Myocardial revascularization in patients with left main coronary disease.

While coronary artery bypass grafting (CABG) has been the standard of care for patients with unprotected left main coronary artery disease, advances in percutaneous coronary intervention (PCI) have made stent placement a reasonable alternative in selected patients. In this review, we address the results of studies comparing PCI with CABG, discuss the invasive evaluation of these patients, and the technical approach to percutaneous revascularization. Furthermore, we discuss future pivotal trials, which will help define long-term outcomes comparing PCI with surgery.

Benefits of High-Intensity Intensive Care Unit Physician Staffing under the Affordable Care Act.

The Affordable Care Act signed into law by President Obama, with its value-based purchasing program, is designed to link payment to quality processes and outcomes. Treatment of critically ill patients represents nearly 1% of the gross domestic product and 25% of a typical hospital budget. Data suggest that high-intensity staffing patterns in the intensive care unit (ICU) are associated with cost savings and improved outcomes. We evaluate the literature investigating the cost-effectiveness and clinical outcomes of high-intensity ICU physician staffing as recommended by The Leapfrog Group (a consortium of companies that purchase health care for their employees) and identify ways to overcome barriers to nationwide implementation of these standards. Hospitals that have implemented the Leapfrog initiative have demonstrated reductions in mortality and length of stay and increased cost savings. High-intensity staffing models appear to be an immediate cost-effective way for hospitals to meet the challenges of health care reform.

The utility of prescreening transesophageal echocardiograms: a prospective study.

BACKGROUND: Recent emphasis on the judicious use of imaging prompted the publication of the 2007 ACC/ASE Appropriateness Use Criteria (AUC) for Echocardiography. However, the intersection of the AUC with the safety and clinical use of transesophageal echocardiography (TEE) is not well established. METHODS: We reviewed 490 consecutive orders for TEEs for appropriateness, significant findings, and reasons for cancellation. RESULTS: We found that 79% (389/490) of ordered studies were performed and 21% (101/490) were not. The number of TEEs cancelled for safety reasons (n = 29) was similar to that cancelled for inappropriateness (n = 36). Only 2% (6/389) of those performed were inappropriate vs. 16% of those that were cancelled. New or unsuspected findings were obtained in half of all performed TEEs; the majority of which were ordered to detect cardiac source of embolism (CSE). CONCLUSIONS: The AUC should specifically consider the utility of clinician-based prescreening of TEEs to encourage appropriate use and safety. Furthermore, given the incremental value of TEE over transthoracic echocardiography in detection of CSE, in some cases, TEE may be considered an appropriate initial test for this indication.

Recovery of pacemakers and defibrillators for analysis and device advance directives: electrophysiologists' perspectives.

BACKGROUND: Following high-profile device failures, the Heart Rhythm Society emphasized the need for postmarketing surveillance by recommending that physicians return all explanted devices to the manufacturer for analysis. METHODS: We conducted a national survey of electrophysiologists (EPs) regarding recovery for analysis of explanted pacemakers and implantable cardioverter defibrillators (devices), and attitudes toward device-specific advance directives to facilitate return of devices. Online survey invitations were sent in four waves from December 2008 to June 2009 to 300 e-mail addresses from the Heart Rhythm Society member database. RESULTS: From 250 invitations, there were 95 responses (38%). Demographics included average age 50 years (range, 31-87); 95% male; 81% Caucasian. Only 23% reported returning all explanted devices to the manufacturers. Of all the respondents, 32% discarded >10 devices/year as medical waste, 42% stored devices in a box in the electrophysiology lab, and 10% donated at least 1 device/year to charity for reuse overseas. Sixty-seven percent felt that it would not be helpful to have an advance directive specifying what the patient would want done with their device postmortem. CONCLUSIONS: Few EPs return all explanted devices or send interrogation reports to the manufacturers, though nearly all said it was easy to do so. A majority either dispose of explanted devices as medical waste or store them in laboratories or offices, and a small percentage donate for reuse in underserved nations or to veterinary hospitals. This study suggests a need for initiatives such as educational campaigns to increase the retrieval and return of devices, either for analysis or reuse.

Clinical utility of intravascular ultrasound in the assessment of coronary allograft vasculopathy: a review.

Coronary artery vasculopathy (CAV) is one of the major factors that limit the long-term survival of heart transplant recipients. It is difficult to diagnose CAV, especially in the early stages. Traditional coronary angiography has been used for the diagnosis of CAV, but this method has limitations. Current literature suggests that intravascular ultrasound (IVUS) is a safe imaging technique that is beneficial for the early diagnosis of CAV; in comparison, IVUS with virtual histology (IVUS-VH) is an even more promising diagnostic utility. Despite its advantages, IVUS is currently not routinely utilized as the primary diagnostic modality for CAV in heart transplant recipients. In this review, we evaluate and summarize the clinical utility of IVUS in the early diagnosis of CAV, including its utility for assessing vessel remodeling, plaque composition, and prognostic value; morphometric analysis; and guiding therapy. After reviewing the relevant published literature, it is our recommendation that the use of IVUS be considered in all post-transplant CAV screening.

Transthoracic and transesophageal echocardiography for the indication of suspected infective endocarditis: vegetations, blood cultures and imaging.

BACKGROUND: The aim of this study was to investigate the ability of transthoracic echocardiography (TTE) to detect vegetations and the relationship between blood cultures and transesophageal echocardiography (TEE). METHODS: Five hundred eleven TTE and TEE pairs performed to evaluate endocarditis were retrospectively analyzed. Vegetation on TTE, prosthetic valve, change in regurgitation, and blood cultures were correlated with vegetation on TEE. RESULTS: TTE detected 45% of vegetations seen on TEE. There was no difference for prosthetic valves. Prosthetic valves (odds ratio, 1.7; P = .03) and increased regurgitation (odds ratio, 1.7; P = .01) were associated with vegetations on TEE; staphylococcal bacteremia and fungemia were not. Negative blood cultures were associated with negative results on TEE (P < .0001), but 27% of patients with prosthetic valves had culture-negative endocarditis or nonbacterial thrombotic endocarditis, and 6% had abscesses missed by TTE. CONCLUSION: This study demonstrates a limited capacity of TTE to detect vegetations. TEE may be an appropriate initial study to evaluate prosthetic valves. TEE for culture-negative endocarditis deserves further study.