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Schenck CS, Chouairi F, Dudzinski DM, Miller PE. Noninvasive Ventilation in the Cardiac Intensive Care Unit. J Intensive Care Med 2024:8850666241243261. [PMID: 38571399 DOI: 10.1177/08850666241243261] [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: 04/05/2024]
Abstract
Over the last several decades, the cardiac intensive care unit (CICU) has seen an increase in the complexity of the patient population and etiologies requiring CICU admission. Currently, respiratory failure is the most common reason for admission to the contemporary CICU. As a result, noninvasive ventilation (NIV), including noninvasive positive-pressure ventilation and high-flow nasal cannula, has been increasingly utilized in the management of patients admitted to the CICU. In this review, we detail the different NIV modalities and summarize the evidence supporting their use in conditions frequently encountered in the CICU. We describe the unique pathophysiologic interactions between positive pressure ventilation and left and/or right ventricular dysfunction. Additionally, we discuss the evidence and strategies for utilization of NIV as a method to reduce extubation failure in patients who required invasive mechanical ventilation. Lastly, we examine unique considerations for managing respiratory failure in certain, high-risk patient populations such as those with right ventricular failure, severe valvular disease, and adult congenital heart disease. Overall, it is critical for clinicians who practice in the CICU to be experts with the application, risks, benefits, and modalities of NIV in cardiac patients with respiratory failure.
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Affiliation(s)
| | - Fouad Chouairi
- Department of Internal Medicine, Duke University School of Medicine, Durham, NC, USA
| | - David M Dudzinski
- Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
- Corrigan Minehan Heart Center, Massachusetts General Hospital, Boston, MA, USA
| | - P Elliott Miller
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT, USA
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2
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Ibrahim R, Shahid M, Tan MC, Martyn T, Lee JZ, William P. Exploring Heart Failure Mortality Trends and Disparities in Women: A Retrospective Cohort Analysis. Am J Cardiol 2023; 209:42-51. [PMID: 37858592 DOI: 10.1016/j.amjcard.2023.09.087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2023] [Revised: 09/14/2023] [Accepted: 09/24/2023] [Indexed: 10/21/2023]
Abstract
Heart failure (HF) remains a significant cause of morbidity and mortality in women. Population-level analyses shed light on existing disparities and promote targeted interventions. We evaluated HF-related mortality data in women in the United States to identify disparities based on race/ethnicity, urbanization level, and geographic region. We conducted a retrospective cohort analysis utilizing the Centers for Disease Control and Prevention Wide-ranging Online Data for Epidemiologic Research database to identify HF-related mortality in the death files from 1999 to 2020. Age-adjusted HF mortality rates were standardized to the 2000 US population. We fit log-linear regression models to analyze mortality trends. Age-adjusted HF mortality rates in women have decreased significantly over time, from 97.95 in 1999 to 89.19 in 2020. Mortality mainly downtrended from 1999 to 2012, followed by a significant increase from 2012 to 2020. Our findings revealed disparities in mortality rates based on race and ethnicity, with the most affected population being non-Hispanic Black (age-adjusted mortality rates [AAMR] 90.36), followed by non-Hispanic White (AAMR 83.25), American Indian/Alaska Native (AAMR 64.27), and Asian/Pacific Islander populations (AAMR 37.46). We also observed that nonmetropolitan (AAMR 103.36) and Midwestern (AAMR 90.45) regions had higher age-adjusted mortality rates compared with metropolitan (AAMR 78.43) regions and other US census regions. In conclusion, significant differences in HF mortality rates were observed based on race/ethnicity, urbanization level, and geographic region. Disparities in HF outcomes persist and efforts to reduce HF-related mortality rates should focus on targeted interventions that address social determinants of health, including access to care and socioeconomic status.
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Affiliation(s)
- Ramzi Ibrahim
- Department of Medicine, University of Arizona Tucson, Tucson, Arizona.
| | - Mahek Shahid
- Department of Medicine, University of Arizona Tucson, Tucson, Arizona
| | - Min-Choon Tan
- Department of Cardiovascular Medicine, Mayo Clinic, Phoenix, Arizona; Department of Medicine, New York Medical College at Saint Michael's Medical Center, Newark, New Jersey
| | - Trejeeve Martyn
- Robert and Suzanne Tomsich Department of Cardiovascular Medicine, George and Linda Kaufman Center for Heart Failure and Recovery, Cleveland Clinic, Cleveland, Ohio; Amyloidosis Center, Cleveland Clinic, Cleveland, Ohio
| | - Justin Z Lee
- Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio
| | - Preethi William
- Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio
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3
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Relation of Ischemic Heart Disease to Outcomes in Patients With Acute Respiratory Distress Syndrome. Am J Cardiol 2022; 176:24-29. [PMID: 35606175 DOI: 10.1016/j.amjcard.2022.04.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Revised: 03/29/2022] [Accepted: 04/05/2022] [Indexed: 11/21/2022]
Abstract
Patients with ischemic heart disease (IHD) are often excluded from acute respiratory distress syndrome (ARDS) clinical trials. As a result, little is known about the impact of IHD in this population. We sought to assess the association between IHD and clinical outcomes in patients with ARDS. Participants from 4 ARDS randomized controlled trials with shared study criteria, definitions, and end points were included. Using multivariable logistic regression, we assessed for the association between IHD and a primary outcome of 60-day mortality. Secondary outcomes included 90-day mortality, 28-day ventilator-free days, and 28-day organ failure. Among 1,909 patients, 102 had a history of IHD (5.4%). Patients with IHD were more likely to be older and male (p <0.05). Noncardiac co-morbidities, severity of illness, and other markers of ARDS severity were not statistically different (all, p >0.05). Patients with IHD had a higher 60-day (39.2% vs 23.3%, p <0.001) and 90-day (40.2% vs 24.0%, p <0.001) mortality, and experienced more frequent renal (45.1% vs 32.0%, p = 0.006) and hepatic (35.3% vs 25.2%, p = 0.023) failure. After multivariable adjustment, 60-day (odds ratio [OR] 1.76; 95% confidence interval [CI]: 1.07 to 2.89, p = 0.025) and 90-day (OR 1.74; 95% CI: 1.06 to 2.85, p = 0.028) mortality remained higher. IHD was associated with 10% fewer ventilator-free days (incidence rate ratio 0.90; 95% CI: 0.85 to 0.96, p = 0.001). In conclusion, co-morbid IHD was associated with higher mortality and fewer ventilator-free days in patients with ARDS. Future studies are needed to identify predictors of mortality and improve treatment paradigms in this critically ill subgroup of patients.
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4
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Il'Giovine ZJ, Starling RC. Needing to vent: best to pitch the vent before heart transplant. EUROPEAN HEART JOURNAL. ACUTE CARDIOVASCULAR CARE 2021; 10:852-854. [PMID: 34518879 DOI: 10.1093/ehjacc/zuab081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Affiliation(s)
- Zachary J Il'Giovine
- Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Kaufman Center for Heart Failure Treatment and Recovery, Cleveland Clinic Foundation, Desk J3-4, 9500 Euclid Avenue, Cleveland, OH 44195, USA
| | - Randall C Starling
- Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Kaufman Center for Heart Failure Treatment and Recovery, Cleveland Clinic Foundation, Desk J3-4, 9500 Euclid Avenue, Cleveland, OH 44195, USA
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5
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Miller PE, Mullan CW, Chouairi F, Sen S, Clark KA, Reinhardt S, Fuery M, Anwer M, Geirsson A, Formica R, Rogers JG, Desai NR, Ahmad T. Mechanical ventilation at the time of heart transplantation and associations with clinical outcomes. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2021; 10:843-851. [PMID: 34389855 DOI: 10.1093/ehjacc/zuab063] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Revised: 06/25/2021] [Accepted: 07/09/2021] [Indexed: 11/13/2022]
Abstract
AIMS The impact of mechanical ventilation (MV) at the time of heart transplantation is not well understood. In addition, MV was recently removed as a criterion from the new US heart transplantation allocation system. We sought to assess for the association between MV at transplantation and 1-year mortality. METHODS AND RESULTS We utilized the United Network for Organ Sharing database and included all adult, single organ heart transplantations from 1990 to 2019. We utilized multivariable logistic regression adjusting for demographics, comorbidities, and markers of clinical acuity. We identified 60 980 patients who underwent heart transplantation, 2.4% (n = 1431) of which required MV at transplantation. Ventilated patients were more likely to require temporary mechanical support, previous dialysis, and had a shorter median waitlist time (21 vs. 95 days, P < 0.001). At 1 year, the mortality was 33.7% (n = 484) for ventilated patients and 11.7% (n = 6967) for those not ventilated at the time of transplantation (log-rank P < 0.001). After multivariable adjustment, patients requiring MV continued to have a substantially higher 90-day [odds ratio (OR) 3.20, 95% confidence interval (CI): 2.79-3.66, P < 0.001] and 1-year mortality (OR 2.67, 95% CI: 2.36-3.03, P < 0.001). For those that survived to 90 days, the adjusted mortality at 1 year continued to be higher (OR 1.48, 95% CI: 1.16-1.89, P = 0.002). CONCLUSION We found a strong association between the presence of MV at heart transplantation and 90-day and 1-year mortality. Future studies are needed to identify which patients requiring MV have reasonable outcomes, and which are associated with substantially poorer outcomes.
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Affiliation(s)
- P Elliott Miller
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT, USA.,Yale National Clinicians Scholar Program, New Haven, CT, USA
| | - Clancy W Mullan
- Division of Cardiac Surgery, Yale School of Medicine, New Haven, CT, USA
| | - Fouad Chouairi
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Sounok Sen
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Katherine A Clark
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Samuel Reinhardt
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Michael Fuery
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Muhammad Anwer
- Division of Cardiac Surgery, Yale School of Medicine, New Haven, CT, USA
| | - Arnar Geirsson
- Division of Cardiac Surgery, Yale School of Medicine, New Haven, CT, USA
| | - Richard Formica
- Department of Surgery, Yale School of Medicine, New Haven, CT, USA.,Section of Nephrology, Yale School of Medicine, New Haven, CT, USA
| | - Joseph G Rogers
- Division of Cardiology, Duke University Medical Center, Durham, NC, USA
| | - Nihar R Desai
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Tariq Ahmad
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT, USA
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6
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Miller PE, Thomas A, Breen TJ, Chouairi F, Kunitomo Y, Aslam F, Damluji AA, Anavekar NS, Murphy JG, van Diepen S, Barsness GW, Brennan J, Jentzer J. Prevalence of Noncardiac Multimorbidity in Patients Admitted to Two Cardiac Intensive Care Units and Their Association with Mortality. Am J Med 2021; 134:653-661.e5. [PMID: 33129785 PMCID: PMC8079541 DOI: 10.1016/j.amjmed.2020.09.035] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Revised: 09/16/2020] [Accepted: 09/21/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND Current cardiac intensive care unit (CICU) practice has seen an increase in patient complexity, including an increase in noncardiac organ failure, critical care therapies, and comorbidities. We sought to describe the changing epidemiology of noncardiac multimorbidity in the CICU population. METHODS We analyzed consecutive unique patient admissions to 2 geographically distant tertiary care CICUs (n = 16,390). We assessed for the prevalence of 0, 1, 2, and ≥3 noncardiac comorbidities (diabetes, chronic lung, liver, and kidney disease, cancer, and stroke/transient ischemic attack) and their associations with hospital and postdischarge 1-year mortality using multivariable logistic regression. RESULTS The prevalence of 0, 1, 2, and ≥3 noncardiac comorbidities was 37.7%, 31.4%, 19.9%, and 11.0%, respectively. Increasing noncardiac comorbidities were associated with a stepwise increase in mortality, length of stay, noncardiac indications for ICU admission, and increased utilization of critical care therapies. After multivariable adjustment, compared with those without noncardiac comorbidities, there was an increased hospital mortality for patients with 1 (odds ratio [OR] 1.30; 95% confidence interval [CI], 1.10-1.54, P = .002), 2 (OR 1.47; 95% CI, 1.22-1.77, P < .001), and ≥3 (OR 1.79; 95% CI, 1.44-2.22, P < .001) noncardiac comorbidities. Similar trends for each additional noncardiac comorbidity were seen for postdischarge 1-year mortality (P < .001, all). CONCLUSIONS In 2 large contemporary CICU populations, we found that noncardiac multimorbidity was highly prevalent and a strong predictor of short- and long-term adverse clinical outcomes. Further study is needed to define the best care pathways for CICU patients with acute cardiac illness complicated by noncardiac multimorbidity.
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Affiliation(s)
- P Elliott Miller
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, Conn; Yale National Clinicians Scholar Program, New Haven, Conn.
| | - Alexander Thomas
- Department of Internal Medicine, Yale School of Medicine, New Haven, Conn
| | - Thomas J Breen
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minn
| | - Fouad Chouairi
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, Conn
| | - Yukiko Kunitomo
- Department of Internal Medicine, Yale School of Medicine, New Haven, Conn
| | - Faisal Aslam
- Department of Internal Medicine, Yale School of Medicine, New Haven, Conn
| | - Abdulla A Damluji
- Inova Center of Outcomes Research, Inova Heart and Vascular Institute, Falls Church, Va; Division of Cardiology, Johns Hopkins Hospital, Baltimore, Md
| | | | - Joseph G Murphy
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minn
| | - Sean van Diepen
- Department of Critical Care Medicine and Division of Cardiology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | | | - Joseph Brennan
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, Conn
| | - Jacob Jentzer
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minn; Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Mayo Clinic, Rochester, Minn
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7
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Jentzer JC, Alviar CL, Miller PE, Metkus T, Bennett CE, Morrow DA, Barsness GW, Kashani KB, Gajic O. Trends in Therapy and Outcomes Associated With Respiratory Failure in Patients Admitted to the Cardiac Intensive Care Unit. J Intensive Care Med 2021; 37:543-554. [PMID: 33759608 DOI: 10.1177/08850666211003489] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
PURPOSE To describe the epidemiology, outcomes, and temporal trends of respiratory failure in the cardiac intensive care unit (CICU). MATERIALS AND METHODS Retrospective cohort analysis of 2,986 unique Mayo Clinic CICU patients from 2007 to 2018 with respiratory failure. Temporal trends were analyzed, along with hospital and 1-year mortality. Multivariable logistic regression was used to determine adjusted hospital mortality trends. RESULTS The prevalence of respiratory failure in the CICU increased from 15% to 38% during the study period (P < 0.001 for trend). Among patients with respiratory failure, the utilization of invasive ventilation decreased and noninvasive ventilation modalities increased over time. Hospital mortality and 1-year mortality were 24% and 54%, respectively, with variation according to the type of respiratory support (highest among patients receiving invasive ventilation alone: 35% and 46%, respectively). Hospital mortality was highest among patients with concomitant cardiac arrest and/or shock (52% for patients with both). Hospital mortality decreased in the overall population from 35% to 25% (P < 0.001 for trend), but was unchanged among patients receiving positive-pressure ventilation. CONCLUSIONS The prevalence of respiratory failure in CICU more than doubled during the last decade. The use of noninvasive respiratory support increased, while overall mortality declined over time. Cardiac arrest and shock accounted for the majority of deaths. Further research is needed to optimize the outcomes of high-risk CICU patients with respiratory failure.
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Affiliation(s)
- Jacob C Jentzer
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA.,Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Mayo Clinic, Rochester MN, USA
| | - Carlos L Alviar
- The Leon H. Charney Division of Cardiology, Bellevue Hospital Center, New York University School of Medicine, New York, NY, USA
| | - P Elliott Miller
- Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, CT, USA.,Yale National Clinician Scholars Program, New Haven, CT, USA
| | - Thomas Metkus
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | | | - David A Morrow
- TIMI Study Group, Cardiovascular Division, Brigham and Women's Hospital, and Harvard Medical School, Boston, MA, USA
| | | | - Kianoush B Kashani
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Mayo Clinic, Rochester MN, USA.,Division of Nephrology and Hypertension, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Ognjen Gajic
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Mayo Clinic, Rochester MN, USA
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8
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Rialp G. Mechanical ventilation: past and present. Med Intensiva 2020; 45:1-2. [PMID: 33678221 DOI: 10.1016/j.medin.2020.08.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Accepted: 08/23/2020] [Indexed: 11/29/2022]
Affiliation(s)
- G Rialp
- Servicio de Medicina Intensiva, Hospital Universitari Son Llàtzer. Carretera de Manacor, km 4, 07198 Palma, Illes Balears.
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9
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Abstract
Supplemental Digital Content is available in the text. The medical complexity and critical care needs of patients admitted to cardiac ICUs are increasing, and prospective studies examining the underlying cardiac and noncardiac diagnoses, the management strategies, and the prognosis of cardiac ICU patients with respiratory failure are needed.
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10
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de Miguel-Díez J, Jiménez-García R, Méndez-Bailón M, Muñoz-Rivas N, Hernández-Barrera V, Puente-Maestu L, de Miguel-Yanes JM, Perez-Farinos N, López-de-Andrés A. National trends in mechanical ventilation among patients hospitalized with heart failure: a population-based study in Spain (2001-2017). Eur J Intern Med 2020; 78:76-81. [PMID: 32327318 DOI: 10.1016/j.ejim.2020.04.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2019] [Revised: 02/16/2020] [Accepted: 04/04/2020] [Indexed: 12/20/2022]
Abstract
BACKGROUND We evaluated seventeen years' trends (2001-2017) in the utilization of non-invasive ventilation (NIV), invasive mechanical ventilation (IMV) or both types of ventilator support (NIV+IMV) among patients hospitalized for heart failure (HF). METHODS Observational retrospective epidemiological study using the Spanish National Hospital Discharge Database. RESULTS Over a total of 3,634,044 HF hospitalized patients, we identified 164,815 who were treated with ventilator support. 70.5% received NIV, 24.9% IMV and 4.6% both procedures. Patients receiving NIV were the oldest and had the highest mean value for Charlson comorbidity index (CCI) score. For all types of ventilation values of CCI≥3 increased significantly over the study period (all p<0.001). Patients who received IMV had the highest IHM (48.1%) followed by those with NIV+IMV (44.7%) and NIV (19.9%). The in hospital mortality (IHM) decreased significantly in patients with NIV+IMV and NIV and remained stable in those with IMV. Compared to admissions without ventilation, the probability of receiving NIV and NIV+IMV increased significantly over time, however IMV decreased significantly. Factors associated with a greater probability of receiving NIV vs not being ventilated included higher age, higher CCI and suffering pneumonia whereas male sex reduced the probability. For IMV and NIV+IMV the factors are the same than for NIV, except male sex that increased the probability for IMV and NIV+IMV. CONCLUSIONS We found a significant change in ventilator strategy in hospitalized HF patients over time. Even if the clinical profile is worsening IHM decreased significantly over time, but only in HF patients who received NIV and NIV+IMV.
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Affiliation(s)
- Javier de Miguel-Díez
- Respiratory Department, Hospital General Universitario Gregorio Marañón, Facultad de Medicina, Universidad Complutense de Madrid, Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM), Madrid 28007, Spain
| | - Rodrigo Jiménez-García
- Department of Public Health & Maternal and Child Health. Faculty of Medicine, Universidad Complutense de Madrid, Madrid 28040, Spain
| | | | - Nuria Muñoz-Rivas
- Medicine Department, Hospital Universitario Infanta Leonor, Madrid 28031, Spain
| | - Valentin Hernández-Barrera
- Preventive Medicine and Public Health Teaching and Research Unit, Health Sciences Faculty, Rey Juan Carlos University, Alcorcón, Madrid 28922, Spain
| | - Luis Puente-Maestu
- Respiratory Department, Hospital General Universitario Gregorio Marañón, Facultad de Medicina, Universidad Complutense de Madrid, Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM), Madrid 28007, Spain
| | - José M de Miguel-Yanes
- Internal Medicine Department, Hospital General Universitario Gregorio Marañón, Facultad de Medicina, Universidad Complutense de Madrid, Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM), Madrid 28007, Spain
| | - Napoleón Perez-Farinos
- Department of Public Health and Psychiatry, Faculty of Medicine, Universidad de Málaga, Boulevard Louis Pasteur, 32, Málaga, 28071, Spain.
| | - Ana López-de-Andrés
- Preventive Medicine and Public Health Teaching and Research Unit, Health Sciences Faculty, Rey Juan Carlos University, Alcorcón, Madrid 28922, Spain
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11
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Miller PE, Caraballo C, Ravindra NG, Mezzacappa C, McCullough M, Gruen J, Levin A, Reinhardt S, Ali A, Desai NR, Ahmad T. Clinical Implications of Respiratory Failure in Patients Receiving Durable Left Ventricular Assist Devices for End-Stage Heart Failure. Circ Heart Fail 2019; 12:e006369. [DOI: 10.1161/circheartfailure.119.006369] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Background:
The impact of respiratory failure on patients undergoing left ventricular assist device (LVAD) implantation is not well understood, especially since these patients were excluded from landmark clinical trials. We sought to evaluate the associations between immediate preimplant and postimplant respiratory failure on outcomes in advanced heart failure patients undergoing LVAD implantation.
Methods and Results:
We included all patients in the Interagency Registry for Mechanically Assisted Circulatory Support who were implanted with continuous-flow LVADs from 2008 to 2016. Of the 16 362 patients who underwent continuous-flow LVAD placement, 906 (5.5%) required preimplant intubation within 48 hours before implantation, and 1001 (6.1%) patients developed respiratory failure within 1 week after implantation. A higher proportion of patients requiring preimplant intubation were Interagency Registry for Mechanically Assisted Circulatory Support profile 1, required mechanical circulatory support, and presented with cardiac arrest or myocardial infarction (
P
<0.001, all). At 1 year, 54.3% of patients intubated preimplant were alive without transplant, 20.1% had been transplanted, and 24.2% died before transplant. Patients requiring preimplant intubation had higher rates of postimplant complications, including bleeding, stroke, and right ventricular assist device implantation (
P
<0.01 for all). Among Interagency Registry for Mechanically Assisted Circulatory Support profile 1 patients, preimplant intubation incurred additional risk of death at 1 year compared with Interagency Registry for Mechanically Assisted Circulatory Support profile 1 patients not intubated (hazard ratio, 1.37 [95% CI, 1.13–1.65];
P
=0.001). After multivariable analysis, both preimplant intubation (hazard ratio, 1.20 [95% CI, 1.03–1.41];
P
=0.021) and respiratory failure within 1 week (hazard ratio, 2.54 [95% CI, 2.26–2.85];
P
<0.001) were associated with higher all-cause 1-year mortality.
Conclusions:
Respiratory failure both before and after LVAD implantation identifies an advanced heart failure population with significantly worse 1-year mortality. This data might be helpful in counseling patients and their families about expectations about life with an LVAD.
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Affiliation(s)
- P. Elliott Miller
- Section of Cardiovascular Medicine (P.E.M., S.R., N.R.D., T.A.), Yale University School of Medicine, New Haven, CT
- Yale National Clinician Scholars Program (P.E.M.), Yale University School of Medicine, New Haven, CT
| | - Cesar Caraballo
- Center for Outcomes Research & Evaluation (CORE) (C.C., N.R.D., T.A.), Yale University School of Medicine, New Haven, CT
| | - Neal G. Ravindra
- Department of Molecular Biophysics and Biochemistry (N.G.R.), Yale University School of Medicine, New Haven, CT
- Integrated Graduate Program in Physical and Engineering Biology (N.G.R.), Yale University School of Medicine, New Haven, CT
| | - Catherine Mezzacappa
- Department of Internal Medicine (C.M., M.M., J.G., A.L.), Yale University School of Medicine, New Haven, CT
| | - Megan McCullough
- Department of Internal Medicine (C.M., M.M., J.G., A.L.), Yale University School of Medicine, New Haven, CT
| | - Jadry Gruen
- Department of Internal Medicine (C.M., M.M., J.G., A.L.), Yale University School of Medicine, New Haven, CT
| | - Andrew Levin
- Department of Internal Medicine (C.M., M.M., J.G., A.L.), Yale University School of Medicine, New Haven, CT
| | - Samuel Reinhardt
- Section of Cardiovascular Medicine (P.E.M., S.R., N.R.D., T.A.), Yale University School of Medicine, New Haven, CT
| | - Ayyaz Ali
- Section of Cardiovascular Surgery (A.A.), Yale University School of Medicine, New Haven, CT
| | - Nihar R. Desai
- Section of Cardiovascular Medicine (P.E.M., S.R., N.R.D., T.A.), Yale University School of Medicine, New Haven, CT
- Center for Outcomes Research & Evaluation (CORE) (C.C., N.R.D., T.A.), Yale University School of Medicine, New Haven, CT
| | - Tariq Ahmad
- Section of Cardiovascular Medicine (P.E.M., S.R., N.R.D., T.A.), Yale University School of Medicine, New Haven, CT
- Center for Outcomes Research & Evaluation (CORE) (C.C., N.R.D., T.A.), Yale University School of Medicine, New Haven, CT
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