Cost-effectiveness of extracorporeal cardiopulmonary resuscitation vs. conventional cardiopulmonary resuscitation in out-of-hospital cardiac arrest: a pre-planned, trial-based economic evaluation.

AIMS: When out-of-hospital cardiac arrest (OHCA) becomes refractory, extracorporeal cardiopulmonary resuscitation (ECPR) is a potential option to restore circulation and improve the patient's outcome. However, ECPR requires specific materials and highly skilled personnel, and it is unclear whether increased survival and health-related quality of life (HRQOL) justify these costs. METHODS AND RESULTS: This cost-effectiveness study was part of the INCEPTION study, a multi-centre, pragmatic randomized trial comparing hospital-based ECPR to conventional CPR (CCPR) in patients with refractory OHCA in 10 cardiosurgical centres in the Netherlands. We analysed healthcare costs in the first year and measured HRQOL using the EQ-5D-5L at 1, 3, 6, and 12 months. Incremental cost-effectiveness ratios (ICERs), cost-effectiveness planes, and acceptability curves were calculated. Sensitivity analyses were performed for per-protocol and as-treated subgroups as well as imputed productivity loss in deceased patients. In total, 132 patients were enrolled: 62 in the CCPR and 70 in the ECPR group. The difference in mean costs after 1 year was €5109 (95% confidence interval -7264 to 15 764). Mean quality-adjusted life year (QALY) after 1 year was 0.15 in the ECPR group and 0.11 in the CCPR group, resulting in an ICER of €121 643 per additional QALY gained. The acceptability curve shows that at a willingness-to-pay threshold of €80.000, the probability of ECPR being cost-effective compared with CCPR is 36%. Sensitivity analysis showed increasing ICER in the per-protocol and as-treated groups and lower probabilities of acceptance. CONCLUSION: Hospital-based ECPR in refractory OHCA has a low probability of being cost-effective in a trial-based economic evaluation.

A simple risk chart for initial risk assessment of 30-day mortality in patients with cardiogenic shock from ST-elevation myocardial infarction.

AIMS: Early risk stratification is important in patients with cardiogenic shock from ST-elevation myocardial infarction (STEMI). We aimed to develop a simple risk chart that includes clinical parameters that are readily available at time of hospital admission to assess risk of 30-day mortality. METHODS AND RESULTS: A series of 544 STEMI patients admitted to undergo primary percutaneous coronary intervention and presenting with cardiogenic shock were included between 2000 and 2012. Overall 30-day mortality was 38.4% and did not change over the years (p-trend=0.64). Baseline variables that were available at time of hospital admission were entered into a logistic regression model in a forward stepwise manner. Only age (odds ratio (OR) per year 1.05, 95% confidence interval (CI) 1.04-1.07, p<0.001), initial serum lactate level (OR per mmol/l 1.17, 95% CI 1.11-1.24, p<0.001) and initial creatinine level above the upper limit of normal (OR 2.89, 95% CI 1.90-4.37, p<0.001) remained independent predictors, and were subsequently used to develop a risk chart that stratifies risk of 30-day mortality into categories ranging from 0-20% to 80-100%. The calibration plot showed a close relationship between expected and observed mortality. The risk chart had a higher discriminative accuracy than the GRACE score (c-index 0.75 vs. 0.66, p=0.009). Adding variables that were obtained from coronary angiography and during clinical course did not significantly improve discriminative accuracy of risk chart (c-index 0.77, p=0.48). CONCLUSION: Mortality of patients with cardiogenic shock from STEMI undergoing primary percutaneous coronary intervention can be well predicted already at time of hospital admission by a risk chart that uses only three variables, namely, age, initial serum lactate and creatinine level.

Intra-operative assessment of human pulmonary alveoli in vivo using Sidestream Dark Field imaging: a feasibility study.

BACKGROUND: In vivo videomicroscopy has been used for years to visualize subpleural alveoli in animal studies. This has led to a better understanding of alveolar physiology. We tested the hypothesis whether a novel handheld videomicroscope could be used for intraoperative detection of alveoli in surgical patients during mechanical ventilation. MATERIAL/METHODS: Using Sidestream Dark Field imaging, we observed 6 patients (3 adults and 3 children) who underwent elective cardiac surgery. In each patient, the tip of the microscope was placed on the visceral pleural surface of the left upper pulmonary lobe after weaning from cardiopulmonary bypass. The acquired images were converted into digital signals and captured on a computer. RESULTS: Although cardiac motion artifacts were present, visceral pleural microvascular blood flow could be observed in adults and infants. In infants, sub-pleural cavities (alveoli) were observed. These alveoli were remarkably similar in dimension and structure to those identified previously as true alveoli in animal studies. Quantification of these alveoli demonstrated that mean alveolar diameter, perimeter and area increased with age among the investigated infants (all parameters p<0.001). CONCLUSIONS: High-quality images of visceral pleural microvessels as well as subpleural cavities, reflecting superficial alveoli, could be obtained in infants. These findings create the opportunity to begin human intervention studies, which should investigate alveolar dynamics during mechanical ventilation in cardio-thoracic surgery in more detail.