Cardiac Magnetic Resonance Assessment of Response to Cardiac Resynchronization Therapy and Programming Strategies.

OBJECTIVES: The objective was to determine the feasibility and effectiveness of cardiac magnetic resonance (CMR) cine and strain imaging before and after cardiac resynchronization therapy (CRT) for assessment of response and the optimal resynchronization pacing strategy. BACKGROUND: CMR with cardiac implantable electronic devices can safely provide high-quality right ventricular/left ventricular (LV) ejection fraction (RVEF/LVEF) assessments and strain. METHODS: CMR with cine imaging, displacement encoding with stimulated echoes for the circumferential uniformity ratio estimate with singular value decomposition (CURE-SVD) dyssynchrony parameter, and scar assessment was performed before and after CRT. Whereas the pre-CRT scan constituted a single "imaging set" with complete volumetric, strain, and scar imaging, multiple imaging sets with complete strain and volumetric data were obtained during the post-CRT scan for biventricular pacing (BIVP), LV pacing (LVP), and asynchronous atrial pacing modes by reprogramming the device outside the scanner between imaging sets. RESULTS: 100 CMRs with a total of 162 imaging sets were performed in 50 patients (median age 70 years [IQR: 50-86 years]; 48% female). Reduction in LV end-diastolic volumes (P = 0.002) independent of CRT pacing were more prominent than corresponding reductions in right ventricular end-diastolic volumes (P = 0.16). A clear dependence of the optimal CRT pacing mode (BIVP vs LVP) on the PR interval (P = 0.0006) was demonstrated. The LVEF and RVEF improved more with BIVP than LVP with PR intervals ≥240 milliseconds (P = 0.025 and P = 0.002, respectively); the optimal mode (BIVP vs LVP) was variable with PR intervals <240 milliseconds. A lower pre-CRT displacement encoding with stimulated echoes (DENSE) CURE-SVD was associated with greater improvements in the post-CRT CURE-SVD (r = -0.69; P < 0.001), LV end-systolic volume (r = -0.58; P < 0.001), and LVEF (r = -0.52; P < 0.001). CONCLUSIONS: CMR evaluation with assessment of multiple pacing modes during a single scan after CRT is feasible and provides useful information for patient care with respect to response and the optimal pacing strategy.

Cost identification analysis of general anesthesia.

BACKGROUND AND AIMS: Rising health costs are challenging anesthesiologists to search for cost-effective anesthetic techniques. We conducted a study to estimate variable cost per case and cost of drug wastage as percentage of total drug cost associated with different modalities of general anesthesia (GA). MATERIAL AND METHODS: This prospective study was carried out after approval by institutional ethical committee in 258 adult patients aged 18-60 years of either sex, American Society of Anesthesiologists physical status I or II, with a surgical duration of 1-4 hours, posted for elective surgery under GA with endotracheal intubation. At the end of surgery, total utilization of each drug, anesthetic gases, and consumables were noted and remaining drug was regarded as wastage. Cost was recorded as per maximum retail price for that particular brand in the market at start of study and total cost was calculated. For purpose of analysis, cases were divided into low flow sevoflurane, high flow sevoflurane, high flow isoflurane, low flow isoflurane, and total intravenous anesthesia (TIVA). RESULTS: The mean variable cost was highest with TIVA (₹2713.82 ± 509.57) and lowest with low flow isoflurane (₹1981.62 ± 335.03; P < 0.001). Drug wastage was 13.1% overall, with highest in low sevoflurane group and lowest in TIVA. CONCLUSION: Low flow anesthesia with isoflurane is more cost-effective as compared to high flow techniques and TIVA even for short duration surgeries. Rational use of drugs and consumables and minimizing wastage can further reduce anesthesia costs.

Cost of a recall of a single-center experience managing the Riata defibrillator lead.

Riata and Riata ST defibrillator leads (St. Jude Medical, Sylmar, California) were recalled in 2011 due to increased risk of insulation failure leading to externalized cables. Fluoroscopic screening can identify insulation failure, although the relation between mechanical failure and electrical failure is unclear. At the time of the recall, the University of Virginia developed a screening program, including fluoroscopic evaluation, education sessions, device interrogation, and remote monitoring for patients with this defibrillator lead. The aim of this study was to review the outcomes of the screening program, including costs, which were absorbed by our institution. Costs were calculated using Medicare reimbursement estimates. Forty-eight patients participated in the screening program. At initial screening, 31% were found to have evidence of insulation failure but electrical function was normal in all leads. The cost of this program was $35,358.72. The cost per diagnosis of mechanical lead failure was $2,357.25. During 2 years of follow-up, 1 patient experienced Riata lead electrical failure without fluoroscopic evidence of insulation failure. Patients were more likely to have a lead revision if there was evidence of insulation failure. Lead revisions occurred at the time of generator change in 88% of patients with insulation failure but in only 14% of patients with a fluoroscopically normal lead (p = 0.04). The cost of recall-related defibrillator lead revisions was $81,704.55. In conclusion, our Riata screening program added expense without clear benefit to patients. In fact, patients may have been put at more risk by undergoing defibrillator lead revisions based solely on the results of the fluoroscopic screening.

Cost and yield of adding electrocardiography to history and physical in screening Division I intercollegiate athletes: a 5-year experience.

BACKGROUND: Electrocardiographic screening of intercollegiate athletes is controversial because the costs and yield are not well defined. Both the American Heart Association (AHA) and the European Society of Cardiology (ESC) have different criteria for screening, partly because the populations being screened are different. OBJECTIVE: The purpose of this study was to determine the cost and yield of a 5-year ECG screening program at a United States Division I college. METHODS: At the University of Virginia, all 1,473 competitive athletes over the course of 5 years were screened with history and physical and with ECGs using ESC guidelines with follow-up testing as dictated by clinical symptoms and ECG findings. RESULTS: History and physical alone uncovered five significant cardiac abnormalities. ECGs were abnormal in 275 (19%), resulting in 359 additional tests. Additional testing confirmed eight significant cardiac abnormalities that were not found by history and physical: 1 bicuspid aortic valve, 4 rapidly conducting accessory pathways, 1 long QT patient, 1 with frequent premature ventricular contractions and low ejection fraction, and 1 with frequent premature ventricular contractions but normal ejection fraction. No cases of hypertrophic cardiomyopathy were found. Total cost of the program was US $894,870. Cost of history and physical screening alone was $343,725 or $68,745 per finding. The marginal cost of adding ECG screening, including resulting tests and procedures. was US$551,145 or US$68,893 per additional finding. CONCLUSION: ECG screening of U.S. college athletes can uncover significant cardiac pathology not discovered by history and physical alone. Although ECG screening also results in many false positives resulting in additional tests, the overall cost per diagnosis of adding ECG screening is similar to that of history and physical screening alone.

Fixed-dose combinations for cough and common cold in India: an assessment of availability and rationality.

This study was conducted to determine the number and composition of the various cough and cold formulations available in the Indian market and to study their pharmacological rationale over a period of 7years. Data for the study was collected from an annual Drug Compendium entitled 'THE DRUG TODAY' of the years 2001, 2004, and 2007. Medications were assessed for total number, different formulations, and number of constituents present in each formulation, their pharmacological group and amount of each constituent per dose. Rationality of available preparations was assessed on a seven-point scoring criteria. There are over thirteen hundred drug products for cough and cold in the Indian market, which is an increase of 71.2% from the year 2001. More than 90% of the preparations were fixed-dose combinations (FDCs). Majority of the cough and cold preparations had 3-4 constituents. Many preparations contained more than one constituent of the same pharmacological group. Some preparations had constituents with opposing action. A wide variation in the amount of each constituent present per dose in different formulations was observed. The number of banned drug combinations for cough and cold showed an increase from 9 in 2001 to 27 in 2007. Rationality assessment of the FDC preparations revealed that most of the preparations were irrational and had no documented benefit in the treatment of common cold. Availability of such a large number of irrational FDCs for cough and cold requires serious review of the legal provisions in India for drug manufacturing and marketing.