Annetine C. Gelijns

Bridge experience with long-term implantable left ventricular assist devices: Are they an alternative to transplantation?

BACKGROUNDnIf long-term use of left ventricular assist devices (LVADs) as bridges to transplantation is successful, the issue of permanent device implantation in lieu of transplantation could be addressed through the creation of appropriately designed trials. Our medium-term experience with both pneumatically and electrically powered ThermoCardiosystems LVADs is presented to outline the benefits and limitations of device support in lieu of transplantation.nnnMETHODS AND RESULTSnDetailed records were kept prospectively for all patients undergoing LVAD insertion. Fifty-eight LVADs were inserted over 5 years, with a survival rate of 74%. Mean patient age was 50 years, and duration of support averaged 98 days. Although common, both preexisting infection and infection during LVAD support were not associated with increased mortality or decreased rate of successful transplantation. Thromboembolic complications were rare, occurring in only three patients (5%) despite the absence of anticoagulation. Ventricular arrhythmias were well tolerated in all patients except in cases of early perioperative right ventricular failure, with no deaths. Right ventricular failure occurred in one third of patients and was managed in a small percentage by right ventricular assist device (RVAD) support and/or inhaled nitric oxide therapy. There were no serious device malfunctions, but five graft-related hemorrhages resulted in two deaths. Finally, a variety of noncardiac surgical procedures were performed in LVAD recipients, with no major morbidity and mortality.nnnCONCLUSIONSnOver all, our medium-term experience with implantable LVAD support is encouraging. Although additional areas of investigation exist, improvements in patients selection and management together with device alterations that have reduced the thromboembolic incidence and facilitated patient rehabilitation lead us to believe that a prospective, randomized trial is indicated to study the role that LVADs may have as an alternative to medical management.

Volume-outcome relationships in cardiovascular operations: New York state, 1990-1995☆☆☆

BACKGROUNDnIt has been known for nearly 20 years that, in cardiovascular operations, a significant inverse relationship exists between clinical outcomes and the volume of procedures performed. Interestingly, this relationship persists 2 decades after it was recognized.nnnOBJECTIVEnThe purpose of this study was to examine the relationship between hospital volume and in-hospital deaths in 3 cardiovascular procedures: coronary artery bypass grafting, elective repair of abdominal aortic aneurysms, and repair of congenital cardiac defects.nnnMETHODSnThe database includes all patients who were hospitalized in New York State during the years 1990 to 1995. Using standard logistic regression techniques, we analyzed the relationship between hospital volume and outcome.nnnRESULTSnNo correlation exists between hospital volume and in-hospital deaths in coronary artery bypass grafting. Statewide, 31 hospitals performed 97,137 operations over the 6-year period (overall mortality rate, 2. 75%). By contrast, most of the hospitals statewide (195 of 230 hospitals) performed 9847 elective abdominal aortic aneurysm repairs with an overall mortality rate of 5.5%. In abdominal aortic aneurysm operations, a significant inverse relationship between hospital volume and in-hospital deaths was determined. Sixteen hospitals performed 7199 repairs for congenital cardiac defects. A significant inverse relationship (which was most pronounced for neonates) was found between volume and death.nnnCONCLUSIONSnThe importance of these findings lies in the rather striking difference between the volume-outcome relationship found for operations for abdominal aortic aneurysms and congenital cardiac defects and the lack of such a relationship for coronary artery bypass grafting. This observation may be largely explained by the quality improvement program in New York State for bypass operations since 1989. If so, these results have important implications for expanding the scope of quality improvement efforts in New York State.

A model for predicting the risk of carotid artery disease.

Objective:To develop a model for the identification of individuals at risk for carotid stenosis (CS) that could be useful in a clinical setting when trying to decide whether screening is worthwhile. Background:Evidence that aggressive medical therapy and life style changes reduce the risk of stroke in individuals with CS is increasing and has led to a renewed interest in screening for CS. Methods:Data on demographics and risk factors were obtained from 2,885,257 individuals who had carotid Duplex scans by Life Line Screening between 2003 and 2008. Multivariable logistic regression analysis was used to identify independent risk factors for CS (>50% stenosis). A scoring system was developed where risk factors were assigned a weighted score. Predictive ability was assessed by calculating C statistics and r2. Results:In the screened cohort, 71,004 patients (2.4%) had CS. Independent risk factors include advanced age, smoking, peripheral arterial disease, high blood pressure, coronary artery disease, diabetes, cholesterol, and abdominal aortic aneurysm. African Americans, Asians, and Hispanics had reduced risk than whites. Exercise and consumption of fruit, vegetables, and nuts had a modest protective effect. A predictive scoring system was created that identifies individuals with CS more efficiently (C statistic = 0.753) than previously published models. Conclusions:We provide a model that enables identification of individuals who have a high probability of having CS. This model can be helpful in designing targeted screening programs that are cost-effective.