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Stevens K, Anandan SR, Rahman H, Parikh S, Leung AG, Benintendi A, Van Ogtrop KM, Stancavage A, Magalee CJ, Manetta F, Saikus C, Lopez S. Caring for Patients Requiring Venous Arterial Extracorporeal Membrane Oxygenation: Can Upstream Palliative Care Make a Difference? Am J Hosp Palliat Care 2024:10499091241226606. [PMID: 38195411 DOI: 10.1177/10499091241226606] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2024] Open
Abstract
OBJECTIVE Palliative care consultation is relevant for patients requiring Venous-Arterial Extracorporeal Membrane Oxygenation (VA-ECMO); however, evidence is limited to support its value. For this population, we compared length of stay (LOS) (primary outcome), operational metrics and goals of care (GOC) frequency before and after a collaboration between cardiothoracic (CT) surgery and Geriatrics and Palliative Medicine (GaP). METHODS Retrospective chart review of patients (18+) admitted to a quaternary center that required VA-ECMO between 2019-2021 and received GaP consultation. Demographics, LOS, times to consult, illness severity, GOC, and outcomes were analyzed. RESULTS 120 patients met inclusion criteria and 64 (53.3%) had GaP consultation. No differences were observed regarding demographics and insertion status (emergent vs elective). Median (IQR) days to GaP consult for 2019, 2020 and 2021 were 6.5 (4.0-14.5), 5.0 (2.0-11.0) and 3.0 (2.0-5.0), respectively (P = .006). Median days from insertion to consult for 2019, 2020 and 2021 were 6.0 (4.0-20.0), 3.0 (1.0-6.0) and 2.0 (1.0-4.0) (P = .003). Among survivors, over the 3-year course, median LOS was not statistically different. Between expired patients, median (IQR) LOS for 2019, 2020, and 2021 was 28.5 (23.0-40.0), 12.0 (8.0-14.0), 11.0 (5.0-17.0) days (P = .013). For patients not seen by GaP, 8 (14.3%) GOC notes were documented, compared with 42 (65.6%) for patients seen. Mortality was similar (53.6% vs 53.1% [GaP]). CONCLUSION For patient on VA-ECMO, early GaP consultation may improve hospital LOS and GOC rates. We suggest organizations consider early palliative integration when instituting mechanical circulatory support.
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Affiliation(s)
- Katie Stevens
- Department of Cardiothoracic Surgery, Zucker School of Medicine at Hofstra Northwell, Manhasset, NY, USA
| | - Samuel R Anandan
- Division of Geriatrics and Palliative Medicine, Department of Medicine, Zucker School of Medicine at Hofstra Northwell, Manhasset, NY, USA
| | - Husneara Rahman
- Biostatistics Unit, Feinstein Institutes for Medical Research, Northwell Health, Great Neck, NY, USA
| | - Sima Parikh
- Division of Geriatrics and Palliative Medicine, Department of Medicine, Zucker School of Medicine at Hofstra Northwell, Manhasset, NY, USA
| | - An Gao Leung
- Division of Geriatrics and Palliative Medicine, Department of Medicine, Zucker School of Medicine at Hofstra Northwell, Manhasset, NY, USA
| | - Andrea Benintendi
- Division of Geriatrics and Palliative Medicine, Department of Medicine, Zucker School of Medicine at Hofstra Northwell, Manhasset, NY, USA
| | - Katlynn M Van Ogtrop
- Division of Geriatrics and Palliative Medicine, Department of Medicine, Zucker School of Medicine at Hofstra Northwell, Manhasset, NY, USA
| | - Alyssa Stancavage
- Department of Cardiothoracic Surgery, Zucker School of Medicine at Hofstra Northwell, Manhasset, NY, USA
| | - Christopher J Magalee
- Division of Geriatrics and Palliative Medicine, Department of Medicine, Zucker School of Medicine at Hofstra Northwell, Manhasset, NY, USA
| | - Frank Manetta
- Department of Cardiothoracic Surgery, Zucker School of Medicine at Hofstra Northwell, Manhasset, NY, USA
| | - Christina Saikus
- Department of Cardiothoracic Surgery, Zucker School of Medicine at Hofstra Northwell, Manhasset, NY, USA
| | - Santiago Lopez
- Division of Geriatrics and Palliative Medicine, Department of Medicine, Zucker School of Medicine at Hofstra Northwell, Manhasset, NY, USA
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Dardik G, Ning Y, Kurlansky P, Almodovar Cruz G, Vinogradsky A, Fried J, Topkara VK, Takeda K. Long-term outcomes of patients bridged to recovery with venoarterial extracorporeal life support. Perfusion 2023:2676591231206524. [PMID: 37861303 DOI: 10.1177/02676591231206524] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2023]
Abstract
OBJECTIVE Our study examines the long-term outcomes of patients discharged from the hospital without heart replacement therapy (HRT) after recovery from cardiogenic shock using venoarterial extracorporeal life support (VA-ECLS). METHODS We retrospectively reviewed 615 cardiogenic shock patients who recovered from VA-ECLS at our institution between January 2015 and July 2021. Of those, 166 patients (27.0%) who recovered from VA-ECLS without HRT were included in this study. Baseline characteristics, discharge labs, vitals, electrocardiograms and echocardiograms were assessed. Patients were contacted to determine vital status. The primary outcome was post-discharge mortality. RESULTS Of 166 patients, 158 patients (95.2%) had post-discharge follow-up, with a median time of follow-up of 2 years (IQR: [1 year, 4 years]). At discharge, the median ejection fraction (EF) was 52.5% (IQR: [32.5, 57.5]). At discharge, 92 patients (56%) were prescribed β-blockers, 28 (17%) were prescribed an ACE inhibitor, ARB or ARNI, and 50 (30%) were prescribed loop diuretics. Kaplan-Meier analysis showed a 1-year survival rate of 85.6% (95% CI: [80.1%, 91.2%]) and a 5-year survival rate of 60.6% (95% CI: [49.9%, 71.3%]). A Cox regression model demonstrated that a history of congestive heart failure (CHF) was strongly predictive of increased mortality hazard (HR = 1.929; p = 0.036), while neither discharge EF nor etiology of VA-ECLS were associated with increased post-discharge mortality. CONCLUSIONS Patients discharged from the hospital after full myocardial recovery from VA-ECLS support without HRT should have close outpatient follow-up due to the risk of recurrent heart failure and increased mortality in these patients.
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Affiliation(s)
- Gabriel Dardik
- Department of Surgery, Columbia University Irving Medical Center, New York, NY, USA
| | - Yuming Ning
- Department of Surgery, Columbia University Irving Medical Center, New York, NY, USA
| | - Paul Kurlansky
- Department of Surgery, Columbia University Irving Medical Center, New York, NY, USA
| | | | - Alice Vinogradsky
- Department of Surgery, Columbia University Irving Medical Center, New York, NY, USA
| | - Justin Fried
- Department of Medicine, Columbia University Irving Medical Center, New York, NY, USA
| | - Veli K Topkara
- Department of Medicine, Columbia University Irving Medical Center, New York, NY, USA
| | - Koji Takeda
- Department of Surgery, Columbia University Irving Medical Center, New York, NY, USA
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Patient selection for heart transplant: balancing risk. Curr Opin Organ Transplant 2022; 27:36-44. [PMID: 34939963 DOI: 10.1097/mot.0000000000000943] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
PURPOSE OF REVIEW Heart failure incidence continues to rise despite a relatively static number of available donor hearts. Selecting an appropriate heart transplant candidate requires evaluation of numerous factors to balance patient benefit while maximizing the utility of scarce donor hearts. Recent research has provided new insights into refining recipient risk assessment, providing additional tools to further define and balance risk when considering heart transplantation. RECENT FINDINGS Recent publications have developed models to assist in risk stratifying potential heart transplant recipients based on cardiac and noncardiac factors. These studies provide additional tools to assist clinicians in balancing individual risk and benefit of heart transplantation in the context of a limited donor organ supply. SUMMARY The primary goal of heart transplantation is to improve survival and maximize quality of life. To meet this goal, a careful assessment of patient-specific risks is essential. The optimal approach to patient selection relies on integrating recent prognostication models with a multifactorial assessment of established clinical characteristics, comorbidities and psychosocial factors.
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Sperry AE, Williams M, Atluri P, Szeto WY, Cevasco M, Bermudez CA, Acker MA, Ibrahim M. The Surgeon's Role in Cardiogenic Shock. Curr Heart Fail Rep 2021; 18:240-251. [PMID: 33956313 DOI: 10.1007/s11897-021-00514-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/07/2021] [Indexed: 11/29/2022]
Abstract
PURPOSE OF REVIEW Cardiogenic shock represents a very challenging patient population due to the undifferentiated pathologies presenting as cardiogenic shock, difficult decision-making, prognostication, and ever-expanding support options. The role of cardiac surgeons on this team is evolving. RECENT FINDINGS The implementation of a shock team is associated with improved outcomes in patients with cardiogenic shock. Early deployment of mechanical circulatory support devices may allow an opportunity to rescue these patients. Cardiothoracic surgeons are a critical component of the shock team who can deploy timely mechanical support and surgical intervention in selected patients for optimal outcomes.
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Affiliation(s)
- Alexandra E Sperry
- Division of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Matthew Williams
- Division of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Pavan Atluri
- Division of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Wilson Y Szeto
- Division of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Marisa Cevasco
- Division of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Christian A Bermudez
- Division of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Michael A Acker
- Division of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Michael Ibrahim
- Division of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA.
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