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Vallabhajosyula S, Sinha SS, Kochar A, Pahuja M, Amico FJ, Kapur NK. The Price We Pay for Progression in Shock Care: Economic Burden, Accessibility, and Adoption of Shock-Teams and Mechanical Circulatory Support Devices. Curr Cardiol Rep 2024:10.1007/s11886-024-02108-4. [PMID: 39325244 DOI: 10.1007/s11886-024-02108-4] [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] [Accepted: 07/22/2024] [Indexed: 09/27/2024]
Abstract
PURPOSE OF REVIEW Cardiogenic shock (CS) is associated with high in-hospital and long-term mortality and morbidity that results in significant socio-economic impact. Due to the high costs associated with CS care, it is important to define the short- and long-term burden of this disease state on resources and review strategies to mitigate these. RECENT FINDINGS In recent times, the focus on CS continues to be on improving short-term outcomes, but there has been increasing emphasis on the long-term morbidity. In this review we discuss the long-term outcomes of CS and the role of hospital-level and system-level disparities in perpetuating this. We discuss mitigation strategies including developing evidence-based protocols and systems of care, improvement in risk stratification and evaluation of futility of care, all of which address the economic burden of CS. CS continues to remain the pre-eminent challenge in acute cardiovascular care, and a combination of multi-pronged strategies are needed to improve outcomes in this population.
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Affiliation(s)
- Saraschandra Vallabhajosyula
- Section of Cardiology, Department of Medicine, Warren Alpert Medical School of Brown University and Brown University Health Cardiovascular Institute, Providence, Rhode Island, USA
| | - Shashank S Sinha
- Inova Schar Heart and Vascular, Inova Fairfax Medical Campus, Falls Church, VA, USA
| | - Ajar Kochar
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Mohit Pahuja
- Division of Cardiology, Department of Medicine, University of Oklahoma Health Sciences College of Medicine, Oklahoma City, OK, USA
| | - Frank J Amico
- Chesapeake Regional Healthcare Medical Center, Chesapeake, VA, USA
| | - Navin K Kapur
- The Cardiovascular Center, Section of Cardiovascular Medicine, Department of Medicine, Tufts University School of Medicine, 800 Washington Street, Box No 80, Boston, MA, 02111, USA.
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Rali AS, Tran L, Dix M, Prokupets R, Lindenfeld J, Taduru S. In Cardiogenic Shock, Age is Not Just a Number. Card Fail Rev 2024; 10:e04. [PMID: 38708377 PMCID: PMC11066850 DOI: 10.15420/cfr.2023.22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2023] [Accepted: 01/26/2024] [Indexed: 05/07/2024] Open
Affiliation(s)
- Aniket S Rali
- Division of Cardiovascular Diseases, Vanderbilt University Medical CenterNashville, Tennessee, US
| | - Lena Tran
- Division of Cardiovascular Diseases, Vanderbilt University Medical CenterNashville, Tennessee, US
| | - Malcolm Dix
- Division of Cardiovascular Diseases, Vanderbilt University Medical CenterNashville, Tennessee, US
| | - Rochelle Prokupets
- Division of Cardiovascular Diseases, Vanderbilt University Medical CenterNashville, Tennessee, US
| | - JoAnn Lindenfeld
- Division of Cardiovascular Diseases, Vanderbilt University Medical CenterNashville, Tennessee, US
| | - Siva Taduru
- Department of Cardiovascular Medicine, University of Kansas Medical CenterKansas City, Kansas, US
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George N, Stephens K, Ball E, Crandall C, Ouchi K, Unruh M, Kamdar N, Myaskovsky L. Extracorporeal Membrane Oxygenation for Cardiac Arrest: Does Age Matter? Crit Care Med 2024; 52:20-30. [PMID: 37782526 PMCID: PMC11267242 DOI: 10.1097/ccm.0000000000006039] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/03/2023]
Abstract
OBJECTIVES The impact of age on hospital survival for patients treated with extracorporeal cardiopulmonary resuscitation (ECPR) for cardiac arrest (CA) is unknown. We sought to characterize the association between older age and hospital survival after ECPR, using a large international database. DESIGN Retrospective analysis of the Extracorporeal Life Support Organization registry. PATIENTS Patients 18 years old or older who underwent ECPR for CA between December 1, 2016, and October 31, 2020. MEASUREMENTS AND MAIN RESULTS The primary outcome was adjusted odds ratio (aOR) of death after ECPR, analyzed by age group (18-49, 50-64, 65-74, and > 75 yr). A total of 5,120 patients met inclusion criteria. The median age was 57 years (interquartile range, 46-66 yr). There was a significantly lower aOR of survival for those 65-74 (0.68l 95% CI, 0.57-0.81) or those greater than 75 (0.54; 95% CI, 0.41-0.69), compared with 18-49. Patients 50-64 had a significantly higher aOR of survival compared with those 65-74 and greater than 75; however, there was no difference in survival between the two youngest groups (aOR, 0.91; 95% CI, 0.79-1.05). A sensitivity analysis using alternative age categories (18-64, 65-69, 70-74, and ≥ 75) demonstrated decreased odds of survival for age greater than or equal to 65 compared with patients younger than 65 (for age 65-69: odds ratio [OR], 0.71; 95% CI, 0.59-0.86; for age 70-74: OR, 0.84; 95% CI, 0.67-1.04; and for age ≥ 75: OR, 0.64; 95% CI, 0.50-0.81). CONCLUSIONS This investigation represents the largest analysis of the relationship of older age on ECPR outcomes. We found that the odds of hospital survival for patients with CA treated with ECPR diminishes with increasing age, with significantly decreased odds of survival after age 65, despite controlling for illness severity and comorbidities. However, findings from this observational data have significant limitations and further studies are needed to evaluate these findings prospectively.
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Affiliation(s)
- Naomi George
- Department of Emergency Medicine, Division of Critical Care, University of New Mexico School of Medicine, Albuquerque, NM
| | - Krista Stephens
- Department of Emergency Medicine, University of New Mexico School of Medicine, Albuquerque, NM
| | - Emily Ball
- Department of Emergency Medicine, University of New Mexico School of Medicine, Albuquerque, NM
| | - Cameron Crandall
- Department of Emergency Medicine, University of New Mexico School of Medicine, Albuquerque, NM
| | - Kei Ouchi
- Department of Emergency Medicine, Division of Critical Care, University of New Mexico School of Medicine, Albuquerque, NM
- Department of Emergency Medicine, University of New Mexico School of Medicine, Albuquerque, NM
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA
- Department of Emergecy Medicine, Harvard Medical School, Boston, MA
- Serious Illness Care Program, Ariadne Labs, Boston, MA
- Department of Psychosocial Oncology and Palliative Care, Cancer Institute, Boston, MA
- Sheps Center for Health Services Research, University of North Carolina, Chapel Hill, NC
- Department of Population Health Sciences, Stanford University, Stanford, CA
- Department of Emergency Medicine, Department of Family Medicine, Department of Surgery, Department of Obstetrics and Gynecology, Acute Care Research Unit, Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI
- Division of Nephrology, Department of Internal Medicine, University of New Mexico School of Medicine, Albuquerque, NM
- Center for Healthcare Equity in Kidney Disease, University of New Mexico School of Medicine, Albuquerque, NM
| | - Mark Unruh
- Department of Psychosocial Oncology and Palliative Care, Cancer Institute, Boston, MA
| | - Neil Kamdar
- Department of Emergency Medicine, Division of Critical Care, University of New Mexico School of Medicine, Albuquerque, NM
- Department of Emergency Medicine, University of New Mexico School of Medicine, Albuquerque, NM
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA
- Department of Emergecy Medicine, Harvard Medical School, Boston, MA
- Serious Illness Care Program, Ariadne Labs, Boston, MA
- Department of Psychosocial Oncology and Palliative Care, Cancer Institute, Boston, MA
- Sheps Center for Health Services Research, University of North Carolina, Chapel Hill, NC
- Department of Population Health Sciences, Stanford University, Stanford, CA
- Department of Emergency Medicine, Department of Family Medicine, Department of Surgery, Department of Obstetrics and Gynecology, Acute Care Research Unit, Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI
- Division of Nephrology, Department of Internal Medicine, University of New Mexico School of Medicine, Albuquerque, NM
- Center for Healthcare Equity in Kidney Disease, University of New Mexico School of Medicine, Albuquerque, NM
| | - Larissa Myaskovsky
- Division of Nephrology, Department of Internal Medicine, University of New Mexico School of Medicine, Albuquerque, NM
- Center for Healthcare Equity in Kidney Disease, University of New Mexico School of Medicine, Albuquerque, NM
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Fernando SM, MacLaren G, Barbaro RP, Mathew R, Munshi L, Madahar P, Fried JA, Ramanathan K, Lorusso R, Brodie D, McIsaac DI. Age and associated outcomes among patients receiving venoarterial extracorporeal membrane oxygenation-analysis of the Extracorporeal Life Support Organization registry. Intensive Care Med 2023; 49:1456-1466. [PMID: 37792052 DOI: 10.1007/s00134-023-07199-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Accepted: 08/08/2023] [Indexed: 10/05/2023]
Abstract
PURPOSE Venoarterial extracorporeal membrane oxygenation (V-A ECMO) can be used to support severely ill patients with cardiogenic shock. While age is commonly used in patient selection, little is known regarding its association with outcomes in this population. We sought to evaluate the association between increasing age and outcomes following V-A ECMO. METHODS We used individual-level patient data from 440 centers in the international Extracorporeal Life Support Organization registry. We included all adult patients receiving V-A ECMO from 2017 to 2019. The primary outcome was hospital mortality. Secondary outcomes included a composite of complications following initiation of V-A ECMO. We conducted Bayesian analyses of the relationship between increasing age and outcomes of interest. RESULTS We included 15,172 patients receiving V-A ECMO. Of these, 8172 (53.9%) died in hospital. For the analysis conducted using weakly informed priors, and as compared to the reference category of age 18-29, the age bracket of 30-39 (odds ratio [OR] 0.94, 95% credible interval [CrI] 0.79-1.10) was not associated with hospital mortality, but age brackets 40-49 (odds ratio [OR] 1.26, 95% CrI: 1.08-1.47), 50-59 (OR 1.78, 95% CrI: 1.55-2.06), 60-69 (OR 2.24, 95% CrI: 1.94-2.59), 70-79 (OR 2.90, 95% CrI: 2.49-3.39) and ≥ 80 (OR 4.02, 95% CrI: 3.13-5.20) were independently associated with increasing hospital mortality. Similar results were found in the analysis conducted with an informative prior, as well as between increasing age and post-ECMO complications. CONCLUSIONS Among patients receiving V-A ECMO for cardiogenic shock, increasing age is strongly associated with increasing odds of death and complications, and this association emerges as early as 40 years of age.
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Affiliation(s)
- Shannon M Fernando
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada.
- Department of Critical Care, Lakeridge Health Corporation, Oshawa, ON, Canada.
| | - Graeme MacLaren
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- Cardiothoracic Intensive Care Unit, National University Heart Centre, National University Hospital, Singapore, Singapore
| | - Ryan P Barbaro
- Division of Pediatric Critical Care Medicine, University of Michigan, Ann Arbor, MI, USA
- Child Health Evaluation and Research Center, University of Michigan, Ann Arbor, MI, USA
| | - Rebecca Mathew
- Division of Cardiology, University of Ottawa Heart Institute, Ottawa, ON, Canada
| | - Laveena Munshi
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Purnema Madahar
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, NY, USA
- Center for Acute Respiratory Failure, New York-Presbyterian Hospital, New York, NY, USA
| | - Justin A Fried
- Division of Cardiology, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, NY, USA
| | - Kollengode Ramanathan
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- Cardiothoracic Intensive Care Unit, National University Heart Centre, National University Hospital, Singapore, Singapore
| | - Roberto Lorusso
- Department of Cardio Thoracic Surgery, Maastricht University Medical Centre, Maastricht University, Maastricht, The Netherlands
- Cardiovascular Research Institute Maastricht, Maastricht, The Netherlands
| | - Daniel Brodie
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Daniel I McIsaac
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
- Department of Anesthesiology and Pain Medicine, University of Ottawa, Ottawa, ON, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
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5
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Braun J, Sahli SD, Spahn DR, Röder D, Neb H, Lotz G, Aser R, Wilhelm MJ, Kaserer A. Predicting Survival for Veno-Arterial ECMO Using Conditional Inference Trees-A Multicenter Study. J Clin Med 2023; 12:6243. [PMID: 37834887 PMCID: PMC10573956 DOI: 10.3390/jcm12196243] [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: 08/17/2023] [Revised: 09/14/2023] [Accepted: 09/25/2023] [Indexed: 10/15/2023] Open
Abstract
BACKGROUND Despite increasing use and understanding of the process, veno-arterial extracorporeal membrane oxygenation (VA-ECMO) therapy is still associated with considerable mortality. Personalized and quick survival predictions using machine learning methods can assist in clinical decision making before ECMO insertion. METHODS This is a multicenter study to develop and validate an easy-to-use prognostic model to predict in-hospital mortality of VA-ECMO therapy, using unbiased recursive partitioning with conditional inference trees. We compared two sets with different numbers of variables (small and comprehensive), all of which were available just before ECMO initiation. The area under the curve (AUC), the cross-validated Brier score, and the error rate were applied to assess model performance. Data were collected retrospectively between 2007 and 2019. RESULTS 837 patients were eligible for this study; 679 patients in the derivation cohort (median (IQR) age 60 (49 to 69) years; 187 (28%) female patients) and a total of 158 patients in two external validation cohorts (median (IQR) age 57 (49 to 65) and 70 (63 to 76) years). For the small data set, the model showed a cross-validated error rate of 35.79% and an AUC of 0.70 (95% confidence interval from 0.66 to 0.74). In the comprehensive data set, the error rate was the same with a value of 35.35%, with an AUC of 0.71 (95% confidence interval from 0.67 to 0.75). The mean Brier scores of the two models were 0.210 (small data set) and 0.211 (comprehensive data set). External validation showed an error rate of 43% and AUC of 0.60 (95% confidence interval from 0.52 to 0.69) using the small tree and an error rate of 35% with an AUC of 0.63 (95% confidence interval from 0.54 to 0.72) using the comprehensive tree. There were large differences between the two validation sets. CONCLUSIONS Conditional inference trees are able to augment prognostic clinical decision making for patients undergoing ECMO treatment. They may provide a degree of accuracy in mortality prediction and prognostic stratification using readily available variables.
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Affiliation(s)
- Julia Braun
- Departments of Biostatistics and Epidemiology, Epidemiology, Biostatistics and Prevention Institute, University of Zurich, 8001 Zurich, Switzerland;
| | - Sebastian D. Sahli
- Institute of Anesthesiology, University and University Hospital Zurich, 8091 Zurich, Switzerland; (S.D.S.); (D.R.S.)
| | - Donat R. Spahn
- Institute of Anesthesiology, University and University Hospital Zurich, 8091 Zurich, Switzerland; (S.D.S.); (D.R.S.)
| | - Daniel Röder
- Department of Anesthesiology, Intensive Care, Emergency and Pain Medicine, University Hospital Würzburg, 97080 Würzburg, Germany;
| | - Holger Neb
- Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Goethe University, 60596 Frankfurt, Germany; (H.N.); (G.L.)
| | - Gösta Lotz
- Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Goethe University, 60596 Frankfurt, Germany; (H.N.); (G.L.)
| | - Raed Aser
- Clinic for Cardiac Surgery, University Heart Center, University and University Hospital Zurich, 8091 Zurich, Switzerland; (R.A.); (M.J.W.)
| | - Markus J. Wilhelm
- Clinic for Cardiac Surgery, University Heart Center, University and University Hospital Zurich, 8091 Zurich, Switzerland; (R.A.); (M.J.W.)
| | - Alexander Kaserer
- Institute of Anesthesiology, University and University Hospital Zurich, 8091 Zurich, Switzerland; (S.D.S.); (D.R.S.)
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Schmitt A, Weidner K, Rusnak J, Ruka M, Egner-Walter S, Mashayekhi K, Tajti P, Ayoub M, Akin I, Behnes M, Schupp T. Age-related outcomes in patients with cardiogenic shock stratified by etiology. J Geriatr Cardiol 2023; 20:555-566. [PMID: 37675262 PMCID: PMC10477585 DOI: 10.26599/1671-5411.2023.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/08/2023] Open
Abstract
BACKGROUND As a result of improved and novel treatment strategies, the spectrum of patients with cardiovascular disease is consistently changing. Overall, those patients are typically older and characterized by increased burden with comorbidities. Limited data on the prognostic impact of age in cardiogenic shock (CS) is available. Therefore, this study investigates the prognostic impact of age in patients with CS. METHODS From 2019 to 2021, consecutive patients with CS of any cause were included. The prognostic value of age (i.e., 60-80 years and > 80 years) was investigated for 30-day all-cause mortality. Spearman's correlations, Kaplan-Meier analyses, as well as multivariable Cox proportional regression analyses were performed for statistics. Subsequent risk assessment was performed based on the presence or absence of CS related to acute myocardial infarction (AMI). RESULTS 223 CS patients were included with a median age of 77 years (interquartile range: 69-82 years). No significant difference in 30-day all-cause mortality was observed for both age-groups (54.6% vs. 63.4%, log-rank P = 0.169; HR = 1.273, 95% CI: 0.886-1.831, P = 0.192). In contrast, when analyzing subgroups stratified by CS-etiology, AMI-related CS patients of the group > 80 years showed an increased risk of 30-day all-cause mortality (78.1% vs. 60.0%, log-rank P = 0.032; HR = 1.635, 95% CI: 1.000-2.673, P = 0.050), which was still evident after multivariable adjustment (HR = 2.072, 95% CI: 1.174-3.656, P = 0.012). CONCLUSIONS Age was not associated with 30-day all-cause mortality in patients with CS of mixed etiology. However, increasing age was shown to be a significant predictor of increased mortality-risk in the subgroup of patients presenting with AMI-CS.
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Affiliation(s)
- Alexander Schmitt
- Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
- European Center for AngioScience (ECAS), German Center for Cardiovascular Research (DZHK) partner site Heidelberg/Mannheim, Mannheim, Germany
| | - Kathrin Weidner
- Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
- European Center for AngioScience (ECAS), German Center for Cardiovascular Research (DZHK) partner site Heidelberg/Mannheim, Mannheim, Germany
| | - Jonas Rusnak
- Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
- European Center for AngioScience (ECAS), German Center for Cardiovascular Research (DZHK) partner site Heidelberg/Mannheim, Mannheim, Germany
| | - Marinela Ruka
- Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
- European Center for AngioScience (ECAS), German Center for Cardiovascular Research (DZHK) partner site Heidelberg/Mannheim, Mannheim, Germany
| | - Sascha Egner-Walter
- Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
- European Center for AngioScience (ECAS), German Center for Cardiovascular Research (DZHK) partner site Heidelberg/Mannheim, Mannheim, Germany
| | - Kambis Mashayekhi
- Department of Internal Medicine and Cardiology, Mediclin Heart Centre Lahr, Lahr, Germany
| | - Péter Tajti
- Gottsegen György National Cardiovascular Center, Budapest, Hungary
| | - Mohamed Ayoub
- Division of Cardiology and Angiology, Heart Center University of Bochum-Bad Oeynhausen, Bad Oeynhausen, Germany
| | - Ibrahim Akin
- Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
- European Center for AngioScience (ECAS), German Center for Cardiovascular Research (DZHK) partner site Heidelberg/Mannheim, Mannheim, Germany
| | - Michael Behnes
- Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
- European Center for AngioScience (ECAS), German Center for Cardiovascular Research (DZHK) partner site Heidelberg/Mannheim, Mannheim, Germany
| | - Tobias Schupp
- Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
- European Center for AngioScience (ECAS), German Center for Cardiovascular Research (DZHK) partner site Heidelberg/Mannheim, Mannheim, Germany
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Peivandi AD, Welp H, Kintrup S, Wagner NM, Dell’Aquila AM. External validation of the REMEMBER score. Front Cardiovasc Med 2023; 10:1192300. [PMID: 37576106 PMCID: PMC10416794 DOI: 10.3389/fcvm.2023.1192300] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Accepted: 07/17/2023] [Indexed: 08/15/2023] Open
Abstract
Background The use of venoarterial extracorporeal membrane oxygenation (VA-ECMO) after coronary artery bypass grafting (CABG) is associated with high in-hospital mortality rates. The pRedicting mortality in patients undergoing venoarterial Extracorporeal MEMBrane oxygenation after coronary artEry bypass gRafting (REMEMBER) score has been created to predict in-hospital mortality in this subgroup of patients. The aim of this study is to externally validate the REMEMBER score. Methods All CABG patients who received VA-ECMO during or after the operation at our center between 01/2012 and 12/2021 were included in the analysis. Discrimination was assessed using concordance statistics, visualized by ROC curve analysis. Calibration-in-the-large and Calibration slope were tested separately. Results A total of 107 patients (male: n = 78, 72.9%) were included in this study. The in-hospital mortality rate in our cohort was 45.8% compared with 55% in the original study. The REMEMBER score median predicted mortality rate was 52% (76.9-36%). However, the REMEMBER score showed low discriminative ability [AUC: 0.623 (p = 0.0244; 95% CI = 0.524-0.715)] and inaccurate calibration (intercept = 0.25074; p = 0.0195; slope = 0.39504; p = 0.0303), indicating poor performance. Conclusions The REMEMBER score did not predict in-hospital mortality and was therefore not applicable in our cohort of patients. Additional external validation studies in a multicenter setting are therefore advisable.
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Affiliation(s)
- Armin Darius Peivandi
- Department of Cardiothoracic Surgery, University Hospital Muenster, Muenster, Germany
| | - Henryk Welp
- Department of Cardiothoracic Surgery, University Hospital Muenster, Muenster, Germany
| | - Sebastian Kintrup
- Department of Anesthesiology, Intensive Care and Pain Therapy, University Hospital Muenster, Muenster, Germany
| | - Nana Maria Wagner
- Department of Anesthesiology, Intensive Care and Pain Therapy, University Hospital Muenster, Muenster, Germany
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Han L, Chen S, Luan Z, Fan M, Wang Y, Sun G, Dai G. Immune function of colon cancer associated miRNA and target genes. Front Immunol 2023; 14:1203070. [PMID: 37465677 PMCID: PMC10351377 DOI: 10.3389/fimmu.2023.1203070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Accepted: 05/15/2023] [Indexed: 07/20/2023] Open
Abstract
Introduction Colon cancer is a complex disease that involves intricate interactions between cancer cells and theimmune microenvironment. MicroRNAs (miRNAs) have recently emerged as critical regulators of gene expression in cancer, including colon cancer. There is increasing evidence suggesting that miRNA dysregulation plays a crucial role in modulating the immune microenvironment of intestinal cancer. In particular, miRNAs regulate immune cell activation, differentiation, and function, as well as cytokine and chemokine production in intestinal cancer. It is urgent to fully investigate the potential role of intestinal cancer-related miRNAs in shaping the immune microenvironment. Methods Therefore, this paper aims to identify miRNAs that are potentially associated with colon cancer and regulate a large number of genes related to immune function. We explored the role of these genes in colon cancer patient prognosis, immune infiltration, and tumor purity based on data of 174 colon cancer patients though convolutional neural network, survival analysis and multiple analysis tools. Results Our findings suggest that miRNA regulated genes play important roles in CD4 memory resting cells, macrophages.M2, and Mast cell activated cells, and they are concentrated in the cytokinecytokine receptor interaction pathway. Discussion Our study enhances our understanding of the underlying mechanisms of intestinal cancer and provides new insights into the development of effective therapies. Additionally, identification of miRNA biomarkers could aid in diagnosis and prognosis, as well as guide personalized treatment strategies for patients with intestinal cancer.
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Affiliation(s)
- Lu Han
- Department of Oncology, The Fifth Medical Center of Chinese PLA General Hospital, Beijing, China
- Medical School of Chinese PLA, Beijing, China
| | - Shiyun Chen
- Department of Oncology, The Fifth Medical Center of Chinese PLA General Hospital, Beijing, China
- Medical School of Chinese PLA, Beijing, China
| | - Zhe Luan
- Department of Gastroenterology and Hepatology, The First Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Mengjiao Fan
- Department of Oncology, The Fifth Medical Center of Chinese PLA General Hospital, Beijing, China
- Medical School of Chinese PLA, Beijing, China
| | - Yanrong Wang
- Department of Oncology, The Fifth Medical Center of Chinese PLA General Hospital, Beijing, China
- Medical School of Chinese PLA, Beijing, China
| | - Gang Sun
- Department of Gastroenterology and Hepatology, The First Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Guanghai Dai
- Department of Oncology, The Fifth Medical Center of Chinese PLA General Hospital, Beijing, China
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Prasad A, Brehm C, Singbartl K. The impact of preservation and recovery of renal function on survival after veno-arterial extracorporeal life support: A retrospective cohort study. Artif Organs 2023; 47:554-565. [PMID: 36325712 DOI: 10.1111/aor.14449] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Revised: 09/23/2022] [Accepted: 10/04/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND Veno-arterial extracorporeal life support (V-A ECLS) has become a cornerstone in the management of critical cardiogenic shock, but it can also precipitate organ injury, e.g., acute kidney injury (AKI). Available studies highlight the effect of non-cardiac organ injury on patient outcomes. Only very little is known about the impact of non-cardiac organ recovery on patient survival. AKI occurs frequently during cardiogenic shock and carries a poor prognosis. We have developed descriptive models to hypothesize on the role of AKI severity versus that of recovery of renal function for patient survival. METHODS Retrospective, observational study including 175 patients who were successfully decannulated from V-A ECLS. We assessed AKI severity using the "Kidney Disease: Improving Global Outcomes" (KDIGO) criteria. We defined recovered or preserved renal function (RPRF) prior to decannulation from V-A ECLS as 0 (AKI with no improvement) or 1 (no AKI or AKI with improvement). We classified patient outcomes as alive or dead at hospital discharge. RESULTS 78% (n = 138) of all patients survived hospital discharge of which 38% (n = 67) never developed AKI. After adjusting for shock severity and non-renal organ injury, RPRF emerged as an independent predictor of survival in both the overall cohort [OR (95% CI) - 4.11 (1.72-9.79)] and the AKI-only sub-cohort [OR (95% CI) - 5.18 (1.8-14.92)]. Neither maximum KDIGO stage nor KDIGO stage at the end of V-A ECLS was independently associated with survival. CONCLUSIONS Our model identifies RPRF, but not AKI severity, as an independent predictor of hospital survival in patients undergoing V-A ECLS for cardiogenic shock. We hypothesize that recovered or preserved non-cardiac organ function during V-A ECLS is crucial for patient survival.
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Affiliation(s)
- Amit Prasad
- Heart and Vascular Institute, PennState Health, Hershey, Pennsylvania, USA
| | - Christoph Brehm
- Heart and Vascular Institute, PennState Health, Hershey, Pennsylvania, USA
| | - Kai Singbartl
- Department of Critical Care Medicine, Mayo Clinic, Phoenix, Arizona, USA
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10
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Sakamoto K, Matoba T, Nakai M, Tahara Y, Nakashima T, Hosoda H, Miyamoto Y, Nishimura K, Sumita Y, Yagi T, Ichimura K, Yonemoto N, Tachibana E, Nagao K, Ikeda T, Sato N, Tsutsui H. Clinical picture of the duration of venoarterial extracorporeal membrane oxygenation: analysis from JROAD-DPC. Heart Vessels 2023; 38:228-235. [PMID: 36173448 DOI: 10.1007/s00380-022-02158-0] [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: 01/31/2022] [Accepted: 08/18/2022] [Indexed: 01/10/2023]
Abstract
Venoarterial extracorporeal membrane oxygenation (VA-ECMO) has been widely used for critically ill patients all over the world; however, comprehensive survey regarding the relationship between VA-ECMO duration and prognosis is limited. We conducted a survey of VA-ECMO patients in the Japanese Registry of All Cardiac and Vascular Diseases-Diagnosis Procedure Combination (JROAD-DPC), which was a health insurance claim database study among cardiovascular centers associated with the Japan Circulation Society, between April 2012 and March 2016. Out of 13,542 VA-ECMO patients, we analyzed 5766 cardiovascular patients treated with VA-ECMO. 68% patients used VA-ECMO only for 1 day and 93% had VA-ECMO terminated within 1 week. In multivariate analysis, the hazard ratio of 1-day support was significantly high at 1.72 (95% confidence intervals; 95% CI 1.53-1.95) (p < 0.001), while that of 2-day [0.60 (95% CI 0.49-0.73)], 3-day [0.75 (95% CI 0.60-0.94)], 4-day [0.43 (95% CI 0.31-0.60)] and 5-day support [0.62 (95% CI 0.44-0.86)] was significantly low. Comprehensive database analysis of JROAD-DPC revealed that cardiovascular patients who were supported with VA-ECMO for 2-5 days showed lower mortality. The optimal VA-ECMO support window should be investigated in further studies.
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Affiliation(s)
- Kazuo Sakamoto
- Department of Cardiovascular Medicine, Kyushu University Hospital, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Tetsuya Matoba
- Department of Cardiovascular Medicine, Kyushu University Hospital, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan.
| | - Michikazu Nakai
- Department of Statistics and Data Analysis, Center for Cerebral and Cardiovascular Disease Information, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Yoshio Tahara
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Takahiro Nakashima
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Hayato Hosoda
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Yoshihiro Miyamoto
- Department of Statistics and Data Analysis, Center for Cerebral and Cardiovascular Disease Information, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Kunihiro Nishimura
- Preventive Medicine and Epidemiology Informatics, Center for Cerebral and Cardiovascular Disease Information, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Yoko Sumita
- Department of Statistics and Data Analysis, Center for Cerebral and Cardiovascular Disease Information, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Tsukasa Yagi
- Department of Cardiology, Kawaguchi Municipal Medical Center, Kawaguchi, Japan
| | - Kenzo Ichimura
- Department of Cardiovascular Medicine, Kyushu University Hospital, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Naohiro Yonemoto
- Department of Biostatistics, Kyoto University School of Public Health, Kyoto, Japan
| | - Eizo Tachibana
- Department of Cardiology, Kawaguchi Municipal Medical Center, Kawaguchi, Japan
| | - Ken Nagao
- Cardiovascular Centre, Nihon University Hospital, Tokyo, Japan
| | - Takanori Ikeda
- Department of Cardiovascular Medicine, Faculty of Medicine, Toho University, Tokyo, Japan
| | - Naoki Sato
- Department of Cardiology, Kawaguchi Cardiovascular and Respiratory Hospital, Saitama, Japan
| | - Hiroyuki Tsutsui
- Department of Cardiovascular Medicine, Kyushu University Hospital, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
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11
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Hendrickson MJ, Jain V, Bhatia K, Chew C, Arora S, Rossi JS, Villablanca P, Kapur NK, Joshi AA, Fox A, Mahmood K, Birati EY, Ricciardi MJ, Qamar A. Trends in Veno-Arterial Extracorporeal Life Support With and Without an Impella or Intra-Aortic Balloon Pump for Cardiogenic Shock. J Am Heart Assoc 2022; 11:e025216. [PMID: 36420809 PMCID: PMC9851440 DOI: 10.1161/jaha.121.025216] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2021] [Accepted: 08/26/2022] [Indexed: 11/25/2022]
Abstract
Background Mechanical circulatory support devices, such as the intra-aortic balloon pump (IABP) and Impella, are often used in patients on veno-arterial extracorporeal life support (VA-ECLS) with cardiogenic shock despite limited supporting clinical trial data. Methods and Results Hospitalizations for cardiogenic shock from 2016 to 2018 were identified from the National Inpatient Sample. Trends in the use of VA-ECLS with and without an IABP or Impella were assessed semiannually. Multivariable logistic regression and general linear regression evaluated the association of Impella and IABP use with in-hospital outcomes. Overall, 12 035 hospitalizations with cardiogenic shock and VA-ECLS were identified, of which 3115 (26%) also received an IABP and 1880 (16%) an Impella. Use of an Impella with VA-ECLS substantially increased from 10% to 18% over this period (P<0.001), whereas an IABP modestly increased from 25% to 26% (P<0.001). In-hospital mortality decreased 54% to 48% for VA-ECLS only, 61% to 58% for VA-ECLS with an Impella, and 54% to 49% for VA-ECLS with an IABP (P<0.001 each). Most (57%) IABPs or Impellas were placed on the same day as VA-ECLS. After adjustment, there were no differences in in-hospital mortality or length of stay with the addition of an IABP or Impella compared with VA-ECLS alone. Conclusions From 2016 to 2018 in the United States, use of an Impella and IABP with VA-ECLS significantly increased. More than half of Impellas and IABPs were placed on the same day as VA-ECLS, and the use of a second mechanical circulatory support device did not impact in-hospital mortality. Further studies are needed to decipher the optimal timing and patient selection for this growing practice.
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Affiliation(s)
| | - Vardhmaan Jain
- Division of Cardiovascular MedicineEmory University School of MedicineAtlantaGA
| | - Kirtipal Bhatia
- Mount Sinai HeartDivision of Advanced Heart Failure and Transplant Cardiology, Mount Sinai St. Lukes HospitalNew YorkNY
| | - Christopher Chew
- Division of CardiologyUniversity of North Carolina School of MedicineChapel HillNC
| | - Sameer Arora
- Division of CardiologyUniversity of North Carolina School of MedicineChapel HillNC
| | - Joseph S. Rossi
- Division of CardiologyUniversity of North Carolina School of MedicineChapel HillNC
| | | | | | - Aditya A. Joshi
- Division of Advanced Heart Failure and Transplant Cardiology, Department of Cardiovascular MedicineUniversity of WashingtonSeattleWA
| | - Arieh Fox
- Zena and Michael A. Wiener Cardiovascular InstituteIcahn School of Medicine at Mount SinaiNew YorkNY
| | - Kiran Mahmood
- Zena and Michael A. Wiener Cardiovascular InstituteIcahn School of Medicine at Mount SinaiNew YorkNY
| | - Edo Y. Birati
- Poriya Medical CenterBar‐Ilan UniversityTiberiasIsrael
| | - Mark J. Ricciardi
- Section of Interventional Cardiology, NorthShore Cardiovascular InstituteUniversity of Chicago Pritzker School of MedicineChicagoIL
| | - Arman Qamar
- Section of Interventional Cardiology, NorthShore Cardiovascular InstituteUniversity of Chicago Pritzker School of MedicineChicagoIL
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12
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Krittanawong C, Rivera MR, Shaikh P, Kumar A, May A, Mahtta D, Jentzer J, Civitello A, Katz J, Naidu SS, Cohen MG, Menon V. SKey Concepts Surrounding Cardiogenic Shock. Curr Probl Cardiol 2022; 47:101303. [PMID: 35787427 DOI: 10.1016/j.cpcardiol.2022.101303] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Accepted: 06/28/2022] [Indexed: 11/03/2022]
Abstract
Cardiogenic shock (CS) is the final common pathway of impaired cardiovascular performance that results in ineffective forward cardiac output producing clinical and biochemical signs of organ hypoperfusion. CS represents the most common cause of shock in the cardiac intensive care unit (CICU) and accounts for a substantial proportion of CICU patient deaths. Despite significant advances in revascularization techniques, pharmacologic therapeutics and mechanical support devices, CS remains associated with a high mortality rate. Indeed, the prevalence of CS within the CICU appears to be increasing. CS can be differentiated as phenotypes reflecting different metabolic, inflammatory, and hemodynamic profiles, depending also on anatomic substrate and congestion profile. Future prospective studies and clinical trials may further characterize these phenotypes and apply targeted intervention for each phenotype and SCAI SHOCK stage rather than a one-size-fits-all approach. Overall, there are 8 key concepts of CS; 1) the mortality associated with CS; 2) Shock attributed to AMI may be declining in both incidence and associated mortality; 3) providers should think about hemodynamic, metabolic, inflammation and cardiac function in totality to assess CS; 4) CS is a dynamic process; 5) no randomized trials evaluating use of the PAC in patients with CS; 6) most data supporting neosynephrine as first line agent in CS; 7) most registries suggest that almost half of CS patients do not have any mechanical support, and the vast majority of the remainder utilize the IABP; and 8) patients with AMI CS should receive emergent PCI of the culprit vessel.
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Affiliation(s)
- Chayakrit Krittanawong
- Section of Cardiology, Baylor College of Medicine, Baylor St. Luke's Medical Center, Texas Heart Institute, Houston, TX.
| | - Mario Rodriguez Rivera
- John T. Milliken Department of Medicine, Division of Cardiovascular Disease. Barnes-Jewish Hospital/Washington University in St.Louis School of Medicine
| | - Preet Shaikh
- John T. Milliken Department of Medicine, Barnes-Jewish Hospital/Washington University in St.Louis School of Medicine
| | - Anirudh Kumar
- Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH
| | - Adam May
- John T. Milliken Department of Medicine, Division of Cardiovascular Disease, Section of Critical Care Cardiology. Barnes-Jewish Hospital/Washington University in St.Louis School of Medicine
| | - Dhruv Mahtta
- Section of Cardiology, Baylor College of Medicine, Baylor St. Luke's Medical Center, Texas Heart Institute, Houston, TX
| | - Jacob Jentzer
- Department of Cardiovascular Medicine; Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota
| | - Andrew Civitello
- Section of Cardiology, Baylor College of Medicine, Baylor St. Luke's Medical Center, Texas Heart Institute, Houston, TX
| | - Jason Katz
- Department of Medicine, Division of Cardiology, Duke University, Durham, NC
| | - Srihari S Naidu
- Department of Cardiology, Westchester Medical Centre, New York Medical College, Valhalla, NY
| | - Mauricio G Cohen
- Cardiovascular Division, University of Miami Miller School of Medicine, FL, USA
| | - Venu Menon
- Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH
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13
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Abstract
ABSTRACT Despite advances in early revascularization, percutaneous hemodynamic support platforms, and systems of care, cardiogenic shock (CS) remains associated with a mortality rate higher than 50%. Several risk stratification models have been derived since the 1990 s to identify patients at high risk of adverse outcomes. Still, limited information is available on the differences between scoring systems and their relative applicability to both acute myocardial infarction and advanced decompensated heart failure CS. Thus, we reviewed the similarities, differences, and limitations of published CS risk prediction models and herein discuss their suitability to the contemporary management of CS care.
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14
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Hernandez-Montfort J, Miranda D, Randhawa VK, Sleiman J, de Armas YS, Lewis A, Taimeh Z, Alvarez P, Cremer P, Perez-Villa B, Navas V, Hakemi E, Velez M, Hernandez-Mejia L, Sheffield C, Brozzi N, Cubeddu R, Navia J, Estep JD. Hemodynamic-based Assessment and Management of Cardiogenic Shock. US CARDIOLOGY REVIEW 2022. [DOI: 10.15420/usc.2021.12] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Cardiogenic shock (CS) remains a deadly disease entity challenging patients, caregivers, and communities across the globe. CS can rapidly lead to the development of hypoperfusion and end-organ dysfunction, transforming a predictable hemodynamic event into a potential high-resource, intense, hemometabolic clinical catastrophe. Based on the scalable heterogeneity from a cellular level to healthcare systems in the hemodynamic-based management of patients experiencing CS, we present considerations towards systematic hemodynamic-based transitions in which distinct clinical entities share the common path of early identification and rapid transitions through an adaptive longitudinal situational awareness model of care that influences specific management considerations. Future studies are needed to best understand optimal management of drugs and devices along with engagement of health systems of care for patients with CS.
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Affiliation(s)
| | - Diana Miranda
- Department of Cardiovascular Medicine, Cleveland Clinic Florida, Weston Hospital, Weston, FL
| | - Varinder Kaur Randhawa
- Department of Cardiovascular Medicine, Kaufman Center for Heart Failure and Recovery, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH
| | - Jose Sleiman
- Department of Cardiovascular Medicine, Cleveland Clinic Florida, Weston Hospital, Weston, FL
| | - Yelenis Seijo de Armas
- Department of Cardiovascular Medicine, Cleveland Clinic Florida, Weston Hospital, Weston, FL
| | - Antonio Lewis
- Department of Cardiovascular Medicine, Cleveland Clinic Florida, Weston Hospital, Weston, FL
| | - Ziad Taimeh
- Department of Cardiovascular Medicine, Kaufman Center for Heart Failure and Recovery, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH
| | - Paulino Alvarez
- Department of Cardiovascular Medicine, Kaufman Center for Heart Failure and Recovery, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH
| | - Paul Cremer
- Department of Cardiovascular Medicine, Kaufman Center for Heart Failure and Recovery, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH
| | - Bernardo Perez-Villa
- Department of Cardiovascular Medicine, Cleveland Clinic Florida, Weston Hospital, Weston, FL
| | - Viviana Navas
- Department of Cardiovascular Medicine, Cleveland Clinic Florida, Weston Hospital, Weston, FL
| | - Emad Hakemi
- Department of Cardiovascular Medicine, Cleveland Clinic Florida, Weston Hospital, Weston, FL
| | - Mauricio Velez
- Department of Cardiovascular Medicine, Cleveland Clinic Florida, Weston Hospital, Weston, FL
| | - Luis Hernandez-Mejia
- Department of Cardiovascular Medicine, Cleveland Clinic Florida, Weston Hospital, Weston, FL
| | - Cedric Sheffield
- Department of Cardiovascular Medicine, Cleveland Clinic Florida, Weston Hospital, Weston, FL
| | - Nicolas Brozzi
- Department of Cardiovascular Medicine, Cleveland Clinic Florida, Weston Hospital, Weston, FL
| | - Robert Cubeddu
- Department of Cardiovascular Medicine, Cleveland Clinic Florida, Weston Hospital, Weston, FL
| | - Jose Navia
- Department of Cardiovascular Medicine, Cleveland Clinic Florida, Weston Hospital, Weston, FL
| | - Jerry D Estep
- Department of Cardiovascular Medicine, Kaufman Center for Heart Failure and Recovery, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH
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15
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Venkataraman S, Bhardwaj A, Belford PM, Morris BN, Zhao DX, Vallabhajosyula S. Veno-Arterial Extracorporeal Membrane Oxygenation in Patients with Fulminant Myocarditis: A Review of Contemporary Literature. MEDICINA (KAUNAS, LITHUANIA) 2022; 58:215. [PMID: 35208538 PMCID: PMC8876206 DOI: 10.3390/medicina58020215] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Revised: 01/12/2022] [Accepted: 01/27/2022] [Indexed: 11/16/2022]
Abstract
Fulminant myocarditis is characterized by life threatening heart failure presenting as cardiogenic shock requiring inotropic or mechanical circulatory support to maintain tissue perfusion. There are limited data on the role of veno-arterial extracorporeal membrane oxygenation (VA-ECMO) in the management of fulminant myocarditis. This review seeks to evaluate the management of fulminant myocarditis with a special emphasis on the role and outcomes with VA-ECMO use.
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Affiliation(s)
- Shreyas Venkataraman
- Department of Medicine, Barnes-Jewish Hospital, Washington University of Saint Louis, St. Louis, MO 63110, USA;
| | - Abhishek Bhardwaj
- Respiratory Institute, Cleveland Clinic Foundation, Cleveland, OH 44106, USA;
| | - Peter Matthew Belford
- Section of Cardiovascular Medicine, Department of Medicine, Wake Forest University School of Medicine, Winston-Salem, NC 27157, USA; (P.M.B.); (D.X.Z.)
| | - Benjamin N. Morris
- Section of Cardiovascular and Critical Care Anesthesia, Department of Anesthesiology, Wake Forest University School of Medicine, Winston-Salem, NC 27157, USA;
| | - David X. Zhao
- Section of Cardiovascular Medicine, Department of Medicine, Wake Forest University School of Medicine, Winston-Salem, NC 27157, USA; (P.M.B.); (D.X.Z.)
| | - Saraschandra Vallabhajosyula
- Section of Cardiovascular Medicine, Department of Medicine, Wake Forest University School of Medicine, Winston-Salem, NC 27157, USA; (P.M.B.); (D.X.Z.)
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16
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Van Den Helm S, Yaw HP, Letunica N, Barton R, Weaver A, Newall F, Horton SB, Chiletti R, Johansen A, Best D, McKittrick J, Butt W, d'Udekem Y, MacLaren G, Linden MD, Ignjatovic V, Monagle P. Platelet Phenotype and Function Changes With Increasing Duration of Extracorporeal Membrane Oxygenation. Crit Care Med 2022; 50:1236-1245. [PMID: 35020670 DOI: 10.1097/ccm.0000000000005435] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES To investigate platelet pathophysiology associated with pediatric extracorporeal membrane oxygenation (ECMO). DESIGN Prospective observational study of neonatal and pediatric ECMO patients from September 1, 2016, to December 31, 2019. SETTING The PICU in a large tertiary referral pediatric ECMO center. PATIENTS Eighty-seven neonates and children (< 18 yr) supported by ECMO. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Arterial blood samples were collected on days 1, 2, and 5 of ECMO and were analyzed by whole blood flow cytometry. Corresponding clinical data for each patient was also recorded. A total of 87 patients were recruited (median age, 65 d; interquartile range [IQR], 7 d to 4 yr). The median duration of ECMO was 5 days (IQR, 3-8 d) with a median length of stay in PICU and hospital of 18 days (IQR, 10-29 d) and 35 days (IQR, 19-75 d), respectively. Forty-two patients (48%) had at least one major bleed according to a priori determined definitions, and 12 patients (14%) had at least one thrombotic event during ECMO. Platelet fibrinogen receptor expression decreased (median fluorescence intensity [MFI], 29,256 vs 26,544; p = 0.0005), while von Willebrand Factor expression increased (MFI: 7,620 vs 8,829; p = 0.0459) from day 2 to day 5 of ECMO. Platelet response to agonist, Thrombin Receptor Activator Peptide 6, also decreased from day 2 to day 5 of ECMO, as measured by binding with anti-P-selectin, PAC-1 (binds activated GPIIb/IIIa), and anti-CD63 monoclonal antibodies (P-selectin area under the curve [AUC]: 63.46 vs 42.82, respectively, p = 0.0022; PAC-1 AUC: 93.75 vs 74.46, p = 0.0191; CD63 AUC: 55.69 vs 41.76, p = 0.0020). CONCLUSIONS The loss of platelet response over time may contribute to bleeding during ECMO. These novel insights may be useful in understanding mechanisms of bleeding in pediatric ECMO and monitoring platelet markers clinically could allow for prediction or early detection of bleeding and thrombosis.
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Affiliation(s)
- Suelyn Van Den Helm
- Haematology, Murdoch Children's Research Institute, Melbourne, VIC, Australia. Department of Paediatrics, The University of Melbourne, Melbourne, VIC, Australia. Department of Clinical Haematology, The Royal Children's Hospital, Melbourne, VIC, Australia. Department of Cardiac Surgery, The Royal Children's Hospital, Melbourne, VIC, Australia. Department of Intensive Care, The Royal Children's Hospital, Melbourne, VIC, Australia. Paediatric Intensive Care Research Group, Murdoch Children's Research Institute, Melbourne, VIC, Australia. Department of Cardiac Surgery, Children's National Heart Institute, Washington, DC. Cardiothoracic Intensive Care Unit, National University Health System, Singapore. School of Biomedical Sciences, The University of Western Australia, Perth, WA, Australia. Kids Cancer Centre, Sydney Children's Hospital, Randwick, NSW, Australia
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17
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Jörg Rustenbach C, Djordjevic I, David L, Ivanov B, Gerfer S, Gaisendrees C, Wendt S, Merkle J, Seo J, Sabashnikov A, Rahmanian P, Kuhn E, Kroener A, Bennink G, Eghbalzadeh K, Wahlers T. Risk factors associated with in-hospital mortality for patients with ECLS due to post cardiotomy cardiogenic shock after isolated coronary surgery. Artif Organs 2022; 46:1158-1164. [PMID: 34985129 DOI: 10.1111/aor.14166] [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: 06/25/2021] [Revised: 11/15/2021] [Accepted: 12/13/2021] [Indexed: 11/30/2022]
Abstract
OBJECTIVES Extracorporeal membrane oxygenation (ECMO) or extracorporeal life support (ECLS) in patients after cardiac surgery and post cardiotomy cardiogenic shock (PCS) is known to be associated with high mortality. Especially in patients after coronary artery bypass grafting (CABG) and PCS, ECLS is frequently established. Aim of this analysis was to evaluate factors associated with in-hospital mortality in patients treated with ECLS due to PCS after CABG. METHODS Between August 2006 and January 2017, 92 consecutive patients with V-A ECLS due to PCS after isolated CABG were identified and included in this retrospective analysis. Patients were divided into survivors (S) and non-survivors (NS) and analysed in regard of risk factors of in-hospital mortality. RESULTS In-hospital mortality added up to 61 patients (66 %). Non-survivors were significantly older (60±12 (S) vs. 67±10 (NS); p=0.013). Bilateral internal mammary artery graft was significantly more frequently used in S (23% (S) vs. 2% (NS); p=0.001). After 24 hours of ECLS support, median lactate levels were significantly higher in NS (1.9(1.3;3.5) mmol/L (S) vs. 3.5(2.1;6.3) mmol/L (NS); p=0.001). NS suffered more often acute kidney injury requiring dialysis (42% (S) vs. 74% (NS); p=0.002). CONCLUSION Mortality in patients with refractory PCS after CABG and consecutive ECLS support remains high. Failing end-organ recovery under ECLS despite optimized concomitant medical therapy is an indicator of adverse outcomes in this specific patient cohort. Moreover, total-arterial revascularization might be beneficial for cardiac recovery in patients suffering PCS after CABG and following ECLS.
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Affiliation(s)
| | - Ilija Djordjevic
- University Hospital Cologne, Department of Cardiothoracic Surgery, Cologne, Germany
| | - Lara David
- University Hospital Cologne, Department of Cardiothoracic Surgery, Cologne, Germany
| | - Borko Ivanov
- University Hospital Cologne, Department of Cardiothoracic Surgery, Cologne, Germany
| | - Stephen Gerfer
- University Hospital Cologne, Department of Cardiothoracic Surgery, Cologne, Germany
| | | | - Stefanie Wendt
- University Hospital Cologne, Department of Cardiothoracic Surgery, Cologne, Germany
| | - Julia Merkle
- University Hospital Cologne, Department of Cardiothoracic Surgery, Cologne, Germany
| | - Joon Seo
- Evangelical Hospital Herne, Department of Thoracic Surgery, Herne, Germany
| | - Anton Sabashnikov
- University Hospital Cologne, Department of Cardiothoracic Surgery, Cologne, Germany
| | - Parwis Rahmanian
- University Hospital Cologne, Department of Cardiothoracic Surgery, Cologne, Germany
| | - Elmar Kuhn
- University Hospital Cologne, Department of Cardiothoracic Surgery, Cologne, Germany
| | - Axel Kroener
- University Hospital Cologne, Department of Cardiothoracic Surgery, Cologne, Germany
| | - Gerardus Bennink
- University Hospital Cologne, Department of Cardiothoracic Surgery, Cologne, Germany
| | - Kaveh Eghbalzadeh
- University Hospital Cologne, Department of Cardiothoracic Surgery, Cologne, Germany
| | - Thorsten Wahlers
- University Hospital Cologne, Department of Cardiothoracic Surgery, Cologne, Germany
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18
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Oude Lansink-Hartgring A, van Minnen O, Vermeulen KM, van den Bergh WM. Hospital Costs of Extracorporeal Membrane Oxygenation in Adults: A Systematic Review. PHARMACOECONOMICS - OPEN 2021; 5:613-623. [PMID: 34060061 PMCID: PMC8166371 DOI: 10.1007/s41669-021-00272-9] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 04/29/2021] [Indexed: 05/05/2023]
Abstract
BACKGROUND Costs associated with extracorporeal membrane oxygenation (ECMO) are an important factor in establishing cost effectiveness. In this systematic review, we aimed to determine the total hospital costs of ECMO for adults. METHODS The literature was retrieved from the PubMed/MEDLINE, EMBASE, and Web of Science databases from inception to 4 March 2020 using the search terms 'extracorporeal membrane oxygenation' combined with 'costs'; similar terms or phrases were then added to the search, i.e. 'Extracorporeal Life Support' or 'ECMO' or 'ECLS' combined with 'costs'. We included any type of study (e.g. randomized trial or observational cohort) evaluating hospital costs of ECMO in adults (age ≥18 years). RESULTS A total of 1768 unique articles were retrieved during our search. We assessed 74 full-text articles for eligibility, of which 14 articles were selected for inclusion in this review; six papers were from the US, five were from Europe, and one each from Japan, Australia, and Taiwan. The sample sizes ranged from 16 to 18,684 patients. One paper exclusively used prospective cost data collection, while all other papers used retrospective data collection. Five papers reported charges instead of costs. There was large variation in hospital costs, ranging from US$22,305 to US$334,608 (2019 values), largely depending on the indication for ECMO support and location. The highest reported costs were for lung transplant recipients who were receiving ECMO support in the US, and the lowest reported costs were for extracorporeal cardiopulmonary resuscitation patients presenting with non-shockable rhythm in Japan. The additional costs of ECMO patients compared with non-ECMO patients varied between US$2518 and US$200,658. Personnel costs varied between 11 and 52% of the total amount. CONCLUSIONS ECMO therapy is an advanced and expensive technology, although reported costs differ considerably depending on ECMO indication and whether charges or costs are measured. Combined with the ongoing gathering of outcome data, cost effectiveness per ECMO indication could be determined in the future.
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Affiliation(s)
- Annemieke Oude Lansink-Hartgring
- Department of Critical Care, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 970 RB, Groningen, The Netherlands.
| | - Olivier van Minnen
- Department of Critical Care, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 970 RB, Groningen, The Netherlands
| | - Karin M Vermeulen
- Department of Epidemiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Walter M van den Bergh
- Department of Critical Care, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 970 RB, Groningen, The Netherlands
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19
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Alonso-Fernandez-Gatta M, Merchan-Gomez S, Toranzo-Nieto I, Gonzalez-Cebrian M, Diego-Nieto A, Barrio A, Martin-Herrero F, Sanchez PL. Short-term mechanical circulatory support in elderly patients. Artif Organs 2021; 46:867-877. [PMID: 34780090 DOI: 10.1111/aor.14117] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Revised: 08/12/2021] [Accepted: 11/08/2021] [Indexed: 12/15/2022]
Abstract
BACKGROUND Age over 70 years seems to confer poor prognosis for patients under mechanical circulatory support (MCS). Advanced age is usually a relative contraindication. Our objective was to assess the impact of age on survival of patients with short-term MCS. METHODS Retrospective analysis of ≥70-year-old patients supported with veno-arterial extracorporeal membrane oxygenation (VA-ECMO) or Impella CP® due to cardiogenic shock and other situations of hemodynamic instability in a referral hospital (elderly group), compared with younger patients (<70 years). We analyze factors associated with survival in elderly group. RESULTS Out of 164 short-term MCS implants from 2013 to October 2020, 45 (27.4%) correspond to ≥70-year-old patients (73.3% VA-ECMO; 26.7% Impella CP®), 80% as bridge to recovery and 15.6% for high-risk percutaneous coronary intervention (PCI). We found no significant differences in complications developed between both groups. Survivals at discharge (40% vs. 43.7%, p = 0.403) and at follow-up (median 13.6 [30] months) were similar in elderly and young patients (35.6% vs. 37.8%, log-rank p = 0.061). Predictive factors of mortality in elderly patients were peripheral artery disease (p = 0.037), higher lactate (p = 0.003) and creatinine (p = 0.035) at implant, longer cardiac arrest (p = 0.003), and worse post-implantation left ventricular ejection fraction (p = 0.003). Patients with indication of MCS for high-risk PCI had higher survival compared to other indications (p = 0.013). CONCLUSION Short-term MCS with VA-ECMO or Impella CP® in elderly patients may be a reasonable option in hemodynamic compromise situations as bridge to recovery or elective high-risk PCI, without a significant increase in complications or mortality. Age should not be an absolute contraindication, but careful selection of candidate patients is necessary.
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Affiliation(s)
| | - Soraya Merchan-Gomez
- Cardiology Department, University Hospital of Salamanca, IBSAL, Salamanca, Spain
| | - Ines Toranzo-Nieto
- Cardiology Department, University Hospital of Salamanca, IBSAL, Salamanca, Spain
| | | | | | - Alfredo Barrio
- Cardiology Department, University Hospital of Salamanca, IBSAL, Salamanca, Spain
| | - Francisco Martin-Herrero
- Cardiology Department, University Hospital of Salamanca, IBSAL, Salamanca, Spain.,CIBER-CV Instituto de Salud Carlos III (ISCIII), Madrid, Spain
| | - Pedro L Sanchez
- Cardiology Department, University Hospital of Salamanca, IBSAL, Salamanca, Spain.,CIBER-CV Instituto de Salud Carlos III (ISCIII), Madrid, Spain
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20
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Effect of Acute Limb Ischemia on the Mortality of Patients with Extracorporeal Membrane Oxygenation Established by Femoral Vein-Arterial Catheterization and Analysis of Related Risk Factors. EVIDENCE-BASED COMPLEMENTARY AND ALTERNATIVE MEDICINE 2021; 2021:3471764. [PMID: 34504534 PMCID: PMC8423565 DOI: 10.1155/2021/3471764] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Accepted: 08/17/2021] [Indexed: 11/18/2022]
Abstract
Extracorporeal membrane oxygenation (ECMO) is a common treatment for cardiopulmonary failure. Although it can effectively reduce the mortality of patients with cardiopulmonary failure, it still has a high mortality rate, such as acute limb ischemia (ALI), stroke, liver and kidney failure, and other related complications and related causes of death. This study aims to explore the impact of ALI on the mortality of VA-ECMO patients in hospital and 6 months after discharge and analyze the occurrence of ALI and related factors that affect the mortality of VA-ECMO in hospital and 6 months after discharge. The results showed that the smoking history was an independent risk factor for ALI, and age, diabetes, cardiac arrest, first time of ECMO, and hyperbilirubinemia were associated risk factors for in-hospital mortality. Cardiac arrest and ALI were associated risk factors for mortality at 6 months after discharge. Although ALI is not significantly associated with VA-ECMO in-hospital mortality, it is a risk factor for mortality at 6 months after discharge, and medical personnel should therefore strive to reduce and avoid ALI.
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21
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Gandjian M, Williamson C, Xia Y, Maturana C, Chervu N, Verma A, Tran Z, Sanaiha Y, Benharash P. Association of Hospital Safety Net Status With Outcomes and Resource Use for Extracorporeal Membrane Oxygenation in the United States. J Intensive Care Med 2021; 37:535-542. [PMID: 33783248 DOI: 10.1177/08850666211007062] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
PURPOSE Safety net hospitals (SNH) have been associated with inferior surgical outcomes and increased resource use. Utilization and outcomes for extracorporeal membrane oxygenation (ECMO), a rescue modality for patients with respiratory or cardiac failure, may vary by safety net status. We hypothesized SNH to be associated with inferior outcomes and costs of ECMO in a national cohort. MATERIALS AND METHODS The 2008-2017 National Inpatient Sample was queried for ECMO hospitalizations and safety net hospitals were identified. Multivariable regression was used to perform risk-adjusted comparisons of mortality, complications and resource utilization at safety net and non-safety net hospitals. RESULTS Of 36,491 ECMO hospitalizations, 28.2% were at SNH. On adjusted comparison SNH was associated with increased odds of mortality (AOR: 1.23), tracheostomy use (AOR: 1.51), intracranial hemorrhage (AOR: 1.39), as well as infectious complications (AOR: 1.21, all P < .05), with NSNH as reference. SNH was also associated with increased hospitalization duration (β=+4.5 days) and hospitalization costs (β=+$32,880, all P < .01). CONCLUSIONS We have found SNH to be associated with inferior survival, increased complications, and higher costs compared to NSNH. These disparate outcomes warrant further studies examining systemic and hospital-level factors that may impact outcomes and resource use of ECMO at SNH.
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Affiliation(s)
- Matthew Gandjian
- Divisions of Cardiac Surgery, Cardiovascular Outcomes Research Laboratories, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Catherine Williamson
- Divisions of Cardiac Surgery, Cardiovascular Outcomes Research Laboratories, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA.,David Geffen School of Medicine, 155697University of California, Los Angeles, CA, USA
| | - Yu Xia
- Division of Cardiac Surgery, 155697University of California, Los Angeles, CA, USA
| | - Carlos Maturana
- David Geffen School of Medicine, 155697University of California, Los Angeles, CA, USA
| | - Nikhil Chervu
- David Geffen School of Medicine, 155697University of California, Los Angeles, CA, USA
| | - Arjun Verma
- Divisions of Cardiac Surgery, Cardiovascular Outcomes Research Laboratories, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Zachary Tran
- Divisions of Cardiac Surgery, Cardiovascular Outcomes Research Laboratories, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Yas Sanaiha
- Divisions of Cardiac Surgery, Cardiovascular Outcomes Research Laboratories, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Peyman Benharash
- Divisions of Cardiac Surgery, Cardiovascular Outcomes Research Laboratories, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA.,Division of Cardiac Surgery, 155697University of California, Los Angeles, CA, USA
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22
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Semaan C, Charbonnier A, Pasco J, Darwiche W, Saint Etienne C, Bailleul X, Bourguignon T, Fauchier L, Angoulvant D, Ivanes F, Genet T. Risk Scores in ST-Segment Elevation Myocardial Infarction Patients with Refractory Cardiogenic Shock and Veno-Arterial Extracorporeal Membrane Oxygenation. J Clin Med 2021; 10:jcm10050956. [PMID: 33804450 PMCID: PMC7957612 DOI: 10.3390/jcm10050956] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Revised: 02/20/2021] [Accepted: 02/23/2021] [Indexed: 12/14/2022] Open
Abstract
Although many risk models have been tested in patients implanted by veno-arterial extracorporeal membrane oxygenation (VA-ECMO), few scores assessed patients’ prognosis in the setting of ST-segment elevation myocardial infarction (STEMI) with refractory cardiogenic shock. We aimed at assessing the performance of risk scores, notably the prEdictioN of Cardiogenic shock OUtcome foR AMI patients salvaGed by VA-ECMO (ENCOURAGE) score, for predicting mortality in this particular population. This retrospective observational study included patients admitted to Tours University Hospital for STEMI with cardiogenic shock and requiring hemodynamic support by VA-ECMO. Among the fifty-one patients, the 30-day and 6-month survival rates were 63% and 56% respectively. Thirty days after VA-ECMO therapy, probabilities of mortality were 12, 17, 33, 66, 80% according to the ENCOURAGE score classes 0–12, 13–18, 19–22, 23–27, and ≥28, respectively. The ENCOURAGE score (AUC of the Receiving Operating Characteristic curve = 0.83) was significantly better compared to other risk scores. The hazard ratio for survival at 30 days for each point of the ENCOURAGE score was 1.10 (CI 95% (1.06, 1.15); p < 0.001). Decision curve analysis indicated that the ENCOURAGE score had the best clinical usefulness of the tested risk scores and the Hosmer–Lemeshow test suggested an accurate calibration. Our data suggest that the ENCOURAGE score is valid and the most relevant score to predict 30-day mortality after VA-ECMO therapy in STEMI patients with refractory cardiogenic shock. It may help decision-making teams to better select STEMI patients with shock for VA-ECMO therapy.
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Affiliation(s)
- Carl Semaan
- Service de Cardiologie, Centre Hospitalier Régional, Universitaire de Tours, 37044 Tours, France; (C.S.); (A.C.); (W.D.); (C.S.E.); (L.F.); (D.A.); (T.G.)
- Faculté de Médecine, Université de Tours, 37032 Tours, France;
| | - Arthur Charbonnier
- Service de Cardiologie, Centre Hospitalier Régional, Universitaire de Tours, 37044 Tours, France; (C.S.); (A.C.); (W.D.); (C.S.E.); (L.F.); (D.A.); (T.G.)
| | - Jeremy Pasco
- Service d’Informatique Médicale, Épidémiologie et Économie de la Santé, Centre Hospitalier Régional, Universitaire de Tours, 37044 Tours, France;
| | - Walid Darwiche
- Service de Cardiologie, Centre Hospitalier Régional, Universitaire de Tours, 37044 Tours, France; (C.S.); (A.C.); (W.D.); (C.S.E.); (L.F.); (D.A.); (T.G.)
- Faculté de Médecine, Université de Tours, 37032 Tours, France;
| | - Christophe Saint Etienne
- Service de Cardiologie, Centre Hospitalier Régional, Universitaire de Tours, 37044 Tours, France; (C.S.); (A.C.); (W.D.); (C.S.E.); (L.F.); (D.A.); (T.G.)
| | - Xavier Bailleul
- Service de Chirurgie Cardiaque, Centre Hospitalier Régional, Universitaire de Tours, 37044 Tours, France;
| | - Thierry Bourguignon
- Faculté de Médecine, Université de Tours, 37032 Tours, France;
- Service de Chirurgie Cardiaque, Centre Hospitalier Régional, Universitaire de Tours, 37044 Tours, France;
| | - Laurent Fauchier
- Service de Cardiologie, Centre Hospitalier Régional, Universitaire de Tours, 37044 Tours, France; (C.S.); (A.C.); (W.D.); (C.S.E.); (L.F.); (D.A.); (T.G.)
- Faculté de Médecine, Université de Tours, 37032 Tours, France;
| | - Denis Angoulvant
- Service de Cardiologie, Centre Hospitalier Régional, Universitaire de Tours, 37044 Tours, France; (C.S.); (A.C.); (W.D.); (C.S.E.); (L.F.); (D.A.); (T.G.)
- Faculté de Médecine, Université de Tours, 37032 Tours, France;
| | - Fabrice Ivanes
- Service de Cardiologie, Centre Hospitalier Régional, Universitaire de Tours, 37044 Tours, France; (C.S.); (A.C.); (W.D.); (C.S.E.); (L.F.); (D.A.); (T.G.)
- Faculté de Médecine, Université de Tours, 37032 Tours, France;
- Correspondence:
| | - Thibaud Genet
- Service de Cardiologie, Centre Hospitalier Régional, Universitaire de Tours, 37044 Tours, France; (C.S.); (A.C.); (W.D.); (C.S.E.); (L.F.); (D.A.); (T.G.)
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23
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Walker KL, Bakir NH, Kotkar KD, Damiano MS, Damiano RJ, Ridolfi G, Moon MR, Itoh A, Masood MF. Cannulation Strategy for Extracorporeal Membrane Oxygenation Does Not Influence Total Hospital Cost. Ann Thorac Surg 2021; 113:49-57. [PMID: 33581159 DOI: 10.1016/j.athoracsur.2020.12.062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Revised: 12/06/2020] [Accepted: 12/28/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND Center for Medicare Services decreased reimbursement rates for peripheral veno-arterial (VA ECMO) and veno-venous (VV ECMO) extracorporeal membrane oxygenation procedures in October 2018. Limited data are available describing hospital costs and clinical resources required to support ECMO patients. METHODS All patients supported on ECMO at our institution between March 2017 and October 2018 were identified. Exclusion criteria were cannulation at referring hospitals, organ transplant recipients, and temporary right ventricular support. The cohort was stratified by initial cannulation strategy. Outcomes were total hospital cost and clinical resource utilization. RESULTS 29 patients were supported on central VA, 72 on peripheral VA, and 37 on VV ECMO. Thirty-day survival was 48% for central vs 37% for peripheral vs 51% for VV. Hospital costs were $187,848 for central vs $178,069 for peripheral vs $172,994 for VV, P=0.91. Mean hospital stay was 25.8 days for central vs 21.5 for peripheral vs 26.2 for VV, P=0.49. Mean intensive care unit stay was 14.1 days for central vs 12.8 for peripheral vs 7.7 for VV, P=0.25. Mean length of ECMO support was 6.5 days for central vs 6.2 for peripheral vs 7.8 for VV, P=0.38. Mean ventilator time was 13.0 days for central vs 8.2 for peripheral vs 10.0 for VV P=0.06. Hemodialysis was utilized in 41% central, 47% peripheral, and 41% VV patients, P=0.75. Theoretical ECMO reimbursement losses ranged from $1,970,698 to $5,648,219 annually under 2018 Center for Medicare Services rates. CONCLUSIONS ECMO cannulation strategy has minimal impact on resource utilization and hospital cost.
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Affiliation(s)
- Karen L Walker
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University in St. Louis School of Medicine, Barnes-Jewish Hospital, St Louis, Missouri
| | - Nadia H Bakir
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University in St. Louis School of Medicine, Barnes-Jewish Hospital, St Louis, Missouri
| | - Kunal D Kotkar
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University in St. Louis School of Medicine, Barnes-Jewish Hospital, St Louis, Missouri
| | - Marci S Damiano
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University in St. Louis School of Medicine, Barnes-Jewish Hospital, St Louis, Missouri
| | - Ralph J Damiano
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University in St. Louis School of Medicine, Barnes-Jewish Hospital, St Louis, Missouri
| | - Gene Ridolfi
- Heart & Vascular Center, Barnes-Jewish Hospital, St Louis, Missouri
| | - Marc R Moon
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University in St. Louis School of Medicine, Barnes-Jewish Hospital, St Louis, Missouri
| | - Akinobu Itoh
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University in St. Louis School of Medicine, Barnes-Jewish Hospital, St Louis, Missouri
| | - Muhammad F Masood
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University in St. Louis School of Medicine, Barnes-Jewish Hospital, St Louis, Missouri.
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24
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Jabaley CS. Venoarterial Extracorporeal Membrane Oxygenation in Elderly Patients With Refractory Cardiogenic Shock: Is Age Truly Just a Number? Crit Care Med 2021; 49:156-159. [PMID: 33337744 DOI: 10.1097/ccm.0000000000004716] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Affiliation(s)
- Craig S Jabaley
- Division of Critical Care Medicine, Department of Anesthesiology, Emory University School of Medicine, Atlanta, GA
- Emory Critical Care Center, Atlanta, GA
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25
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Gutsche JT, Grant MC, Kiefer JJ, Ghadimi K, Lane-Fall MB, Mazzeffi MA. The Year in Cardiothoracic Critical Care: Selected Highlights from 2019. J Cardiothorac Vasc Anesth 2020; 36:45-57. [PMID: 33051148 DOI: 10.1053/j.jvca.2020.09.114] [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: 09/15/2020] [Accepted: 09/16/2020] [Indexed: 11/11/2022]
Abstract
In 2019, cardiothoracic and vascular critical care remained an important focus and subspecialty. This article continues the annual series to review relevant contributions in postoperative critical care that may affect the cardiac anesthesiologist. Herein, the pertinent literature published in 2019 is explored and organized by organ system.
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Affiliation(s)
- J T Gutsche
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA.
| | - M C Grant
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - J J Kiefer
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - K Ghadimi
- Department of Anesthesiology and Critical Care, Duke University, Durham, NC
| | - M B Lane-Fall
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - M A Mazzeffi
- Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, MD
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26
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Wolfe JD, Schilling JD. A Short Bridge Over a Wide River: The Role of Extracorporeal Membrane Oxygenation in Older Adults With Cardiogenic Shock. J Card Fail 2020; 26:1090-1092. [PMID: 32956815 DOI: 10.1016/j.cardfail.2020.09.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Accepted: 09/11/2020] [Indexed: 01/11/2023]
Affiliation(s)
- Jonathan D Wolfe
- Department of Medicine, Division of Cardiology, Washington University School of Medicine, Saint Louis, Missouri
| | - Joel D Schilling
- Department of Medicine, Division of Cardiology, Washington University School of Medicine, Saint Louis, Missouri.
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Chouairi F, Vallabhajosyula S, Mullan C, Mori M, Geirsson A, Desai NR, Ahmad T, Miller PE. Transition to Advanced Therapies in Elderly Patients Supported by Extracorporeal Membrane Oxygenation Therapy. J Card Fail 2020; 26:1086-1089. [PMID: 32777479 DOI: 10.1016/j.cardfail.2020.07.019] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Revised: 07/29/2020] [Accepted: 07/30/2020] [Indexed: 12/18/2022]
Abstract
BACKGROUND Although the use of extracorporeal membrane oxygenation (ECMO) continues to increase, very little is known about how age influences the transition to definitive advanced therapies. METHODS Using the National Inpatient Sample database from 2008 to 2017, we analyzed patients supported by ECMO for cardiogenic shock and separated patients into 2 age cohorts: < 65 years and ≥ 65 years. Primary outcomes of interest included the proportion of patients undergoing orthotopic cardiac transplantation (OHT) and left ventricular assist device (LVAD) implantation. RESULTS Over the study period, we identified 16,132 hospitalizations of people with cardiogenic shock requiring ECMO support. Significantly fewer patients in the older group underwent OHT compared to the younger group (0.4% vs 1.2%, P < 0.001). Compared to the younger group, a lower proportion of those ≥ 65 years received an LVAD (3.7% vs 5.8%, P < 0.001). LVAD implantation increased over the study period in both age cohorts, whereas OHT increased only in the < 65 group (P < 0.05, all). After multivariable adjustment, patients in the oldest age group were still less likely to receive an LVAD (odds ratio 0.54; confidence interval: 0.43-0.69, P < 0.001) and continued to have the highest odds of in-hospital mortality (odds ratio 1.53; confidence interval : 1.39-1.69, P < 0.001). CONCLUSIONS Survival of patients ≥ 65 years requiring ECMO for cardiogenic shock is poor and less commonly includes transition to definitive advanced therapies. Although we must stress that no patient should be denied ECMO based solely on age, we believe our results may be helpful for providers when counseling patients and their families.
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Affiliation(s)
- Fouad Chouairi
- Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Saraschandra Vallabhajosyula
- Department of Cardiovascular Medicine and Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic, Rochester, Minnesota
| | - Clancy Mullan
- Section of Cardiac Surgery, Yale University School of Medicine, New Haven, Connecticut
| | - Makoto Mori
- Section of Cardiac Surgery, Yale University School of Medicine, New Haven, Connecticut
| | - Arnar Geirsson
- Section of Cardiac Surgery, Yale University School of Medicine, New Haven, Connecticut
| | - Nihar R Desai
- Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, Connecticut; Center for Outcomes Research & Evaluation (CORE), Yale University School of Medicine, New Haven, Connecticut
| | - Tariq Ahmad
- Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, Connecticut; Center for Outcomes Research & Evaluation (CORE), Yale University School of Medicine, New Haven, Connecticut
| | - P Elliott Miller
- Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, Connecticut; Yale National Clinician Scholars Program, Yale University School of Medicine, New Haven, Connecticut.
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28
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Predicting Survival After Extracorporeal Membrane Oxygenation by Using Machine Learning. Ann Thorac Surg 2020; 110:1193-1200. [PMID: 32454016 DOI: 10.1016/j.athoracsur.2020.03.128] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Revised: 03/26/2020] [Accepted: 03/31/2020] [Indexed: 01/21/2023]
Abstract
BACKGROUND Venoarterial (VA) extracorporeal membrane oxygenation (ECMO) undoubtedly saves many lives, but it is associated with a high degree of patient morbidity, mortality, and resource use. This study aimed to develop a machine learning algorithm to augment clinical decision making related to VA-ECMO. METHODS Patients supported by VA-ECMO at a single institution from May 2011 to October 2018 were retrospectively reviewed. Laboratory values from only the initial 48 hours of VA-ECMO support were used. Data were split into 70% for training, 15% for validation, and 15% withheld for testing. Feature importance was estimated, and dimensionality reduction techniques were used. A deep neural network was trained to predict survival to discharge, and the final model was assessed using the independent testing cohort. Model performance was compared with that of the SAVE (Survival After Veno-arterial ECMO) score by using a receiver operator characteristic curve. RESULTS Of the 282 eligible adult patients who were undergoing VA-ECMO, 117 (41%) survived to discharge. A total of 1.96 million laboratory values were extracted from the electronic medical record, from which 270 different summary variables were derived for each patient. The most important variables in predicting the primary outcome included lactate, age, total bilirubin, and creatinine. For the testing cohort, the final model achieved 82% overall accuracy and a greater area under the curve than the SAVE score (0.92 vs 0.65; P = .01) in predicting survival to discharge. CONCLUSIONS This proof of concept study demonstrates the potential for machine learning models to augment clinical decision making for patients undergoing VA-ECMO. Further development with multi-institutional data is warranted.
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Shen L, Tam CW, Jones MM, Hoyler M, Ivascu NS. Noteworthy Literature From 2019 for Cardiothoracic Critical Care. Semin Cardiothorac Vasc Anesth 2020; 24:149-158. [PMID: 32340560 DOI: 10.1177/1089253220919284] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
This annual article summarizes key findings from notable studies published in 2019 relevant to the practice of cardiothoracic critical care medicine. This year's article encompasses updates to the literature on enhanced recovery after cardiac surgery, extracorporeal membranous oxygenation, delirium, and primary graft dysfunction after heart transplant.
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Affiliation(s)
- Liang Shen
- Weill Cornell Medical College, New York, NY, USA
| | | | | | - Marguerite Hoyler
- NewYork-Presbyterian Hospital/Weill Cornell Medical Center, New York, NY, USA
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Jäämaa-Holmberg S, Salmela B, Suojaranta R, Lemström KB, Lommi J. Cost-utility of venoarterial extracorporeal membrane oxygenation in cardiogenic shock and cardiac arrest. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2020; 9:333-341. [PMID: 32004079 DOI: 10.1177/2048872619900090] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND The use of venoarterial extracorporeal membrane oxygenation in cardiogenic shock keeps increasing, but its cost-utility is unknown. METHODS We studied retrospectively the cost-utility of venoarterial extracorporeal membrane oxygenation in a five-year cohort of consequent patients treated due to refractory cardiogenic shock or cardiac arrest in a transplant centre in 2013-2017. In our centre, venoarterial extracorporeal membrane oxygenation is considered for all cardiogenic shock patients potentially eligible for heart transplantation, and for selected postcardiotomy patients. We assessed the costs of the index hospitalization and of the one-year hospital costs, and the patients' health-related quality of life (response rate 71.7%). Based on the data and the population-based life expectancies, we calculated the amount and the costs of quality-adjusted life years gained both without discount and with an annual discount of 3.5%. RESULTS The cohort included 102 patients (78 cardiogenic shock; 24 cardiac arrest) of whom 67 (65.7%) survived to discharge and 66 (64.7%) to one year. The effective costs per one hospital survivor were 242,303€. Median in-hospital costs of the index hospitalization per patient were 129,967€ (interquartile range 150,340€). Mean predicted number of quality-adjusted life years gained by the treatment was 20.9 (standard deviation 9.7) without discount, and the median cost per quality-adjusted life year was 7474€ (interquartile range 10,973€). With the annual discount of 3.5%, 13.0 (standard deviation 4.8) quality-adjusted life years were gained with the cost of 12,642€ per quality-adjusted life year (interquartile range 15,059€). CONCLUSIONS We found the use of venoarterial extracorporeal membrane oxygenation in refractory cardiogenic shock and cardiac arrest justified from the cost-utility point of view in a transplant centre setting.
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Affiliation(s)
- Salla Jäämaa-Holmberg
- Heart and Lung Center, Helsinki University Hospital, Finland.,Faculty of Medicine, University of Helsinki, Finland
| | | | | | - Karl B Lemström
- Heart and Lung Center, Helsinki University Hospital, Finland.,Faculty of Medicine, University of Helsinki, Finland
| | - Jyri Lommi
- Heart and Lung Center, Helsinki University Hospital, Finland
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Prasad A, Brehm CE, Goldenberg M, Ghodsizad A, Koerner MM, El-Banayosy A, Singbartl K. Early prediction of transition to durable mechanical circulatory support in patients undergoing peripheral veno-arterial extracorporeal membrane oxygenation for critical cardiogenic shock. Artif Organs 2019; 44:402-410. [PMID: 31660618 DOI: 10.1111/aor.13590] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2019] [Revised: 10/22/2019] [Accepted: 10/24/2019] [Indexed: 01/02/2023]
Abstract
Peripheral veno-arterial extracorporeal membrane oxygenation (pVA-ECMO) has gained increasing value in the management of patients with critical cardiogenic shock (cCS), allowing time for myocardial recovery. Failure of myocardial recovery has life-altering consequences: transition to durable mechanical circulatory support (dMCS), urgent heart transplantation, or withdrawal of support. Clinical factors controlling myocardial recovery under these circumstances remain largely unknown. Using a retrospective cohort, we developed a model for early prediction of transition to dMCS in patients undergoing pVA-ECMO for cCS. To promote myocardial recovery, our clinical management centered around left ventricular pressure unloading, that is, targeting pulmonary capillary wedge pressures (PCWP) ≤18 mm Hg. We collected demographic data, laboratory findings, inotrope use, and two-dimensional transthoracic echocardiography measurements, all limited to the first 72h of pVA-ECMO (D1-3). Out of 70 patients who were alive after pVA-ECMO, 27 patients underwent implantation of dMCS. There was no significant difference in survival to hospital discharge between patients with or without transition to dMCS. Ejection fractionD1-3 (per 10% increase, OR 0.37 [0.17-0.79]) and amount of inotropic supportD1-3 (OR 4.77 [1.6-14.18]) but neither myocardial wall tension nor PCWP emerged as significant predictors of transition to dMCS. Optimism-corrected c-index (0.90 [0.89-0.90]) revealed an excellent discriminative ability of our model. In summary, our model for early prediction of transition to dMCS in patients with cCS undergoing pVA-ECMO identifies indicators of inotropic state as relevant factors. Absence of markers for myocardial oxygen consumption or left ventricular pressure loading allows us to hypothesize sufficient cardiac unloading in our cohort with PCWP-targeted management.
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Affiliation(s)
- Amit Prasad
- Heart and Vascular Institute, Penn State Health, Hershey, PA, USA
| | | | | | - Ali Ghodsizad
- Miami Transplant Institute, University of Miami, Miami, FL, USA
| | - Michael M Koerner
- Advanced Cardiac Care and Transplant Institute, INTEGRIS Baptist Medical Center, Oklahoma City, OK, USA
| | - Aly El-Banayosy
- Advanced Cardiac Care and Transplant Institute, INTEGRIS Baptist Medical Center, Oklahoma City, OK, USA
| | - Kai Singbartl
- Critical Care Medicine, Mayo Clinic, Phoenix, AZ, USA
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Biancari F, Saeed D, Fiore A, Dalén M, Ruggieri VG, Jónsson K, Gatti G, Zipfel S, Dell’Aquila AM, Chocron S, Bounader K, Amr G, Settembre N, Pälve K, Loforte A, Gabrielli M, Livi U, Lechiancole A, Pol M, Netuka I, Spadaccio C, Pettinari M, De Keyzer D, Reichart D, Ragnarsson S, Alkhamees K, Lichtenberg A, Fux T, El Dean Z, Fiorentino M, Mariscalco G, Jeppsson A, Welp H, Perrotti A. Postcardiotomy Venoarterial Extracorporeal Membrane Oxygenation in Patients Aged 70 Years or Older. Ann Thorac Surg 2019; 108:1257-1264. [DOI: 10.1016/j.athoracsur.2019.04.063] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2019] [Revised: 04/01/2019] [Accepted: 04/15/2019] [Indexed: 12/13/2022]
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Biancari F, Dell'Aquila AM, Mariscalco G. Predicting mortality after postcardiotomy venoarterial extracorporeal membrane oxygenation. ANNALS OF TRANSLATIONAL MEDICINE 2019; 7:S100. [PMID: 31576307 DOI: 10.21037/atm.2019.04.74] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Fausto Biancari
- Heart Center, Turku University Hospital and Department of Surgery, University of Turku, Turku, Finland.,Department of Surgery, University of Oulu, Oulu, Finland
| | | | - Giovanni Mariscalco
- Department of Cardiac Surgery, Glenfield Hospital, University Hospitals of Leicester, Leicester, UK
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