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Ahmed MM, Meece LE, Guo Y, Jeng EI, Parker AM, Vilaro JR, Al-Ani MA, Aranda JM. Left Ventricular Assist Device Use in Minorities: An Analysis of the National Inpatient Sample. ASAIO J 2024; 70:14-21. [PMID: 37788482 DOI: 10.1097/mat.0000000000002046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/05/2023] Open
Abstract
Minorities are less likely to receive a left ventricular assist device (LVAD). This, however, is based on total implant data. By examining rates of LVAD implant among patients admitted with heart failure complicated by cardiogenic shock, we sought to further elucidate LVAD utilization rates and racial disparities. Utilizing the National Inpatient Sample from 2013 to 2019, all patients admitted with a primary diagnosis of heart failure complicated by cardiogenic shock were included for analysis. Those who then received an LVAD during that hospitalization defined the LVAD utilization which was examined for any racial disparities. Left ventricular assist device utilization was low across all racial groups with no significant difference noted in univariate analysis. Non-Hispanic Blacks had the highest length of stay (LOS), the highest proportion of discharge to home (71.52%), and the lowest inpatient mortality (6.33%). Multivariable modeling confirmed the relationship between race and LOS; however, no differences were noted in mortality. Non-Hispanic Blacks were found to be less likely to receive an LVAD; however, when controlling for payer, median household income, and comorbidities, this relationship was no longer seen. Left ventricular assist devices remain an underutilized therapy in cardiogenic shock. When using a multivariable model, race does not appear to affect LVAD utilization.
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Affiliation(s)
- Mustafa M Ahmed
- From the Division of Cardiovascular Medicine, University of Florida, Gainesville, Florida
| | - Lauren E Meece
- From the Division of Cardiovascular Medicine, University of Florida, Gainesville, Florida
| | - Yi Guo
- Department of Health Outcomes and Biomedical Informatics, College of Medicine, University of Florida, Gainesville, Florida
| | - Eric I Jeng
- Division of Thoracic and Cardiovascular Surgery, University of Florida, Gainesville, Florida
| | - Alex M Parker
- From the Division of Cardiovascular Medicine, University of Florida, Gainesville, Florida
| | - Juan R Vilaro
- From the Division of Cardiovascular Medicine, University of Florida, Gainesville, Florida
| | - Mohammad A Al-Ani
- From the Division of Cardiovascular Medicine, University of Florida, Gainesville, Florida
| | - Juan M Aranda
- From the Division of Cardiovascular Medicine, University of Florida, Gainesville, Florida
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Shourav MMI, Goswami RM, Pham SM, Anisetti B, Markovic D, Lin MP. Trends and predictors of intracranial hemorrhage in patients with advanced heart failure on left ventricular assist device from 2005 to 2014 in the United States. J Stroke Cerebrovasc Dis 2023; 32:107340. [PMID: 37683528 DOI: 10.1016/j.jstrokecerebrovasdis.2023.107340] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Revised: 08/31/2023] [Accepted: 09/01/2023] [Indexed: 09/10/2023] Open
Abstract
OBJECTIVES Left ventricular assist devices are known to extend survival in patients with advanced heart failure; however, their association with intracranial hemorrhage is also well-known. We aimed to explore the risk trend and predictors of intracranial hemorrhage in patients with left ventricular assist devices. MATERIAL AND METHODS We included patients aged 18 years or older with left ventricular assist devices hospitalized in the US from 2005 to 2014 using the National Inpatient Sample. We computed the survey-weighted percentages with intracranial hemorrhage across the 10-year study period and assessed whether the proportions changed over time. Predictors of intracranial hemorrhage were evaluated using multivariable logistic regression model. RESULTS Of 33,246 hospitalizations, 568 (1.7%) had intracranial hemorrhage. The number of left ventricular assist devices placements increased from 873 in 2005 to 5175 in 2014. However, the risk of intracranial hemorrhage remained largely unchanged (1.7% to 2.3%; linear trend, P = 0.604). The adjusted odds of intracranial hemorrhage were increased with the presence of one of the following variables: female sex (odds ratio [OR], 1.58; 95% CI, 1.03-2.43), history of ischemic stroke (OR, 3.13; 95% CI, 1.86-5.28), or Charlson Comorbidity Index score of 3 or more (OR, 77.40; 95% CI, 10.03-597.60). CONCLUSIONS Over the last decade, the risk of intracranial hemorrhage has remained relatively unchanged despite an increase in the use of left ventricular assist devices in patients with advanced heart failure. Women, higher Charlson Comorbidity Index scores, and history of ischemic stroke were associated with higher odds of intracranial hemorrhage in patients with left ventricular assist devices.
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Affiliation(s)
| | - Rohan M Goswami
- Department of Heart Failure and Transplant, Mayo Clinic, Jacksonville, FL, USA
| | - Si M Pham
- Department of Cardiothoracic Surgery, Mayo Clinic, Jacksonville, FL, USA
| | | | - Daniela Markovic
- Department of Statistics, University of California Los Angeles, Los Angeles, CA, USA
| | - Michelle P Lin
- Department of Neurology, Mayo Clinic, Jacksonville, FL, USA
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Akiyama K, Colombo PC, Stöhr EJ, Ji R, Wu IY, Itatani K, Miyazaki S, Nishino T, Nakamura N, Nakajima Y, McDonnell BJ, Takeda K, Yuzefpolskaya M, Takayama H. Blood flow kinetic energy is a novel marker for right ventricular global systolic function in patients with left ventricular assist device therapy. Front Cardiovasc Med 2023; 10:1093576. [PMID: 37260947 PMCID: PMC10228750 DOI: 10.3389/fcvm.2023.1093576] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Accepted: 05/02/2023] [Indexed: 06/02/2023] Open
Abstract
Objectives Right ventricular (RV) failure remains a major concern in heart failure (HF) patients undergoing left ventricular assist device (LVAD) implantation. We aimed to measure the kinetic energy of blood in the RV outflow tract (KE-RVOT) - a new marker of RV global systolic function. We also aimed to assess the relationship of KE-RVOT to other echocardiographic parameters in all subjects and assess the relationship of KE-RVOT to hemodynamic parameters of RV performance in HF patients. Methods Fifty-one subjects were prospectively enrolled into 4 groups (healthy controls, NYHA Class II, NYHA Class IV, LVAD patients) as follows: 11 healthy controls, 32 HF patients (8 NYHA Class II and 24 Class IV), and 8 patients with preexisting LVADs. The 24 Class IV HF patients included 21 pre-LVAD and 3 pre-transplant patients. Echocardiographic parameters of RV function (TAPSE, St', Et', IVA, MPI) and RV outflow color-Doppler images were recorded in all patients. Invasive hemodynamic parameters of RV function were collected in all Class IV HF patients. KE-RVOT was derived from color-Doppler imaging using a vector flow mapping proprietary software. Kruskal-Wallis test was performed for comparison of KE-RVOT in each group. Correlation between KE-RVOT and echocardiographic/hemodynamic parameters was assessed by linear regression analysis. Receiver operating characteristic curves for the ability of KE-RVOT to predict early phase RV failure were generated. Results KE-RVOT (median ± IQR) was higher in healthy controls (55.10 [39.70 to 76.43] mW/m) than in the Class II HF group (22.23 [15.41 to 35.58] mW/m, p < 0.005). KE-RVOT was further reduced in the Class IV HF group (9.02 [5.33 to 11.94] mW/m, p < 0.05). KE-RVOT was lower in the LVAD group (25.03 [9.88 to 38.98] mW/m) than the healthy controls group (p < 0.005). KE-RVOT had significant correlation with all echocardiographic parameters and no correlation with invasive hemodynamic parameters. RV failure occurred in 12 patients who underwent LVAD implantation in the Class IV HF group (1 patient was not eligible due to death immediately after the LVAD implantation). KE-RVOT cut-off value for prediction of RV failure was 9.15 mW/m (sensitivity: 0.67, specificity: 0.75, AUC: 0.66). Conclusions KE-RVOT, a novel noninvasive measure of RV function, strongly correlates with well-established echocardiographic markers of RV performance. KE-RVOT is the energy generated by RV wall contraction. Therefore, KE-RVOT may reflect global RV function. The utility of KE-RVOT in prediction of RV failure post LVAD implantation requires further study.
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Affiliation(s)
- Koichi Akiyama
- Department of Anesthesiology, Kindai University Hospital, Osakasayama, Japan
- Department of Medicine, Division of Cardiothoracic and Vascular Surgery, Columbia University Irving Medical Center, New York, NY, United States
| | - Paolo C. Colombo
- Department of Medicine, Division of Cardiology, Columbia University Irving Medical Center, New York, NY, United States
| | - Eric J. Stöhr
- COR-HELIX (CardiOvascular Regulation and Exercise Laboratory-Integration and Xploration), Institute of Sport Science, Leibniz University Hannover, Hannover, Germany
| | - Ruiping Ji
- Department of Medicine, Division of Cardiology, Columbia University Irving Medical Center, New York, NY, United States
| | - Isaac Y. Wu
- Department of Anesthesiology, University of Rochester Medical Center, Rochester, NY, United States
| | - Keiichi Itatani
- Department of Cardiovascular Surgery, Nagoya City University, Nagoya, Japan
| | | | | | - Naotoshi Nakamura
- iBLab (interdisciplinary Biology Laboratory), Division of Natural Science, Graduate School of Science, Nagoya University, Nagoya, Japan
| | - Yasufumi Nakajima
- Department of Anesthesiology, Kindai University Hospital, Osakasayama, Japan
| | - Barry J McDonnell
- School of Sport & Health Sciences, Cardiff Metropolitan University, Cardiff, United Kingdom
| | - Koji Takeda
- Department of Medicine, Division of Cardiothoracic and Vascular Surgery, Columbia University Irving Medical Center, New York, NY, United States
| | - Melana Yuzefpolskaya
- Department of Medicine, Division of Cardiology, Columbia University Irving Medical Center, New York, NY, United States
| | - Hiroo Takayama
- Department of Medicine, Division of Cardiothoracic and Vascular Surgery, Columbia University Irving Medical Center, New York, NY, United States
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Afzal A, van Zyl J, Nisar T, Kluger AY, Jamil AK, Felius J, Hall SA, Kale P. Trends in Hospital Admissions for Systolic and Diastolic Heart Failure in the United States Between 2004 and 2017. Am J Cardiol 2022; 171:99-104. [PMID: 35365288 DOI: 10.1016/j.amjcard.2022.01.047] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2021] [Revised: 01/23/2022] [Accepted: 01/26/2022] [Indexed: 12/21/2022]
Abstract
Heart failure (HF) affects 6 million people in the United States and costs $30 billion annually. It is unclear whether improvements in length of stay and mortality over the last few decades hold true for both systolic and diastolic HF. To better assess the epidemiological and economic burden of HF, we assessed the trends in outcomes and costs for both systolic and diastolic HF. We identified hospitalizations for systolic and diastolic HF in the National Inpatient Sample database and evaluated trends over the period from 2004 to 2017, adjusting for demographics and co-morbidities. The proportion of patients admitted with an exacerbation of systolic HF increased from 42% to 63% over the study period. We found an overall decreasing trend between 2004 and 2011 in the length of stay for HF in general with a sharper decrease in diastolic than systolic HF. Inpatient mortality decreased between 2004 and 2007 and stabilized between 2008 and 2016. Systolic HF was associated with higher mortality than diastolic HF. The total inflation-adjusted cost did not change significantly over the study period, with systolic HF costing, on average, $3,036 more than diastolic HF per admission. In conclusion, systolic HF overtook diastolic HF, accounting for most HF hospitalizations in 2008. The higher hospitalization costs for systolic HF relative to diastolic HF may have resulted, in part, from greater use of advanced support devices in patients with systolic HF.
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Affiliation(s)
- Aasim Afzal
- Center for Advanced Heart and Lung Disease, Baylor University Medical Center, Dallas, Texas; Annette C. and Harold C. Simmons Transplant Institute and.
| | | | - Tariq Nisar
- Annette C. and Harold C. Simmons Transplant Institute and
| | - Aaron Y Kluger
- Baylor Heart and Vascular Institute, Baylor Scott & White Research Institute, Dallas, Texas
| | - Aayla K Jamil
- Annette C. and Harold C. Simmons Transplant Institute and
| | - Joost Felius
- Annette C. and Harold C. Simmons Transplant Institute and
| | - Shelley A Hall
- Center for Advanced Heart and Lung Disease, Baylor University Medical Center, Dallas, Texas; Annette C. and Harold C. Simmons Transplant Institute and
| | - Parag Kale
- Center for Advanced Heart and Lung Disease, Baylor University Medical Center, Dallas, Texas; Annette C. and Harold C. Simmons Transplant Institute and
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Nishida H, Ota T, Onsager D, Grinstein J, Jeevanandam V, Song T. Ten-year, single center experience of ambulatory axillary intra-aortic balloon pump support for heart failure. J Cardiol 2021; 79:611-617. [PMID: 34895789 DOI: 10.1016/j.jjcc.2021.11.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2021] [Revised: 10/22/2021] [Accepted: 10/27/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND The axillary intra-aortic balloon pump has an advantage over the femoral intra-aortic balloon pump in terms of mobility. While axillary intra-aortic balloon pump has been widely used recently as a mode of mechanical circulatory support, the number of reported cases is limited. The purpose of this study is to summarize our experience and to evaluate the safety and efficacy of axillary intra-aortic balloon pump support. METHODS Between July 2009 and July 2019, 241 patients underwent axillary intra-aortic balloon pump support for heart failure. The intended therapeutic goals were bridge to heart transplantation (n=146), left ventricular assist device (n=66), and recovery (n=29). Intra-aortic balloon pumps were inserted through a graft sutured onto the axillary artery in 142 patients (58.9%) and percutaneously in 99 patients (41.1%). It was placed from the right axillary artery in 147 patients (61.0%) and left in 94 patients (39.0%). Primary outcome measures of interest included achievement of intended therapeutic goal, hemodynamic data, ambulatory data, intra-aortic balloon pump-related death, and complications. RESULTS Ambulation was possible in 217 patients (90.0%) during support. Hemodynamic parameters improved significantly after axillary intra-aortic balloon pump support. In total, 13 patients (5.4%) died and 10 patients (4.1%) required escalation of mechanical support. There were no deaths directly attributable to intra-aortic balloon pumps. Intra-aortic balloon pump-related stroke occurred in 6 patients (2.5%). Overall, 86.7% were successfully bridged to intended therapy (transplantation 90.4%, left ventricular assist device 90.9%, and recovery 58.6%). CONCLUSIONS Axillary intra-aortic balloon pumps allow most patients to ambulate during support, improve hemodynamics, and lead to the intended goals successfully.
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Affiliation(s)
- Hidefumi Nishida
- Department of Surgery, University of Chicago Medicine, Chicago, IL, USA.
| | - Takeyoshi Ota
- Department of Surgery, University of Chicago Medicine, Chicago, IL, USA
| | - David Onsager
- Department of Surgery, University of Chicago Medicine, Chicago, IL, USA
| | - Jonathan Grinstein
- Department of Medicine, University of Chicago Medicine, Chicago, IL, USA
| | | | - Tae Song
- Department of Surgery, University of Chicago Medicine, Chicago, IL, USA
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6
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Notarianni A, Tickoo M, Bardia A. Mechanical Cardiac Circulatory Support: an Overview of the Challenges for the Anesthetist. CURRENT ANESTHESIOLOGY REPORTS 2021; 11:421-428. [PMID: 34611458 PMCID: PMC8484296 DOI: 10.1007/s40140-021-00486-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/25/2021] [Indexed: 11/29/2022]
Abstract
Purpose of Review Owing to increased utilization of Mechanical Circulatory Support (MCS) devices, patients with these devices frequently present for surgeries requiring anesthetic support. The current article provides basics of perioperative management of these devices. Recent Findings Use of extracorporeal membrane oxygenation (ECMO) and left ventricular assist devices (LVADs) are on the rise with recently updated management guidelines. Veno-venous ECMO utilization has been widely utilized as a salvage therapy during the COVID-19 pandemic. Summary Intra-Aortic Balloon Pumps continue to be one of the most frequently used devices after acute myocardial infarction. ECMO is utilized for pulmonary or cardiopulmonary support as salvage therapy. LVADs are used in patients with end-stage heart failure as a destination therapy or bridge to transplant. Each of these devices present with their own set of management challenges. Anesthetic management of patients with MCS devices requires a thorough understanding of underlying operating and hemodynamic principles.
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Affiliation(s)
- Andrew Notarianni
- Department of Anesthesiology, Yale School of Medicine, New Haven, CT 06515 USA
| | - Mayanka Tickoo
- Pulmonary and Critical Care Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT USA
| | - Amit Bardia
- Department of Anesthesiology, Yale School of Medicine, New Haven, CT 06515 USA
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7
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Kilic A, Macickova J, Duan L, Movahedi F, Seese L, Zhang Y, Jacoski MV, Padman R. Machine Learning Approaches to Analyzing Adverse Events Following Durable LVAD Implantation. Ann Thorac Surg 2021; 112:770-777. [DOI: 10.1016/j.athoracsur.2020.09.040] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Revised: 09/05/2020] [Accepted: 09/21/2020] [Indexed: 12/31/2022]
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Casida JM, Pavol M, Craddock H, Schroeder SE, Cagliostro B, Budhathoki C. Patient-Reported Issues Following Left Ventricular Assist Device Implantation Hospitalization. ASAIO J 2021; 67:658-665. [PMID: 33587467 DOI: 10.1097/mat.0000000000001381] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
The purpose of this study was to explore the information reported by patients via a smartphone application (VAD Care App) used for left ventricular assist device (LVAD) self-care monitoring and reporting post hospital discharge. Specific aims were to examine the type and frequency of issues reported by patients through the app during months 1, 3, and 6 postdischarge. An exploratory-descriptive research design was used with 17 patients (12 males and 5 females) with durable LVADs, mean age of 48.6 ± 16 years. Data generated by the patients' daily smartphone app usage more than 6 months were extracted from the server. Data were coded and clustered according to issues reported by patients via the app and analyzed with descriptive statistics. Three clusters of issues were found: physiologic, behavioral (self-care), and signs and symptoms. LVAD flows and pulsatility indices, hypertension, driveline care, and heart failure symptoms were worse at month 1, and then appeared to improve at months 3-6. However, abnormal levels of the international normalization ratio were common at all assessment points. Further research is needed to understand the mechanism of the reported issues on treatment outcomes, then develop and test interventions to inform evidence-based practice and clinical guidelines for smartphone apps used in LVAD self-care monitoring.
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Affiliation(s)
- Jesus M Casida
- From the School of Nursing, Johns Hopkins University, Baltimore, Maryland
| | - MaryKay Pavol
- Columbia University Medical Center, New York City, New York
| | - Heidi Craddock
- Barnes-Jewish Hospital Washington University, St. Louis, Missouri
| | | | | | - Chakra Budhathoki
- From the School of Nursing, Johns Hopkins University, Baltimore, Maryland
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9
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Pandey D, Mahmood A, Harounian J, Fleming-Damon C, Mencias M, Portenoy RK, Knotkova H. Providing End-of-Life Care for Patients With Left Ventricular Assist Devices: Experience of a Hospice Agency. J Pain Symptom Manage 2021; 61:891-897. [PMID: 33059016 DOI: 10.1016/j.jpainsymman.2020.10.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Revised: 10/05/2020] [Accepted: 10/06/2020] [Indexed: 10/23/2022]
Abstract
CONTEXT Patients with left ventricular assist devices (LVADs) need expert palliative care at the end of life. In the U.S., hospice may provide this care, but few patients enroll, and information about hospice experience with LVAD-implanted patients is limited. OBJECTIVE To describe hospice experience with LVAD-implanted patients. METHODS This is a retrospective descriptive study of all LVAD-implanted patients admitted to a hospice agency. Data were extracted from the electronic health record. RESULTS The 13 patients had a mean age of 63 years (range 20-89) and a mean LVAD duration of 32.5 months (range 8.2-70.0). Hospice diagnosis was heart failure in 10 patients and cancer in three patients; all patients were multimorbid. Eight patients enrolled in hospice on one occasion, four had two enrollments, and one had five. All patients received services for <180 days, three for <7 days, and four patients for >90 days. Just-in-time inservicing was used to prepare hospice teams for challenging care needs, including bleeding, delirium, infections, and mechanical failure. Of the nine patients who died while receiving hospice services, one enrolled with a plan to deactivate the LVAD immediately after hospice enrollment, and six died after discontinuation of the LVAD or other life-sustaining therapy during the course of hospice care. Five deaths occurred in a hospice inpatient unit. CONCLUSION To provide specialist palliative care to LVAD-implanted patients, hospices must be prepared to manage complex and highly varied needs. To do this, hospices must have adequate staff support and access to acute care.
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Affiliation(s)
- Deepali Pandey
- MJHS Institute for Innovation in Palliative Care, New York, New York, USA
| | - Ashraf Mahmood
- MJHS Institute for Innovation in Palliative Care, New York, New York, USA
| | - Joshua Harounian
- MJHS Institute for Innovation in Palliative Care, New York, New York, USA
| | - Colleen Fleming-Damon
- MJHS Institute for Innovation in Palliative Care, New York, New York, USA; MJHS Hospice and Palliative Care, New York, New York, USA
| | | | - Russell K Portenoy
- MJHS Institute for Innovation in Palliative Care, New York, New York, USA; MJHS Hospice and Palliative Care, New York, New York, USA; Department of Family and Social Medicine, Albert Einstein College of Medicine, The Bronx, New York, USA; Department of Neurology, Albert Einstein College of Medicine, The Bronx, New York, USA
| | - Helena Knotkova
- MJHS Institute for Innovation in Palliative Care, New York, New York, USA; Department of Family and Social Medicine, Albert Einstein College of Medicine, The Bronx, New York, USA.
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Kilic A, Dochtermann D, Padman R, Miller JK, Dubrawski A. Using machine learning to improve risk prediction in durable left ventricular assist devices. PLoS One 2021; 16:e0247866. [PMID: 33690687 PMCID: PMC7946192 DOI: 10.1371/journal.pone.0247866] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Accepted: 02/15/2021] [Indexed: 11/24/2022] Open
Abstract
Risk models have historically displayed only moderate predictive performance in estimating mortality risk in left ventricular assist device therapy. This study evaluated whether machine learning can improve risk prediction for left ventricular assist devices. Primary durable left ventricular assist devices reported in the Interagency Registry for Mechanically Assisted Circulatory Support between March 1, 2006 and December 31, 2016 were included. The study cohort was randomly divided 3:1 into training and testing sets. Logistic regression and machine learning models (extreme gradient boosting) were created in the training set for 90-day and 1-year mortality and their performance was evaluated after bootstrapping with 1000 replications in the testing set. Differences in model performance were also evaluated in cases of concordance versus discordance in predicted risk between logistic regression and extreme gradient boosting as defined by equal size patient tertiles. A total of 16,120 patients were included. Calibration metrics were comparable between logistic regression and extreme gradient boosting. C-index was improved with extreme gradient boosting (90-day: 0.707 [0.683–0.730] versus 0.740 [0.717–0.762] and 1-year: 0.691 [0.673–0.710] versus 0.714 [0.695–0.734]; each p<0.001). Net reclassification index analysis similarly demonstrated an improvement of 48.8% and 36.9% for 90-day and 1-year mortality, respectively, with extreme gradient boosting (each p<0.001). Concordance in predicted risk between logistic regression and extreme gradient boosting resulted in substantially improved c-index for both logistic regression and extreme gradient boosting (90-day logistic regression 0.536 versus 0.752, 1-year logistic regression 0.555 versus 0.726, 90-day extreme gradient boosting 0.623 versus 0.772, 1-year extreme gradient boosting 0.613 versus 0.742, each p<0.001). These results demonstrate that machine learning can improve risk model performance for durable left ventricular assist devices, both independently and as an adjunct to logistic regression.
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Affiliation(s)
- Arman Kilic
- Division of Cardiac Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, United States of America
- * E-mail:
| | | | - Rema Padman
- Carnegie Mellon University, Pittsburgh, PA, United States of America
| | - James K. Miller
- Carnegie Mellon University, Pittsburgh, PA, United States of America
| | - Artur Dubrawski
- Carnegie Mellon University, Pittsburgh, PA, United States of America
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11
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Burstein DS, Griffis H, Zhang X, Cantor RS, Dai D, Shamszad P, Huang YS, Morales DLS, Hall M, Lin KY, O'Connor MJ, Zinn M, Edens RE, Parrino PE, Kirklin JK, Rossano JW. Resource utilization in children with paracorporeal continuous-flow ventricular assist devices. J Heart Lung Transplant 2021; 40:478-487. [PMID: 33744087 DOI: 10.1016/j.healun.2021.02.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Revised: 02/16/2021] [Accepted: 02/18/2021] [Indexed: 10/22/2022] Open
Abstract
BACKGROUND Paracorporeal continuous-flow ventricular assist devices (PCF VAD) are increasingly used in pediatrics, yet PCF VAD resource utilization has not been reported to date. METHODS Pediatric Interagency Registry for Mechanically Assisted Circulatory Support (PediMACS), a national registry of VADs in children, and Pediatric Health Information System (PHIS), an administrative database of children's hospitals, were merged to assess VAD implants from 19 centers between 2012 and 2016. Resource utilization, including hospital and intensive care unit length of stay (LOS), and costs are analyzed for PCF VAD, durable VAD (DVAD), and combined PCF-DVAD support. RESULTS Of 177 children (20% PCF VAD, 14% PCF-DVAD, 66% DVAD), those with PCF VAD or PCF-DVAD are younger (median age 4 [IQR 0-10] years and 3 [IQR 0-9] years, respectively) and more often have congenital heart disease (44%; 28%, respectively) compared to DVAD (11 [IQR 3-17] years; 14% CHD); p < 0.01 for both. Median post-VAD LOS is prolonged ranging from 43 (IQR 15-82) days in PCF VAD to 72 (IQR 55-107) days in PCF-DVAD, with significant hospitalization costs (PCF VAD $450,000 [IQR $210,000-$780,000]; PCF-DVAD $770,000 [IQR $510,000-$1,000,000]). After adjusting for patient-level factors, greater post-VAD hospital costs are associated with LOS, ECMO pre-VAD, greater chronic complex conditions, and major adverse events (p < 0.05 for all). VAD strategy and underlying cardiac disease are not associated with LOS or overall costs, although PCF VAD is associated with higher daily-level costs driven by increased pharmacy, laboratory, imaging, and clinical services costs. CONCLUSION Pediatric PCF VAD resource utilization is staggeringly high with costs primarily driven by pre-implantation patient illness, hospital LOS, and clinical care costs.
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Affiliation(s)
- Danielle S Burstein
- Division of Cardiology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.
| | - Heather Griffis
- Healthcare Analytics Unit, Center for Pediatric Clinical Effectiveness and PolicyLab, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Xuemei Zhang
- Healthcare Analytics Unit, Center for Pediatric Clinical Effectiveness and PolicyLab, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Ryan S Cantor
- Kirklin Institute for Research in Surgical Outcomes, University of Alabama at Birmingham, Birmingham, Alabama
| | - Dingwei Dai
- Healthcare Analytics Unit, Center for Pediatric Clinical Effectiveness and PolicyLab, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Pirouz Shamszad
- Division of Cardiology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Yuan-Shung Huang
- Healthcare Analytics Unit, Center for Pediatric Clinical Effectiveness and PolicyLab, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - David L S Morales
- Division of Cardiothoracic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | | | - Kimberly Y Lin
- Division of Cardiology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Matthew J O'Connor
- Division of Cardiology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Matthew Zinn
- Division of Cardiology, The University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - R Erik Edens
- Department of Pediatrics, Children's Minnesota, Minneapolis, Minnesota
| | - P Eugene Parrino
- Division of Cardiothoracic Surgery, Ochsner Clinic Foundation, New Orleans, Louisiana
| | - James K Kirklin
- Division of Cardiothoracic Surgery, Department of Surgery, The University of Alabama at Birmingham, Birmingham, Alabama
| | - Joseph W Rossano
- Division of Cardiology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
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12
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Ramirez JL, Zarkowsky DS, Ramirez FD, Gasper WJ, Cohen BE, Conte MS, Grenon SM, Iannuzzi JC. Depression Predicts Non-Home Discharge After Abdominal Aortic Aneurysm Repair. Ann Vasc Surg 2021; 74:131-140. [PMID: 33503503 DOI: 10.1016/j.avsg.2020.12.019] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Revised: 12/08/2020] [Accepted: 12/08/2020] [Indexed: 12/27/2022]
Abstract
BACKGROUND Mental health's impact on vascular surgical patients has long been overlooked. While outside the expertise of most surgeons, understanding the role that depression plays in the postoperative course could provide additional insight into opportunities to improve surgical outcomes and healthcare value. Additionally, non-home discharge (NHD) to a rehabilitation or skilled nursing facility after surgery is associated with impaired quality of life and higher postdischarge complications, readmissions, and mortality. We hypothesized that depression would be associated with an increased risk for NHD following abdominal aortic aneurysm (AAA) repair. METHODS Nonruptured AAA repair cases were identified from the National Inpatient Sample (NIS) using ICD-9 codes between 2005 and 2014. Depression, comorbidities, postoperative complications, and discharge destination were evaluated using statistical tests as appropriate to the data. A hierarchical multivariable logistic regression controlling for hospital level variation was used to examine the independent association between depression, and the primary outcome of NHD controlling for median income and confounders meeting P < 0.05 on univariate analysis. RESULTS There were 99,934 total cases analyzed, of which 4,755 (4.8%) were diagnosed with depression and 10,618 (11.9%) required NHD. Patients with depression were younger, more likely to be women, white, have diabetes, chronic obstructive pulmonary disease, hypertension, tobacco use, and more likely to experience a postoperative complication. On adjusted multivariable analysis, patients with depression were more likely to require NHD (odds ratio [OR] 1.87, 95% confidence interval [CI]: 1.68-2.08, c-statistic = 0.82). On stratified analysis by operative approach, depression had a larger effect estimate in endovascular repair (OR 2.19; 95% CI: 1.90-2.52) versus open repair (OR 1.60; 95% CI: 1.38-1.87). CONCLUSIONS In a nationally representative sample, patients with depression were more likely to require NHD after AAA repair. This study highlights the importance that depression plays in postoperative outcomes after AAA repair. Furthermore, addressing mental health preoperatively has the potential to improve outcomes in patients undergoing AAA repair.
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Affiliation(s)
- Joel L Ramirez
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA
| | - Devin S Zarkowsky
- Division of Vascular Surgery and Endovascular Therapy, University of Colorado, Aurora, CO
| | - Faustine D Ramirez
- Department of Pediatrics, University of California, San Francisco, San Francisco, CA
| | - Warren J Gasper
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA
| | - Beth E Cohen
- Department of Medicine, University of California, San Francisco, San Francisco, CA; Department of Medicine, Veterans Affairs Medical Center, San Francisco, CA
| | - Michael S Conte
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA
| | - S Marlene Grenon
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA
| | - James C Iannuzzi
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA.
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13
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Lovelace J, Shabaneh O, De La Cruz N, Owoade DR, Nwabuo CC, Nair N, Appiah D. The Joint Association of Septicemia and Cerebrovascular Diseases with In-Hospital MortalityAmong Patients with Left Ventricular Assist Device in the United States. J Stroke Cerebrovasc Dis 2021; 30:105610. [PMID: 33482570 DOI: 10.1016/j.jstrokecerebrovasdis.2021.105610] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Revised: 12/31/2020] [Accepted: 01/05/2021] [Indexed: 01/28/2023] Open
Abstract
OBJECTIVES Left ventricular assist device (LVAD) is associated with complications such as cerebrovascular diseases (CEVD) as well as septicemia which is often preventable. With their use increasing in the U.S., identifying patients with LVAD who are at high risk for short-term mortality is essential for targeted effective patient management strategies to prevent adverse outcomes. We investigated the individual and joint association of CEVD and septicemia with the risk of in-hospital mortality in patients with LVAD in the U.S. MATERIALS AND METHODS We used data from the National Inpatient Sample from 2004 to 2015 to identify patients ≥18 years of age who underwent LVAD implantation by means of International Classification of Disease, 9th Revision, codes. Multivariable hierarchical negative binomial regression models were used to estimate risk ratios (RR) and 95% confidence intervals (CI) for in-hospital mortality by CEVD-septicemia status. RESULTS The mean age of the 4638 patients was 56 years, and 23% of them were women. Approximately 13% of patients had septicemia; 7% had CEVD and 2% had both conditions. In models adjusted for demographic, lifestyle/behavior factors and comorbid conditions, the risk of in-hospital mortality was almost threefold higher among patients with septicemia alone (RR=2.84, CI:2.24-3.60); two-and-half fold higher among patients with CEVD alone (RR=2.53, CI:1.85-3.48); and almost fourfold among patients with both septicemia and CEVD (RR=3.76, CI: 2.38-5.94, Pinteraction = <0.001) CONCLUSION: The presence of both septicemia and CEVD was associated with a substantially higher risk of in-hospital mortality among LVAD patients when compared to septicemia or CEVD alone.
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Affiliation(s)
- Jessica Lovelace
- School of Medicine, Texas Tech University Health Sciences Center, Lubbock, TX, United States
| | - Obadeh Shabaneh
- School of Medicine, St. George's University, St. George's, Grenada
| | - Noah De La Cruz
- College of Osteopathic Medicine, Sam Houston State University, Conroe, TX, United States
| | - Damilola R Owoade
- Department of Epidemiology and Population Health, University of Louisville, Louisville KY, United States
| | - Chike C Nwabuo
- Division of Cardiology, Johns Hopkins University, Baltimore, MD, United States
| | - Nandini Nair
- School of Medicine, Texas Tech University Health Sciences Center, Lubbock, TX, United States
| | - Duke Appiah
- Department of Public Health, Texas Tech University Health Sciences Center, 3601 4th Street, STOP 9430, Lubbock, TX 79430, United States.
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14
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Right Ventricular Failure Post-Implantation of Left Ventricular Assist Device: Prevalence, Pathophysiology, and Predictors. ASAIO J 2021; 66:610-619. [PMID: 31651460 DOI: 10.1097/mat.0000000000001088] [Citation(s) in RCA: 40] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
Despite advances in left ventricular assist device (LVAD) technology, right ventricular failure (RVF) continues to be a complication after implantation. Most patients undergoing LVAD implantation have underlying right ventricular (RV) dysfunction (either as a result of prolonged LV failure or systemic disorders) that becomes decompensated post-implantation. Additional insults include intra-operative factors or a sudden increase in preload in the setting of increased cardiac output. The current literature estimates post-LVAD RVF from 3.9% to 53% using a diverse set of definitions. A few of the risk factors that have been identified include markers of cardiogenic shock (e.g., dependence on inotropes and Interagency Registry for Mechanically Assisted Circulatory Support profiles) as well as evidence of cardiorenal or cardiohepatic syndromes. Several studies have devised multivariable risk scores; however, their performance has been limited. A new functional assessment of RVF and a novel hepatic marker that describe cholestatic properties of congestive hepatopathy may provide additional predictive value. Furthermore, future studies can help better understand the relationship between pulmonary hypertension and post-LVAD RVF. To achieve our ultimate goal-to prevent and effectively manage RVF post-LVAD-we must start with a better understanding of the risk factors and pathophysiology. Future research on the different etiologies of RVF-ranging from acute post-surgical complication to late-onset RV cardiomyopathy-will help standardize definitions and tailor therapies appropriately.
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15
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Ramirez JL, Zahner GJ, Arya S, Grenon SM, Gasper WJ, Sosa JA, Conte MS, Iannuzzi JC. Patients with depression are less likely to go home after critical limb revascularization. J Vasc Surg 2020; 74:178-186.e2. [PMID: 33383108 DOI: 10.1016/j.jvs.2020.12.079] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2020] [Accepted: 12/10/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND Although often overlooked during the preoperative evaluation, recent evidence has suggested that depression in patients with peripheral artery disease is associated with increased postoperative complications, including decreased primary and secondary patency after revascularization and an increased risk of major amputation and mortality. Postoperative nonhome discharge (NHD) is an important outcome for patients and has also been associated with other adverse outcomes; however, the effect that depression has on NHD after vascular surgery has remained unexplored. We hypothesized that depression would be associated with an increased risk of NHD after revascularization for chronic limb threatening ischemia (CLTI). METHODS Endovascular, open, and hybrid (combined open and endovascular) cases of revascularization for CLTI were identified from the 2012 to 2014 National (Nationwide) Inpatient Sample. CLTI, diagnoses of depression, and medical comorbidities were defined using the corresponding International Classification of Diseases, Ninth Revision, Clinical Modification codes. A hierarchical multivariable binary logistic regression controlling for hospital level variation and for confounders meeting P <.01 on bivariate analysis was used to examine the association between depression and NHD. A sensitivity analysis after coarsened exact matching for baseline characteristics that differed between the two groups was performed to reduce any imbalance. RESULTS A total of 64,817 cases were identified, of which 5472 (8.4%) included a diagnosis of depression and 16,524 (25.5%) NHD. The patients with depression were younger and more likely to be women and white, have multiple comorbidities and a nonelective admission, and experience a postoperative complication (P <.05). On unadjusted analyses, patients with depression had an 8% absolute increased risk of requiring NHD (32.1% vs 24.9%; P <.001). On multivariable analysis, patients with depression had an increased odds for NHD (odds ratio [OR], 1.50; 95% confidence interval [CI], 1.40-1.61; c-statistic, 0.81) compared with those without depression. After stratification by operative approach, depression had a larger effect estimate in endovascular revascularization (OR, 1.57; 95% CI, 1.42-1.74) compared with open (OR, 1.45; 95% CI, 1.30-1.62). A test for interaction between depression and gender identified that men with depression had greater odds of NHD compared with women with depression (OR, 1.68; 95% CI, 1.51-1.88; vs OR, 1.37; 95% CI, 1.25-1.51; interaction P <.01). A sensitivity analysis after coarsened exact matching confirmed these findings. CONCLUSIONS To the best of our knowledge, the present study is the first to identify an association between depression and NHD after revascularization for CLTI. These results provide further evidence of the negative effects that comorbid depression has on patients undergoing revascularization for CLTI. Future studies should examine whether treating depression can improve the outcomes in this patient population.
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Affiliation(s)
- Joel L Ramirez
- Department of Surgery, University of California, San Francisco, San Francisco, Calif
| | - Greg J Zahner
- Department of Medicine, Massachusetts General Hospital, Boston, Mass
| | - Shipra Arya
- Division of Vascular Surgery, Department of Surgery, Stanford University, Palo Alto, Calif
| | - S Marlene Grenon
- Department of Surgery, University of California, San Francisco, San Francisco, Calif
| | - Warren J Gasper
- Department of Surgery, University of California, San Francisco, San Francisco, Calif
| | - Julie Ann Sosa
- Department of Surgery, University of California, San Francisco, San Francisco, Calif
| | - Michael S Conte
- Department of Surgery, University of California, San Francisco, San Francisco, Calif
| | - James C Iannuzzi
- Department of Surgery, University of California, San Francisco, San Francisco, Calif.
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16
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Leiter RE, Santus E, Jin Z, Lee KC, Yusufov M, Chien I, Ramaswamy A, Moseley ET, Qian Y, Schrag D, Lindvall C. Deep Natural Language Processing to Identify Symptom Documentation in Clinical Notes for Patients With Heart Failure Undergoing Cardiac Resynchronization Therapy. J Pain Symptom Manage 2020; 60:948-958.e3. [PMID: 32585181 DOI: 10.1016/j.jpainsymman.2020.06.010] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Revised: 06/07/2020] [Accepted: 06/11/2020] [Indexed: 11/26/2022]
Abstract
CONTEXT Clinicians lack reliable methods to predict which patients with congestive heart failure (CHF) will benefit from cardiac resynchronization therapy (CRT). Symptom burden may help to predict response, but this information is buried in free-text clinical notes. Natural language processing (NLP) may identify symptoms recorded in the electronic health record and thereby enable this information to inform clinical decisions about the appropriateness of CRT. OBJECTIVES To develop, train, and test a deep NLP model that identifies documented symptoms in patients with CHF receiving CRT. METHODS We identified a random sample of clinical notes from a cohort of patients with CHF who later received CRT. Investigators labeled documented symptoms as present, absent, and context dependent (pathologic depending on the clinical situation). The algorithm was trained on 80% and fine-tuned parameters on 10% of the notes. We tested the model on the remaining 10%. We compared the model's performance to investigators' annotations using accuracy, precision (positive predictive value), recall (sensitivity), and F1 score (a combined measure of precision and recall). RESULTS Investigators annotated 154 notes (352,157 words) and identified 1340 present, 1300 absent, and 221 context-dependent symptoms. In the test set of 15 notes (35,467 words), the model's accuracy was 99.4% and recall was 66.8%. Precision was 77.6%, and overall F1 score was 71.8. F1 scores for present (70.8) and absent (74.7) symptoms were higher than that for context-dependent symptoms (48.3). CONCLUSION A deep NLP algorithm can be trained to capture symptoms in patients with CHF who received CRT with promising precision and recall.
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Affiliation(s)
- Richard E Leiter
- Harvard Medical School, Boston, Massachusetts, USA; Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA; Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA.
| | - Enrico Santus
- Massachusetts Institute of Technology, Boston, Massachusetts, USA
| | - Zhijing Jin
- Massachusetts Institute of Technology, Boston, Massachusetts, USA
| | - Katherine C Lee
- Department of Surgery, University of California San Diego Health, San Diego, California, USA
| | - Miryam Yusufov
- Harvard Medical School, Boston, Massachusetts, USA; Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Isabel Chien
- Massachusetts Institute of Technology, Boston, Massachusetts, USA
| | - Ashwin Ramaswamy
- Department of Surgery, NewYork-Presbyterian Hospital/Weill Cornell Medical Center, New York, New York, USA
| | - Edward T Moseley
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Yujie Qian
- Massachusetts Institute of Technology, Boston, Massachusetts, USA
| | - Deborah Schrag
- Harvard Medical School, Boston, Massachusetts, USA; Division of Population Sciences, Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Charlotta Lindvall
- Harvard Medical School, Boston, Massachusetts, USA; Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA; Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
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17
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Nishida H, Koda Y, Kalantari S, Nguyen A, Chung B, Grinstein J, Kim G, Sarswat N, Smith B, Song T, Onsager D, Jeevanandam V, Ota T. Outcomes of Ambulatory Axillary Intraaortic Balloon Pump as a Bridge to Heart Transplantation. Ann Thorac Surg 2020; 111:1264-1270. [PMID: 32882197 DOI: 10.1016/j.athoracsur.2020.06.077] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Revised: 06/05/2020] [Accepted: 06/11/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND The axillary intraaortic balloon pump (IABP) is frequently used in selected patients for circulatory support as a bridge to heart transplantation. The purpose of this study was to investigate the safety and efficacy of axillary intraaortic balloon pump (IABP) support for heart transplant candidates. METHODS The study investigators collected data on 133 patients who underwent axillary IABP support as a bridge to transplantation from July 2009 to April 2019. Of these patients, 94 (70.7%) underwent IABP insertion with surgical axillary grafts, and 39 (29.3%) underwent percutaneous IABP insertion. The outcomes of interest included ambulatory data, IABP-related complications, and successful heart transplantation with this type of support. RESULTS The overall preoperative ejection fraction was 20.3% ± 8.0%. The median duration of axillary IABP support was 21days, with 131patients (98.5%) mobilizing with the device. Hemodynamic variables significantly improved after the axillary IABP support was placed. Overall, 122 patients (91.7%) were successfully bridged to heart transplantation. Six patients (4.5%) required escalation to further mechanical support. Two patients (1.5%) died while awaiting transplantation. Four patients (3.0%) experienced a stroke during axillary IABP support (3 before transplantation and1 after transplantation). Two of the 3 patients with a stroke diagnosis before transplantation recovered and eventually underwent heart transplantation. CONCLUSIONS With axillary IABP support, most patients were able to ambulate and undergo physical rehabilitation while waiting for heart transplantation. This study demonstrates that axillary IABP results in a high success rate of bridge to transplantation and a low number of complications. Thus, an ambulatory axillary IABP provided efficient and safe support for selected patients as a bridge to heart transplantation.
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Affiliation(s)
- Hidefumi Nishida
- Department of Surgery, University of Chicago Medicine, Chicago, Illinois
| | - Yojiro Koda
- Department of Surgery, University of Chicago Medicine, Chicago, Illinois
| | - Sara Kalantari
- Department of Medicine, University of Chicago Medicine, Chicago, Illinois
| | - Ann Nguyen
- Department of Medicine, University of Chicago Medicine, Chicago, Illinois
| | - Bow Chung
- Department of Medicine, University of Chicago Medicine, Chicago, Illinois
| | - Jonathan Grinstein
- Department of Medicine, University of Chicago Medicine, Chicago, Illinois
| | - Gene Kim
- Department of Medicine, University of Chicago Medicine, Chicago, Illinois
| | - Nitasha Sarswat
- Department of Medicine, University of Chicago Medicine, Chicago, Illinois
| | - Bryan Smith
- Department of Medicine, University of Chicago Medicine, Chicago, Illinois
| | - Tae Song
- Department of Surgery, University of Chicago Medicine, Chicago, Illinois
| | - David Onsager
- Department of Surgery, University of Chicago Medicine, Chicago, Illinois
| | | | - Takeyoshi Ota
- Department of Surgery, University of Chicago Medicine, Chicago, Illinois.
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18
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Gazda AJ, Kwak MJ, Akkanti B, Nathan S, Kumar S, de Armas IS, Baer P, Patel B, Kar B, Gregoric ID. Complications of LVAD utilization in older adults. Heart Lung 2020; 50:75-79. [PMID: 32709497 DOI: 10.1016/j.hrtlng.2020.07.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Revised: 07/08/2020] [Accepted: 07/13/2020] [Indexed: 11/24/2022]
Abstract
BACKGROUND Yearly rate and mean patient age of left ventricular assist device (LVAD) implantation increased from 2009 to 2014. Data are lacking regarding trends of LVAD implantation in older adults. OBJECTIVES To describe the trends of LVAD implantation in older adults and the clinical impact of associated procedural complications. METHODS We retrospectively analyzed the National Inpatient Sample from 2005 to 2014, calculated the percentage of older adults (>65 years of age) among those who underwent LVAD implantation, and compared their clinical characteristics. Primary outcomes were in-hospital mortality and discharge home. RESULTS In total, 4491 patients were included. The percentage of older adults among those receiving LVAD increased from 12.53% to 31.65% (p<0.01). Older adults were more likely to develop postoperative delirium (17.90% vs. 11.92% in younger patients; p<0.01), which portended lesser odds of discharge home. CONCLUSIONS Delirium develops with greater incidence in older adults undergoing LVAD implantation, which decreases odds of favorable discharge disposition.
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Affiliation(s)
- Alexander J Gazda
- Department of Internal Medicine, McGovern Medical School, Houston, TX
| | - Min Ji Kwak
- Department of Internal Medicine: Geriatric and Palliative Care Medicine, McGovern Medical School, 6431 Fannin St MSB 5.126 Houston, TX 77030, USA.
| | - Bindu Akkanti
- Department of Internal Medicine, McGovern Medical School, Houston, TX; Department of Internal Medicine: Pulmonary, Critical Care and Sleep Medicine, McGovern Medical School, Houston, TX, USA
| | - Sriram Nathan
- Department of Advanced Cardiopulmonary Therapeutics and Transplantation, McGovern Medical School, Houston, TX, USA
| | - Sachin Kumar
- Department of Advanced Cardiopulmonary Therapeutics and Transplantation, McGovern Medical School, Houston, TX, USA
| | - Ismael Salas de Armas
- Department of Advanced Cardiopulmonary Therapeutics and Transplantation, McGovern Medical School, Houston, TX, USA
| | - Patrick Baer
- Memorial Hermann Hospital, Trauma Service Line, Houston, TX, USA
| | - Bela Patel
- Department of Internal Medicine, McGovern Medical School, Houston, TX; Department of Internal Medicine: Pulmonary, Critical Care and Sleep Medicine, McGovern Medical School, Houston, TX, USA
| | - Biswajit Kar
- Department of Advanced Cardiopulmonary Therapeutics and Transplantation, McGovern Medical School, Houston, TX, USA
| | - Igor D Gregoric
- Department of Advanced Cardiopulmonary Therapeutics and Transplantation, McGovern Medical School, Houston, TX, USA
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19
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Gonuguntla K, Patil S, Cowden RG, Kumar M, Rojulpote C, Bhattaru A, Tiu JG, Robinson P. Predictors of in-hospital mortality in patients with left ventricular assist device. Ir J Med Sci 2020; 189:1275-1281. [DOI: 10.1007/s11845-020-02246-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Accepted: 04/28/2020] [Indexed: 01/09/2023]
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20
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Saeed MY, Van Story D, Payne CJ, Wamala I, Shin B, Bautista-Salinas D, Zurakowski D, del Nido PJ, Walsh CJ, Vasilyev NV. Dynamic Augmentation of Left Ventricle and Mitral Valve Function With an Implantable Soft Robotic Device. JACC Basic Transl Sci 2020; 5:229-242. [PMID: 32215347 PMCID: PMC7091510 DOI: 10.1016/j.jacbts.2019.12.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2019] [Revised: 12/03/2019] [Accepted: 12/03/2019] [Indexed: 01/18/2023]
Abstract
Left ventricular failure is strongly associated with secondary mitral valve regurgitation. Implantable soft robotic devices are an emerging technology that enables augmentation of a native function of a target tissue. We demonstrate the ability of a novel soft robotic ventricular assist device to dynamically augment left ventricular contraction, provide native pulsatile flow, simultaneously reshape the mitral valve apparatus, and eliminate the associated regurgitation in an Short-term large animal model of acute left ventricular systolic dysfunction.
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Key Words
- FS, fractional shortening
- HF, heart failure
- IQR, interquartile range
- IVS, interventricular septum
- LHF, left heart failure
- LV, left ventricular
- LVEDP, left ventricular end-diastolic pressure
- LVSD, left ventricular systolic dysfunction
- MV, mitral valve
- MVR, mitral valve regurgitation
- RV, right ventricle
- SRVAD, soft robotic ventricular assist device
- left ventricular systolic dysfunction
- mitral valve
- secondary mitral regurgitation
- soft robotic
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Affiliation(s)
- Mossab Y. Saeed
- Department of Cardiac Surgery, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - David Van Story
- Department of Cardiac Surgery, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Christopher J. Payne
- Department of Cardiac Surgery, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts
- Wyss Institute for Biologically Inspired Engineering, Harvard University, Boston, Massachusetts
- John A. Paulson Harvard School of Engineering and Applied Sciences, Harvard University, Boston, Massachusetts
| | - Isaac Wamala
- Department of Cardiac Surgery, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Borami Shin
- Department of Cardiac Surgery, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Daniel Bautista-Salinas
- Department of Cardiac Surgery, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts
- School of Industrial Engineering, Technical University of Cartagena, Cartagena, Spain
| | - David Zurakowski
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Pedro J. del Nido
- Department of Cardiac Surgery, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Conor J. Walsh
- Wyss Institute for Biologically Inspired Engineering, Harvard University, Boston, Massachusetts
- John A. Paulson Harvard School of Engineering and Applied Sciences, Harvard University, Boston, Massachusetts
| | - Nikolay V. Vasilyev
- Department of Cardiac Surgery, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts
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21
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Sanaiha Y, Downey P, Lyons R, Nsair A, Shemin RJ, Benharash P. Trends in utilization, mortality, and resource use after implantation of left ventricular assist devices in the United States. J Thorac Cardiovasc Surg 2020; 161:2083-2091.e4. [PMID: 32249087 DOI: 10.1016/j.jtcvs.2019.12.121] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2019] [Revised: 12/11/2019] [Accepted: 12/18/2019] [Indexed: 10/25/2022]
Abstract
OBJECTIVES Adoption of implantable left ventricular assist devices has dramatically improved survival and quality of life in suitable patients with end-stage heart failure. In the era of value-based healthcare delivery, assessment of clinical outcomes and resource use associated with left ventricular assist devices is warranted. METHODS Adult patients undergoing left ventricular assist device implantation from 2008 to 2016 were identified using the National Inpatient Sample. Hospitals were designated as low-volume, medium-volume, or high-volume institutions based on annual institutional left ventricular assist device case volume. Multivariable logistic regression was used to evaluate adjusted odds of mortality across left ventricular assist device volume tertiles. RESULTS Over the study period, an estimated 23,972 patients underwent left ventricular assist device implantation with an approximately 3-fold increase in the number of annual left ventricular assist device implantations performed (P for trend <.001). In-hospital mortality in patients with left ventricular assist devices decreased from 19.6% in 2008 to 8.1% in 2016 (P for trend <.001) and was higher at low-volume institutions compared with high-volume institutions (12.0% vs 9.2%, P < .001). Although the overall adjusted mortality was higher at low-volume compared with high-volume institutions (adjusted odds ratio, 1.66; 95% confidence interval, 1.28-2.15), this discrepancy was only significant for 2008 and 2009 (low-volume 2008 adjusted odds ratio, 5.5; 95% confidence interval, 1.9-15.8; low-volume 2009 adjusted odds ratio, 2.3; 95% confidence interval, 1.4-3.8). CONCLUSIONS Left ventricular assist device use has rapidly increased in the United States with a concomitant reduction in mortality and morbidity. With maturation of left ventricular assist device technology and increasing experience, volume-related variation in mortality and resource use has diminished. Whether the apparent uniformity in outcomes is related to patient selection or hospital quality deserves further investigation.
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Affiliation(s)
- Yas Sanaiha
- Cardiovascular Outcomes Research Laboratories (CORELAB), University of California Los Angeles, Los Angeles, Calif
| | - Peter Downey
- Cardiovascular Outcomes Research Laboratories (CORELAB), University of California Los Angeles, Los Angeles, Calif; Division of Cardiac Surgery, University of California Los Angeles, Los Angeles, Calif
| | - Robert Lyons
- Cardiovascular Outcomes Research Laboratories (CORELAB), University of California Los Angeles, Los Angeles, Calif; Division of Cardiac Surgery, University of California Los Angeles, Los Angeles, Calif
| | - Ali Nsair
- Ahmanson/UCLA Cardiomyopathy Center, Los Angeles, Calif
| | - Richard J Shemin
- Cardiovascular Outcomes Research Laboratories (CORELAB), University of California Los Angeles, Los Angeles, Calif; Division of Cardiac Surgery, University of California Los Angeles, Los Angeles, Calif
| | - Peyman Benharash
- Cardiovascular Outcomes Research Laboratories (CORELAB), University of California Los Angeles, Los Angeles, Calif; Division of Cardiac Surgery, University of California Los Angeles, Los Angeles, Calif.
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Jawitz OK, Fudim M, Raman V, Blumer V, Caliskan K, DeVore AD, Mentz RJ, Milano C, Soliman O, Rogers J, Patel CB. Renal Outcomes in Patients Bridged to Heart Transplant With a Left Ventricular Assist Device. Ann Thorac Surg 2020; 110:567-574. [PMID: 31904371 DOI: 10.1016/j.athoracsur.2019.11.021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2019] [Revised: 09/10/2019] [Accepted: 11/11/2019] [Indexed: 01/06/2023]
Abstract
BACKGROUND Patients with end-stage heart failure are increasingly being bridged to heart transplant (BTT) with mechanical circulatory support; however the association between a left ventricular assist device (LVAD) BTT strategy and posttransplant renal outcomes is unclear. The aim of this study was to analyze the association of LVAD BTT with the development of posttransplant renal failure using a large national registry. METHODS We queried the 2009 to 2018 United Network for Organ Sharing registry for all adults undergoing first-time heart or heart-kidney transplantation and stratified patients by use of pretransplant durable LVAD. The primary outcome of interest was posttransplant renal failure, which was evaluated with multivariable logistic regression. RESULTS Of 18,307 patients meeting inclusion criteria, 7887 were (43%) and 10,420 were not (57%) BTT with an LVAD. BTT patients had slightly better baseline renal function (estimated glomerular filtration rate, 68.7 vs 65.8 mL/min, P < .001) and were less likely to receive a heart-kidney transplant (2.7% vs 4.8%, P < .001). On multivariable logistic regression, LVAD BTT strategy was not independently associated with posttransplant renal failure (odds ratio, 1.13; 95% confidence interval, 0.86-1.49). Similarly LVAD BTT among patients with preoperative renal dysfunction was not associated with posttransplant renal failure (adjusted odds ratio, 1.40; 95% confidence interval, 0.91-2.18). CONCLUSIONS BTT with an LVAD does not appear to be associated with worse renal outcomes regardless of baseline renal function. Furthermore, an LVAD BTT strategy in patients with chronic kidney disease may enable clinicians to identify candidates suitable for isolated heart transplantation without increasing their risk for posttransplant renal failure.
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Affiliation(s)
- Oliver K Jawitz
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina; Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina.
| | - Marat Fudim
- Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina; Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, North Carolina
| | - Vignesh Raman
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Vanessa Blumer
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, North Carolina
| | - Kadir Caliskan
- Department of Cardiology, Erasmus University, Rotterdam, Netherlands
| | - Adam D DeVore
- Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina; Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, North Carolina
| | - Robert J Mentz
- Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina; Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, North Carolina
| | - Carmelo Milano
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Osama Soliman
- Department of Cardiology, College of Medicine, Nursing and Health Science, National University of Ireland Galway, Galway, Ireland
| | - Joseph Rogers
- Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina; Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, North Carolina
| | - Chetan B Patel
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, North Carolina
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Trends in Firearm Injuries Among Children and Teenagers in the United States. J Surg Res 2020; 245:529-536. [DOI: 10.1016/j.jss.2019.07.056] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2019] [Revised: 06/22/2019] [Accepted: 07/18/2019] [Indexed: 01/12/2023]
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Cram P, Girotra S, Matelski J, Koh M, Landon B, Han L, Lee DS, Ko DT. Utilization of Advanced Cardiovascular Therapies in the United States and Canada: An Observational Study of New York and Ontario Administrative Data. Circ Cardiovasc Qual Outcomes 2020; 13:e006037. [PMID: 31957474 PMCID: PMC7006709 DOI: 10.1161/circoutcomes.119.006037] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2019] [Accepted: 12/03/2019] [Indexed: 12/19/2022]
Abstract
BACKGROUND Endovascular aortic aneurysm repair (EVAR), left ventricular assist device (LVAD), and transcatheter aortic valve replacement (TAVR) are expensive cardiovascular technologies with potential to benefit large numbers of patients. There are few population-based studies comparing utilization between countries. Our objective was to compare patient characteristics and utilization patterns of EVAR, LVAD, and TAVR in Ontario, Canada, and New York State, United States. METHODS AND RESULTS We performed a retrospective cohort study using administrative data to identify all adults who received EVAR, LVAD, or TAVR in Ontario and New York between 2012 and 2015. We compared socio-demographics of EVAR, LVAD, and TAVR recipients in Ontario and New York. We compared standardized utilization rates between jurisdictions for each procedure. We identified 3295 EVAR recipients from Ontario and 6236 from New York (mean age 74.6 versus 74.5 years; P=0.61): 136 LVAD recipients from Ontario and 686 from New York (age, 57.4 versus 57.7 years; P=0.80): 1708 TAVR recipients from Ontario and 4838 from New York (age, 83.1 versus 83.1; P=1.0). A significantly smaller percentage of EVAR and TAVR recipients in Ontario were female compared to New York (EVAR, 15.8% versus 22.1% female; P<0.001; TAVR, 45.9% versus 51.8%; P<0.001), but for LVAD the percentage female was similar (21.3% versus 20.8%; P=0.99). Utilization was significantly higher in New York for all procedures: EVAR (12.8 procedures per-100 000 adults per-year in Ontario, 20.2 in New York; P<0.001); LVAD (0.3 in Ontario versus 1.3 in New York; P<0.001); and TAVR (6.6 in Ontario, 14.3 in New York; P<0.001). Higher utilization of EVAR and TAVR in New York relative to Ontario increased substantially with increasing age. CONCLUSIONS We observed significantly higher utilization of EVAR, LVAD, and TAVR in New York compared to Ontario. Our results highlight important differences in how 2 different countries are using advanced cardiovascular therapies.
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Affiliation(s)
- Peter Cram
- Department of Medicine, University of Toronto, Toronto, ON
- Division of General Internal Medicine and Geriatrics, Sinai Health System and University Health Network, Toronto, ON
- ICES, Toronto, ON
- North American Observatory on Health Systems and Policies, University of Toronto, Toronto, ON
| | - Saket Girotra
- Department of Medicine, University of Iowa, Iowa City, IA
- Comprehensive Access Delivery Research and Evaluation, Iowa City Veterans Affairs Medical Center, Iowa City, IA
| | - John Matelski
- Division of General Internal Medicine and Geriatrics, Sinai Health System and University Health Network, Toronto, ON
| | | | - Bruce Landon
- Department of Health Care Policy, Harvard Medical School and Division of General Medicine, Beth Israel Deaconess Medical Center
| | | | - Douglas S. Lee
- Department of Medicine, University of Toronto, Toronto, ON
- ICES, Toronto, ON
- Peter Munk Cardiac Centre and Joint Department of Medical Imaging, University Health Network, Toronto, ON
- Institute of Health Policy, Management & Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON
| | - Dennis T. Ko
- Department of Medicine, University of Toronto, Toronto, ON
- ICES, Toronto, ON
- Division of Cardiology, Schulich Heart Centre, Sunnybrook Health Sciences Centre, Toronto, ON
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Benjamin EJ, Muntner P, Alonso A, Bittencourt MS, Callaway CW, Carson AP, Chamberlain AM, Chang AR, Cheng S, Das SR, Delling FN, Djousse L, Elkind MSV, Ferguson JF, Fornage M, Jordan LC, Khan SS, Kissela BM, Knutson KL, Kwan TW, Lackland DT, Lewis TT, Lichtman JH, Longenecker CT, Loop MS, Lutsey PL, Martin SS, Matsushita K, Moran AE, Mussolino ME, O'Flaherty M, Pandey A, Perak AM, Rosamond WD, Roth GA, Sampson UKA, Satou GM, Schroeder EB, Shah SH, Spartano NL, Stokes A, Tirschwell DL, Tsao CW, Turakhia MP, VanWagner LB, Wilkins JT, Wong SS, Virani SS. Heart Disease and Stroke Statistics-2019 Update: A Report From the American Heart Association. Circulation 2019; 139:e56-e528. [PMID: 30700139 DOI: 10.1161/cir.0000000000000659] [Citation(s) in RCA: 5401] [Impact Index Per Article: 1080.2] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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Zahner GJ, Cortez A, Duralde E, Ramirez JL, Wang S, Hiramoto J, Cohen BE, Wolkowitz OM, Arya S, Hills NK, Grenon SM. Association of comorbid depression with inpatient outcomes in critical limb ischemia. Vasc Med 2019; 25:25-32. [DOI: 10.1177/1358863x19880277] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
There is a growing body of evidence that peripheral artery disease (PAD) may be impacted by depression. The objective of this study is to determine whether outcomes, primarily major amputation, differ between patients with depression and those without who presented to hospitals with critical limb ischemia (CLI), the end-stage of PAD. A retrospective cohort of patients hospitalized for CLI during 2012 and 2013 was identified from the National Inpatient Sample (NIS) using ICD-9 codes. The primary outcome was major amputation and secondary outcomes were length of stay and other complications. The sample included 116,008 patients hospitalized for CLI, of whom 10,512 (9.1%) had comorbid depression. Patients with depression were younger (64 ± 14 vs 67 ± 14 years, p < 0.001) and more likely to be female (55% vs 41%, p < 0.001), white (73% vs 66%, p < 0.001), and tobacco users (46% vs 41%, p < 0.001). They were also more likely to have prior amputations (9.8% vs 7.9%, p < 0.001). During the hospitalization, the rate of major amputation was higher in patients with comorbid depression (11.5% vs 9.1%, p < 0.001). In multivariable analysis, excluding patients who died prior to/without receiving an amputation ( n = 2621), comorbid depression was associated with a 39% increased odds of major amputation (adjusted OR 1.39, 95% CI 1.30, 1.49; p < 0.001). Across the entire sample, comorbid depression was also independently associated with a slightly longer length of stay (β = 0.199, 95% CI 0.155, 0.244; p < 0.001). These results provide further evidence that depression is a variable of interest in PAD and surgical quality databases should include mental health variables to enable further study.
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Affiliation(s)
- Greg J Zahner
- Department of Surgery, University of California, San Francisco, San Francisco, CA, USA
| | - Abigail Cortez
- Department of Orthopedic Surgery, University of California, Los Angeles, Los Angeles, CA, USA
| | - Erin Duralde
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Joel L Ramirez
- Department of Surgery, University of California, San Francisco, San Francisco, CA, USA
| | - Sue Wang
- Department of Surgery, Brigham and Women’s Hospitals, Boston, MA, USA
| | - Jade Hiramoto
- Department of Surgery, University of California, San Francisco, San Francisco, CA, USA
| | - Beth E Cohen
- Department of Medicine, University of California, San Francisco, San Francisco, CA, USA
- Department of Medicine, Veterans Affairs Medical Center, San Francisco, CA, USA
| | - Owen M Wolkowitz
- Department of Psychiatry, University of California, San Francisco, San Francisco, CA, USA
| | - Shipra Arya
- Department of Surgery, Division of Vascular Surgery, Stanford University, Stanford, CA, USA
- Surgical Services, VA Palo Alto Medical Center, Palo Alto, CA, USA
| | - Nancy K Hills
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA, USA
| | - S Marlene Grenon
- Department of Surgery, University of California, San Francisco, San Francisco, CA, USA
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Sanaiha Y, Xing H, Morales RR, Morchi R, Ragalie W, Benharash P. Abdominal Operations After Left Ventricular Assist Device Implantation and Heart Transplantation. J Surg Res 2019; 243:481-487. [DOI: 10.1016/j.jss.2019.06.045] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2019] [Revised: 05/02/2019] [Accepted: 06/10/2019] [Indexed: 02/07/2023]
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Lindvall C, Udelsman B, Malhotra D, Brovman EY, Urman RD, D'Alessandro DA, Tulsky JA. In-hospital mortality in older patients after ventricular assist device implantation: A national cohort study. J Thorac Cardiovasc Surg 2019; 158:466-475.e4. [DOI: 10.1016/j.jtcvs.2018.10.142] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2018] [Revised: 09/10/2018] [Accepted: 10/17/2018] [Indexed: 01/24/2023]
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Walther CP, Winkelmayer WC, Niu J, Cheema FH, Nair AP, Morgan JA, Fedson SE, Deswal A, Navaneethan SD. Acute Kidney Injury With Ventricular Assist Device Placement: National Estimates of Trends and Outcomes. Am J Kidney Dis 2019; 74:650-658. [PMID: 31160142 DOI: 10.1053/j.ajkd.2019.03.423] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2018] [Accepted: 03/12/2019] [Indexed: 11/11/2022]
Abstract
RATIONALE & OBJECTIVE Ventricular assist devices (VADs) are used for end-stage heart failure not amenable to medical therapy. Acute kidney injury (AKI) in this setting is common due to heart failure decompensation, surgical stress, and other factors. Little is known about national trends in AKI diagnosis and AKI requiring dialysis (AKI-D) and associated outcomes with VAD implantation. We investigated national estimates and trends for diagnosed AKI, AKI-D, and associated patient and resource utilization outcomes in hospitalizations in which implantable VADs were placed. STUDY DESIGN Cohort study of 20% stratified sample of US hospitalizations. SETTING & PARTICIPANTS Patients who underwent implantable VAD placement in 2006 to 2015. EXPOSURE No AKI diagnosis, AKI without dialysis, AKI-D. OUTCOMES In-hospital mortality, length of stay, estimated hospitalization costs. ANALYTICAL APPROACH Multivariate logistic and linear regression using survey design methods to account for stratification, clustering, and weighting. RESULTS An estimated 24,140 implantable VADs were placed, increasing from 853 in 2006 to 3,945 in 2015. AKI was diagnosed in 56.1% of hospitalizations and AKI-D occurred in 6.5%. AKI diagnosis increased from 44.0% in 2006 to 2007 to 61.7% in 2014 to 2015; AKI-D declined from 9.3% in 2006 to 2007 to 5.2% in 2014 to 2015. Mortality declined in all AKI categories but this varied by category: those with AKI-D had the smallest decline. Adjusted hospitalization costs were 19.1% higher in those with diagnosed AKI and 39.6% higher in those with AKI-D, compared to no AKI. LIMITATIONS Administrative data; timing of AKI with respect to VAD implantation cannot be determined; limited pre-existing chronic kidney disease ascertainment; discharge weights not derived for subpopulation of interest. CONCLUSIONS A decreasing proportion of patients undergoing VAD implantation experience AKI-D, but mortality among these patients remains high. AKI diagnosis with VAD implantation is increasing, possibly reflecting changes in AKI surveillance, awareness, and coding.
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Affiliation(s)
- Carl P Walther
- Selzman Institute for Kidney Health, Section of Nephrology, Department of Medicine.
| | | | - Jingbo Niu
- Selzman Institute for Kidney Health, Section of Nephrology, Department of Medicine
| | - Faisal H Cheema
- Division of Cardiothoracic Transplantation and Circulatory Support
| | - Ajith P Nair
- Section of Cardiology, Department of Medicine, Baylor College of Medicine
| | - Jeffrey A Morgan
- Division of Cardiothoracic Transplantation and Circulatory Support; Department of Cardiopulmonary Transplantation and Center for Cardiac Support, Texas Heart Institute
| | - Savitri E Fedson
- Section of Cardiology, Department of Medicine, Baylor College of Medicine; Section of Cardiology, Michael E. DeBakey Veterans Affairs Medical Center; Center for Medical Ethics and Health Policy, Baylor College of Medicine
| | - Anita Deswal
- Section of Cardiology, Department of Medicine, Baylor College of Medicine; Section of Cardiology, Michael E. DeBakey Veterans Affairs Medical Center
| | - Sankar D Navaneethan
- Selzman Institute for Kidney Health, Section of Nephrology, Department of Medicine; Section of Nephrology, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX
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30
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Tankumpuan T, Asano R, Koirala B, Dennison-Himmelfarb C, Sindhu S, Davidson PM. Heart failure and social determinants of health in Thailand: An integrative review. Heliyon 2019; 5:e01658. [PMID: 31193015 PMCID: PMC6513778 DOI: 10.1016/j.heliyon.2019.e01658] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2018] [Revised: 12/10/2018] [Accepted: 05/01/2019] [Indexed: 12/26/2022] Open
Abstract
Background Heart failure is a highly burdensome syndrome and is rapidly increasing in prevalence in low and middle-income countries and outcomes are influenced at the level of the patient, provider and health system. Understanding heart failure beyond a biomedical perspective and the relationship between health outcomes and social determinants of health is critical for informing policy development and improving health outcomes. Aim To identify the social determinants of health for improving health outcomes for individuals with heart failure in Thailand. Method This integrative review included studies published between January 1, 2008, and March 31, 2016 in both the Thai and English language identified through searching Scopus, PubMed, and CINAHL. Results Six experimental, eight descriptive and two qualitative studies were identified met the inclusion and exclusion criteria. The majority of study participants were elderly, female, had low-education and income levels, were participating in a universal coverage scheme and living in a rural setting. All interventions were delivered at the level of the individual, focusing on education to improve knowledge, self-care, and functional status. Findings showed an improvement in health outcomes which were moderated by social determinants of health such as gender and income. Conclusion As the burden of heart failure increases in Thailand and other emerging economies, developing culturally appropriate, affordable and acceptable models of intervention considering social determinants of health is necessary.
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Affiliation(s)
| | - Reiko Asano
- The Johns Hopkins University School of Nursing, United States
| | - Binu Koirala
- The Johns Hopkins University School of Nursing, United States
| | | | | | - Patricia M Davidson
- The Johns Hopkins University School of Nursing, United States.,University of Technology Sydney, Australia
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Outcomes after left ventricular assist device implantation in patients with acute kidney injury. J Thorac Cardiovasc Surg 2019; 159:477-486.e3. [PMID: 31053433 DOI: 10.1016/j.jtcvs.2019.03.064] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2018] [Revised: 02/28/2019] [Accepted: 03/22/2019] [Indexed: 01/09/2023]
Abstract
OBJECTIVE The study objective was to compare outcomes for patients with and without acute kidney injury during hospitalizations when left ventricular assist devices are implanted. METHODS By using the National Inpatient Sample from 2008 to 2013, we identified patients with an International Classification of Diseases, Ninth Revision procedure code for left ventricular assist device implantation (37.66). We ascertained the presence of acute kidney injury and acute kidney injury requiring dialysis using validated International Classification of Diseases, Ninth Revision codes. We used logistic regression to examine the association of nondialysis-requiring acute kidney injury and acute kidney injury requiring dialysis with mortality, procedural complications, and discharge destination. RESULTS We identified 8362 patients who underwent left ventricular assist device implantation, of whom 3760 (45.0%) experienced nondialysis-requiring acute kidney injury and 426 (5.1%) experienced acute kidney injury requiring dialysis. In-hospital mortality was 3.9% for patients without acute kidney injury, 12.2% for patients with nondialysis-requiring acute kidney injury, and 47.4% for patients with acute kidney injury requiring dialysis. Patients with nondialysis-requiring acute kidney injury and acute kidney injury requiring dialysis had higher adjusted odds of mortality (3.24, 95% confidence interval [CI], 2.04-5.13 and 20.8, 95% CI, 9.7-44.2), major bleeding (1.38, 95% CI, 1.08-1.77 and 2.44, 95% CI, 1.47-4.04), sepsis (2.69, 95% CI, 1.93-3.75 and 5.75, 95% CI, 3.46-9.56), and discharge to a nursing facility (2.15, 95% CI, 1.51-3.07 and 5.89, 95% CI, 2.67-12.99). CONCLUSIONS More than 1 in 10 patients with acute kidney injury and approximately 1 in 2 patients with acute kidney injury requiring dialysis died during their hospitalization, with only 30% of patients with acute kidney injury requiring dialysis discharged to home. This information is necessary to support shared decision-making for patients with advanced heart failure and acute kidney injury.
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Thompson MP, Pagani FD, Liang Q, Franko LR, Zhang M, McCullough JS, Strobel RJ, Aaronson KD, Kormos RL, Likosky DS. Center Variation in Medicare Spending for Durable Left Ventricular Assist Device Implant Hospitalizations. JAMA Cardiol 2019; 4:153-160. [PMID: 30698605 PMCID: PMC6439617 DOI: 10.1001/jamacardio.2018.4717] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2018] [Accepted: 11/30/2018] [Indexed: 12/15/2022]
Abstract
Importance Hospitalizations for durable left ventricular assist device (LVAD) implants are expensive and increasingly common. Insights into center-level variation in Medicare spending for these hospitalizations are needed to inform value improvement efforts. Objective To examine center-level variation in Medicare spending for durable LVAD implant hospitalizations and its association with clinical outcomes. Design, Setting, and Participants Retrospective cohort study of linked Medicare administrative claims and Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) clinical data comprising 106 centers in the United States providing durable LVAD implant. Centers were grouped into quartiles based on the mean price-standardized Medicare spending of their patients. The study included Medicare beneficiaries receiving primary durable LVAD implant between January 2008 and December 2014. Data were analyzed between November 2017 and October 2018. Main Outcomes and Measures Price-standardized Medicare payments and clinical outcomes. Overall and component (facility diagnosis-related group payments, outlier payments, physician services) payments and clinical outcomes (postimplant length of stay and adverse events) were compared across payment quartiles. Results The study sample included 4442 hospitalized patients, with mean (SD) age of 63.0 (10.8) years, 18.7% female, 27.2% nonwhite, and 6.1% Hispanic ethnicity. Among 4442 hospitalizations, the mean (SD) price-standardized Medicare payment was $176 825 ($60 286) and ranged from $122 953 to $271 472 across 106 centers. The difference in price-standardized payments between lowest and highest spending quartiles was $55 446 ($152 714 vs $208 160; 36%; P < .001), with outlier payments making up most of the difference ($42 742; 77%), followed by DRG ($6929; 13%) and physician services ($5774; 10%). After risk standardization, there was a modest decline in the difference in payments between quartiles ($53 221; 35%), with outlier payments accounting for a larger proportion of the difference (84%). After adjusting for patient characteristics, higher price-standardized payment quartiles were associated with longer postimplant length of stay but were not associated with any adverse events. Conclusions and Relevance Medicare payments for durable LVAD implant hospitalizations vary widely across centers; this was not well explained by prices or case mix. While associated with longer postimplant length of stay, increased spending was not associated with adverse events. As the supply and demand for durable LVAD therapy continues to rise, identifying opportunities to reduce variation in spending from both explained and unexplained sources will ensure high-value use.
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Affiliation(s)
- Michael P. Thompson
- Department of Cardiac Surgery, University of Michigan Medical School, Ann Arbor
| | - Francis D. Pagani
- Department of Cardiac Surgery, University of Michigan Medical School, Ann Arbor
| | - Qixing Liang
- School of Public Health, Department of Biostatistics, University of Michigan, Ann Arbor
| | | | - Min Zhang
- School of Public Health, Department of Biostatistics, University of Michigan, Ann Arbor
| | - Jeffrey S. McCullough
- Department of Health Management and Policy, School of Public Health, University of Michigan
| | | | - Keith D. Aaronson
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor
| | - Robert L. Kormos
- Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Donald S. Likosky
- Department of Cardiac Surgery, University of Michigan Medical School, Ann Arbor
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Vallabhajosyula S, Arora S, Sakhuja A, Lahewala S, Kumar V, Shantha GPS, Egbe AC, Stulak JM, Gersh BJ, Gulati R, Rihal CS, Prasad A, Deshmukh AJ. Trends, Predictors, and Outcomes of Temporary Mechanical Circulatory Support for Postcardiac Surgery Cardiogenic Shock. Am J Cardiol 2019; 123:489-497. [PMID: 30473325 DOI: 10.1016/j.amjcard.2018.10.029] [Citation(s) in RCA: 62] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2018] [Revised: 10/24/2018] [Accepted: 10/29/2018] [Indexed: 12/30/2022]
Abstract
Postcardiac surgery cardiogenic shock (PCCS) is seen in 2% to 6% of patients who undergo cardiac surgery. There are limited large-scale data on the use of mechanical circulatory support (MCS) in these patients. This study sought to evaluate the in-hospital mortality, trends, and resource utilization for PCCS admissions with and without MCS. A retrospective cohort of PCCS between 2005 and 2014 with and without the use of temporary MCS was identified from the National Inpatient Sample. Admissions for permanent MCS and heart transplant were excluded. Propensity-matching for baseline characteristics was performed. The primary outcome was in-hospital mortality and secondary outcomes included trends in use, hospital costs and lengths of stay. In the period between 2005 and 2014, there were 132,485 admissions with PCCS, with 51.3% requiring MCS. The intra-aortic balloon pump was the predominant device used with a steady increase in other devices. MCS use for more frequent in younger patients, males and those with higher co-morbidity. There was a decrease in MCS use across all demographic categories and hospital characteristics over time. Older age, female sex, previous cardiovascular morbidity and MCS use were independently predictive of higher in-hospital mortality. In 6,830 propensity-matched pairs, PCCS admissions that required MCS use, had higher in-hospital mortality (odds ratio 2.4; p<0.001), higher hospital costs ($98,759 ± 907 vs $81,099 ± 698; p<0.001) but not a longer length of stay compared with those without MCS use. In conclusion, in patients with PCCS, this study noted a steady decrease in MCS use. Use of MCS identified PCCS patients at higher risk for in-hospital mortality and greater resource utilization.
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Affiliation(s)
- Saraschandra Vallabhajosyula
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota; Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic, Rochester, Minnesota
| | - Shilpkumar Arora
- Division of Cardiovascular Diseases, Department of Medicine, Robert Packer Hospital/Guthrie Clinic, Towanda, Pennsylvania
| | - Ankit Sakhuja
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic, Rochester, Minnesota
| | - Sopan Lahewala
- Division of Cardiovascular Diseases, Department of Medicine, Jersey City Medical Center, Jersey City, New Jersey
| | - Varun Kumar
- Division of Cardiovascular Diseases, Department of Medicine, Robert Packer Hospital/Guthrie Clinic, Towanda, Pennsylvania
| | - Ghanshyam P S Shantha
- Division of Cardiovascular Diseases, Department of Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa
| | - Alexander C Egbe
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - John M Stulak
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
| | - Bernard J Gersh
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Rajiv Gulati
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Charanjit S Rihal
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Abhiram Prasad
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
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Shah Z, Vuddanda V, Rali A, Pamulapati H, Masoomi R, Gupta K. National Trends and Procedural Complications from Endomyocardial Biopsy: Results from the National Inpatient Sample, 2007–2014. Cardiology 2018; 141:125-131. [DOI: 10.1159/000493786] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2018] [Accepted: 09/12/2018] [Indexed: 11/19/2022]
Abstract
Aim: The aim of this study is to report recent trends in the performance of endomyocardial biopsy (EMB) and its in-hospital complications (and their predictors) in the United States (US). Method: We analyzed Nationwide Inpatient Sample (NIS) database from years 2007 through 2014 to identify patients who underwent EMB. Once identified, the patients were subdivided into those with no history of heart transplant (HT) (cohort 1) and those with history of HT (cohort 2). We then studied the major complication of pericardial effusion, hemopericardium or/and cardiac tamponade that required a pericardiocentesis or a pericardial window (CTRPD) following the EMB procedure. Results: We observed a steady increase in the in-patient EMB procedures, with more EMB procedures being performed in males and in Caucasians. In cohort 1, the CTRPD was higher (0.70%) as compared to cohort 2 (0.19; p = 0.01). CTRPD in women was higher compared to men (0.94 vs. 0.53% p = 0.022). Most of the EMB procedures are performed in teaching hospitals. The CTRPD rate was significantly higher in the nonteaching hospitals when compared to teaching hospitals in both cohort 1 and cohort 2 (3.4 vs. 0.53% and 1 vs.0.18%, respectively; p = 0.01 and < 0.001, respectively). The overall mortality in cohort 1 was 4.3% as compared to 2.5% in cohort 2; p = 0.01. In cohort 1, the mortality was significantly higher in the group that had EMB-related complications versus the group without the complications (20 vs. 2.5%; p < 0.001). Conclusion: There has been an increase in the number of EMB procedures in the US in recent years. Though the overall risk of CTRPD is very low, the risk is significantly higher in cohort 1, women, and in nonteaching hospitals. The study results provide data benchmarks for assessing EMB outcomes in the US.
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Vallabhajosyula S, Arora S, Lahewala S, Kumar V, Shantha GPS, Jentzer JC, Stulak JM, Gersh BJ, Gulati R, Rihal CS, Prasad A, Deshmukh AJ. Temporary Mechanical Circulatory Support for Refractory Cardiogenic Shock Before Left Ventricular Assist Device Surgery. J Am Heart Assoc 2018; 7:e010193. [PMID: 30571481 PMCID: PMC6404446 DOI: 10.1161/jaha.118.010193] [Citation(s) in RCA: 59] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2018] [Accepted: 10/23/2018] [Indexed: 12/13/2022]
Abstract
Background There are limited data on the role of temporary mechanical circulatory support ( MCS ) devices for cardiogenic shock before left ventricular assist device ( LVAD ) surgery. This study sought to evaluate the trends of use and outcomes of MCS in cardiogenic shock before LVAD surgery. Methods and Results This was a retrospective cohort study from 2005 to 2014 using the National Inpatient Sample (20% stratified sample of US hospitals). This study identified admissions undergoing LVAD surgery with preoperative cardiogenic shock. Admissions for other cardiac surgery and heart transplant were excluded. Temporary MCS was identified using administrative codes. The primary outcome was hospital mortality and secondary outcomes were hospital costs and lengths of stay in admissions with and without MCS use. In this 10-year period, 9753 admissions were identified with 40.6% requiring pre- LVAD MCS . There was a temporal increase in the frequency of cardiogenic shock associated with an increase in non-intra-aortic balloon pump MCS devices. The cohort receiving MCS had greater in-hospital myocardial infarction, ventricular arrhythmias, and use of coronary angiography. On multivariable analysis, older age, myocardial infarction, and need for MCS devices were independently predictive of higher in-hospital mortality. In 696 propensity-matched pairs, use of MCS was predictive of higher in-hospital mortality (odds ratio 1.4 [95% confidence interval 1.1-1.6]; P=0.02) and higher hospital costs, but similar lengths of stay. Conclusions In patients with cardiogenic shock bridged to LVAD therapy, there was a steady increase in preoperative MCS use. Use of MCS identified patients at higher risk for in-hospital mortality and greater resource utilization.
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Affiliation(s)
- Saraschandra Vallabhajosyula
- Department of Cardiovascular MedicineMayo ClinicRochesterMN
- Division of Pulmonary and Critical Care MedicineDepartment of MedicineMayo ClinicRochesterMN
| | - Shilpkumar Arora
- Division of Cardiovascular DiseasesRobert Packer Hospital/Guthrie ClinicTowandaPA
| | - Sopan Lahewala
- Division of Cardiovascular DiseasesJersey City Medical CenterJersey CityNJ
| | - Varun Kumar
- Division of Cardiovascular DiseasesRobert Packer Hospital/Guthrie ClinicTowandaPA
| | | | - Jacob C. Jentzer
- Department of Cardiovascular MedicineMayo ClinicRochesterMN
- Division of Pulmonary and Critical Care MedicineDepartment of MedicineMayo ClinicRochesterMN
| | - John M. Stulak
- Department of Cardiovascular SurgeryMayo ClinicRochesterMN
| | | | - Rajiv Gulati
- Department of Cardiovascular MedicineMayo ClinicRochesterMN
| | | | - Abhiram Prasad
- Department of Cardiovascular MedicineMayo ClinicRochesterMN
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Shaban H, Yee J. A Tale of Two Failures: A Guide to Shared Decision-Making for Heart and Renal Failure. Adv Chronic Kidney Dis 2018; 25:375-378. [PMID: 30309453 DOI: 10.1053/j.ackd.2018.08.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2018] [Accepted: 08/06/2018] [Indexed: 01/14/2023]
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Tripathi B, Arora S, Kumar V, Thakur K, Lahewala S, Patel N, Dave M, Shah M, Savani S, Sharma P, Bandyopadhyay D, Shantha GPS, Egbe A, Chatterjee S, Patel NK, Gopalan R, Figueredo VM, Deshmukh A. Hospital Complications and Causes of 90-Day Readmissions After Implantation of Left Ventricular Assist Devices. Am J Cardiol 2018; 122:420-430. [PMID: 29960661 DOI: 10.1016/j.amjcard.2018.04.015] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2018] [Revised: 04/01/2018] [Accepted: 04/03/2018] [Indexed: 11/26/2022]
Abstract
Left ventricular assist devices (LVADs) have emerged as an attractive option in patients with advance heart failure. Nationwide readmission database 2013 to 2014 was utilized to identify LVAD recipients using ICD-9 procedure code 37.66. The primary outcome was 90-day readmission. Readmission causes were identified using ICD-9 codes in primary diagnosis field. The secondary outcomes were LVAD associated with hospital complications. Hierarchic 2-level logistic models were used to evaluate study outcomes. We identified 4,693 LVAD recipients (mean age 57 years, 76.2% males). Of which 53.9% were readmitted in first 90 days of discharge. Cardiac causes (33.3%), bleeding (21.3%), and infections (12.4%) were leading etiologies of 90-day readmissions. Significant predictors (odds ratio, 95% confidence interval, p value) of readmission were disposition to nursing facilities (1.33, 1.09 to 1.63, p = 0.01) and longer length of stay (1.01, 1.00 to 1.01, p <0.01). Although private insurance (0.75, 0.66 to 0.86, p <0.01), and self-pay (0.58, 0.42 to 0.81, p <0.01) predicted lower readmissions. Cardiac complications (36.3%), major bleeding (29.8%), and postoperative infections (10.4%) were most common LVAD-related complications. In conclusion, high early readmission rate was observed among LVAD recipients with Cardiac complications, bleeding complications, and infections were driving force for major complications and most of readmissions.
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Kilic A, Chen CW, Gaffey AC, Wald JW, Acker MA, Atluri P. Preoperative renal dysfunction does not affect outcomes of left ventricular assist device implantation. J Thorac Cardiovasc Surg 2018; 156:1093-1101.e1. [PMID: 30017440 DOI: 10.1016/j.jtcvs.2017.12.044] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2017] [Revised: 10/19/2017] [Accepted: 12/09/2017] [Indexed: 11/18/2022]
Abstract
OBJECTIVE Selection criteria for durable left ventricular assist device (LVAD) implantation remain unclear. One such criterion is renal function. In this study we evaluated outcomes of LVAD implantation in patients with preoperative renal dysfunction. METHODS Patients with implanted LVADs as destination therapy (DT) or bridge to transplantation (BTT) at a single institution between 2006 and 2015 were included. Primary stratification was according to pre-implantation glomerular filtration rate (GFR): >60 mL/min versus <60 mL/min or dialysis dependence. The primary outcome was post-LVAD implantation overall survival. RESULTS Two hundred thirty-eight patients underwent LVAD implantation during the study period as DT (60%; n = 142) or BTT (40%; n = 96). Reduced GFR was present in 56% (n = 132), with 8% (n = 18) being dialysis-dependent. Normal versus reduced GFR cohorts were well matched except for a higher incidence of coronary artery disease in the patients with reduced GFR (61% vs 48%; P = .04). Mean follow-up was 13.5 ± 17.0 months. Unadjusted and risk-adjusted survival at 1, 3, 6, and 12 months after LVAD implantation were similar between the cohorts for DT and BTT. Rates of transplantation were comparable in BTT patients (61% normal vs 53% reduced GFR; P = .43). Recovery of renal function to a GFR >60 mL/min occurred in 43% (n = 17) and 57% (n = 42) of patients with reduced GFR in the BTT and DT cohorts, respectively, by 1 year post implantation. CONCLUSIONS Well selected patients with preexisting renal dysfunction can undergo LVAD implantation with acceptable outcomes. Approximately half of LVAD recipients with preimplantation renal dysfunction will recover normal renal function within the first postoperative year. Renal dysfunction alone should not serve as an absolute contraindication to LVAD therapy.
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Affiliation(s)
- Arman Kilic
- Division of Cardiac Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Carol W Chen
- Division of Cardiovascular Surgery, University of Pennsylvania, Philadelphia, Pa
| | - Ann C Gaffey
- Division of Cardiovascular Surgery, University of Pennsylvania, Philadelphia, Pa
| | - Joyce W Wald
- Division of Cardiology, University of Pennsylvania, Philadelphia, Pa
| | - Michael A Acker
- Division of Cardiovascular Surgery, University of Pennsylvania, Philadelphia, Pa
| | - Pavan Atluri
- Division of Cardiovascular Surgery, University of Pennsylvania, Philadelphia, Pa.
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Ghosal S, Trivedi J, Chen J, Rogers MP, Cheng A, Slaughter MS, Kong M, Huang J. Regional Cerebral Oxygen Saturation Level Predicts 30-Day Mortality Rate After Left Ventricular Assist Device Surgery. J Cardiothorac Vasc Anesth 2018; 32:1185-1190. [DOI: 10.1053/j.jvca.2017.08.029] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2017] [Indexed: 11/11/2022]
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Rossano JW, Cantor RS, Dai D, Shamszad P, Huang YS, Hall M, Lin KY, Edens RE, Parrino PE, Kirklin JK. Resource Utilization in Pediatric Patients Supported With Ventricular Assist Devices in the United States: A Multicenter Study From the Pediatric Interagency Registry for Mechanically Assisted Circulatory Support and the Pediatric Health Information System. J Am Heart Assoc 2018; 7:JAHA.117.008380. [PMID: 29858364 PMCID: PMC6015374 DOI: 10.1161/jaha.117.008380] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Background Few data exist on resource utilization with pediatric ventricular assist devices (VADs). We tested the hypothesis that device type and adverse events are associated with increased resource utilization in pediatric patients supported with VADs. Methods and Results The Pediatric Interagency Registry for Mechanically Assisted Circulatory Support, a national registry of VADs in patients <19 years old, and the Pediatric Health Information System, an administrative database, were merged. Univariate analysis was performed assessing the association of all factors with the total cost and length of stay first. Significant variables (P<0.05) were subjected to multivariable analysis. The study included 142 patients from 19 centers with VAD implants from October 2012 to June 2016. The median age was 9 years (interquartile range [IQR] 2‐15), 84 (59%) supported with a continuous‐flow VAD. Overall median hospital costs were $750 000 (IQR $539 000 to $1 100 000) with a median hospital length of stay of 81 days (IQR 54‐128). On multivariable analysis, device type and postoperative complications were not associated with resource utilization. Factors associated with increased costs included patient age, lower‐volume VAD center, being intubated, being on extracorporeal membrane oxygenation, number of complex chronic medical conditions, and length of stay. Among continuous‐flow VAD patients, discharge to home before transplant versus remaining hospitalized was associated with lower hospital costs (median $600 000 [IQR $400 000 to $820 000] versus median $680 000 [IQR $500 000 to $970 000], P=0.03). Conclusion VADs in pediatric patients are associated with high resource utilization. Increased resource utilization was associated with lower‐volume VAD centers, disease severity at VAD implantation, and the presence of complex chronic medical conditions. Further study is needed to develop cost‐effective strategies in this complex population.
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Affiliation(s)
- Joseph W Rossano
- The Cardiac Center, Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA .,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA
| | - Ryan S Cantor
- Cardiothoracic Surgery, The University of Alabama at Birmingham, AL
| | - Dingwei Dai
- Healthcare Analytics Unit, Center for Pediatric Clinical Effectiveness and PolicyLab, The Children's Hospital of Philadelphia, PA
| | - Pirouz Shamszad
- The Cardiac Center, Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Yuan-Shung Huang
- Healthcare Analytics Unit, Center for Pediatric Clinical Effectiveness and PolicyLab, The Children's Hospital of Philadelphia, PA
| | | | - Kimberly Y Lin
- The Cardiac Center, Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | | | | | - James K Kirklin
- Cardiothoracic Surgery, The University of Alabama at Birmingham, AL
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Trends and Cost of Heart Transplantation and Left Ventricular Assist Devices. JACC-HEART FAILURE 2018; 6:424-432. [DOI: 10.1016/j.jchf.2018.03.005] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/31/2018] [Revised: 02/27/2018] [Accepted: 03/06/2018] [Indexed: 11/17/2022]
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Abstract
RATIONALE Aspiration pneumonia is a subset of pneumonias prevalent in elderly patients and patients with neurologic disorders. Researchers in previous studies mostly reported incidence and/or mortality rates based on regional data or in specific subgroups of patients. There is a paucity of nationwide data in the contemporary U.S. POPULATION OBJECTIVES To describe U.S. national trends in acute care hospital admission for aspiration pneumonia from 2002 to 2012. METHODS We used the U.S. National (Nationwide) Inpatient Sample database to identify patients admitted with a primary diagnosis of aspiration pneumonia between 2002 and 2012. We estimated trends in the incidence, in-hospital mortality, length of stay, and total hospitalization cost for patients admitted for aspiration pneumonia and stratified on the basis of patient age (≥65 yr vs. <65 yr). Multivariable logistic regression analysis was used to identify independent predictors for in-hospital mortality. RESULTS A total of 406,798 patients (weighted total, 1,741,517) admitted for aspiration pneumonia were included in this study. There were 84,200 (20.7%) patients younger than 65 years of age and 322,598 patients (79.3%) aged 65 years or older. From 2002 to 2012, the overall incidence of aspiration pneumonia decreased from 8.2 to 7.1 cases per 10,000 people, and in-hospital mortality decreased from 18.6 to 9.8%. For patients aged 65 years or older, the incidence decreased from 40.7 to 30.9 cases per 10,000 people, and the in-hospital mortality decreased from 20.7 to 11.3%. The median total hospitalization charges increased in both groups (age ≥65 yr, from $16,173 to $30,280; age <65 yr, from $17,517 to $30,526). In multivariable logistic analysis, patients aged 65 years or older or treatment in a nonteaching hospital were independent predictors of in-hospital mortality. CONCLUSIONS The incidence and mortality of patients admitted to acute care hospitals for aspiration pneumonia decreased between 2002 and 2012 in the United States. This difference was more evident for elderly patients. However, the cost of hospitalization almost doubled. Being older than 65 years of age is an independent predictor of in-hospital mortality among patients admitted for aspiration pneumonia. Strategies to prevent aspiration pneumonia in the community should be implemented in the aging U.S. POPULATION
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Benjamin EJ, Virani SS, Callaway CW, Chamberlain AM, Chang AR, Cheng S, Chiuve SE, Cushman M, Delling FN, Deo R, de Ferranti SD, Ferguson JF, Fornage M, Gillespie C, Isasi CR, Jiménez MC, Jordan LC, Judd SE, Lackland D, Lichtman JH, Lisabeth L, Liu S, Longenecker CT, Lutsey PL, Mackey JS, Matchar DB, Matsushita K, Mussolino ME, Nasir K, O'Flaherty M, Palaniappan LP, Pandey A, Pandey DK, Reeves MJ, Ritchey MD, Rodriguez CJ, Roth GA, Rosamond WD, Sampson UKA, Satou GM, Shah SH, Spartano NL, Tirschwell DL, Tsao CW, Voeks JH, Willey JZ, Wilkins JT, Wu JH, Alger HM, Wong SS, Muntner P. Heart Disease and Stroke Statistics-2018 Update: A Report From the American Heart Association. Circulation 2018; 137:e67-e492. [PMID: 29386200 DOI: 10.1161/cir.0000000000000558] [Citation(s) in RCA: 4550] [Impact Index Per Article: 758.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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Gosev I, Kiernan MS, Eckman P, Soleimani B, Kilic A, Uriel N, Rich JD, Katz JN, Cowger J, Lima B, McGurk S, Brisco-Bacik MA, Lee S, Joseph SM, Patel CB. Long-Term Survival in Patients Receiving a Continuous-Flow Left Ventricular Assist Device. Ann Thorac Surg 2018; 105:696-701. [DOI: 10.1016/j.athoracsur.2017.08.057] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2016] [Revised: 08/24/2017] [Accepted: 08/28/2017] [Indexed: 12/28/2022]
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Bansal N, Hailpern SM, Katz R, Hall YN, Kurella Tamura M, Kreuter W, O'Hare AM. Outcomes Associated With Left Ventricular Assist Devices Among Recipients With and Without End-stage Renal Disease. JAMA Intern Med 2018; 178:204-209. [PMID: 29255896 PMCID: PMC5801100 DOI: 10.1001/jamainternmed.2017.4831] [Citation(s) in RCA: 65] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
IMPORTANCE Left ventricular assist devices (LVADs) are widely used both as a bridge to heart transplant and as destination therapy in advanced heart failure. Although heart failure is common in patients with end-stage renal disease (ESRD), little is known about outcomes after LVAD implantation in this population. OBJECTIVE To determine the utilization of and outcomes associated with LVADs in nationally representative cohorts of patients with and without ESRD. DESIGN, SETTING AND PARTICIPANTS We described LVAD utilization and outcomes among Medicare beneficiaries after ESRD onset (defined as having received maintenance dialysis or a kidney transplant) from 2003 to 2013 based on Medicare claims linked to data from the United States Renal Data System (USRDS), a national registry for ESRD. We compared Medicare beneficiaries with ESRD to a 5% sample of Medicare beneficiaries without ESRD. EXPOSURES ESRD (vs no ESRD) among patients who underwent LVAD placement. MAIN OUTCOMES AND MEASURES The primary outcome was survival after LVAD placement. RESULTS Among the patients with ESRD, the mean age was 58.4 (12.1) years and 62.0% (96) were male. Among those without ESRD, the mean age was 62.2 (12.6) years and 75.1% (196) were male. From 2003 to 2013, 155 Medicare beneficiaries with ESRD (median and interquartile range [IQR] days from ESRD onset to LVAD placement were 1655 days [453-3050 days]) and 261 beneficiaries without ESRD in the Medicare 5% sample received an LVAD. During a median follow-up of 762 days (IQR, 92-3850 days), 127 patients (81.9%) with and 95 (36.4%) without ESRD died. more than half of patients with ESRD (80 [51.6%]) compared with 11 (4%) of those without ESRD died during the index hospitalization. The median time to death was 16 days (IQR 2-447 days) for patients with ESRD compared with 2125 days (IQR, 565-3850 days) for those without ESRD. With adjustment for demographics, comorbidity and time period, patients with ESRD had a markedly increased adjusted risk of death (hazard ratio, 36.3; 95% CI, 15.6-84.5), especially in the first 60 days after LVAD placement. CONCLUSIONS AND RELEVANCE Patients with ESRD at the time of LVAD placement had an extremely poor prognosis, with most surviving for less than 3 weeks. This information may be crucial in supporting shared decision-making around treatments for advanced heart failure for patients with ESRD.
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Affiliation(s)
- Nisha Bansal
- University of Washington, Division of Nephrology, Kidney Research Institute, Seattle
| | - Susan M Hailpern
- University of Washington, Division of Nephrology, Kidney Research Institute, Seattle
| | - Ronit Katz
- University of Washington, Division of Nephrology, Kidney Research Institute, Seattle
| | - Yoshio N Hall
- University of Washington, Division of Nephrology, Kidney Research Institute, Seattle
| | - Manjula Kurella Tamura
- Division of Nephrology, Stanford University, Palo Alto, California.,Veterans Affairs Palo Alto Health Care System, Palo Alto, California
| | - William Kreuter
- University of Washington, Division of Nephrology, Kidney Research Institute, Seattle
| | - Ann M O'Hare
- University of Washington, Division of Nephrology, Kidney Research Institute, Seattle.,Kaiser Permanente Washington Research Institute, Seattle, Washington.,Veterans Affairs Puget Sound Health Care System, Seattle, Washington
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Kormos RL, McCall M, Althouse A, Lagazzi L, Schaub R, Kormos MA, Zaldonis JA, Sciortino C, Lockard K, Kuntz N, Dunn E, Teuteberg JJ. Left Ventricular Assist Device Malfunctions. Circulation 2017; 136:1714-1725. [DOI: 10.1161/circulationaha.117.027360] [Citation(s) in RCA: 49] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2017] [Accepted: 06/20/2017] [Indexed: 11/16/2022]
Affiliation(s)
- Robert L. Kormos
- From Heart and Vascular Institute (R.L.K., A.A., L.L., C.S., J.J.T.); Artificial Heart Program (M.C., R.S., K.L., N.K., E.D.), University of Pittsburgh Medical Center, PA; Department of Bioengineering, Rochester Institute of Technology, NY (M.A.K.); and Department of Engineering, University of Pittsburgh, PA (J.A.Z.)
| | - Michael McCall
- From Heart and Vascular Institute (R.L.K., A.A., L.L., C.S., J.J.T.); Artificial Heart Program (M.C., R.S., K.L., N.K., E.D.), University of Pittsburgh Medical Center, PA; Department of Bioengineering, Rochester Institute of Technology, NY (M.A.K.); and Department of Engineering, University of Pittsburgh, PA (J.A.Z.)
| | - Andrew Althouse
- From Heart and Vascular Institute (R.L.K., A.A., L.L., C.S., J.J.T.); Artificial Heart Program (M.C., R.S., K.L., N.K., E.D.), University of Pittsburgh Medical Center, PA; Department of Bioengineering, Rochester Institute of Technology, NY (M.A.K.); and Department of Engineering, University of Pittsburgh, PA (J.A.Z.)
| | - Luigi Lagazzi
- From Heart and Vascular Institute (R.L.K., A.A., L.L., C.S., J.J.T.); Artificial Heart Program (M.C., R.S., K.L., N.K., E.D.), University of Pittsburgh Medical Center, PA; Department of Bioengineering, Rochester Institute of Technology, NY (M.A.K.); and Department of Engineering, University of Pittsburgh, PA (J.A.Z.)
| | - Richard Schaub
- From Heart and Vascular Institute (R.L.K., A.A., L.L., C.S., J.J.T.); Artificial Heart Program (M.C., R.S., K.L., N.K., E.D.), University of Pittsburgh Medical Center, PA; Department of Bioengineering, Rochester Institute of Technology, NY (M.A.K.); and Department of Engineering, University of Pittsburgh, PA (J.A.Z.)
| | - Michael A. Kormos
- From Heart and Vascular Institute (R.L.K., A.A., L.L., C.S., J.J.T.); Artificial Heart Program (M.C., R.S., K.L., N.K., E.D.), University of Pittsburgh Medical Center, PA; Department of Bioengineering, Rochester Institute of Technology, NY (M.A.K.); and Department of Engineering, University of Pittsburgh, PA (J.A.Z.)
| | - Jared A. Zaldonis
- From Heart and Vascular Institute (R.L.K., A.A., L.L., C.S., J.J.T.); Artificial Heart Program (M.C., R.S., K.L., N.K., E.D.), University of Pittsburgh Medical Center, PA; Department of Bioengineering, Rochester Institute of Technology, NY (M.A.K.); and Department of Engineering, University of Pittsburgh, PA (J.A.Z.)
| | - Christopher Sciortino
- From Heart and Vascular Institute (R.L.K., A.A., L.L., C.S., J.J.T.); Artificial Heart Program (M.C., R.S., K.L., N.K., E.D.), University of Pittsburgh Medical Center, PA; Department of Bioengineering, Rochester Institute of Technology, NY (M.A.K.); and Department of Engineering, University of Pittsburgh, PA (J.A.Z.)
| | - Kathleen Lockard
- From Heart and Vascular Institute (R.L.K., A.A., L.L., C.S., J.J.T.); Artificial Heart Program (M.C., R.S., K.L., N.K., E.D.), University of Pittsburgh Medical Center, PA; Department of Bioengineering, Rochester Institute of Technology, NY (M.A.K.); and Department of Engineering, University of Pittsburgh, PA (J.A.Z.)
| | - Nicole Kuntz
- From Heart and Vascular Institute (R.L.K., A.A., L.L., C.S., J.J.T.); Artificial Heart Program (M.C., R.S., K.L., N.K., E.D.), University of Pittsburgh Medical Center, PA; Department of Bioengineering, Rochester Institute of Technology, NY (M.A.K.); and Department of Engineering, University of Pittsburgh, PA (J.A.Z.)
| | - Elizabeth Dunn
- From Heart and Vascular Institute (R.L.K., A.A., L.L., C.S., J.J.T.); Artificial Heart Program (M.C., R.S., K.L., N.K., E.D.), University of Pittsburgh Medical Center, PA; Department of Bioengineering, Rochester Institute of Technology, NY (M.A.K.); and Department of Engineering, University of Pittsburgh, PA (J.A.Z.)
| | - Jeffrey J. Teuteberg
- From Heart and Vascular Institute (R.L.K., A.A., L.L., C.S., J.J.T.); Artificial Heart Program (M.C., R.S., K.L., N.K., E.D.), University of Pittsburgh Medical Center, PA; Department of Bioengineering, Rochester Institute of Technology, NY (M.A.K.); and Department of Engineering, University of Pittsburgh, PA (J.A.Z.)
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Tadmouri A, Blomkvist J, Landais C, Seymour J, Azmoun A. Cost-effectiveness of left ventricular assist devices for patients with end-stage heart failure: analysis of the French hospital discharge database. ESC Heart Fail 2017; 5:75-86. [PMID: 28741873 PMCID: PMC5793974 DOI: 10.1002/ehf2.12194] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2017] [Revised: 04/25/2017] [Accepted: 06/20/2017] [Indexed: 01/20/2023] Open
Abstract
AIMS Although left ventricular assist devices (LVADs) are currently approved for coverage and reimbursement in France, no French cost-effectiveness (CE) data are available to support this decision. This study aimed at estimating the CE of LVAD compared with medical management in the French health system. METHODS AND RESULTS Individual patient data from the 'French hospital discharge database' (Medicalization of information systems program) were analysed using Kaplan-Meier method. Outcomes were time to death, time to heart transplantation (HTx), and time to death after HTx. A micro-costing method was used to calculate the monthly costs extracted from the Program for the Medicalization of Information Systems. A multistate Markov monthly cycle model was developed to assess CE. The analysis over a lifetime horizon was performed from the perspective of the French healthcare payer; discount rates were 4%. Probabilistic and deterministic sensitivity analyses were performed. Outcomes were quality-adjusted life years (QALYs) and incremental CE ratio (ICER). Mean QALY for an LVAD patient was 1.5 at a lifetime cost of €190 739, delivering a probabilistic ICER of €125 580/QALY [95% confidence interval: 105 587 to 150 314]. The sensitivity analysis showed that the ICER was mainly sensitive to two factors: (i) the high acquisition cost of the device and (ii) the device performance in terms of patient survival. CONCLUSIONS Our economic evaluation showed that the use of LVAD in patients with end-stage heart failure yields greater benefit in terms of survival than medical management at an extra lifetime cost exceeding the €100 000/QALY. Technological advances and device costs reduction shall hence lead to an improvement in overall CE.
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Affiliation(s)
- Abir Tadmouri
- Health Economics and Outcome Research (HEOR) Department, ClinSearch, Malakoff, France
| | - Josefin Blomkvist
- Health Economics and Outcome Research (HEOR) Department, ClinSearch, Malakoff, France
| | - Cécile Landais
- Health Economics and Outcome Research (HEOR) Department, ClinSearch, Malakoff, France
| | - Jerome Seymour
- Health Economics and Outcome Research (HEOR) Department, ClinSearch, Malakoff, France
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Ischemic Optic Neuropathy in Cardiac Surgery: Incidence and Risk Factors in the United States from the National Inpatient Sample 1998 to 2013. Anesthesiology 2017; 126:810-821. [PMID: 28244936 DOI: 10.1097/aln.0000000000001533] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
BACKGROUND Ischemic optic neuropathy is the most common form of perioperative visual loss, with highest incidence in cardiac and spinal fusion surgery. To date, potential risk factors have been identified in cardiac surgery by only small, single-institution studies. To determine the preoperative risk factors for ischemic optic neuropathy, the authors used the National Inpatient Sample, a database of inpatient discharges for nonfederal hospitals in the United States. METHODS Adults aged 18 yr or older admitted for coronary artery bypass grafting, heart valve repair or replacement surgery, or left ventricular assist device insertion in National Inpatient Sample from 1998 to 2013 were included. Risk of ischemic optic neuropathy was evaluated by multivariable logistic regression. RESULTS A total of 5,559,395 discharges met inclusion criteria with 794 (0.014%) cases of ischemic optic neuropathy. The average yearly incidence was 1.43 of 10,000 cardiac procedures, with no change during the study period (P = 0.57). Conditions increasing risk were carotid artery stenosis (odds ratio, 2.70), stroke (odds ratio, 3.43), diabetic retinopathy (odds ratio, 3.83), hypertensive retinopathy (odds ratio, 30.09), macular degeneration (odds ratio, 4.50), glaucoma (odds ratio, 2.68), and cataract (odds ratio, 5.62). Female sex (odds ratio, 0.59) and uncomplicated diabetes mellitus type 2 (odds ratio, 0.51) decreased risk. CONCLUSIONS The incidence of ischemic optic neuropathy in cardiac surgery did not change during the study period. Development of ischemic optic neuropathy after cardiac surgery is associated with carotid artery stenosis, stroke, and degenerative eye conditions.
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Benjamin EJ, Blaha MJ, Chiuve SE, Cushman M, Das SR, Deo R, de Ferranti SD, Floyd J, Fornage M, Gillespie C, Isasi CR, Jiménez MC, Jordan LC, Judd SE, Lackland D, Lichtman JH, Lisabeth L, Liu S, Longenecker CT, Mackey RH, Matsushita K, Mozaffarian D, Mussolino ME, Nasir K, Neumar RW, Palaniappan L, Pandey DK, Thiagarajan RR, Reeves MJ, Ritchey M, Rodriguez CJ, Roth GA, Rosamond WD, Sasson C, Towfighi A, Tsao CW, Turner MB, Virani SS, Voeks JH, Willey JZ, Wilkins JT, Wu JH, Alger HM, Wong SS, Muntner P. Heart Disease and Stroke Statistics-2017 Update: A Report From the American Heart Association. Circulation 2017; 135:e146-e603. [PMID: 28122885 PMCID: PMC5408160 DOI: 10.1161/cir.0000000000000485] [Citation(s) in RCA: 6139] [Impact Index Per Article: 877.0] [Reference Citation Analysis] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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50
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Wappenschmidt J, Sonntag SJ, Buesen M, Gross-Hardt S, Kaufmann T, Schmitz-Rode T, Autschbach R, Goetzenich A. Fluid Dynamics in Rotary Piston Blood Pumps. Ann Biomed Eng 2016; 45:554-566. [DOI: 10.1007/s10439-016-1700-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2016] [Accepted: 07/19/2016] [Indexed: 10/21/2022]
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