Comparison of Outcomes Among Patients With Cardiogenic Shock Admitted on Weekends Versus Weekdays

Cardiogenic shock (CS) is associated with high mortality and often requires involvement of a multidisciplinary provider team to deliver timely care. Care coordination is more difficult on weekends, which may lead to a delay in care. We sought to assess the effect of weekend admissions on outcomes in patients admitted with CS. Patients admitted with CS were identified from 2005 to 2014 in the National Inpatient Sample using ICD9 code 785.51. Baseline demographics, in-hospital procedures, and outcomes were obtained and compared by day of admission. A multivariable model was used to assess the impact of weekend admission on in-hospital mortality. A total of 875,054 CS admissions were identified (age 67.4 ± 15.1 years, 40.2% female, 72.1% Caucasian), with 23% of patients being admitted on weekends. Baseline co-morbidities were similar between groups. Weekend admissions were associated with higher in-hospital mortality (40.6% vs 37.5%) and cardiac arrest (20.3% vs 18.1%, p < 0.001 for both) consistently over the study period. Use of temporary and permanent mechanical support devices and heart transplantation were slightly less common for weekend admissions. In a multivariable model adjusting for relevant confounders, weekend admission was associated with a 10% increased mortality in patients with CS. In conclusion, patients with CS admitted on weekends had higher in-hospital mortality and were slightly less likely to receive mechanical support and advanced therapies compared with those admitted on weekdays. Future studies and health system initiatives should focus on rectifying these disparities with around-the-clock multidisciplinary coordinated care for CS.

Serially Measured Cytokines and Cytokine Receptors in Relation to Clinical Outcome in Patients With Stable Heart Failure

In this prospective cohort study of 250 stable heart failure patients with trimonthly blood sampling, we investigated associations of 17 repeatedly measured cytokines and cytokine receptors with clinical outcome during a median follow-up of 2.2 (25th-75th percentile, 1.4-2.5) years. Sixty-six patients reached the primary end point (composite of cardiovascular mortality, heart failure hospitalization, heart transplantation, left ventricular assist device implantation). Repeatedly measured levels of 8 biomarkers correlated with clinical outcomes independent of clinical characteristics. Rates of change over time (slopes of biomarker evolutions) remained independently associated with outcome for 15 biomarkers. Thus, temporal patterns of cytokines and cytokine receptors, in particular tumour necrosis factor ligand superfamily member 13B and interleukin-1 receptor type 1, might contribute to personalized risk assessment.

Mechanical Circulatory Support in Chronic Total Occlusion Percutaneous Coronary Intervention: Insights From a Multicenter U.S. Registry

OBJECTIVE

To study outcomes with use of percutaneous mechanical circulatory support (MCS) devices in chronic total occlusion (CTO) percutaneous coronary intervention (PCI).

METHODS

We examined characteristics and outcomes of 1598 CTO-PCIs performed from 2012-2017 at 12 high-volume centers.

RESULTS

Patient age was 66 ± 10 years; 86% were men. An MCS device was used electively in 69 procedures (4%) and urgently in 22 procedures (1%). The most commonly used elective MCS device was Impella 2.5 or CP (62%). Compared to patients without elective MCS, patients with elective MCS had higher prevalence of prior heart failure (55% vs 29%; P<.001), prior coronary artery bypass graft surgery (49% vs 35%; P=.02), and lower left ventricular ejection fraction (34 ± 14% vs 50 ± 14%; P<.001). MCS patients had a higher prevalence of moderate/ severe calcification (88% vs 55%; P<.001) and higher J-CTO scores (3.1 ± 1.2 vs 2.6 ± 1.2; P<.01), and a greater proportion underwent retrograde crossing attempts (55% vs 39%; P<.01). Despite more complex characteristics in MCS patients, technical success rates (88% vs 87%; P=.70) and procedural success rates (83% vs 87%; P=.32) were similar in the two groups. Use of elective MCS was associated with longer procedure and fluoroscopy times, and higher incidences of in-hospital major adverse cardiovascular events (8.7% vs 2.5%; P<.01) and bleeding (7.3% vs 1.0%; P<.001).

CONCLUSION

Elective MCS was used in 4% of patients undergoing CTO-PCI. Despite more complex clinical and angiographic characteristics, elective use of MCS in high-risk patients is associated with similar technical and procedural success rates, but higher risk of complications, compared to cases without elective MCS.

Prophylactic levosimendan for the prevention of low cardiac output syndrome and mortality in paediatric patients undergoing surgery for congenital heart disease

BACKGROUND

Low cardiac output syndrome remains a serious complication, and accounts for substantial morbidity and mortality in the postoperative course of paediatric patients undergoing surgery for congenital heart disease. Standard prophylactic and therapeutic strategies for low cardiac output syndrome are based mainly on catecholamines, which are effective drugs, but have considerable side effects. Levosimendan, a calcium sensitiser, enhances the myocardial function by generating more energy-efficient myocardial contractility than achieved via adrenergic stimulation with catecholamines. Thus potentially, levosimendan is a beneficial alternative to standard medication for the prevention of low cardiac output syndrome in paediatric patients after open heart surgery.

OBJECTIVES

To review the efficacy and safety of the postoperative prophylactic use of levosimendan for the prevention of low cardiac output syndrome and mortality in paediatric patients undergoing surgery for congenital heart disease.

SEARCH METHODS

We identified trials via systematic searches of CENTRAL, MEDLINE, Embase, and Web of Science, as well as clinical trial registries, in June 2016. Reference lists from primary studies and review articles were checked for additional references.

SELECTION CRITERIA

We only included randomised controlled trials (RCT) in our analysis that compared prophylactic levosimendan with standard medication or placebo, in infants and children up to 18 years of age, who were undergoing surgery for congenital heart disease.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and assessed risk of bias according to a pre-defined protocol. We obtained additional information from all but one of the study authors of the included studies. We used the five GRADE considerations (study limitations, consistency of effect, imprecision, indirectness, and publication bias) to assess the quality of evidence from the studies that contributed data to the meta-analyses for the prespecified outcomes. We created a 'Summary of findings' table to summarise the results and the quality of evidence for each outcome.

MAIN RESULTS

We included five randomised controlled trials with a total of 212 participants in the analyses. All included participants were under five years of age. Using GRADE, we assessed there was low-quality evidence for all analysed outcomes. We assessed high risk of performance and detection bias for two studies due to their unblinded setting. Levosimendan showed no clear effect on risk of mortality (risk ratio (RR) 0.47, 95% confidence interval (CI) 0.12 to 1.82; participants = 123; studies = 3) and no clear effect on low cardiac output syndrome (RR 0.64, 95% CI 0.39 to 1.04; participants = 83; studies = 2) compared to standard treatments. Data on time-to-death were not available from any of the included studies.There was no conclusive evidence on the effect of levosimendan on the secondary outcomes. The length of intensive care unit stays (mean difference (MD) 0.33 days, 95% CI -1.16 to 1.82; participants = 188; studies = 4), length of hospital stays (MD 0.26 days, 95% CI -3.50 to 4.03; participants = 75; studies = 2), duration of mechanical ventilation (MD -0.04 days, 95% CI -0.08 to 0.00; participants = 208; studies = 5), and the risk of mechanical circulatory support or cardiac transplantation (RR 1.49, 95% CI 0.19 to 11.37; participants = 60; studies = 2) did not clearly differ between the groups. Published data about adverse effects of levosimendan were limited. A meta-analysis of hypotension, one of the most feared side effects of levosimendan, was not feasible because of the heterogeneous expression of blood pressure values.

AUTHORS' CONCLUSIONS

The current level of evidence is insufficient to judge whether prophylactic levosimendan prevents low cardiac output syndrome and mortality in paediatric patients undergoing surgery for congenital heart disease. So far, no significant differences have been detected between levosimendan and standard inotrope treatments in this setting.The authors evaluated the quality of evidence as low, using the GRADE approach. Reasons for downgrading were serious risk of bias (performance and detection bias due to unblinded setting of two RCTs), serious risk of inconsistency, and serious to very serious risk of imprecision (small number of included patients, low event rates).

Prophylactic levosimendan for the prevention of low cardiac output syndrome and mortality in paediatric patients undergoing surgery for congenital heart disease

BACKGROUND

Low cardiac output syndrome remains a serious complication, and accounts for substantial morbidity and mortality in the postoperative course of paediatric patients undergoing surgery for congenital heart disease. Standard prophylactic and therapeutic strategies for low cardiac output syndrome are based mainly on catecholamines, which are effective drugs, but have considerable side effects. Levosimendan, a calcium sensitiser, enhances the myocardial function by generating more energy-efficient myocardial contractility than achieved via adrenergic stimulation with catecholamines. Thus potentially, levosimendan is a beneficial alternative to standard medication for the prevention of low cardiac output syndrome in paediatric patients after open heart surgery.

OBJECTIVES

To review the efficacy and safety of the postoperative prophylactic use of levosimendan for the prevention of low cardiac output syndrome and mortality in paediatric patients undergoing surgery for congenital heart disease.

SEARCH METHODS

We identified trials via systematic searches of CENTRAL, MEDLINE, Embase, and Web of Science, as well as clinical trial registries, in June 2016. Reference lists from primary studies and review articles were checked for additional references.

SELECTION CRITERIA

We only included randomised controlled trials (RCT) in our analysis that compared prophylactic levosimendan with standard medication or placebo, in infants and children up to 18 years of age, who were undergoing surgery for congenital heart disease.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and assessed risk of bias according to a pre-defined protocol. We obtained additional information from all but one of the study authors of the included studies. We used the five GRADE considerations (study limitations, consistency of effect, imprecision, indirectness, and publication bias) to assess the quality of evidence from the studies that contributed data to the meta-analyses for the prespecified outcomes. We created a 'Summary of findings' table to summarise the results and the quality of evidence for each outcome.

MAIN RESULTS

We included five randomised controlled trials with a total of 212 participants in the analyses. All included participants were under five years of age. Using GRADE, we assessed there was low-quality evidence for all analysed outcomes. We assessed high risk of performance and detection bias for two studies due to their unblinded setting. Levosimendan showed no clear effect on risk of mortality (risk ratio (RR) 0.47, 95% confidence interval (CI) 0.12 to 1.82; participants = 123; studies = 3) and no clear effect on low cardiac output syndrome (RR 0.64, 95% CI 0.39 to 1.04; participants = 83; studies = 2) compared to standard treatments. Data on time-to-death were not available from any of the included studies.There was no conclusive evidence on the effect of levosimendan on the secondary outcomes. The levosimendan groups had shorter length of intensive care unit stays (mean difference (MD) 0.33 days, 95% CI -1.16 to 1.82; participants = 188; studies = 4; I² = 35%), length of hospital stays (0.26 days, 95% CI -3.50 to 4.03; participants = 75; studies = 2), and duration of mechanical ventilation (MD -0.04 days, 95% CI -0.08 to 0.00; participants = 208; studies = 5; I² = 0%). The risk of mechanical circulatory support or cardiac transplantation favoured the levosimendan groups (RR 1.49, 95% CI 0.19 to 11.37; participants = 60; studies = 2). Published data about adverse effects of levosimendan were limited. A meta-analysis of hypotension, one of the most feared side effects of levosimendan, was not feasible because of the heterogeneous expression of blood pressure values.

AUTHORS' CONCLUSIONS

The current level of evidence is insufficient to judge whether prophylactic levosimendan prevents low cardiac output syndrome and mortality in paediatric patients undergoing surgery for congenital heart disease. So far, no significant differences have been detected between levosimendan and standard inotrope treatments in this setting.The authors evaluated the quality of evidence as low, using the GRADE approach. Reasons for downgrading were serious risk of bias (performance and detection bias due to unblinded setting of two RCTs), serious risk of inconsistency, and serious to very serious risk of imprecision (small number of included patients, low event rates).

Determinants for increased resource utilization after surgery for prosthetic valve endocarditis

Mechanical circulatory support (11 intra-aortic balloon pump; two right ventricular assist device; one left ventricular assist device) was required in 14 patients (9.4%). At 30 days, mortality was 12.8% (n=17) and morbidity 78.5% (117 patients experienced at least one complication). At one, five and 10 years, the overall survival was 78.4 +/- 3.5%, 76.7 +/- 3.6% and 74.9 +/- 3.8%, respectively. The duration of postoperative MV was 8 +/- 20.7 days, while ICU and hospital stays were 11 +/- 20.8 and 37 +/- 30.2 days, respectively. The following predictors for increased resource utilization were identified: preoperative ventilatory support, mechanical circulatory support, recent myocardial infarction, and urgency for MV >3 days; preoperative ventilator support and mechanical circulatory support for ICU >7 days; and urgency and age for HS >42 days.

CONCLUSION

A critical preoperative state and perioperative mechanical circulatory were strongly predictive of increased resource utilization. Hence, if resource utilization is to be reduced, an early operation seems more appropriate than to postpone surgery until an uncertain or unattainable re-normalization of organ dysfunction becomes evident.

BACKGROUND AND AIM OF THE STUDY

Surgery for prosthetic valve endocarditis (PVE) is associated with significant morbidity and mortality. As treatment also demands substantial healthcare resources, a search was made for determinants of increased resource utilization.

METHODS

Between 2000 and 2010, a total of 149 consecutive patients (107 males, 42 females; mean age 63.5 +/- 13.8 years) underwent re-do surgery for PVE at the authors' institution; 92 patients (61.7%) had aortic valve replacement, 42 (28.2%) had mitral valve replacement, and 15 (10.1%) had double valve replacement. Multivariate binary regression analysis was used to identify predictors of increased resource utilization, defined as mechanical ventilation (MV) >3 days, intensive care unit (ICU) stay >7 days, and hospital stay (HS) >42 days.

RESULTS

Preoperatively, 14 patients (9.4%) presented with shock and 17 (11.4%) with acute renal failure. Ventilatory and pharmacological circulatory support was required in 17 (11.4%) and 19 (12.8%) patients, respectively. The logistic EuroSCORE was >20% in 121 patients (81.2%). Staphylococci were the most common infecting microorganisms (41 patients; 27.5%), while 53 cases (35.6%) were culture-negative. The operative, cardiopulmonary bypass and aortic cross-clamp times were 259 + 88.3 min, 149 +/- 62.4 min, and 112 +/- 44.3 min, respectively.

[Circulatory support in cardiology]

Mechanical cardiac assist had progressively changed. Emergency depends of INTERMACS classification. The clinical evolution of patients under cardiac assist determines patient follow up: long duration mechanical support (and not "destination therapy"), recovery and weaning or planned heart transplantation. In case of emergency, extracorporeal membrane oxygenation allowed to stabilize patients and oriented them to one of these options.

[The use of assisted circulation in cardiosurgical clinic]

The first experience with the use of different artificial circulation systems for the treatment of critical cardiac insufficiency in A. N. Bakulev Research Centre of Cardiovascular Surgery is described. The authors analyse their efficiency, indications for use, possible causes of complications and fatal outcome.

Cardiac arrest with continuous mechanical chest compression during percutaneous coronary intervention

Mechanical chest compression may be necessary to make coronary intervention possible during resuscitation. We report our experience using the Lund University Cardiac Arrest System (LUCAS, Jolife, Lund, Sweden) which is a gas-driven sternal compression device that incorporates a suction cup for active decompression. During the last 13 months LUCAS has been used in our catheterisation laboratory to maintain adequate organ perfusion pressure in 13 patients with cardiac arrest or severe hypotension and bradycardia (male/female ratio 1.6, mean age 59+/-19). The mean compression time was 105+/-60min (range 45-240), and the mean systolic and diastolic blood pressure obtained was 81+/-23 and 34+/-21mmHg, respectively. Angiography and eventually percutanous coronary intervention was possible in all cases during ongoing automatic chest compression. Three patients survived the procedure, but no patients were discharged alive. In two cases we found inadequate flow in the anterior descending artery, and in one case the invasive measurements revealed inadequate coronary perfusion pressure. There were no excessive intra-thoracic or intra-abdominal injuries. We conclude that the LUCAS device is suitable during cardiac catheterisation and intervention, and the device ensures an adequate systemic blood pressure in most patients without life-threatening injuries.

Study on Mechanical Circulatory Support and Currently Available Supporting Parts in China

The research and development on extracorporeal and assisted circulation in China have been painstaking. On one hand, China has the largest population of 1.3 [corrected] billion in the world, and the demands for supporting equipment are huge. On the other hand, as a developing country, China is not wealthy. It is urgent to design and fabricate affordable circulatory support parts, machines, and artificial hearts for Chinese market. In this regard, we have made our own heart-lung machine, mechanical and tissue valves, oxygenators, and artificial hearts and their improved versions. The cost of these parts is much lower as compared with those in the Western market. Although the results of clinical application are good so far, the quality of these lifesaving parts needs to be continuously improved.

[Influence of extracorporeal circuits surface on hemostasis system during off-pump surgeries]

It is demonstrated that special surface of extracorporeal circuit promotes reduction of artificial circulation negative influence on hemostasis system. During artificial circulation coating "duraflo" gradually loses its protective characteristics due to washout of heparin molecules from the surface of extracorporeal circuit, whereas chemical link between heparin and protein in "safe-line" coating is more stable. The results of the study demonstrate no advantages of heparin coating of extracorporeal circuits over protein one. Finally, all the advantages of extracorporeal circuits with "safe-line" coating lead to a decrease of postoperative blood loss.

Under-utilization of mechanical circulatory support in Canada: why and what can be done?

In October of 2002, a workshop was held as part of the Canadian Cardiovascular Congress in Edmonton, Canada, entitled "Under-Utilization of Mechanical Circulatory Support in Canada. Why and What Can Be Done?" The workshop examined various issues related to the use of mechanical circulatory support devices in the Canadian context. Representatives from all Canadian centers with active mechanical circulatory support programs were invited to participate and participants included surgeons and cardiologists, as well as other affiliated health professionals. Opinions were solicited from the workshop participants and a series of recommendations were formulated.

The waiting game: bridging to paediatric heart transplantation

BACKGROUND

Although mechanical circulatory support might not increase the number of adults surviving to transplantation, because of the shortage of donor organs, the situation might be different for children. Our aim was to assess the effect of mechanical assist devices to bridge children with end-stage cardiomyopathy to heart transplantation.

METHODS

A 5-year retrospective review was undertaken with data from the UK paediatric transplant programme and from bridging to transplant done at two paediatric transplant centres in the UK.

FINDINGS

Between Jan 1, 1998 and Dec 31, 2002, 22 children with end-stage cardiomyopathy, median age 5.7 years (range 1.2-17), were supported by a mechanical assist device as a bridge to first heart transplantation, with a 77% survival rate to hospital discharge. Nine were supported by a paracorporeal ventricular assist device, six received transplantation, five survived to discharge (55%), with one late death. 13 were supported by extra-corporeal membrane oxygenation, and 12 were transplanted and survived to discharge (92%) with one late death. With urgent listing, the median waiting time for a heart was 7.5 days (range 1.5-22 days). The correlation between the proportion of patients bridged to transplantation and the proportion of patients dying while on the transplant waiting list was r=-0.93, p=0.02.

INTERPRETATION

Our findings lend support to the hypothesis that a national mechanical assist programme to bridge children to transplantation can minimise the number dying while on the heart transplant waiting list. In the context of urgent listing and a short waiting time, extra-corporeal membrane oxygenation seems to provide the safest form of support.

Clinically available extracorporeal assist devices

Mechanical circulatory support has been shown to be of benefit to allow recovery after conventional heart surgery and as a successful bridge to heart transplantation. Recent clinical trials with implantable left ventricular assist devices (LVADs) have been completed with these devices showing restoration of normal hemodynamics and successful bridge to transplantation. A major advantage of the implantable devices is the ability for the patient to be discharged and followed up at an outpatient setting. However, multiple advantages to extracorporeal devices still remain, which are the focus of this review. One advantage of the extracorporeal devices is that they can be placed in much smaller patients than currently available implantable LVADs. Also, because of differences in design of the assist devices, the extracorporeal devices can be placed without the need for the cardiopulmonary bypass and with decreased operative time and dissection. Perhaps the biggest advantage of the extracorporeal devices is that they can provide a support for both the right and left side of the heart as opposed to the implantable LVADs, which are only used as left ventricular assist devices. This article describes in detail the advantages and disadvantages of the extracorporeal devices as well as the operative techniques used to implant them. As the number of patients with heart failure continues to rise, so will the need for mechanical circulatory support. Though the majority of these patients will be served by a long-term implantable device, there will remain a subset of patients that will be best suited for treatment with extracorporeal devices.

Evolving short-term and long-term mechanical assist for cardiac-failure -- a decade of experience in Münster

Technological advances and growing expertise has lead to referral of much sicker patients with a greater incidence of heart failure prior to and after cardiac surgical procedures. The diversity of the heart failure patient cohort mandates a differentiated protocol for mechanical support adapted to the clinical requirements. It is desirable to have appropriate mechanical support available for different circumstances of heart failure. In this paper, we review the first decade of the Muenster University Hospital experience with the use of intra-aortic ballon pump, extracorporal membrane oxygenators, short term uni- and biventricular assist systems such as Thoratec and Medos devices, as well as long term left ventricular assist systems such as the TCI Heartmate and the Novacor system. The patient profiles, indications, contraindications, and future trends are reviewed within the framework of a contemporary university hospital Servive.

Current strategy of circulatory support for profound heart failure

The purpose of this study is to assess the current strategy of mechanical circulatory support for profound heart failure. In the last 10 years, 37 patients with profound heart failure underwent mechanical circulatory support after open heart surgery and 9 patients with non-cardiotomy cardiogenic shock received emergency circulatory support. All patients showed severe cardiac failure and/or fatal ventricular arrhythmia and required circulatory support as a life-saving measure. After cardiovascular surgery, 12 of those patients underwent venoarterial bypass (VAB), 13 had biventricular bypass (BVB), 8 had left ventricular bypass (LVB) and the remaining 4 patients received left ventricular assist device (LVAD). And 9 patients with non-cardiotomy cardiogenic shock received percutaneous cardiopulmonary support (or PCPS) as an emergency assist system. Weaning and discharge rates of the patients by the type of circulatory supports were 41.7% and 25.0% with VAB, 69.3% and 46.2% with BVB, 87.5% and 37.5% with LVB, 75.0% and 50.0% with LVAD, and 44.4% and 11.1% with PCPS, respectively. Clinical results of post-cardiotomy circulatory support (64.9% of weaning and 37.8% of discharge) were acceptable, but the patients with non-cardiotomy cardiac failure needed early application of more advanced circulatory support.

Analysis of deaths after heart transplantation: the University of Ottawa Heart Institute experience

This study reviews the clinical outcome of the 132 orthotopic heart transplantations performed at our institute from 1984 through 1991 and focuses on the pathology of those patients who died. The study comprised 124 adults (mean age, 45.6 +/- 0.9 years) and eight children. Twenty-six adult and one pediatric deaths occurred. Operative mortality (within 30 days) was 10.6%, with 84.8% of patients surviving to discharge. Actuarial probabilities of survival at 1 and 5 years were 84% +/- 3% and 71% +/- 6%, respectively. Of the 27 deaths, six (22.2%) occurred in the operating room (from hemorrhage, graft failure, and hyperacute rejection); 14 (51.9%) occurred in-hospital after surgery (from sepsis, rejection, cytomegalovirus disease, or myocardial infarct), and seven (25.9%) occurred after discharge (from rejection and/or recurrent coronary artery disease). Two groups of patients were at higher risk: patients in cardiogenic shock requiring pretransplantation mechanical support, with in-hospital mortality of 39.1%; and patients with previous valve replacement who were taking oral anticoagulants, with intraoperative mortality of 50.0%. Pathologic examination revealed occasional instances of unsuspected coronary artery disease in the donor hearts with more than 50% stenoses of the left anterior descending coronary arteries in three of 21 (14.3%) of cases. Complications of the transplantation or related therapeutic procedures were common among those who died. The complications ranged from functionally insignificant anatomic curiosities to life-threatening problems. These complications are tabulated and shown.

Temporary mechanical ventricular support: Part 2

Temporary mechanical circulatory support is currently indicated in postcardiotomy cardiogenic shock and if necessary as a bridge to transplantation where no ventricular recovery is expected. Which mechanical support system to employ as a bridge to transplantation remains debatable. Implantable devices presently used are prototypes of proposed permanent devices for the treatment of severe heart failure in patients for whom transplantation is not suitable or available.

Artificial heart and assist devices: directions, needs, costs, societal and ethical issues

A Working Group appointed by the Director of the National Heart, Lung, and Blood Institute (NHBLI) has reviewed the current status of mechanical circulatory support systems (MCSS), and has examined the potential need for such devices, their cost, and certain societal and ethical issues related to their use. The media have reported the limited clinical investigative use of pneumatically energized total artificial hearts (which actually replace the patient's heart) and left ventricular assist devices (which support or replace the function of the left ventricle by pumping blood from the left heart to the aorta with the patient's heart in place). However, electrically energized systems, which will allow full implantation, permit relatively normal everyday activity, and involve battery exchange or recharge two or three times a day, are currently approaching long-term validation in animals prior to clinical testing. Such long-term left ventricular assist devices have been the primary goal of the NHLBI targeted artificial heart program. Although the ventricular assist device is regarded as an important step in the sequence of MCSS development, the Working Group believes that a fully implantable, long-term, total artificial heart will be a clinical necessity and recommends that the mission of the targeted program include the development of such systems. Past estimates of the potential usage of artificial hearts have been reviewed in the context of advances in medical care and in the prevention of cardiovascular disease. In addition, a retrospective analysis of needs was carried out within a defined population. The resulting projection of 17,000-35,000 cases annually, in patients below age 70, falls within the general range of earlier estimates, but is highly sensitive to many variables. In the absence of an actual base of data and experience with MCSS, projection of costs and prognoses was carried out using explicit sets of assumptions. The total cost of a left ventricular assist device, its implantation and maintenance for a projected average of 4 1/2 years of survival might be approximately $150,000 (in 1983 dollars). The gross annual cost to society could fall in the range of $2.5-$5 billion. Ethical issues associated with use of the artificial heart are not unique. For individual patients these relate primarily to risk-benefit, informed consent, patient selection, and privacy. However, for society as a whole, the larger concern relates to the distribution of national resources.(ABSTRACT TRUNCATED AT 400 WORDS)

What role should the intra-aortic balloon have in cardiac surgery

Intra-aortic balloon pumping (IABP) to assist the failing circulation has become widely applied and accepted since its introduction in 1968. The elective, preoperative use of IABP for patients undergoing cardiac surgery has now become the controversy. The purposes of this report are to examine our experience with IABP and to determine its appropriate role in high-risk patients. IABP was utilized in 75 of 2333 (3.2%) adult cardiac surgical patients at Emory University Hospital from January 1976 through June 1978. IABP was required for refractory shock following cardiopulmonary bypass (CB) in 53 patients, for preoperative cardiogenic shock after acute myocardial infarction (CSMI) in nine and was electively placed prior to CB in 13. Sixty-two patients (81%) were able to separate from CB with IABP and pharmacologic support and were assisted 24-432 hours (median 64 hours). Fifty-five (73%) were weaned from IABP. Fifty (67%) are hospital survivors; late deaths have occurred in six patients (8%). Hemodynamic effect of IABP was demonstrated by comparison of pumping 1:1 to 1:8 mode in five balloon-dependent patients after CB. IABP was found to decrease systolic blood pressure, left ventricular filling pressure and peripheral resistance (p < .05). It increased diastolic and mean blood pressure, cardiac index and the endocardial viability ratio (p < .05). The post-CB use of IABP resulted in highest salvage when utilized to support failing hearts that required surgery despite recent preoperative infarction or when intraoperative ischemic injury had occurred. Poorest results were in patients with extensive chronic myocardial damage. Except in the case of preoperative cardiogenic shock, it was impossible to establish statistically reliable criteria for patients in whom elective preoperative insertion was found to be necessary. Careful surgical and anesthesia management with good monitoring can be used instead of preoperative IABP in the majority of (if not all) hemodynamically stable patients regardless of risk classification.