NEWS BRIEFS
NEWS BRIEFS
Watch CABG on the Net
You have an opportunity to see a video of a quadruple bypass at the www.ahn.com/ liveevents/openheart/f_main.htm Web site.
Denton Cooley, MD, renowned cardiac surgeon and a member of Cost Management in Cardiac Care’s editorial board, and his team performed the two-and-a-half-hour surgery at St. Luke’s Episcopal Hospital in Houston.
About the surgery, Cooley says the team performed the bypass on the right side beyond the point where the patient had a stent placed a couple of months ago.
He says the procedure was straightforward, and the two vessels at the back of the heart were large enough to accept a good vein bypass.
"Everything was going along smoothly," he says, "until we tackled an artery in the front, which was about the size of a kite string and almost completely occluded. We had to peel out some of the obstruction in there in order to do that bypass. That was extremely tedious and time-consuming, and far more technically difficult than I had anticipated."
The patient tolerated the procedure well, her condition is favorable, and, said Cooley, "all four bypasses now will carry her to a successful outcome."
Cooley is surgeon-in-chief at the Texas Heart Institute in Houston. Three decades ago, he made history with the nation’s first successful human heart transplant and the world’s first total artificial human heart implant.
Bypass vs. PTCA: Study finds mortality differences
Experts have been debating the relative merits of bypass surgery and percutaneous transluminal coronary angioplasty (PTCA) for years, but investigators have been limited by the small numbers of patients enrolled. In addition, many experts believe the left anterior descending (LAD) coronary artery — particularly the proximal portion of that artery — is more subject to complications than other arteries, and nearly all previous studies have not examined the contributing role of this artery to the outcome.
A large new study provides the best data yet comparing the two procedures. More than 30,000 patients undergoing each of the procedures were included, and, after three years, mortality was lower in the subset of PTCA patients who had one vessel disease not involving the LAD.
There were no statistically significant differences between the two procedures in cases of one-vessel disease in the non-proximal LAD and in cases of two-vessel disease not involving the proximal LAD. However, bypass surgery was superior to PTCA in patients with one- or two-vessel disease, including the proximal LAD and in all cases of three-vessel disease.
AHA updates procedures for infective endocarditis
The American Heart Association (AHA) issued a scientific statement that updates procedures for the diagnosis and treatment of infective endocarditis.1
Variability in the disease’s clinical presentation requires a diagnostic strategy that is both sensitive for detection and specific for exclusion across all forms, according to the AHA statement. Previous diagnostic criteria relied on tests that measured bacteremia, regurgitant murmur, and blood vessel complications. The new diagnostic strategy includes using echocardiography to detect infection.
The guidelines include information about treating some of the more unusual causes of endocarditis, such as Legionella — a bacteria that can develop in individuals who have prosthetic cardiac valves — or fungal infections, such as Candida, Aspergillus, and Pseudomonas — often found among IV drug users or in individuals who have central venous catheters.
The AHA document reviews and updates current literature with respect to diagnostic challenges and strategies, difficult therapeutic situations, and management choices.
It offers three categories of diagnosing: "definite" cases proven at surgery; "possible" cases where there is some evidence of endocarditis; and "rejected" cases, meaning there is a diagnosis other than endocarditis, or the symptoms of the illness resolve after four or more days of antibiotic therapy. To access the statement, go to the Web site http://www.ahajournals.org.
Reference
1. Bayer AS, Bolger AF, Taubert KA, et al. Diagnosis and management of infective endocarditis and its complications. Circulation 1998; 98:2,936-2,948.
High doses of epinephrine no better than standard
Clinical trials have shown no benefit of high doses of epinephrine in the management of out-of-hospital cardiac arrest.1
Investigators compared repeated high doses (5 mg) of epinephrine with repeated standard doses (1 mg) in more than 3,000 patients whose ventricular fibrillation continued despite the administration of external electrical shocks or if they had asystole or pulseless electrical activity at the time epinephrine was administered.
In the high-dose group, 40.4% of the patients had a return of spontaneous circulation, as compared with 36.4% of the standard-dose group. About one quarter of both groups survived to be admitted to the hospital, and equivalent groups survived to be discharged from the hospital. There was no significant difference in neurologic status according to treatment among those discharged. High-dose epinephrine improved the rate of successful resuscitation in patients with asystole, but not in those with ventricular fibrillation.
Reference
1. Gueugniaud P, Mols P, Goldstein P, et al., for the European Epinephrine Study Group. A comparison of repeated high doses and repeated standard doses of epinephrine for cardiac arrest outside the hospital. N Engl J Med 1998; 339:1,595-1,601.
No difference in hospitals with on-site cath facilities
A new study recently determined if there are differences in long-term mortality and resource consumption in hospitals with on-site cardiac catheterization facilities, as compared to hospitals without such facilities.1
As part of the Cooperative Cardiovascular Project pilot, researchers compared the costs and outcomes of 2,500 Medicare heart attack patients admitted over one year to Connecticut hospitals with cath labs to those of patients admitted to hospitals without.
It was no surprise the cardiac cath rate was higher in the hospitals with facilities, but the revascularization rate was similar in both groups during the initial episode of care and at three years. Mortality rates were similar for patients admitted to both types of hospitals at 30 days and at three years. The adjusted readmission rates were significantly lower among patients admitted to hospitals with cardiac cath facilities. However, the overall mean days in the hospital for the three years after admission was comparable for both groups of patients.
Adjusting for baseline patient characteristics, there was no significant difference in the three-year costs. The authors concluded that with higher rates of cardiac catheterization and lower readmission rates, patients admitted to hospitals with on-site cardiac cath facilities did not have significantly different hospital costs compared with patients admitted to hospitals without these facilities.
Reference
1. Krumholz HM, Chen J, Murillo JE, et al. Admission to hospitals with on-site cardiac catheterization facilities: Impact on long-term costs and outcomes. Circulation 1998; 98:2,010-2,016.
IGF-1 improves cardiac function in burn victims
Severely burned patients receiving an IV infusion of SomatoKine (Celtrix Pharmaceuticals) for five days showed a 16% improvement in cardiac output and a 15% increase in stroke volume over saline-treated controls, report investigators at the American Heart Association conference in Dallas late last year.
Following severe burn injury, heart and circulatory functional changes occur, including relative depression of heart function. This may lead to inadequate blood supply to other parts of the body, resulting in tissue damage, organ failure, shock, and ultimately death. No side effects were noted in the study with the insulin-like growth factor-I (IGF-I), and the observed improvements were not accompanied by undesirable increases in left ventricular wall thickness or increased oxygen consumption by the heart muscle.
"Although anabolic agents such as insulin-like growth factor-I have been known to attenuate cardiac dysfunction after severe burn trauma, the use of these agents in burn therapy has been complicated by systemic side effects such as hypoglycemia," explains the principal investigator. SomatoKine — IGF-I complexed to its major binding protein, BP-3 — demonstrated efficacy and an impressive safety profile.
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