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Biomedical subjects

Patrick T O'Gara

Publications and source records attributed to Patrick T O'Gara.

At least 19 recordsLinked to original sources
PubMed2006

ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (writing Committee to Revise the 1998 guidelines for the management of patients with valvular heart disease) developed in collaboration with the Society of Cardiovascular Anesthesiologists endorsed by the Society for Cardiovascular Angiography and Interventions and the Society of Thoracic Surgeons.

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Heart Valve Diseases↗
PubMed2006

ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (writing committee to revise the 1998 Guidelines for the Management of Patients With Valvular Heart Disease): developed in collaboration with the Society of Cardiovascular Anesthesiologists: endorsed by the Society for Cardiovascular Angiography and Interventions and the Society of Thoracic Surgeons.

Explore the source record for details and available documents.

Adolescent↗
PubMed2006

Valvular heart disease in pregnancy.

Women with valvular disease who are pregnant or planning to conceive require careful evaluation and management. Pregnancy is associated with normal physiologic changes that can aggravate many valvular conditions and may require the initiation or increase of cardiovascular medications to manage fluid overload or arrhythmias. Most women will tolerate pregnancy and delivery without major complication, though some types of valvular heart disease are poorly tolerated and require more intensive management, or even termination of the pregnancy. In addition, patients at risk of thromboembolism and those who have prosthetic cardiac valves require anticoagulation. The decision regarding the choice and intensity of anticoagulation requires careful balance between the individual risks of thrombosis and bleeding in the mother and harm to the fetus.

Female↗
PubMed2006

Infective endocarditis: diagnosis and management.

Despite advances in antimicrobial therapy, diagnostic imaging and cardiac surgery, infective endocarditis (IE) remains challenging clinically and is associated with high morbidity and mortality. Diagnosis relies on several factors: initial clinical suspicion, microbiological data and echocardiographic findings. The use of an integrated diagnostic schema, such as the modified Duke criteria, is useful. Transthoracic or transesophageal echocardiography should be performed promptly for all suspected IE cases. Although the choice of investigation might be influenced by availability, the approach to imaging should be tailored to the individual's clinical situation. Promptly administered intravenous antimicrobial therapy is essential, while the use of antiplatelet or antithrombin therapy to prevent embolic complications is not supported by clinical data. Deciding whether to undertake cardiac surgery for the treatment of IE can be extremely difficult. The principal indications are the development of heart failure from acute, severe aortic or mitral regurgitation, or perivalvular extension of infection. The timing of surgery following central nervous system embolization is problematic because of the risk of hemorrhagic transformation. Prophylactic surgery to prevent embolization is currently advocated only for the management of large, mobile vegetations, when undertaken at centers performing high volumes of heart valve surgery. In this review, we describe diagnostic approaches for IE, particularly echocardiography, and provide recommendations for treatment, paying particular attention to surgery in the acute setting.

Anti-Infective Agents↗
PubMed2005

Implications of periaortic hematoma in patients with acute aortic dissection (from the International Registry of Acute Aortic Dissection).

The clinical profiles, presentation, and outcomes of patients with acute aortic dissections and associated periaortic hematomas on aortic imaging have not been described in a large cohort. This study sought to assess the prognostic implications of periaortic hematomas in patients with aortic dissections and to identify factors associated with in-hospital mortality in patients with periaortic hematomas. The study population was 971 patients with acute aortic dissections enrolled in the International Registry of Acute Aortic Dissection with available imaging data on presentation with the presence or absence of periaortic hematomas. Patients with periaortic hematomas (n = 227, 23.4%) were more likely to be women, to have a history of hypertension and atherosclerosis, and to present early to the hospital. At presentation, they had greater frequencies of shock, cardiac tamponade, coma, and/or altered consciousness. Clinical outcomes were significantly worse in patients with periaortic hematomas, including significantly greater mortality (33% vs 20.3%, p <0.001). A multivariate model demonstrated periaortic hematomas to be an independent predictor of mortality in patients with aortic dissections (odds ratio 1.71, 95% confidence interval 1.15 to 2.54, p = 0.007). In conclusion, this study provides insight into the profiles, presentation, and outcomes of patients with periaortic hematomas and acute aortic dissections. The early identification and aggressive management of patients with periaortic hematomas may potentially improve clinical outcomes.

Acute Disease↗
PubMed2005

Acute intramural hematoma of the aorta: a mystery in evolution.

BACKGROUND: The definition, prevalence, outcomes, and appropriate treatment strategies for acute intramural hematoma (IMH) continue to be debated. METHODS AND RESULTS: We studied 1010 patients with acute aortic syndromes who were enrolled in the International Registry of Aortic Dissection (IRAD) to delineate the prevalence, presentation, management, and outcomes of acute IMH by comparing these patients with those with classic aortic dissection (AD). Fifty-eight (5.7%) patients had IMH, and this cohort tended to be older (68.7 versus 61.7 years; P<0.001) and more likely to have distal aortic involvement (60.3% versus 35.3%; P<0.001) compared with 952 patients with AD. Patients with IMH described more severe initial pain than did those with AD but were less likely to have ischemic leg pain, pulse deficits, or aortic valve insufficiency; moreover, they required a longer time to diagnosis and more diagnostic tests. Overall mortality of IMH was similar to that of classic AD (20.7% versus 23.9%; P=0.57), as was mortality in patients with IMH of the descending aorta (8.3% versus 13.1%; P=0.60) and the ascending aorta (39.1% versus 29.9%; P=0.34) compared with AD. IMH limited to the aortic arch was seen in 7 patients, with no deaths, despite medical therapy in only 6 of the 7 individuals. Among the 51 patients whose initial diagnostic study showed IMH only, 8 (16%) progressed to AD on a serial imaging study. CONCLUSIONS: The IRAD data demonstrate a 5.7% prevalence of IMH in patients with acute aortic syndromes. Like classic AD, IMH is a highly lethal condition when it involves the ascending aorta and surgical therapy should be considered, but this condition is less critical when limited to the arch or descending aorta. Fully 16% of patients have evidence of evolution to dissection on serial imaging.

Acute Disease↗
PubMed2005

Does circadian and seasonal variation in occurrence of acute aortic dissection influence in-hospital outcomes?

The risk of acute aortic dissection (AAD) exhibits chronobiological variations with peak onset in the morning and in winter. However, it is not known whether the time of day or season of the year of the AAD affects clinical outcomes. We studied 1,032 patients enrolled in the International Registry of Acute Aortic Dissection from January 1997 to December 2001. For circadian and seasonal analysis, the time and date of symptom onset were available for 741 and 1,007 patients, respectively, and were grouped into four 6h periods (morning, afternoon, evening, and night) and four seasons (winter, spring, summer, and autumn). The chi2 test for goodness of fit was used to evaluate non-uniformity of the time of day and time of year for critical in-hospital clinical events, including death. While highest incidence of AAD occurred in the morning and winter, clinical events (including mortality) were similar during the four different periods of the 24 h (chi2 = 1.9, p = 0.60) and seasonal (chi2 = 1.2, p = 0.75) periods.

Aged↗
PubMed2004

Differences in clinical presentation, management, and outcomes of acute type a aortic dissection in patients with and without previous cardiac surgery.

BACKGROUND: There are less data on the clinical and diagnostic imaging characteristics, management, and outcomes of patients with previous cardiac surgery (PCS) presenting with acute type A aortic dissection (AAD). METHODS AND RESULTS: In 617 patients with AAD, we evaluated the differences in the clinical characteristics, management, and in-hospital outcomes of the cohorts with and without PCS. A history of PCS was present in 100 of 617 patients. Patients with PCS were more likely to be males (P=0.02), older (P=0.014), and to have a history of previous aortic dissection (P<0.001) or aneurysms (P<0.001). In contrast, PCS patients were less likely to have presenting chest pain (P<0.001). Cardiac tamponade was less common in PCS patients (P=0.007). Fewer AAD patients with PCS underwent surgical repair (P=0.001). Hospital mortality was not adversely influenced by PCS (odds ratio [OR], 1.46; 95% confidence interval [CI], 0.81 to 2.63), but a trend for increased death was seen in patients with previous aortic valve replacement (AVR) (OR, 2.31; 95% CI, 0.98 to 5.43). Age 70 years or older, previous AVR, shock, and renal failure identified PCS patients at risk for death. CONCLUSIONS: Our study highlights differences in clinical characteristics, management, and outcomes of AAD patients with PCS. Importantly, PCS, with the exception of previous AVR, does not adversely influence early outcomes of AAD patients, including those undergoing surgical repair. However, because of otherwise dismal outcomes with medical management of AAD, our data indicate that a history of PCS (even that of previous AVR) should not preclude physicians from recommending surgical correction of type A aortic dissection in appropriate patients.

Acute Kidney Injury↗
PubMed2004

Comparison of aortic dissection in patients with and without Marfan's syndrome (results from the International Registry of Aortic Dissection).

Among 1,049 patients diagnosed with aortic dissection in a multinational registry, patients with Marfan's syndrome were typically younger and had unique presentations. Despite their younger age at presentation, patients with Marfan's syndrome and aortic dissection had a high mortality rate, similar to patients without Marfan's syndrome, an older patient cohort. Our data support the importance of aneurysm surveillance and prophylactic surgical intervention for patients with Marfan's syndrome to potentially reduce the risk of mortality.

Adult↗
PubMed2004

Acute type B aortic dissection in elderly patients: clinical features, outcomes, and simple risk stratification rule.

BACKGROUND: The clinical features and outcomes of elderly patients with acute type B aortic dissection (ABAD) are less well known. Accordingly, we sought to evaluate the clinical features and outcomes and derive a simple risk stratification rule for elderly with ABAD. METHODS: We categorized 383 patients with ABAD enrolled in the International Registry of Acute Aortic Dissection into two strata (aged less than 70 years and aged 70 years or more) and compared their clinical features and in-hospital outcomes. Further, we developed a clinical decision rule to risk-stratify elderly with ABAD. RESULTS: Forty-two percent (161 of 383) of patients with ABAD were aged 70 years or more. Hypertension, diabetes, history of prior aortic aneurysm, and arteriosclerosis were more common in the elderly patients, whereas Marfan syndrome and cocaine abuse were less common. The in-hospital complication of hypotension/shock was more common among elderly, and malperfusion of a visceral organ less frequent among elderly patients. In-hospital mortality was higher in the elderly cohort compared with the younger patients (16% versus 10%, p = 0.07). A classification tree identified that elderly patients with hypotension/shock had the highest risk of death (56%). In absence of this, any branch vessel involvement was associated with the next highest mortality rate (28.6%) followed by presence of periaortic hematoma (10.5%). In contrast, elderly patients without any of these three risk factors had an extremely low mortality rate (1.3%). CONCLUSIONS: Our study highlights important differences between older and younger patients with ABAD in their clinical characteristics, management, and outcomes. We also propose a simple decision rule that allows stepwise risk-stratification in elderly patients with ABAD.

Aged↗
PubMed2004

Branch vessel complications are increased in aortic dissection patients with renal insufficiency.

Morbidity and mortality from aortic dissection remain high despite advances in diagnosis and treatment. Simple markers to identify patients at high risk for non-aortic complications of dissection are lacking. We investigated the effect of renal insufficiency on the presentation, complications, and outcome of patients with acute aortic dissection. We evaluated 638 patients with type A and 365 patients with type B aortic dissection enrolled in the International Registry of Acute Aortic Dissection (IRAD) between January 1996 and December 2000. Chi-squared and Student's ttesting were performed to identify the effect of renal insufficiency on patient presentation, management, and outcome. Patients with renal insufficiency more often required nitroprusside for blood pressure control (type A: 40.7% vs 31.1%, p = 0.049; type B: 66.7% vs 37.3, p = 0.0001) and had a greater risk of mesenteric ischemia (type A: 10.7% vs 1.4%, p < 0.0001; type B: 17.7% vs 3.0%, p < 0.0001). In conclusion, aortic dissection patients with renal insufficiency are at increased risk for drug-resistant hypertension and aortic branch vessel compromise. Routine measurement of serum creatinine provides a readily accessible clinical marker for important complications. Upon recognition, renal impairment indicates a need for close monitoring, aggressive blood pressure control, and evaluation of aortic branch vessel circulations.

Acute Disease↗
PubMed2004

Tailored surgical therapy for acute native mitral valve endocarditis.

BACKGROUND AND AIM OF THE STUDY: Mitral valve repair has been shown superior to valve replacement for the treatment of non-infectious valve disease. The criteria and results of valve repair for native valve endocarditis are still being defined. The study aim was to examine the short- and long-term results of mitral valve repair and replacement for acute infective endocarditis and to define criteria for the use of each technique. METHODS: A total of 53 consecutive patients who presented with acute native mitral valve infective endocarditis (diagnosed less than six weeks before surgery) between January 1992 and June 2002 was retrospectively analyzed. RESULTS: Twenty-one patients (40%) underwent mitral valve repair, and 32 (60%) underwent valve replacement. Operative mortality was 0% for the repair group and 13% (4/32) for the replacement group (p = 0.14). Median follow up was 4 years (range: 6-108 months). At five years follow up, a median ejection fraction (EF) of 60% and mitral regurgitation (MR) grade of 1/4 was observed, with an overall late survival of 85% (19/21), in the repair group, while the replacement group had a median EF of 55% and an overall late survival of 73% (p = 0.73). Recurrent endocarditis occurred in 2/21 (10%) in the repair group and 1/32 (3%) in the replacement group (p = 0.34). CONCLUSION: Mitral valve repair is a safe and effective technique to treat acute native mitral valve infective endocarditis with favorable short- and long-term morbidity and mortality. Patients with advanced endocarditis and annular destruction require valve replacement. Mitral valve repair should be performed when technically feasible.

Acute Disease↗