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1.
Pharmacotherapy ; 39(5): 609-613, 2019 May.
Artigo em Inglês | MEDLINE | ID: mdl-30892740

RESUMO

BACKGROUND: Historically, there is perceived pressure to achieve therapeutic levels of tacrolimus quickly after heart transplant (HT). We evaluated the association between time within therapeutic tacrolimus range and time to therapeutic trough and rejection in the 30 days following HT. METHODS: This is a single-center retrospective cohort study of consecutive adult HT patients receiving immunosuppression. Goal trough tacrolimus levels were 10-15 ng/ml. Surveillance endomyocardial biopsies were performed weekly for 4 weeks. Outcomes included the effect of time to and time-in-therapeutic tacrolimus range (Rosendaal method) on 30-day clinical rejection, 1R/1B, and 2R or higher histologic occurrences. RESULTS: We reviewed 67 HT patients (median age 58.8 yrs). For clinical rejection versus no-rejection groups, the median (25th, 75th percentile) time to therapeutic tacrolimus levels was 9.5 (8, 12.3) days versus 9.0 (7, 13) days (p=0.623). The median time-in-therapeutic tacrolimus range was 34.1% (23.2, 42.2) versus 36.2% (19.9, 51.2), respectively (p=0.512). Similarly, we observed no significant differences in time to and time-in-therapeutic tacrolimus range in patients who developed grade 1R/1B (p=0.650 and p=0.725) or grade 2R or higher histology (p=0.632 and p=0.933). CONCLUSIONS: Our small single-center analysis suggests that neither time to nor time in therapeutic tacrolimus range predicted acute rejection within 30 days of HT.

2.
ESC Heart Fail ; 2018 Jul 27.
Artigo em Inglês | MEDLINE | ID: mdl-30052326

RESUMO

AIMS: Heart failure (HF) and diabetes mellitus (DM) often coexist and have bidirectional association. Advanced HF is associated with worsened glycaemic control. This meta-analysis investigated the effects of left ventricular assist device (LVAD) implantation on markers of DM control. METHODS AND RESULTS: We performed a systematic search of MEDLINE and Cochrane through October 2017 to identify studies evaluating advanced HF patients who had received an LVAD and reported markers of glycaemic control. The primary outcome was glycosylated haemoglobin A1c (HbA1c), and the secondary outcomes included fasting glucose, daily insulin requirements, and body mass index (BMI). Outcomes were pooled using a Hartung-Knapp random-effects model producing a mean difference (MD) and 95% confidence interval (CI). Thirteen studies, including 820 participants, were included. HbA1c was 1.23% lower following LVAD implantation (95% CI -1.49 to -0.98). Greater HbA1c reductions were seen with higher pre-LVAD values. Similarly, fasting plasma glucose (-24.4 mg/dL, 95% CI -33.4 to -15.5), daily insulin requirements (-18.8 units, 95% CI -28.8 to -8.7), and serum creatinine levels (MD -0.20, 95% CI -0.35 to -0.06) were significantly lower than pre-LVAD levels. We saw no difference in BMI (MD 0.09, 95% CI -1.24 to 1.42). CONCLUSIONS: LVAD implantation was associated with significant improvement in HbA1c, fasting plasma glucose, and daily insulin need in advanced HF patients.

3.
Circulation ; 135(24): e1115-e1134, 2017 Jun 13.
Artigo em Inglês | MEDLINE | ID: mdl-28533303

RESUMO

Cardiac arrest in patients on mechanical support is a new phenomenon brought about by the increased use of this therapy in patients with end-stage heart failure. This American Heart Association scientific statement highlights the recognition and treatment of cardiovascular collapse or cardiopulmonary arrest in an adult or pediatric patient who has a ventricular assist device or total artificial heart. Specific, expert consensus recommendations are provided for the role of external chest compressions in such patients.


Assuntos
American Heart Association , Reanimação Cardiopulmonar/normas , Parada Cardíaca/epidemiologia , Parada Cardíaca/terapia , Coração Auxiliar/normas , Adulto , Reanimação Cardiopulmonar/tendências , Criança , Serviços Médicos de Emergência/normas , Serviços Médicos de Emergência/tendências , Circulação Extracorpórea/normas , Circulação Extracorpórea/tendências , Coração Auxiliar/tendências , Humanos , Estados Unidos/epidemiologia
4.
Artif Organs ; 40(2): 123-8, 2016 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-26043796

RESUMO

Our aim was to identify relevant literature supporting the use of phosphodiesterase-5 (PDE5) inhibitors in patients with persistent pulmonary hypertension with signs of postprocedural right ventricular (RV) dysfunction following left ventricular assist device (LVAD) implantation. We searched MEDLINE, SCOPUS, and Web of Science from inception through November 27, 2014 for citations evaluating patients with end-stage heart failure necessitating LVAD, continuous and pulsatile, who received a PDE5 inhibitor to prevent RV failure. Outcomes of interest included changes in mean pulmonary artery pressure, pulmonary vascular resistance, central venous pressure, cardiac index, and mean arterial pressure. Results are presented qualitatively. Four citations (n = 83 patients) were included. These included a single case report, two retrospective case series, and a prospective open-label study with a historical control. All four studies utilized the PDE5 inhibitor sildenafil with various doses for up to 3 months. Sildenafil routinely reduced mean pulmonary artery pressures as soon as 90 min after administration. Reductions in pulmonary vascular resistance were also seen shortly after the procedure and maintained through 12-15 weeks. While one study saw improvements in postoperative central venous pressures, another did not. Evidence supporting PDE5 inhibitor use to attenuate RV failure in patients requiring an LVAD is weak.


Assuntos
Pressão Sanguínea/efeitos dos fármacos , Insuficiência Cardíaca/cirurgia , Coração Auxiliar , Inibidores da Fosfodiesterase 5/uso terapêutico , Disfunção Ventricular Direita/tratamento farmacológico , Insuficiência Cardíaca/complicações , Coração Auxiliar/efeitos adversos , Humanos , Hipertensão Pulmonar/complicações , Hipertensão Pulmonar/tratamento farmacológico , Resultado do Tratamento , Resistência Vascular/efeitos dos fármacos , Disfunção Ventricular Direita/complicações
5.
Conn Med ; 79(8): 469-75, 2015 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-26506678

RESUMO

BACKGROUND: Enlargement of the left atrium is a marker of mortality in the general population. Left atrial volume index (LAVI) has long been proposed as a measure of prognosis in patients with heart failure (HF). The aim of this meta-analysis was to assess the utility of using baseline LAVI as an independent predictor of all-cause mortality in patients with HF. METHODS: A search of Medline and Embase bibliographic databases was performed to identify studies meeting the following inclusion criteria: 1) studies evaluating a cohort of patients with HF (both reduced and preserved ejection fraction); 2) studies conducting multivariate analysis or patient matching to determine the relationship between baseline LAVI measured by echocardiography and all-cause mortality; and 3) studies reporting data on the relationship between baseline LAVI (per difference in mL/m2) and all-cause mortality. Adjusted hazard ratios depicting the association between baseline LAVI and all-cause mortality were pooled using traditional random-effects meta-analysis. RESULTS: 1,188 publications were reviewed from which four studies were included in the present meta-analysis. We found each 10 mL/m2 increase in baseline LAVI was associated with a 22% increased adjusted hazard of all-cause mortality (95% confidence interval, 13% to 31%, I2 = 14%). CONCLUSION: Baseline LAVI is an important independent predictor of all-cause mortality in patients with heart failure and should be reported routinely in these patients undergoing echocardiography.


Assuntos
Átrios do Coração/diagnóstico por imagem , Insuficiência Cardíaca/diagnóstico por imagem , Insuficiência Cardíaca/mortalidade , Ecocardiografia , Átrios do Coração/patologia , Humanos
6.
Tex Heart Inst J ; 42(5): 471-3, 2015 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-26504445

RESUMO

The timing of surgery for active infective endocarditis is challenging when patients exhibit mechanical dysfunction and hemodynamic compromise. Extracorporeal membrane oxygenation has been described in treating sepsis but not, insofar as we know, in treating the acute mechanical sequelae that arise from infective endocarditis. We report perhaps the first case that shows the usefulness of extracorporeal membrane oxygenation as a bridge to definitive treatment in a 35-year-old man who had infective endocarditis followed by aorto-atrial fistula and cardiopulmonary collapse.


Assuntos
Doenças da Aorta/terapia , Endocardite Bacteriana/terapia , Oxigenação por Membrana Extracorpórea , Cardiopatias/terapia , Choque/terapia , Infecções Estreptocócicas/terapia , Fístula Vascular/terapia , Estreptococos Viridans/isolamento & purificação , Adulto , Antibacterianos/uso terapêutico , Doenças da Aorta/diagnóstico , Doenças da Aorta/microbiologia , Doenças da Aorta/fisiopatologia , Ponte Cardiopulmonar , Desbridamento , Ecocardiografia Doppler em Cores , Ecocardiografia Transesofagiana , Endocardite Bacteriana/diagnóstico , Endocardite Bacteriana/microbiologia , Cardiopatias/diagnóstico , Cardiopatias/microbiologia , Cardiopatias/fisiopatologia , Implante de Prótese de Valva Cardíaca , Hemodinâmica , Humanos , Masculino , Anuloplastia da Valva Mitral , Choque/diagnóstico , Choque/microbiologia , Choque/fisiopatologia , Infecções Estreptocócicas/diagnóstico , Infecções Estreptocócicas/microbiologia , Abuso de Substâncias por Via Intravenosa/complicações , Fatores de Tempo , Resultado do Tratamento , Fístula Vascular/diagnóstico , Fístula Vascular/microbiologia , Fístula Vascular/fisiopatologia
7.
Conn Med ; 79(1): 5-11, 2015 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-26244190

RESUMO

BACKGROUND: While advancements in ventricular assist device (VAD) therapy have improved survival and quality of life for select patients with advanced heart failure (HF), variations in provider knowledge and opinions may ultimately serve as barriers to therapy. METHODS AND RESULTS: A 12-item survey assessing experience, knowledge, and perspectives of VAD therapy was sent to 106 practicing cardiologists at three neighboring institutions. We received 34 responses for a total response rate of 32.1%. The majority of respondents elected to refer patients with refractory disease for VAD therapy, while only 29.4% elected to refer when standard medical therapy is withdrawn due to hypotension. CONCLUSIONS: While providers are well-informed on the fundamentals of advanced therapy, identifying patients with advanced HF who may benefit from referral remains an educational challenge. An automated referral program that identifies patients with advanced HF based on validated clinical parameters could increase appropriately timed referrals to HF specialists to further improve survival and quality of life outcomes with advanced therapy.


Assuntos
Cardiologia , Insuficiência Cardíaca/cirurgia , Coração Auxiliar , Padrões de Prática Médica , Encaminhamento e Consulta , Humanos , Inquéritos e Questionários
8.
Conn Med ; 79(1): 13-8, 2015 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-26244191

RESUMO

OBJECTIVE: To determine whether a novel, service-centric, medical emergency team (MET) model can impact cardiac arrest (CA) rates. METHODS: A retrospective pre- vs. postintervention analysis was performed on patients ≥ 18 years who had a CA between 2007 and 2012. A service centric MET model was initially implemented on the inpatient cardiology service and expanded hospital wide during 2008-2009, maturing to 10 teams in 2010. Service centric is defined as a medical or surgical service-specific MET team based on the location of the patient. RESULTS: The rate of CA (per 1,000 hospital days) in the year 2007 prior to the initiation of MET was compared to rates during program maturation (2008/2009) and after full maturation to 10 teams (2010-2012). A total of 1,140,233 hospital-care days were analyzed between 2007 and 2012, with 745 CAs recorded (0.65 events per 1,000 hospital days). The overall CA rate was higher prior to MET initiation (0.84 in 2007) compared to postinitiation (0.59 in 2008/09) and maturation to 10 teams (0.64 in 2010-12) (P < 0.003 for both pre- vs postcomparisons). No differences in CA rates were detected between either post-MET initiation time frames (P = 0.342). Similar trends in CA rates were observed in the intensive care unit (ICU) (3.96 vs 2.14 vs 2.68 per 1,000 hospital days in 2007, 2008/2009, and 2010-2012 respectively, with P < 0.001 for both pre- vs postcomparisons). CONCLUSIONS: A service-centric MET program was associated with a reduction in the rate of CAs both hospital wide and in the ICU. These observations maybe explained by the earlier intervention in care of unstable patients by an expanded group of caregivers.


Assuntos
Serviço Hospitalar de Emergência/organização & administração , Parada Cardíaca/prevenção & controle , Equipe de Assistência ao Paciente/organização & administração , Serviço Hospitalar de Emergência/normas , Feminino , Parada Cardíaca/epidemiologia , Humanos , Masculino , Pessoa de Meia-Idade , New England/epidemiologia , Avaliação de Resultados (Cuidados de Saúde) , Equipe de Assistência ao Paciente/normas , Melhoria de Qualidade , Estudos Retrospectivos
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