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Patients suffering advanced heart failure with reduced ejection fraction (HFrEF) account for a large portion of patients admitted to hospitals worldwide. Mortality and 30-day readmission rates for HFrEF are now a focus of value-based payment models, making management of this disease a priority for hospitals, physicians, and payers alike. Angiotensin-converting enzyme inhibitors have been the cornerstone of therapy for decades. However, with treatment, the prognosis for patients with advanced HFrEF remains poor. Fortunately, advances in medical therapy and mechanical support offer some patients improvement in both survival and quality of life. We review advances in short- and long-term mechanical support and explore changes to organ allocation for cardiac transplantation. In addition, we provide a guide to facilitate appropriate referral to an advanced heart failure team.

Background The benefit of extracorporeal membrane oxygenation (ECMO) for patients with severe acute respiratory distress from COVID-19 refractory to medical management and lung-protective mechanical ventilation has not been adequately determined. Methods We reviewed the clinical course of 37 patients with laboratory-confirmed SARS-CoV-2 infection supported by venovenous ECMO at four ECMO referral centers within a large healthcare system. Patient characteristics, progression of hemodynamics and inflammatory markers, and clinical outcomes were evaluated. Results The patients had median age of 51 years (interquartile range [IQR] 40-59), and 73% were male. Peak plateau pressures, vasopressor requirements, and arterial PaCO2 all improved with ECMO support. In our patient population, 24/37 patients (64.8%) survived to decannulation and 21/37 patients (56.8%) survived to discharge. Among patients discharged alive from the ECMO facility, 12 patients were discharged to a long-term acute care or rehabilitation facility, 2 were transferred back to the referring hospital for ventilatory weaning, and 7 were discharged directly home. For patients who were successfully decannulated, median length of time on ECMO was 17 days (IQR 10-33.5). Conclusions Venovenous ECMO represents a useful therapy for patients with refractory severe acute respiratory distress syndrome from COVID-19., Graphical abstract

Objective Extracorporeal membrane oxygenation (ECMO) use in adult patient populations has grown rapidly with wide variation in practices and outcomes. We evaluated the impact on patient outcomes, resource use, and costs of an initiative to coordinate and standardize best practices across ECMO programs within a large integrated health care system. Methods The ECMO Collaborative Project brought clinicians and service-line leaders from 4 programs within a single health care system together with operational subject matter experts tasked with developing and implementing standardized guidelines, order sets, and an internal database to support an automated quarterly report card. Patient outcomes, resource use, and financial measures were compared for the 16 months before (January 2017 to April 2018; “precollaborative,” n = 185) versus the 14 months after (November 2018 to December 2019, “postcollaborative,” n = 243) a 6-month implementation and blanking period. Subset analyses were performed for venoarterial ECMO, venovenous ECMO, and extracorporeal cardiopulmonary resuscitation. Results Survival to discharge/transfer increased significantly (in-hospital mortality hazard ratio, 0.75; 95% confidence interval [95% CI], 0.58-0.99) for the postcollaborative versus the precollaborative period (107/185, 57.8% vs 113/243, 46.5%, P = .03), predominantly due to improvement among patients receiving venoarterial ECMO (hazard ratio, 0.61; 95% CI, 0.41-0.91). The percentage of patients successfully weaned from ECMO increased from 58.9% (109/185) to 70% (170/243), P = .02. Complication rates decreased by 40% (incidence rate ratio, 0.60; 95% CI, 0.49-0.72). No significant changes were observed in ECMO duration, intensive care unit or hospital length of stay, or cost-per-case; payment-per-case and contribution-margin-per-case both decreased significantly. Conclusions The ECMO Collaborative Project improved survival to discharge/transfer, weaning rates and complications, without additional costs, through coordination and standardization across ECMO programs within a health care system.

A 97-year-old woman with a history of hypertension presented to the emergency department after a mechanical fall at home. She had symptoms of retrosternal chest pain and regurgitation for years, probably due to achalasia, which were presumed to be due to gastro-oesophageal reflux disease and

Anatomy: The diaphragm is the main inspiratory muscle in mammals, it is a highly active muscle with a duty cycle of 30-40%, and therefore, the diaphragm may be particularly susceptible to inactivity or disuse (1). It is innervated by the phrenic nerves that arise from the nerve roots C3 through C5, and is primarily composed of fatigue-resistant slow-twitch type I and fast-twitch IIa myofibers. As the diaphragm contracts, the abdominal contents are displaced caudally, abdominal pressure increases and the lower ribcage expands (2). The phrenic nerve contains sensory, motor and sympathetic nerve fibers, and it supplies motor supply to the diaphragm and sensory supply to the central tendon (3). Both phrenic nerves run along the anterior scalene muscle deep to the carotid sheath. The right phrenic nerve passes over the brachiocephalic artery and posterior to the subclavian vein and over the right atrium. It enters the diaphragm at the level of T8 vertebrae. The left phrenic nerve also runs posterior to the left subclavian vein and passes over the pericardium of the left ventricle and penetrates the left hemidiaphragm separately (3). See Figures 1 and 2.