The Penn classification of acute type A aortic dissection enabled stratification of patients by operative mortality risk. The system requires further validation, but might facilitate new ways to analyze mortality data for this disorder.
Background: The care pathway for patients undergoing transcatheter aortic valve replacement (TAVR), particularly in the US, was initially based on open surgical techniques and often includes general anesthesia, transesophageal echocardiographic monitoring, and cardiothoracic intensive care unit (ICU) stays. Whether a subgroup of patients could benefit from early extubation, fewer days in the ICU, and early ambulation in terms of both cost and effectiveness is unknown. Methods and Results: A fast track (FT) protocol was initiated at two institutions in our health system with specific inclusion criteria. Patients with complications or morbidity post procedure deemed ineligible to continue on the FT pathway were designated as deviations. Baseline characteristics, success and deviations, subsequent course, and direct costs were compared for FT eligible and ineligible patients over a 6-month study period. Among 99 patients undergoing Transfemoral TAVR, 39 (39%) met FT inclusion criteria. The mean age of eligible and ineligible patients was similar at 85 years, but by design, eligible patients had fewer co-morbid conditions. Successful completion of the FT protocol was achieved in 28 patients (72%). Patients on the FT had shorter ICU stays (28 6 103 vs 45 6 46 hours, P < 0.0001) and post-operative length of stay (4.3 6 4.4 vs 7.2 6 5.3 days, P < 0.0001), and incurred lower direct costs ($44,923 6 $14,187 vs $56, 339 6 17,808, P < 0.0001). Conclusions: It is feasible to identify a large percentage of suitable patients preprocedure who are eligible for a FT postprocedure care pathway. There was no evidence for compromise of care and successful completion of the pathway was associated with shorter length of stay and fewer direct costs. V C 2014 Wiley Periodicals, Inc.
Ascending aortic dilatation is diagnosed in almost one-fourth of patients treated with TAVI. Their intraprocedural risk of adverse aortic events is low. The ascending aortic dilatation does not affect mid-term survival in the TAVI population.
Summary:Three patients with leptospirosis whose condition worsened after initiation of antibiotic therapy are reported. Their clinical deterioration appeared to be due to the development of the Jarisch-Herxheimer reaction rather than to progression oftheir underlying infection. Relevant aspects of the management of patients with leptospirosis are discussed.
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