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1.
Catheter Cardiovasc Interv ; 99(4): 1165-1171, 2022 03.
Artigo em Inglês | MEDLINE | ID: mdl-34837459

RESUMO

Health care practices are influenced by variety of factors. These factors that include social determinants, race and ethnicity, and gender not only affect access to health care but can also affect quality of care and patient outcomes. These are a source of health care disparities. This article acknowledges that these disparities exist in getting optimal care in structural heart disease, reviews the literature and proposes steps that can help reduce these disparities on personal and committee levels.


Assuntos
Cardiologia , Equidade em Saúde , Cardiopatias , Disparidades em Assistência à Saúde , Cardiopatias/diagnóstico por imagem , Cardiopatias/terapia , Humanos , Resultado do Tratamento
2.
Resuscitation ; 136: 126-130, 2019 03.
Artigo em Inglês | MEDLINE | ID: mdl-30716427

RESUMO

BACKGROUND: Extracorporeal cardiopulmonary resuscitation (ECPR) is a resource-intensive tool that provides haemodynamic and respiratory support in patients who have suffered cardiac arrest. In this study, we investigated the cost-utility of ECPR (cost/QALY) in cardiac arrest patients treated at our institution. METHODS: We performed a retrospective review of patients who received ECPR following cardiac arrest between 2012 and 2018. All medical care-associated charges with ECPR and subsequent hospital admission were recorded. The quality-of-life of survivors was assessed with the Health Utilities Index Mark II. The cost-utility of ECPR was calculated with cost and quality-of-life data. RESULTS: ECPR was used in 32 patients (15/32 in-hospital, 47%) with a median age of 55.0 years (IQR 46.3-63.3 years), 59% male and 66% African American. The median duration of ECPR support was 2.1 days (IQR 0.9-3.8 days). Survival to hospital discharge was 16%. The median score of the Health Utilities Index Mark II at discharge for the survivors was 0.44 (IQR 0.32-0.52). The median operating cost for patients undergoing ECMO was $125,683 per patient (IQR $49,751-$206,341 per patient). The calculated cost-utility for ECPR was $56,156/QALY gained. CONCLUSIONS: The calculated cost-utility is within the threshold considered cost-effective in the United States (<$150,000/QALY gained). These results are comparable to the cost-effectiveness of heart transplantation for end-stage heart failure. Larger studies are needed to assess the cost-utility of ECPR and to identify whether other factors, such as patient characteristics, affect the cost-utility benefit.


Assuntos
Reanimação Cardiopulmonar/métodos , Oxigenação por Membrana Extracorpórea/economia , Custos Hospitalares/estatística & dados numéricos , Parada Cardíaca Extra-Hospitalar/terapia , Adulto , Idoso , Análise Custo-Benefício , Oxigenação por Membrana Extracorpórea/mortalidade , Feminino , Humanos , Tempo de Internação/economia , Masculino , Pessoa de Meia-Idade , Parada Cardíaca Extra-Hospitalar/economia , Parada Cardíaca Extra-Hospitalar/mortalidade , Anos de Vida Ajustados por Qualidade de Vida , Sistema de Registros , Estudos Retrospectivos
3.
Int J Cardiovasc Imaging ; 35(1): 23-32, 2019 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-30062535

RESUMO

Echocardiographic assessment of left ventricular (LV) filling pressures is performed using a multi-parametric algorithm. Left atrial (LA) strain was recently found to accurately classify the degree of diastolic dysfunction. We hypothesized that LA strain could be used as a stand-alone marker and sought to identify and test a cutoff, which would accurately detect elevated LV pressures. We studied 76 patients with a spectrum of LV function who underwent same-day echocardiogram and invasive left-heart catheterization. Speckle tracking was used to measure peak LA strain. The protocol involved a retrospective derivation group (N = 26) and an independent prospective validation cohort (N = 50) to derive and then test a peak LA strain cutoff which would identify pre-A-wave LV diastolic pressure > 15 mmHg. The guidelines-based assessment of filling pressures and peak LA strain were compared side-by-side against invasive hemodynamic data. In the derivation cohort, receiver-operating characteristic analysis showed area under curve of 0.76 and a peak LA strain cutoff < 20% was identified as optimal to detect elevated filling pressure. In the validation cohort, peak LA strain demonstrated better agreement with the invasive reference (81%) than the guidelines algorithm (72%). The improvement in classification using LA strain compared to the guidelines was more pronounced in subjects with normal LV function (91% versus 81%). In summary, the use of a peak LA strain to estimate elevated LV filling pressures is more accurate than the current guidelines. Incorporation of LA strain into the non-invasive assessment of LV diastolic function may improve the detection of elevated filling pressures.


Assuntos
Função do Átrio Esquerdo , Ecocardiografia Doppler de Pulso , Disfunção Ventricular Esquerda/diagnóstico por imagem , Função Ventricular Esquerda , Pressão Ventricular , Idoso , Diástole , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Valva Mitral/diagnóstico por imagem , Valva Mitral/fisiopatologia , Valor Preditivo dos Testes , Prognóstico , Estudos Prospectivos , Reprodutibilidade dos Testes , Estudos Retrospectivos , Volume Sistólico , Valva Tricúspide/diagnóstico por imagem , Valva Tricúspide/fisiopatologia , Disfunção Ventricular Esquerda/fisiopatologia
4.
J Am Soc Echocardiogr ; 31(1): 79-88, 2018 01.
Artigo em Inglês | MEDLINE | ID: mdl-29111121

RESUMO

BACKGROUND: Recent American Society of Echocardiography (ASE)/European Association of Cardiovascular Imaging (EACVI) guidelines for echocardiographic evaluation of left ventricular (LV) diastolic function provide a practical, simplified diagnostic algorithm for estimating LV filling pressure. The aim of this study was to test the accuracy of this algorithm against invasively measured pressures and compare it with the accuracy of the previous 2009 guidelines in the same patient cohort. METHODS: Ninety patients underwent transthoracic echocardiography immediately before left heart catheterization. Mitral inflow E/A ratio, E/e', tricuspid regurgitation velocity, and left atrial volume index were used to estimate LV filling pressure as normal or elevated using the ASE/EACVI algorithm. Invasive LV pre-A pressure was used as a reference, with >12 mm Hg defined as elevated. RESULTS: Invasive LV pre-A pressure was elevated in 40 (44%) and normal in 50 (56%) patients. The 2016 algorithm resulted in classification of 9 of 90 patients (10%) as indeterminate but estimated LV filling pressures in agreement with the invasive reference in 61 of 81 patients (75%), with sensitivity of 0.69 and specificity of 0.81. The 2009 algorithm could not definitively classify 4 of 90 patients (4.4%), but estimated LV filling pressures in agreement with the invasive reference in 64 of 86 patients (74%), with sensitivity of 0.79 and specificity of 0.70. CONCLUSIONS: The 2016 ASE/EACVI guidelines for estimation of filling pressures are more user friendly and efficient than the 2009 guidelines and provide accurate estimates of LV filling pressure in the majority of patients when compared with invasive measurements. The simplicity of the new algorithm did not compromise its accuracy and is likely to encourage its incorporation into clinical decision making.


Assuntos
Algoritmos , Ecocardiografia Doppler/métodos , Cardiopatias/diagnóstico , Guias de Prática Clínica como Assunto , Função Ventricular Esquerda/fisiologia , Pressão Ventricular/fisiologia , Diástole , Feminino , Cardiopatias/fisiopatologia , Humanos , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Estudos Prospectivos
5.
J Invasive Cardiol ; 28(4): 133-8, 2016 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-26887027

RESUMO

BACKGROUND AND PURPOSE: This study sought to investigate demographic, clinical, and procedural determinants of outcomes in patients treated with percutaneous veno-arterial (VA) extracorporeal membrane oxygenation (ECMO) initiated in the cardiac catheterization laboratory with a portable system. METHODS: We performed a retrospective review of patients treated with percutaneous VA-ECMO during the study period at our institution. A logistic regression model was applied to investigate the association between sequential organ failure assessment (SOFA) score and survivor status. Fisher's exact test was used to examine the association between survivor status and cannula size (15 Fr vs >15 Fr). RESULTS: Percutaneous VA-ECMO was initiated in 25 patients. At 30 days, 10 patients were alive (40%). Fifteen patients had cardiac arrest (CA) prior to ECMO initiation, of which 5 were alive at 30 days (33%). Survivors had a lower baseline median SOFA score (9 vs 16; P=.02; odds ratio, 0.577). Use of a smaller cannula was associated with survival (P=.01). There was an association between the size of the arterial cannula and increased blood transfusions (P<.01). CONCLUSIONS: Lower presenting SOFA score and smaller cannula size were associated with increased survival in patients with cardiogenic shock (CS) or CA who underwent percutaneous VA-ECMO placed in the cardiac catheterization laboratory using a portable system. Calculation of the SOFA score at presentation may help physicians determine which patients may derive benefit from ECMO. Smaller cannula size, while decreasing the amount of flow, may result in decreased bleeding and increased survival.


Assuntos
Oxigenação por Membrana Extracorpórea , Parada Cardíaca , Escores de Disfunção Orgânica , Choque Cardiogênico , Cânula , Oxigenação por Membrana Extracorpórea/efeitos adversos , Oxigenação por Membrana Extracorpórea/instrumentação , Oxigenação por Membrana Extracorpórea/métodos , Feminino , Parada Cardíaca/diagnóstico , Parada Cardíaca/mortalidade , Parada Cardíaca/terapia , Humanos , Masculino , Pessoa de Meia-Idade , Avaliação de Processos e Resultados em Cuidados de Saúde , Valor Preditivo dos Testes , Estudos Retrospectivos , Medição de Risco/métodos , Choque Cardiogênico/diagnóstico , Choque Cardiogênico/mortalidade , Choque Cardiogênico/terapia , Análise de Sobrevida , Estados Unidos
6.
J Invasive Cardiol ; 27(3): 148-54, 2015 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-25740967

RESUMO

BACKGROUND: Comparative effectiveness research (CER) is taking a more prominent role in formalizing hospital treatment protocols and health-care coverage policies by having health-care providers consider the impact of new devices on costs and outcomes. CER balances the need for innovation with fiscal responsibility and evidence-based care. This study compared the clinical and economic impact of percutaneous ventricular assist devices (pVAD) with intraaortic balloon pumps for high-risk patients undergoing percutaneous coronary intervention (PCI). METHODS: This study conducted a review of all comparative randomized control trials of the pVADS (Impella and TandemHeart) vs IABP for patients undergoing high-risk percutaneous coronary intervention (PCI). A retrospective analysis of the 2010 and 2011 Medicare MEDPAR data files was also performed to compare procedural costs and hospital length of stay (LOS). Readmission rates between the devices were also studied. RESULTS: Based on available trials, there is no significant clinical benefit with pVAD compared to IABP. Use of pVADs is associated with increased length of Intensive Care Unit stay and a total longer LOS. The incremental budget impact for pVADs was $33,957,839 for the United States hospital system (2010-2011). CONCLUSIONS: pVADs are not associated with improved clinical outcomes, reduced hospital length of stay, or reduced readmission rates. Management of high-risk PCI and cardiogenic shock patients with IABP is more cost effective than a routine use of pVADS. Use of IABP as initial therapy in high-risk PCI and cardiogenic shock patients may result in savings of up to $2.5 billion annually of incremental costs to the hospital system.


Assuntos
Coração Auxiliar/economia , Intervenção Coronária Percutânea/economia , Choque Cardiogênico/economia , Choque Cardiogênico/terapia , Análise Custo-Benefício , Humanos , Balão Intra-Aórtico/instrumentação , Ensaios Clínicos Controlados Aleatórios como Assunto , Estados Unidos
7.
Interv Cardiol ; 9(1): 17-22, 2014 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-29588772

RESUMO

Complex percutaneous coronary intervention (PCI), encompassing an ever-expanding range of challenging lesion sets and patient populations, accounts for a significant proportion of PCI procedures being performed currently. Specific lesion types associated with lower rates of procedural success and higher rates of recurrence or major adverse cardiac events (MACE) include multivessel disease, unprotected left main coronary artery disease, fibrocalcific or undilatable lesions, chronic total occlusions, degenerated saphenous vein graft lesions, thrombotic lesions, and bifurcation disease. Validated tools and technical strategies currently exist to address most procedural scenarios encountered and should be familiar to the complex PCI operator. Anticipated clinical outcomes, projected resource utilization, and cost considerations should all factor into the decisions of when, how, and in whom to intervene.

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