Performance of Surgical Risk Scores to Predict Mortality after Transcatheter Aortic Valve Implantation

AbstractBackground:Predicting mortality in patients undergoing transcatheter aortic valve implantation (TAVI) remains a challenge.Objectives:To evaluate the performance of 5 risk scores for cardiac surgery in predicting the 30-day mortality among patients of the Brazilian Registry of TAVI.Methods:The Brazilian Multicenter Registry prospectively enrolled 418 patients undergoing TAVI in 18 centers between 2008 and 2013. The 30-day mortality risk was calculated using the following surgical scores: the logistic EuroSCORE I (ESI), EuroSCORE II (ESII), Society of Thoracic Surgeons (STS) score, Ambler score (AS) and Guaragna score (GS). The performance of the risk scores was evaluated in terms of their calibration (Hosmer–Lemeshow test) and discrimination [area under the receiver–operating characteristic curve (AUC)].Results:The mean age was 81.5 ± 7.7 years. The CoreValve (Medtronic) was used in 86.1% of the cohort, and the transfemoral approach was used in 96.2%. The observed 30-day mortality was 9.1%. The 30-day mortality predicted by the scores was as follows: ESI, 20.2 ± 13.8%; ESII, 6.5 ± 13.8%; STS score, 14.7 ± 4.4%; AS, 7.0 ± 3.8%; GS, 17.3 ± 10.8%. Using AUC, none of the tested scores could accurately predict the 30-day mortality. AUC for the scores was as follows: 0.58 [95% confidence interval (CI): 0.49 to 0.68, p = 0.09] for ESI; 0.54 (95% CI: 0.44 to 0.64, p = 0.42) for ESII; 0.57 (95% CI: 0.47 to 0.67, p = 0.16) for AS; 0.48 (95% IC: 0.38 to 0.57, p = 0.68) for STS score; and 0.52 (95% CI: 0.42 to 0.62, p = 0.64) for GS. The Hosmer–Lemeshow test indicated acceptable calibration for all scores (p > 0.05).Conclusions:In this real world Brazilian registry, the surgical risk scores were inaccurate in predicting mortality after TAVI. Risk models specifically developed for TAVI are required.

Testosterone Deficiency Increases Hospital Readmission and Mortality Rates in Male Patients with Heart Failure

Background:Testosterone deficiency in patients with heart failure (HF) is associated with decreased exercise capacity and mortality; however, its impact on hospital readmission rate is uncertain. Furthermore, the relationship between testosterone deficiency and sympathetic activation is unknown.Objective:We investigated the role of testosterone level on hospital readmission and mortality rates as well as sympathetic nerve activity in patients with HF.Methods:Total testosterone (TT) and free testosterone (FT) were measured in 110 hospitalized male patients with a left ventricular ejection fraction < 45% and New York Heart Association classification IV. The patients were placed into low testosterone (LT; n = 66) and normal testosterone (NT; n = 44) groups. Hypogonadism was defined as TT < 300 ng/dL and FT < 131 pmol/L. Muscle sympathetic nerve activity (MSNA) was recorded by microneurography in a subpopulation of 27 patients.Results:Length of hospital stay was longer in the LT group compared to in the NT group (37 ± 4 vs. 25 ± 4 days; p = 0.008). Similarly, the cumulative hazard of readmission within 1 year was greater in the LT group compared to in the NT group (44% vs. 22%, p = 0.001). In the single-predictor analysis, TT (hazard ratio [HR], 2.77; 95% confidence interval [CI], 1.58–4.85; p = 0.02) predicted hospital readmission within 90 days. In addition, TT (HR, 4.65; 95% CI, 2.67–8.10; p = 0.009) and readmission within 90 days (HR, 3.27; 95% CI, 1.23–8.69; p = 0.02) predicted increased mortality. Neurohumoral activation, as estimated by MSNA, was significantly higher in the LT group compared to in the NT group (65 ± 3 vs. 51 ± 4 bursts/100 heart beats; p < 0.001).Conclusion:These results support the concept that LT is an independent risk factor for hospital readmission within 90 days and increased mortality in patients with HF. Furthermore, increased MSNA was observed in patients with LT.

Mortality from Cardiovascular Diseases in the Elderly: Comparative Analysis of Two Five-year Periods

Background:Cardiovascular diseases are the leading cause of death in Brazil. The better understanding of the spatial and temporal distribution of mortality from cardiovascular diseases in the Brazilian elderly population is essential to support more appropriate health actions for each region of the country.Objective:To describe and to compare geospatially the rates of mortality from cardiovascular disease in elderly individuals living in Brazil by gender in two 5-year periods: 1996 to 2000 and 2006 to 2010.Methods:This is an ecological study, for which rates of mortality were obtained from DATASUS and the population rates from the Brazilian Institute of Geography and Statistics (Instituto Brasileiro de Geografia e Estatística). An average mortality rate for cardiovascular disease in elderly by gender was calculated for each period. The spatial autocorrelation was evaluated by TerraView 4.2.0 through global Moran index and the formation of clusters by the index of local Moran-LISA.Results:There was an increase, in the second 5-year period, in the mortality rates in the Northeast and North regions, parallel to a decrease in the South, South-East and Midwest regions. Moreover, there was the formation of clusters with high mortality rates in the second period in Roraima among females, and in Ceará, Pernambuco and Roraima among males.Conclusion:The increase in mortality rates in the North and Northeast regions is probably related to the changing profile of mortality and improvement in the quality of information, a result of the increase in surveillance and health care measures in these regions.

Development and Validation of Predictive Models of Cardiac Mortality and Transplantation in Resynchronization Therapy

AbstractBackground:30-40% of cardiac resynchronization therapy cases do not achieve favorable outcomes.Objective:This study aimed to develop predictive models for the combined endpoint of cardiac death and transplantation (Tx) at different stages of cardiac resynchronization therapy (CRT).Methods:Prospective observational study of 116 patients aged 64.8 ± 11.1 years, 68.1% of whom had functional class (FC) III and 31.9% had ambulatory class IV. Clinical, electrocardiographic and echocardiographic variables were assessed by using Cox regression and Kaplan-Meier curves.Results:The cardiac mortality/Tx rate was 16.3% during the follow-up period of 34.0 ± 17.9 months. Prior to implantation, right ventricular dysfunction (RVD), ejection fraction < 25% and use of high doses of diuretics (HDD) increased the risk of cardiac death and Tx by 3.9-, 4.8-, and 5.9-fold, respectively. In the first year after CRT, RVD, HDD and hospitalization due to congestive heart failure increased the risk of death at hazard ratios of 3.5, 5.3, and 12.5, respectively. In the second year after CRT, RVD and FC III/IV were significant risk factors of mortality in the multivariate Cox model. The accuracy rates of the models were 84.6% at preimplantation, 93% in the first year after CRT, and 90.5% in the second year after CRT. The models were validated by bootstrapping.Conclusion:We developed predictive models of cardiac death and Tx at different stages of CRT based on the analysis of simple and easily obtainable clinical and echocardiographic variables. The models showed good accuracy and adjustment, were validated internally, and are useful in the selection, monitoring and counseling of patients indicated for CRT.

Pulmonary Embolism Mortality in Brazil from 1989 to 2010: Gender and Regional Disparities

Abstract Background: A significant variation in pulmonary embolism (PE) mortality trends have been documented around the world. We investigated the trends in mortality rate from PE in Brazil over a period of 21 years and its regional and gender differences. Methods: Using a nationwide database of death certificate information we searched for all cases with PE as the underlying cause of death between 1989 and 2010. Population data were obtained from the Brazilian Institute of Geography and Statistics (IBGE). We calculated age-, gender- and region-specific mortality rates for each year, using the 2000 Brazilian population for direct standardization. Results: Over 21 years the age-standardized mortality rate (ASMR) fell 31% from 3.04/100,000 to 2.09/100,000. In every year between 1989 and 2010, the ASMR was higher in women than in men, but both showed a significant declining trend, from 3.10/100,000 to 2.36/100,000 and from 2.94/100,000 to 1.80/100,000, respectively. Although all country regions showed a decline in their ASMR, the largest fall in death rates was concentrated in the highest income regions of the South and Southeast Brazil. The North and Northeast regions, the lowest income areas, showed a less marked fall in death rates and no distinct change in the PE mortality rate in women. Conclusions: Our study showed a reduction in the PE mortality rate over two decades in Brazil. However, significant variation in this trend was observed amongst the five country regions and between genders, pointing to possible disparities in health care access and quality in these groups.

Mortality from Circulatory System Diseases and Malformations in Children in the State of Rio de Janeiro

Abstract Background: The epidemiological profile of mortality in a population is important for the institution of measures to improve health care and reduce mortality Objective: To estimate mortality rates and the proportional mortality from cardiovascular diseases and malformations of the circulatory system in children and adolescents. Methods: This is a descriptive study of mortality from cardiovascular diseases, malformations of the circulatory system, from all causes, ill-defined causes and external causes in children and adolescents in the state of Rio de Janeiro from 1996 to 2012. Populations were obtained from the Brazilian Institute of Geography and Statistics (Instituto Brasileiro de Geografia e Estatística - IBGE) and deaths obtained from the Department of Informatics of the Unified Health System (DATASUS)/Ministry of Health. Results: There were 115,728 deaths from all causes, 69,757 in males. The annual mortality from cardiovascular diseases was 2.7/100,000 in men and 2.6/100,000 in women. The annual mortality from malformations of the circulatory system was 7.5/100,000 in men and 6.6/100,000 in women. Among the specific causes of circulatory diseases, cardiomyopathies had the highest rates of annual proportional mortality, and from malformations of the circulatory system, it occurred due to unspecified malformations of the circulatory system, at all ages and in both genders. Conclusion: Mortality from malformations of the circulatory system was most striking in the first years of life, while cardiovascular diseases were more relevant in adolescents. Low access to prenatal diagnosis or at birth probably prevented the proper treatment of malformations of the circulatory system.

Transcatheter Aortic Valve Implantation and Morbidity and Mortality-Related Factors: a 5-Year Experience in Brazil

Abstract Background: Transcatheter aortic valve implantation has become an option for high-surgical-risk patients with aortic valve disease. Objective: To evaluate the in-hospital and one-year follow-up outcomes of transcatheter aortic valve implantation. Methods: Prospective cohort study of transcatheter aortic valve implantation cases from July 2009 to February 2015. Analysis of clinical and procedural variables, correlating them with in-hospital and one-year mortality. Results: A total of 136 patients with a mean age of 83 years (80-87) underwent heart valve implantation; of these, 49% were women, 131 (96.3%) had aortic stenosis, one (0.7%) had aortic regurgitation and four (2.9%) had prosthetic valve dysfunction. NYHA functional class was III or IV in 129 cases (94.8%). The baseline orifice area was 0.67 ± 0.17 cm2 and the mean left ventricular-aortic pressure gradient was 47.3±18.2 mmHg, with an STS score of 9.3% (4.8%-22.3%). The prostheses implanted were self-expanding in 97% of cases. Perioperative mortality was 1.5%; 30-day mortality, 5.9%; in-hospital mortality, 8.1%; and one-year mortality, 15.5%. Blood transfusion (relative risk of 54; p = 0.0003) and pulmonary arterial hypertension (relative risk of 5.3; p = 0.036) were predictive of in-hospital mortality. Peak C-reactive protein (relative risk of 1.8; p = 0.013) and blood transfusion (relative risk of 8.3; p = 0.0009) were predictive of 1-year mortality. At 30 days, 97% of patients were in NYHA functional class I/II; at one year, this figure reached 96%. Conclusion: Transcatheter aortic valve implantation was performed with a high success rate and low mortality. Blood transfusion was associated with higher in-hospital and one-year mortality. Peak C-reactive protein was associated with one-year mortality.

Trends in Mortality Rate from Cardiovascular Disease in Brazil, 1980-2012

Abstract Background: Studies have questioned the downward trend in mortality from cardiovascular diseases (CVD) in Brazil in recent years. Objective: to analyze recent trends in mortality from ischemic heart disease (IHD) and stroke in the Brazilian population. Methods: Mortality and population data were obtained from the Brazilian Institute of Geography and Statistics and the Ministry of Health. Risk of death was adjusted by the direct method, using as reference the world population of 2000. We analyzed trends in mortality from CVD, IHD and stroke in women and men in the periods of 1980-2006 and 2007-2012. Results: there was a decrease in CVD mortality and stroke in women and men for both periods (p < 0.001). Annual mortality variations for periods 1980-2006 and 2007-2012 were, respectively: CVD (total): -1.5% and -0.8%; CVD men: -1.4% and -0.6%; CVD women: -1.7% and -1.0%; DIC (men): -1.1% and 0.1%; stroke (men): -1.7% and -1.4%; DIC (women): -1.5% and 0.4%; stroke (women): -2.0% and -1.9%. From 1980 to 2006, there was a decrease in IHD mortality in men and women (p < 0.001), but from 2007 to 2012, changes in IHD mortality were not significant in men [y = 151 + 0.04 (R2 = 0.02; p = 0.779)] and women [y = 88-0.54 (R2 = 0.24; p = 0.320). Conclusion: Trend in mortality from IHD stopped falling in Brazil from 2007 to 2012.

Sexual and asexual reproduction in Didemnum rodriguesi (Ascidiacea, Didemnidae)

Sexual and asexual reproduction and associated population dynamics were investigated in the colonial ascidian Didemnum rodriguesi Rocha & Monniot, 1993 (Didemnidae) in southern Brazil. Investment in sexual (production of new individuals) and asexual (colony growth) reproduction was compared between seasons. Permanently marked quadrats were repeatedly photographed to measure changes in colonies. Eggs and larvae were counted monthly in collected colonies. This species alternates seasonally between sexual (summer) and asexual (winter) reproduction. In summer, colonies were smaller, brooded eggs and larvae and recruitment rates were greater, while in winter, colony size was larger and eggs and larvae were absent. There is a relationship between fecundity and colony area. Fragmentation and fusion of colonies were similar in summer and winter, as well as mortality. In conclusion, D. rodriguesi has a lifecycle usual for high latitude ascidians with a limited time length for sexual reproduction and alternate investment in sexual and asexual reproduction along the year.

Influência de elementos climáticos na mortalidade de cidades brasileiras

In this paper, preliminary to a series of investigations that the A. has the purpose to make about the influence of climatic factors particularly upon the prevalence of the most important acute infectious diseases in Brazil, he raises the question whether such factors do affect in this country the total death rates, as it is reasonable to suppose, according to what has been observed in temperate zones of northern and southern hemispheres. The inclusion of absolute humidity among other climatic factors to be dealt with seems justifiable according to Rogers and Stallybrass. Owing to scarcety of reliable data the A. was obliged to limit to a five-years period (1940-1944) the complete proposed investigation, which includes seven of the most important cities, scattered throughout the brazilian territory, from north to south - Belém, recife, Salvador, Rio, S. Paulo, Curitiba and Porto Alegre. Reference is made to their normal climatic conditions and monthly death-rates variations with their mean values and standard deviations. In a first part dealing with seasonal variations only for purposes of comparison, he points out that in there tropical cities of Brazil, without very clear seasonal differentiation, the curve of general mortality reached its highest point in austral autumn season and the remaining four (including Rio near the tropic) in the spring, with the exception of Curitiba, where the peak coincided with the summer season. He shows how such important causes of deaths, as diarrheas, common respiratory diseases and tuberculosis, whose seasonal distribution for each one of the seven cities is referred, may explain such seasonal variations. On a second part, a study is made of the general mortality distribution by four-months periods selected in accordance respectively with the highest or lowest values of rainfall and of mean temperature and humidity during period 1940-1944. Finally he compares the monthly waves of such climatic factors and the corresponding waves of total death - rates and finds through correlation coefficients 17 significant values with respect to their standard errors. Variations in the death - rates seemed to be perhaps more closely and uniformly associated with variations of mean humidity, as is indicated by coefficients ranging from + 0.3 to 0.6.

Spatial and seasonal trends of a natural population of Biomphalaria occidentalis in northeastern Argentina

This study aims to analyze the age of a population of Biomphalaria occidentalis on a pound of Riachuelo river basin, wich is one of the three most important Middle Paraná river affluents in Corrientes province. Samples were drawn from three stations, were spatial and temporal numerical variations of the snail, as well as its relation with different environmental parameters, mainly temperature, rainfall, pH and conductivity, were analyzed. Snail abundance is given in number of individuals/hour. The differences between the three sampling stations, estimated by nonparametric tests, was nonsignificant. A relative scale to the greatest shell diameter was employed to build the age pyramids. Temporal fluctuations of snail abundance correlated negatively with the highest monthly accumulated temperatures (P < 0.05). Although different floristic compositions were observed at the three stations, no significant numerical variations were detected in B. occidentalis spatial distribution. Reproductive activity took place between March-April and November with overlapping cohort system. During summer (December-Febuary) mortality increased along with temperature and reproductive activity was not evident.

Influence of short time exposure to an insect growth regulator, hexaflumuron, on mortality and adult emergence of vector mosquitoes

Hexaflumuron, an insect growth regulator (IGR), was found to greatly affect the development of immatures and emergence of adults of three species of vector mosquitoes, Culex quinquefasciatus, Aedes aegypti and Anopheles stephensi, when larvae were subjected to short time exposure of < or = 1h. This IGR could completely prevent adult emergence even at a minimum exposure time of 10 min at 0.001, 0.01 and 0.1 mg/l. On treatment, larval and pupal mortality as well as varying degrees of morphogenetic abnormalities were induced in immatures and adults of the three species. Four weeks of control achieved in a slow moving sullage canal breeding Culex quinquefasciatus indicates that this IGR can be of use in such breeding habitats.

Chagas Disease Vector Control in Tupiza, Southern Bolivia

Heavy domestic and peridomestic infestations of Triatoma infestans were controlled in two villages in southern Bolivia by the application of deltamethrin SC25 (2.5% suspension concentrate) at a target dose of 25 mg a.i./m². Actual applied dose was monitored by HPLC analysis of filter papers placed at various heights on the house walls, and was shown to range from 0 to 59.6 about a mean of 28.5 mg a.i./m². Wall bioassays showed high mortality of T. infestans during the first month after the application of deltamethrin. Mortality declined to zero as summer temperatures increased, but reappeared with the onset of the following winter. In contrast, knockdown was apparent throughout the trial, showing no discernible temperature dependence. House infestation rates, measured by manual sampling and use of paper sheets to collect bug faeces, declined from 79% at the beginning of the trial to zero at the 6 month evaluation. All but one of the houses were still free of T. infestans at the final evaluation 12 months after spraying, although a small number of bugs were found at this time in 5 of 355 peridomestic dependencies. Comparative cost studies endorse the recommendation of large-scale application of deltamethrin, or pyrethroid of similar cost-effectiveness, as a means to eliminate domestic T. infestans populations in order to interrupt transmission of Chagas disease

Field Monitoring of Cypermethrin Residual Effect on the Mortality Rates of the Phlebotomine Sand Fly Lutzomyia longipalpis in the State of Paraíba, Brazil

In a visceral leishmaniasis endemic locality of northeast of Brasil where all settlements were treated with cypermethrin, a follow-up of Lutzomyia longipalpis populations was carried out by regular collections. The residual effect of the insecticide was studied using biological assays on three different types of walls. The results showed that the insecticides had an effect on intradomiciliar Lu. longipalpis populations limited to two months, and had no significant effect on peridomiciliar vector populations. The mortality rates of the tested sandflies were variable according to the type of wall. The decreasing of the insecticide effect was marked since the 3rd month, and mortality rates were identical whatever the type of wall since the 4th month. Unsufficient residual effect was detected after the 4th month.