DyeVert™ PLUS EZ System for Preventing Contrast-Induced Acute Kidney Injury in Patients Undergoing Diagnostic Coronary Angiography and/or Percutaneous Coronary Intervention: A UK-Based Cost-Utility Analysis.

BACKGROUND: Contrast-induced acute kidney injury (CI-AKI) is a complication commonly associated with invasive angiographic procedures and is considered the leading cause of hospital-acquired acute kidney injury. CI-AKI can lead to a prolonged hospital stay, with a substantial economic impact, and increased mortality. The DyeVert™ PLUS EZ system (FDA approved and CE marked) is a device that has been developed to divert a portion of the theoretical injected contrast media volume (CMV), reducing the overall volume of contrast media injected and aortic reflux, and potentially improving long-term health outcomes. OBJECTIVES: To assess the long-term costs and health outcomes associated with the introduction of the DyeVert™ PLUS EZ system into the UK health care service for the prevention of CI-AKI in a cohort of patients with chronic kidney disease (CKD) stage 3-4 undergoing diagnostic coronary angiography (DAG) and/or percutaneous coronary intervention (PCI), and to compare these costs and outcomes with those of the current practice. METHODS: A de novo economic model was developed based on the current pathway of managing patients undergoing DAG and/or PCI and on evidence related to the clinical effectiveness of DyeVert™ in terms of its impact on relevant clinical outcomes and health service resource use. Clinical data used to populate the model were derived from the literature or were based on assumptions informed by expert clinical input. Costs included in the model were from the NHS and personal social services perspective and obtained from the literature and UK-based routine sources. Probabilistic distributions were assigned to the majority of model parameters so that a probabilistic analysis could be undertaken, while deterministic sensitivity analyses were also carried out to explore the impact of key parameter variation on the model results. RESULTS: Base-case results indicate that the intervention leads to cost savings (- £435) and improved effectiveness (+ 0.028 QALYs) over the patient's lifetime compared with current practice. Output from the probabilistic analysis points to a high likelihood of the intervention being cost-effective across presented willingness-to-pay (WTP) thresholds. The overall long-term cost saving for the NHS associated with the introduction of the DyeVert™ PLUS EZ system is over £19.7 million for each annual cohort of patients. The cost savings are mainly driven by a lower risk of subsequent diseases and their associated costs. CONCLUSIONS: The introduction of the DyeVert™ PLUS EZ system has the potential to reduce costs for the health care service and yield improved clinical outcomes for patients with CKD stage 3-4 undergoing angiographic procedures.

Primary angioplasty for infarction due to isolated right ventricular artery occlusion.

We report an unusual case of an isolated right ventricular infarction with haemodynamic compromise caused by spontaneous isolated proximal occlusion of the right ventricular branch of the right coronary artery (RCA), successfully treated by balloon angioplasty. A 58-year-old gentleman presented with epigastric pain radiating into both arms. Electrocardiograph with right ventricular leads confirmed ST elevation in V4R and a diagnosis of isolated right ventricular infarction was made. Urgent primary percutaneous intervention was performed which revealed occlusion of the right ventricular branch of the RCA. During the procedure, the patient's blood pressure dropped to 80/40 mmHg, and echocardiography showed impaired right ventricular systolic function. Despite aggressive fluid resuscitation, the patient remained hypotensive, continued to have chest pain and persistent electrocardiograph changes, and hence balloon angioplasty was performed on the proximal right ventricular branch which restored flow to the vessel and revealed a severe ostial stenosis. This was treated with further balloon angioplasty which restored TIMI 3 flow with resolution of patient's symptoms. Repeat echocardiography showed complete resolution of the ST-elevation in leads V4R and V5R and partial resolution in V1. Subsequent dobutamine-stress echocardiography at 4 wk showed good left and right ventricular contractions. The patient was discharged after a 3-d in-patient stay without any complications.

Percutaneous intervention on anomalous circumflex coronary arteries--a single centre experience.

BACKGROUND: Anomalies of the origin and course of the circumflex artery are amongst the most common seen at coronary angiography. There is limited information regarding patient and procedural characteristics, technical feasibility and outcomes associated with percutaneous intervention (PCI) to these vessels. The aim of this study is to examine our experience with PCI to anomalous circumflex vessels and compare this to some aspects of percutaneous intervention on non-anomalous circumflex vessels. METHODS: Over a 41 month period, 20 PCI procedures on anomalous circumflex vessels were identified and 1550 PCI procedures on non-anomalous circumflex arteries. RESULTS: In 9 anomalous cases, the circumflex arose from the left coronary cusp, in 7 cases from the right coronary cusp, and in the remaining 4 cases from the proximal right coronary artery. There were no differences in demographics or pattern or severity of coronary disease between the 2 groups. A higher proportion of patients with anomalous vessels presented acutely. Screening times were longer in the anomalous group. All 20 procedures were associated with immediate procedural success. There was one peri-procedural myocardial infarction unrelated to anomalous circumflex intervention. After a median follow-up period of 7.3 months, the only major adverse cardiac event recorded in the anomalous group was an ischaemia-driven revascularisation to a non-target vessel branch. We describe techniques which can be used to improve support and facilitate successful PCI to anomalous circumflex vessels. CONCLUSION: PCI to anomalous circumflex vessels may be technically challenging, but is feasible and carries favourable short and long-term clinical outcomes. SUMMARY: This single centre observational study demonstrates that percutaneous coronary intervention to anomalous circumflex coronary arteries although technically challenging can be performed with satisfactory procedural success rates and favourable short and longer-term clinical outcomes. It describes various techniques that can be employed to optimise successful intervention.

Predicting outcome in patients with left ventricular systolic chronic heart failure using a nutritional risk index.

Mortality in patients with chronic heart failure (CHF) is high and associated with body mass. However, the best method of assessing nutritional status in patients with CHF is not clear. We sought to demonstrate the prognostic use of a nutritional risk index (NRI) in ambulatory patients with CHF. Consecutive patients attending their first quarterly review appointment in the HF clinic were recruited. All patients had systolic left ventricular (LV) dysfunction. An NRI was calculated as: (1.5 × serum albumin [grams per liter]) + (current body weight/ideal weight). Patients were followed up every 4 months. Of the 538 patients enrolled in the study 75% were men. The patients' age was 71 ± 10 years (mean ± SD) and total median follow-up in survivors was 68 months (interquartile range 54 to 74). New York Heart Association classes II and III accounted for 60% and 27%, respectively, with 80% having moderate LV impairment or worse. Based on the NRI 23% of patients were at risk of malnutrition. Severely malnourished patients were older. There was no relation between NRI and LV function. The NRI was a univariable predictor of mortality (chi-square 25, p <0.001) and was an independent predictor of outcome in multivariable analysis (chi-square 12, p <0.001). In conclusion, the NRI is useful as a prognostic marker in patients with CHF in an outpatient setting. NRI might be of use as a surrogate marker for nutritional status in trials of dietary supplementation in CHF.

Chronotropic incompetence and survival in chronic heart failure.

BACKGROUND: Failure of the heart rate to rise normally during an incremental exercise test is termed chronotropic incompetence (CI). It is common in patients with chronic heart failure (CHF), and we wanted to explore the relation between CI and outcome in unselected patients with CHF. METHODS: 411 patients with left ventricular systolic dysfunction who underwent cardiopulmonary exercise testing (CPET) were included. CI was defined as a failure to achieve 80% of the maximum predicted heart rate (HR). A CI index was also calculated: (Peak HR-Rest HR)/(220-age-Rest HR)∗100. Cox regression was used to assess the univariate and multivariate relationship between variables and all-cause mortality. Survivors were followed for a median of 89months (IQR 62.8-98.6). The majority were male (81.4%) with a median age of 67years (IQR 60-73). A subgroup of 266 patients had NT-proBNP values. RESULTS: CI was present in 42.3% of the population. The mean CI index was 65.7% (SD 41.3%). Patients without CI exercised for longer (510s) and had higher peak VO(2) values (21.1mL/kg/min) than those with CI (424 seconds and 18mL/kg/min). Only peak VO(2), age and ß blocker use were independent prognostic variables. In the subset of patients with NT-proBNP available, Log[NT-proBNP] was the most powerful predictor of mortality followed by peak VO(2) and ß blocker use. CONCLUSIONS: Patients with CI had lower exercise time and peak VO(2). However CI was not a significant predictor of mortality in patients with CHF undergoing CPET.

Red cell distribution width: an inexpensive and powerful prognostic marker in heart failure.

AIMS: Red cell distribution width (RDW) is prognostic in patients with heart failure (HF), but it has not been compared with N-terminal brain natriuretic peptide (NT-proBNP). We sought to make this comparison. METHODS AND RESULTS: Patients referred to a specialist HF clinic between 2001 and 2008 were assessed comprehensively including medical history, echocardiogram, and blood tests. Cox-regression was used to assess the multivariable relationship between RDW, NT-proBNP, and all-cause mortality. A total of 1087 patients were recruited; median (IQR) follow-up was 52 months (29-66); age 72 years (64-78); 74% male; 70% ischaemic heart disease; 20% diabetic; 85% NYHA >or= 2, and 63% with at least moderate LV impairment (EF < 35% equivalent). In a multivariable model, both RDW and NT-proBNP were independently prognostic (RDW: chi(2) = 21.8 vs. 49.1 both P < 0.001). In a model using quartiles of each variable, the relative risk for each was similar for the second and third quartiles compared with the first. A larger increase in risk for NT-proBNP is seen in the fourth quartile. CONCLUSION: Red cell distribution width is a readily available test in the HF-population with similar independent prognostic power to NT-proBNP across the first to third quartiles. Prognostic models in HF should include RDW and further investigation is necessary to determine the pathological mechanism of the relationship.