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Background: Multidisciplinary heart failure (HF) clinics decrease hospital admission rates and healthcare use, while improving patient outcomes. To understand the contemporary availability of HF clinics in Ontario, Canada, and the services provided, we performed an environmental scan of physician-led and nurse practitioner (NP)–led HF clinics. Methods: Between November, 2019 and February 2020, we identified Ontario HF clinics led by physicians or NPs. Following an invitation, we conducted a semi-structured interview to evaluate the services offered and qualitatively compared our findings to the results of the 2010 Ontario provincial survey. Results: The number of HF clinics (36 vs 34 in 2010) and physicians (157 vs 143 in 2010) have not changed since the 2010 survey. Of the 36 clinics we identified, 30 participated in our interview (22 physician-led and 8 NP-led). Twenty-five clinics (83%) were hospital-based, of which 9 (30%) were part of an academic institution. Comparisons of our findings to the 2010 study on 30 clinics show an approximately 3-fold increase (P

BACKGROUND Venoarterial extracorporeal membrane oxygenation (VA ECMO) is associated with variable outcomes. In this meta-analysis, we evaluated the mortality after VA ECMO across multiple etiologies of cardiogenic shock (CS). METHODS In June 2019, we performed a systematic search selecting observational studies with ≥10 adult patients reporting on short-term mortality (30-day or mortality at discharge) after initiation of VA ECMO by CS etiology published after 2009. We performed meta-analyses using random effect models and used metaregression to evaluate mortality across CS etiology. RESULTS We included 306 studies (29,289 patients): 25 studies on after heart transplantation (HTx) (771 patients), 13 on myocarditis (906 patients), 33 on decompensated heart failure (HF) (3,567 patients), 64 on after cardiotomy shock (8,231 patients), 10 on pulmonary embolism (PE) (221 patients), 80 on acute myocardial infarction (AMI) (7,774 patients), and 113 on after cardiac arrest [CA] (7,814 patients). With moderate certainty on effect estimates, we observed significantly different mortality estimates for various etiologies (p < 0.001), which is not explained by differences in age and sex across studies: 35% (95% CI: 29-42) for after HTx, 40% (95% CI: 33-46) for myocarditis, 53% (95% CI: 46-59) for HF, 52% (95% CI: 38-66) for PE, 59% (95% CI: 56-63) for cardiotomy, 60% (95% CI: 57-64) for AMI, 64% (95% CI: 59-69) for post‒in-hospital CA, and 76% (95% CI: 69-82) for post-out‒of-hospital CA. Univariable metaregression showed that variation in mortality estimates within etiology group was partially explained by population age, proportion of females, left ventricle venting, and CA. CONCLUSIONS Using an overall estimate of mortality for patients with CS requiring VA ECMO is inadequate given the differential outcomes by etiology. To further refine patient selection and management to improve outcomes, additional studies evaluating patient characteristics impacting outcomes by specific CS etiology are needed.

Purpose Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is associated with improved outcomes in patients with cardiogenic shock (CS). However, studies evaluating its benefit have reported contradictory results. One of the main factors impacting outcomes is likely related to etiology of CS. This meta-analysis aimed to evaluate mortality after VA-ECMO across multiple etiologies of CS. Methods In June 2019, we systematically searched for studies in electronic databases and references of previous meta-analyses. We selected observational studies with ≥10 adults patients reporting on short-term mortality (30 days or discharge) after the initiation of VA-ECMO by CS etiology published after 2009. We meta-analyzed mortality using random effect models and performed meta-regression to evaluate the impact of CS etiology and other study characteristics. We evaluated the quality of the evidence using the GRADE tool. Results We included 342 studies (29,515 patients) with CS due to myocarditis (11 studies, 846 patients), acute myocardial infarction - AMI (66 studies, 3,849 patients), decompensated heart failure-HF (30 studies, 3,251 patients), post-heart transplant (23 studies, 703 patients), post-cardiotomy (93 studies, 12,076 patients), and post-cardiac arrest-CA (119 studies, 8,790 patients). Studies on myocarditis included younger populations (median age 47 years, 25th - 75th percentile 43-53), and higher proportion of female patients (48%). Studies on AMI and post-cardiotomy reported older population age (61 years, 56-65). Pooled mortality was significantly different by CS etiology: in post-heart transplant 36% (95%CI 29%-43%), myocarditis 41% (34%-47%), HF 51% (44%-58%), post-cardiotomy 58% (55%-62%), post-AMI 60% (56%-64%), post-in-hospital CA 63% (56%-69%), and post-out-of-hospital CA 76% (69%-82%). Differences in age, sex and recruitment time across studies did not explain the differences in mortality in patients with different CS etiology. The quality of the evidence was deemed moderate. Conclusion The benefit of VA-ECMO differs significantly depending on CS etiology. Further studies evaluating other factors impacting mortality in each patient population may further refine patient selection and management to improve short-term outcomes.

Purpose Fulminant myocarditis (FM) is a rare disease that may progress rapidly to refractory cardiogenic shock requiring temporary mechanical circulatory support. Venoarterial extracorporeal membrane oxygenation (VA-ECMO) has been used to provide biventricular support in these patients, however, studies have demonstrated conflicting results, likely due to small sample size. We conducted a systematic review and meta-analysis to evaluate short-term mortality after VA-ECMO in patients with FM. Methods Seven relevant databases were systematically searched on June 1st, 2019 to identify studies evaluating death at 30 days and/or hospital discharge (short-term mortality) after VA-ECMO support for FM. We included studies with n≥5, published after 2009. Mortality risk was meta-analyzed using random effect models. We performed a meta-regression analysis to explore heterogeneity based on a priori defined factors. We assessed the quality of the evidence using the GRADE approach. Results We included 12 retrospective studies (Figure) with 859 patients, mean age 38 ± 12 years to 59 ± 17 years, proportion of female patients ranged from 40% to 60%. In 5 studies (n=144), FM was verified by biopsy. In 4 studies (n=67), the reported use of steroids ranged from 13% to 41%, and in 4 studies (n=207), co-therapy with IABP ranged from 65% to 96%. The pooled short-term mortality was 41% (95% CI 34-47%; I2=64%). The exploration of heterogeneity showed that age and sex significantly impacted short-term mortality after VA-ECMO with lowest mortality in studies with younger populations and higher proportion of female patients. Conclusion In patients with rapidly progressive FM, short-term mortality was 41%. Mortality might be even lower in younger and in female patients. Cardiopulmonary support with VA-ECMO provides an invaluable tool in the treatment of fatal FM, where appropriate patient selection can further improve their outcomes.

Background The clinical effectiveness of cardiac rehabilitation (CR) on health-related quality of life (HRQOL) is an area that has not been consistently explored. The objective of this systematic review was to evaluate the effectiveness of providing any core component of CR on HRQOL domains. Methods We performed a meta-analysis and meta-regression of randomized controlled trials (RCTs) on the core components of CR. RCTs included adult patients with diagnosed coronary artery disease via angiography, myocardial infarction, angina, or who had undergone coronary revascularization. The Cochrane Library, MEDLINE, EMBASE, CINAHL, SCI-EXPANDED, Psych INFO, and Web of Science were searched from inception to April 27, 2017. Outcomes included overall, physical, emotional, and social HRQOL. Outcomes were reported as standardized mean change (SMC) with 95% confidence intervals (CIs). Effect size changes of 0.2, 0.5, and 0.8 SD units reflect a small, moderate, and large effect, respectively. Results Forty-nine reports of 41 RCTs with 11,747 patients were included. Summary effect sizes were: overall HRQOL SMC, 0.28 (95% CI, 0.05-0.50), physical HRQOL SMC, 0.47 (95% CI, 0.13-0.81), emotional HRQOL SMC, 0.37 (95% CI, −0.02 to 0.77), and social HRQOL SMC, 0.13 (95% CI, −0.06 to 0.32). Meta-regression revealed type of CR intervention and year of publication as positive statistically significant treatment effect modifiers. Conclusions Receiving CR was shown to improve HRQOL, with exercise-, nonexercise-, and psychological-based interventions playing a vital role. Although these improvements in HRQOL were modest they still reflect an incremental benefit compared with receiving usual care.