We reviewed clinical data on 29 patients (17 acquired disease and 12 congenital disease) who underwent tricuspid valve replacement using a Carpentier-Edwards porcine valve or a St. Jude Medical valve at Niigata University Hospital between January 1978 and October 1995, and analyzed risks related to the outcome. Age ranged from 8 to 62 years, and 17 females were included. New York Heart Association functional class was IV in 9 patients (31%). Previous valve surgery had been performed in 10 patients (34%). An urgent surgery was required in 4 patients and simultaneous mitral (with aortic) valve replacement in 13 (45%). Mean follow-up period was 6.7 years. Hospital mortality occurred in 5 patients (17.2%) and all of them had acquired valvular diseases with functional class IV. There were 6 late deaths and none of them related to the tricuspid prosthesis. Nonfatal morbidity occurred in 2 patients (a thrombosed valve and a chronic hemolytic anemia) with a St. Jude valve. Late functional class was I or II in all patients except 3 with severe left-ventricular dysfunction or bioprosthetic failure. Late postoperative echocardiographic examination showed moderate tricuspid stenosis or regurgitation in 3 patients with a Carpentier-Edwards valve. By the Kaplan-Meier method, functional class (P < 0.01) and baseline diseases (p < 0.05) were found to affect probability of freedom from cardiac- and/or valve-related mortality including hospital death. In conclusion, the present study indicates that similarly good outcome would be expected whether using a St. Jude Medical valve or a Carpentier-Edwards porcine valve, and that both functional class IV and combined acquired valvular disease are risk factors for mortality after tricuspid valve replacement. Patient-specific selection of the prosthesis would be preferable in tricuspid valve replacement.
We utilized balloon compression in two cases of arterial hemorrhage from duodenal ulcers. The bleeding was quickly controlled in both cases. The advantages of this technique are its simplicity and ease of performance, and the fact that it does not require precise identification of the bleeding point in the duodenal bulb. No serious complications, such as perforation or stenosis, are associated with this technique. During the healing of the ulcer, balloon expansion may result in decreased duodenal bulb deformity. The following points, however, should be clarified in future studies: a) the stability of the duodenal bulb after longer-term balloon compression, and b) the optimum amount of cold water to be injected into the balloon and the optimum compression time.
Introduction: A quarter of patients hospitalized for heart failure either die or are re-hospitalized within 30 days. Optimization of guideline directed medical therapy (GDMT) has been shown to decrease both mortality and hospital readmissions. Methods: We used an existing heart failure clinical dashboard registry at our Veterans Affairs (VA) hospital to determine the rates of hospitalization from any medical cause and GDMT prescription rates from November to December 2022. We performed a retrospective chart review to validate dashboard results. Results: Twenty-nine patients in the registry were hospitalized within the last 30 days, with 5 patients excluded due to ongoing hospitalization; 19 were classified as heart failure with reduced ejection fraction (HFrEF, LVEF ≤ 40%), 4 as heart failure with preserved ejection fraction (LVEF ≥ 50%), and 2 unknown (no EF in 3 years). The rates of quadruple GDMT was 16% in all heart failure patients and 21% in patients with HFrEF (table 1). We performed a root cause analysis of low GDMT rates (figure 1). We used this data to secure buy-in from hospitalist medicine and cardiology to support a full-time cardiology pharmacist to screen all currently admitted patients with HFrEF. We created a standardized note template that gives recommendations for GDMT optimization prior to discharge. Conclusions: Although there is strong evidence that GDMT improves patient outcomes, many recently hospitalized patients are not optimized even after accounting for relative contraindications. We demonstrate that using tools such as a clinical dashboard and problem visualization with quality improvement methodology can both make GDMT optimization more tangible and also create buy-in from the health system to implement change.
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