Transcaval access for the emergency delivery of 5.0 liters per minute mechanical circulatory support in cardiogenic shock.

OBJECTIVES: The purpose of this study was to describe the feasibility and early outcomes of transcaval access for delivery of emergency mechanical circulatory support (MCS) in cardiogenic shock. BACKGROUND: Vascular access for implantation of MCS in patients with cardiogenic shock is often challenging due to peripheral arterial disease and vasoconstriction. Transcaval delivery of MCS may be an alternative. We describe a series of patients we implanted an Impella 5.0 device, on-table without CT planning, through a percutaneous transcaval access route. METHODS: Ten patients with progressive or refractory cardiogenic shock underwent Impella 5.0 implantation via transcaval access. Demographic, clinical and procedural variables and in-hospital outcomes were collected. RESULTS: All ten underwent emergency implantation of the 7 mm diameter Impella 5.0 device via transcaval access. Six were women, with median age of 55.5 years (range, 29-69). Cardiogenic shock was attributed to idiopathic nonischemic cardiomyopathy (n = 4), myocarditis (n = 2), ischemic cardiomyopathy (n = 2), heart transplant rejection (n = 1), and unknown etiology (n = 1). Median duration of support was 92.1 hr (range, 21.2-165.4). Seven (70%) survived to device explant, with six (60%) surviving to access port closure and discharge. Among survivors, five recovered heart function and one received destination therapy left ventricular assist device. CONCLUSIONS: Transcaval access is feasible for emergency nonsurgical implantation of the Impella 5.0 device in cardiogenic shock with small or diseased iliofemoral arteries. This allows early institution of higher-flow MCS than conventional femoral artery implantation of the 3.5 L Impella CP device, and enables a bridge-to-recovery or bridge-to-destination strategy.

Primary percutaneous coronary intervention at centers with and without on-site surgical support: Insights from the Blue Cross Blue Shield of Michigan Cardiovascular Consortium (BMC2).

BACKGROUND: Primary percutaneous coronary intervention (PPCI) is being increasingly performed nationally at sites without on-site cardiac surgery; however, recent guidelines only provide a Class IIa recommendation for this practice. The state of Michigan has permitted PPCI without on-site surgery under a closely monitored system that mandates auditing of all procedures and quarterly feedback on quality and outcomes. This study sought to compare outcomes of patients undergoing PPCI at centers with and without on-site surgery in the state of Michigan. METHODS: Consecutive patients who underwent PPCI at 47 hospitals in Michigan from January 2010 to December 2015 were included. From this cohort, 4,091 patients from sites with and without on-site cardiac surgery were propensity matched in a 1:1 fashion to compare baseline characteristics, procedural details, and in-hospital outcomes. RESULTS: Of the 25,886 PPCIs performed at 47 hospitals in Michigan from 2010 to 2015, 21,610 (83.5%) were performed at sites with on-site surgery and 4,276 (16.5%) at sites without on-site surgery. Using propensity score matched cohorts (4,091 patients for each site type), we found no significant differences in baseline characteristics. Overall mortality (5.4% vs 5.8%; P=.442); composite outcome of in-hospital mortality, contrast-induced nephropathy, bleeding, and stroke (13.8% vs 12.8%; P=.152); and individual outcomes within the composite group showed no significant differences. Additionally, there were no clinically meaningful differences in rates of urgent/emergent coronary artery bypass graft or length of stay. Significant differences, however, were found in procedural access site, antiplatelet therapy, contrast volume, and anticoagulant strategy. CONCLUSIONS: Primary PCI performed at centers with and without cardiac surgery have comparable outcomes and complication rates when performed with close monitoring of quality and outcomes.

Characteristics and In-Hospital Outcomes of Peripartum Cardiomyopathy Diagnosed During Delivery in the United States From the Nationwide Inpatient Sample (NIS) Database.

BACKGROUND: Peripartum cardiomyopathy (PPCM) is associated with advanced maternal age, African-American race, hypertensive disorders of pregnancy, and multiple-gestation pregnancies. Less is known regarding racial differences in risk factors and predictors of adverse in-hospital outcomes. METHODS AND RESULTS: A total of 1,337 women with PPCM were identified with the use of the Nationwide Inpatient Sample (2004-2011). Clinical profiles and maternal outcomes in delivering mothers with and without PPCM were compared and stratified by race. In multivariate analysis, established risk factors for PPCM were confirmed. Anemia (odds ratio [OR] 2.0, 95% confidence interval [CI] 1.6-2.5; P < .0001), asthma (OR 2.2, 95% CI 1.5-3.2; P = .0002), smoking (OR 33.6, 95% CI 9.3-159.4; P < .0001), and thyroid disease (OR 5.9; 95% CI 1.5-21.3; P = .01) were associated with PPCM. Risk factors significant in whites, African Americans, and Hispanics were hypertension during pregnancy and anemia. Patients with PPCM had higher rates of in-hospital adverse outcomes (P < .0001), but no differences in race or comorbidities predicted adverse events. CONCLUSIONS: Hypertensive disorders during pregnancy and anemia were associated with PPCM in whites, African Americans, and Hispanics, providing further evidence that vascular stress may play a role in the pathogenesis of PPCM. Thyroid disorders may represent a novel risk factor for PPCM.

Portrayal of organ donation and transplantation on American primetime television.

Recently, both living and deceased organ donation rates have hit a plateau, despite increases in need for viable organs. One approach to improve donation rate is public education and policy; thus, it is necessary to understand the information the public is receiving regarding organ donation. We hypothesized that primetime medical dramas portray organ donation and transplantation in a negative manner. We compiled data on all primetime medical drama episodes with transplant themes from November 2008 through June 2010 and assessed depictions of organ donors and transplant candidates. Positive and negative thematic elements surrounding the process and individuals involved were also identified. One hundred and fifty-five million and 145 million households watched episodes containing any negative message and any positive message, respectively. Episodes containing only negative messages had over twice the household viewership per episode compared to episodes containing only positive messages (8.4 million vs. 4.1 million, p = 0.01). Widespread exposure to these representations may reinforce public misconceptions of transplantation. The transplant community should consider the popularity of medical dramas as an opportunity to impact the perception of organ donation and transplantation for millions of Americans.

Trends and outcomes of non-primary PCI at sites without cardiac surgery on-site: The early Michigan experience.

INTRODUCTION: Non-primary percutaneous coronary intervention (non-PPCI) recently received certificate of need approval in the state of Michigan at sites without cardiac surgery on-site (cSoS). This requires quality oversight through participation in the BMC2 registry. While previous studies have indicated the safety of this practice, real-world comprehensive outcomes, case volume changes, economic impacts, and readmission rates at diverse healthcare centers with and without cSoS remain poorly understood. METHODS: Consecutive patients undergoing non-PPCI at 47 hospitals (33 cSoS and 14 non-cSoS) in Michigan from April 2016 to March 2018 were included. Using propensity-matching, patients were analyzed to assess outcomes and trends in non-PPCI performance at sites with and without cSOS. RESULTS: Of 61,864 PCI's performed, 50,817 were non-PPCI, with 46,096 (90.7%) performed at sites with cSoS and 4,721 (9.3%) at sites without cSoS. From this cohort, 4,643 propensity-matched patients were analyzed. Rates of major adverse cardiac events (2.6% vs. 2.8%; p = 0.443), in-hospital mortality (0.6% vs. 0.5%; p = 0.465), and several secondary clinical and quality outcomes showed no clinically significant differences. Among a small subset with available post-discharge data, there were no differences in 90-day readmission rates, standardized episode costs, or post-discharge mortality. Overall PCI volume remained stable, with a near three-fold rise in non-PPCI at sites without cSoS. CONCLUSIONS: Non-PPCI at centers without cardiac SoS was associated with similar comprehensive outcomes, quality of care, 90-day episode costs, and post-discharge mortality compared with surgical sites. Mandatory quality oversight serves to maintain appropriate equivalent outcomes and may be considered for other programs, including the performance of non-PPCI at ambulatory surgical centers in the near future.

Pheochromocytoma-Induced Takotsubo Cardiomyopathy.

Pheochromocytoma, a rare catecholamine-secreting tumor, typically manifests itself with paroxysmal hypertension, tachycardia, headache, and diaphoresis. Less often, symptoms related to substantial hemodynamic compromise and cardiogenic shock occur. We report the case of a 66-year-old woman who presented with abdominal pain. Examination revealed a large right adrenal mass, cardiogenic shock, and severe heart failure in the presence of normal coronary arteries. Within days, the patient's hemodynamic status and left ventricular ejection fraction improved markedly. Results of imaging and biochemical tests confirmed the diagnosis of pheochromocytoma-induced takotsubo cardiomyopathy. Medical therapy and right adrenalectomy resolved the patient's heart failure, and she was asymptomatic postoperatively. We recommend awareness of the link between pheochromocytoma and takotsubo cardiomyopathy, and we discuss relevant diagnostic and management principles.

Hospitalization costs for acute myocardial infarction patients treated with percutaneous coronary intervention in the United States are substantially higher than Medicare payments.

BACKGROUND: Acute coronary syndromes account for half of all deaths secondary to cardiovascular disease and represent a significant economic burden in the United States. Therefore, assessing hospitalization costs relative to Medicare reimbursement for these patients is important in understanding the impact of these patients on hospitals. We hypothesized that hospitalization costs for acute myocardial infarction patients treated with percutaneous coronary intervention (PCI) were higher than their associated Medicare payments. METHODS: Using the Nationwide Inpatient Sample, we evaluated hospitalization costs for patients treated with PCI from 2001 through 2009 by multiplying hospital charges by the group average cost-to-charge ratio for each patient's hospitalization. Primary end points examined were total hospital costs and trends over time, which were correlated with clinical outcomes and insurance payments. Costs were inflation adjusted with 2009 as the reference year. RESULTS: Median hospitalization costs of PCI increased from $15 889 (interquartile range [IQR] = $12 057-$21 204) in 2001 to $19 349 (IQR = $14 660-$26 282) in 2009. From 2004 to 2009, inflation-adjusted costs for PCI decreased at a rate of 0.3% per year. In 2009, a total of 265,531 patients received PCI for acute myocardial infarction. Of these, 143 654 were <65 years old, and 121 876 were ≥65 years old. Average 2009 Medicare payments ranged from $9303 to $17 500 depending on the Medicare Severity-Diagnosis Related Groups (MS-DRG) billed, leaving hospitals at a loss of anywhere from $4493 to $7940 per patient when comparing costs and reimbursements across all included MS-DRG codes. CONCLUSIONS: Hospitalization costs for patients treated with PCI have been stabilizing over the last few years; however, there still remains a significant disparity between Medicare reimbursements and hospitalization costs, which has potential implications on patient outcomes, quality of care, and hospital sustainability.