) on left ventricular (LV) function. We performed a systematic review and meta-analysis of studies published between January 1980 and November 2017 on the impact of successful CTO PCI on LV function. A total of 34 observational studies including 2735 patients were included in the meta-analysis. Over a weighted mean follow-up of 7.9 months, successful CTO PCI was associated with an increase in LV ejection fraction by 3.8% (95%CI 3.0-4.7, P < 0.0001, I = 45%). In secondary analysis of 15 studies (1248 patients) that defined CTOs as occlusions of at least 3-month duration and reported follow-up of at least 3-months after the procedure, successful CTO PCI was associated with improvement in LV ejection fraction by 4.3% (95%CI [3.1, 5.6], P < 0.0001). In the 10 studies (502 patients) that reported LV end-systolic volume, successful CTO PCI was associated with a decrease ...
Journal of the American College of Cardiology, 2016
Background: Bleeding is a common complication in percutaneous coronary intervention (PCI) and inc... more Background: Bleeding is a common complication in percutaneous coronary intervention (PCI) and increases length of stay (LOS), costs, and mortality. Designed for rapid hemostasis, vascular closure devices (VCDs) are beneficial cases with a high bleeding risk but are utilized less often in these cases. A real-time decision support tool may improve prospectice identification of cases where VCDs may improve clinical outcomes and cost.
Journal of Cardiovascular Translational Research, 2010
Reperfusion injury may offset the optimal salvage of myocardium achieved during primary coronary ... more Reperfusion injury may offset the optimal salvage of myocardium achieved during primary coronary angioplasty. Thus, coronary reperfusion must be combined with cardioprotective adjunctive therapies in order to optimize myocardial salvage and minimize infarct size. Forty-three patients with their first ST-elevation myocardial infarction were randomized to myocardial postconditioning or standard of care at the time of primary coronary angioplasty. Postconditioning was performed immediately upon crossing the lesion with the guide wire and consisted of four cycles of 30 s occlusion followed by 30 s of reperfusion. End-points included infarct size, myocardial perfusion grade (MPG), left-ventricular ejection fraction (LVEF), and long-term clinical events (death and heart failure). Despite similar ischemic times (≅4.5 h) (p = 0.9) a reduction in infarct size was observed among patients treated with the postconditioning protocol. Peak creatine phosphokinase (CPK), as well as its myocardial band (MB) fraction, was significantly lower in the postconditioning group when compared with the control group (CPK--control, 2,444 ± 1,928 IU/L vs. PC, 2,182 ± 1,717 IU/L; CPK-MB--control, 242 ± 40 IU/L vs. PC, 195 ± 33 IU/L; p = 0.64 and p &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.01, respectively). EF in the postconditioning group was improved when compared with the control group (control, 43% ± 15 vs. PC, 52% ± 9; p = 0.05). After a mean follow-up of 3.4 years, a 6-point absolute difference in LVEF was still evident in the postconditioning group (p = 0.18). MPG was better among patients treated with the postconditioning protocol compared with control (2.5 ± 0.5 vs. 2.1 ± 0.6; p = 0.02). Due to the small sample size no significant differences in clinical events were detected (p value for death = 0.9; p value for heart failure = 0.2). A simple postconditioning protocol applied at the onset of mechanical reperfusion, resulted in reduction of infarct size, better epicardial and myocardial flow, and improvement in left ventricular function. The beneficial effects of postconditioning on cardiac function persist beyond 3 years.
Journal of the American College of Cardiology, 2012
(MINAP) database and patient notes. Mortality data was confirmed using the Office of National Sta... more (MINAP) database and patient notes. Mortality data was confirmed using the Office of National Statistics database with follow-up ranging from 3 to 44 months. Results: The mean age was 60Ϯ14years and 80.3% patients were male. The incidence of previous coronary disease in the cohort was 27.8%, 32.8% patients were hypertensive, 37.7% smokers, 24.6% hypercholesterolaemic and 8.2% had known diabetes. 45% patients had a witnessed arrest and 43.4% were directly conveyed to the pPCI centre. Mean arrest-to-arrival time in the cohort was 115Ϯ24mins with a mean call-to-balloon time of 168Ϯ24mins. The rate of successful pPCI in the cohort was 85% with 21.7% having 3-vessel disease. Shock was present in 16% and severe left ventricular impairment in 25% patients. The in-hospital mortality within the cohort was 21%. Of the patients who died 14 were cardiovascular deaths, 3 being shortly after return of spontaneous circulation in the catheterisation laboratory, and 6 of all deaths were secondary to hypoxic brain injury in Intensive Care. 79% of all patients survived to discharge. Of the patients who survived 92% were discharged with no neurological deficit. At follow-up (12-44 months in 62% patients) 100% of patients who survived to discharge were still alive. Conclusions: Here we present descriptive data of a large, contemporary cohort of STEMI admissions for pPCI that are complicated by OOHCA. Here we show a 79% survival rate to discharge, a higher proportion than previously reported, with good long term prognosis after discharge.
Journal of the American College of Cardiology, 2013
Background: Patients who present with ST-Elevation Myocardial Infarction (STEMI) complicated by c... more Background: Patients who present with ST-Elevation Myocardial Infarction (STEMI) complicated by cardiogenic shock (CS) that suffer a cardiac arrest have high mortality rates. Little data exist on using Extracorporeal Membrane Oxygenation (ECMO) as a rescue device during CPR in the CS patient. methods: We reviewed all patients from 8/2011 to 10/2012 who presented to a high volume, tertiary percutaneous coronary intervention (PCI) center, with STEMI complicated by CS that developed a PEA arrest during PCI and remained hemodynamically unstable despite mechanical CPR, IABP and inotropes. All patients were placed on percutaneous arterio-venous ECMO as a rescue device. All patients were intubated and all were hypoperfused with profound metabolic acidosis. Mechanical CPR via the LUCAS device was used in all patients. Median time of arrest from initiation of ECMO was 52 (range 16-133) minutes. Antegrade perfusion was established below the arterial ECMO sheath in all cases. ECMO was required for a median time of 4 (range 3-6) days. results: The 5 patients included 2 females and 3 males with a median age of 64. Therapeutic hypothermia (TH) was instituted after initiation of ECMO in 4 (80%) of the cases. Ejection fractions of less than 10% were noted in 4 patients, and 1 patient had no cardiac output present prior to initiation of ECMO. Of 5 patients, 4 (80%) survived to hospital discharge and all of the survivors had good neurocognitive recovery (CPC 1 or 2) at discharge. Of the 4 survivors, discharge EF improved to a median of 45% (range 25-65%). Bleeding which required transfusion occurred in all cases. conclusions: ECMO can be a lifesaving rescue technique when instituted by an experienced Shock Team in the CV lab for refractory PEA arrest occurring in the CV lab. Lucas CPR was a valuable adjunct. Striking recovery of LV function can also occur in several days. The combination of ECMO and TH was associated with excellent neurologic outcomes as well. ECMO may have a role in selected PCI centers with advanced specialized teams.
Journal of the American College of Cardiology, 2012
Background: Therapeutic hypothermia (TH) is neuroprotective and increases survival in cardiac arr... more Background: Therapeutic hypothermia (TH) is neuroprotective and increases survival in cardiac arrest survivors. Cardiac arrest is often seen in the setting of ST-elevation myocardial infarction (STEMI), and cardiogenic shock (CS) is a known poor prognostic factor. Methods: From Feb 2006 to July 2011, 252 consecutive cardiac arrest patients who remained comatose following return of spontaneous circulation were enrolled in a TH protocol, integrated into a regional STEMI transfer network. Patients were treated regardless of past medical history, initial rhythm or hemodynamic status. The aim of this study was to determine if there were any predictors of CS in this population and their effect on morbidity and mortality. Results: Of the 252 patients, 92 (36.5%) were in CS. Survival with favorable neurologic outcome (CPC 1 or 2) was poorer in CS patients than no CS patients, 33/92 (35.9%) vs 83/160 (51.9%), p=0.014. Patients in CS were older 65.5 vs 61.5 years p=0.02 and had a higher incidence of preexisting cardiomyopathy (CM) 41/92 (44.6%) vs 41/160 (25.6%) p=0.002 and concurrent STEMI 43/92 (46.7%) vs 44/160 (27.5%) p=0.002. Ischemic CM was the most common type 34/41 (83.0%). The odds ratio of CS in patients with pre-existing CM was OR=2.33 (1.36, 4.02). The odds ratio of CS in patients with concurrent STEMI was OR=2.31 (1.35, 3.96). There was no statistical difference in gender, initial rhythm, transfer distance, history of CAD, HTN, or CHF between patients in CS versus those without CS. There was a trend of lower survival with CPC 1/2 in pre-existing CM patients than those without 12/41 (29.3%) vs 21/51 (41.2%) p=0.24. There was a trend of higher survival with CPC 1/2 in patients in CS and concurrent STEMI than CS alone 19/43 (44.2%) vs 14/49 (28.6%) p=0.12. Conclusion: Pre-existing CM and concurrent STEMI are associated with higher incidence of CS. Prior CM is common among those with CS. CS has an unexpectedly favorable outcome with TH. TH should be the standard of care for unresponsive cardiac arrest patients in CS.
Revista de gastroenterologia del Peru : organo oficial de la Sociedad de Gastroenterologia del Peru, Apr 1, 2009
D2 gastrectomy has been regarded as an inconvenient procedure with high morbidity and no survival... more D2 gastrectomy has been regarded as an inconvenient procedure with high morbidity and no survival benefit in the West. Recent studies, however, have shown low mortality and a survival benefit of D2 gastrectomy. In the Instituto de Enfermedades Neoplasicas (INEN) of Lima Peru D2 gastrectomy is performed since 1990 after training of some of the authors in the NCC of Tokyo Japan. Distal Pancreatectomy was performed only if the pancreas was involved.The aim of this study was to evaluate the peri operative mortality and survival in a group of patients who had a standard D2 lymphadenectomy according to the rules of the Japanese Research Society for Gastric Cancer. Data were collected prospectively, and patients were followed for more than 7 years. Between 1990 and 1999, 938 patients with localized gastric cancer were registered at INEN. Of these, 801 patients underwent curative resection with extended lymphadenectomy (D2). Postoperative morbidity/mortality, type of gastrectomy, mean of lymph nodes removed, pTNM stages and Survival Time and were analyzed. Sub total distal gastrectomy was performed in 511 patients and total gastrectomy in 290 patients. The mean number of lymph nodes removed was 46.48 per patient (54.91 nodes for total and 41.69 for sub total distal gastrectomy). Hospital mortality was 2.9%. 11% were Stage (TNM) IA, 9.4% stage IB, 19% stage II, 24.6% stage IIIA, 13.1% stage IIIB and 23% stage IV. Five-year actuarial survival was 47.5%. Five-year survival of patients with TNM stages IA, IB, II, IIIA, IIIB and IV were 85.8%, 79.4%, 60%, 46.7% 33% and 14.3% respectively. Gastrectomy with D2 lymphadenectomy may be performed with low morbidity and mortality if the operation is performed in specialized centers with a strict quality control system, and without removing the pancreas during total gastrectomy unless it is suspected to be involved. This procedure could provide a good probability of long-term survival, even for patients with invaded regional lymph nodes.
Revista de gastroenterologia del Peru : organo oficial de la Sociedad de Gastroenterologia del Peru, Jul 1, 2007
To evaluate the short and long term outcome of liver resections for hepatocellular carcinoma a re... more To evaluate the short and long term outcome of liver resections for hepatocellular carcinoma a retrospective analysis was performed on 232 consecutive patients with hepatocellular carcinoma resected between January 1990 and December 2006 at the Department of Abdomen of the Instituto de Enfermedades Neoplasicas of Lima Peru. Disease-free survival (DFS) and overall survival (OS) were determined by Kaplan-Meier method, Prognostic factors were evaluated using univariate and multivariate analysis The median age was 36 years. 44.2% were associated with hepatitis B, only 16.3% had cirrhosis. The median size of the tumors was 15 cm. The median value of AFP was 5,467 ng/ml. The majority of patients underwent a major hepatectomy (74.2 % had four or more segments resected)Overall morbidity and mortality were 13.7% and 5.3% respectively. After a median follow-up of 40 months, tumour recurrence appeared in 53.3% of the patients. The 1, 3, and 5 year overall survival rates were 66.5%, 38.7% and 26.7%respectively. The 1, 3, and 5 year disease-free survival rates were 53.7%, 27.6%, and 19.9%. On multivariate analysis, presence of multiple nodules (p&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;0.000), cirrhosis (p=0.001), and macroscopic vascular invasion (p=0.001) were found to be independent prognostic factors related to a worse long-term survival. Surgical resection is the optimal therapy for large HCC and can be safely performed with a reasonable long-term survival.
<jats:p>Background: Patients with cardiac arrest associated with STEMI are routinely exclud... more <jats:p>Background: Patients with cardiac arrest associated with STEMI are routinely excluded from clinical trials and therefore, almost no data exist regarding their outcomes with primary PCI. Patients with out of hospital cardiac arrest (OOHCA) are a particularly high-risk cohort and the appropriate reperfusion strategy for these patients is controversial.</jats:p> <jats:p> Methods/Results: We determined the outcomes of patients who sustained a cardiac arrest prior to primary PCI in 1,500 consecutive patients with STEMI admitted to or transferred to a regional PCI center. Overall 159(10.6%) STEMI patients sustained a cardiac arrest prior to PCI, including 47 (3.1%) with OOHCA. The in-hospital, 30-day and 1-year mortality for patients without cardiac arrest, cardiac arrest excluding OOHCA and patients with OOHCA are included in table <jats:xref ref-type="table" /> . 53.3% of the deaths in OOHCA were related to anoxic brain injury compared to 9.1% of the deaths in patients with in-hospital cardiac arrest (p&lt;0.003). Thirty-six percent of patients with OOHCA underwent a cooling protocol (return of spontaneous circulation and persistent neurologic impairment) with a 41% in-hospital mortality. </jats:p> <jats:p>Conclusions: Cardiac arrest prior to PCI (including both OOHCA and in-hospital) in patients with STEMI is a major predictor for in-hospital mortality. Patients with cardiac arrest who survive to discharge subsequently do well. OOHCA has a higher mortality than in-hospital cardiac arrest and the majority of deaths are due to anoxic brain injury. Still, nearly 70% of OOHCA survived to discharge without neurological impairment.</jats:p> <jats:p> <jats:table-wrap orientation="portrait" position="anchor"> <jats:graphic xmlns:xlink="http://www.w3.org/1999/xlink" orientation="portrait" position="float" xlink:href="2227T1.jpeg" /> </jats:table-wrap> </jats:p>
Circulation: Cardiovascular Quality and Outcomes, 2014
Background: Approximately 15% of Medicare patients who undergo percutaneous coronary intervention... more Background: Approximately 15% of Medicare patients who undergo percutaneous coronary intervention (PCI) are readmitted to the hospital within 30 days of discharge. A risk prediction algorithm which accurately identifies PCI patients’ risk for readmission may provide an opportunity to implement strategies to optimize care transitions to reduce inpatient readmissions and hospitalization costs in higher risk patients. Methods: We retrospectively applied a published validated 30-day readmission risk prediction algorithm to all PCI cases across three high volume centers within a single health care system between July 1, 2009 and September 30, 2013. Readmission risk scores were calculated and cases were grouped by low- (<6), intermediate- (6-10) and high-risk (≥11). Inpatient readmissions were compared between groups. Based on 4.25-year historical data and mean total variable costs per inpatient readmission, we assessed the impact of reducing the readmission rate by 50% in high-risk pa...
Introduction: The preferred access site for cardiac catheterization in patients with prior corona... more Introduction: The preferred access site for cardiac catheterization in patients with prior coronary artery bypass surgery (CABG) continues to be debated. Methods: We performed a systematic review and meta-analysis of two randomized trials and eighteen observational studies, including 58,237 patients with prior CABG (27,063 in the radial group; 31,174 in the femoral group) that underwent cardiac catheterization with or without intervention. Outcomes included (1) access-site complications rate; (2) crossover rate to a different vascular access; (3) procedure time; and (4) contrast volume. Data were extracted by two independent authors; using a random effects model, standardized mean differences (SMD) and 95% confidence interval (CI) were calculated for continuous outcomes, whereas odds ratio (OR) and 95% CI were calculated for binary outcomes. Results: Among randomized trials, the crossover rate (OR:12.63; 95% CI: 1.57,101.62; p=0.021) was higher in the radial group, while contrast vo...
Journal of the American College of Cardiology, 2020
Background: Recurrent drug-eluting stent restenosis (DES ISR) can be challenging to treat. Vascul... more Background: Recurrent drug-eluting stent restenosis (DES ISR) can be challenging to treat. Vascular brachytherapy (VBT) has been used with encouraging results. Methods: We report the long-term outcomes of patients with recurrent DES ISR treated with VBT from January 2014 to September 2018 [target lesion failure (TLF), defined as the composite of clinically driven target lesion revascularization (TLR), myocardial infarction (MI) and cardiac death]. We performed a Cox proportional analysis to identify factors associated with recurrent TLF. We examined the impact of intravascular ultrasound (IVUS) use on long-term outcomes. Results: 116 patients (143 lesions) underwent VBT. During a median follow-up of 24.7 (14.5-35.4) months, the incidence of TLF, TLR, target lesion MI, and cardiac death related to the target lesion were 35.7%, 32.2%, 11.2%, and 0%, respectively. Initial presentation with acute coronary syndrome (ACS) was independently associated with TLF (hazard ratio [HR] 1.975, 95% CI 1.120-3.485, p=0.019). Lesions treated with IVUS guidance had a lower incidence of TLR (14.3% vs. 39.6%, log-rank p=0.038), and a trend towards a lower incidence of TLF (19% vs. 42.6%, log-rank p=0.086). Conclusion: VBT can improve the treatment of recurrent DES-ISR, but target lesion failure occurs in one-third of patients at two years. Initial presentation with ACS was associated with higher TLF and the use of intravascular ultrasound with a trend for a lower incidence of TLF.
Catheterization and Cardiovascular Interventions, 2020
To examine the outcomes of vascular brachytherapy (VBT) for recurrent drug‐eluting stents (DES) i... more To examine the outcomes of vascular brachytherapy (VBT) for recurrent drug‐eluting stents (DES) in‐stent restenosis (ISR).
e16096Background: Modulation of immune system has demonstrated tumor response in Gastric Cancer. ... more e16096Background: Modulation of immune system has demonstrated tumor response in Gastric Cancer. Tumor infiltrating lymphocytes and microsatellite instability are predictive biomarkers for response...
Aim: To correlate levels of tumor-infiltrating lymphocytes (TIL) evaluated using the Internationa... more Aim: To correlate levels of tumor-infiltrating lymphocytes (TIL) evaluated using the International Immuno-Oncology Biomarker Working Group methodology, and both density of tumor-infiltrating immune cell and clinicopathological features in different malignancies. Methods: 209 pathological samples from gastric cancer, cervical cancer (CC), non-small-lung cancer, cutaneous melanoma (CM) and glioblastoma were tested for TIL in hematoxylin eosin, and density of CD3+, CD4+, CD8+, CD20+, CD68+ and CD163+ cells by digital analysis. Results: TIL levels were higher in invasive margin compartments (IMC). TIL in IMC, intratumoral and stromal compartments predicted survival. CC and gastric cancer had higher TIL in intratumoral; CC and CM had higher TIL in stromal compartment and IMC. CM had the highest density of lymphocyte and macrophage populations. CD20 density was associated with survival in the whole series. Conclusion: Standardized evaluation of TIL levels may provide valuable prognostic i...
Journal of the American College of Cardiology, 2018
Background: The burden and impact of sleep deprivation in cardiology has received limited study. ... more Background: The burden and impact of sleep deprivation in cardiology has received limited study. Methods: Multidisciplinary, online-based survey on sleep health pattern and potential impact of sleep deprivation involving 44 closed-ended questions distributed via email list to cardiovascular providers, involving physicians, nurses, and technicians. Results: Of 239 respondents, 75% were men and 66% were interventional cardiologists. Nearly all (90%) had call responsibilities with 43% doing ≥7-call nights/month. For those sleep deprived, 19% could go home early the following day. Sleep disorders were reported in 21%, with 23% using sleep-inducing medications (7% used regularly). Main factors diminishing the quality and/or quantity of sleep were related to: a) work (68%), b) family and/or personal activities (58%), and c) staying up late at night writing or studying (49%). Coffee consumption and use of energy drinks or supplements was reported by 79% and 24% respectively. Digital devices were used often (42%) at bedtime. Sleep deprivation was associated with difficulty concentrating (59%), lack of motivation (55%), and irritability (69%). Work performance was felt to be hindered by 45% of participants and 8.4% reported a complication and/or negative patient outcome likely related to sleep deprivation. Many (56%) felt burnout and 86% opined that policies should exist that allows sleep-deprived individuals to go home early post-call. Most respondents (67%) felt that disclosure of sleep deprivation was not routinely required; yet 47% felt that disclosure should happen there is very limited time for sleep. Conclusion: Cardiologists are prone to sleep deprivation, mainly because of frequent call coverage responsibilities. Our survey elucidates several potential contributing factors; such as underlying sleep disorders, use of digital devices, and caffeinated products. Work-related and/or academic responsibilities are felt to diminish the quality and/or quantity of sleep. Sleep deprivation may impact work performance, with >8% reporting such to be associated with complications. More study is required to identify measures to attenuate the burden and impact of sleep deprivation.
long-term outcomes were compared for patients who received gemcitabine versus either 5-FU or cape... more long-term outcomes were compared for patients who received gemcitabine versus either 5-FU or capecitabine. Results: A total of 57 patients were included for analysis. Thirty patients received gemcitabine, 23 received capecitabine, and 4 received 5-FU infusion. Full results are detailed in Table 1. The 5-FU/capecitabine and gemcitabine groups were comparable with regard to age, gender, and carbohydrate antigen 19-9 levels. There were no significant differences in peri-operative complication or readmission rates. There were more node positive resections in the 5FU/ capecitabine group (59 vs 20%, p = 0.006), while other pathologic outcomes were comparable. Median disease-free survival was 15.5 months in the 5-FU/capecitabine group versus 14.3 months in the gemcitabine group (p = 0.61); overall survival was 29.2 versus 26.5 months (p = 0.61). Conclusion: Neoadjuvant chemoradiation with gemcitabine demonstrated an advantage over 5-FU or capecitabine in BRPC, with more node negative resections. This improvement in pathology did not translate to a survival benefit in this study.
Objective To evaluate perceptions toward pharmacogenetic testing of patients undergoing percutane... more Objective To evaluate perceptions toward pharmacogenetic testing of patients undergoing percutaneous coronary intervention (PCI) who are prescribed dual antiplatelet therapy (DAPT) and whether geographical differences in these perceptions exist. Participants and methods TAILOR-PCI is the largest genotype-based cardiovascular clinical trial randomizing participants to conventional DAPT or prospective genotyping-guided DAPT. Enrolled patients completed surveys before and 6 months after randomization. Results A total of 1327 patients completed baseline surveys of whom 28, 29, and 43% were from Korea, Canada and the USA, respectively. Most patients (77%) valued identifying pharmacogenetic variants; however, fewer Koreans (44%) as compared with Canadians (91%) and USA (89%) patients identified pharmacogenetics as being important (P < 0.001). After adjusting for age, sex, and country, those who were confident in their ability to understand genetic information were significantly more likely to value identifying pharmacogenetic variants (odds ratio: 30.0; 95% confidence interval: 20.5-43.8). Only 21% of Koreans, as opposed to 86 and 77% of patients in Canada and USA, respectively, were confident in their ability to understand genetic information (P < 0.001). Conclusion Although genetically mediated clopidogrel resistance is more prevalent amongst Asians, Koreans undergoing PCI identified pharmacogenetic variants as less important to their healthcare, likely related to their lack of confidence in their ability to understand genetic information. To enable successful implementation of pharmacogenetic testing on a global scale, the possibility of international population differences in perceptions should be considered.
We sought to examine the impact of coronary chronic total occlusion (CTO) percutaneous coronary i... more We sought to examine the impact of coronary chronic total occlusion (CTO) percutaneous coronary intervention (PCI) on left ventricular (LV) function. We performed a systematic review and meta-analysis of studies published between January 1980 and November 2017 on the impact of successful CTO PCI on LV function. A total of 34 observational studies including 2735 patients were included in the meta-analysis. Over a weighted mean follow-up of 7.9 months, successful CTO PCI was associated with an increase in LV ejection fraction by 3.8% (95%CI 3.0-4.7, P < 0.0001, I = 45%). In secondary analysis of 15 studies (1248 patients) that defined CTOs as occlusions of at least 3-month duration and reported follow-up of at least 3-months after the procedure, successful CTO PCI was associated with improvement in LV ejection fraction by 4.3% (95%CI [3.1, 5.6], P < 0.0001). In the 10 studies (502 patients) that reported LV end-systolic volume, successful CTO PCI was associated with a decrease ...
Journal of the American College of Cardiology, 2016
Background: Bleeding is a common complication in percutaneous coronary intervention (PCI) and inc... more Background: Bleeding is a common complication in percutaneous coronary intervention (PCI) and increases length of stay (LOS), costs, and mortality. Designed for rapid hemostasis, vascular closure devices (VCDs) are beneficial cases with a high bleeding risk but are utilized less often in these cases. A real-time decision support tool may improve prospectice identification of cases where VCDs may improve clinical outcomes and cost.
Journal of Cardiovascular Translational Research, 2010
Reperfusion injury may offset the optimal salvage of myocardium achieved during primary coronary ... more Reperfusion injury may offset the optimal salvage of myocardium achieved during primary coronary angioplasty. Thus, coronary reperfusion must be combined with cardioprotective adjunctive therapies in order to optimize myocardial salvage and minimize infarct size. Forty-three patients with their first ST-elevation myocardial infarction were randomized to myocardial postconditioning or standard of care at the time of primary coronary angioplasty. Postconditioning was performed immediately upon crossing the lesion with the guide wire and consisted of four cycles of 30 s occlusion followed by 30 s of reperfusion. End-points included infarct size, myocardial perfusion grade (MPG), left-ventricular ejection fraction (LVEF), and long-term clinical events (death and heart failure). Despite similar ischemic times (≅4.5 h) (p = 0.9) a reduction in infarct size was observed among patients treated with the postconditioning protocol. Peak creatine phosphokinase (CPK), as well as its myocardial band (MB) fraction, was significantly lower in the postconditioning group when compared with the control group (CPK--control, 2,444 ± 1,928 IU/L vs. PC, 2,182 ± 1,717 IU/L; CPK-MB--control, 242 ± 40 IU/L vs. PC, 195 ± 33 IU/L; p = 0.64 and p &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.01, respectively). EF in the postconditioning group was improved when compared with the control group (control, 43% ± 15 vs. PC, 52% ± 9; p = 0.05). After a mean follow-up of 3.4 years, a 6-point absolute difference in LVEF was still evident in the postconditioning group (p = 0.18). MPG was better among patients treated with the postconditioning protocol compared with control (2.5 ± 0.5 vs. 2.1 ± 0.6; p = 0.02). Due to the small sample size no significant differences in clinical events were detected (p value for death = 0.9; p value for heart failure = 0.2). A simple postconditioning protocol applied at the onset of mechanical reperfusion, resulted in reduction of infarct size, better epicardial and myocardial flow, and improvement in left ventricular function. The beneficial effects of postconditioning on cardiac function persist beyond 3 years.
Journal of the American College of Cardiology, 2012
(MINAP) database and patient notes. Mortality data was confirmed using the Office of National Sta... more (MINAP) database and patient notes. Mortality data was confirmed using the Office of National Statistics database with follow-up ranging from 3 to 44 months. Results: The mean age was 60Ϯ14years and 80.3% patients were male. The incidence of previous coronary disease in the cohort was 27.8%, 32.8% patients were hypertensive, 37.7% smokers, 24.6% hypercholesterolaemic and 8.2% had known diabetes. 45% patients had a witnessed arrest and 43.4% were directly conveyed to the pPCI centre. Mean arrest-to-arrival time in the cohort was 115Ϯ24mins with a mean call-to-balloon time of 168Ϯ24mins. The rate of successful pPCI in the cohort was 85% with 21.7% having 3-vessel disease. Shock was present in 16% and severe left ventricular impairment in 25% patients. The in-hospital mortality within the cohort was 21%. Of the patients who died 14 were cardiovascular deaths, 3 being shortly after return of spontaneous circulation in the catheterisation laboratory, and 6 of all deaths were secondary to hypoxic brain injury in Intensive Care. 79% of all patients survived to discharge. Of the patients who survived 92% were discharged with no neurological deficit. At follow-up (12-44 months in 62% patients) 100% of patients who survived to discharge were still alive. Conclusions: Here we present descriptive data of a large, contemporary cohort of STEMI admissions for pPCI that are complicated by OOHCA. Here we show a 79% survival rate to discharge, a higher proportion than previously reported, with good long term prognosis after discharge.
Journal of the American College of Cardiology, 2013
Background: Patients who present with ST-Elevation Myocardial Infarction (STEMI) complicated by c... more Background: Patients who present with ST-Elevation Myocardial Infarction (STEMI) complicated by cardiogenic shock (CS) that suffer a cardiac arrest have high mortality rates. Little data exist on using Extracorporeal Membrane Oxygenation (ECMO) as a rescue device during CPR in the CS patient. methods: We reviewed all patients from 8/2011 to 10/2012 who presented to a high volume, tertiary percutaneous coronary intervention (PCI) center, with STEMI complicated by CS that developed a PEA arrest during PCI and remained hemodynamically unstable despite mechanical CPR, IABP and inotropes. All patients were placed on percutaneous arterio-venous ECMO as a rescue device. All patients were intubated and all were hypoperfused with profound metabolic acidosis. Mechanical CPR via the LUCAS device was used in all patients. Median time of arrest from initiation of ECMO was 52 (range 16-133) minutes. Antegrade perfusion was established below the arterial ECMO sheath in all cases. ECMO was required for a median time of 4 (range 3-6) days. results: The 5 patients included 2 females and 3 males with a median age of 64. Therapeutic hypothermia (TH) was instituted after initiation of ECMO in 4 (80%) of the cases. Ejection fractions of less than 10% were noted in 4 patients, and 1 patient had no cardiac output present prior to initiation of ECMO. Of 5 patients, 4 (80%) survived to hospital discharge and all of the survivors had good neurocognitive recovery (CPC 1 or 2) at discharge. Of the 4 survivors, discharge EF improved to a median of 45% (range 25-65%). Bleeding which required transfusion occurred in all cases. conclusions: ECMO can be a lifesaving rescue technique when instituted by an experienced Shock Team in the CV lab for refractory PEA arrest occurring in the CV lab. Lucas CPR was a valuable adjunct. Striking recovery of LV function can also occur in several days. The combination of ECMO and TH was associated with excellent neurologic outcomes as well. ECMO may have a role in selected PCI centers with advanced specialized teams.
Journal of the American College of Cardiology, 2012
Background: Therapeutic hypothermia (TH) is neuroprotective and increases survival in cardiac arr... more Background: Therapeutic hypothermia (TH) is neuroprotective and increases survival in cardiac arrest survivors. Cardiac arrest is often seen in the setting of ST-elevation myocardial infarction (STEMI), and cardiogenic shock (CS) is a known poor prognostic factor. Methods: From Feb 2006 to July 2011, 252 consecutive cardiac arrest patients who remained comatose following return of spontaneous circulation were enrolled in a TH protocol, integrated into a regional STEMI transfer network. Patients were treated regardless of past medical history, initial rhythm or hemodynamic status. The aim of this study was to determine if there were any predictors of CS in this population and their effect on morbidity and mortality. Results: Of the 252 patients, 92 (36.5%) were in CS. Survival with favorable neurologic outcome (CPC 1 or 2) was poorer in CS patients than no CS patients, 33/92 (35.9%) vs 83/160 (51.9%), p=0.014. Patients in CS were older 65.5 vs 61.5 years p=0.02 and had a higher incidence of preexisting cardiomyopathy (CM) 41/92 (44.6%) vs 41/160 (25.6%) p=0.002 and concurrent STEMI 43/92 (46.7%) vs 44/160 (27.5%) p=0.002. Ischemic CM was the most common type 34/41 (83.0%). The odds ratio of CS in patients with pre-existing CM was OR=2.33 (1.36, 4.02). The odds ratio of CS in patients with concurrent STEMI was OR=2.31 (1.35, 3.96). There was no statistical difference in gender, initial rhythm, transfer distance, history of CAD, HTN, or CHF between patients in CS versus those without CS. There was a trend of lower survival with CPC 1/2 in pre-existing CM patients than those without 12/41 (29.3%) vs 21/51 (41.2%) p=0.24. There was a trend of higher survival with CPC 1/2 in patients in CS and concurrent STEMI than CS alone 19/43 (44.2%) vs 14/49 (28.6%) p=0.12. Conclusion: Pre-existing CM and concurrent STEMI are associated with higher incidence of CS. Prior CM is common among those with CS. CS has an unexpectedly favorable outcome with TH. TH should be the standard of care for unresponsive cardiac arrest patients in CS.
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Papers by Ivan Chavez