Cardiovascular Systems (United States)

Evidence-based Standards for Psychosocial Care for Children with Cancer and their Families were published in 2015. Determining how often care delivery practices and approaches align with the Standards is important for understanding the reach of the Standards. Medical (n = 73) and psychosocial (n = 99) providers from 129 of 197 (65%) Children's Oncology Group (COG) programs in the United States completed an online survey. Participants reported the frequency, timing, and psychosocial care delivery approaches for each Standard. Program size was considered, and the data were compared with those from a similar 2016 survey. Using a 5-point scale, services consistent with the Standards are provided across programs-mean frequencies of 3.29-4.61 (5-point scale). Standards related to screening and monitoring (M = 4.42) are delivered more often than Standards related to intervention and support (M = 4.25), supportive care and bereavement (M = 3.88), and family and community (M = 3.72) (p < 0.001). Ratings of quality of care are near the midpoint of the scale. Findings are consistent with a 2016 report, although care related to family and community support was less frequent in 2023. Program size and provider discipline were not associated with quality or frequency. Providers report that psychosocial care aligned with the Standards is generally provided and perceive quality of care positively. Variability in types of care, frequency, and quality, and lack of change from when the Standards were first published, highlight the importance of improving the implementation of evidence-based approaches.

O tecido adiposo marrom (TAM) per¬manece ativo em adultos, oxidando ácidos graxos e liberando energia na forma de calor. Adipócitos marrons e termogênese aumen¬tada são alvos para o tratamento da obesi¬dade e suas comorbidades. O TAM apre¬senta grande atividade de síntese e secreta várias moléculas sinalizadoras de funciona¬mento autócrino, parácrino e endócrino, chamadas coletivamente de “batocinas” ou adipocinas do TAM. As batocinas atuam na homeostase do sistema cardiovascular, sis¬tema nervoso central, tecido adiposo bran¬co, fígado e músculo esquelético e exercem efeitos benéficos sobre o TAM. Além disso, ressalta-se a crescente importância das ba-tocinas denominadas Fator de Crescimento de Fibroblastos-21 (FGF21), Fator de Cres-cimento Endotelial Vascular A (VEGF-A), Proteína Morfogenética Óssea 8 (BMP8), Neuregulina 4 (NRG-4) e Miostatina. A função sistêmica das batocinas confere ao TAM um perfil de órgão endócrino. O melhor conhecimento das batocinas e seus efeitos em diferentes tecidos-alvo permite imaginar novos alvos terapêuticos para o tratamento da obesidade e suas comorbida¬des e doenças do músculo esquelético.

ObjectiveTo evaluate the safety and efficacy of percutaneous left atrial appendage occlusion (LAAO) using conscious sedation (CS).BackgroundSeveral percutaneous structural heart disease interventions are safely and efficiently performed using CS instead of general anaesthesia (GA). This concept has not been evaluated in a large multicenter cohort of patients undergoing LAAO.MethodsPatients from the prospective, global Amplatzer Amulet Occluder Observational Study were divided into two groups (GA vs CS). Baseline information, periprocedural and postprocedural efficacy and complications, as well as outcomes through 7 days post implant were compared.ResultsPatients undergoing transesophageal-guided implants were categorised by GA (n=607, 64%) or CS (n=342, 36%) usage. Mean age was 75 years in both groups. LAAO technical success was achieved in 99% of both groups. The procedure duration (GA: 35±22 min vs CS: 27±19 min, p<0.001), total amount of contrast medium (GA: 105±81 mL vs CS: 86±66 mL, p<0.001) and fluoroscopic time (GA: 13±9 min vs CS: 12±13 min, p<0.001) were less in CS cases. Procedure-related or device-related serious adverse events during the first 7 days were numerically higher in the CS group (GA: 4.9% vs CS: 7.6%, p=0.114). Peridevice residual flow was absent or ≤5 mm 1–3 months after the procedure in 99.7% of the GA and in 100% of the CS group (p=1.000).ConclusionsIn a large global study, LAAO with the Amplatzer Amulet occluder is safe and feasible using CS. Procedure duration and total amount of contrast were less with CS than GA cases.Trial registration numberNCT02447081; Results.

Over the past two decades, left ventricular assist device (LVAD) support has emerged as standard therapy for adult patients with advanced, life-threatening heart failure. First-generation pulsatile devices have been replaced by rotary blood pumps that continuously unload the failing left ventricle. So-called continuous-flow LVADs (CF-LVADs) are smaller, more reliable, durable, and energy efficient, and less traumatic to implant than first-generation devices. Survival of 80% at one year and 70% at two years has been widely achieved (1). However, CF-LVADs have introduced a new, non-pulsatile physiology in which blood encounters supraphysiologic shear stress, and as a result, unforeseen consequences have emerged. CF-LVADs operate with an impeller that spins at thousands of revolutions per minute (RPM) to generate forward flow. Within current-generation devices, blood passes through narrow flow gaps (50 to 500 µm) at high velocity. Consequently, blood encounters shear stress that exceeds physiologic values by more than two orders of magnitude. Indeed, current-generation LVADs generate peak shear stress of up to 1,500 Pa (2). For reference, physiologic levels of intravascular shear stress in mammals are approximately two to eight Pa (2). Irrefutable evidence demonstrates that supraphysiologic shear stress from CF-LVADs causes blood trauma that contributes to adverse events. Pathologic degradation of von Willebrand factor (VWF) leads to an acquired bleeding diathesis, gastrointestinal angiodysplasia, and gastrointestinal bleeding in 20% to 40% of LVAD patients (3,4). Platelet activation and (at least subclinical) hemolysis cause a procoagulant state that contributes to LVAD thrombosis and thromboembolism (5). As a result, “LVAD hemocompatibility”, a term that characterizes the clinical impact of biophysical interactions and blood trauma at the blood-device interface, is gaining attention as a major area for improvement of future-generation LVADs. Lack of pulsatile blood flow has also raised concerns. Potential benefits of pulsatility include prevention of aortic valve thrombosis, leaflet fusion, de novo aortic insufficiency, favorable myocardial remodeling, avoidance of arterial stiffening, better end-organ function, reduced bleeding, and reduced stroke (6). Consequently, pulsation algorithms are being developed to generate pulsatility with CF-LVADs. Also problematic, CF-LVADs operate at fixed RPM, independent of patient physiology. These devices do not sense or adjust device parameters in response to dynamic changes in cardiac rate, rhythm, preload, afterload, intracardiac hemodynamics, or systemic metabolic demands. “Physiologic control”, a term used to describe automatic responsiveness to changes in patient physiology, is another focus for improvement of future-generation LVADs. Devices with physiologic control may sense and adjust to pathologic conditions such as exacerbation of heart failure, hypotension, hypovolemia, and malignant arrhythmia. Optimization of ventricular (un)loading may increase favorable myocardial remodeling and facilitate LVAD weaning and explantation in the setting of myocardial recovery. Finally, full sternotomy and cardiopulmonary bypass (CPB) deter referral of less sick patients for LVAD therapy. Minimally-invasive implantation strategies without CPB that include mini-thoracotomy, subxiphoid access, device placement in an infraclavicular pacemaker-like pocket, and percutaneous implantation may increase referral of earlier-stage heart failure patients and increase the public health impact of LVAD support. In summary, next-generation LVADs are needed to reduce adverse events and improve outcomes. Toroidal-flow is a novel LVAD flow strategy designed to improve hemocompatibility while providing pulsatility with physiologic device control. As such, the first-of-its-kind, toroidal-flow TORVAD is a disruptive technology with the potential to alter mechanical circulatory support therapy. TORVAD Windmill Cardiovascular Systems, Inc. (Austin, TX, USA) is developing the TORVAD (2,7-10), a positive-displacement, rotary LVAD (Figure 1). The toroidal-flow mechanism generates low shear stress (7), minimal blood trauma (2), pulsatile blood flow (9), and operates with physiologic control (8,10). Open in a separate window Figure 1 The Toroidal-Flow TORVAD, Device and Mechanism of Flow. (A) The toroidal-flow TORVAD consists of an inflow cannula with sewing ring, torus pumping chamber, and outflow graft. An epicardial ECG lead senses the patient’s native heart rhythm and triggers TORVAD support with asynchronous or synchronous pulsatile, counter-pulsatile, or co-pulsatile pumping modes. (B) To simultaneously fill and eject, the TORVAD spins two magnetic pistons (Pa and Pb) in sequence within the doughnut-shaped torus chamber. During support, each piston remains stationary while the other piston spins. While the first piston (Pa) is temporarily fixed as a virtual valve between the torus inflow and outflow, the second piston (Pb) rotates within the torus to eject 30 mL of blood. After one cycle, the pistons switch positions, and the first piston (Pa) spins while the second piston (Pb) remains stationary. The result is unidirectional, pulsatile blood flow with low shear stress and a high level of physiologic control. ECG, electrocardiogram.

Background:Significant geographical variations exist in amputation rates and utilization of diagnostic and therapeutic vascular procedures before lower extremity amputations in the United States. The purpose of this study was to evaluate the rates of diagnostic and therapeutic vascular procedures in the year prior to amputation in a contemporary population and correlate with pathological findings of the amputation specimens.Methods:A retrospective analysis was conducted of non-traumatic amputations from 2011 to 2017 at a rural community hospital. We reviewed the proportion of patients undergoing diagnostic (ankle brachial index with duplex ultrasound, computerized tomography angiogram and invasive angiogram) and therapeutic (endovascular and surgical revascularization) vascular procedures in the year prior to amputation. Prevalence of tissue viability and osteomyelitis were evaluated in all amputated specimens and atherosclerotic vascular disease (ASVD) was evaluated in major amputations. We also analyzed primary amputation rates among different subgroups.Results:698 patients were included with 248 (36%) major amputations and 450 (64%) minor amputations. Any diagnostic procedure was performed in 59% of the major amputations and 49% of the minor amputations (P = 0.01). Any therapeutic revascularization procedure was performed in 34% of the major amputations and 28% of the minor amputations (P = 0.08). The pathology of major amputation specimens revealed severe ASVD in 57% and mild-moderate ASVD in 27% of specimens. Tissue viability was significantly higher in major amputations (90% vs 30%, P = 0.04) and osteomyelitis was significantly higher in minor amputations (50% vs 14%, P = 0.03). Primary amputations were performed in 66% of major amputations, 72% of minor amputations, 81% with mild to moderate ASVD and 54% with severe ASVD.Conclusion:Diagnostic and therapeutic vascular procedures appear under-utilized for patients undergoing lower extremity amputations at a rural community hospital. ASVD rates and tissue viability imply that revascularization could be of significant benefit to avoid major amputation.

Abstract This paper presents an approach for real-time estimation of the systemic vascular resistance (SVR) of heart failure patients who have a left ventricular assist device (LVAD). Notably, an approach is described that relies only on sensing that is built into the LVAD, so no additional sensors or measurements are required. The estimation of SVR is accomplished using a variant of the extended Kalman filter (EKF) algorithm, making use of a reduced-order systemic circulation model, and requires LVAD flowrate as an input to the systemic circulation and measurement of the LVAD differential pressure. Experiments using a hybrid mock circulatory loop (hMCL) are used to show the efficacy of this approach for both types of LVAD pumping modalities; i.e., continuous flow (CF) turbomachines and pulsatile flow (PF) positive-displacement pumps. The mock loop uses a real-time hardware-in-the-loop simulation of the cardiovascular system (CVS) where physiological parameters and particularly the SVR can be set to known values, allowing a basis for evaluating the accuracy of the estimation algorithms. It was found that SVR value estimates were accurate within 1.3% and 0.7% compared to the set model values for the continuous and PF LVADs, respectively. The use of this SVR estimation approach utilizing built-in LVAD sensing technology has potential for use in further real-time estimation endeavors, monitoring of patient physiology, and providing alerts to physicians.