Decreased right ventricular strain before LVAD implantation is associated with adverse early outcome

Objectives

Right ventricular (RV) failure occurring after left ventricular assist device (LVAD) implantation is associated with increased mortality.

Purpose

We sought to determine whether RV strain by echocardiography predicts outcomes following LVAD.

Methods

Consecutive patients who underwent continuous flow LVAD placement at our clinic between February 2007 and October 2018 were included. Patients with complex congenital heart disease and arrhythmogenic right ventricular cardiomyopathy were excluded. Baseline characteristics, pre-operative hemodynamic catheterization (1 week) transthoracic echocardiography (1 month) measurements were obtained from the medical record. Speckle tracking RV free wall longitudinal 2D strain was measured using TomTec Imaging System. Univariate and multivariable analysis performed to identify predictors of mortality following LVAD.

Results

The study group was comprised of 323 patients (mean age 60.8±11.5, 79.9% male) of which 256 had adequate image quality for RV strain. RV strain was impaired in most patients (mean −11.7±3.47). RV strain of −8.1% was identified as predictive of poor outcomes. RV strain did not correlate with other measures of RV dysfunction including pulmonary artery pulsatility index (PAPi) and RVFAC. After adjusting for PAPi, RA pressure, and clinical cumulative risk scores (Matthews, Kormos and Lietz-Miller) impaired RV free wall longitudinal strain (OR: 1.14; 95% CI: 1.01–1.29, p=0.025), tricuspid regurgitation (by vena contracta width (TRvc) (OR: 1.19; 95% CI: 1.05–1.36, p=:0.0021) and smaller LVEDD (OR: 0.95; 95% CI: 0.92–0.99, p:0.023) predicted 30-day all-cause mortality and RV failure. Decreased RV free wall strain also predicted peri-operative mortality (22.58% vs. 4.89%, p=0.0003) and prolonged inotropic support (247.0.±277.4 vs. 122.8±139.3, p=0.024).

Conclusions

RV free wall strain is a non-invasive independent predictor of 30-day adverse outcomes (RV failure or all-cause mortality) Routine measurement of RV free strain may identify those patients at highest risk for early and long term mortality following LVAD.

Funding Acknowledgement

Type of funding source: None

Braden scale: validity in community-based older adults receiving home health care

The purpose of this study was to examine the validity of the Braden Scale and optimal frequency of risk reassessment in older adults receiving home health care. Data were collected from the records of 1,711 nonhospice patients aged 60 years or older who did not have pressure ulcers at the beginning of home health care. Patient records were followed forward chronologically to one of two outcomes: pressure ulcer development or pressure ulcer absence (pressure ulcer free when home health services were no longer required, institutionalization, death, or end of study period). After commencement of home health care, 108 subjects developed a stage I-IV pressure ulcer (incidence = 6.3%). A Braden Scale cutoff score of 19 provided the best measure of sensitivity (61%) and specificity (68%). Findings suggest initial assessment of pressure ulcer risk for older adults should begin on entry into home health care, and they indicate the need for weekly reassessments for the first 4 weeks with every other week reassessments thereafter until day 62, dependent on patient condition and the frequency of home visits. Reassessment with each subsequent 62-day recertification period may be sufficient for patients remaining on the active caseload.

Pressure ulcers in community-based older adults receiving home health care. Prevalence, incidence, and associated risk factors

OBJECTIVES

To determine the prevalence and incidence of pressure ulcers in community-based adults receiving home health care and to identify risk factors for incident Stage II to IV pressure ulcers.

DESIGN

Retrospective cohort study.

SETTING

A large midwestern urban home health care agency.

PATIENTS

The study cohort was 1711 nonhospice, nonintravenous therapy subjects admitted between January 1995 and March 1996 who were > or = age 60 and pressure ulcer-free on admission.

MEASUREMENTS

Data on risk factors were extracted from admission information. Patient records were followed forward chronologically to the outcomes: pressure ulcer development or no pressure ulcer.

MAIN RESULTS

The incidence of Stage II to IV pressure ulcers was 3.2%. Cox regression analyses revealed that limitation in activity to a wheelchair, needing assistance with the activities of daily living--dressing, bowel and/or bladder incontinence, a Braden Scale mobility subscore of very limited, anemia, adult child as primary caregiver, male gender, a recent fracture, oxygen use, and skin drainage predicted pressure ulcer development (P < or = 0.05) in this exploratory model.

CONCLUSIONS

Patients > or = age 60 who are admitted to a home health care agency with 1 or more of these risk factors require close monitoring for pressure ulcer development and should be taught preventive interventions on admission.

The cost of healing pressure ulcers across multiple health care settings

The reported costs of treating pressure ulcers have varied widely from study to study. Previous studies have focused on single health care settings and computed only the costs occurring while the patient was a resident in that facility. The purpose of this study was to assess the cost of managing pressure ulcers from their initial occurrence in long-term care through their natural history, including hospital treatment of complications. The 30 patients in this year-long study developed 45 ulcers. The mean length of treatment for an ulcer was 116 days (SD = 127). The mean cost of treatment, including long-term care and hospital costs, was $2,731 per ulcer (SD = 12,184); excluding hospital costs, the mean cost of treatment was $489 per ulcer (SD = 629). The mean cost of treatment per patient was $4,647 (SD = 15,102); excluding hospital costs, the mean treatment cost was $1,284 per patient (SD = 1,380). Eighty percent of the total cost of pressure ulcer treatment was generated by the 4% of patients who required hospitalization for their pressure ulcers. In the absence of complications, pressure ulcers can be treated successfully and cost-effectively in long-term care.

Effect of chronic 5-lipoxygenase inhibition on airway hyperresponsiveness in asthmatic subjects

The leukotrienes are known bronchoactive agonists with potential proinflammatory effects that may be involved in mediating airway hyperresponsiveness. We investigated the effects of zileuton, an inhibitor of 5-lipoxygenase (5-LO), on airway responsiveness to cold, dry air in patients with moderate asthma. A group of 10 asthmatic patients underwent cold, dry air hyperventilation challenge; challenges were performed before drug treatment and 1 to 10 d after the completion of treatment with study drugs. The cold air minute ventilation required to cause a 15% decrease in FEV1 (PD15 VE) increased by 58% compared with the response before treatment, 1 to 10 d after the completion of 13 wk of treatment with zileuton. The geometric mean (geometric mean/SEM and geometric mean x SEM) PD15 VE increased from 24.5 (20.4, 29.5) L/min to 38.8 (34.7, 43.7) L/min (p = 0.01). Zileuton treatment inhibited 5-LO as measured ex vivo by ionophore-stimulated LTB4 levels in whole blood. In four of seven subjects, LTB4 levels before zileuton ingestion fell from 110.88 +/- 25.42 to 5.40 +/- 1.95 ng/ml 2 h post-zileuton dosing (p = 0.02, pre- versus 2 h postzileuton ingestion). Consistent with the short half-life of zileuton, 6 h postzileuton dosing the ionophore-stimulated, LTB4 levels in whole blood had increased to 89.68 +/- 35.54 ng/ml (p = 0.41, pre- versus 6 h postzileuton ingestion). Based on the first-order kinetics of zileuton, its effect on 5-LO activity should have been dissipated less than 16 h postingestion. Thus, chronic zileuton treatment decreased airway hyperresponsiveness as determined by reactivity to cold, dry air.(ABSTRACT TRUNCATED AT 250 WORDS)

Cost of pressure ulcer prevention in long-term care

OBJECTIVE

To describe the total cost of pressure ulcer prevention, component costs of each intervention, and the relationship of costs to subjects' risk level.

DESIGN

3-month cohort trial.

SETTING

A 600-bed, state-supported, long-term care facility.

PATIENTS

A total of 539 war veterans, 83% of whom were male; mean age was 73 years.

MAIN OUTCOME MEASURES

Cost to facility for using each of four preventive interventions: turning, pressure-reducing mattresses, chair cushions, miscellaneous preventive devices.

RESULTS

Sixty-eight percent of subjects received a preventive intervention. Total 3-month facility cost of prevention was $132,114, and 97% of the cost was consumed by 30% of the subjects. Turning was the most expensive component, accounting for $99,567. The daily cost of turning for subjects who received it was $8.83 +/- 1.66. Cost increased with subject risk level. Low cost devices were instituted for lower risk subjects, whereas high cost interventions (turning) were reserved for the highest risk subjects.

CONCLUSIONS

This long-term care facility expended substantial resources on prevention, and most resources (97%) were expended on less than half (30%) of subjects. Turning was, by far, the most expensive intervention, and the nursing staff reserved it for highest risk subjects. Strategies that substitute moderately priced mattresses for frequent turning may decrease the cost of prevention, as long as mattress cost is less than the daily turning costs it replaces. Future research to define the optimum combinations of preventive interventions for patients of various risk levels is needed.

The effects of prolonged pressure on skin blood flow in elderly patients at risk for pressure ulcers

Although the physiological effects of pressure on tissue have been demonstrated in the animal model, little is known about its effect in ill, elderly patients who are at risk for pressure ulcers. This study describes the pattern of dermal blood flow during a period of constant, low-level, compressive pressure in this population of patients. Dermal blood flow was measured over the trochanter of 16 elderly (> 60 years) subjects who were defined as at risk for pressure ulcer development by the Braden Scale for Predicting Pressure Ulcer Risk. Using a laser-Doppler velocitometer, blood flow at baseline and during 60 minutes of left-side lying on an air mattress were measured. Mean blood flow at baseline was 0.79 (SD 0.43). Following 60 minutes of compressive pressure, mean blood flow was 0.65 (SD 0.87). Blood flow tracings during the 60-minute period of continuous, compressive pressure revealed an inconsistent pattern of response; the flow increased, decreased, or showed no change. This distribution of responses suggests that significantly more variability in blood flow response exist in at-risk individuals than was previously believed.

Use of crystalline hemoglobin as replacement of RBC mass

Replacement of a circulatory RBC mass was performed isovolemically in experimental dogs using either 7% crystalline hemoglobin solution with a low P50 (the oxygen tension necessary to produce 50% saturation of hemoglobin at pH 7.4 and 37 degrees C) or with an albumin solution. Progressive RBC depletion caused increased cardiac output in both groups. Oxygen delivery was better preserved after using the crystalline hemoglobin solution, and, under conditions of extreme anemia, oxygen transport using this solution enabled dogs to survive the otherwise lethal insult. Although administration of crystalline hemoglobin preserved oxygen transport, oxygen off-loading was at a lower tension because of the lower P50. Decreased mixed venous oxygen tension, which presumably reflects lower tissue oxygen tension, was associated with systemic vasoconstriction. The administration of oxygen-carrying solutions with low P50 values results in a relatively vasoconstricted state. This vascular response is mediated by changes in tissue oxygen tension, rather than by impaired tissue oxygen consumption.