Jentzer, Jacob C.

Background There are limited data on the role of temporary mechanical circulatory support ( MCS ) devices for cardiogenic shock before left ventricular assist device ( LVAD ) surgery. This study sought to evaluate the trends of use and outcomes of MCS in cardiogenic shock before LVAD surgery. Methods and Results This was a retrospective cohort study from 2005 to 2014 using the National Inpatient Sample (20% stratified sample of US hospitals). This study identified admissions undergoing LVAD surgery with preoperative cardiogenic shock. Admissions for other cardiac surgery and heart transplant were excluded. Temporary MCS was identified using administrative codes. The primary outcome was hospital mortality and secondary outcomes were hospital costs and lengths of stay in admissions with and without MCS use. In this 10‐year period, 9753 admissions were identified with 40.6% requiring pre‐ LVAD MCS . There was a temporal increase in the frequency of cardiogenic shock associated with an increase in non–intra‐aortic balloon pump MCS devices. The cohort receiving MCS had greater in‐hospital myocardial infarction, ventricular arrhythmias, and use of coronary angiography. On multivariable analysis, older age, myocardial infarction, and need for MCS devices were independently predictive of higher in‐hospital mortality. In 696 propensity‐matched pairs, use of MCS was predictive of higher in‐hospital mortality (odds ratio 1.4 [95% confidence interval 1.1–1.6]; P =0.02) and higher hospital costs, but similar lengths of stay. Conclusions In patients with cardiogenic shock bridged to LVAD therapy, there was a steady increase in preoperative MCS use. Use of MCS identified patients at higher risk for in‐hospital mortality and greater resource utilization.

BackgroundSerum albumin is a strong prognostic indicator for many disease processes, yet limited data exist regarding its prognostic relationship in pulmonary arterial hypertension (PAH). Our study aims to assess the relationship of hypoalbuminemia with disease severity and mortality in this population.HypothesisSerum albumin concentrations are a predictor of outcomes in PAH.MethodsA retrospective review of all patients with World Health Organization group 1 PAH evaluated between March 2001 and August 2008 was performed. Patients were stratified into groups based on serum albumin concentration ≤3.3 g/dL (hypoalbuminemia) vs >3.3 g/dL. Clinical, hemodynamic, and survival comparisons were compared between groups using Student t test and χ2 test, followed by univariate analysis and multivariate logistic regression.ResultsA total of 163/273 (59.7%) patients had a documented serum albumin concentration. Hypoalbuminemia was present in 41 (25.2%) patients and serum albumin ≤3.3 g/dL represented the lowest quartile of serum albumin. Patients with hypoalbuminemia had higher rates of renal dysfunction (26.8% vs 9.8%, P =0.0069) and hepatic dysfunction (29.3% vs 6.6%, P <0.001), and lower hemoglobin levels (11.6 vs 13.4 g/dL, P < 0.001). Hemodynamic and functional capacity assessments were comparable between groups. Independent predictors of mortality included low albumin levels (hazard ratio [HR]: 0.485, P = 0.008), high right atrial systolic area (HR: 1.062, P = 0.003), low Fick‐derived cardiac index (HR: 1.465, P = 0.016), and high New York Heart Association functional class (HR: 1.767, P = 0.042). Patients with hypoalbuminemia demonstrated a significantly lower survival rate at latest follow‐up (P = 0.01).ConclusionsLower serum albumin concentrations in patients with PAH are associated with higher mortality and can serve as a marker of disease severity in this patient population.

The data on speckle-tracking echocardiography (STE) in patients with sepsis are limited. This systematic review from 1975 to 2016 included studies in adults and children evaluating cardiovascular dysfunction in sepsis, severe sepsis, and septic shock utilizing STE for systolic global longitudinal strain (GLS). The primary outcome was short- or long-term mortality. Given the significant methodological and statistical differences between published studies, combining the data using meta-analysis methods was not appropriate. A total of 120 studies were identified, with 5 studies (561 patients) included in the final analysis. All studies were prospective observational studies using the 2001 criteria for defining sepsis. Three studies demonstrated worse systolic GLS to be associated with higher mortality, whereas 2 did not show a statistically significant association. Various cutoffs between −10% and −17% were used to define abnormal GLS across studies. This systematic review revealed that STE may predict mortality in patients with sepsis; however, the strength of evidence is low due to heterogeneity in study populations, GLS technologies, cutoffs, and timing of STE. Further dedicated studies are needed to understand the optimal application of STE in patients with sepsis.

Background Optimal methods of mortality risk stratification in patients in the cardiac intensive care unit ( CICU ) remain uncertain. We evaluated the ability of the Sequential Organ Failure Assessment ( SOFA ) score to predict mortality in a large cohort of unselected patients in the CICU. Methods and Results Adult patients admitted to the CICU from January 1, 2007, to December 31, 2015, at a single tertiary care hospital were retrospectively reviewed. SOFA scores were calculated daily, and Acute Physiology and Chronic Health Evaluation ( APACHE )‐ III and APACHE ‐ IV scores were calculated on CICU day 1. Discrimination of hospital mortality was assessed using area under the receiver‐operator characteristic curve values. We included 9961 patients, with a mean age of 67.5±15.2 years; all‐cause hospital mortality was 9.0%. Day 1 SOFA score predicted hospital mortality, with an area under the receiver‐operator characteristic curve value of 0.83; area under the receiver‐operator characteristic curve values were similar for the APACHE ‐ III score, and APACHE ‐ IV predicted mortality ( P >0.05). Mean and maximum SOFA scores over multiple CICU days had greater discrimination for hospital mortality ( P <0.01). Patients with an increasing SOFA score from day 1 and day 2 had higher mortality. Patients with day 1 SOFA score <2 were at low risk of mortality. Increasing tertiles of day 1 SOFA score predicted higher long‐term mortality ( P <0.001 by log‐rank test). Conclusions The day 1 SOFA score has good discrimination for short‐term mortality in unselected patients in the CICU, which is comparable to APACHE ‐ III and APACHE ‐ IV . Advantages of the SOFA score over APACHE include simplicity, improved discrimination using serial scores, and prediction of long‐term mortality.

Background: Noncardiovascular comorbidities and critical illness are increasing in cardiovascular intensive care units (CICUs). There are limited data comparing critical care delivery, resource utilization, and costs between contemporary CICUs and medical intensive care units (MICUs). Methods: All CICU (n = 6967; 22 748 patient-days) and MICU (n = 10 892; 39 211 patient-days) admissions to Cedars-Sinai Medical Center, a tertiary care academic medical center, between January 2011 and December 2016 were reviewed. Both the CICU and MICU admitted patients for primary cardiovascular or medical conditions during the study period, but not for postoperative surgical care. Results: Patients admitted to the CICU were more frequently older, male, and had more preexisting cardiac disease ( P < .0001). More than one-fifth (21.4%) of CICU patients had a noncardiovascular primary admission diagnosis, compared to 89.2% of MICU patients. Cardiovascular intensive care unit patients had lower Acute Physiology and Chronic Health Evaluation III scores (51.1 [19.9] vs 61.1 [24.9], P < .0001) and shorter median hospital length of stay ( P < .001), but not in-unit stay, as compared to MICU patients. Mechanical ventilation, vasopressors, inotropes, renal replacement therapy, and/or blood transfusion were required in 35.0% of CICU patients compared with 62.2% of MICU patients ( P < .0001). The unit mortality rate was lower for CICU than MICU patients (4.8% vs 13.0%, P < .0001), as was the hospital mortality rate (9.3% vs 21.6%, P < .0001). The standardized mortality ratio was 0.73 for the CICU and 0.86 for the MICU. There was no difference in the mean direct cost of care per patient-day between the CICU and MICU ($4011 USD [376] vs $3990 USD [214], P = .77). Conclusions: The burden of noncardiovascular diseases and the requirement for critical care therapies are high in contemporary CICU patients but remain lower compared to the MICU population. Our findings support the growing complexity of care in tertiary CICUs. Further studies are required to explore the association between critical care delivery and outcomes in this evolving population.

Background Troponin‐T elevation is seen commonly in sepsis and septic shock patients admitted to the intensive care unit. We sought to evaluate the role of admission and serial troponin‐T testing in the prognostication of these patients. Methods and Results This was a retrospective cohort study from 2007 to 2014 on patients admitted to the intensive care units at the Mayo Clinic with severe sepsis and septic shock. Elevated admission troponin‐T and significant delta troponin‐T were defined as ≥0.01 ng/mL and ≥0.03 ng/mL in 3 hours, respectively. The primary outcome was in‐hospital mortality. Secondary outcomes included 1‐year mortality and lengths of stay. During this 8‐year period, 944 patients met the inclusion criteria with 845 (90%) having an admission troponin‐T ≥0.01 ng/mL. Serial troponin‐T values were available in 732 (78%) patients. Elevated admission troponin‐T was associated with older age, higher baseline comorbidity, and severity of illness, whereas significant delta troponin‐T was associated with higher severity of illness. Admission log 10 troponin‐T was associated with unadjusted in‐hospital (odds ratio 1.6; P =0.003) and 1‐year mortality (odds ratio 1.3; P =0.04), but did not correlate with length of stay. Elevated delta troponin‐T and log 10 delta troponin‐T were not significantly associated with any of the primary or secondary outcomes. Admission log 10 troponin‐T remained an independent predictor of in‐hospital mortality (odds ratio 1.4; P =0.04) and 1‐year survival (hazard ratio 1.3; P =0.008). Conclusions In patients with sepsis and septic shock, elevated admission troponin‐T was associated with higher short‐ and long‐term mortality. Routine serial troponin‐T testing did not add incremental prognostic value in these patients.

Abstract Background: The association between new-onset left ventricular (LV) dysfunction during sepsis with long-term heart failure outcomes is lesser understood. Methods: Retrospective cohort study of all adult patients with severe sepsis and septic shock between 2007 and 2014 who underwent echocardiography within 72 h of admission to the intensive care unit. Patients with prior heart failure, LV dysfunction, and structural heart disease were excluded. LV systolic dysfunction was defined as LV ejection fraction <50% and LV diastolic dysfunction as ≥grade II. Primary composite outcome included new hospitalization for acute decompensated heart failure and all-cause mortality at 2-year follow-up. Secondary outcomes included persistent LV dysfunction, and hospital mortality and length of stay. Results: During this 8-year period, 434 patients with 206 (48%) patients having LV dysfunction were included. The two groups had similar baseline characteristics, but those with LV dysfunction had worse function as demonstrated by worse LV ejection fraction, cardiac index, and LV diastolic dysfunction. In the 331 hospital survivors, new-onset acute decompensated heart failure hospitalization did not differ between the two cohorts (15% vs. 11%). The primary composite outcome was comparable at 2-year follow-up between the groups with and without LV dysfunction (P = 0.24). Persistent LV dysfunction was noted in 28% hospital survivors on follow-up echocardiography. Other secondary outcomes were similar between the two groups. Conclusions: In patients with severe sepsis and septic shock, the presence of new-onset LV dysfunction did not increase the risk of long-term adverse heart failure outcomes.