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.

Survival Outcome in Critically Ill Patients Receiving Extracorporeal Membrane Oxygenation Support: Early Experience from a University Hospital in Thailand.

Objective Extracorporeal membrane oxygenation (ECMO) is a relatively new technology used for life support in patients with cardiopulmonary failure from various causes. The objective of this study is to review the first 5-year experience in adopting this technology in a teaching hospital in southern Thailand. Methods The data of ECMO-supported patients in Songklanagarind Hospital, from the years 2014 to 2018, were retrospectively reviewed. Data sources were from electronic medical records and the database of the perfusion service. Parameters in focus included prior conditions and indications of ECMO, type of ECMO and cannulation method, complications during and after the treatment, and discharge statuses. Results A total of 83 patients received ECMO life support during the 5-year period and the number of cases per year increased. The proportion of venovenous: venoarterial ECMO in our institute was 49:34 cases and there were three cases who used ECMO as a part of cardiopulmonary resuscitation. Moreover, there were 57 cases who used ECMO for cardiac failure and 26 cases were for respiratory causes, while premature withdrawal was decided in 26 cases (31.3%). Overall survival from ECMO was 35/83 cases (42.2%) and survival to discharge was 32/83 (38.6%). During therapy, ECMO could restore serum pH to the normal range in all cases. Furthermore, those who used ECMO for respiratory failure had significantly higher survival probability (57.7%) when compared to the cardiac counterpart (29.8%, p -value = 0.03). Patients with younger ages also had significantly better survival outcomes. The most common complications were cardiac (75 cases, 85.5%), followed by renal (45 cases, 54.2%), and hematologic systems (38 cases, 45.8%). In those who survived to discharge, average ECMO duration was 9.7 days. Conclusion Extracorporeal life support is a technology that bridges the patients with cardiopulmonary failure to their recovery or definitive surgery. Despite the high complication rate, survival can be expected, especially in respiratory failure cases and relatively young patients.

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.

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.

Predictors of death after receiving a modified Blalock-Taussig shunt in cyanotic heart children: A competing risk analysis.

OBJECTIVE: To determine risk factors affecting time-to-death ≤90 and >90 days in children who underwent a modified Blalock-Taussig shunt (MBTS). METHODS: Data from a retrospective cohort study were obtained from children aged 0-3 years who experienced MBTS between 2005 and 2016. Time-to-death (prior to Glenn/repair), time-to-alive up until December 2017 without repair, and time-to-progression to Glenn/repair following MBTS were presented using competing risks survival analysis. Demographic, surgical and anesthesia-related factors were recorded. Time-to-death ≤90 days and >90 days was analyzed using multivariate time-dependent Cox regression models to identify independent predictors and presented by adjusted hazard ratios (HR) and 95% confidence intervals (CI). RESULTS: Of 380 children, 119 died, 122 survived and 139 progressed to Glenn/repair. Time-to-death probability (95% CI) within 90 days was 0.18 (0.14-0.22). Predictors of time-to-death ≤90 days (n = 63) were low weight (<3 kg) (HR 7.6, 95% CI:2.8-20.4), preoperative ventilator support (HR 2.7, 95% CI:1.3-5.6), postoperative shunt thrombosis (HR 5.0, 95% CI:2.4-10.4), bleeding (HR 4.5, 95% CI:2.1-9.4) and renal failure (HR 4.1, 95% CI:1.5-10.9). Predictors of time-to-death >90 days (n = 56) were children diagnosed with pulmonary atresia with ventricular septal defect and single ventricle (compared to tetralogy of fallot) (HR 3.2, 95% CI:1.2-7.7 and HR 3.1, 95% CI:1.3-7.6, respectively), shunt size/weight ratio >1.1 vs <0.65 (HR 6.8, 95% CI:1.4-32.6) and longer duration of mechanical ventilator (HR 1.002, 95% CI:1.001-1.004). Shunt size/weight ratio ≥1.0 (vs <1.0) and ≥0.65 (vs <0.65) were predictors for overall time-to-death in neonates and toddlers, respectively (HR 13.1, 95% CI:2.8-61.4 and HR 7.8, 95% CI:1.7-34.8, respectively). CONCLUSIONS: Perioperative factors were associated with time-to-death ≤90 days, whereas particular cardiac defect, larger shunt size/weight ratio, and longer mechanical ventilation were associated with time-to-death >90 days after receiving MBTS. Larger shunt size/weight ratio should be reevaluated within 90 days to minimize the risk of shunt over flow.

Risk factors for in-hospital shunt thrombosis and mortality in patients weighing less than 3 kg with functionally univentricular heart undergoing a modified Blalock-Taussig shunt.

OBJECTIVES: To determine the association between several perioperative variables and in-hospital shunt thrombosis and mortality in patients weighing less than 3 kg with functional univentricular heart (UVH) who underwent modified Blalock-Taussig shunt. METHODS: Between January 2006 and February 2016, 85 patients who weighed less than 3 kg with functional UVH and underwent modified Blalock-Taussig shunt were reviewed. In-hospital shunt thrombosis and mortality were the primary outcomes. The associations between perioperative variables and outcomes were assessed with univariate and multivariate analyses. RESULTS: In-hospital shunt thrombosis was 14% (12 of 85). Hospital mortality was 18% (15 of 85), which resulted in an 82% discharge survival rate. Shunt thrombosis was significantly associated with in-hospital mortality (odds ratio 18.9, 95% confidence interval 4.5-78.9). There were no statistically significant associations between weight, specific diagnosis of functional UVH and shunt thrombosis or mortality. Multivariate analysis identified delayed initiation of anticoagulant (P < 0.01) and postoperative cardiac arrest (P < 0.01) as risk factors of shunt thrombosis, while intraoperative bradycardia (P < 0.01), high postoperative haemoglobin (P = 0.03) and shunt thrombosis (P < 0.01) were risk factors for hospital mortality. CONCLUSIONS: In this high-risk group of patients who weighed less than 3 kg with functional UVH and who underwent modified Blalock-Taussig shunt, in-hospital mortality was strongly associated with the occurrence of shunt thrombosis. Our study highlighted the perioperative variables of delayed postoperative initiation of anticoagulant, cardiac arrest and the occurrence of intraoperative bradycardia that were significant risk factors for shunt thrombosis and mortality. Achieving better quality of perioperative care potentially improves outcomes.

Somatic mutations of K-ras and BRAF in Thai colorectal cancer and their prognostic value.

BACKGROUND: The study aimed to determine the incidence of K-ras and BRAF mutations in colorectal cancers (CRCs) in Thai patients and evaluate association with clinicopathological parameters including treatment outcomes in terms of event free survival (EFS). MATERIALS AND METHODS: Two-hundred colorectal cancer specimens were collected for studies of K-Ras codon 12, 13 and 61, and BRAF codon 600 by polymerase chain reaction and direct nucleotide sequencing. RESULTS: The overall incidence of K-Ras mutations in our patients was 23%. K-ras mutation frequencies in CRC stages (AJCC) I, II, III and IV were 6.7%, 16.1%, 23.3% and 26.6%, respectively (p-value>0.05). The three most common mutation forms were G12D, G12V and G13D. K-Ras mutation status was associated with poorer EFS in stage I-III CRCs (p-value 0.03). CONCLUSIONS: The study found a lower mutation frequency of K-Ras and BRAF compared to reports involving other ethnic groups. However, K-Ras mutations did have a negative prognostic value in early-stage CRCs.