Creating a useful vascular center: a statewide survey of what primary care physicians really want

AbstractObjectiveMultidisciplinary vascular centers (VCs) have been proposed to integrate vascular patient care. No studies, however, have assessed referring physician interest or which services should be provided. A statewide survey of primary care physicians (PCPs) was performed to answer these questions.MethodsQuestionnaires were mailed to 3711 PCPs, asking about familiarity with vascular disease, potential VC usage, and services VCs should provide. Univariate and multivariate analysis was used to determine which PCPs would refer patients, the services desired, and which patients would be referred.ResultsOf 1006 PCPs who responded, 66% would refer patients to a VC, especially patients younger than 50 years (P < .001) and those with lower extremity disease (P < .001) or abdominal aortic aneurysm (P < .001). PCPs practicing within 50 miles of a VC (P < .001), those in practice less than 5 years (P < .001), and those without specific training in vascular disease during residency (P = .004) were most likely to refer patients. Vascular surgery (97%), interventional radiology (90%), and a noninvasive vascular laboratory (82%) were considered the most important services, and physician educational services (62%) were also desirable. PCPs did not think cardiology, cardiac surgery, smoking cessation programs, or diabetes or lipid management are needed. Reasons for VC nonuse included travel distance (23%), sufficient local services (21%), and insurance issues (12%). Only 16% of PCPs believe that their patients with vascular disease currently receive optimal care.ConclusionThere is considerable interest in VCs among PCPs. In contrast to recently described models, VCs need not incorporate cardiology, cardiac surgery, smoking cessation programs, or diabetes or lipid management. VCs should include vascular surgery, interventional radiology, a noninvasive vascular laboratory, and physician educational services

Haematological and infectious complications associated with the treatment of patients with congenital cardiac disease: consensus definitions from the Multi-Societal Database Committee for Pediatric and Congenital Heart Disease

A complication is an event or occurrence that is associated with a disease or a healthcare intervention, is a departure from the desired course of events, and may cause, or be associated with, suboptimal outcome. A complication does not necessarily represent a breech in the standard of care that constitutes medical negligence or medical malpractice. An operative or procedural complication is any complication, regardless of cause, occurring (1) within 30 days after surgery or intervention in or out of the hospital, or (2) after 30 days during the same hospitalization subsequent to the operation or intervention. Operative and procedural complications include both intraoperative/intraprocedural complications and postoperative/postprocedural complications in this time interval. The MultiSocietal Database Committee for Pediatric and Congenital Heart Disease has set forth a comprehensive list of complications associated with the treatment of patients with congenital cardiac disease, related to cardiac, pulmonary, renal, haematological, infectious, neurological, gastrointestinal, and endocrinal systems, as well as those related to the management of anaesthesia and perfusion, and the transplantation of thoracic organs. The objective of this manuscript is to examine the definitions of operative morbidity as they relate specifically to the haematological system and to infectious complications. These specific definitions and terms will be used to track morbidity associated with surgical and transcatheter interventions and other forms of therapy in a common language across many separate databases. The MultiSocietal Database Committee for Pediatric and Congenital Heart Disease has prepared and defined a near-exhaustive list of haematological and infectious complications. Within each subgroup, complications are presented in alphabetical order. Clinicians caring for patients with congenital cardiac disease will be able to use this list for databases, quality improvement initiatives, reporting of complications, and comparing strategies for treatmen

Human fitting of pediatric and infant continuous-flow total artificial heart: visual and virtual assessment

BackgroundThis study aimed to determine the fit of two small-sized (pediatric and infant) continuous-flow total artificial heart pumps (CFTAHs) in congenital heart surgery patients.MethodsThis study was approved by Cleveland Clinic Institutional Review Board. Pediatric cardiac surgery patients (n = 40) were evaluated for anatomical and virtual device fitting (3D-printed models of pediatric [P-CFTAH] and infant [I-CFTAH] models). The virtual sub-study consisted of analysis of preoperative thoracic radiographs and computed tomography (n = 3; 4.2, 5.3, and 10.2 kg) imaging data.ResultsP-CFTAH pump fit in 21 out of 40 patients (fit group, 52.5%) but did not fit in 19 patients (non-fit group, 47.5%). I-CFTAH pump fit all of the 33 patients evaluated. There were critical differences due to dimensional variation (p &lt; 0.0001) for the P-CFTAH, such as body weight (BW), height (Ht), and body surface area (BSA). The cutoff values were: BW: 5.71 kg, Ht: 59.0 cm, BSA: 0.31 m2. These cutoff values were additionally confirmed to be optimal by CT imaging.ConclusionsThis study demonstrated the range of proper fit for the P-CFTAH and I-CFTAH in congenital heart disease patients. These data suggest the feasibility of both devices for fit in the small-patient population

Long-term functional health status and exercise test variables for patients with pulmonary atresia with intact ventricular septum: A Congenital Heart Surgeons Society study

Background: A bias favoring biventricular (BV) repair exists regarding choice of repair pathway for patients with pulmonary atresia with intact ventricular septum (PAIVS). We sought to determine the implications of moving borderline candidates down a BV route in terms of late functional health status (FHS) and exercise capacity (EC). Methods: Between 1987 and 1997, 448 neonates with PAIVS were enrolled in a multi-institutional study. Late EC and FHS were assessed following repair (mean 14 years) using standardized exercise testing and 3 validated FHS instruments. Relationships between FHS, EC, morphology, and 3 end states (ie, BV, univentricular [UV], or 1.5-ventricle repair [1.5V]) were evaluated. Results: One hundred two of 271 end state survivors participated (63 BV, 25 UV, and 14 1.5V). Participants had lower FHS scores in domains of physical functioning (P<.001) compared with age- and sex-matched normal controls, but scored significantly higher in nearly all psychosocial domains. EC was higher in 1.5V-repair patients (P ¼ .02), whereas discrete FHS measures were higher in BV-repair patients. Peak oxygen consumption was low across all groups, and was positively correlated with larger initial tricuspid valve z-score (P<.001), with an enhanced effect within the BV-repair group. Conclusions: Late patient-perceived physical FHS and measured EC are reduced, regardless of PAIVS repair pathway, with an important dichotomy whereby patients with PAIVS believe they are doing well despite important physical impediments. For those with smaller initial tricuspid valve z-score, achievement of survival with BV repair may be at a cost of late deficits in exercise capacity, emphasizing that better outcomes may be achieved for borderline patients with a 1.5V- or UV-repair strategy. (J Thorac Cardiovasc Surg 2013;145:1018-27

Editorial: Extra-corporeal membrane oxygenation in pediatric cardiac patients

[First paragraph] Bartlett pioneered the use of Extra-Corporeal Membrane Oxygenation (ECMO) for prolonged cardio-respiratory support in critical patients in the 1970's (1), reporting on the first pediatric patient to survive: a young child with myocardial dysfunction after surgery for transposition of the great arteries (2). Early clinical successes led to increased use of ECMO to support children with respiratory and cardiac failure. ECMO was initially used for resuscitation after cardiac arrest in pediatric patients, and then as peri-operative stabilization for palliative and corrective procedures for congenital heart defects. Despite the recent advances in Ventricular Assist Device technology, ECMO remains the most commonly used system of mechanical circulatory and respiratory assistance in pediatric cardiac patients. The advantages of ECMO include: its familiarity among the caregivers involved with the management of pediatric patients with complex congenital heart defects, the capability of providing cardiac (bi-ventricular) and respiratory support, the availability across all pediatric age and body weight groups and the relatively low costs. Furthermore, ECMO is ideal suited for pediatric patients with a combination of cardiac and respiratory failure, frequently occurring after repair of complex congenital heart defects, and in cases of rapid deployment during a cardio-circulatory arrest. Disadvantages of ECMO include the need of a dedicated team of specialists, intensive care monitoring and the risk of major potential complications such as bleeding, thrombosis, infections and multi-organ failure. In this Research Topic several experts in the field report on the state of the art knowledge on the topic

Effects of Sociodemographic Factors on Access to and Outcomes in Congenital Heart Disease in the United States

Congenital heart defects (CHDs) are complex conditions affecting the heart and/or great vessels that are present at birth. These defects occur in approximately 9 in every 1000 live births. From diagnosis to intervention, care has dramatically improved over the last several decades. Patients with CHDs are now living well into adulthood. However, there are factors that have been associated with poor outcomes across the lifespan of these patients. These factors include sociodemographic and socioeconomic positions. This commentary examined the disparities and solutions within the evolution of CHD care in the United States

One size does not fit all: the influence of age at surgery on outcomes following Norwood operation.

BACKGROUND: Given our large catchment area that often results in later presentation age, we sought to understand our institutional outcomes for the Norwood operation in the context of published data. Specifically, we studied whether operative and late dea