Duration of resuscitation efforts for in-hospital cardiac arrest by predicted outcomes: Insights from Get With The Guidelines - Resuscitation

BACKGROUND

The duration of resuscitation efforts has implications for patient survival of in-hospital cardiac arrest (IHCA). It is unknown if patients with better predicted survival of IHCA receive longer attempts at resuscitation.

METHODS

In a multicenter observational cohort of 40,563 adult non-survivors of resuscitation efforts for IHCA between 2000 and 2012, we determined the pre-arrest predicted probability of survival to discharge with good neurologic status, categorized into very low (<1%), low (1-3%), average (>3%-15%), and above average (>15%). We then determined the association between predicted arrest survival probability and the duration of resuscitation efforts.

RESULTS

The median duration of resuscitation efforts among all non-survivors was 19min (interquartile range 13-28min). Overall, the median duration of resuscitation efforts was longer in non-survivors with a higher predicted probability of survival with good neurologic status (median of 16, 17, 20, and 23min among the groups predicted to have very low, low, average, and above probabilities, respectively; P<0.001). However, the duration of resuscitation was often discordant with predicted survival, including longer than median duration of resuscitation efforts in 40.4% of patients with very low predicted survival and shorter than median duration of resuscitation efforts in 31.9% of patients with above average predicted survival.

CONCLUSIONS

The duration of resuscitation efforts in patients with IHCA was generally consistent with their predicted survival. However, nearly a third of patients with above average predicted outcomes received shorter than average (less than 19min) duration of resuscitation efforts.

Pre-operative echocardiography among patients with coronary artery disease in the United States Veterans Affairs healthcare system: A retrospective cohort study

Background

Echocardiography is not recommended for routine pre-surgical evaluation but may have value for patients at high risk of major adverse cardiovascular events (MACE). The objective of this study was to evaluate whether pre-operative echocardiography is associated with lower risk of post-operative MACE among patients with coronary artery disease.

Methods

Using administrative and registry data, we examined associations of echocardiography within 3 months prior to surgery with postoperative MACE (myocardial infarction, revascularization, or death within 30 days) among patients with coronary artery disease undergoing elective, non-cardiac surgeries in the United States Veterans Affairs healthcare system in 2000–2012.

Results

Echocardiography preceded 4,378 (16.4 %) of 26,641 surgeries. MACE occurred within 30 days following 944 (3.5 %) surgeries. A 10 % higher case-mix adjusted rate of pre-operative echocardiography assessed at the hospital level was associated with a hospital-level risk of MACE that was 1.0 % (95 % confidence interval [CI] 0.1 %, 2.0 %) higher overall and 1.7 % (95 % CI 0.2 %, 3.2 %) higher among patients with recent myocardial infarction, valvular heart disease, or heart failure. At the patient level, pre-operative echocardiography was associated with an odds ratio for MACE of 1.9 (95 % CI 1.7, 2.2) overall and 1.8 (95 % CI 1.5, 2.2) among patients with recent myocardial infarction, valvular heart disease, or heart failure adjusting for MACE risk factors.

Conclusions

Pre-operative echocardiography was not associated with lower risk of post-operative MACE, even in a high risk population. Future guidelines should encourage pre-operative echocardiography only in specific patients with cardiovascular disease among whom findings can be translated into effective changes in care.

Electronic supplementary material

The online version of this article (doi:10.1186/s12872-016-0357-5) contains supplementary material, which is available to authorized users.

Guideline Recommended Medical Therapy for Cardiovascular Diseases in the Obese: Insights From the Veterans Affairs Clinical Assessment, Reporting, and Tracking (CART) Program

BACKGROUND

Stigma against the obese is well described in health care and may contribute to disparities in medical decision-making. It is unknown whether similar disparity exists for obese patients in cardiovascular care. We evaluated the association between body mass index (BMI) and prescription of guideline-recommended medications in patients undergoing elective percutaneous coronary intervention.

METHODS AND RESULTS

Using data from the Veterans Affairs Clinical Assessment, Reporting, and Tracking System Program, we identified patients undergoing elective percutaneous coronary intervention from 2007 to 2012, stratifying them by category of BMI. We described rates of prescription for class I guideline recommended medications for each BMI category (normal, overweight, and obese). Multivariable logistic regression assessed the association between BMI category and medication prescription. Seventeen thousand thirty-seven patients were identified, with 35.3% having overweight BMI, and 50.8% obese BMI. Obese patients were more likely than normal BMI patients to be prescribed β-blockers (OR 1.34), statins (OR 1.39), or ACE/ARB (odds ratio [OR] 1.52; all significant) when indicated. Overweight patients were more likely than normal BMI patients to be prescribed statins (OR 1.29) and angiotensin-converting enzymes/angiotensin II receptor blockers (OR 1.41) when indicated. There was no association between BMI category and prescription of anticoagulants.

CONCLUSIONS

Over 85% of patients undergoing elective percutaneous coronary intervention in the Veterans Affairs are overweight or obese. Rates of guideline-indicated medication prescription were <70% among all patients, and across BMI categories, with an association between increased BMI and greater use of guideline-recommended medications. Our findings offer a possible contribution to the obesity paradox seen in many cardiovascular conditions.

Abstract 322: Duration of Resuscitation Efforts for In-Hospital Cardiac Arrest by Predicted Survival Outcomes: Insights from Get With The Guidelines - Resuscitation

Background. The duration of cardiopulmonary resuscitation has implications for patient survival of in-hospital cardiac arrest (IHCA). However, the duration of resuscitation efforts should be balanced against the probability of patient survival. It is unknown whether the duration of attempted resuscitation for IHCA is associated with the predicted probability of patient survival.

Methods. We identified 40,563 non-survivors of resuscitation efforts for IHCA within the Get With The Guidelines [[Unable to Display Character: &#8211;]] Resuscitation Registry between 2000 and 2012. In these patients, we determined the pre-arrest predicted probability of survival to discharge with good neurologic status using the previously validated GO-FAR score. Using this tool, predicted survival was categorized into very low (<1%), low (1-3%), average (>3% to 15%), and above average (>15%). Duration of resuscitation efforts were measured in minutes from the onset of cardiac arrest to termination of resuscitation efforts. We then compared the duration of resuscitation efforts by predicted survival categories.

Results. Among 40,563 non-survivors of IHCA, the predicted survival to discharge was very low in 4801 (11.8%) patients, low in 8889 (21.9%), average in 19910 (49.1%) patients, and above average in 6963 (17.2%) patients. The median duration of attempted resuscitation was 19 minutes and the duration of attempted resuscitation was longer in non-survivors with a higher predicted probability of survival (median duration in minutes from very low to above average categories of predicted survival, 16 vs 17 vs 20 vs 23, P<.001). However, the duration of attempted resuscitation was often discordant with predicted survival (Figure), including shorter than median duration of attempted resuscitation in 31.9% of patients with above average predicted survival.

Conclusions. In a national cohort of non-survivors of IHCA, the duration of attempted resuscitation correlated overall with predicted arrest survival. However, nearly a third of patients with above average predicted survival received shorter than average attempted resuscitation efforts. Emphasis on an adequate duration of attempted resuscitation, particularly among patients with better than average predicted outcomes, may have implications for improving in-hospital cardiac arrest outcomes.

Abstract 384: Monitoring of Preoperative Anticoagulation Status in Post-PCI Patients on Warfarin Undergoing Non-Cardiac Surgery: Risk of Major Adverse Cardiac Events and Transfusion

Background: There is limited data on an optimal approach to preoperative INR screening in patients prescribed warfarin, with current guidelines lacking definitive recommendations on timing or need of INR assessment. Outcomes for these patients are largely unknown. Accordingly, we describe rates of pre-operative INR testing rates and its association with postoperative major adverse cardiac events (MACE) and transfusions among post-PCI patients on warfarin undergoing non-cardiac surgery (NCS).

Methods: We identified all post-PCI VA patients undergoing NCS from 2004-2011 who were prescribed warfarin. Among these, we assessed rates and results of INR assessment (>1.5, ≤ 1.5, or unknown) within 5 days of NCS. We measured the association of INR status with 30d MACE and post-operative RBC transfusions, using multivariable regression analysis to adjust for cardiovascular and operative risk factors. We also adjusted for the use of perioperative bridging therapy with heparin products.

Results: Among 1,357 post-PCI patients on warfarin undergoing NCS, 534 (39.3%) had an INR drawn within 5 days of surgery. INR was high (>1.5) in 166 (31.1%) and low (≤ 1.5) in 368 (68.9%). Unadjusted MACE rates were similar between those without an INR (5.3%), with a low INR (8.2%), and with a high INR (6.0%) (p-value = 0.17). PRBC transfusion was higher in those with a high INR (17.5%) compared to low (12.5%) or no INR (9.5%) (p-value=0.008). After adjustment, MACE was significantly associated with ESRD, prior MI, use of bridging therapy, and inpatient surgery status, but not INR status (Table). PRBC transfusion was associated with a high INR (OR 3.95, CI 1.91-8.17) and use of bridging therapy with heparin (OR 1.81, CI 1.07-3.05).

Conclusions: Strategies for monitoring and managing cardiac patients on warfarin are heterogeneous in the pre-operative period, with nearly half of patients undergoing NCS without pre-operative INR evaluation. The presence of a high INR value predicted pRBC transfusion, but not MACE. Our study suggests a role for pre-operative screening of INR in patients on warfarin to assess risk for post-operative bleeding.

Abstract 284: Association of Pre-Operative INR Evaluation with Risk of Major Adverse Cardiac Events and Bleeding Complications in Cardiac Patients Undergoing Non-Cardiac Surgery

Background: Routine laboratory testing is common in pre-operative patients, independent of specific clinical indication. One example is routine INR checks in patients without prior anticoagulant use. However, its efficacy in detecting significant coagulopathy and reducing adverse outcomes is unknown. We describe the frequency of pre-operative INR testing in a cohort of post-PCI patients not on anticoagulation undergoing non-cardiac surgery (NCS) within the VA system, and associated adverse events.

Methods: We identified all post-PCI VA patients not prescribed warfarin undergoing NCS from 2004-2011 and determined the rates of INR assessment within 120 hours (5d) of surgery. We then measured the association of INR status (>1.5, ≤ 1.5, and unknown) with MACE within 30d and in-hospital bleeding events. We also conducted a secondary analysis excluding patients undergoing “low risk” operations, defined as eye, ear, or integumentary surgeries.

Results: Among 20,118 post-PCI patients undergoing NCS who were not on warfarin, 3,678 (18.3%) had a pre-operative INR check. Of those, 108 (0.5%) had INR > 1.5. Patients with INR > 1.5 were more likely to suffer MACE events than those with INR assessed but ≤ 1.5, or unknowns (16.7% vs. 5.5% vs. 3.4%, p<0.001). They were also more likely to have bleeding events (18.5% vs. 9.8% vs. 4.9%, p<0.0001). After excluding patients undergoing low-risk surgeries (n=5,739), these trends remained significant.

Conclusions: Among post-PCI patients not on warfarin undergoing NCS, nearly one-fifth had an INR checked pre-operatively. Both the presence of an INR test and an INR value >1.5 were associated with higher risks for both MACE and bleeding events, as compared to those patients without INR assessment. Our study shows that pre-operative INR testing in patients not on anticoagulants is relatively uncommon, and that testing, when it does occur, appears to be associated with higher rates of MACE and bleeding. Further research is needed to understand which patients without prior anticoagulation would benefit from pre-operative INR checks.

Abstract 183: Optimal Medical Therapy for Cardiovascular Disease in the Obese Undergoing Elective Percutaneous Coronary Intervention: Insights from the VA CART Program

Background: Stigma against obese patients is well described in primary care settings and may contribute to bias in therapeutic decision-making. It is unknown if similar stigma exists in obese patients referred for elective PCI. Accordingly, we evaluated the association between body mass index (BMI) and pre-procedural guideline-recommended medication use in patients undergoing elective PCI. The presence of lower medication use in overweight and obese patients may suggest the presence of a treatment bias.

Methods: Using data from the VA Clinical Assessment, Reporting, and Tracking System (CART) Program, we identified patients undergoing elective PCI from 2007-2012. We classified patients by BMI into normal (19-25), overweight (25-30), obese (>30). Rates of guideline-indicated medication use by BMI were assessed among eligible patients: beta-blockers (BB) for HF or prior MI, statins for CAD or equivalent (DM, CVD, PAD), anticoagulation for AFib and CHADS2> 1, and ACEI/ARB for HF. We also assessed composite rates of BB and statin in eligible MI patients and BB and ACEI/ARB use in eligible HF patients, respectively. Multivariable logistic regression analyses assessed the association between BMI class and use of indicated medications.

Results: Among 9,630 patients undergoing elective PCI from 2007-2012, 13.9% of patients had normal BMI, 35.6% overweight, and 50.6% obese. Overweight and obese patients were more likely to have sleep apnea, HTN and DM, while normal BMI patients were more likely to smoke, have lung disease, and CVD. Rates of medication use ranged from 45% to 69% depending on the class of medication assessed. After adjustment for CV risk factors, overweight and obese patients were more likely to receive statins and ACE/ARBs and equally likely to receive the other classes of medications compared to normal BMI patients (Table).

Conclusions: Over 85% of patients undergoing elective PCI in the VA are overweight or obese. Rates of indicated medication use remained low across BMI categories (<70%). There was an association between overweight and obese patients with greater use of some guideline-indicated medications, suggesting that a treatment bias against obesity prior to elective PCI does not exist. Future studies should assess for any impact of BMI on treatment of patients during and following elective PCI.

Impact of pre-procedural beta blockade on inpatient mortality in patients undergoing primary percutaneous coronary intervention for ST elevation myocardial infarction

Early use of β blockers (BBs) in acute myocardial infarction remains controversial, with some studies demonstrating benefit and others harm. The aim of this study was to assess the association between pre-percutaneous coronary intervention (PCI) BB use and in-hospital outcomes in patients who underwent primary PCI for ST-segment elevation myocardial infarction between 2007 and 2009 at institutions participating in the Blue Cross Blue Shield of Michigan Cardiovascular Consortium (BMC-2). Inverse propensity score weighting was used to account for the nonrandomized use of pre-PCI BBs. The cohort comprised 7,667 patients, with 4,769 (62%) receiving pre-PCI BBs. These patients were older, with higher rates of diabetes mellitus, hypertension, and previous myocardial infarction, PCI, or coronary artery bypass grafting. In adjusted models, pre-PCI BB use was associated with lower rates of intraprocedural ventricular tachycardia or ventricular fibrillation (odds ratio [OR] 0.58, p <0.01) and lower in-hospital mortality (OR 0.65, p = 0.022), with increases in rates of emergent coronary artery bypass grafting (OR 1.56, p <0.01) and repeat PCI (OR 1.93, p <0.01). There were no significant increases in rates of cardiogenic shock and congestive heart failure. In conclusion, pre-PCI BB use in this population was associated with decreased arrhythmia and mortality, without increasing rates of cardiogenic shock and heart failure but with higher rates of repeat PCI and emergent coronary artery bypass grafting, suggesting that there may yet remain a role for early BB use in pre-PCI patients with ST-segment elevation myocardial infarctions.

Abstract 352: A Multimodal Radiation Reduction Intervention for Intra-procedural Radiation Exposure in Patients Undergoing Cardiac Catheterization in Veterans Affairs Hospitals

Background: Radiation exposure to patients from invasive cardiac procedures is substantial and contributes to a significant portion of overall radiation exposure from medical testing. Efforts to minimize intra-procedural radiation exposure are important for patient safety. This pilot study evaluated the effectiveness of a multimodal radiation intervention to reduce intra-procedural radiation exposure.

Methods: Two VA cardiac catheterization laboratories (Site 1, Site 2) were evaluated for baseline radiation dosing use over a three month period. Following this initial run-in period, the operators and cath lab staff underwent a three-tiered intervention: 1) radiation safety and minimization education, 2) an in-lab radiation monitoring protocol with verbal feedback at pre-specified radiation doses and 3) monthly site and provider-specific report cards comparing radiation dose at the site and provider level within the VA system. Radiation dosing (RD, measured as Dose-Area-Product [Gy*cm2]) was then measured following this intervention at monthly intervals over a three-month period.

Results: We examined 624 cases at Site 1 and 258 cases at Site 2 in the pre-intervention period, and 502 (site 1) and 208 (site 2) in the post-intervention period. Site 1 did not differ significantly in median RD following intervention (71.9 Gy*cm2 [IQR 48.0-114.0] pre-intervention versus 79.5 Gy*cm2 [IQR 50.0-124.8] post-intervention, p=0.34; see Fig 1). Site 2 showed a significant decrease in median radiation dose following intervention (118.72 Gy*cm2 [IQR 73.6-190.0] vs. 92.8 Gy*cm2 [IQR 56.6-158.3], p = 0.004, Fig 1). The national median radiation dose over the same time interval did not change significantly (91.53 Gy*cm2 [IQR 58.0-145.4] pre-intervention versus 90.0 Gy*cm2 [IQR 56.3-142.0] post-intervention, p=0.47, Fig 1).

Conclusion: A three-tiered, multi-modal radiation reduction intervention was associated with reduced radiation exposure in a laboratory with high baseline radiation utilization. Similar reductions were not observed in a laboratory with low baseline radiation utilization. These findings suggest that radiation reduction interventions targeted at higher radiation use centers may result in meaningful decreases in patient radiation exposure.

Are changes in carotid intima-media thickness related to risk of nonfatal myocardial infarction? A critical review and meta-regression analysis

BACKGROUND

Carotid intima-media thickness (CIMT) is increasingly being used as a surrogate end point in randomized control trials (RCTs) of novel cardiovascular therapies. However, it remains unclear whether changes in CIMT that result from these therapies correlate with nonfatal myocardial infarction (MI).

METHODS

We performed a literature search of RCTs from 1990-2009 that used CIMT. Eligible RCTs (1) included quantitative and sequential assessments in CIMT at least 1 year apart and (2) reported nonfatal MI. Across RCTs, random-effects metaregression was employed to correlate differences in mean change in CIMT between treatment and control groups over time with the log odds ratios of developing nonfatal MI during follow-up.

RESULTS

Overall, we identified 28 RCTs with 15,598 patients. Differences in mean change in CIMT over time between treatment and control groups correlated with developing nonfatal MI during follow-up: for each 0.01 mm per year smaller rate of change in CIMT, the odds ratio for MI was 0.82 (95% CI, 0.69 to 0.96; P = .018). Results were similar in subgroups of RCTs with >1 year follow-up (P = .018) and those with at least 50 subjects in the treatment group (P = .019). However, there was no significant relationship between mean change in CIMT and nonfatal MI in RCTs evaluating statin therapy or those with high CIMTs at baseline (P > .20 in both instances).

CONCLUSIONS

Less progression in CIMT over time is associated with a lower likelihood of nonfatal MI in selected RCTs; however, these findings were inconsistent at times, suggesting caution in using CIMT as a surrogate end point.

An ecological risk assessment of the acute and chronic effects of the herbicide clopyralid to rainbow trout (Oncorhynchus mykiss)

Clopyralid (3,6-dichloro-2-pyridinecarboxylic acid) is a pyridine herbicide frequently used to control invasive, noxious weeds in the northwestern United States. Clopyralid exhibits low acute toxicity to fish, including the rainbow trout (Oncorhynchus mykiss) and the threatened bull trout (Salvelinus confluentus). However, there are no published chronic toxicity data for clopyralid and fish that can be used in ecological risk assessments. We conducted 30-day chronic toxicity studies with juvenile rainbow trout exposed to the acid form of clopyralid. The 30-day maximum acceptable toxicant concentration (MATC) for growth, calculated as the geometric mean of the no observable effect concentration (68 mg/L) and the lowest observable effect concentration (136 mg/L), was 96 mg/L. No mortality was measured at the highest chronic concentration tested (273 mg/L). The acute:chronic ratio, calculated by dividing the previously published 96-h acutely lethal concentration (96-h ALC(50); 700 mg/L) by the MATC was 7.3. Toxicity values were compared to a four-tiered exposure assessment profile assuming an application rate of 1.12 kg/ha. The Tier 1 exposure estimation, based on direct overspray of a 2-m deep pond, was 0.055 mg/L. The Tier 2 maximum exposure estimate, based on the Generic Exposure Estimate Concentration model (GEENEC), was 0.057 mg/L. The Tier 3 maximum exposure estimate, based on previously published results of the Groundwater Loading Effects of Agricultural Management Systems model (GLEAMS), was 0.073 mg/L. The Tier 4 exposure estimate, based on published edge-of-field monitoring data, was estimated at 0.008 mg/L. Comparison of toxicity data to estimated environmental concentrations of clopyralid indicates that the safety factor for rainbow trout exposed to clopyralid at labeled use rates exceeds 1000. Therefore, the herbicide presents little to no risk to rainbow trout or other salmonids such as the threatened bull trout.

An ecological risk assessment of the exposure and effects of 2,4-D acid to rainbow trout (Onchorhyncus mykiss)

Numerous state and federal agencies are increasingly concerned with the rapid expansion of invasive, noxious weeds across the United States. Herbicides are frequently applied as weed control measures in forest and rangeland ecosystems that frequently overlap with critical habitats of threatened and endangered fish species. However, there is little published chronic toxicity data for herbicides and fish that can be used to assess ecological risk of herbicides in aquatic environments. We conducted 96-h flowthrough acute and 30-day chronic toxicity studies with swim-up larvae and juvenile rainbow trout (Onchorhyncus mykiss) exposed to the free acid form of 2,4-D. Juvenile rainbow trout were acutely sensitive to 2,4-D acid equivalent at 494 mg/L (95% confidence interval [CI] 334-668 mg/L; 96-h ALC(50)). Accelerated life-testing procedures, used to estimate chronic mortality from acute data, predicted that a 30-day exposure of juvenile rainbow trout to 2,4-D would result in 1% and 10% mortality at 260 and 343 mg/L, respectively. Swim-up larvae were chronically more sensitive than juveniles using growth as the measurement end point. The 30-day lowest observable effect concentration (LOEC) of 2,4-D on growth of swim-up larvae was 108 mg/L, whereas the 30-day no observable effect concentration (NOEC) was 54 mg/L. The 30-day maximum acceptable toxicant concentration (MATC) of 2,4-D for rainbow trout, determined as the geometric mean of the NOEC and the LOEC, was 76 mg/L. The acute:chronic ratio was 6.5 (i.e., 494/76). We observed no chronic effects on growth of juvenile rainbow trout at the highest concentration tested (108 mg/L). Worst-case aquatic exposures to 2,4-D (4 mg/L) occur when the herbicide is directly applied to aquatic ecosystems for aquatic weed control and resulted in a 30-day safety factor of 19 based on the MATC for growth (i.e., 76/4). Highest nontarget aquatic exposures to 2,4-D applied following terrestrial use is calculated at 0.136 mg/L and resulted in a 30-day safety factor of 559 (e.g., 76/0.163). Assessment of the exposure and response data presented herein indicates that use of 2,4-D acid for invasive weed control in aquatic and terrestrial habitats poses no substantial risk to growth or survival of rainbow trout or other salmonids, including the threatened bull trout (Salvelinus confluentus).

Risk Factors for Mortality in Patients With Cardiac Device-Related Infection

Background— Because of the increased use of pacemakers and implantable cardioverter defibrillators, infection has become a complication with significant morbidity and mortality. Data on risk factors for mortality in patients with cardiac-device related infection are limited. We evaluated the prognostic significance of key clinical and echocardiographic variables in a large retrospective population of patients with cardiac-device related infection.

Methods and Results— Two hundred ten patients with cardiac-device related infection were identified at the University of Michigan between 1995 and 2006. Data were abstracted on key clinical and echocardiographic variables, treatment strategy, and 6-month outcomes. We used multivariable Cox proportional hazards models to examine clinical and echocardiographic variables that were associated with 6-month mortality. Mean age for our study population was 63�17 years, and 72 (44%) were women. All-cause 6-month mortality was 18% (n=37). Independent variables associated with death were systemic embolization (hazard ratio 7.11; 95% CI 2.74 to 18.48), moderate or severe tricuspid regurgitation (hazard ratio 4.24; 95% CI 1.84 to 9.75), abnormal right ventricular function (hazard ratio 3.59; 95% CI 1.57 to 8.24), and abnormal renal function (hazard ratio 2.98; 95% CI 1.17 to 7.59). Size and mobility of cardiac device vegetations were not independently associated with mortality.

Conclusions— We identified several clinical and echocardiographic variables that identify patients with cardiac-device related infection who are at high-risk for mortality and may benefit from more aggressive evaluation.

A simpler technique for reduction of uterine septum

Hysteroscopic resection of the uterine septum is currently the accepted technique for dealing with this congenital uterine abnormality. Its advantages over the transabdominal approach are: it can be performed on an outpatient basis, it requires minimal recovery time, and it does not commit the patient to a subsequent cesarean section. This communication reports on a new transcervical approach that does not require the use of a hysteroscope. Thirty-four patients have now undergone resection of uterine septae using this technique. The results have been consistently good, requiring a short operative time and minimal instrumentation. We have experienced no complications.

Reproductive outcome following conservative surgery for tubal pregnancy in women with a single fallopian tube

Between the years 1974 and 1980, 13 patients underwent a conservative (salpingotomy) surgical procedure for tubal pregnancy in their only fallopian tube. In this group, one patient has been lost to follow-up, and one has intentionally avoided pregnancy, although tubal patency was documented by hysterosalpingogram. All the remaining patients have had at least one term pregnancy. The diagnosis was confirmed in all instances by laparoscopy prior to laparotomy. In 11 patients, the ectopic pregnancy was unruptured. One ectopic pregnancy had ruptured and one had resulted in a tubal abortion. All patients underwent essentially the same conservative procedure, performed by the same surgical team, with close adherence to the principles of microsurgery. This technique is described in detail. Since each of these patients had only one tube, this report reaffirms the value of conservative surgery for tubal pregnancy.