Clinical Characteristics and Outcomes of Patients Screened for Transcatheter Tricuspid Valve Replacement: The TriACT Registry

BACKGROUND

Transcatheter tricuspid valve replacement (TTVR) abolishes tricuspid regurgitation (TR) and has emerged as a definitive treatment for TR.

OBJECTIVES

The purpose of this multicenter, observational study was to determine the clinical characteristics and short-term outcomes of patients with TR screened for TTVR.

METHODS

Patients underwent TTVR screening at 7 centers on a compassionate-use basis. The primary endpoints were NYHA functional class and TR grade at 30-day follow-up. Secondary endpoints included all-cause mortality, heart failure hospitalization, technical success, and reasons for TTVR screening failure.

RESULTS

A total of 149 patients (median age 79 years [Q1-Q3: 72-84 years], 54% women) underwent TTVR screening. The TTVR screening failure rate was 74%, mainly related to large tricuspid annular diameter. Patients undergoing TTVR (n = 38) had significant functional improvements (NYHA functional class I or II from 21% to 68%; P < 0.001), with TR ≤1+ in 97% at 30-day follow-up (P < 0.001 from baseline). Technical success was achieved in 91%, with no intraprocedural mortality or conversion to surgery. At 30-day follow-up, mortality was 8%, heart failure hospitalization 5%, major bleeding 18%, and reintervention 9%. Patients who failed screening for TTVR and subsequently underwent "bailout" transcatheter edge-to-edge repair (n = 26) had favorable outcomes (NYHA functional class I or II from 27% to 58%; P < 0.001), with TR ≤1+ in 43% at 30-day follow-up (P < 0.001 from baseline).

CONCLUSIONS

This first real-world report of TTVR screening demonstrated a high screening failure rate, mainly related to large tricuspid annular diameter. Patients undergoing TTVR had superior TR reduction and symptom alleviation compared with bailout tricuspid transcatheter edge-to-edge repair, at the cost of greater procedural complications.

Acute Afterload Mismatch After Transcatheter Tricuspid Valve Repair

Acute afterload mismatch and left ventricular dysfunction after mitral valve repair are well established. The impact of transcatheter tricuspid valve repair (TTVr) on right ventricular (RV) function is less clearly defined. To our knowledge, there are no reports of acute RV dysfunction after TTVr. Here we report a case of acute afterload mismatch after successful TTVr. (Level of Difficulty: Advanced.).

Milrinone as Compared with Dobutamine in the Treatment of Cardiogenic Shock

BACKGROUND

Cardiogenic shock is associated with substantial morbidity and mortality. Although inotropic support is a mainstay of medical therapy for cardiogenic shock, little evidence exists to guide the selection of inotropic agents in clinical practice.

METHODS

We randomly assigned patients with cardiogenic shock to receive milrinone or dobutamine in a double-blind fashion. The primary outcome was a composite of in-hospital death from any cause, resuscitated cardiac arrest, receipt of a cardiac transplant or mechanical circulatory support, nonfatal myocardial infarction, transient ischemic attack or stroke diagnosed by a neurologist, or initiation of renal replacement therapy. Secondary outcomes included the individual components of the primary composite outcome.

RESULTS

A total of 192 participants (96 in each group) were enrolled. The treatment groups did not differ significantly with respect to the primary outcome; a primary outcome event occurred in 47 participants (49%) in the milrinone group and in 52 participants (54%) in the dobutamine group (relative risk, 0.90; 95% confidence interval [CI], 0.69 to 1.19; P = 0.47). There were also no significant differences between the groups with respect to secondary outcomes, including in-hospital death (37% and 43% of the participants, respectively; relative risk, 0.85; 95% CI, 0.60 to 1.21), resuscitated cardiac arrest (7% and 9%; hazard ratio, 0.78; 95% CI, 0.29 to 2.07), receipt of mechanical circulatory support (12% and 15%; hazard ratio, 0.78; 95% CI, 0.36 to 1.71), or initiation of renal replacement therapy (22% and 17%; hazard ratio, 1.39; 95% CI, 0.73 to 2.67).

CONCLUSIONS

In patients with cardiogenic shock, no significant difference between milrinone and dobutamine was found with respect to the primary composite outcome or important secondary outcomes. (Funded by the Innovation Fund of the Alternative Funding Plan for the Academic Health Sciences Centres of Ontario; ClinicalTrials.gov number, NCT03207165.).

Abstract 125: Capital Do-Re-Mi: A Randomized Trial of Dobutamine Compared to Milrinone in Cardiogenic Shock

Introduction: Cardiogenic shock (CS) is associated with significant morbidity and mortality. Although inotropic support is a mainstay of medical therapy for CS, little evidence exists to guide the selection of inotropic agents in clinical practice.

Methods: In this double blind randomized controlled trial, we assigned patients with SCAI class B to E shock to either milrinone or dobutamine for inotropic support. Therapy was titrated based on clinical, biochemical and hemodynamic response as evaluated by the treating physician. The primary outcome was a combined endpoint of in hospital mortality, non-fatal MI, stroke, new initiation of renal replacement therapy (RRT), need for MCS or cardiac transplant, or cardiac arrest with successful resuscitation. Secondary outcomes included individual components of the primary outcome.

Results: Among 192 participants, there was no significant difference in the primary outcome, occurring in 49% (47 of 96) of patients in the milrinone arm and 54% (52 of 96) patients in the dobutamine group (RR 0.90, 95% CI of 0.69-1.19, p-value = 0.47). There were also no differences in important secondary outcomes between milrinone and dobutamine, including in-hospital mortality 37% (35 of 96) vs 43% (41 of 96) (RR 0.85, 95% CI 0.60-1.21, p-value = 0.38) or need for RRT 22% (21 of 96) vs 17% (16 of 96) (RR 1.31, 95% CI 0.73-2.36, p-value = 0.36).

Conclusions: In this randomized clinical trial of milrinone and dobutamine in CS, there was no difference in the primary composite outcome or in important secondary outcomes. The selection of inotropic agent could reasonably be based on physician comfort, cost and individual response to therapy.

Factors potentially influencing academic performance among medical students

BACKGROUND

Studies are needed to examine predictors of success in medical school. The aim of this work is to explore factors that potentially influence excellence of medical students.

METHODS

The study was conducted in the Medical Faculty of King Abdulaziz University during October 2012. A self-administered questionnaire was used. Medical students with a grade point average (GPA) ≥4.5 (out of 5) were included and compared to randomly selected medical students with a GPA <4.5, who were available at the time of the study.

RESULTS

A total of 359 undergraduate students participated in the study. 50.4% of the sample was students with a GPA ≥4.5. No statistically significant difference regarding the time spent on outings and social events was found. However, 60.7% of high GPA students spend less than 2 hours on social networking per day as compared to 42.6% of the lower GPA students (P<0.01). In addition, 79% of high GPA students prefer to study alone (P=0.02), 68.0% required silence and no interruptions during studying time (P=0.013), and 47% revise their material at least once before an exam (P=0.02).

CONCLUSION

Excellent medical students have many different characteristics. For example, they do not use social networking for prolonged periods of time, and they have strong motivation and study enjoyment. Further studies are needed to examine whether these differences have a real impact on GPA or not.

Response to imatinib therapy in adult patients with chronic myeloid leukemia in Saudi population: a single-center study

No study has been published yet in the Arab world regarding response and outcome of imatinib in patients with chronic myeloid leukemia (CML). This study evaluated a total of 122 patients with CML treated with imatinib between 2001 and 2012. Survival, hematologic, cytogenetic and molecular responses and adverse events were assessed. The 5-year overall survival (OS), event free survival (EFS) and progression-free survival (PFS) rates were: 95.4 ± 2.3%, 81.4 ± 4.6% and 90.8 ± 3.2%, respectively. Significant differences in OS (p = 0.001), EFS (p = 0.001) and PFS (p = 0.001) were noted when patients were stratified by cytogenetic response. Survival by Sokal risk groups was not significant (p = 0.293). Complete hematologic response was achieved in 94 patients (93.1%), cytogenetic response in 84 (83.2%), major molecular response in 62 (61.4%) and complete molecular response in 34 (33.7%). This article presents the first evidence on the effectiveness of imatinib in patients with CML from Saudi Arabia and highlights similarities and differences in response patterns in published studies.

Endoscopic injection therapy for nonvariceal upper gastrointestinal bledding: Effective and safe

Twenty-nine patients underwent endoscopic injection therapy (EIT) for non-variceal upper gastrointestinal (UGI) bleeding lesions when intensive conservative medical therapy was considered ineffective. Permanent hemostasis was achieved in 23 cases (79.3%) after one session of injection therapy and 27 cases (93.1%) after two sessions. No major complications occurred following EIT and no mortality related to the bleeding nor to the injection therapy occurred. Two patients had to have surgery after the EIT failed to control the bleeding. This study confirms what has been previously reported that injection therapy is a highly effective and safe procedure which could be used in non-variceal UGI bleeding when medical therapy fails.

Airgun injuries: A national health hazard

Between 1983 and 1989, 41 patients were admitted to King Fahad Hospital (KFH) in Al-Baha, Saudi Arabia with airgun injuries. Of the patients admitted, 83% were under 18 years of age. The majority of injuries (80.5%) were trivial. However, 19.5% had serious injuries that required major surgery. These injuries were considered potentially lethal. Public education via media will probably be effective in reducing the number of injuries caused by these weapons.