Oxygen Therapy in Patients With Intermediate-Risk Acute Pulmonary Embolism: A Randomized Trial

BACKGROUND

The effect of supplemental oxygen therapy in patients with intermediate-risk pulmonary embolism (PE) who do not have hypoxemia at baseline is uncertain.

RESEARCH QUESTION

Does supplemental oxygen improve echocardiographic parameters in nonhypoxemic patients with intermediate-risk PE?

STUDY DESIGN AND METHODS

This pilot trial randomly assigned nonhypoxemic patients with stable PE and echocardiographic right ventricle (RV) enlargement to receive anticoagulation plus supplemental oxygen for the first 48 h vs anticoagulation alone. The primary outcome was normal echocardiographic RV size 48 h after randomization. Secondary efficacy outcomes were the numerical change in the RV to left ventricle (LV) diameter ratio measured 48 h and 7 days after randomization with respect to the baseline ratio measured at inclusion.

RESULTS

The study was stopped prematurely because of the COVID-19 pandemic after recruiting 70 patients (mean ± SD age, 67.3 ± 16.1 years; 36 female [51.4%]) with primary outcome data. Forty-eight h after randomization, normalization of the RV size occurred in 14 of the 33 patients (42.4%) assigned to oxygen and in eight of the 37 patients (21.6%) assigned to ambient air (P = .08). In the oxygen group, the mean RV to LV ratio was reduced from 1.28 ± 0.28 at baseline to 1.01 ± 0.16 at 48 h (P < .001); in the ambient air group, mean RV to LV ratios were 1.21 ± 0.18 at baseline and 1.08 ± 0.19 at 48 h (P < .01). At 90 days, one major bleeding event and one death (both in the ambient air group) had occurred.

INTERPRETATION

In analyses limited by a small number of enrollees, compared with ambient air, supplemental oxygen did not significantly increase the proportion of patients with nonhypoxemic intermediate-risk PE whose RV to LV ratio normalized after 48 h of treatment. This pilot trial showed improvement in some ancillary efficacy outcomes and provides support for a definitive clinical outcomes trial.

TRIAL REGISTRY

ClinicalTrials.gov; No.: NCT04003116; URL: www.

CLINICALTRIALS

gov.

National Early Warning Score-2 for Identification of Patients with Intermediate-High-Risk Pulmonary Embolism

Consensus statements have proposed the use of the National Early Warning Score 2 (NEWS2) to identify stable patients with acute pulmonary embolism (PE) and an intermediate-high risk of adverse outcomes. We aimed to externally validate NEWS2 and compare it to another predictive score (Bova). Using NEWS2 (cutoff ≥5 and ≥7) and the Bova score (cutoff >4), we classified patients as intermediate-high risk (vs. non-intermediate-high risk), and we compared the test characteristics of these risk classification tools for a complicated course within 30 days after PE diagnosis. We also assessed the validity of NEWS2 for predicting a complicated course by adding the results of echocardiography and troponin testing to the model. Of the 848 enrolled patients, the NEWS2 score ≥5 classified 471 (55.5%) and the Bova score classified 37 (4.4%) as intermediate-high risk. NEWS2 had a significantly lower specificity for a 30-day complicated course than Bova (45.4 vs. 96.3%, respectively; p < 0.001). Using the higher score threshold (≥7), the NEWS2 classified 99 (11.7%) as intermediate-high risk, and the specificity was 88.9% (difference with Bova, 7.4%; p < 0.001). The proportion of patients with intermediate-high risk PE was 2.4% for the combination of a positive troponin testing and echocardiographic right ventricle dysfunction and a positive NEWS2 (score ≥7), while the specificity was 97.8% (difference with Bova, 1.5%; p = 0.07). Bova outperforms NEWS2 for predicting a complicated course among stable patients with PE. Addition of troponin testing and echocardiography improved the specificity of NEWS2, although it was not superior to Bova. CLINICALTRIALS.GOV NUMBER: : NCT02238639.

The rationale, design, and methods of a trial to evaluate the efficacy and safety of oxygen therapy in patients with intermediate-risk acute pulmonary embolism

BACKGROUND

In patients with intermediate-risk pulmonary embolism (PE), reversal of hypoxic vasoconstriction could constitute a target for treatment that protects the right ventricular (RV) function until endogenous fibrinolysis occurs. The Air vs oxygen for Intermediate-Risk pulmonary embolism (AIR) trial aims to assess the effect of oxygen therapy in patients with intermediate-risk acute PE who do not have hypoxemia at baseline.

METHODS AND ANALYSES

AIR is a prospective, multicenter, randomized, open-label, parallel-group, proof-of-concept trial. A total of 90 patients hospitalized with intermediate-risk PE and an oxygen saturation of 90% or higher at baseline will be randomized in a 1:1 fashion to receive supplemental oxygen or ambient air. The primary outcome is a RV/LV diameter ratio equal or less than 1.0 on echocardiography measured 48 hours after the start of treatment. Secondary efficacy outcomes are the numerical change in the ratio of the RV to the LV diameter measured 48 hours and 7 days after the start of treatment, with respect to the baseline ratio measured at randomization. Clinical adverse events will be also collected.

RESULTS

Enrollment started in July 2019 and is expected to proceed until 2022. Median age of the first 50 patients was 74 years (interquartile range, 61-81), and 50% were female.

CONCLUSIONS

This multicenter trial will provide information about the value of supplemental oxygen in patients with intermediate-risk acute PE who do not have hypoxemia at baseline. The results will contribute to research that may assist patients with intermediate-risk PE in the future.

Comparison of various prognostic scores for identification of patients with intermediate-high risk pulmonary embolism

BACKGROUND

Various risk assessment tools have been proposed to identify stable patients with acute pulmonary embolism (PE) who are at high risk of early adverse outcome (i.e., intermediate-high risk).

METHODS

We evaluated the ability of the 2019 ESC, Bova, modified FAST and PEITHO-3 models for predicting a 30-day complicated course (death, haemodynamic collapse, and/or recurrent PE) in a cohort of 848 stable patients with acute PE. We also tested whether replacement of echocardiographic right ventricle (RV) dysfunction by computed tomographic (CT) RV enlargement provides comparable prognostic information for identifying these patients.

RESULTS

A complicated course occurred in 63 (7.4 %) of the 848 patients with PE during the first month of follow-up. The proportion of patients designated as having intermediate-high risk PE was 6.7 % with the ESC model, 4.4 % with the Bova score, 15.7 % with the FAST score, and 5.2 % with the PEITHO-3 model. However, among patients identified as intermediate-high risk, the 30-day complicated course rate was higher with the Bova score (21.6 %) than with the ESC model (17.5 %), the PEITHO-3 model (15.9 %), or the modified FAST score (14.3 %). When echocardiographic RV dysfunction was replaced by CT RV enlargement in the models, the proportion of patients classified as having intermediate-high risk PE and the rate of an adverse outcome among them slightly increased.

CONCLUSIONS

The Bova score might identify patients with intermediate-high risk PE slightly better than the ESC, PEITHO-3, and modified FAST score. When echocardiography is not readily available, CT-assessed RV enlargement might be used for identifying intermediate-high risk PE.

CLINICALTRIALS

gov number: NCT02238639.

Significado pronóstico de los diagnósticos alternativos a la TEP hallados en la tomografía computarizada de tórax de pacientes ingresados por agudización de EPOC: subanálisis predefinido del ensayo SLICE

BACKGROUND

Among patients hospitalized for an exacerbation of chronic obstructive pulmonary disease (COPD), the SLICE trial showed that the addition of an active diagnostic strategy for pulmonary embolism (PE) to usual care compared with usual care alone did not improve a composite set of health outcomes. The objective of this subanalysis was to determine the frequency and prognostic significance of findings on computed tomography pulmonary angiogram (CTPA) supporting an alternative diagnosis to PE.

METHODS

We analyzed all patients randomized to the intervention in the SLICE trial who received a CTPA that did not show PE. We used multivariable logistic regression to assess the independent association between findings supporting an alternative diagnosis to PE and a composite of readmission for COPD or death within 90 days after randomization.

RESULTS

Among the 746 patients who were randomized, this subanalysis included 175 patients in the intervention group who received a CTPA that did not show PE. Eighty-four (48.0%) patients had acute bronchial infection, 13 (7.4%) had lung cancer, 10 (5.7%) had congestive heart failure, 8 (4.6%), 18 (10.3%) had other diagnoses, and 42 (24.0%) had a normal CTPA. In multivariable analysis, findings supporting an alternative diagnosis to PE were not significantly associated with the primary outcome (odds ratio: 0.64; 95% confidence interval: 0.30-1.38; P=0.26).

CONCLUSIONS

Among patients hospitalized for an exacerbation of COPD, CTPA identified an alternative diagnosis in 76% of the patients. However, specific management of these patients was not associated with improved outcomes within 90 days after randomization.

Quantitative Bias Analysis of misclassification in case-control studies: an example with Human Papillomavirus and Oropharyngeal Cancer

OBJECTIVE

Laprise et al. (2019) observed a positive association between oral sex practices and oropharyngeal cancers (OPC) among HPV-negative individuals. Because oral HPV infections are likely to be transmitted through oral sex, these results are counterintuitive. We revisit Laprise et. al's analysis with the objective of estimating the impact of misclassification of HPV infection on the association between oral sex practices and OPC.

METHODS

Data were drawn from the Head and Neck Cancer (HeNCe) Life study, a hospital-based case control study of head and neck cancer with frequency-matched controls by age and sex from 4 major referral hospitals in Montreal, Canada. We included only OPC cases (n = 188) and controls (n = 429) and used predictive value weighting, under differential and non-differential scenarios, to evaluate the misclassification. Subsequently, we used logistic regression and 95% confidence intervals to estimate the association between oral sex practice and OPC among HPV-negative individuals.

RESULTS

Our results showed that the previously reported association between oral sex practices and OPC among HPV-negative individuals was attenuated or nullified both under differential and non-differential scenarios.

CONCLUSION

The association between oral sex practice and OPC could be explained by biases in the data (e.g., HPV mediator misclassification). Our results highlight the need for widespread adoption of Quantitative Bias Analysis in oral health research.

Lipoprotein lipase and lipogenic enzyme activities in adipose tissue from rats fed different lipid sources

This work was designed to study the effect of different lipid sources on the activities of lipoprotein lipase and lipogenic enzymes in adipose tissue from rats fed ad libitum or energy-controlled diets. Male Wistar rats were fed diets containing 40% of energy as fat (olive oil, sunflower oil, palm oil or beef tallow), for 4 wk. Under ad libitum feeding no differences were found among dietary fat groups in final body weight, adipose tissue weights and total body fat. Under energy-controlled feeding, despite isoenergetic intake, rats fed the beef tallow diet gained significantly less weight than rats fed the other three diets. Beef tallow fed rats showed the lowest values for adipose tissue weights and total body fat. When rats had free access to food no effect of dietary lipid source on lipogenic enzyme activities was found. In contrast, under energy-controlled feeding rats fed the beef tallow diet showed significantly higher activities of glucose-6-phosphate dehydrogenase and fatty acid synthase than rats fed the other three diets. Heparin-releasable lipoprotein lipase activity in perirenal and subcutaneous adipose tissues was not different among rats fed olive oil, safflower oil, palm oil or beef tallow. When comparing both adipose tissue anatomical locations, significantly higher activities were found in subcutaneous than in perirenal fat pad independently of dietary fat. In conclusion, under our experimental protocol, lipogenesis in rat adipose tissue does not seem to be affected by dietary fat type.

Differential effects of diets that provide different lipid sources on hepatic lipogenic activities in rats under ad libitum or restricted feeding

This work was designed to study the effect of different lipid sources on hepatic lipogenic enzyme activity in rats fed ad libitum or energy-controlled diets. Male Wistar rats were fed diets containing 40% of energy as fat (olive oil, sunflower oil, palm oil, or beef tallow) for 4 wk. In experiment 1 rats had free access to food, and in experiment 2 rats were fed a controlled amount of food. In both experiments, rats fed the olive oil diets had higher activities of glucose-6-phosphate dehydrogenase, malic enzyme, fatty acid synthase, and acetyl-CoA carboxylase (P < 0.05) than rats fed the other fats. It is unlikely that this effect could be attributed to the stimulation by insulin or triiodothyronine because serum values did not differ among the groups. Enzymatic activities were positively and significantly correlated with liver triacylglycerol content, but not with serum triacylglycerol levels. No interaction between lipid source and feeding protocol was found. Oleic acid and components in olive oil other than fatty acids, such as phytosterols, may account for the effects of dietary fat on lipogenic enzyme activity.

Monoclonal antibodies to human apolipoproteins: application to the study of high density lipoprotein subpopulations

We produced, selected and cloned hybridomas that secrete monoclonal antibodies against human apolipoprotein (apo) A-I. All of the antibodies corresponded to the IgG(1) subclass and were named 1C11, 2B4, 2C10, 7C5, 8A4 and 8A5. The antibodies were characterized by their reactivity with whole lipoproteins, apolipoproteins, synthetic peptides and fragments generated by cleavage of the apo A-I. Three of the monoclonal antibodies studied (2B4, 2C10 and 7C5) were similarly inhibited by an amino-terminal peptide (amino acid sequence 1-20) of apo A-I, whereas antibodies 1C11, 8A4 and 8A5 had no reaction. Other results show that monoclonal antibody 1C11 recognizes an epitope located between amino acids 135-148. We evaluated the monoclonal antibody 8A4 against different HDL subpopulations by competitive displacement analysis and it showed a similar reactivity with the HDL particles: LpA-I and LpA-I:A-II. This antibody was used to standardize a sandwich ELISA to quantitate LpA-I in plasma. We conclude that these monoclonal antibodies are relevant for the study of apo A-I epitope expression and for quantitating apo A-I containing lipoparticles.

[Lipoprotein particles LpA-I, LpA-I: A-II and LpB in coronary artery disease]

BACKGROUND

High density lipoproteins are an heterogeneous population of particles. Two main subpopulations have been identified, one contains Apo A-I and Apo A-II and is denominated LpA-I:A-II and another one contains only Apo A-I and is denominated LpA-I.

AIM

To measure the concentrations of these particles in patients with stable coronary artery disease.

PATIENTS AND METHODS

Serum lipids, A-I and B apolipoproteins, LpA-I, LpA-I:A-II and LpB particles were measured in 73 men aged 33 to 82 years with angiographically documented coronary artery disease (CAD) and 33 control subjects aged 39 to 76 years. LpA-I, LpA-I:A-II and LpB were measured by a noncompetitive enzyme linked immunoassay using previously characterized monoclonal antibodies against ApoA-I, ApoA-II and apoB.

RESULTS

Patients with CAD had significantly higher mean levels of LDL cholesterol than the control group (p = 0.038). The mean concentration of LpA-I particles in patients with CAD was significantly lower (p = 0.031) than in control subjects, while the concentration of LpA-I:A-II particles was significantly higher (p = 0.016). The percentage of coronary stenosis correlated negatively with LpA-I and positively with LpA-I:A-II. The best relative risk (RR) indicator in these patients was LDL-cholesterol. The relative risk increases 2.5 fold when LpA-I falls below the cut-off level. Likewise, the relative risk increases 3-fold when LpA-I:A-II raises over the cut-off level.

CONCLUSIONS

Our findings indicate that the quantification of LpA-I and LpA-I:A-II particles might allow a more accurate evaluation of the CAD risk than HDL cholesterol. LpA-I might represent the antiatherogenic fraction of HDL.

In vitro effect of estradiol, progesterone, testosterone, and of combined estradiol/progestins on low density lipoprotein (LDL) oxidation in postmenopausal women

OBJECTIVE

One of the mechanisms currently proposed to explain the cardioprotective effect of hormone replacement therapy (HRT) is the antioxidative property of estrogens. Considering that HRT involves the administration of an estrogen, usually combined with a progestin and sometimes with an androgen, we investigated the following in vitro: (1) the effect of estradiol, progesterone, and testosterone on the oxidation of low density lipoprotein; (2) the possible pro-oxidative effect of progesterone and testosterone on native low density lipoprotein; and (3) the possible modification of the antioxidant effect of estradiol on low density lipoprotein induced by progestins.

DESIGN

Low density lipoprotein was isolated from blood samples obtained from 20 untreated postmenopausal women and divided in multiple aliquots, each containing 0.5 mg LDL protein. In Protocol 1 (n = 10) different doses of estradiol, progesterone, and testosterone ranging from 0 to 26 micrograms/ml were tested inducing oxidation with 15 microM copper sulfate. In Protocol 2 (n = 6) we studied the rate of oxidation of low density lipoprotein incubated with progesterone or testosterone without any oxidative induction. In Protocol 3 (n = 10) we studied the concomitant effect of 15 microM estradiol with four separate progestins (progesterone, medroxyprogesterone acetate, norethindrone, and norgestrel) in different doses (0, 5, 15, and 50 microM). After incubation for 4 h at 37 degrees C, malonaldehyde was measured as a marker of low density lipoprotein oxidation. The results were expressed in mean +/- SD.

RESULTS

Protocol 1: Estradiol induced a dose-dependent decrease in malonaldehyde generation, from a baseline of 61.8 +/- 30.2 nmol/mg protein to 11.6 +/- 7.1 nmol/mg protein at the highest dose of estradiol tested (p < 0.0001). Progesterone or testosterone did not modify malonaldehyde generation. Protocol 2: Progesterone and testosterone did not show pro-oxidative action. Protocol 3: Estradiol 15 microM alone induced a 35% decrease in malonaldehyde generation, from a baseline of 75.4 +/- 25.4 to 49.3 +/- 18.8 nmol/mg protein (p < 0.0001). Norgestrel and norethindrone did not modify the antioxidant effect of estradiol (p > 0.05). Progesterone and medroxyprogesterone acetate induced a further reduction of malonaldehyde concentration to 37.2 +/- 20.8 and 38.6 +/- 18.2 nmol/mg protein, only at the highest dose tested (p < 0.02 and p < 0.01, respectively).

CONCLUSIONS

Our results demonstrate that, in contrast with the potent antioxidant effect of estradiol, progesterone and testosterone did not show any pro- or antioxidant effect on low density lipoprotein in vitro. Furthermore, progestins did not counteract the antioxidant effect of estradiol in vitro.

[Immune response against modified low-density lipoproteins in patients with non-insulin-dependent diabetes mellitus]

BACKGROUND

Diabetes mellitus is a risk factor for atherosclerosis. Low density lipoproteins are considered a key factor in the formation of atheroma and the immune system has an important contribution to this process.

AIM

To quantify the immune response against modified low density lipoproteins in patients with non insulin dependent diabetes mellitus.

MATERIAL AND METHODS

LDLs obtained from blood of healthy subjects, were glycated or altered with malondialdehyde and used as antigens. Serum autoantibodies against these LDLs were measured by ELISA in 22 patients with non insulin dependent diabetes mellitus aged 46 to 67 years old and 13 healthy controls aged 41 to 65 years old. Basal and LDL stimulated tumor necrosis factor a production in vitro, by peripheral leukocytes of diabetics and controls was also measured.

RESULTS

The ratio of glycated LDL/native LDL antibodies was higher in diabetics than in controls (9.37 +/- 2.72 and 0.41 +/- 0.11 respectively p < 0.05) and the ratio of MDA modified LDL/native LDL antibodies was not significantly different (8.64 +/- 3.83 and 2.14 +/- 1.26 respectively, NS). Tumor necrosis or production by leukocytes was higher in diabetics than in controls in basal conditions (53.3 +/- 15.3 and 26.9 +/- 14.7 arbitrary units (a.u.) respectively), when stimulated with native LDL (46.5 +/- 5 and 24.3 +/- 9.4 a.u. respectively), when stimulated with malondialdehyde modified LDL (50 +/- 16.2 and 24.4 +/- 7.7 a.u. respectively) or when stimulated with glycated LDL (38.3 +/- 8.8 and 14.4 +/- 7.5 a.u. respectively).

CONCLUSIONS

Diabetic patients have an enhanced immune response against low density lipoproteins, factor that could contribute to the accelerated atherogenesis of this disease.

[Effects of low doses of aprotinin in heart surgery]

OBJECTIVES

To study the effect of aprotinin (Trasylol) administration on bleeding after surgery and on the need for blood transfusion in patients undergoing cardiopulmonary bypass with extracorporeal circulation (ECC).

PATIENTS AND METHODS

One hundred ten patients were studied prospectively, divided into two groups. In the aprotinin group (n = 80), the ECC pump was primed with 140 mg of aprotinin and followed with continuous intravenous perfusion at 70 mg/h from the start of ECC until the patient left the operating theater. The control group (n = 30) served as reference. The parameters compared were the hematocrit, number of platelets, prothrombin time and activated coagulation time, as well as drainage of blood through thoracic tubes at 3 and 24 h after surgery and the amount of blood transfused both during and after the procedure.

RESULTS

Blood loss was significantly lower in the aprotinin group as compared with the control group, both at 3 h (227 +/- 193 vs 380 +/- 169 ml; p < 0.05) and at 24 h (422 +/- 322 ml vs 736 +/- 342 ml; p < 0.05) after surgery. There was also a significant decrease in blood requirements in the aprotinin group (550 +/- 450 ml vs 872 +/- 747 ml; p < 0.05). There were no differences between the two groups for the other parameters studied.

CONCLUSIONS

Administration of aprotinin at low doses during surgery in patients undergoing cardiac surgery with ECC significantly reduces postoperative bleeding and the amount of blood transfused.

Prognostic implications of clinical, electrocardiographic and hemodynamic findings in chronic Chagas' disease

To evaluate the prognostic importance of 19 clinical, electrocardiographic and hemodynamic variables, 556 chronic chagasic patients were submitted to an extensive protocol, including left cineventriculogram and Holter monitoring, and followed for up to 15 years. The protagonist role of the magnitude of the myocardial compromise in the evolution of chagasic patients is underscored by our results, which indicated the independent prognostic value of an ejection fraction below 0.30 (P < 0.001), a heart rate higher than 89 beats/min (P < 0.01), grade IV functional capacity (P < 0.05), end systolic stress > 120 g/cm2 (P < 0.05), and end diastolic volume index > 200 ml/m2 (P < 0.05). When only patients with an ejection fraction over 0.29 were considered, variables with independent prognostic value were: the cardio-thoracic ratio (P < 0.01), functional capacity (P < 0.05) and heart rate (P < 0.05). Survival analysis demonstrated that the presence of complex (Lown III, IV) ventricular arrhythmias increased mortality significantly (P < 0.01) only in patients with an ejection fraction over 0.29. Therefore, preservation of myocardial function is the capital measure in the treatment of chronic chagasic patients.

[The anti-arrhythmia effect of carbamazepine in chagasic patients with advanced myocardial damage]

Oral administration of 600 mg/day of carbamazepine to 14 arrhythmic chagasic patients with advanced myocardial damage and no signs of congestive heart failure did not alter the frequency of ventricular extrasystoles, but reduced the total number of supraventricular ectopic beats in 7/14 patients and the episodes of complex ventricular arrhythmias in up to 43% of patients. This assessment was made from 24 hour continuous Holter recording during the course of this double-blind, placebo controlled, randomized crossover study. Serum levels of carbamazepine were also determined and found within therapeutic limits. Six patients complained of minor side effects. One patient presented with iatrogenic complete AV block, another case had proarrhythmic effect and one patient had to be withdrawn from the study because of gastric irritation. No instance of contractile depression was observed. Accordingly, carbamazepine is a therapeutic alternative for treatment of symptomatic complex ventricular or supraventricular arrhythmias in chronic chagasic patients without evidence of conduction system involvement or with intolerance to other antiarrhythmic drugs.

Thromboembolism in patients with pericardial valves in the absence of chronic anticoagulation: 12 years' experience

Between January 1977 and January 1989, 465 pericardial bioprostheses were implanted in 424 patients. The mean age of patients was 59.1 years (range 16-81 y.) At the time of surgery, 68% of the patients suffered from chronic atrial fibrillation. Mitral valve replacement was performed in 167 patients, aortic valve replacement in 216, multiple replacement in 40 (36 mitral and aortic, 3 mitral and tricuspid, and 1 mitral, aortic and tricuspid), and 1 pulmonary valve replacement. The different types of pericardial valve used were: Ionescu-Shiley 408, Mitral Medical 23, Bioflo 30, and Hancock 4. Hospital mortality was 10.1% with an attrition rate of 1.8 episodes per 100 patients/year. The 12-year actuarial survival rate was 65.1%. No patient underwent long-term anticoagulant treatment. The first 144 patients undergoing mitral and multiple valve replacements received temporary anticoagulation for the first 8 weeks after surgery. There was no valve thrombosis observed. Altogether 19 thromboembolic events (6 early and 13 late) were clinically documented. One patient died after an embolic event. The linearized rates of thromboembolism were 1.64 episodes per 100 patients/year for mitral and multiple valve replacements and 0.33 episodes per 100 patients/year for aortic valve replacement, with an overall rate of 1.0 episodes per 100 patients/year. Excluding early thromboembolism, the linearized rate was 1.02 episodes per 100 patients/year overall. The actuarial freedom from embolism was 92.4% overall, 88.2% for the mitral and multiple valve replacement group, and 97.6% for the aortic valve replacement group at a maximum follow-up of 12 years.(ABSTRACT TRUNCATED AT 250 WORDS)

Duplication of the right atrioventricular orifice in a patient with common atrium and mitral cleft

The following case involved duplication of the right atrioventricular valve in a patient with a common atrium. The accessory orifice, formed by two fine leaflets, connected the right atrium with the right ventricular outflow tract and had no subvalvular apparatus. Successful surgical correction was accomplished under standard cardiopulmonary bypass.