Tuesday, January 25, 2011

Economics of presence of heart failure program

The Economic Effect of a Tertiary Hospital-Based Heart Failure Program

Douglas Gregory, PhD, David DeNofrio, MD and Marvin A. Konstam, MD

OBJECTIVES: This study was designed to determine the economic effect of a tertiary heart failure (HF) program at an academic medical center.

BACKGROUND: Most hospitals use cross-sectional financial models to analyze the economic contribution of clinical programs for a budget period. We estimated the incremental value of a tertiary hospital HF program on the basis of the longitudinal utilization of a sample of HF patients.

METHODS: The primary data source was a sample of 82 HF patients referred for cardiac transplant evaluation at an academic medical center during calendar years 2000 to 2001. Cumulative recurrent rates of utilization, cost, and reimbursement for hospital services were computed as functions of time using reliability models. The economic contribution of patients transplanted was contrasted with those not transplanted.

RESULTS: Mean hospitalizations and outpatient encounters per patient at the end of the first year of follow-up for those transplanted were 2.1 (95% confidence interval [CI] 1.6 to 2.7) and 11.9 (95% CI 9.2 to 15.4), compared with 1.1 (95% CI 0.8 to 1.6) and 6.0 (95% CI 4.8 to 7.6), respectively, for those not transplanted. Mean revenue and direct cost per patient were $194,470 (95% CI $136,683 to $276,689) and $146,623 (95% CI $96,377 to $233,065), respectively, for transplanted patients and $43,587 (95% CI$28,149 to $67,503) and $33,424 (95% CI $21,584 to $51,760), respectively, for non-transplanted patients. The point estimates of first-year contribution margins per patient for transplanted and non-transplanted patients were $47,847 and $10,163, respectively.

CONCLUSIONS: Newly evaluated patients for cardiac transplantation at an academic medical center generated substantial incident demands for inpatient and outpatient services over a two-year follow-up period. The estimated contribution margin associated with these services was positive. Hospitals without cardiac transplantation that serve high-acuity HF patients may generate favorable long-term contribution margins, on the basis of the results for the non-transplant group.

Saturday, January 22, 2011

Cath lab: Retinal Emboli after Cardiac Cath (Adult)

Clinical significance of retinal emboli during diagnostic and therapeutic cardiac catheterization in patient with coronary artery disease

Javad Kojuri email, Morteza Mehdizadeh email, Hamed Rostami email and Danial Shahidian email

BMC Cardiovascular Disorders 2011, 11:5doi:10.1186/1471-2261-11-5

Published:21 January 2011

Abstract (provisional)


Cardiac catheterization may cause retinal embolization, a risk factor for cerebrovascular emboli and stroke. We describe the incidence of clinically silent and apparent retinal emboli following diagnostic and interventional coronary catheterization and associated risk factors.


Three hundred selected patients attending a tertiary referral center for diagnostic and therapeutic cardiac catheterization were studied. Direct retinal examination and examination of the visual field and acuity were done before and after catheterization by a retinal specialist.


There was 5 case of retinal embolus before catheterization, and 19 patients (incidence 6.3%) developed new retinal arteriolar emboli after catheterization. Only 1 patient developed clinically apparent changes in vision. Two conventional risk factors (age and hypertension) were significantly associated with new retinal emboli. The risk of retinal emboli was also significantly associated with operator expertise.


Retinal embolism was found after coronary catheterization in 6.3% of our patients. This finding indicates that the retinal, and possibly the cerebral circulation, may be compromised more frequently than is clinically apparent as a complication of coronary catheterization. Age and hypertension are independent predictors of retinal embolism (clinical trial registrationNCT01157338)

EP: Do ablation lesions grow in size?

Circulation: Arrhythmia and Electrophysiology 2011

Enlargement of Catheter Ablation Lesions in Infant Hearts with Cryothermal Enlargement of Catheter Ablation Lesions in Infant Hearts with Cryothermal Versus Radiofrequency Energy: An Animal Study


Background—Radiofrequency catheter ablation in immature hearts has been associated with marked enlargement of lesions over time, with potential for related late adverse events. It remains unknown whether cryothermal ablation lesions display a similar pattern of growth.

Methods and Results—Ablation lesions (n=384) were performed in 32 infant miniature swine in right and left atria, ventricles, and atrioventricular (AV) grooves preselected by a randomized factorial design devised to compare radiofrequency and cryothermal lesions produced by 7-French 4 mm electrode-tip catheters. Animals were sacrificed acutely or at 1, 6, or 12 months according to the randomization scheme. The miniature swine weighed 8.8±1.2 kg and were 63±13 days of age at time of ablation. The minimum temperature during cryoablation was -79.8±3.4°C and the average temperature during radiofrequency ablation was 54.4±5.5°C. On morphometric analyses, no differences in the rate of growth of ablation lesions were noted between the two energy modalities in atria (P=0.44), ventricles (P=0.57), or AV grooves (P=0.69). Lesion volumes increased 3.3-fold in atria [95% confidence interval (CI) 2.3, 4.3, P=0.001] and 2.2-fold in ventricles [95% CI (1.4, 3.0), P<0.0001], p="0.22)." p="">

Conclusions—Ablation lesions produced by cryothermal energy in immature atrial and ventricular myocardium enlarge to a similar extent to radiofrequency ablation. In contrast, AV groove lesion volumes do not increase significantly with either energy modality.

Thursday, January 20, 2011

Cath lab: Outcome of ASD created by Transseptal puncture

The Incidence and Long-Term Clinical Outcome of Iatrogenic Atrial Septal Defects Secondary to Transseptal Catheterization with a 12Fr Transseptal Sheath

  1. Sheldon M. Singh1*,
  2. Pamela S. Douglas2 and
  3. Vivek Y. Reddy1

  1. 1 Mount Sinai School of Medicine, New York, NY;
  2. 2 Duke Clinical Research Institute, Durham,


Background—Studies assessing the presence of a residual iatrogenic atrial septal defect (iASD) after transseptal catheterization with 8Fr transseptal sheaths have suggested that the majority of these iASD close within 6 months. However, these studies have been limited by small patient numbers and short follow-up. Additionally, there are a number of novel catheter procedures in interventional cardiology and electrophysiology that employ larger transseptal sheaths. The objective of this study was to assess the incidence of and complications associated with iASD in a large cohort of patients undergoing transseptal catheterization with a 12Fr transseptal sheath.

Methods and Results—253 patients without a pre-existing inter-atrial shunt undergoing WATCHMAN implantation as part of the PROTECT AF study were included in this current study. Patients underwent transesophageal echocardiography (TEE) with echo-contrast immediately post-procedure, 45-days, 6 months, and 12 months. 87% of patients had an iASD immediately post-procedure, the majority of which sealed by 6 months (incidence of iASD - 34% at 45 days, 11% at 6 months, 7% at 12 months). While the majority of iASDs were >3mm in diameter immediately post-procedure, the minority of iASD were >3mm during the follow-up period. Additionally, inter-atrial shunting was predominantly left-to-right when an iASD was present. There was no significant difference in the rate of stroke and/or systemic embolism during the follow up period in patients with or without iASD.

Conclusions—Transseptal catheterization procedures with a large diameter transseptal sheath have a high spontaneous closure rate of iASD, and is not associated with an increased rate of stroke / systemic embolization during long-term follow-up.

  • Received July 29, 2010.
  • Accepted December 20, 2010.

Tuesday, January 11, 2011

Cardiology in India 2011

JACC 2011;57:377-9
Tiny Nair, Trivandrum.

It was an intense academic debate. That is what the American College of Cardiology (ACC) wanted it to be. How to reduce door-to-balloon time in ST-segment elevation myocardial infarction (STEMI), the goal being 90 min, beyond which time myocardial salvage deteriorates. An active emergency medical service, in-ambulance electrocardiogram (ECG) and triage, and direct catheterization laboratory transfers are critical to achieving this. The National Cardiovascular Data Registry (NCDR) data showed that it is possible to achieve this, and it was so in 88% cases in the U.S. (1).

"Kapi ready, get up!" shouted my wife. Kapi, the local name of coffee in Kerala, has been an addiction here for generations. This southern-most state of India, "God's own country," is also the most literate state in India. Kerala has one of the best educational and health care standards in India, with 100% literacy and an infant mortality rate of 12 per 1,000 live births (Indian average of 53) (2). My wife's stern voice and the aroma of south Indian coffee woke me up, still groggy from the multiple phone calls that I had received last night about that heart failure patient in the intensive cardiac care unit (ICCU). As I grabbed the coffee, I lifted the telephone to call up to learn how the patient was. "He is better, sir," the resident told me, "but his relatives want him to be shifted home because they can't afford to keep him in the ICCU any more, now that it is 3 days... ." In this country, including this medically advanced, literate state, medical insurance is still just a vague new concept. With more than 90% of the patients without any health insurance, the patient's family has to bear the entire cost of the treatment, and to make payments now. I could understand the unusual request of the relatives.

"Are you not going to the hospital today? I am ready for school," screamed my 12-year-old son, whose...

Fetal AS with MR

Pathophysiology, Fetal intervention and Outcome

LV remodeling - Imaging (Review)

Marvin Konstam et al. JACC Img. 2011;4:98-108

3D-TEE evaluation of mitral valve

JACC Img 2011;4:94-97

Wednesday, January 5, 2011

EP: Phenotype-Negative Long QT syndrome

J Am Coll Cardiol, 2011; 57:51-59
© 2011 by the American College of Cardiology Foundation

(+ Editorial)

Ilan Goldenberg, MD et al.

Risk for Life-Threatening Cardiac Events in Patients With Genotype-Confirmed Long-QT Syndrome and Normal-Range Corrected QT Intervals

Objectives: This study was designed to assess the clinical course and to identify risk factors for life-threatening events in patients with long-QT syndrome (LQTS) with normal corrected QT (QTc) intervals.

Background: Current data regarding the outcome of patients with concealed LQTS are limited.

Methods: Clinical and genetic risk factors for aborted cardiac arrest (ACA) or sudden cardiac death (SCD) from birth through age 40 years were examined in 3,386 genotyped subjects from 7 multinational LQTS registries, categorized as LQTS with normal-range QTc (≤440 ms [n = 469]), LQTS with prolonged QTc interval (>440 ms [n = 1,392]), and unaffected family members (genotyped negative with ≤440 ms [n = 1,525]).

Results: The cumulative probability of ACA or SCD in patients with LQTS with normal-range QTc intervals (4%) was significantly lower than in those with prolonged QTc intervals (15%) (p <> but higher than in unaffected family members (0.4%) (p < 0.001). Risk factors ACA or SCD in patients with normal-rangeQTc intervals included mutation characteristics (transmembrane-missense vs. nontransmembrane or nonmissense mutations: hazard ratio: 6.32; p = 0.006) and the LQTS genotypes (LQTS type 1:LQTS type 2, hazard ratio: 9.88; p = 0.03; LQTS type 3:LQTS type 2, hazard ratio: 8.04; p = 0.07), whereas clinical factors, including sex and QTc duration, were associated with a significant increase in the risk for ACA or SCD only in patients with prolonged QTc intervals (female age >13 years, hazard ratio: 1.90; p = 0.002; QTc duration, 8% risk increase per 10-ms increment; p = 0.002).

Conclusions: Genotype-confirmed patients with concealed LQTS make up about 25% of the at-risk LQTS population. Genetic data, including information regarding mutation characteristics and the LQTS genotype, identify increased risk for ACA or SCD in this overall lower risk LQTS subgroup.

General Cardiology: Kawasaki - Non-coronary Cardiac Involvement in Acute Kawasaki

J Am Coll Cardiol, 2011; 57:86-92,
© 2011 by the American College of Cardiology Foundation

Noncoronary Cardiac Abnormalities Are Associated With Coronary Artery Dilation and With Laboratory Inflammatory Markers in Acute Kawasaki Disease

Beth F. Printz, Lynn A. Sleeper, Jane W. Newburger, L. LuAnn Minich, Timothy Bradley, Meryl S. Cohen, Deborah Frank, MD, PhD, Jennifer S. Li, MD, MHS, Renee Margossian, Girish Shirali, Masato Takahashi, Steven D. Colan, Pediatric Heart Network Investigators

Objectives: We explored the association of noncoronary cardiac abnormalities with coronary artery dilation and with laboratory inflammatory markers early after Kawasaki disease (KD) diagnosis.

Background: Left ventricular (LV) dysfunction, mitral regurgitation (MR), and aortic root dilation occur early after diagnosis; their associations with coronary artery dilation and inflammatory markers have not been well-described.

Methods: Centrally interpreted echocardiograms were obtained at KD diagnosis and 1 and 5 weeks after diagnosis on 198 subjects in the National Institutes of Health-sponsored Pediatric Heart Network KD pulsedsteroid trial. Regression models were constructed to investigate the relationships among early LV dysfunction, MR, and aortic root dilation with coronary artery dilation and laboratory inflammatory markers.

Results: At diagnosis, LV systolic dysfunction was present in 20% of subjects and was associated with coronary artery dilation, seen in 29% (p = 0.004). Although LV dysfunction improved rapidly, LV dysfunction at diagnosis predicted greater odds of coronary artery dilation at 1 and 5 weeks after diagnosis (5-week odds ratio: 2.7, 95% confidence interval: 1.2 to 6.3). At diagnosis, MR was present in 27% of subjects and aortic root dilation was present in 8%; each was associated with larger coronary artery size at diagnosis. Left ventricular dysfunction was associated with higher erythrocyte sedimentation rate and, at diagnosis only, lower serum albumin; MR was associated with higher erythrocyte sedimentation rate and lower albumin at all times. Aortic root size had little association with inflammatory markers.

Conclusions: Noncoronary cardiac abnormalities are associated with coronary artery dilation and laboratory evidence of inflammation in the first 5 weeks after KD, suggesting a shared inflammatory mechanism. (Trial of Pulse Steroid Therapy in Kawasaki Disease [A Trial Conducted by the Pediatric Heart Network]