Sentara Norfolk General Hospital (SNGH) is a large academic hospital, which serves as the primary teaching institution for the adjacent Eastern Virginia Medical School. Located in Norfolk, Virginia, in the Ghent neighborhood and adjacent to Downtown, the hospital serves as the Hampton Roads region's only Level I trauma center. The hospital is interconnected to the Sentara Heart Hospital, however, it is considered a separate institution. Together with the adjacent Children's Hospital of the King's Daughters, Eastern Virginia Medical School and the Norfolk Department of Health, the Eastern Virginia Medical Center is the largest conglomerate center for health in Hampton Roads. For a time, the U.S. News & World Report rated it the best in Virginia. In 2016, SNGH is tied with VCU Medical Center ranked as #2 while University of Virginia Health System ranked first.S.
BACKGROUND AND AIMS:The TRISCEND II trial demonstrated superior clinical benefits for patients with ≥severe tricuspid regurgitation (TR) treated with the EVOQUE transcatheter tricuspid valve replacement (TTVR) system plus medical therapy vs medical therapy alone. This work reports 1-year and 18-month outcomes in patients stratified by baseline TR severity. METHODS:The multicentre, prospective TRISCEND II trial enrolled 400 patients with symptomatic, ≥severe TR, and randomized 2:1 to TTVR (n = 267) or control (n = 133). In a post hoc analysis, patients were stratified into severe TR (n = 172) and massive/torrential TR (n = 220) cohorts. Clinical and quality-of-life outcomes were reported at 1 year, with Kaplan-Meier estimates for all-cause mortality and heart failure (HF) hospitalization assessed at 18 months. Study oversight included an independent echocardiographic core laboratory, clinical events committee, and data safety monitoring board. RESULTS:One year after TTVR, TR was ≤mild in 95.2% of severe TR and 95.3% of massive/torrential TR patients. The primary safety and effectiveness endpoint (win ratio) favoured TTVR over control regardless of baseline TR severity: severe {1.64 [95% confidence interval (CI): 1.11, 2.43]} and massive/torrential [2.20 (1.55, 3.14)]. At 18 months, TTVR patients had similar mortality to controls [rate difference: severe 0.2% (-11.6, 11.9), massive/torrential -5.8% (-17.6, 6.0)], whereas HF hospitalization rates favoured TTVR in the massive/torrential cohort [vs control, severe 9.8% (-3.0, 22.7), massive/torrential -15.2% (-28.9, -1.5)]. CONCLUSIONS:Patients with ≥severe TR benefit from TTVR, experiencing improvements in TR severity, functional capacity, and quality of life regardless of baseline TR severity, with a signal for greater benefit in patients with more advanced disease.
Obstructive sleep apnea is a condition characterized by recurrent upper airway collapse during sleep, which may be associated with sleep disruption and repetitive oxygen desaturations. It is diagnosed by nocturnal in-lab polysomnography or home sleep apnea testing. We present a case of an otherwise healthy individual who had home sleep apnea testing that revealed persistent, unexplained hypoxemia which, on further investigation, was found to be due to a saddle pulmonary embolism.
ABSTRACT Objective To evaluate treatment effect heterogeneity across phenotypic clusters of patients with cryptogenic embolic stroke using causal inference methods. Methods From a retrospective, multicenter cohort of patients with cryptogenic embolic stroke, we estimated the treatment effect of anticoagulation versus antiplatelet therapy in patients with ESUS in two ways: (1) Partitioning Around Medoids and (2) causal survival forest modeling. We assessed cluster‐level associations with time to primary outcome (recurrent stroke, major bleeding, or death) using Kaplan–Meier survival analysis to assess cluster differences. We then extracted SHapley Additive exPlanations (SHAP) feature importances from the causal forest model to identify candidate effect modifiers from the causal forest. Results Among 1869 patients with ESUS, three phenotypically distinct clusters were extracted with significant differences in event‐free survival across clusters (log‐rank p < 0.0001). There was no significant population‐level benefit of anticoagulation over antiplatelet therapy ( p = 0.23). SHAP feature importance analysis identified several candidate effect modifiers; however, only higher LVEF ( β = −327, 95% CI: −580 to −74, p = 0.011) and cancer history ( β = −226, 95% CI: −441 to −11, p = 0.039) were independent predictors of response to antiplatelet over anticoagulation using best linear projections. Phenotypic cluster assignment did not significantly predict treatment effect heterogeneity. Interpretation Three distinct phenotypic clusters of cryptogenic stroke patients emerged with a differential risk of the composite outcome, but they did not predict responsiveness to anticoagulation. LVEF and cancer history, however, showed differential outcomes across antithrombotic strategies. These findings demonstrate the potential of causal inference methods for identifying effect heterogeneity and individualizing treatment strategies.
