Risk analysis in patients bridged to transplantation.

BACKGROUND: Efforts to predict mortality in bridge to cardiac transplant patients have concentrated on preventricular assist device (VAD) status. To more fully identify factors influencing survival to transplant, we reviewed the preoperative and postoperative VAD courses of 105 bridge to transplant patients. METHODS: Sixty-four parameters (34 pre-VAD, 30 post-VAD), including hemodynamics, complications, and evaluations of major organ function were examined and analyzed. RESULTS: Thirty-three patients (31%) died on VADs and 72 were transplanted. There were two posttransplant operative deaths (3%). By univariate analysis 23 of 64 factors were significant. These 23 factors were entered into a stepwise logistic regression analysis to identify predictors of survival to transplant. Four factors, including pre-VAD intubation (p < 0.005), cardiopulmonary bypass (CPB) time during VAD insertion (p < 0.0001), mean pulmonary artery pressure (first postoperative day after VAD) (p < 0.0002), and highest post-VAD creatinine (p < 0.01) were independent predictors of transplantation. CONCLUSIONS: Other than the need for intubation, pre-VAD variables were of little value in predicting survival to transplant. Problems during VAD insertion (long CPB time) and post-VAD renal insufficiency were independent predictors. Severe complications that developed during the interval of VAD support, including cerebrovascular accident, bleeding and infection, were surprisingly not predictors for transplantation.

Transfer of patients receiving advanced mechanical circulatory support.

OBJECTIVE: Improving results with ventricular assist devices have led to their wider clinical application. Centers can stabilize, support, and wean or transfer patients to regional transplant centers. METHODS: Prospectively collected data were reviewed to evaluate the clinical results of patients transferred to our institution while receiving advanced mechanical circulatory support. RESULTS: Since 1993, 16 patients were accepted while receiving support with either extracorporeal membrane oxygenation or a ventricular assist device. The 10 male and 6 female patients ranged in age from 9 to 60 years (mean, 42.1 years). Thirteen had had cardiac surgical procedures, two had acute myocardial infarctions, and one had myocarditis. The distance transported ranged from 0.2 to 309 miles (mean, 132 miles). Twelve patients were transferred by ground, and 4 were transported by air. Seven patients were originally supported with extracorporeal membrane oxygenation, 6 with centrifugal pumps, and 3 with ABIOMED ventricular assist devices (ABIOMED, Inc, Danvers, Mass). Two patients had clinical complications during transfer, and one had a cerebrovascular accident, recovered, was weaned, and survived. A second patient had hemodynamic deterioration. There were no technical complications associated with transport. Six patients were left on the original support device; 3 of the 6 were weaned and survived, and 3 died during support. The 10 remaining patients were switched to other ventricular assist devices: 9 patients to Thoratec devices (Thoratec Laboratories, Pleasanton, Calif) and 1 patient to a Novacor device (Baxter Healthcare Corp, Novacor Division, Oakland, Calif). Six of the 10 patients underwent transplantation and survived. Four patients died while being supported by the devices. Nine patients were discharged, with 1 late death at 29 months. Eight patients are alive 4 to 65 months after discharge. CONCLUSIONS: These data suggest that patients receiving advanced support can be moved between clinical centers with acceptable risks. Because 33% of the survivors were weaned, transplantation is not required for survival.

Critical pathways as an effective tool to reduce cardiac transplantation hospitalization and charges.

A critical pathway is a component of managed care focusing on outcome-oriented, cost-effective care. This retrospective review of 74 cardiac transplants in 72 patients evaluated the influence of critical pathways on clinical management, length of hospitalization, and hospital charges. Transplant patients were divided into group 1 (n = 51), which received standard primary nursing care, and group 2 (n = 23), which received nursing case management using a critical pathway. The number of intensive care unit days for group 2 was significantly smaller than for group 1, as were duration of hospitalization and hospital charges. The critical pathway provided for systematic delivery of care and decreased length of hospitalization and charges without compromising safety or quality.

Is migration kin structured?

We estimate the strength of kin-structured migration in six human populations (five from New Guinea and one from Finland) and in one population of nonhuman primates. We also test the hypothesis that migration is not kin structured by generating a sampling distribution of the estimator under the null hypothesis of independent random migration. We are unable to detect a statistically significant level of kin-structured migration in any population. However, five of our six human populations were from Papua New Guinea, and we cannot dismiss the possibility that migration is kin structured in other parts of the world.