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Scholarly Works (3 results)

  • Article
  • Peer Reviewed
UC San Diego Previously Published Works (2019)

This study sought to prospectively evaluate the prevalence, risk factors, and short-term major clinical outcomes of mobile thrombus detected on transvenous leads in patients undergoing lead extraction.

The prevalence and clinical significance of thrombus on transvenous leads in patients undergoing lead extraction is not well characterized.

Consecutive patients undergoing transvenous lead extraction for noninfectious indications were enrolled. Preoperative transesophageal echocardiograms were performed prospectively for all patients to examine for mobile thrombus. Anticoagulation was not started for thrombus unless other indications were present. Clinical endpoints of mortality and cardiovascular morbidity (symptomatic pulmonary embolism, myocardial infarction, or cerebrovascular accident) were assessed at a minimum of 2-month follow-up.

A total of 108 patients underwent lead extraction for noninfectious indications. Lead thrombi were detected in 20 (18.5%) patients and all were <2 cm. Clinical and lead characteristics were not associated with formation of lead thrombi, except for younger patient age. In patients with detected thrombi, there were no short-term deaths, symptomatic pulmonary embolisms, or myocardial infarctions, except 1 patient with a stroke 3 months after lead extraction (7% vs. 5%; p = 1.00). Median follow-up was 9 months.

Mobile thrombi on transvenous leads are commonly found in patients referred for transvenous lead extraction and are rarely associated with acute major adverse outcomes. Careful extraction of leads with small incidentally detected thrombi can likely be performed without major acute clinical sequelae. Larger studies with longer follow-up are needed to further assess the long-term clinical significance of lead thrombi.

    Cover page: Prevalence and Short-Term Clinical Outcome of Mobile Thrombi Detected on&nbsp;Transvenous Leads in Patients Undergoing Lead Extraction.
    • Article
    • Peer Reviewed
    UC San Diego Previously Published Works (2019)
      Cover page: Reply Lead-Adherent Echodensities: The Rule Rather Than the Exception!Creative Commons 'BY-NC-ND' version 4.0 license
      • Article
      • Peer Reviewed
      UCLA Previously Published Works (2021)

      Background

      Although specific interventions previously demonstrated benefit in patients with ARDS, use of these interventions is inconsistent, and patient mortality remains high. The impact of variability in center management practices on ARDS mortality rates remains unknown.

      Research question

      What is the impact of treatment variability on mortality in patients with moderate to severe ARDS in the United States?

      Study design and methods

      We conducted a multicenter, observational cohort study of mechanically ventilated adults with ARDS and Pao2 to Fio2 ratio of ≤ 150 with positive end-expiratory pressure of ≥ 5 cm H2O, who were admitted to 29 US centers between October 1, 2016, and April 30, 2017. The primary outcome was 28-day in-hospital mortality. Center variation in ventilator management, adjunctive therapy use, and mortality also were assessed.

      Results

      A total of 2,466 patients were enrolled. Median baseline Pao2 to Fio2 ratio was 105 (interquartile range, 78.0-129.0). In-hospital 28-day mortality was 40.7%. Initial adherence to lung protective ventilation (LPV; tidal volume, ≤ 6.5 mL/kg predicted body weight; plateau pressure, or when unavailable, peak inspiratory pressure, ≤ 30 mm H2O) was 31.4% and varied between centers (0%-65%), as did rates of adjunctive therapy use (27.1%-96.4%), methods used (neuromuscular blockade, prone positioning, systemic steroids, pulmonary vasodilators, and extracorporeal support), and mortality (16.7%-73.3%). Center standardized mortality ratios (SMRs), calculated using baseline patient-level characteristics to derive expected mortality rate, ranged from 0.33 to 1.98. Of the treatment-level factors explored, only center adherence to early LPV was correlated with SMR.

      Interpretation

      Substantial center-to-center variability exists in ARDS management, suggesting that further opportunities for improving ARDS outcomes exist. Early adherence to LPV was associated with lower center mortality and may be a surrogate for overall quality of care processes. Future collaboration is needed to identify additional treatment-level factors influencing center-level outcomes.

      Trial registry

      ClinicalTrials.gov; No.: NCT03021824; URL: www.clinicaltrials.gov.
        Cover page: Variation in Early Management Practices in&nbsp;Moderate-to-Severe ARDS in the United&nbsp;States The Severe ARDS: Generating Evidence Study
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