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Heart failure is defined as reduced ability of the heart to pump blood and maintain normal bodily function. Heart transplantation is currently the preferred treatment for end-stage heart failure but the supply of donor hearts is insufficient to meet the need and many patients are not eligible for transplantation due to age or comorbid conditions. Implantable mechanical pumps can assist the circulation of blood by the ventricles. Left ventricular assist devices (LVADs) have been approved by the U.S. Food and Drug Administration (FDA) for use in patients awaiting transplant (a bridge to transplant) and as a last resort in patients with refractory heart failure who are not eligible for a heart transplant (destination therapy). In January 2010, the first newer generation, rotary continuous flow ventricular assist device (HeartMate II) was approved by the FDA for destination therapy. Eligibility criteria are essentially the same as those used to select patients for the pivotal clinical trial that included patients with shortness of breath and/or fatigue at rest or during minimal exertion despite treatment with optimal therapy for heart failure associated with a low ejection fraction (
Several common chronic conditions such as atherosclerotic heart disease and hypertension as well as other diseases can result in heart failure, a reduced ability of the heart to pump blood and maintain normal bodily functions. More than 100,000 people in the U.S. with progressive heart failure are refractory to available treatments and have high rates of hospitalization and mortality and a poor quality of life due to limited physical and social activities and psychological stress. Heart transplantation is currently the preferred treatment for end-stage heart failure. Unfortunately, the supply of donor hearts is far less than needed and many patients do not meet the criteria for heart transplantation primarily due to old age and comorbidities such as diabetes with damage to vital organs, pulmonary hypertension, renal insufficiency, malignancies and morbid obesity. Implantable mechanical pumps that assist the circulation of blood by one or both ventricles of the heart have evolved over several decades. Typically blood flows from the native left ventricle of the heart into the surgically implanted assist device and is pumped out into the aorta via an implanted conduit. Currently, long-term implantable left ventricular assist devices require an external source of power and control module. Surgical placement of a left ventricular assist device is increasingly done as a last resort for patients with refractory heart failure who are not eligible for heart transplantation, so called destination therapy. Some patients may improve after they receive a ventricular assist device as destination therapy and become eligible for heart transplantation even though this was not the initial therapeutic goal. A limited number may recover enough heart function to not need a heart transplant or mechanical assist device. Although survival with a newer generation continuous flow ventricular assist device is approaching that of a heart transplant, long-term use of the device by patients who are eligible for a heart transplant is not currently accepted practice. Conversely, many patients that receive a ventricular assist device as a bridge to transplant use the device for increasingly prolonged periods while waiting for a donated heart and some may become ineligible for a heart transplant. The purpose of this report is to review the scientific evidence for use of ventricular assist devices as destination therapy for patients with severe, refractory heart failure who are not eligible for heart transplantation at the time the device is implanted. Although many patients receive the same types of ventricular assist devices as a bridge to heart transplantation or recovery, the characteristics, hence risk profiles, of patients receiving bridge therapy are different from patients selected to receive a device as permanent destination therapy. Furthermore many bridged patients do receive a heart transplant that alters patient outcomes. This review focused on evidence about patient outcomes, patient selection and cost effectiveness of ventricular assist devices specifically intended as destination therapy. The primary goals of destination therapy are to: prolong survival, improve daily function and health-related quality of life, minimize harms including infection, major bleeding episodes, thromboembolic events including strokes and device malfunction or failure especially those that require hospital care. The key questions were: #1. How does use of an FDA-approved, current generation LVAD as destination therapy (i.e., the HeartMate II left ventricular assist device) effect patient outcomes? #2. What patient or site characteristics have been associated with patient benefits or harms when the FDA-approved, current generation LVAD is used as destination therapy? #3. What is the range of cost-effectiveness estimates of using the FDA-approved, current generation LVAD as destination therapy in end-stage heart failure and what explains variation in these estimates?
Most patients with critical cardiac or thoracic conditions will at some stage pass through the cardiothoracic critical care unit. Critical care presents more complex clinical data than any other area of medicine. The new edition of Core Topics in Cardiothoracic Critical Care focuses on the latest practise in the management of patients in cardiothoracic intensive care. The practice of cardiothoracic critical care medicine is constantly evolving, and this new edition reflects the modernized learning styles for trainees. Each chapter includes key learning points as well as sample multiple choice questions and answers to assist in exam preparation. This edition also features updated chapters on ECMO, perioperative management of patients undergoing emergency cardiothoracic surgery, and advanced modes of organ support for patients. This text provides key knowledge in a concise and accessible manner for trainees, clinicians and consultants from specialities and disciplines such as cardiology and anaesthesia, and nursing and physiotherapy.
The clinical practice of anesthesia has undergone many advances in the past few years, making this the perfect time for a new state-of-the-art anesthesia textbook for practitioners and trainees. The goal of this book is to provide a modern, clinically focused textbook giving rapid access to comprehensive, succinct knowledge from experts in the field. All clinical topics of relevance to anesthesiology are organized into 29 sections consisting of more than 180 chapters. The print version contains 166 chapters that cover all of the essential clinical topics, while an additional 17 chapters on subjects of interest to the more advanced practitioner can be freely accessed at www.cambridge.org/vacanti. Newer techniques such as ultrasound nerve blocks, robotic surgery and transesophageal echocardiography are included, and numerous illustrations and tables assist the reader in rapidly assimilating key information. This authoritative text is edited by distinguished Harvard Medical School faculty, with contributors from many of the leading academic anesthesiology departments in the United States and an introduction from Dr S. R. Mallampati. This book is your essential companion when preparing for board review and recertification exams and in your daily clinical practice.
Rotary blood pumps increasingly are being used in open heart surgery and in assisted circulation for patients with heart disease. These rotary devices include vortex (centrifugal) and axial pumps, which can be utilized in conditions where the use of conventional pulsatile pumps would entail problems of cost and size. Rapid progress is now being made in developing new devices for controlling blood flow within the heart and great vessels as well as extracorporeally for use in coronary and intensive care units and, in the future, for long-term use. This book provides information on the physiology of nonpulsatile circulation, the development of rotary pump engineering, and the clinical application of rotary blood pumps. It also presents an overview of future developments in this important field.
Introductory Chapter: Introduction to Advanced Concepts in Endocarditis.
A unique, in-depth discussion of the uses and conduct of cost-effectiveness analyses (CEAs) as decision-making aids in the health and medical fields, this volume is the product of over two years of comprehensive research and deliberation by a multi-disciplinary panel of economists, ethicists, psychometricians, and clinicians. Exploring cost-effectiveness in the context of societal decision-making for resource allocation purposes, this volume proposes that analysts include a "reference-case" analysis in all CEAs designed to inform resource allocation and puts forth the most explicit set of guidelines (together with their rationale) ever defined on the conduct of CEAs. Important theoretical and practical issues encountered in measuring costs and effectiveness, evaluating outcomes, discounting, and dealing with uncertainty are examined in separate chapters. Additional chapters on framing and reporting of CEAs elucidate the purpose of the analysis and the effective communication of its findings. Cost-Effectiveness in Health and Medicine differs from the available literature in several key aspects. Most importantly, it represents a consensus on standard methods--a feature integral to a CEA, whose principal goal is to permit comparisons of the costs and health outcomes of alternative ways of improving health. The detailed level at which the discussion is offered is another major distinction of this book, since guidelines in journal literature and in CEA-related books tend to be rather general--to the extent that the analyst is left with little guidance on specific matters. The focused overview of the theoretical background underlying areas of controversy and of methodological alternatives, and, finally, the accessible writing style make this volume a top choice on the reading lists of analysts in medicine and public health who wish to improve practice and comparability of CEAs. The book will also appeal to decision-makers in government, managed care, and industry who wish to consider the uses and limitations of CEAs.
Introductory Chapter: Dedicated Initial Giants Breaking the Barriers to Successful Cardiac Transplantation Therapy.
Heart failure affects over 5 million patients in the United States alone, and is a chronic and debilitating disease. While a number of pharmacologic therapies have shown varying degrees of effectiveness, many recent advances in the treatment of heart failure has focused on device based therapies. In Device Therapy in Heart Failure, William H. Maisel and a panel of authorities on the use and implementation of device based therapies provide a comprehensive overview of the current and developing technologies that are used to treat heart failure. Individual chapters provide an in-depth analysis of devices such as CRT’s and ICD’s, while broader topics such as the pathophysiology of heart failure and its current medical therapies are also discussed. Additional topics include Pacing and Defibrillation for Atrial Arrhythmias, Atrial Fibrillation Ablation, and Percutaneous Treatment of Coronary Artery Disease.
The 19 chapters which comprise this text cover all aspects of heart failure, and are extremely readable and well-organized. The references selected for each chapter are highly sufficient and there is excellent coverage of all the pharmaceutical treatments, which have proven effective in the management of heart failure; moreover, there are chapters on the non-pharmacological management as well. The book instructs the physician in how to use the newer drugs, either singly or in combination and the clinical trials chapter gives the reader a balanced view of what is happening in research.