Clinical, angiographic, echocardiographic and electrophysiologic data were examined in 101 patients with a history of sustained ventricular arrhythmia not associated with acute myocardial infarction. These patients included 66 survivors of out of hospital cardiac arrest and 35 patients presenting with hemodynamically well tolerated sustained ventricular tachycardia. On univariate analysis, patients in the cardiac arrest group had a lower incidence of previous myocardial infarction and left ventricular aneurysm and a higher ejection fraction compared with the ventricular tachycardia group. During electrophysiologic testing, the arrhythmia induced in the patients in the cardiac arrest group was fast and polymorphic and frequently degenerated into ventricular fibrillation. In contrast, in the ventricular tachycardia group, a slower, monomorphic and hemodynamically well tolerated ventricular tachycardia was commonly induced. On multivariate analysis, a polymorphic pattern of the induced ventricular arrhythmia was the only independent variable that distinguished the survivors of cardiac arrest from those presenting with sustained ventricular tachycardia. These results suggest that 1) the survivors of cardiac arrest and patients presenting with sustained well tolerated ventricular tachycardia are clinically distinct groups; and 2) the polymorphic tachycardia induced during programmed electrical stimulation in the survivors of cardiac arrest may indicate an unstable tachycardia mechanism. This may explain why these patients present with ventricular fibrillation and cardiac arrest, whereas others present with hemodynamically stable ventricular tachycardia.
An ADS can provide safe CIED management for surgery, but it requires specialized provider training and strong support from the EPCS. Due to the complexity of CIED management, an ADS will likely only be feasible in high-volume settings.
To determine presurgical immune state, the authors used mass cytometry to quantify cell type-specific intracellular signaling responses to ex vivo ligands in presurgical blood samples. These ligands include lipopolysaccharide, IL-6, IL-10, and IL-2/granulocyte macrophage colony-stimulating factor, which have all previously been found to modulate signaling processes in specific immune cells that are perturbed by surgery. Clinical outcomes were measured before surgery, daily during hospitalization, and every third day for up to 6 weeks after hospital discharge. Fatigue and functional impairment were scored using the surgical recovery scale, whereas function of the operated hip and pain was measured using the Western Ontario and McMaster Universities Arthritis Index scale.The final analysis set included 25 patients. Immune correlates accounted for 15% to 50% of observed patient variability in functional recovery and regression of pain. Correlations were identified between signaling activities in cluster differentiation (CD)14 + monocytes, dendritic cells, and granulocytes for 2 clinical recovery parameters: time required to regress to mild functional impairment of the operated hip and time required to regress to mild pain. In particular, lipopolysaccharide-evoked signaling responses (pMAPKAPK2, pCREB, and prpS6) in dendritic cells and CD14 + monocytes were associated with prolonged recovery of the operated hip and slower resolution of postoperative pain (|R| = 0.39-0.70, intermediate-to-strong correlation; false discovery rate < 0.01). In addition, IL-2/ granulocyte macrophage colony-stimulating factor signaling responses in plasmocytoid dendritic cells and granulocytes (pERK, p90RSK, pMAPKAPK2) were correlated with shortened functional recovery of the operated hip (|R| = 0.39-0.54). Immune correlates were similar in both presurgical and postsurgical blood samples.In summary, the authors found that evoked signaling response in innate cells of myeloid lineage was the strongest indicators of the recovery process. These identified immune correlates may provide a mechanistic framework for developing a diagnostic test that will predict speed of functional recovery after hip arthroplasty.
COMMENTClinicians are well aware that postoperative recovery is extremely variable among patients having similar surgical operations. If we could risk-stratify patients based on their predicted recovery profile, it would facilitate patient-individualized and cost-conscious approaches to perioperative care. Specifically, patients might be better empowered to make appropriate arrangements for their postoperative needs. Indeed, patients at risk for protracted recovery could be stratified to resource-intense interventions, such as prehabilitation programs, in an attempt to expedite their recovery.This study from Stanford University identified that immune cell type-specific states and activation after surgery explained much of the interindividual differences in outcomes. Importantly, in an analysis of the same groups of orthopedic surgery pat...
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