Two-Year Outcomes of Early Cannulation Arteriovenous Grafts for End-Stage Renal Disease.

BACKGROUND: Almost 80% of patients with end-stage renal disease (ESRD) initiate dialysis via a central venous catheter (CVC). CVCs are associated with multiple complications and a high cost of care. The purpose of our project is to determine the impact of early cannulation arteriovenous grafts (ECAVGs) on quality of care and costs. METHODS: The dialysis access modality, complications, secondary interventions, hospital outcomes, and detailed costs were tracked for 397 sequential patients who underwent access creation between July 2014 and October 2018. Complications were grouped into deep vein thrombosis, line infections, sepsis, pneumothorax, and other. Secondary interventions included angioplasty, angioplasty and stent grafting, thrombectomy, surgical revision, and explantation. Hospital outcomes included length of stay, inpatient mortality, 30-day readmission, and discharge disposition. Costs included supplies, medications, laboratory tests, labor, and other direct costs. All variables were measured at the time of the index procedure, 30 days, 90 days, 180 days, 270 days, 1 year, 18 months, and 2 years. RESULTS: There were 131 patients who underwent arteriovenous fistula (AVF) and 266 who received ECAVG for dialysis access. The total cost of care per patient was $17,523 for AVF and $5,894 for ECAVG at 1 year (P < 0.01). Primary-assisted patency for AVF was 49.3% versus 81.4% for ECAVG (P = 0.027), and secondary-assisted patency for AVF was 63.8% versus 85.4% for ECAVG at 1 year (P = 0.011). There was a survival advantage for ECAVGs at 1 year (78.6% for AVF vs 85.0% for ECAVG, P = 0.034). Patients who received ECAVG had fewer CVC days (2.3% vs 19.1% for AVF, P < 0.001), fewer complications (1.6% vs. 21.5% for AVF, P < 0.001), and fewer secondary interventions (17.0% vs 52.5% for AVF, P < 0.001). CONCLUSIONS: This is the first study on patients with ESRD to report detailed outcomes and cost analysis as it relates to AVF versus ECAVG. ECAVGs have an advantage over AVFs due to lower overall cost and better clinical outcomes at 1 year. Implementation of an urgent start dialysis access program centered around ECAVGs may help achieve the national goal of better health care at a lower cost for patients with ESRD.

The impact of arterial cannulation strategy on operative outcomes in aortic surgery: evidence from a comprehensive meta-analysis of comparative studies on 4476 patients.

OBJECTIVES: There is a growing perception that peripheral cannulation through the femoral artery, by reversing the flow in the thoracoabdominal aorta, may increase the risk of retrograde brain embolization in aortic surgery. Central cannulation sites, including the right axillary artery, have been reported to improve operative outcomes by allowing antegrade blood flow. However, peripheral cannulation still remains largely used because a consensus for the routine use of central cannulation approaches has not been reached. METHODS: A meta-analysis of comparative studies reporting operative outcomes using central cannulation versus peripheral cannulation was performed. Pooled weighted incidence rates for end points of interest were obtained using an inverse variance model. RESULTS: A total of 4476 patients were included in the final analysis. Central cannulation was used in 2797 patients, and peripheral cannulation was used in 1679 patients. Central cannulation showed a protective effect on in-hospital mortality (risk ratio, 0.59; 95% confidence interval, 0.48-0.7; P < .001) and permanent neurologic deficit (risk ratio, 0.71; 95% confidence interval, 0.55-0.90; P = .005) when compared with peripheral cannulation. A trend toward an increased benefit in terms of reduced in-hospital mortality was observed when only the right axillary artery was used as the central cannulation approach (risk ratio, 0.35; 95% confidence interval, 0.22-0.55; P < .001; I(2) = 0%). CONCLUSIONS: Central cannulation was superior to peripheral cannulation in reducing in-hospital mortality and the incidence of permanent neurologic deficit. This superiority was particularly evident when the axillary artery was used for central cannulation.

A novel clinical prediction rule for 30-day mortality following balloon aortic valuloplasty: the CRRAC the AV score.

OBJECTIVES: We seek to identify predictors of 30-day mortality after balloon aortic valvuloplasty (BAV). BACKGROUND: To date, there is no validated method of predicting patient outcomes after percutaneous aortic valve interventions. METHODS: Data for consecutive patients with severe aortic stenosis who underwent BAV at the Mount Sinai Medical Center from January 2001 to July 2007 were retrospectively reviewed. Cox-proportional hazards regression was used to identify significant predictors of 30-day mortality, and the resultant model was compared to the EuroSCORE using Akaike's Information Criterion and area under the receiver-operating curve (AUC). RESULTS: The analysis included 281 patients (age 83 ± 9 years, 61% women, aortic valve area: 0.64 ± 0.2 cm(2)) and 36 (12.8%) of whom died within 30 days of BAV. With identified risk factors for 30-day mortality, critical status, renal dysfunction, right atrial pressure, and cardiac output, we constructed the CRRAC the AV risk score. Thirty-day survival was 72% in the highest tertile versus 94% in the lower two tertiles of the score. Compared to the additive and logistic EuroSCORE, the risk score demonstrated superior discrimination (AUC = 0.75 vs. 0.60 and 0.63, respectively). CONCLUSIONS: We derived a risk score, the CRRAC the AV score that identifies patients at high-risk of 30-day mortality after BAV. Validation of the developed risk prediction score, the CRRAC the AV score, is needed in other cohorts of post-BAV patients and potentially in patients undergoing other catheter-based valve interventions.

Neonatal balloon aortic valvuloplasty-predictive value of current risk score algorithms for treatment strategies.

BACKGROUND: Neonatal valvular aortic stenosis (AoS) represents a spectrum of different degrees of hypoplasia and malformation of all left heart structures. Uncertainty exists on threshold values for biventricular circulation of newborns with critical AoS. Our aim was to assess the predictive value of current risk scores for treatment strategies in critical AoS. METHODS AND RESULTS: The echocardiograms of all newborns with AoS treated by balloon valvuloplasty (AoVP) or Norwood operation between January 2006 and September 2008 were reviewed retrospectively and the Rhodes-, Colan-score and the univentricular repair survival advantage (UVR-SA) tool were applied. The results were compared to the actual outcome. Out of 28 patients 19 were treated by an initial AoVP and nine by an initial Norwood operation. In three a secondary Norwood operation was done. According to the Rhodes-score 24 patients should have been treated by a univentricular strategy but 12 of them (50%) live with biventricular circulation. The Colan-score resulted in 19 univentricular decisions and 7 (37%) of these patients now live with biventricular circulation. Applying the UVR-SA tool 2/12 (17%) patients predicted for a univentricular strategy received successful biventricular circulation and 2/16 (12%) of the suggested biventricular patients have a univentricular circulation. Hence, 14/28 (50%) patients had discordant treatment decisions. CONCLUSION: No prospectively tested criteria for patient selection (biventricular vs. univentricular) are available for critically ill newborns with AoS. Retrospective application of the current risk scores showed unsatisfactory results. Treatment decisions are based on local experience and expertise.

Understanding risk assessment in cardiac surgery patients.

Understanding the risk of surgery in valvular disease is of interest because aging of the population renders decision making more difficult and the magnitude of risk will influence not only the decision to intervene but also the choice of intervention and its timing. To assist clinicians in assessing the risk of cardiac surgery, multivariate risk scores are increasingly used to estimate operative mortality. Overall, the currently available scores, mostly U.S. Society of Thoracic Surgeons score and European System for Cardiac operative Risk Evaluation, achieve acceptable discrimination but suboptimal calibration in estimating the operative mortality of heart valve surgery. The intrinsic limitations of scoring systems highlight the fact that risk scores should be integrated into clinical judgment but should not be a substitute for it. A multidisciplinary approach involving cardiologists, cardiac surgeons, and anesthesiologists is required for this purpose, especially in high-risk patients.

[General surgery and closed mitral commissurotomy: when necessity makes the rules]. / Chirurgien généraliste et commissurotomie mitrale à coeur fermé: ou quand la nécessité fait loi.

Since emergency transfer of patients from Africa to European cardiovascular facilities is difficult, surgeons at the Principal Hospital in Dakar, Senegal, have reevaluated closed mitral commissurotomy. The purpose of this study was to ascertain patient selection criteria, optimal operative conditions, immediate and middle-term outcome, and cost of closed mitral commissurotomy. From June 1995 to March 1998, closed mitral commissurotomy was carried out on 21 patients (13 women and 8 men). Inclusion criteria were symptomatic mitral stenosis with a mitral surface less than 1.5 square centimeters. Exclusion criteria were associated valve disease, Wilkins score higher than 8, severe pulmonary artery hypertension, and evidence of mitral thrombus. One patient died on the fourth postoperative day and one patient developed transient hemiparesis. Twenty patients showed significant functional improvement. Mean mitral surface increased from 0.87 to 1.8 square centimeters. Follow-up at one-year confirmed stable results. Only one patient developed grade 3 mitral insufficiency but it was well tolerated and did not require valve replacement. The cost of the procedure was 1,000,000 F CFA in second category and 820,000 F CFA in third category. The findings of this study show that closed mitral commissurotomy can be performed without circulatory assistance equipment in African facilities such as the Principal Hospital in Dakar, that immediate and middle-term results are excellent, and that African surgeons should continue to learn the technique.

Utilization of intensive care unit technology.

Technology utilization in acute and critical care holds great promise for improving the management and outcome of patients. However, before this promise can be realized, technology has to be properly evaluated for appropriateness of use. This evaluation must include both the clinical impact on patient outcomes as well as the economic impact. Following this initial evaluation, for technologies deemed appropriate for use, careful preparation of clinicians in the use of the technology is necessary. Education must prioritize how the technology is to be used as well as provide incentives for the clinicians to change their current practice. If these three key steps are followed, technology can achieve the promise of improving patient management and outcome. Unfortunately, evidence exists which suggests that these three steps are not followed in many, if not most, hospitals in the United States. In this article, a method of implementing these three steps is presented. However, it is essential that national organizations and societies become active in this process, lest widespread variation in technology utilization continue.

Percutaneous aortic balloon valvuloplasty in octogenarians: morbidity and mortality.

STUDY OBJECTIVE: To examine the morbidity, mortality, and hospital course of an elderly patient sample (mean age, 86 years; 95% CI, 84 to 87) having percutaneous aortic balloon valvuloplasty. DESIGN: Retrospective consecutive case series before and after balloon valvuloplasty. SETTING: Tertiary care referral hospital. PATIENTS: Consecutive sample of 26 patients aged 80 years or older with symptomatic aortic stenosis referred for balloon valvuloplasty from July 1987 to July 1988. MEASUREMENTS AND MAIN RESULTS: Percutaneous aortic balloon valvuloplasty reduced the transvalvular gradient from 59 (95% CI, 51 to 67) to 31 mm Hg (95% CI, 26 to 35; P less than 0.0001) and increased aortic valve area from 0.45 (95% CI, 0.38 to 0.51) to 0.67 cm2 (95% CI, 0.58 to 0.76; P less than 0.0001). The mean length of hospital stay for the entire study population was 11.2 days (95% CI, 7.3 to 15.2) at a total hospital charge per patient of $29,600 (95% CI, 21,050 to 38,150). For patients having procedural complications (11 complications in 8 patients), surgical procedures, or cardiogenic shock, the mean hospital stay increased to 16.2 days (95% CI, 6.2 to 26.2; P less than 0.05) and the hospital charge increased to $44,400 (95% CI, 24,280 to 64,520; P less than 0.01). Two patients who presented with cardiogenic shock died, and 1 patient had an aortic valve replacement before discharge. Four patients were recently discharged (less than 1 month) and follow-up was obtained in the remaining 19 patients at 6.1 months (95% CI, 4.1 to 8.1). Five more patients, including the remaining patient who presented with cardiogenic shock, died after discharge for an overall mortality of 32%. Twelve of the remaining fourteen patients had fewer symptoms and improved an average of 1.1 New York Heart Association classes (95% CI, 0.7 to 1.4; P less than 0.0001). CONCLUSIONS: Percutaneous aortic balloon valvuloplasty in patients 80 years and older improves hemodynamics and symptoms of heart failure during short-term follow-up in most patients, but overall mortality is high in this elderly patient population. Hospital charges and length of stay were much higher in patients with complications or coexisting medical illnesses. Valvuloplasty is a reasonable alternative treatment for patients with aortic stenosis who require palliative treatment of symptoms and have high surgical risk.