Contemporary outcomes of continuous-flow biventricular assist devices.

BACKGROUND: Significant right ventricular failure (RVF) complicating left ventricular assist device (LVAD) placement has been reported at 10–30%. Although primarily indicated for left ventricular failure, ventricular assist devices (VADs) have become utilized in a biventricular setup to combat right ventricular failure (RVF) following LVAD implantation. With the advent of continuous-flow LVADs (CF-LVADs) superseding their pulsatile predecessors, the shift towards CF-biventricular assist devices (CF-BiVADs) come with the prospect of improved outcomes over previous pulsatile BiVADs. We aim to review the literature and determine the outcomes of CF-BiVAD recipients. METHODS: A systematic review was performed to determine the outcomes of CF-BiVADs. Pre-operative demographics and device configuration data was collected. Primary outcomes evaluated were short-term survival, long-term survival, duration of support, and survival to transplant. Secondary outcomes evaluated included intensive care unit (ICU) and hospital length of stay (ICU-LOS and HLOS, respectively), pump thrombosis, pump exchange. Median and interquartile range was reported where appropriate. A major limitation was the likely overlap of cohorts across publications, which may have contributed to some selection bias. RESULTS: Of 1,282 screened, 12 publications were evaluated. Sample size ranged from 4 to 93 CF-BiVAD recipients, and follow-up ranged from 6 to 24 months. Mean age ranged from 34 to 52 years old. Forty-five percent of CF-BiVADs had right atrial (RA-) inflow cannulation, with the remaining being right ventricular (RV). Thirty-day survival was a median of 90% (IQR 82–97.8%) and 12-month survival was a median of 58.5% (IQR 47.5–62%). Where reported, rate of pump thrombosis (predominantly the right VAD) was a median of 31% (IQR 14–36%), although pump exchange was only 9% (IQR 1.5–12.5%). CONCLUSIONS: RVF post-LVAD implantation is a high morbidity and mortality complication. There is no on-label continuous-flow RVAD currently available. Thus, the modifications of LVADs for right ventricular support to combat pump thrombosis has resulted in various techniques. BiVAD recipients are predominantly transplant candidates, and complications of pump thrombosis and driveline infection whilst on wait-list are of great consequence. This study demonstrates the need for an on-label CF-BiVAD

Marine spatial planning: risk or opportunity for fisheries in the North Sea?

The North Sea is one of the busiest marine areas in the world. It is also a major fisheries ground. Bordered by seven countries with their own spatial uses and claims, the stage is set for complex and demanding governance challenges. Recent decades have also seen user groups multiply, competition for space and resources increase, and the pressure on the marine environment and its living natural resources grow. As governments strive to balance conservation and economic development needs, they also have to deal with inter-as well as intra-national user conflicts. Marine Spatial Planning (MSP) has arrived as a new approach to these issues. It is argued that for North Sea fishing people and their communities MSP holds risks as well as opportunities, depending on which institutions are formed and what role they are allowed to play in the planning process

Taking It to the Extreme:The Effect of Coalition Cabinets on Foreign Policy

Institutional constraints have been offered by some scholars as an explanation for why multiparty coalitions should be more peaceful than single-party cabinets. Yet others see the same institutional setting as a prescription for more aggressive behavior. Recent research has investigated these conflicting expectations, but with mixed results. We examine the theoretical bases for these alternative expectations about the effects of coalition politics on foreign policy. We find that previous research is limited theoretically by confounding institutional effects with policy positions, and empirically by analyzing only international conflict data. We address these limitations by examining cases of foreign policy behavior using the World Event/Interaction Survey (WEIS) dataset. Consistent with our observation that institutional constraints have been confounded with policy positions, we find that coalitions are neither more aggressive nor more peaceful, but do engage in more extreme foreign policy behaviors. These findings are discussed with regard to various perspectives on the role of institutions in shaping foreign policy behavior.</p