Validation of the prognostic scoring system for in-hospital mortality prediction in cardiogenic shock patients requiring veno-arterial extracorporeal membrane oxygenation.

BACKGROUND: A few prognostic scoring systems have been developed for predicting mortality in patients with cardiogenic shock requiring veno-arterial extracorporeal membrane oxygenation (VA-ECMO), albeit with variations in performance. This study aimed to assess and compare various mortality prediction models in a cohort of patients receiving VA-ECMO following cardiogenic shock or arrest. METHODS: We retrospectively analyzed 77 patients with cardiogenic shock who were placed on VA-ECMO support between March 2014 and August 2021. The APACHE II, SAPS II, SAVE, Modified SAVE, ENCOURAGE, and ECMO-ACCEPTS scores were calculated for each patient to predict the in-hospital mortality. RESULTS: Fifty-six (72.7%) patients died. All prediction model scores, except the ECMO-ACCEPTS, differed significantly between non-survivors and survivors as follows: ENCOURAGE, 23 versus 16 (p < 0.001); SAVE, -6 versus -3 (p = 0.008); Modified SAVE, -5 versus 0 (p = 0.005); APACHE II, 32 versus 22 (p = 0.009); and SAPS II, 67 versus 49 (p = 0.002). The ENCOURAGE score demonstrated the best discriminatory ability with an area under the receiver-operating characteristic curve of 0.81 (95% confidence interval: 0.7-0.81). All prognostic scoring systems possessed limited calibration ability. However, the SAPS II, SAVE, and ENCOURAGE scores had lower Akaike and Bayesian information criteria values, which were consistent with the results of the Hosmer-Lemeshow C statistic test, indicating better performance than the other scores. CONCLUSIONS: The ENCOURAGE score can help predict in-hospital mortality in all subsets of VA-ECMO patients, even though it was originally designed to predict intensive care unit mortality in the post-acute myocardial infarction setting.

Cost-utility analysis of transcatheter aortic valve implantation versus surgery in severe aortic stenosis patients with intermediate surgical risk in Thailand.

BACKGROUND: Transcatheter Aortic Valve Implantation (TAVI) has been shown to provide comparable survival benefit and improvement in quality of life to surgical aortic valve replacement (SAVR) for treating patients with severe aortic stenosis (AS) at intermediate surgical risk. This study aimed to evaluate the cost-utility of TAVI compared with SAVR for severe aortic stenosis with intermediate surgical risk in Thailand. METHODS: A two-part constructed model was used to analyze lifetime costs and quality-adjusted life-years (QALYs) from societal and healthcare perspectives. The study cohort comprised severe AS patients at intermediate surgical risk with an average age of 80 years. The landmark trials were used to populate the model in terms of mortality and adverse event rates. All cost-related data and quality of life were based on Thai population. Costs and QALYs were discounted at 3% annually and presented as 2021 values. Incremental cost-effectiveness ratios (ICERs) were calculated. Deterministic and probabilistic sensitivity analyses were conducted. RESULTS: In comparison to SAVR, TAVI resulted in higher total cost (THB 1,717,132 [USD 52,415.51] vs. THB 893,524 [USD 27,274.84]) and higher QALYs (4.88 vs. 3.98) in a societal perspective. The estimated ICER was THB 906,937/QALY (USD 27,684.27/QALY). From a healthcare system perspective, TAVI also had higher total cost than SAVR (THB 1,573,751 [USD 48,038.79] vs. THB 726,342 [USD 22,171.63]) with similar QALYs gained to the societal perspective. The estimated ICER was THB 933,145/QALY (USD 933,145/QALY). TAVI was not cost-effective at the Thai willingness to pay (WTP) threshold of THB 160,000/QALY (USD 4,884/QALY). The results were sensitive to utility of either SAVR or TAVI treatment and cost of TAVI valve. CONCLUSION: In patients with severe AS at intermediate surgical risk, TAVI is not a cost-effective strategy compared with SAVR at the WTP of THB 160,000/QALY (USD 4,884/QALY) from the perspectives of society and healthcare system.

The incidence of phlebitis development of high concentration of continuous amiodarone infusion with in-line filter compared to the low concentration without in-line filter: a retrospective propensity score-matched analysis.

BACKGROUND: Phlebitis-associated peripheral infusion of intravenous amiodarone is common in clinical practice, with an incidence between 5% and 65%. Several factors, including drug concentration, catheter size, and in-line filter used, are significantly associated with phlebitis occurrence. We performed a retrospective propensity score-matched analysis to find out whether in-line filter will reduce the incidence of amiodarone-induced phlebitis (AIP) in high concentration of amiodarone infusion compared to low concentration without in-line filter. METHODS: Clinical records of all patients who required intravenous amiodarone infusion for cardiac arrhythmias, between January 2017 to December 2019 were retrieved. The incidence of AIP was recorded and subsequently compared among high concentration (2 mg/ml) with an in-line filter and low concentration (1.5 mg/ml) infusion without an in-line filter after a 1 to 2 propensity score matched. RESULTS: The data indicated that among the 214 cases of amiodarone infusion collected, 28 cases used an in-line filter with high concentration while 186 cases received a low concentration of amiodarone infusion without an in-line filter. After 1:2 propensity score matching, the incidence of phlebitis in the high concentration with in-line filter group was significantly higher than the low concentration without in-line filter group (28.6% vs. 3.6%, P<0.01). CONCLUSIONS: Despite the usage of in-line filter, the high concentration of amiodarone infusion resulted in a higher incidence of peripheral phlebitis. Central venous catheterization for a high concentration of amiodarone infusion is recommended.

Cost-Utility Analysis of Transcatheter Aortic Valve Implantation versus Surgery in High-Risk Severe Aortic Stenosis Patients in Thailand.

Background: Transcatheter aortic valve implantation (TAVI) has been shown to be effective in treating patients with severe symptomatic AS who are high-risk population for conventional surgical aortic valve replacement (SAVR). This study aimed to evaluate the cost-utility of TAVI compared with SAVR for severe aortic stenosis with high surgical risk in Thailand. Methods: Lifetime costs and quality-adjusted life years (QALYs) from societal and healthcare perspectives were estimated using a two-part constructed model. The study population consisted of 80-year-old severe AS patients with high surgical risk. Mortality and complication rates were obtained from landmark trials. All cost-related and utility data were based on Thai population. Costs and QALYs were discounted at a rate of 3% annually and presented as 2021 values. Incremental cost-effectiveness ratios (ICERs) were computed. Sensitivity analyses were performed both deterministically and probabilistically. Results: The findings from a societal perspective revealed that TAVI treatment was associated with higher cost (THB 1,551,895 [USD 47,371.64] vs THB 548,438 [USD 16,741.09] and higher QALYs than SAVR treatment (3.15 vs 2.31 QALYs). The estimated ICER was THB 1,196,191/QALY (USD 36,513.78 QALY). For the healthcare system perspective, TAVI treatment resulted in a higher total cost than SAVR treatment (THB 1,451,317 [USD 44,301.49] vs THB 432,398 [USD 13,198.95]) with comparable gains in LY and QALYs from a societal perspective. The ICER was calculated to be THB 1,214,624/QALY (USD 37,076.42/QALY). TAVI was not cost-effective at the Thai willingness to pay (WTP) threshold of THB 160,000/QALY (USD 4884/QALY). The model was the most sensitive to changes in TAVI valve cost and TAVI or SAVR treatment utilities. Conclusion: TAVI is not a cost-effective strategy in patients with severe AS who are at high surgical risk when compared to SAVR at the WTP of THB 160,000/QALY (USD 4884/QALY) from the perspectives of society and the healthcare system.

Comparison of intraoperative arterial blood pressure lability during general anaesthesia in masked, uncontrolled hypertensive and adequately controlled hypertensive patients: a prospective observational study.

INTRODUCTION: Hypertensive patients are known to have increased perioperative arterial blood pressure (BP) lability, which is related to cardiovascular events. Masked uncontrolled hypertensive patients are at high cardiovascular risk. This study aimed to compare BP lability during general anaesthesia in treated hypertensive patients with normal clinic BP, between masked uncontrolled hypertension and adequately controlled hypertension. MATERIAL AND METHODS: Forty-three patients with apparently controlled BP were initially enrolled in this prospective observational study. Home BP was monitored and patients classified into diagnostic groups. Perioperative BP profiles were recorded from before anaesthesia induction until discharge from the recovery room. BP lability was assessed using 3 methods: (1) out-of-range probability, (2) standard deviation (SD) and variance (VAR), and (3) mean and time-averaged absolute change in BP from one measurement to the next (ARV and TARV). RESULTS: Sixteen masked hypertensive and 21 adequately controlled hypertensive patients were analysed. The masked group had higher of BP lability [95% CI] as measured by SD than the adequately controlled group during intraoperative and postoperative periods (SBP-SD, intraoperative 17.97 [15.33, 20.60] vs. 13.528 [11.22, 15.82], P = 0.014; postoperative 10.40 [7.65, 13.16] vs. 5.49 [2.96, 8.02], P = 0.012). MAP-SD, intraoperative 12.35 [10.70, 13.99] vs. 9.66 [8.22, 11.10], P = 0.017; postoperative 7.21 [5.05, 9,38] vs. 4.06 [2.09, 6.05], P = 0.037). ARV and TARV also revealed higher intraoperative SBP lability; non-time-averaged (mmHg) 12.40 [10.43, 14.37] vs. 9.50 [7.78, 11.22], P = 0.031 and time-averaged (mmHg min-1) 2.35 [1.95, 2,74] vs. 1.82 [1.49, 2.16], P = 0.047). CONCLUSIONS: Masked uncontrolled hypertensive patients had significantly higher BP lability in SBP and MAP during the intraoperative and immediate postoperative periods.

Prediction Of Serum Digoxin Concentration Using Estimated Glomerular Filtration Rate In Thai Population.

PURPOSE: Serum digoxin concentration (SDC) monitoring may be unavailable in some healthcare settings. Predicted SDC comes into play in the efficacy and toxicity monitoring of digoxin. Renal function is the important parameter for predicting SDC. This study was conducted to compare measured and predicted SDC when using creatinine clearance (CrCl) from Cockcroft-Gault (CG) equation and estimated glomerular filtration rate (eGFR) calculated from CKD-Epidemiology Collaboration (CKD-EPI), re-expressed Modification of Diet in Renal Disease (Re-MDRD4), Thai-MDRD4, and Thai-eGFR equations in Sheiner's and Konishi's pharmacokinetic models. PATIENTS AND METHODS: In this retrospective study, patients with cardiovascular disease with a steady-state of SDC within 0.5-2.0 mcg/L were enrolled. CrCl and studied eGFR adjusted for body surface area (BSA) were used in the models to determine the predicted SDC. The discrepancies of the measured and the predicted SDC were analyzed and compared. RESULTS: One hundred and twenty-four patients ranging in age from 22 to 88 years (median 60 years, IQR 50.2, 69.2) were studied. Their serum creatinine ranged from 0.40 to 1.80 mg/dL (median 0.90 mg/dL, IQR 0.79, 1.10). The mean±SD of measured SDC was 1.12±0.34 mcg/L. In the Sheiner's model, the mean predicted SDC was calculated by using the CG and the BSA adjusted CKD-EPI equations and was not different when compared with the measured levels (1.10±0.36 mcg/L (p=0.669) and 1.08±0.42 mcg/L (p=0.374), respectively). The CG, CKD-EPI, and Re-MDRD4 equations were a better fit for patients with creatinine ≥0.9 mg/dL for prediction with minimal errors. In the Konishi's model, the predicted SDC using the CG and the studied eGFR equation was lower than the measured SDC (p<0.05). CONCLUSION: In Sheiner's model, the CG and the BSA adjusted CKD-EPI equations should be used for predicting SDC, especially in patients with serum creatinine ≥0.9 mg/dL. The other studied eGFRs underestimated SDC in both Sheiner's and Konishi's model.

The relationship between myocardial and hepatic T2 and T2* at 1.5T and 3T MRI in normal and iron-overloaded patients.

Background Cardiac and liver iron assessment using magnetic resonance imaging (MRI) is non-invasive and used as a preclinical "endpoint" in asymptomatic patients and for serial iron measurements in iron-overloaded patients. Purpose To compare iron measurements between hepatic and myocardial T2* and T2 at 1.5T and 3T MRI in normal and iron-overloaded patients. Material and Methods The T2 and T2* values from the regions of interest (ROIs) at mid-left ventricle and mid-hepatic slices were evaluated by 1.5T and 3T MRI scans for healthy and iron-overloaded patients. Results For iron-overloaded patients, the myocardial T2 (1.5T) and myocardial T2 (3T) values were 60.3 ms (range = 56.2-64.8 ms) and 55 ms (range = 51.6-60.1 ms) (ρ = 0.3679) while the myocardial T2* (3T) 20.5 ms (range = 18.4-25.9 ms) was shorter than the myocardial T2* (1.5T) 35.9 ms (range = 31.4-39.5 ms) (ρ = 0.6454). The hepatic T2 at 1.5T and 3T were 19.1 ms (range = 14.8-27.9 ms) and 15.5 ms (14.6-20.4 ms) (ρ = 0.9444) and the hepatic T2* at 1.5T and 3T were 2.7 ms (range = 1.8-5.6 ms) and 1.8 ms (range = 1.1-2.9 ms) (ρ = 0.9826). The line of best fit exhibiting the linearity of the hepatic T2* (1.5T) and hepatic T2* (3T) had a slope of 2 and an intercept of -0.387 ms (R = 0.984). Conclusion Our study found myocardial T2 (1.5T) nearly equal to T2 (3T) with myocardial T2* (3T) 1.75 shorter than myocardial T2* (1.5T). The relationship of hepatic T2* (1.5T) and hepatic T2* (3T) was linear with T2* (1.5T) approximately double to T2* (3T) in iron-overloaded patients. This linear relationship between hepatic T2* (1.5T) and hepatic T2 (3T) could be an alternative method for estimating liver iron concentration (LIC) from 3T.

Alcohol septal ablation without myocardial contrast echocardiography for hypertrophic obstructive cardiomyopathy.

OBJECTIVE: Review the efficacy and safety of using the anatomical characteristics of the first septal branch to select the target vessel for alcohol septal ablation (ASA) in treating patients with medically refractory symptoms hypertrophic obstructive cardiomyopathy (HOCM), ASA without guided myocardial contrast echocardiography (MCE). MATERIAL AND METHOD: Fifteen patients with HOCM and refractory to medical therapy were screened by echocardiography and coronary angiography between November 2007 and January 2010 in Songklanagarind university hospital. The procedure was abandoned in three patients due to vessel unsuitability. The clinical and hemodynamic data of 12 patients with HOCM before and after ASA were reviewed. The authors used the anatomical characteristics of vessel to identify the suitable septal perforator artery. RESULTS: ASA was done successfully in 12 patients. The averages of left ventricular outflow tract (LVOT) peak/mean pressure gradients (PPG/MPG) were 92.4 +/- 22.5/48.8 +/- 12.8 before and 21.6 +/- 11/12.8 +/- 5 mmHg immediately after ASA. The mean absolute alcohol volume was 2.5 +/- 0.64 ml. One patient had to have alcohol injection into two septal branches. Transient complete atrioventricular block occurred in two patients. All patients reported substantial symptomatic improvement. CONCLUSION: Most patients with medically refractory symptom HCOM have suitable first septal branches for ASA. ASA without MCE in those with suitable first septal branches is effective and safe.

Coronary spasm due to type A aortic dissection complicated by hemopericardium: a case report of another possible cause of coronary malperfusion.

Coronary malperfusion complicating Type A aortic dissection is relatively rare. The diagnosis of Type A aortic dissection as the cause of coronary ischemia is a challenge. The mechanism of coronary malperfusion has been proposed. We report a 45-year-old man presenting with acute inferior wall ST segment elevation myocardial infarction who was finally diagnosed to have Type A aortic dissection complicated by hemopericardium and cardiac tamponade. Coronary spasm is the most likely cause of transient myocardial ischemia in this patient and should be considered as another possible cause of coronary malperfusion in patients with Type A aortic dissection.