Opportunities for Expanding Access to Veterinary Care: Lessons From COVID-19.

The COVID-19 pandemic impacted people and professions around the world, including veterinary medicine. The epidemiology of SARS-CoV-2 broadened the definition of vulnerability in human populations, and the virus' economic impacts exacerbated well-established financial barriers to providing equal access to medical care. The objective of this study was to explore how the pandemic was impacting access to companion animal care in the months March-September of 2020, with a focus on traditionally vulnerable as well as newly vulnerable populations. Additionally, this study sought to identify areas on which the veterinary profession can focus in order to help increase access to veterinary care, including the veterinary school curriculum, continuing education, and telemedicine. We conducted surveys and interviews with animal owners (n = 1009), veterinarians and clinic staff (n = 516), and access to veterinary care organizations (n = 17). Collectively, these responses highlighted how the COVID-19 pandemic created new, and amplified existing, issues with accessing and providing veterinary care. Three critical themes arose; (1) opportunities for further learning for the veterinary profession; including curricula around telemedicine, financially resilient business models and understanding health disparities and vulnerable populations; (2) a need for a network of collaboration and communication across veterinary clinics and access to care organizations and (3) future preparedness for health, economic or other crises response. Overall, the pandemic emphasized the complexity of access to care, as well as the role of veterinarians in public health. This information can be used to develop strategies to aid in increased access to veterinary care now and in the face of future disasters.

Management of spontaneous coronary artery dissection complicated by cardiogenic shock using mechanical circulatory support with the Impella device.

OBJECTIVE: The aim is to evaluate the feasibility of using mechanical circulatory support, specifically the Impella device, in spontaneous coronary artery dissection (SCAD) patients with cardiogenic shock. BACKGROUND: The therapeutic options for managing SCAD complicated by cardiogenic shock are limited. Risky revascularization procedures are often necessary. METHODS: This was a multicenter case series in the United States. Approximately 20 cases of Impella implantation in patients with SCAD are known. The implanting physician for each of these cases was contacted and de-identified records were requested. The records were analyzed for Impella indications, outcomes, and complications. RESULTS: Records from four cases were received. All patients survived to hospital discharge and no major complications were observed. In two cases, cardiogenic shock developed in the absence of ongoing ischemia, suggesting a Takotsubo-like cardiomyopathy. In these cases, the Impella provided hemodynamic support until the patient's cardiac function recovered. CONCLUSION: Although a small case series, given the scarcity of SCAD cases complicated by cardiogenic shock and the limited therapies available to treat these patients, these data are of clinical value in highlighting the feasibility of Impella use in SCAD. The Impella can be valuable for procedural support and in cardiogenic shock, especially in cases without evidence of ongoing ischemia.

Unloading the Left Ventricle Before Reperfusion in Patients With Anterior ST-Segment-Elevation Myocardial Infarction.

BACKGROUND: In ST-segment-elevation myocardial infarction (STEMI), infarct size correlates directly with heart failure and mortality. Preclinical testing has shown that, in comparison with reperfusion alone, mechanically unloading the left ventricle (LV) before reperfusion reduces infarct size and that 30 minutes of unloading activates a cardioprotective program that limits reperfusion injury. The DTU-STEMI pilot trial (Door-To-Unload in STEMI Pilot Trial) represents the first exploratory study testing whether LV unloading and delayed reperfusion in patients with STEMI without cardiogenic shock is safe and feasible. METHODS: In a multicenter, prospective, randomized exploratory safety and feasibility trial, we assigned 50 patients with anterior STEMI to LV unloading by using the Impella CP followed by immediate reperfusion (U-IR) versus delayed reperfusion after 30 minutes of unloading (U-DR). The primary safety outcome was a composite of major adverse cardiovascular and cerebrovascular events at 30 days. Efficacy parameters included the assessment of infarct size by using cardiac magnetic resonance imaging. RESULTS: All patients completed the U-IR (n=25) or U-DR (n=25) protocols with respective mean door-to-balloon times of 72 versus 97 minutes. Major adverse cardiovascular and cerebrovascular event rates were not statistically different between the U-IR versus U-DR groups (8% versus 12%, respectively, P=0.99). In comparison with the U-IR group, delaying reperfusion in the U-DR group did not affect 30-day mean infarct size measured as a percentage of LV mass (15±12% versus 13±11%, U-IR versus U-DR, P=0.53). CONCLUSIONS: We report that LV unloading using the Impella CP device with a 30-minute delay before reperfusion is feasible within a relatively short time period in anterior STEMI. The DTU-STEMI pilot trial did not identify prohibitive safety signals that would preclude proceeding to a larger pivotal study of LV unloading before reperfusion. An appropriately powered pivotal trial comparing LV unloading before reperfusion to the current standard of care is required. CLINICAL TRIAL REGISTRATION: URL: https://www.clinicaltrials.gov . Unique identifier: NCT03000270.

Percutaneous intervention through a Cabrol composite graft.

Similar to other surgical techniques, ascending thoracic aortic repair has evolved through a series of modifications, each with improvement in longevity, morbidity, and mortality. Until recently, most, if not all, aortic composite graft-coronary ostial anastamotic complications have been addressed with repeat surgery. Due to this, most interventional cardiologists have little to no experience in approaching postsurgical aortic composite graft-coronary ostial anastamotic lesions percutaneously when the anatomy is altered by a Cabrol interposition graft. Nevertheless, it is important that operators are aware of the various surgical techniques used to repair the ascending aorta and reimplant the coronary arteries. Furthermore, in the present era of addressing more and more stenotic lesions percutaneously, it is important to have knowledge into which type of lesion lends itself to a percutaneous approach. Our review of the literature reveals that there have been no reported cases of percutaneous interventions of the native coronary arteries through a Cabrol composite graft. We report the first case of percutaneous intervention of an unprotected left main anastamotic stenosis through a Cabrol composite graft.