Transapical aortic valve replacement in extreme-risk patients: outcome, risk factors and mid-term results.

OBJECTIVES: Transcatheter aortic valve replacement (TAVR) provides good results in selected high-risk patients. However, it is unclear whether this procedure carries advantages in extreme-risk profile patients with logistic EuroSCORE above 35%. METHODS: From January 2009 to July 2011, of a total number of 92 transcatheter aortic valve procedures performed, 40 'extreme-risk' patients underwent transapical TAVR (TA-TAVR) (EuroSCORE above 35%). Variables were analysed as risk factors for hospital and mid-term mortality, and a 2-year follow-up (FU) was obtained. RESULTS: The mean age was: 81 ± 10 years. Twelve patients (30%) had chronic pulmonary disease, 32 (80%) severe peripheral vascular disease, 14 (35%) previous cardiac surgery, 19 (48%) chronic renal failure (2 in dialysis), 7 (17%) previous stroke (1 with disabilities), 3 (7%) a porcelain aorta and 12 (30%) were urgent cases. Mean left ventricle ejection fraction (LVEF) was 49 ± 13%, and mean logistic EuroSCORE was 48 ± 11%. Forty stent-valves were successfully implanted with six Grade-1 and one Grade-2 paravalvular leakages (success rate: 100%). Hospital mortality was 20% (8 patients). Causes of death following the valve academic research consortium (VARC) definitions were: life-threatening haemorrhage (1), myocardial infarction (1), sudden death (1), multiorgan failure (2), stroke (1) and severe respiratory dysfunction (2). Major complications (VARC definitions) were: myocardial infarction for left coronary ostium occlusion (1), life-threatening bleeding (2), stroke (2) and acute kidney injury with dialysis (2). Predictors for hospital mortality were: conversion to sternotomy, life-threatening haemorrhage, postoperative dialysis and long intensive care unit (ICU) stay. Variables associated with hospital mortality were: conversion to sternotomy (P = 0.03), life-threatening bleeding (P = 0.02), acute kidney injury with dialysis (P = 0.03) and prolonged ICU stay (P = 0.02). Mean FU time was 24 months: actuarial survival estimates for all-cause mortality at 6 months, 1 year, 18 months and 2 years were 68, 57, 54 and 54%, respectively. Patients still alive at FU were in good clinical condition, New York Heart Association (NYHA) class 1-2 and were never rehospitalized for cardiac decompensation. CONCLUSIONS: TA-TAVR in extreme-risk patients carries a moderate risk of hospital mortality. Severe comorbidities and presence of residual paravalvular leakages affect the mid-term survival, whereas surviving patients have an acceptable quality of life without rehospitalizations for cardiac decompensation.

Formas de fósforo no solo em sistemas de milho exclusivo e consorciado com feijão sob adubação orgânica e mineral

Os sistemas de manejo do solo modificam a dinâmica do fósforo alterando o conteúdo das diferentes formas de P. Objetivou-se avaliar o efeito de sistemas de cultivo em longo prazo (16 anos de plantio) sobre as diferentes formas de P no solo. Os tratamentos constaram de combinações entre dois sistemas de cultivo: milho exclusivo (M) e milho consorciado com feijão (MF), com duas doses (0 e 40 m³ ha-1 ano-1) de adubo orgânico (AO), e três doses (0, 250 e 500 kg ha-1) de N-P-K, 4-14-8 (AM). Solo sob um fragmento de Floresta Atlântica foi utilizado como referência de um estado em equilíbrio. Os valores de P orgânico total (Pot) variaram de 184,2 a 280,2 e de 147,9 a 282,9 mg kg-1, em amostras de solo das camadas de 0-10 e 10-20 cm, respectivamente, sendo os maiores valores observados para combinação 500 kg ha-1 + adubação orgânica, correspondendo, em média, a 26,4 % do P total no solo. Houve tendência da relação C/Pot manter-se constante, entre os tratamentos, constatando-se aumento dos valores de Pot com o aumento do teor de carbono orgânico total no solo. O adubo mineral promoveu incremento do P na biomassa microbiana (Pbm) apenas no sistema de milho exclusivo. Em média, o aumento do Pbm foi de 262 e 164 % para o sistema que recebeu o composto orgânico no sistema de milho exclusivo e consorciado com feijão, respectivamente. Em média, a fração de P orgânico solúvel em meio ácido correspondeu a 90 % do Pot predominando sobre a fração solúvel em base. Nos tratamentos com 500 kg ha-1 de 4-14-8 e 500 kg ha-1 + composto orgânico, no sistema de consórcio, foram obtidos aumentos nos valores de P total lábil de 53 e 157 %, respectivamente, comparados aos da testemunha. O P orgânico lábil (Pol) correspondeu, em média, a 3,7 % do Pot para os sistemas de cultivo, já para a Floresta Atlântica, esta relação foi de 10,7 %, nas duas profundidades. Os aumentos nos teores das formas mais lábeis de P, proporcionados pela adubação orgânica, evidenciam a importância deste sistema de manejo no favorecimento da ciclagem de P.

Anemia and brain oxygen after severe traumatic brain injury.

PURPOSE: To investigate the relationship between hemoglobin (Hgb) and brain tissue oxygen tension (PbtO(2)) after severe traumatic brain injury (TBI) and to examine its impact on outcome. METHODS: This was a retrospective analysis of a prospective cohort of severe TBI patients whose PbtO(2) was monitored. The relationship between Hgb-categorized into four quartiles (≤9; 9-10; 10.1-11; >11 g/dl)-and PbtO(2) was analyzed using mixed-effects models. Anemia with compromised PbtO(2) was defined as episodes of Hgb ≤ 9 g/dl with simultaneous PbtO(2) < 20 mmHg. Outcome was assessed at 30 days using the Glasgow outcome score (GOS), dichotomized as favorable (GOS 4-5) vs. unfavorable (GOS 1-3). RESULTS: We analyzed 474 simultaneous Hgb and PbtO(2) samples from 80 patients (mean age 44 ± 20 years, median GCS 4 (3-7)). Using Hgb > 11 g/dl as the reference level, and controlling for important physiologic covariates (CPP, PaO(2), PaCO(2)), Hgb ≤ 9 g/dl was the only Hgb level that was associated with lower PbtO(2) (coefficient -6.53 (95 % CI -9.13; -3.94), p < 0.001). Anemia with simultaneous PbtO(2) < 20 mmHg, but not anemia alone, increased the risk of unfavorable outcome (odds ratio 6.24 (95 % CI 1.61; 24.22), p = 0.008), controlling for age, GCS, Marshall CT grade, and APACHE II score. CONCLUSIONS: In this cohort of severe TBI patients whose PbtO(2) was monitored, a Hgb level no greater than 9 g/dl was associated with compromised PbtO(2). Anemia with simultaneous compromised PbtO(2), but not anemia alone, was a risk factor for unfavorable outcome, irrespective of injury severity.

Trends in food availability in Switzerland, 1961-2007.

Trends in food availability in Switzerland were assessed using the Food and Agricultural Organization food balance sheets for the period 1961-2007. A relatively stable trend in the daily caloric supply was found: 3545 kcal/day in 1961 and 3465 kcal/day in 2007. Calories associated with carbohydrates decreased (slope±s.e.: -1.1±0.2 kcal/day/year), namely regarding cereals (-2.9±0.6 kcal/day/year) and fruit (-1.5±0.1 kcal/day/year), while the availability of sugars increased (1.2±0.5 kcal/day/year). In 1961, protein, fat, carbohydrates and alcohol represented 10.6, 33.5, 50.0 and 5.9% of total caloric supply, respectively; in 2007, the values were 10.8, 40.3, 43.7 and 5.2%. In 1961, palm, groundnut and sunflowerseed oil represented 3.4, 30.7 and 5.3% of total vegetable oils, respectively; in 2007, the values were 10.4, 3.7 and 31.6%. We conclude that between 1961 and 2007 total caloric availability remained relatively stable in Switzerland; the health effects of the increased and differing fat availability should be evaluated.