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Posts Tagged ‘Antiarrhythmic drugs’

The Cost to Value Conundrum in Cardiovascular Healthcare Provision


The Cost to Value Conundrum in Cardiovascular Healthcare Provision

Author: Larry H. Bernstein, MD, FCAP

I write this introduction to Volume 2 of the e-series on Cardiovascular Diseases, which curates the basic structure and physiology of the heart, the vasculature, and related structures, e.g., the kidney, with respect to:

1. Pathogenesis
2. Diagnosis
3. Treatment

Curation is an introductory portion to Volume Two, which is necessary to introduce the methodological design used to create the following articles. More needs not to be discussed about the methodology, which will become clear, if only that the content curated is changing based on success or failure of both diagnostic and treatment technology availability, as well as the systems needed to support the ongoing advances.  Curation requires:

  • meaningful selection,
  • enrichment, and
  • sharing combining sources and
  • creation of new synnthesis

Curators have to create a new perspective or idea on top of the existing media which supports the content in the original. The curator has to select from the myriad upon myriad options available, to re-share and critically view the work. A search can be overwhelming in size of the output, but the curator has to successfully pluck the best material straight out of that noise.

Part 1 is a highly important treatment that is not technological, but about the system now outdated to support our healthcare system, the most technolog-ically advanced in the world, with major problems in the availability of care related to economic disparities.  It is not about technology, per se, but about how we allocate healthcare resources, about individuals’ roles in a not full list of lifestyle maintenance options for self-care, and about the important advances emerging out of the Affordable Care Act (ACA), impacting enormously on Medicaid, which depends on state-level acceptance, on community hospital, ambulatory, and home-care or hospice restructuring, which includes the reduction of management overhead by the formation of regional healthcare alliances, the incorporation of physicians into hospital-based practices (with the hospital collecting and distributing the Part B reimbursement to the physician, with “performance-based” targets for privileges and payment – essential to the success of an Accountable Care Organization (AC)).  One problem that ACA has definitively address is the elimination of the exclusion of patients based on preconditions.  One problem that has been left unresolved is the continuing existence of private policies that meet financial capabilities of the contract to provide, but which provide little value to the “purchaser” of care.  This is a holdout that persists in for-profit managed care as an option.  A physician response to the new system of care, largely fostered by a refusal to accept Medicaid, is the formation of direct physician-patient contracted care without an intermediary.

In this respect, the problem is not simple, but is resolvable.  A proposal for improved economic stability has been prepared by Edward Ingram. A concern for American families and businesses is substantially addressed in a macroeconomic design concept, so that financial services like housing, government, and business finance, savings and pensions, boosting confidence at every level giving everyone a better chance of success in planning their personal savings and lifetime and business finances.

http://macro-economic-design.blogspot.com/p/book.html

Part 2 is a collection of scientific articles on the current advances in cardiac care by the best trained physicians the world has known, with mastery of the most advanced vascular instrumentation for medical or surgical interventions, the latest diagnostic ultrasound and imaging tools that are becoming outdated before the useful lifetime of the capital investment has been completed.  If we tie together Part 1 and Part 2, there is ample room for considering  clinical outcomes based on individual and organizational factors for best performance. This can really only be realized with considerable improvement in information infrastructure, which has miles to go.  Why should this be?  Because for generations of IT support systems, they are historically focused on billing and have made insignificant inroads into the front-end needs of the clinical staff.

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Percutaneous Endocardial Ablation of Scar-Related Ventricular Tachycardia

Reporter: Aviva Lev-Ari, PhD, RN

UPDATED on 11/15/2013

Atrial Fibrillation Catheter Ablation Versus Surgical Ablation Treatment (FAST)

A 2-Center Randomized Clinical Trial

  1. Lucas V.A. Boersma, MD, PhD, FESC;
  2. Manuel Castella, MD, PhD;
  3. WimJan van Boven, MD;
  4. Antonio Berruezo, MD;
  5. Alaaddin Yilmaz, MD;
  6. Mercedes Nadal, MD;
  7. Elena Sandoval, MD;
  8. Naiara Calvo, MD;
  9. Josep Brugada, MD, PhD, FESC;
  10. Johannes Kelder, MD;
  11. Maurits Wijffels, MD, PhD;
  12. Lluís Mont, MD, PhD, FESC

+Author Affiliations


  1. From the Departments of Cardiology (L.V.A.B., J.K., M.W.) and Cardiothoracic Surgery (W.J.v.B., A.Y.), St. Antonius Hospital, Nieuwegein, the Netherlands, and Thorax Institute, Hospital Clinic, University of Barcelona, Barcelona, Catalonia, Spain (M.C., A.B., M.N., E.S., N.C., J.B., L.M.).
  1. Correspondence to Lucas V.A. Boersma, MD, PhD, FESC, Cardiology Department, St. Antonius Hospital, PO 2500, Nieuwegein, Netherlands. E-maill.boersma@antoniusziekenhuis.nl

Abstract

Background—Catheter ablation (CA) and minimally invasive surgical ablation (SA) have become accepted therapy for antiarrhythmic drug–refractory atrial fibrillation. This study describes the first randomized clinical trial comparing their efficacy and safety during a 12-month follow-up.

Methods and Results—One hundred twenty-four patients with antiarrhythmic drug–refractory atrial fibrillation with left atrial dilatation and hypertension (42 patients, 33%) or failed prior CA (82 patients, 67%) were randomized to CA (63 patients) or SA (61 patients). CA consisted of linear antral pulmonary vein isolation and optional additional lines. SA consisted of bipolar radiofrequency isolation of the bilateral pulmonary vein, ganglionated plexi ablation, and left atrial appendage excision with optional additional lines. Follow-up at 6 and 12 months was performed by ECG and 7-day Holter recording. The primary end point, freedom from left atrial arrhythmia >30 seconds without antiarrhythmic drugs after 12 months, was 36.5% for CA and 65.6% for SA (P=0.0022). There was no difference in effect for subgroups, which was consistent at both sites. The primary safety end point of significant adverse events during the 12-month follow-up was significantly higher for SA than for CA (n=21 [34.4%] versus n=10 [15.9%]; P=0.027), driven mainly by procedural complications such as pneumothorax, major bleeding, and the need for pacemaker. In the CA group, 1 patient died at 1 month of subarachnoid hemorrhage.

Conclusion—In atrial fibrillation patients with dilated left atrium and hypertension or failed prior atrial fibrillation CA, SA is superior to CA in achieving freedom from left atrial arrhythmias after 12 months of follow-up, although the procedural adverse event rate is significantly higher for SA than for CA.

Clinical Trial Registration—URL: http://clinicaltrials.gov. Unique identifier:NCT00662701.

Key Words:

SOURCE

http://circ.ahajournals.org/content/125/1/23.short

 A single-center experience of clinical and electrophysiologic outcomes of patients undergoing percutaneous endocardial ablation of scar-related Ventricular Tachycardia (VT) is reported in

IMAJ Isr Med Assoc J 2010; 12: 667-670.

http://www.ima.org.il/imaj/ar10nov-04.pdf

 Catheter ablation can control or prevent recurrent ischemic VT and reduce incidence of implantable cardioverter defibrillator (ICD) therapy. The ablation can be done during VT in patients with stable VTs or during sinus rhythm in patients with unstable unmappable VTs by targeting the scar border using electroanatomic substrate mapping. VT ablation should be offered to ischemic patients with recurrent uncontrolled VT. Radiofrequency ablation of VT in patients with ischemic cardiomyopathy was proposed to treat and control recurrent VT

J Cardiovasc Electrophys 2005; 16(Suppl 1): S59-70.

Curr Opin Cardiol 2005; 20: 42-7.

An experience with VT ablation in patients with ischemic cardiomyopathy using the electroanatomic mapping system (CARTO) was presented in

Circulation 1997; 95: 1611-22

There are several reasons for the limited success of ischemic VT ablation. Ventricular scars are not electrically homogenous. They are composed of variable regions of dense fibrosis that create conduction block and surviving myocyte bundles with interstitial fibrosis and diminished coupling, which produce circuitous slow conduction paths that promote reentry

Circulation 1993; 88: 915-26.

Repeated programmed stimulation typically induces more than one monomorphic VT. Multiple VTs can be due to different circuits in widely disparate areas of scar, different axis from the same region of the scar, or changes in activation remote from the circuit due to functional regions of block

Circulation 2007; 115: 2750-60.

Catheter ablation using conventional techniques are suitable for stable VT. VT reentry circuit can be defined using electroanatomic mapping (CARTO) only during stable and tolerable tachycardia. However, many patients with reduced ejection fraction secondary to coronary heart disease have unstable VTs. These patients do not tolerate sustained VT or rapid pacing. Thus, electric or pace mapping is not available in most cases (unmappable VT with catheter technique). In these cases, scar mapping and ablation can be done only during sinus rhythm using the CARTO system

IMAJ Isr Med Assoc J 2007; 9: 260-4.

Radiofrequency catheter ablation of ventricular tachycardia in the setting of ischemic cardiomyopathy has emerged recently as a useful adjunctive therapy to ICD. Scar related reentrant ventricular tachycardia is the most common underlying mechanism of sustained monomorphic VT in patients with ischemic heart disease.

Limitations of Alternative Treatment Methods:

1.            Recurrent ICD shocks have had physiological and psychological side effects.

2.            Antiarrythmic drugs are used to reduce incidence of ICD therapy, but their role in reducing mortality is not proven. In addition, these drugs have important side effects including pro-arrythmic effect and worsening of heart failure status.

Conclusions: Ablation of ischemic VT using electroanatomic scar mapping is feasible, has an acceptable success rate and should be offered for ischemic patients with recurrent uncontrolled VT.

REFERENCES

1. Marchlinski F, Garcia F, Siadatan A, et al. Ventricular tachycardia/ventricular

fibrillation ablation in the setting of ischemic heart disease. J Cardiovasc

Electrophys 2005; 16(Suppl 1): S59-70.

2. Stevenson WG. Catheter ablation of monomorphic ventricular tachycardia.

Curr Opin Cardiol 2005; 20: 42-7.

3. Gepstein L, Hayam G, Ben-Haim SA. A novel method for nonfluoroscopic

catheter-based electroanatomical mapping of the heart. In vitro and in vivo

accuracy results Circulation 1997; 95: 1611-22.

4. Gepstein L, Evans SJ. Electroanatomical mapping of the heart: basic concepts

and implications for the treatment of cardiac arrhythmias Pacing Clin

Electrophysiology 1998; 21: 1268-78.

5. Stevenson WG, Soejima K. Catheter ablation for ventricular tachycardia.

Circulation 2007; 115: 2750-60.

6. Marchlinski FE, Callans DJ, Gottlieb CD, Zado E. Linear ablation lesions for

control of unmappable ventricular tachycardia in patients with ischemic and

nonischemic cardiomyopathy. Circulation 2000; 101: 1288-96.

7. Khan HH, Maisel WH, Ho C, et al. Effect of radiofrequency catheter ablation

of ventricular tachycardia on left ventricular function in patients with prior

myocardial infarction. J Interv Card Electrophysiol 2002; 7: 243-7.

8. Stevenson WG, Wilber DJ, Natale A, et al; for the Multicenter Thermocool

VT Ablation Trial Investigators. Irrigated radiofrequency catheter ablation

guided by electroanatomic mapping for recurrent ventricular tachycardia

after myocardial infarction. The Multicenter Thermocool Ventricular

Tachycardia Ablation Trial. Circulation 2008; 118: 2773-82.

9. Reddy VY, Reynolds MR, Neuzil P, et al. Prophylactic catheter ablation for

the prevention of defibrillator therapy. N Engl J Med 2007; 357: 2657-65.

10. Szumowski L, Sanders P, Walczak F, et al. Mapping and ablation of

polymorphic ventricular tachycardia after myocardial infarction. J Am Coll

Cardiol 2004; 44: 1700-6.

11. Stevenson WG, Delacretaz E. Radiofrequency catheter ablation of ventricular

tachycardia. Heart 2000; 84: 553-9.

12. de Bakker JM, van Capelle FJ, Janse MJ, et al. Slow conduction in the infarcted

human heart. ‘Zigzag’ course of activation. Circulation 1993; 88: 915-26.

13. Suleiman M, Gepstein L, Roguin A, et al. Catheter ablation of cardiac

arrhythmias guided by electroanatomic imaging (CARTO): a single-center

experience. IMAJ Isr Med Assoc J 2007; 9: 260-4.

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