Gated heart pool scan measuring left ventricular ejection fraction (LVEF) was performed preoperatively in 72 patients presenting for elective repair of abdominal aortic aneurysm. Patients with a positive cardiac history were more likely to have a LVEF of less than or equal to 45 per cent (P less than 0.001). The operative mortality rate was 4 per cent. Each of three patients who died had a LVEF less than or equal to 35 per cent and developed cardiac failure which led to renal failure. Five other patients developed cardiac failure manifested by acute pulmonary oedema during the early postoperative period. There was no statistically significant association between a positive cardiac history and the occurrence of postoperative cardiac failure or death. However, patients with a LVEF of less than or equal to 45 per cent were more likely to develop postoperative cardiac failure (P = 0.004) while patients with a LVEF of less than or equal to 35 per cent had a greater chance of dying (P less than 0.001). No patient died with a LVEF greater than 35 per cent. Preoperative evaluation of LVEF can select patients at high risk of cardiac death from repair of abdominal aortic aneurysm. Such patients could be followed conservatively if they remain asymptomatic and the aneurysm does not enlarge. If operation is considered mandatory, patients with a low LVEF should receive intensive perioperative monitoring with enhancement of ventricular performance.
One hundred and thirty‐one patients undergoing 142 carotid endarterectomy procedures were randomized to have their operation performed either with or without intra‐operative electroencephalographic (EEG) monitoring. Patients with EEG monitoring were shunted if both the internal carotid back pressure (ICBP) was less than 50 mmHg and ipsilateral change was evident on the EEG after clamping. Patients without EEG monitoring were shunted if ICBP was less than 50 mmHg. There was one postoperative death (0.7%) with neurological deficits occurring in five patients (3.5%). There were significantly fewer neurological deficits (P = 0.02) in patients with no EEG change (one of 59) compared with those with EEG change (two of 13). There was a highly significant increase (P = 0.005) in incidence of neurological deficit (two of five patients) when ICBP was considered ‘adequate’ at 50 mmHg or greater but EEG change occurred. No neurological deficit occurred in 14 patients who were not shunted with ICBP < 50 mmHg but with no EEG change. There was no difference in the incidence of neurological deficit in patients with low and high ICBP when both 50 and 55 mmHg were used as the cut‐off points. It is concluded that EEG monitoring is useful in identifying patients requiring shunting during carotid endarterectomy. Use of a shunt is recommended if there is EEG change regardless of ICBP; conversely, if ICBP is low but there is no EEG change it would appear safe to proceed without shunting.
Venous ultrasound imaging was compared with ascending contrast venography for the diagnosis of suspected deep vein thrombosis (DVT) in the femoral, popliteal and calf vein segments of 44 limbs in 44 patients. One femoral and one calf vein segment could not be imaged (1.5% of the segments examined), but during the same period venography failed in six patients because of an inability to cannulate a swollen limb. Ultrasound imaging compared with venography as a means of diagnosing DVT showed an overall sensitivity of 95% and a specificity of 92%. The sensitivity and specificity of ultrasound imaging for the diagnosis of both femoral and popliteal vein thromboses were 100% and 97%, respectively, and for calf vein thrombosis were 85% and 83%, respectively. This study supports the recommendation that ultrasound imaging is now the investigation of choice for the diagnosis of DVT provided that the scan is performed by an experienced vascular technologist. Ultrasound imaging may also define other pathological conditions presenting in the differential diagnosis of DVT, such as superficial thrombophlebitis and Baker's cyst.
Objectives:The aim of this study was to describe patient level costing methods and develop a database of healthcare resource use and cost in patients with AHF receiving ventricular assist device (VAD) therapy.Methods:Patient level micro-costing was used to identify documented activity in the years preceding and following VAD implantation, and preceding heart transplant for a cohort of seventy-seven consecutive patients listed for heart transplantation (2009–12). Clinician interviews verified activity, established time resource required for each activity, and added additional undocumented activities. Costs were sourced from the general ledger, salary, stock price, pharmacy formulary data, and from national medical benefits and prostheses lists. Linked administrative data analyses of activity external to the implanting institution, used National Weighted Activity Units (NWAU), 2014 efficient price, and admission complexity cost weights and were compared with micro-costed data for the implanting admission.Results:The database produced includes patient level activity and costs associated with the seventy-seven patients across thirteen resource areas including hospital activity external to the implanting center. The median cost of the implanting admission using linked administrative data was $246,839 (interquartile range [IQR] $246,839–$271,743), versus $270,716 (IQR $211,740–$378,482) for the institutional micro-costing (p = .08).Conclusions:Linked administrative data provides a useful alternative for imputing costs external to the implanting center, and combined with institutional data can illuminate both the pathways to transplant referral and the hospital activity generated by patients experiencing the terminal phases of heart failure in the year before transplant, cf-VAD implant, or death.
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