RESUMO
BACKGROUND: Dofetilide is a class III antiarrhythmic drug indicated for the conversion and maintenance of normal sinus rhythm in symptomatic patients with atrial fibrillation/atrial flutter. Delay in initiation of dofetilide therapy may increase the duration of hospitalization from two nights to three nights to complete US Food and Drug Administration-required monitoring. Therefore, substantial cost savings may be associated with implementation of an institution-specific dofetilide initiation protocol in order to reduce hospitalization to two nights. This could potentially be achieved through protocol-defined utilization of the option for a condensed dosing interval for the first three doses of dofetilide in order to ensure the administration of two doses on the first day of hospitalization. OBJECTIVE: The primary objective of this study was to assess the impact of an institution-specific dofetilide initiation protocol on mean hospital length of stay and cost for dofetilide initiation. METHODS: The study design was a retrospective review of 150 patients admitted to the Clement J. Zablocki Veterans Affairs Medical Center for the purpose of dofetilide initiation. Matching time periods of 18 months before and after implementation of the institution-specific dofetilide initiation protocol were used to randomly select 75 patients from each time period for comparison. RESULTS: A significant reduction in mean hospital length of stay of 0.56 nights post-implementation of the institution-specific dofetilide initiation protocol was identified (95% confidence interval 0.20-0.92; P = 0.0029). Assuming hospital adjusted expenses per inpatient day of US$1831-2413, a reduction in hospital length of stay of 0.56 nights resulted in estimated cost savings of US$1025-1351 per admission for dofetilide initiation. CONCLUSION: Implementation of an institution-specific dofetilide initiation protocol decreases mean hospital length of stay and cost for dofetilide initiation.
RESUMO
To date, many pharmacological agents used to treat or prevent arrhythmias in open-heart cases create undesired systemic side effects. For example, antiarrhythmic drugs administered intravenously can produce drops in systemic pressure in the already compromised cardiac patient. While performing open-heart procedures, surgeons will often either create a small port or form a pericardial cradle to create suitable fields for operation. This access yields opportunities for target pharmacological delivery (antiarrhythmic or ischemic preconditioning agents) directly to the myocardial tissue without undesired side effects. We have developed a swine model for testing pharmacological agents for target delivery within the pericardial fluid. While fully anesthetized, each animal was instrumented with a Swan-Ganz catheter as well as left and right ventricle pressure catheters, and pacing leads were placed in the right atrial appendage and the right ventricle. A medial sternotomy was then performed and a pericardial access cradle was created; a plunge pacing lead was placed in the left atrial appendage and a bipolar pacing lead was placed in the left ventricle. Utilizing a programmer and a cardiac mapping system, the refractory period of the atrioventricular node (AVN), atria and ventricles was determined. In addition, atrial fibrillation (AF) induction was produced utilizing a Grass stimulator and time in AF was observed. These measurements were performed prior to treatment, as well as 30 min and 60 min after pericardial treatment. Additional time points were added for selected studies. The heart was then cardiopleged and reanimated in a four chamber working mode. Pressure measurements and function were recorded for 1 hr after reanimation. This treatment strategy model allowed us to observe the effects of pharmacological agents that may decrease the incidence of cardiac arrhythmias and/or ischemic damage, during and after open-heart surgery.
