A couple of weeks ago, I took care of a patient who desperately needed to get better from acute CHF. At that time, we placed the patient on an impella… but the next day, it was deemed that he needed ECMO to reperfuse his organs. After a week on ECMO with continued impella support, ECMO was titrated down and off while maintaining 3.9L/min flow from the impella. During the wean off ECMO, the patient had been extubated and was mentating clearly and interacting appropriately.
Fast forward a couple days after getting extubated, the patient was ripe for an LVAD. But which one? (We ended up placing the patient on HeartWare LVAD).
- Cost-effectiveness: HeartWare > HeartMate II (UK NHS study, April 2014)
- LV Geometry: HeartWare = HeartMate II (J CT Surg, 2013)
- Stroke & GI bleed risk: HeartWare > HeartMate II (J Card Surg 2013)
- Risk of device failure: HeartWare < HeartMate II
- ENDURANCE trial: Randomized patients eligible for DT 2:1 to the HeartWare centrifugal flow LVAD versus the HeartMate II axial flow LVAD. The trial did reach its primary noninferiority endpoint of stroke free survival at 2 years (55.0% in the HeartWare patients versus 57.4% in the HeartMate II patients). Of note, a change in the design of the HeartWare device during the trial (sintering of the inflow cannula) appeared to decrease the incidence of pump thrombosis. Overall, the stroke rate was higher in the HeartWare arm whereas device malfunctions requiring exchange or urgent transplantation were more common in the HeartMate II arm. Data analysis suggested that better blood pressure control in the HeartWare arm may decrease the stroke rate and a second cohort of patients is being enrolled with more attention being paid to blood pressures management.
- ROADMAP study: (Risk Assessment and Comparative Effectiveness of Left Ventricular Assist Device and Medical Management in Heart Failure Patients) was an observational study of the Thoratec HeartMate II LVAD compared to optimal medical management in patients with advanced heart failure. Thirty day mortality was the same in both groups (1%) while one year survival was 80% in the LVAD group compared to 64% in the medical group (on an as treated basis). Functional status and quality of life improved significantly more in the LVAD group (analyzed by 6 minute walk, health related quality of life, and NYHA class). Unfortunately, adverse events in the LVAD group remained similar to what was previously reported in the DT trial, with bleeding being the most frequent adverse event.
- Bridge to Transplant: HeartWare = HeartMate II (Ann Thor Surg, Feb 2014)
- ADVANCE trial (bridge to transplant): 94% survival at 180 days with HeartWare
- PPT: LVAD Update 2015
- Anesthesia for LVAD
“There’s an emergent case coming for impella placement.”
Impella? I’ve read about these devices and I’m familiar with managing patients on LVADs as well as providing anesthesia for LVAD placement. But, I’ve never done an Impella on a critically unstable patient.
- U/S guidance: probe position similar to infraclavicular block. Find 3rd, 4th rib.
- Pt position: Head away from side of block. Ipsilateral arm abducted.
- PEC 2: Inject 20 ml 0.25% bupi between pec minor and serratus.
- PEC 1: Inject 10 ml 0.25% bupi between pec major and pec minor.
- Serratus: 5th rib, mid-axillary line. Inject 30 ml 0.125% bupi along top (superficial) and bottom (deep) of serratus muscle (which is just deep to the latissmus dorsi).
Subject: I’m strongly “Opposed” to AB 72 (Bonta).
As a physician anesthesiologist, I routinely treat patients during life’s most difficult and uncertain moments, often in life-sustaining surgeries. I agree that patients should not be surprised by out-of-network charges that can arise during these difficult times.
However, AB 72 (Bonta) shifts the onus of arranging for patient care from health plans and insurers onto physicians like me who might not be able to reach contract agreements with health care services plans and insurers.
As such, I’m concerned the net effect of this bill will be to disincentivize health plans and insurers from negotiating fair payment arrangements with physicians and building adequate provider networks.
Moreover, AB 72 (Bonta) requires physicians to be responsible for appealing, then arbitrating compensation disputes…a losing battle and a time consuming process that takes time way from our practice…time better spent caring for our patients.
Most troubling of all, this bill undermines my right to negotiate a fair contract with health plans and insurers by statutorily imposing on me payments that another physician has accepted as the value of their services. Contracted rates of payment already represent substantial discounts to usual and customary market rates. AB 72 (Bonta) will rapidly force a spiral of even lower rates (driven by health plan and insurers) leading to even more restricted provider networks and further reduce access to quality health care for all Californians.
Suggested amendments by the California Medical Association that would have removed our opposition have been summarily rejected by the author and sponsor. Therefore, I strongly urge your “NO” vote on AB 72 (Bonta).
J.H. Alexander and P.K. Smith
Appropriate selection of patients for coronary-artery bypass grafting (CABG) is critical to ensure good outcomes. The evaluation of patients for CABG relies on a systematic assessment of the characteristics and coronary anatomy known to be associated with a survival benefit from CABG as compared with medical therapy or percutaneous coronary intervention (PCI). There is increasing evidence that treatment decisions for patients with complex coronary artery disease are best made through a process of shared decision making that includes the patient, the patient’s family, an interventional cardiologist, a cardiac surgeon, and ideally, the patient’s general cardiologist or primary care physician.
Stroke remains the most serious complication of CABG, occurring in 1 to 2% of patients in the perioperative period. Notable risk factors for stroke include a history of neurologic events, advanced age, peripheral or cerebrovascular disease, and diabetes. Aortic atherosclerosis is also a major risk factor for stroke after CABG because of the necessary manipulation or clamping of the ascending thoracic aorta. The use of a single aortic cross-clamp and epiaortic ultrasonography during CABG have been associated with a reduction in the risk of stroke over the past decade.
Patients with multivessel coronary artery disease and diabetes have an increased cardiovascular risk as compared with those without diabetes, and they have a survival benefit from CABG as compared with PCI. Patients with left ventricular dysfunction or mitral-valve disease also have an increased cardiovascular risk and have a survival benefit from CABG.
A. Recent trials and observational studies have updated previous work by including higher-risk patients and reflecting changes in practice. The most important was the SYNTAX study, which randomly assigned 1800 patients with either three-vessel or left main coronary artery disease to CABG or PCI. Evaluation of each participant included determination of the SYNTAX score (a measure of the extent and complexity of coronary artery disease) and the anticipated complexity of PCI. SYNTAX scores are used to classify the complexity of coronary artery disease as low (≤22), intermediate (23 to 32), or high (≥33). Overall, patients with three-vessel disease in the SYNTAX trial had a survival benefit with CABG as compared with PCI (rate of death, 9.2% vs. 14.6%, P=0.006). In patients with the least complex three-vessel disease (SYNTAX score ≤22), PCI was noninferior to CABG. In patients with more complex disease (SYNTAX score ≥23), CABG was superior to PCI. The survival benefit of CABG over PCI for patients with multivessel coronary artery disease has been confirmed in other studies and appears to be consistent when PCI is performed with second-generation drug-eluting stents. In the SYNTAX study, the outcomes of the two procedures were indistinguishable in patients with isolated left main coronary artery disease or left main coronary artery disease and single-vessel coronary artery disease (SYNTAX score <33). However, in patients with left main and two- or three-vessel coronary artery disease (SYNTAX score ≥33), there was a significant reduction in the rate of the composite end point of death, myocardial infarction, stroke, or repeat revascularization with CABG as compared with PCI (29.7% vs. 46.5%, P=0.003).
A. The evidence in favor of CABG is almost entirely based on studies of patients with stable ischemic heart disease. Nevertheless, the recommendations for CABG are commonly extended to include patients with acute coronary syndromes, including unstable angina and stable non–ST-segment elevation myocardial infarction. In practice, more than 60% of CABG procedures are performed during an acute care hospitalization and 29% follow a recent myocardial infarction. The best initial treatment for patients with acute ST-segment elevation myocardial infarction is reperfusion therapy with either PCI or fibrinolytic therapy. As compared with CABG, PCI restores coronary blood flow more rapidly, preserves myocardium, and improves outcomes. In this patient population, CABG is reserved for those who have a coronary anatomy that is not amenable to PCI or who have mechanical complications, such as ventricular septal defect, myocardial rupture, or papillary-muscle rupture with acute, severe mitral regurgitation.
Figure 1. Coronary-Artery Bypass Grafting.
Table 1. Indications for Coronary-Artery Bypass Grafting (CABG).
Good to keep in mind the risk/benefit ratios.
Neil Ruparelia, DPhil, MRCP1,2; Azeem Latib, MD1; and Antonio Colombo, MD1
1San Raffaele Scientific Institute, Milan, Italy
2Imperial College, London, United Kingdom
Transcatheter aortic valve implantation (TAVI) has rapidly expanded following the first reported case in 2002 to now being the recommended treatment option for high-risk or inoperable patients with severe symptomatic aortic stenosis (AS). While the first studies clearly demonstrated safety and efficacy of this revolutionary technology, they also identified some limitations including vascular complications, stroke, the requirement for permanent pacemaker implantation, and residual aortic regurgitation. Subsequent studies have consistently demonstrated that the presence of more-than-mild paravalvular regurgitation and the occurrence of a vascular complication to be independent predictors of mortality. In an attempt to reduce the incidence of these limitations, a number of technological refinements have been made to TAVI devices and their delivery systems. We therefore aimed to investigate the impact of these changes relating to intraprocedural…
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