Cardiogenic shock in Taiwan from 2003 to 2017 (CSiT-15 study).

BACKGROUND: This study investigated temporal trends in the treatment and mortality of patients with cardiogenic shock (CS) in Taiwan in relation to acute myocardial infarction (AMI) accreditation implemented in 2009 and the unavailability of percutaneous ventricular assist devices. METHODS: Data of patients diagnosed as having CS between January 2003 and December 2017 were collected from Taiwan's National Health Insurance Research Database. Each case was followed from the date of emergency department arrival or hospital admission for the first incident associated with a CS diagnosis up to a 1-year interval. Measurements included demographics, comorbidities, treatment, mortality, and medical costs. Using an interrupted time-series (ITS) design with multi-level mixed-effects logistic regression model, we assessed the impact of AMI accreditation implementation on the mortality of patients with AMI and CS overall and stratified by the hospital levels. RESULTS: In total, 64 049 patients with CS (mean age:70 years; 62% men) were identified. The incidence rate per 105 person-years increased from 17 in 2003 to 25 in 2010 and plateaued thereafter. Average inpatient costs increased from 159 125 points in 2003 to 240 993 points in 2017, indicating a 1.5-fold increase. The intra-aortic balloon pump application rate was approximately 22-25% after 2010 (p = 0.093). Overall, in-hospital, 30-day, and 1-year mortality declined from 60.3%, 63.0%, and 69.3% in 2003 to 47.9%, 50.8% and 59.8% in 2017, respectively. The decline in mortality was more apparent in patients with AMI-CS than in patients with non-AMI-CS. The ITS estimation revealed a 2% lower in-hospital mortality in patients with AMI-CS treated in district hospitals after the AMI accreditation had been implemented for 2 years. CONCLUSIONS: In Taiwan, the burden of CS has consistently increased due to high patient complexity, advanced therapies, and stable incidence. Mortality declined over time, particularly in patients with AMI-CS, which may be attributable to advancements in AMI therapies and this quality-improving policy.

Regenerative Therapy for Patients with Congenital Heart Disease.

Congenital heart disease (CHD) is the most common birth defect, affecting 1 in 100 babies. Among CHDs, single ventricle (SV) physiologies, such as hypoplastic left heart syndrome and tricuspid atresia, are particularly severe conditions that require multiple palliative surgeries, including the Fontan procedure. Although the management strategies for SV patients have markedly improved, the prevalence of ventricular dysfunction continues to increase over time, especially after the Fontan procedure. At present, the final treatment for SV patients who develop heart failure is heart transplantation; however, transplantation is difficult to achieve because of severe donor shortages. Recently, various regenerative therapies for heart failure have been developed that increase cardiomyocytes and restore cardiac function, with promising results in adults. The clinical application of various forms of regenerative medicine for CHD patients with heart failure is highly anticipated, and the latest research in this field is reviewed here. In addition, regenerative therapy is important for children with CHD because of their natural growth. The ideal pediatric cardiovascular device would have the potential to adapt to a child's growth. Therefore, if a device that increases in size in accordance with the patient's growth could be developed using regenerative medicine, it would be highly beneficial. This review provides an overview of the available regenerative technologies for CHD patients.

Resource Utilization in Pediatric Patients Supported With Ventricular Assist Devices in the United States: A Multicenter Study From the Pediatric Interagency Registry for Mechanically Assisted Circulatory Support and the Pediatric Health Information System.

BACKGROUND: Few data exist on resource utilization with pediatric ventricular assist devices (VADs). We tested the hypothesis that device type and adverse events are associated with increased resource utilization in pediatric patients supported with VADs. METHODS AND RESULTS: The Pediatric Interagency Registry for Mechanically Assisted Circulatory Support, a national registry of VADs in patients <19 years old, and the Pediatric Health Information System, an administrative database, were merged. Univariate analysis was performed assessing the association of all factors with the total cost and length of stay first. Significant variables (P<0.05) were subjected to multivariable analysis. The study included 142 patients from 19 centers with VAD implants from October 2012 to June 2016. The median age was 9 years (interquartile range [IQR] 2-15), 84 (59%) supported with a continuous-flow VAD. Overall median hospital costs were $750 000 (IQR $539 000 to $1 100 000) with a median hospital length of stay of 81 days (IQR 54-128). On multivariable analysis, device type and postoperative complications were not associated with resource utilization. Factors associated with increased costs included patient age, lower-volume VAD center, being intubated, being on extracorporeal membrane oxygenation, number of complex chronic medical conditions, and length of stay. Among continuous-flow VAD patients, discharge to home before transplant versus remaining hospitalized was associated with lower hospital costs (median $600 000 [IQR $400 000 to $820 000] versus median $680 000 [IQR $500 000 to $970 000], P=0.03). CONCLUSION: VADs in pediatric patients are associated with high resource utilization. Increased resource utilization was associated with lower-volume VAD centers, disease severity at VAD implantation, and the presence of complex chronic medical conditions. Further study is needed to develop cost-effective strategies in this complex population.

Blunt thoracic trauma and cardiac injury in the athlete: contemporary management.

Commotio cordis and cardiac injuries are rare events usually following a chest blunt traumas during sports activities. Various etiologies have been identified to cause electrical (commotio cordis) and/or structural (contusion and further injuries) damage, but high-velocity tools such as baseballs or hockey pucks (also called projectiles) have been chiefly identified. Clinical consequences are challenging, varying from uncomplicated supraventricular arrhythmias to cardiac wall rupture. Ventricular fibrillation is the most remarkable outcome leading to cardiac arrest in some individuals. In this article, up-to-date epidemiological and pathophysiological issues are discussed, along with the most suitable assistance protocols of the injured athlete in the sports arena. Current knowledge about traumatic sports injuries and ensuing cardiovascular sequelae made significant steps forwards than in the past. The majority of athletes (especially the youngest ones) wearing chest protectors are usually preserved from serious outcomes and sudden cardiac death, but further technical effort is encouraged to attain more satisfactory barriers against projectile's impact. Educational campaigns among students, closer team surveillance, implementation of the sports arenas with adequate rescue devices and medical assistance remain mandatory items in contact sports activity.

Low blood pressure, low serum cholesterol and anemia predict early necessity of ventricular assist device implantation in patients with advanced heart failure at the time of referral from non-ventricular assist device institutes.

BACKGROUND: The timing of ventricular assist device (VAD) implantation is always a matter of debate, especially when a patient is referred from a non-VAD institute. We focused on objective noninvasive parameters at the time of admission to a VAD implant center and analyzed the factors predicting the necessity of early VAD. METHODS AND RESULTS: We retrospectively analyzed advanced heart failure (HF) patients referred since January 2011, including patients less than 65 years old. They all had a history of hospitalization for HF management in non-VAD institutes within 1 month before referral. We excluded patients transferred with mechanical circulatory support. We enrolled 46 patients (40 males, 39.8±13.4 years old). Among them, 26 patients had a VAD implanted or died within 120 days. By multivariable logistic analysis using admission parameters, systolic blood pressure (BP) <93 mmHg [odds ratio (OR) 13.335], hemoglobin <12.7 g/dl (OR 12.175) and serum total cholesterol <144 mg/dl (OR 8.096) were significant predictors of early VAD requirement. We constructed a scoring system according to the ORs, and the area under the receiver-operating characteristic curve was 0.913. CONCLUSIONS: Low BP, low serum cholesterol and anemia on admission predict early VAD in advanced HF patients who have been treated in non-VAD institutes. Such patients should be promptly referred to a VAD implant center.

Ventricular assist devices and anesthetic implications for noncardiac procedures.

Approximately 5 million Americans experience heart failure, which affects 10 in every 1000 people older than 65 years. Ventricular assist devices (VADs) are a type of mechanical circulatory support that aids in systemic perfusion by maintaining unidirectional flow while reducing the oxygen demand of the failing ventricle. There are 3 generations of VADs in circulation used as a bridge to transplantation, a bridge to recovery, or as destination therapy. Due to the increasing use of these devices, it is likely that anesthetists will encounter patients with these devices more frequently, which requires adequate preoperative discussion with the care team. Intraoperatively, it is important to realize that patients with VADs are at higher risk for aspiration, to recognize electromagnetic interference from surgical devices, to maintain hemodynamic stability, and to monitor coagulation status. With proper knowledge, and adequate preoperative preparation and intraoperative care, anesthetists should be able to achieve safe and successful patient outcomes through anesthesia care.

Lifetime circulatory support must not be restricted to transplant centers.

Heart failure that does not respond to maximum medical management is a frightening and debilitating condition. The patients have poor quality of life and become progressively more dependent on hospital admissions for escalating medical therapy. Long-term circulatory support can provide symptomatic relief and improved survival for those who do not have access to cardiac transplantation. User-friendly blood pumps with proven durability already exist. Rotary blood pumps must be made available in centers other than those involved in transplantation. The mystique must be removed from this relatively simple intervention.

Care of patients with heart failure and the use of ventricular assist devices.

Heart failure is becoming increasingly common as the population ages. Ventricular assist devices are used as a bridge for patients whose heart failure can no longer be controlled by medication and require a heart transplant. This article examines the care, rehabilitation and education of these patients.

Rationing: don't give up.

It's not only necessary, but possible, if the public can be educated.

Development and clinical application of the MicroMed DeBakey VAD.

A miniaturized axial flow pump to provide left ventricular assistance has been developed. Such a device has the potential to address limitations of the larger pulsatile devices. Clinical trials of the MicroMed DeBakey VAD (ventricular assist device) began in Europe in November 1998. As of December 1, 1999, 18 patients have been implanted with the MicroMed DeBakey VAD. Hemodynamic evaluations along with blood chemistry analysis were recorded routinely. Exercise tolerance was observed. In most patients, end-organ function has improved and has not deteriorated in any patient. Patients have been able to perform normal low-level activity and have tolerated positional changes without evidence of postural hemodynamic changes. Select patients have taken supervised out-of-hospital excursions. This initial clinical experience with the MicroMed DeBakey VAD suggests that the miniaturized axial flow pump can provide ventricular support to bridge patients to cardiac transplant and may provide an improved quality of life for the end-stage heart failure recipient.

Mechanical circulatory support as a bridge to cardiac transplantation: toward the 21st century.

Mechanical circulatory support is used to sustain the lives of patients awaiting cardiac transplantation who would otherwise die before a donor organ became available. Currently available ventricular assist devices used for mechanical circulatory support, risk factors and complications associated with use of these devices, and selection of candidates for treatment with mechanical support as a bridge to cardiac transplantation are reviewed. The importance of early insertion of the devices before end-organ dysfunction occurs is examined.

Physiologic aspects of the TCI Heartmate mechanical left ventricular assist device.

This article focuses on information related to the physiologic aspects of the TCI mechanical left ventricular assist device (LVAD). The two types of LVADs designed by ThermoCardiosystems, Inc., Woburn, Massachusetts, are discussed, but most of the information provided relates to the pneumatic TCI LVAD. The structure and function of the two LVADs, including device similarities and differences, are discussed first. Then physiologic, device, and treatment variables that influence the nursing care of patients requiring the pneumatic TCI LVAD are presented. Pneumatic console operator role and qualifications used at Sharp HealthCare and suggestions for future nursing research involving the TCI LVAD are provided.