Biomedical subjects

David O Hodge

Publications and source records attributed to David O Hodge.

At least 19 recordsLinked to original sources

PubMed2007

Vasovagal syncope in patients with reduced left ventricular function.

Vasovagal syncope (VVS) is mediated by arterial mechanoreceptors, resulting in reflexive changes in heart rate and vascular tone. The Bezold-Jarisch reflex was originally described as enhanced contraction and activation of left ventricular mechanoreceptors, but later studies implicated other triggers, including coronary, carotid, and cerebral arterial mechanoreceptors. VVS is uncommon in patients with left ventricular dysfunction. We hypothesized that VVS could occur in this subset and examined patient characteristics and hemodynamic responses during tilt table testing. From 1996 through 1998, 128 consecutive patients with ejection fraction <40% underwent tilt table testing (70 degrees , 45 min). A total of 15 patients (11.7%) had a positive neurocardiogenic response thought to be the cause of syncope. Clinical data and hemodynamic responses were reviewed. Mean patient age (+/-SEM) was 70.1 +/- 12.2 years. Nine patients were male. Mean ejection fraction was 27.7% +/- 7.1%. Thirteen had electrophysiologic studies with normal findings or abnormal findings insufficient to account for syncope. Hemodynamic analysis of 14 patients who had a vasovagal response during passive tilt table testing showed a mean time to positive response of 17.6 +/- 12.7 min. Cardioinhibitory responses (pauses >3 sec or heart rate < 40 beats/min for > or =10 sec) were not observed. Five responses were classified as mixed type (>10% decrease in heart rate without a cardioinhibitory response) and 9 as vasodepressor type (< or =10% decrease in heart rate). VVS occurs in patients who have clinically significant left ventricular dysfunction. Although this study had a small cohort size, the predominantly vasodepressor response without a cardioinhibitory component warrants further investigation into mechanisms of VVS in these patients.

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PubMed2007

The risk of glaucoma in pseudoexfoliation syndrome.

PURPOSE: To determine the conversion rate of pseudoexfoliation syndrome (PEX) to pseudoexfoliative glaucoma or treated ocular hypertension. METHODS: Retrospective community-based study of newly diagnosed cases of PEX syndrome in all residents of Olmsted County, Minnesota between 1976 and 1991. The end point was considered the initiation of therapy, which included patients with glaucoma (optic disc damage or visual field defects), or with elevated intraocular pressure (IOP) >21 mm Hg in the presence of risk factors; the subsequent development of damage in the latter group was also determined. RESULTS: Two hundred fifty-five patients (318 eyes) had newly diagnosed PEX over the 15-year interval. Mean age was 73+/-10 years; 78% (199/255) were female. Of all PEX patients, 16% were placed on therapy at the time of initial diagnosis of PEX. In the remaining PEX patients, the probability of being placed on therapy was 44% at 15 years. Bilateral PEX was present in 25% at initial diagnosis and developed in another 29% by 15 years. Of those not placed on therapy, 16% (23/142) had IOP increase 5+ mm Hg during follow-up, with 11% (16/142) reaching 22 mm Hg or more. The strongest risk factors for converting to therapy were IOP at initial diagnosis of PEX and bilateral involvement. CONCLUSIONS: In a geographically defined population of PEX patients, 16% required treatment upon presentation. Of the remaining PEX patients, 44% received therapy over the next 15 years.

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PubMed2006

Early and late results of the modified fontan operation for heterotaxy syndrome 30 years of experience in 142 patients.

OBJECTIVES: We sought to evaluate the early and late results of the modified Fontan operation for patients with heterotaxy syndrome, assess variables traditionally known to correlate with poor outcome, and assess current health status of survivors after the Fontan procedure. BACKGROUND: The natural history of unoperated cardiac lesions in heterotaxy is known to be poor. Therefore, the Fontan operation has been proposed to improve survival. METHODS: Patients with heterotaxy were identified from the Mayo Clinic Fontan database. Hospital and outpatient records were abstracted for preoperative, operative, and postoperative clinical and hemodynamic data. All patients not known to be deceased were sent health status questionnaires. RESULTS: A total of 142 patients with heterotaxy syndrome had a modified Fontan operation. Asplenia was present in 76 patients (54%). Median age at operation was 9 years (range 2 to 35 years). Median follow-up was 4 years (range 0 to 23 years). There were a total of 61 deaths (43%), with 32 (23%) within 30 days of operation or before hospital discharge. The 5-, 10-, and 15-year survival was 64%, 57%, and 53%, respectively. In the modern era (1995 to 2004) early mortality was 10%. Of the 81 survivors, questionnaires were available from 41 (51%). Eighty percent reported having no or mild symptoms. However, 19 (46%) had arrhythmias, 5 (12%) had a thromboembolic event, and 1 (2%) developed protein-losing enteropathy. CONCLUSIONS: Early survival has improved for heterotaxy patients after the Fontan operation; however, late morbidity and mortality remain substantial. Better strategies for long-term treatment of this high-risk group need to be identified.

Adolescent↗

PubMed2006

Trends in prevalence and outcome of heart failure with preserved ejection fraction.

BACKGROUND: The prevalence of heart failure with preserved ejection fraction may be changing as a result of changes in population demographics and in the prevalence and treatment of risk factors for heart failure. Changes in the prevalence of heart failure with preserved ejection fraction may contribute to changes in the natural history of heart failure. We performed a study to define secular trends in the prevalence of heart failure with preserved ejection fraction among patients at a single institution over a 15-year period. METHODS: We studied all consecutive patients hospitalized with decompensated heart failure at Mayo Clinic Hospitals in Olmsted County, Minnesota, from 1987 through 2001. We classified patients as having either preserved or reduced ejection fraction. The patients were also classified as community patients (Olmsted County residents) or referral patients. Secular trends in the type of heart failure, associated cardiovascular disease, and survival were defined. RESULTS: A total of 6076 patients with heart failure were discharged over the 15-year period; data on ejection fraction were available for 4596 of these patients (76 percent). Of these, 53 percent had a reduced ejection fraction and 47 percent had a preserved ejection fraction. The proportion of patients with the diagnosis of heart failure with preserved ejection fraction increased over time and was significantly higher among community patients than among referral patients (55 percent vs. 45 percent). The prevalence rates of hypertension, atrial fibrillation, and diabetes among patients with heart failure increased significantly over time. Survival was slightly better among patients with preserved ejection fraction (adjusted hazard ratio for death, 0.96; P=0.01). Survival improved over time for those with reduced ejection fraction but not for those with preserved ejection fraction. CONCLUSIONS: The prevalence of heart failure with preserved ejection fraction increased over a 15-year period, while the rate of death from this disorder remained unchanged. These trends underscore the importance of this growing public health problem.

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PubMed2006

Corneal keratocyte deficits after photorefractive keratectomy and laser in situ keratomileusis.

PURPOSE: To measure changes in keratocyte density up to five years after photorefractive keratectomy (PRK) and laser in situ keratomileusis (LASIK). DESIGN: Prospective, nonrandomized clinical trial. METHODS: Eighteen eyes of 12 patients received PRK to correct a mean refractive error of -3.73 +/- 1.30 diopters, and 17 eyes of 11 patients received LASIK to correct a mean refractive error of -6.56 +/- 2.44 diopters. Corneas were examined by using confocal microscopy before and six months, one year, two years, three years, and five years after the procedures. Keratocyte densities were determined in five stromal layers in PRK patients and in six stromal layers in LASIK patients. Differences between preoperative and postoperative cell densities were compared by using paired t tests with Bonferroni correction for five comparisons. RESULTS: After PRK, keratocyte density in the anterior stroma decreased by 40%, 42%, 45%, and 47% at six months, two years, three years, and five years, respectively (P < .001). At five years, keratocyte density decreased by 20% to 24% in the posterior stroma (P < .05). After LASIK, keratocyte density in the stromal flap decreased by 22% at six months (P < .02) and 37% at five years (P < .001). Keratocyte density in the anterior retroablation zone decreased by 18% (P < .001) at one year and 42% (P < .001) at five years. At five years, keratocyte density decreased by 19% to 22% (P < .05) in the posterior stroma. CONCLUSIONS: Keratocyte density decreases for at least five years in the anterior stroma after PRK and in the stromal flap and the retroablation zone after LASIK.

Adult↗

PubMed2006

Relapse and mortality following cardioversion of new-onset vs. recurrent atrial fibrillation and atrial flutter in the elderly.

AIMS: Trials of rate control vs. rhythm control for atrial fibrillation or flutter included few patients with new-onset arrhythmia. Our objective was to assess the relapse rate and the effect of the relapse of new-onset atrial arrhythmias on mortality after direct-current cardioversion (DCCV). METHODS AND RESULTS: A cohort of 351 patients with atrial fibrillation (new onset in 179) and 126 patients with atrial flutter (new onset in 78) was followed-up after DCCV. Cox proportional hazard models were used. Median age was 74.6 years. Mean follow-up for relapse was 7.7 months; for death, 29.4 months. Patients with new-onset atrial flutter [adjusted hazard ratio (HR) = 1] were more likely to maintain sinus rhythm than the patients with recurrent atrial flutter (adjusted HR = 2.5, P < 0.01), new-onset atrial fibrillation (adjusted HR = 2.4, P < 0.01), or recurrent atrial fibrillation (adjusted HR = 2.7, P < 0.01). Patients with new-onset atrial fibrillation were as likely to have relapses as patients with recurrent atrial fibrillation or flutter. Relapse of atrial arrhythmia after DCCV was associated with increased mortality (adjusted HR= 3.1, P < 0.01). CONCLUSION: DCCV is more successful in maintaining sinus rhythm in patients with new-onset atrial flutter than in patients with new-onset atrial fibrillation. Relapse of atrial arrhythmia after cardioversion is associated with increased mortality.

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PubMed2006

Prognostic utility of single-photon emission computed tomography in adult patients with hypertrophic cardiomyopathy.

BACKGROUND: Data derived from stress myocardial perfusion imaging (MPI) carry prognostic significance in young patients with hypertrophic cardiomyopathy (HCM), but there are limited data on the utility of stress MPI in patients with HCM who are older. This study examined the prognostic significance of stress MPI in an adult population of patients with HCM. METHODS: We examined 158 patients with HCM (aged 60 +/- 16 years, 61% men) who underwent exercise or pharmacologic stress MPI. Summed stress score (SSS, normal = 56) and summed reversibility scores were calculated for each patient. Follow-up was complete in 157 (99%) patients at a median duration of 5.2 years. RESULTS: Normal single-photon emission computed tomography (SPECT) images were present in 38% of the population. Summed stress score (P = .01) and summed reversibility score (P = .03) were both significantly associated with cardiovascular death. Survival at 10 years was significantly better in those with normal versus abnormal SPECT (89% vs 67%, P = .04). Ten-year survival also was better in those without versus those with ischemia (90% vs 64%, P = .02). Five-year survival could be stratified by SSS risk categories: low risk (SSS > or = 53), 97%; intermediate risk (SSS = 48-52), 94%; and high risk (SSS < or = 47), 79% (P = .04). Bivariate models of SSS and other significant covariates supported an independent relation of SSS to cardiovascular death. CONCLUSIONS: In an older population of patients with HCM referred for SPECT imaging, abnormal stress MPI identifies those at increased risk of cardiovascular death.

Adolescent↗

PubMed2006

The value of stress single photon emission computed tomography in patients without known coronary artery disease presenting with dyspnea.

BACKGROUND: Dyspnea is a complex system with multiple etiologies, including myocardial ischemia ("anginal equivalent"). Few studies have examined the utility of stress testing to detect coronary artery disease in this setting. The purpose of this study was to examine the prevalence, severity, and prognostic value of perfusion defects detected by stress single photon emission computed tomography (SPECT) imaging in patients with dyspnea. METHODS: SPECT imaging was performed in 1864 patients (age 65.8 +/- 10.2 years, 52% male, 23% diabetic, 89% overweight/obese) without known coronary artery disease referred for evaluation of dyspnea. Dyspnea was rated mild, moderate, or severe. SPECT scans were categorized low, intermediate, or high risk. The associations of stress SPECT imaging results with clinical variables and mortality were analyzed. RESULTS: An abnormal perfusion SPECT image was present in 45% of patients and a high-risk scan in 11%. Male sex, diabetes, and clinical severity of dyspnea were the strongest predictors of both an abnormal and high-risk SPECT scan. A high-risk scan was present in 5% of nondiabetic women with mild dyspnea versus 22% of diabetic men with dyspnea of any severity. At 10 years, survival by SPECT scan category was low risk 75%, intermediate risk 68%, and high risk 53% (P < .001). CONCLUSIONS: In this population of older overweight patients referred for evaluation of dyspnea, there was a high prevalence of abnormal (45%) and high-risk (11%) SPECT scans. High-risk scans were associated with much worse 10-year survival.

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PubMed2006

Secular trends in renal dysfunction and outcomes in hospitalized heart failure patients.

BACKGROUND: Renal dysfunction and worsening renal function (WRF) during heart failure (HF) therapy predict outcomes. We determined whether the severity of renal dysfunction, the incidence of WRF or outcomes have changed over time (secular trends) in patients hospitalized for HF therapy. METHODS AND RESULTS: A total of 6440 consecutive unique patients admitted for HF to Mayo Clinic Hospitals Rochester, MN, January 1, 1987, to December 31, 2002, were identified and data extracted from electronic databases. Over the study period, age and admission creatinine increased, whereas estimated glomerular filtration rate and hemoglobin decreased (P < .0001 for all). The prevalence of hypertension and diabetes among HF patients also increased over time (P < .0001). The incidence of WRF was stable. Renal dysfunction and development of WRF were associated with mortality. When adjusted for the changes in baseline characteristics of HF patients, mortality declined over the study period. CONCLUSION: Hospitalized HF patients are increasingly elderly, have a greater prevalence of diseases that lead to renal dysfunction, and have more severe renal dysfunction and anemia on admission. However, adjusting for these secular trends in patient characteristics, mortality after HF admission is improving. These data enhance our understanding of the changing natural history of HF.

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PubMed2006

Frequency and determinants of early rapid filling abnormality.

BACKGROUND: The frequency and determinants of early rapid diastolic filling abnormalities in the community and in cardiac patients are poorly understood. METHODS AND RESULTS: Early left ventricular (LV) rapid filling was assessed via equilibrium radionuclide angiocardiography in 70 community volunteers (LV ejection fraction [EF] > or = 0.50) and 778 cardiac patients, all aged at least 45 years. The frequency of early rapid filling and the independent clinical, therapeutic, and hemodynamic variables predictive of early rapid filling abnormality were determined. Depending on the parameter assessed, early rapid filling was abnormal in 27% to 54% of the community volunteers, 34% to 53% of cardiac patients with an LVEF of 0.50 or greater, and 42% to 67% of cardiac patients with an LVEF lower than 0.50. On the basis of multivariate analysis, models of clinical, therapeutic, and hemodynamic variables were modestly predictive of early rapid filling abnormality. Age, sex, valvular insufficiency, hypertension, digoxin use, and heart rate were independent determinants of early rapid filling. CONCLUSIONS: In participants aged older than 44 years, early rapid filling was frequently abnormal in the community volunteers and in patients with an LVEF of 0.50 or greater and was most common in patients with an LVEF lower than 0.50. Clinical, therapeutic, and hemodynamic variables had modest independent predictive value for early rapid filling abnormality.

Age Distribution↗

PubMed2006

Differences in left ventricular ejection fraction and volumes measured at rest and poststress by gated sestamibi SPECT.

BACKGROUND: Some studies suggested that the poststress left ventricle ejection fraction (LV EF) is lower than rest LV EF in patients with stress-induced ischemia. METHODS AND RESULTS: By using a 2-day protocol and 30 mCi Tc-99m sestamibi, LV EF, end-systolic volume (ESV), and end-diastolic volume (EDV) were measured with gated SPECT. Of 99 eligible patients, 91 had technically adequate studies. Poststress LV EF minus rest LV EF was defined as DeltaLV EF. DeltaEDV and DeltaESV were similarly defined. Rest and poststress LV EF (r = 0.89), EDV (r = 0.78), and ESV (r = 0.93) were highly correlated (P <.001). Rest LV EF, EDV, and ESV were not significantly different between patients with and without stress-induced ischemia. DeltaLV EF was significantly lower in patients with stress-induced ischemia (-3.5% +/- 4.5% vs -1.1% +/- 4.7%, P = .02). Mean LV EF poststress in ischemic patients was 55.0% +/- 10.5% vs 61.2% +/- 10.0% in nonischemic patients (P = .008). However, only 1 patient (3%) with ischemia had DeltaLV EF that exceeded the 95% confidence limit of DeltaLV EF for normal patients. Ischemia was significantly associated with increased DeltaEDV and DeltaESV (P < .01). CONCLUSIONS: Stress-induced ischemia is associated with poststress reduction in LV EF and increased poststress EDV and ESV. However, the effect of ischemia on the difference between poststress and rest EF measurements is modest and rarely exceeds the confidence limits in normal patients undergoing 2-day protocols. In most patients, poststress LV EF is an accurate reflection of rest LV EF.

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PubMed2006

Changes in corneal thickness in patients with treated and untreated ocular hypertension.

PURPOSE: The elevated intraocular pressure (IOP) in eyes with ocular hypertension is often accompanied by increased corneal thickness. We tested the hypotheses that chronically elevated IOP causes a slow increase in corneal thickness and that lowering the IOP reverses this slow increase. METHODS: Fifty patients with ocular hypertension were randomized to medication and observation groups in the Mayo Clinic site of the Ocular Hypertension Treatment Study. Central corneal thickness was measured using an optical pachymeter at baseline and annually for 6 years. The rates of change of corneal thickness was compared between the groups. Epithelial thickness was measured by confocal microscopy 8 years after the baseline examination. RESULTS: Corneal thickness increased 1.5 +/- 3.3 microm/yr in the observation group (n = 23) and decreased -1.3 +/- 2.8 microm/yr in the medication group (n = 27, P = 0.002). Both rates were significantly different from zero (P = 0.04 and P = 0.02, respectively). Epithelial thickness was 46.4 +/- 4.9 microm in the observation group and 41.3 +/- 4.4 microm in the medication group (P = 0.008). CONCLUSION: Results of this single-center series imply that corneal thickness increases slowly in eyes with ocular hypertension and decreases slowly if the IOP is lowered by topical medications. These phenomena could be explained by a causal relationship between elevated IOP and a slow increase in corneal thickness. A decrease in epithelial thickness accounts for a portion of the thinning that occurs with treatment. If confirmed in a larger series, these findings indicate that the effects of previous treatment on thickness should be considered if corneal thickness is to be used as a discriminant factor in the management of patients with ocular hypertension.

Antihypertensive Agents↗

PubMed2006

Effects of glaucoma medications on corneal endothelium, keratocytes, and subbasal nerves among participants in the ocular hypertension treatment study.

PURPOSE: To compare subbasal corneal nerve and keratocyte density and endothelial characteristics of ocular hypertensive patients treated with medications or observation. METHODS: Participants in the Ocular Hypertensive Treatment Study (OHTS) randomized at Mayo Clinic to medication or observation were evaluated with specular microscopy annually for 6 years. Confocal microscopy was performed 78 to 108 months after enrollment. Subbasal nerve density was calculated by manual tracing and digital image analysis. Keratocyte density was determined by manual counting methods. Data were compared using a t test and a rank sum test. RESULTS: After 6 years, corneal endothelial cell density, percent hexagonal cells, and coefficient of variation of cell area for the observation (n = 21) and medication groups (n = 26) were similar (2415 +/- 300 vs. 2331 +/- 239 cells/mm; 63% +/- 11% vs. 65% +/- 10%; and 0.32 +/- 0.07 vs. 0.30 +/- 0.06, respectively). Of 38 participants undergoing confocal examination, the medication group (n = 19) had fewer nerves (3.8 +/- 2.1 vs. 5.9 +/- 2.0 nerves/frame; P = 0.02) and a lower nerve density (5643 +/- 2861 vs. 9314 +/- 3743 mum/mm; P = 0.007) than the observation patients (n = 10). An additional 9 patients in the observation group, who began medication before confocal scanning, had intermediate nerve densities. Full-thickness keratocyte density was similar, with 22,257 +/- 2419 and 23,430 +/- 3285 cell/mm in the observation and medication groups, respectively. CONCLUSIONS: Chronic administration of glaucoma medications causes a decrease in the number and density of corneal subbasal nerve fiber bundles but does not affect keratocyte density or corneal endothelial characteristics.

Antihypertensive Agents↗

PubMed2006

Reproducibility of measurements of regional myocardial blood flow in a model of coronary artery disease: Comparison of H215O and 13NH3 PET techniques.

UNLABELLED: PET absolute myocardial blood flow (MBF) with H(2)15O and 13NH3 are widely used in clinical and research settings. However, their reproducibility with a 16-myocardial segment model has not been examined in chronic coronary artery disease (CAD). We examined the short-term reproducibility of PET H(2)15O MBF and PET 13NH3 MBF in an animal model of chronic CAD. METHODS: Twelve swine (mean weight +/- SD, 38 +/- 5 kg) underwent percutaneous placement of a copper stent in the mid circumflex coronary artery, resulting in an intense inflammatory fibrotic reaction with luminal stenosis at 4 wk. Each animal underwent repeated resting MBF measurements by PET H(2)15O and PET 13NH3. Attenuation-corrected images were analyzed using commercial software to yield absolute MBF (mL/min/g) in 16 myocardial segments. MBF was also normalized to the rate.pressure product (RPP). RESULTS: By Bland-Altman reproducibility plots, the mean difference was 0.01 +/- 0.18 mL/min/g and 0.01 +/- 0.11 mL/min/g, with confidence limits of +/-0.36 and +/-0.22 mL/min/g for uncorrected regional PET H(2)15O MBF and for uncorrected regional PET 13NH3 MBF, respectively. The repeatability coefficient ranged from 0.09 to 0.43 mL/min/g for H(2)15O and from 0.09 to 0.18 mL/min/g for 13NH3 regional MBF. RPP correction did not improve reproducibility for either PET H(2)15O or PET 13NH3 MBF. The mean difference in PET H(2)15O MBF was 0.03 +/- 0.14 mL/min/g and 0.02 +/- 0.19 mL/min/g for infarcted and remote regions, respectively, and in PET 13NH3 MBF was 0.03 +/- 0.11 mL/min/g and 0.00 +/- 0.09 mL/min/g for infarcted and remote regions, respectively. CONCLUSION: PET H(2)15O and PET 13NH3 resting MBF showed excellent reproducibility in a closed-chest animal model of chronic CAD. Resting PET 13NH3 MBF was more reproducible than resting PET H(2)15O MBF. A high level of reproducibility was maintained in areas of lower flow with infarction for both isotopes.

Animals↗

PubMed2005

Effect of atrial fibrillation pattern on survival in a community-based cohort.

The clinical presentation of recurrent atrial fibrillation (AF) has been categorized into 3 general patterns: paroxysmal, persistent, and permanent AF. This community-based cohort study characterized the effect of the AF pattern on survival. Community residents in Olmsted County, Minnesota, with electrocardiographically proven new-onset AF during 1996 and 1997 were retrospectively identified and prospectively followed. Observed survival was estimated using the Kaplan-Meier method and compared with the expected survival. Log-rank tests were used for group comparisons. The association between the baseline variables and mortality was assessed using Cox proportional hazards models. Of 270 patients (mean +/- SD age 73 +/- 14 years; 148 men [55%]), 143 had paroxysmal AF, 40 had persistent AF, and 87 had permanent AF. The cohort's observed survival was significantly worse than expected (p <0.001). The factors associated with increased mortality included older age, concomitant heart failure, and concomitant chronic obstructive pulmonary disease (all p <0.001). Permanent AF was associated with higher mortality than paroxysmal AF (hazard ratio 1.6, 95% confidence interval 1.1 to 2.3). Persistent AF was associated with better survival (hazard ratio 0.3, 95% confidence interval 0.1 to 0.8). In conclusion, survival among patients with persistent AF was significantly better than that among patients with paroxysmal AF or permanent AF. The ability to maintain sinus rhythm may be associated with better survival.

Age Factors↗

PubMed2005

Improved survival in asymptomatic diabetic patients with high-risk SPECT imaging treated with coronary artery bypass grafting.

BACKGROUND: The Bypass Angioplasty Revascularization Investigation trial demonstrated that symptomatic diabetics with multivessel coronary artery disease had a survival advantage with initial coronary artery bypass grafting (CABG) versus percutaneous coronary intervention (PCI). No published study has examined different treatments and outcome in asymptomatic diabetics. METHODS AND RESULTS: This study group consisted of 826 asymptomatic diabetics (age 62+/-12 years; 76% men) without known coronary artery disease who had abnormal myocardial perfusion during stress single photon emission computed tomography (SPECT). SPECT images were classified as low-, intermediate-, and high-risk. Early revascularization (CABG or PCI < or =4 months after SPECT) was performed in 76 patients. Survival (follow-up, 5.3+/-3.3 years) was compared in patients treated with CABG, PCI, or medical therapy. Revascularization (CABG or PCI) was performed in 54 of 261 patients with high-risk scans and was independently associated with improved survival (chi2=4.55; P=0.03 after multivariate adjustment). Subset analysis demonstrated that the survival advantage was confined to patients treated with CABG (n=39), with a 5-year survival CABG at 85%, PCI at 72%, and medical therapy at 67% (P=0.02 for 3 groups). Although CABG was associated with better survival, mortality remained high (3% per year). There was no survival advantage by treatment for patients with less-severe SPECT abnormalities. CONCLUSIONS: These nonrandomized data suggest that CABG improves survival in asymptomatic diabetic patients with high-risk SPECT, although revascularization was performed infrequently in these patients. These results parallel those of the Bypass Angioplasty Revascularization Investigation trial in symptomatic diabetic patients.

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PubMed2005

Long-term results of the Fontan operation for double-inlet left ventricle.

The purpose of this study was to quantify and determine predictors of long-term survival and functional outcome in patients with double-inlet left ventricle (DILV) after the Fontan operation. The Fontan operation has become the procedure of choice for DILV. Early survival has improved, but mortality and morbidity persist. Record review and follow-up questionnaires were used to ascertain the status of 225 patients with DILV who had Fontan operations from 1974 to 2001 at the Mayo Clinic. The median age at operation was 9 years. The median follow-up period was 12 years (range 3 months to 25 years). There were 22 deaths (9.3%) <30 days after the operation. Early mortality decreased to 3% (2 of 70 patients) after 1989. Overall late survival was 78% (159 of 203 patients). Actuarial survival for the 203 early operative survivors at 5, 10, 15, and 20 years was 91%, 80%, 73%, and 69%, respectively. Forty-nine percent (99 of 203) had additional surgical procedures after the Fontan operation. Other frequent late events were atrial flutter or fibrillation (57%), protein-losing enteropathy (9%), and thromboembolic events (6%). Current health status was described as good or excellent by 84% of patients, fair by 18%, and poor by 12%. In conclusion, the Fontan operation for DILV is now performed with a low operative mortality rate. Long-term survival has improved, and most patients have good functional status.

Adolescent↗

PubMed2005

Exercise single-photon emission computed tomography provides effective risk stratification of elderly men and elderly women.

BACKGROUND: In a recent study, we reported that the Duke treadmill score was unable to effectively stratify elderly patients according to risk. The purpose of this study was to evaluate the prognostic value of exercise single-photon emission computed tomography (SPECT) in this same population and to examine results by gender. METHODS AND RESULTS: A cohort of 247 elderly (age > or =75 years) patients (108 women, 139 men, age 77+/-3 years) who underwent exercise thallium-201 SPECT were followed up for a median duration of 6.4 years. SPECT variables were significantly associated with cardiac death: summed stress score (SSS) chi2=19.5, P<0.001; summed difference score chi2=12.3, P<0.001; increased lung uptake chi2=9.6, P=0.002; and left ventricular enlargement chi2=8.3, P=0.004. The Duke score was not significantly associated with cardiac death (chi2<1, P=NS). The SSS classified most patients as low risk (49%) or high risk (35%); the Duke score classified the majority (68%) as intermediate risk. Annual cardiac mortality rates for patients categorized by SSS as low risk and high risk were 0.8% and 5.8%, respectively. Cardiac survival rates according to SSS risk categories were significantly different for both women (P=0.012) and men (P=0.003). CONCLUSIONS: SPECT classified most elderly patients into clinically useful low- and high-risk categories and accurately predicted outcomes in both genders. If these results can be validated in future studies, exercise SPECT rather than standard treadmill testing may emerge as the initial noninvasive testing strategy in elderly patients who are able to exercise.

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