Learning Curve in Left Ventricular Assist Device Implantation: Low Volumes Do Not Equate Bad Outcomes

ABSTRACT Introduction: Most implantations of left ventricular assist devices (LVAD) are performed in low-volume centers. This study aimed to evaluate the procedural learning curve of HeartMate II (HM2) implantations by comparing outcomes between two time periods in a low-volume center. Methods: All 51 consecutive patients undergoing HM2 implantation between January 2009 and December 2017 were reviewed and allocated into 2 groups: early-era group (from 2009 to 2014; n=25) and late-era group (from 2015 to 2017; n=26). The primary outcome was the 90-day mortality rate, and the secondary outcome was a composite of mortality, neurological event, reoperation for bleeding, need for temporary right ventricular assist device, and pump thrombosis at 90 days. Median follow-up time was 51 months (0-136). A cumulative sum (CUSUM) control analysis was used to establish a threshold of implantations that optimizes outcomes. Results: Patients in the early era had a higher rate of diabetes, previous stroke, and inotrope support before HM2 implantation. The 90-day mortality rate was not significantly higher in the early era (24% vs. 15%, P=0.43), but the composite endpoint was significantly higher (76% vs. 42%, P=0.01). The CUSUM analysis found a threshold of 23 operations after which the composite endpoint was optimized. Conclusion: Patients undergoing HM2 implantation in a low-volume center have improving outcomes with number of cases and optimized results after a threshold of 23 cases. Significant changes in patient selection, surgical techniques, and patient management might lead to improved outcomes after LVAD implantation.

El perfil cardiovascular de los nuevos agentes anestésicos inhalados: desfluorane y sevofluorane

Drogas nuevas entran continuamente en la práctica clínica reemplazando a otras ya establecidas. Para ser de valor clínico, deberán tener ventajas claramente identificables con respecto a las drogas existentes y estar disponible a un costo apropiado para estas ventajas. Sobre la base del perfil cardiovascular, el desfluorane y el sevofluorane parecen ser similares al isofluorane. El sevofluorane no se ha asociado con un aumento en la frecuencia cardíaca mientras que altos MAC o aumentos rápidos de isofluorane y desfluorane fueron asociados con taquicardia. Su aceptabilidad en la práctica clínica dependerá en gran medida de otros beneficios farmacocinéticos y farmacodinámicos que de su perfil cardiovascular