Explore the vast range of titles available.

Miscommunication in the OR is a threat to patient safety and surgical efficiency. Our objective was to measure the frequency and causes of communication interference between robotic team members. We observed 78 robotic surgeries over 215 h. 65.4% were General Surgery, most commonly cholecystectomy, identifying Speech Communication Interference (SCI) events, defined as “surgery-related group discourse that is disrupted according to the goals of the communication or the physical and situational context of the exchange”. We noted the causes and strategies to correct the miscommunication, near misses, and case delays associated with each SCI event. Post-surgery interviews supported observations and were analyzed thematically. Overall, we observed 687 SCI events (mean 8.8 ± 6.5 per case, 3.2 per hour), ranging from one to 28 per case. 48 (7.0%) occurred during docking and 136 (19.8%) occurred during a critical moment. The most common causes were concurrent tasks (66.1%); loud noises (10.8%) from patient cart, lightbox fan, and suction machine; and overlapping conversations (4.2%). 94.8% resulted in a case delay. These events distracted from monitoring patient safety and resulted in near misses. Mitigating strategies included leaning out of the surgeon console to repeat the message and employing a messenger. These findings help characterize miscommunication in robotic surgery. Possible interventions include microphones and headsets, positioning the surgeon console closer to the bedside, moving loud equipment further away, and upgrading the patient cart speaker.

In this trial, patients with mild-to-moderate heart failure were randomly assigned to receive an implantable cardioverter–defibrillator (ICD) alone or an ICD plus cardiac-resynchronization therapy. Patients in the latter group had lower rates of death and hospitalization for heart failure. The use of implantable cardioverter–defibrillators (ICDs) improves survival among patients who have New York Heart Association (NYHA) class II or III heart failure with left ventricular systolic dysfunction despite optimal medical therapy. 1 Cardiac-resynchronization therapy (CRT) improves symptoms of heart failure, quality of life, exercise capacity, 2 – 6 and left ventricular function 7 when used in patients with NYHA functional class III or ambulatory class IV heart failure with a wide QRS complex. CRT has also been shown to reduce mortality among patients not receiving an ICD. 8 However, studies have not shown a survival benefit of CRT in patients with NYHA class II . . .

In 4 of 15 patients with idiopathic atrial fibrillation, four novel, heterozygous mutations in GJA5 — the gene for the gap-junction protein connexin 40 — were identified. These supplement the list of mutations that cause atrial fibrillation and will improve our understanding of the molecular basis of atrial fibrillation. In 4 of 15 patients with idiopathic atrial fibrillation, four novel, heterozygous mutations in GJA5 — the gene for the gap-junction protein connexin 40 — were identified. Atrial fibrillation is characterized by rapid, erratic electrical activation of the atrial myocardium, resulting in the loss of effective contractility, an increased likelihood of clot formation, and an increased risk of stroke. 1 The rapid atrial activity may be conducted to the ventricles, resulting in the deterioration of heart function. In addition to causing substantial morbidity, atrial fibrillation confers an increased risk of mortality that is independent of coexisting risk factors. 2 In the United States, more than 2 million adults have atrial fibrillation, with the prevalence increasing with age (5.9 percent among those older than 65 years). 3 Thus, the socioeconomic burden . . .

Expert subjective reporting of mid-wall septal fibrosis on late gadolinium enhancement (LGE) images has been shown to predict major cardiovascular outcomes in patients with non-ischemic dilated cardiomyopathy (NIDCM). This study aims to establish objective criteria for non-experts to report clinically relevant septal fibrosis and compare its performance by such readers versus experts for the prediction of cardiovascular events. LGE cardiovascular magnetic resonance (CMR) was performed in 118 consecutive patients with NIDCM (mean age 57 ± 14, 42 % female) and the presence of septal fibrosis scored by expert readers. CMR-naive readers performed signal threshold-based LGE quantification by referencing mean values of remote tissue and applying these to a pre-defined anatomic region to measure septal fibrosis. All patients were followed for the primary composite outcome of cardiac mortality or appropriate implantable cardioverter-defibrillator (ICD) therapy. The mean LVEF was 32 ± 12 %. At a median follow-up of 1.9 years, 20 patients (17 %) experienced a primary composite outcome. Expert visual scoring identified 55 patients with septal fibrosis. Non-expert septal fibrosis quantification was highly reproducible and identified mean septal fibrosis burden for three measured thresholds as follows; 5SD: 2.9 ± 3.6 %, 3SD: 6.9 ± 6.3 %, and 2SD: 11.1 ± 7.5 % of the left ventricular (LV) mass, respectively. By ROC analysis, optimal thresholds for prediction of the primary outcome were; 5SD: 2.74 % (HR 8.7, p < 0.001), 3SD: 6.63 % (HR 5.7, p = 0.001) and 2SD: 10.15 % (HR 6.1, p = 0.001). By comparison, expert visual scoring provided a HR of 5.3 (p = 0.001). In adjusted analysis, objective quantification by a novice reader (>5SD threshold) was the strongest independent predictor of the primary outcome (HR 8.7) and provided improved risk reclassification beyond LVEF alone (NRI 0.54, 95 % CI 0.16–0.92, p = 0.005). Novice readers were able to achieve superior risk prediction for future cardiovascular events versus experts using objective criteria for septal fibrosis in patients with NIDCM. Patients with a septal fibrosis burden >2.74 % of the LV mass (>5SD threshold) were at a 9-fold higher risk of cardiac death or appropriate ICD therapy versus those not meeting this criteria. As such, this study validates reproducible criteria applicable to all levels of expertise to identify NIDCM patients at high risk of future cardiovascular events.

Increasing numbers of patients requiring arrhythmia device implantation are taking warfarin. The common practice of warfarin interruption and perioperative bridging with heparin is associated with a high rate of postoperative hemorrhagic complications. We assessed the safety of device implantation without interruption of warfarin therapy. Three patient groups were studied: Group 1 consisted of 117 consecutive patients on long-term warfarin therapy with significant risk of thromboembolism (atrial fibrillation with CHADS 2 score ≥2, mechanical heart valve, recent venous thromboembolism) who underwent arrhythmia device implantation without interruption of warfarin. Group 2 was 117 patients who served as age- and sex-matched controls matched to procedure type not taking warfarin. Group 3 consisted of 38 similar thromboembolic risk historical control patients who underwent interruption of warfarin therapy and bridging with dalteparin before and 24 hours after surgery. Active fixation leads were used by subclavian or axillary vein puncture, with septal fixation in the ventricle in 56% of patients. Hemorrhagic and thromboembolic complications were assessed at discharge and at 7 and 30 days after surgery. During an 18-month period, 1,562 consecutive adult patients underwent heart rhythm device implantation or replacement. One hundred seventeen of the 447 patients on warfarin were considered high risk and remained on warfarin for their procedure. The mean international normalized ratio in group 1 patients was 2.2 ± 0.4 (age 79 ± 11 years, 73 male). Significant hematoma was noted in 9 patients (7.7%), and one required surgical revision (0.9%). Five group 2 patients (control) had significant hematomas (4.3%), none of which required revision ( P = .41). In group 3, 9 patients developed significant hematomas (23.7%, P = .012), 3 of whom required reoperation (7.9%, P = .046). There were no deaths, thromboembolic events, cardiac tamponade, or hemothorax in any patient. The only risk factor for hematoma in the warfarin patients was the number of leads implanted. Arrhythmia devices can be implanted safely in patients with high thromboembolic risk without interruption of warfarin. This strategy may be associated with reduced risk of significant pocket hematoma compared with dalteparin bridging.

Supraventricular tachycardia (SVT) includes all forms of tachycardia that either arise above the bifurcation of the bundle of His or that have mechanisms dependent on the bundle of His. We conducted a review of the techniques used to differentiate the mechanisms of SVT. We searched the PubMed and MEDLINE databases for English-language literature published from 1970 to 2008. Articles were selected for either their historical importance or up-to-date clinical data. This review focuses on techniques for scrutinizing electrocardiograms of patients, analyzing in particular the onset of tachycardia, the mode of tachycardia termination, and the effects of premature ventricular contractions, premature atrial contractions, and aberrancy during tachycardia. Both short-term and long-term management of SVT are examined, including the urgent treatment of patients in the emergency department. This review also describes management of patients who have ongoing symptomatic SVT, outlining such available treatment options as atrioventricular node-blocking drugs, antiarrhythmic drugs, and catheter ablation.

Corrected QT (QTc) interval prolongation has been shown to be an independent predictor of mortality in many clinical settings and is a common finding in hospitalized patients. The causes and outcomes of patients with extreme QTc interval prolongation during a hospital admission are poorly described. The aim of this study was to prospectively identify patients with automated readings of QTc intervals >550 ms at 1 academic tertiary hospital. One hundred seventy-two patients with dramatic QTc interval prolongation (574 ± 53 ms) were identified (mean age 67.6 ± 15.1 years, 48% women). Most patients had underlying heart disease (60%), predominantly ischemic cardiomyopathy (43%). At lease 1 credible and presumed reversible cause associated with QTc interval prolongation was identified in 98% of patients. The most common culprits were QTc interval–prolonging medications, which were deemed most responsible in 48% of patients, with 25% of these patients taking ≥2 offending drugs. Two patients were diagnosed with congenital long-QT syndrome. Patients with electrocardiograms available before and after hospital admission demonstrated significantly lower preadmission and postdischarge QTc intervals compared with the QTc intervals recorded in the hospital. In conclusion, in-hospital mortality was high in the study population (29%), with only 4% of patients experiencing arrhythmic deaths, all of which were attributed to secondary causes.

Ejection fraction (EF) is an important method of mortality prediction among cardiac patients, and has been used to identify the highest risk patients for enrollment in the defibrillator primary prevention trials. Evidence suggests that measures of EF by different imaging modalities may not be equivalent. In the SCD-HeFT (Sudden Cardiac Death in Heart Failure Trial), the type of imaging modality for EF assessment was not mandated. Baseline assessment of EF was performed using either echocardiography, radionuclide angiography (RNA), or contrast angiography. Multivariable analysis using a Cox proportional hazards model was used to examine whether the modality of assessing EF affected the likelihood of survival. Among the 2,521 patients enrolled in SCD-HeFT, EF was measured by RNA in 616 (24%), echocardiography in 1,469 (58%), and contrast angiography in 436 (17%). Mean EF as measured by RNA was 25.1% ± 6.9%; by echocardiography, 23.8 ± 6.9%; and by angiography, 21.9 ± 6.9%. These measures were significantly different ( P < .001), and each pairwise comparison differed significantly ( P < .001 for each). Multivariable analysis showed no significant difference in survival between patients enrolled based on RNA versus echocardiography (HR 1.06, 95% CI 0.88-1.28), RNA versus angiography (HR 1.25, 95% CI 0.97-1.62), or echocardiography versus angiography (HR 1.18, 95% CI 0.94-1.48). Among patients enrolled in SCD-HeFT, the distribution of ejection fractions measured by radionuclide angiography differed from those measured by echocardiography or contrast angiograms. Survival did not differ according to modality of EF assessment.

Out patient ambulatory monitoring is often performed in patients with syncope that present in the primary care setting to include or exclude an arrhythmia. The cost-effectiveness of 2 monitoring strategies was assessed in a prospective randomized trial. One hundred patients referred for ambulatory monitoring with syncope or presyncope were randomized to a 1-month external loop recorder (n = 49) or 48-hour Holter monitor (n = 51). Patients were offered crossover if there was failed activation or no symptom recurrence. The primary end point was symptom-rhythm correlation during monitoring. Direct costs were calculated based on the 2003 Ontario Health Insurance Plan fee schedule, combined with calculation of labor, materials, service, and overhead for diagnostic testing and related equipment. Before enrollment, the cost of all previous health care resource use was US$472 ± US$397 (range US$21-US$1965). In the loop recorder group, 63% of patients had symptom recurrence and successful activation, compared with 24% in the Holter group ( P < .0001). The cost per Holter was US$177.64, and per loop recorder, US$533.56, with a similar cost per diagnosis with the 2 techniques. The incremental cost-effectiveness ratio of the loop recorder was US$901.74 per extra successful diagnosis. A strategy of Holter followed by offered loop recorder trended toward lower cost than initial loop recorder followed by Holter (US$481 ± US$267 vs US$551 ± US$83, P = .08), but was associated with a lower overall diagnostic yield (49% vs 63%) and a resultant higher cost per diagnosis (US$982 vs US$871, P = .08). Bootstrapping suggested that 90% of incremental cost-effectiveness ratios were less than US$1250. Despite the increased upfront cost of external loop recorders, the marked improvement in diagnostic yield offsets the cost. External loop recorders are an economically attractive alternative. First-line use of external loop recorders in patients with “community-acquired” syncope and presyncope should be considered to optimize diagnostic yield given its value.

In the Sudden Cardiac Death in Heart Failure Trial, 811 patients were randomly assigned to receive implantable cardioverter–defibrillators (ICDs). Of these patients, 269 (33.2%) received at least one ICD shock over a median follow-up period of 45.5 months. The occurrence of ICD shocks, whether appropriate or inappropriate, was associated with a significant increase in the subsequent risk of death from all causes. The occurrence of ICD shocks, whether appropriate or inappropriate, was associated with a significant increase in the subsequent risk of death from all causes. The Sudden Cardiac Death in Heart Failure Trial (SCD-HeFT) (ClinicalTrials.gov number, NCT00000609) and the Multicenter Automatic Defibrillator Implantation Trial II (MADIT II) both showed that therapy with implantable cardioverter–defibrillators (ICDs) improves survival among patients who are at risk for sudden cardiac death but who have not previously had a sustained ventricular arrhythmia. 1 – 3 On the basis of these data, recent clinical guidelines consider the implantation of an ICD for “primary prevention” (i.e., prevention of a first life-threatening arrhythmic event) to be standard high-quality care for patients who meet the entry criteria for these trials. 4 One result of this broader use . . .