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Wich LA, Gudex LM, Dann TM, Matich HJ, Thompson AJ, Atie M, Johnson MD, Bartlett RH, Rojas-Peña A, Hirschl RB, Potkay JA. A Reduced Resistance, Concentric-Gated Artificial Membrane Lung for Pediatric End-Stage Lung Failure. ASAIO J 2025; 71:254-262. [PMID: 39269894 PMCID: PMC11864902 DOI: 10.1097/mat.0000000000002308] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/15/2024] Open
Abstract
The goal of the low-resistance pediatric artificial lung (PAL-LR) is to serve as a pumpless bridge-to-transplant device for children with end-stage lung failure. The PAL-LR doubles the exposed fiber length of the previous PAL design. In vitro and in vivo studies tested hemocompatibility, device flow, gas exchange and pressure drop performance. For in vitro tests, average rated blood flow (outlet SO 2 of 95%) was 2.56 ± 0.93 L/min with a pressure drop of 25.88 ± 0.90 mm Hg. At the targeted pediatric flow rate of 1 L/min, the pressure drop was 8.6 mm Hg compared with 25 mm Hg of the PAL. At rated flow, the average O 2 and CO 2 transfer rates were 101.75 ± 10.81 and 77.93 ± 8.40 mL/min, respectively. The average maximum O 2 and CO 2 exchange efficiencies were 215.75 ± 22.93 and 176.99 ± 8.40 mL/(min m 2 ), respectively. In vivo tests revealed an average outlet SO 2 of 100%, and average pressure drop of 2 ± 0 mm Hg for a blood flow of 1.07 ± 0.02 L/min. Having a lower resistance, the PAL-LR is a promising step closer to a pumpless artificial membrane lung that alleviates right ventricular strain associated with idiopathic pulmonary hypertension.
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Affiliation(s)
- Lauren A Wich
- Department of Surgery and ECLS Laboratory, University of Michigan Medical School, Ann Arbor, MI 48109, USA
| | - Leah M Gudex
- Department of Surgery and ECLS Laboratory, University of Michigan Medical School, Ann Arbor, MI 48109, USA
| | - Tyler M Dann
- Department of Surgery and ECLS Laboratory, University of Michigan Medical School, Ann Arbor, MI 48109, USA
| | - Hannah J Matich
- Department of Surgery and ECLS Laboratory, University of Michigan Medical School, Ann Arbor, MI 48109, USA
| | - Alex J Thompson
- Department of Surgery and ECLS Laboratory, University of Michigan Medical School, Ann Arbor, MI 48109, USA
| | - Michael Atie
- Department of Surgery and ECLS Laboratory, University of Michigan Medical School, Ann Arbor, MI 48109, USA
| | - Matthew D Johnson
- Department of Surgery and ECLS Laboratory, University of Michigan Medical School, Ann Arbor, MI 48109, USA
| | - Robert H Bartlett
- Department of Surgery and ECLS Laboratory, University of Michigan Medical School, Ann Arbor, MI 48109, USA
| | - Alvaro Rojas-Peña
- Department of Surgery and ECLS Laboratory, University of Michigan Medical School, Ann Arbor, MI 48109, USA
- Department of Surgery, Section of Transplantation, University of Michigan, Ann Arbor, MI 48109, USA
| | - Ronald B Hirschl
- Department of Surgery and ECLS Laboratory, University of Michigan Medical School, Ann Arbor, MI 48109, USA
- Department of Surgery, Section of Pediatric Surgery, University of Michigan, Ann Arbor, MI 48109, USA
| | - Joseph A Potkay
- Department of Surgery and ECLS Laboratory, University of Michigan Medical School, Ann Arbor, MI 48109, USA
- VA Ann Arbor Healthcare System, Ann Arbor, MI 48105, USA
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Harris CS, Lee HJ, Alderete IS, Halpern SE, Gordee A, Jamieson I, Scales C, Hartwig MG. The cost of lung transplantation in the United States: How high is too high? JTCVS OPEN 2024; 18:407-431. [PMID: 38690426 PMCID: PMC11056443 DOI: 10.1016/j.xjon.2024.01.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/26/2023] [Revised: 11/02/2023] [Accepted: 01/05/2024] [Indexed: 05/02/2024]
Abstract
Objectives To identify patient and process factors that contribute to the high cost of lung transplantation (LTx) in the perioperative period, which may allow transplant centers to evaluate situations in which transplantation is most cost-effective to inform judicious resource allocation, avoid futile care, and reduce costs. Methods The MarketScan Research databases were used to identify 582 privately insured patients undergoing single or bilateral LTx between 2013 and 2019. The patients were subdivided into groups by disease etiology using the United Network of Organ Sharing classification system. Multivariable generalized linear models using a gamma distribution with a log link were fit to examine the associations between the etiology of lung disease and costs during the index admission, 3 months before admission, and 3 months after discharge. Results Our results indicate that the index admission contributed the most to the total transplantation costs compared to the 3 months before admission and after discharge. The regression-adjusted mean index hospitalization cost was 35% higher for patients with pulmonary vascular disease compared to those with obstructive lung disease ($527,156 vs $389,055). The use of extracorporeal membrane oxygenation, mechanical ventilation, and surgical complications in the post-transplantation period were associated with higher costs during the index admission. Surprisingly, age ≥55 was associated with lower costs during the index admission. Conclusions This analysis identifies pivotal factors influencing the high cost of LTx, emphasizing the significant impact of the index admission, particularly for patients with pulmonary vascular disease. These insights offer transplant centers an opportunity to enhance cost-effectiveness through judicious resource allocation and service bundling, ultimately reducing overall transplantation costs.
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Affiliation(s)
- Chelsea S. Harris
- Department of Surgery, Duke University School of Medicine, Durham, NC
| | - Hui-Jie Lee
- Department of Surgery, Duke University School of Medicine, Durham, NC
| | - Isaac S. Alderete
- Department of Surgery, Duke University School of Medicine, Durham, NC
| | | | - Alexander Gordee
- Department of Surgery, Duke University School of Medicine, Durham, NC
| | - Ian Jamieson
- Department of Surgery, Duke University School of Medicine, Durham, NC
| | - Charles Scales
- Department of Surgery, Duke University School of Medicine, Durham, NC
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Kakuturu J, Dhamija A, Chan E, Lagazzi L, Thibault D, Badhwar V, Hayanga JWA. Mortality and cost of post-cardiotomy extracorporeal support in the United States. Perfusion 2023; 38:1468-1477. [PMID: 35930658 DOI: 10.1177/02676591221117355] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Extracorporeal membrane oxygenation (ECMO) has been used increasingly for cardiopulmonary rescue. Despite recent advances however, post-cardiotomy shock (PCS)-ECMO survival remains comparatively poor. We sought to evaluate outcomes and define factors that predict in-hospital mortality. METHODS We used the Nationwide Inpatient Sample (NIS) to evaluate adult hospitalizations with a primary procedure code for coronary artery bypass grafting (CABG), and/or valve procedures performed between 2013 and 2018, which also required post cardiotomy ECMO support. Patient-related factors and hospital costs were evaluated to identify those associated with in-hospital mortality. RESULTS There were 1,247,835 admissions for cardiac surgical procedures during the study period. Post-cardiotomy shock-ECMO support was provided in 4475 (0.3%) within the study cohort. A total of 2000 (44.7%) hospitalizations involved isolated valvular procedures, 1700 (38.0%) isolated CABG, and 775 (17.3%) involved a combination of both. Overall, in-hospital mortality was 42.1% (n = 1880). Factors significantly associated with in-hospital mortality included patients with multiple comorbidities (> 7) and those undergoing combination of valve and CABG procedures. Only 26.6% of those who survived to discharge, were discharged home independently. CONCLUSION Survival to independent home discharge is rare following PCS-ECMO. Its high mortality is associated with multiple comorbidities and combination of CABG and valve surgery.
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Affiliation(s)
- Jahnavi Kakuturu
- Department of Cardiovascular and Thoracic Surgery, West Virginia University, Morgantown, WV, USA
| | - Ankit Dhamija
- Department of Cardiovascular and Thoracic Surgery, West Virginia University, Morgantown, WV, USA
| | - Ernest Chan
- Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Luigi Lagazzi
- Department of Cardiovascular and Thoracic Surgery, West Virginia University, Morgantown, WV, USA
| | - Dylan Thibault
- Department of Cardiovascular and Thoracic Surgery, West Virginia University, Morgantown, WV, USA
| | - Vinay Badhwar
- Department of Cardiovascular and Thoracic Surgery, West Virginia University, Morgantown, WV, USA
| | - J W A Hayanga
- Department of Cardiovascular and Thoracic Surgery, West Virginia University, Morgantown, WV, USA
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Awori Hayanga J, Kakuturu J, Toker A, Asad F, Siler A, Hayanga H, Badhwar V. Early trends in ECMO mortality during the first quarters of 2019 and 2020: Could we have predicted the onset of the pandemic? Perfusion 2023; 38:1409-1417. [PMID: 35838449 PMCID: PMC9289645 DOI: 10.1177/02676591221114959] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To compare mortality trends in patients requiring Extracorporeal Membrane Oxygenation (ECMO) support between the first quarters of 2019 and 2020 and determine whether these trends might have predicted the severe acute respiratory syndrome coronavirus-2 (SARS)-Cov-2 pandemic in the United States. METHODS We analyzed 5% Medicare claims data at aggregate, state, hospital, and encounter levels using MS-DRG (Medicare Severity-Diagnosis Related Group) codes for ECMO, combining state-level data with national census data. Necessity and sufficiency relations associated with change in mortality between the 2 years were modeled using qualitative comparative analysis (QCA). Multilevel, generalized linear modeling was used to evaluate mortality trends. RESULTS Based on state-level data, there was a 3.36% increase in mortality between 2019 and 2020. Necessity and sufficiency evaluation of aggregate data at state and institutional levels did not identify any association or combinations of risk factors associated with this increase in mortality. However, multilevel and generalized linear models using disaggregated patient-level data to evaluate institution mortality and patient death, identified statistically significant differences between the first (p = .019) and second (p = .02) months of the 2 years, the first and second quarters (p < .001 and p = .042, respectively), and the first 6 months (p < .001) of 2019 and 2020. CONCLUSION Mortality in ECMO patients increased significantly during the first quarter of 2020 and may have served as an early warning of the SARS-Cov-2 pandemic. Granular data shared in real-time may be used to better predict public health threats.
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Affiliation(s)
- J.W. Awori Hayanga
- Department of Cardiovascular and Thoracic Surgery, WVU Heart and Vascular Institute, West Virginia University, Morgantown, WV, USA
| | - Jahnavi Kakuturu
- Department of Cardiovascular and Thoracic Surgery, WVU Heart and Vascular Institute, West Virginia University, Morgantown, WV, USA
| | - Alper Toker
- Department of Cardiovascular and Thoracic Surgery, WVU Heart and Vascular Institute, West Virginia University, Morgantown, WV, USA
| | - Fatima Asad
- Department of Cardiovascular and Thoracic Surgery, WVU Heart and Vascular Institute, West Virginia University, Morgantown, WV, USA
| | - Anthony Siler
- Department of Cardiovascular and Thoracic Surgery, WVU Heart and Vascular Institute, West Virginia University, Morgantown, WV, USA
| | - Heather Hayanga
- Department of Cardiovascular and Thoracic Surgery, WVU Heart and Vascular Institute, West Virginia University, Morgantown, WV, USA
| | - Vinay Badhwar
- Department of Cardiovascular and Thoracic Surgery, WVU Heart and Vascular Institute, West Virginia University, Morgantown, WV, USA
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Reza J, Mila A, Ledzian B, Sun J, Silvestry S. Incremental cost-effectiveness of extracorporeal membranous oxygenation as a bridge to cardiac transplant or left ventricular assist device placement in patients with refractory cardiogenic shock. JTCVS OPEN 2022; 11:132-145. [PMID: 36172402 PMCID: PMC9510879 DOI: 10.1016/j.xjon.2022.06.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Revised: 03/26/2022] [Accepted: 06/27/2022] [Indexed: 11/18/2022]
Abstract
Objective Emerging literature has described using venoarterial extracorporeal membranous oxygenation (ECMO) as a bridge to transplant or left ventricular assist device (LVAD) placement. We sought to identify the incremental cost-effectiveness ratio (ICER) of ECMO used as a bridge to cardiac transplant or LVAD. Methods Patients with refractory cardiogenic shock who received venoarterial ECMO and were bridged to either cardiac transplant (n = 7) or a HeartMate 3 LVAD (n = 6) placement were included. Markov modeling was used, comparing ECMO bridging with non–ECMO-bridged patients. Cohorts entered the model alive and at every 1-year cycle, were exposed to risk of death, and ran forward for 20 years after transplant or LVAD. Results Patients bridged with ECMO to cardiac transplant were stratified as group 1 whereas those bridged with ECMO to LVAD were stratified as group 2. The average ECMO run was 3 days in group 1 versus 11 days in group 2. Among group 1 patients, the ICER was $246,629 but was paired with a longer life expectancy. The ICER of group 2 patients was –$107,088 and was not paired with a longer life expectancy. The average inpatient cost for group 1 was found to be $636,023 versus $769,471 for group 2 patients. The average inpatient costs for patients not bridged to ECMO who received cardiac transplant or LVAD was $538,928 and $325,242, respectively. Conclusions Using ECMO to bridge to transplant or LVAD placement is not cost effective. However, patients bridged to transplant are paired with longer life expectancy in contrast to patients bridged to LVAD.
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Affiliation(s)
- Joseph Reza
- General Surgery Residency Program, AdventHealth Orlando, Orlando, Fla
- Address for reprints: Joseph Reza, MD, 3401 N. Broad St. C501. Philadelphia, PA 19140.
| | - Ashley Mila
- General Surgery Residency Program, AdventHealth Orlando, Orlando, Fla
| | - Bradford Ledzian
- AdventHealth Transplant Institute, Thoracic Transplant and Cardiovascular Surgery, AdventHealth Orlando, Orlando, Fla
| | - Jingwei Sun
- Center for Academic Research, AdventHealth Orlando, Orlando, Fla
| | - Scott Silvestry
- AdventHealth Transplant Institute, Thoracic Transplant and Cardiovascular Surgery, AdventHealth Orlando, Orlando, Fla
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Patterson CM, Shah A, Rabin J, DiChiacchio L, Cypel M, Hoetzenecker K, Catarino P, Lau CL. EXTRACORPOREAL LIFE SUPPORT AS A BRIDGE TO LUNG TRANSPLANTATION: WHERE ARE WE NOW? J Heart Lung Transplant 2022; 41:1547-1555. [DOI: 10.1016/j.healun.2022.06.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Revised: 04/21/2022] [Accepted: 06/05/2022] [Indexed: 11/16/2022] Open
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Benvenuto LJ, Arcasoy SM. The new allocation era and policy. J Thorac Dis 2022; 13:6504-6513. [PMID: 34992830 PMCID: PMC8662501 DOI: 10.21037/jtd-2021-17] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2020] [Accepted: 05/25/2021] [Indexed: 12/01/2022]
Abstract
Since the Department of Health and Human Services (DHHS) issued the Final Rule in 1998 as a guideline for organ transplantation and allocation policies, the lung allocation system has undergone two major changes. The first change came with the implementation of the lung allocation score (LAS) instead of waiting time as the primary determinant for donor lung allocation. The LAS model helped allocate donor lungs based on medical urgency and likelihood of post-transplant success. The LAS has been successful in prioritizing the sickest candidates and reducing waitlist mortality in line with the Final Rule mandates. However, the LAS model did not address geographic variability in donor lung supply and demand, leading to disparities in waiting list survival based on a patient’s listing location, which was inconsistent with the Final Rule. In an urgent response to a lawsuit filed by a patient demanding broader geographic access to lungs in November 2017, the second major change in lung allocation occurred when the primary allocation unit for donor lungs expanded from the local donation service area (DSA) to a 250-nautical mile radius around the donor hospital. The Organ Procurement and Transplantation Network has since undergone a review of the current organ allocation systems and has approved a continuous organ distribution framework to guide the creation of a new organ allocation system without rigid geographic borders. In this review, we will describe the history of lung allocation, the changes to the allocation system and their consequences, and the potential future of lung allocation policy in the U.S.
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Affiliation(s)
- Luke J Benvenuto
- The Lung Transplant Program, New York-Presbyterian Hospital and Columbia University Irving Medical Center, Department of Medicine, Division of Pulmonary, Allergy and Critical Care Medicine, New York, NY, USA
| | - Selim M Arcasoy
- The Lung Transplant Program, New York-Presbyterian Hospital and Columbia University Irving Medical Center, Department of Medicine, Division of Pulmonary, Allergy and Critical Care Medicine, New York, NY, USA
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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: 5.0] [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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Peel JK, Keshavjee S, Krahn M, Sander B. Economic evaluations and costing studies of lung transplantation: A scoping review. J Heart Lung Transplant 2021; 40:1625-1640. [PMID: 34538540 DOI: 10.1016/j.healun.2021.08.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2021] [Revised: 07/31/2021] [Accepted: 08/19/2021] [Indexed: 10/20/2022] Open
Abstract
BACKGROUND Evaluation of the joint clinical and economic impacts of lung transplant and associated technologies is crucial for evidence-informed decision-making and wise allocation of scarce healthcare resources. We performed a scoping review to summarize and categorize the available evidence of the costs and cost-effectiveness of lung transplantation. METHODS A systematic search of MEDLINE, EMBASE, NHS EED, and EconLit was performed to identify studies involving lung transplantation for adults that measured costs, cost-effectiveness, or which described themselves as economic evaluations. A scoping review was performed in adherence to the framework described by Arksey & O'Malley. Risk of bias was assessed in included studies using the ECOBIAS and CHEC-list tools. RESULTS In total, 324 studies were identified, of which 28 met inclusion criteria. Cost-utility estimates of lung transplant versus waitlist, from the healthcare payer perspective and a time-horizon of at least 10-years ranged between $42,459 and $154,051 per quality-adjusted life year. Common topics of study included lung transplant versus waitlist care, immunosuppression, organ retrieval and allocation, and mechanical life support. CONCLUSIONS Sources of variation in costs-assessments and economic evaluations included differences in the type of study performed, payer perspective adopted, study time horizon, and variation in clinical practice. The best available cost-utility estimates for lung transplant versus waitlist may represent cost-effectiveness under some circumstances, but high-quality evidence is lacking. Further cost-utility analyses, with sufficient methodologic rigour, are required to overcome the observed variation in results and confirm cost-effectiveness of the current standard of care in lung transplantation.
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Affiliation(s)
- J K Peel
- Department of Anesthesiology & Pain Medicine, University of Toronto, ON, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, ON, Canada; Toronto Health Economics and Technology Assessment Collaborative, Toronto, ON, Canada.
| | - S Keshavjee
- Division of Thoracic Surgery, Toronto General Hospital, University Health Network, ON, Canada; Toronto General Hospital Research Institute, University Health Network, Toronto, ON, Canada
| | - M Krahn
- Institute of Health Policy, Management and Evaluation, University of Toronto, ON, Canada; Toronto Health Economics and Technology Assessment Collaborative, Toronto, ON, Canada; Toronto General Hospital Research Institute, University Health Network, Toronto, ON, Canada; Department of Medicine, University Health Network, Toronto, ON, Canada
| | - B Sander
- Institute of Health Policy, Management and Evaluation, University of Toronto, ON, Canada; Toronto Health Economics and Technology Assessment Collaborative, Toronto, ON, Canada; Toronto General Hospital Research Institute, University Health Network, Toronto, ON, Canada; Department of Medicine, University Health Network, Toronto, ON, Canada
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Dhamija A, Thibault D, Fugett J, Hayanga HK, McCarthy P, Badhwar V, Awori Hayanga JW. Incremental effect of complications on mortality and hospital costs in adult ECMO patients. Perfusion 2021; 37:461-469. [PMID: 33765884 DOI: 10.1177/02676591211005697] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Extracorporeal membrane oxygenation (ECMO) is a resource-intense modality whose usage is expanding rapidly. It is a costly endeavor and best conducted in a multidisciplinary setting. There is a growing impetus to mitigate the mortality and costs associated with ECMO. We sought to examine the impact of complications on mortality and hospital costs in patients on ECMO. METHODS Using the NIS database, we performed multivariable logistic regression to assess the influence of complications on the primary outcome, in-hospital mortality. Similarly, we performed multivariable survey linear regression analysis to evaluate the effect of the complications on hospital costs. RESULTS Of the 12,637 patients supported using ECMO between 2004 and 2013, 9836 (78%) developed at least one complication. The three most common complications were acute kidney injury (32.8%), bloodstream infection (31.8%), and bleeding (27.8%). An ECMO hospitalization with no complications was associated with median costs of $53,470, a single complication with costs of $97,560, two complications with costs of $139,035, and three complication with costs of $162,284. A single complication was associated with a 165% increase in odds of mortality. Two or three complications resulted in 375% or 627% higher odds of mortality, respectively. Having one, two, or three complications was associated with 24%, 38%, or 38% increase in median costs respectively (Figure 1). Complications associated with the highest median costs were central line-associated bloodstream infection $217,751; liver failure $176,201; bloodstream infection $169,529. CONCLUSION In-hospital mortality and costs increase with each incremental complication in patients on ECMO. Accurate prediction and mitigation of complications is likely to improve outcomes and cost.
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Affiliation(s)
- Ankit Dhamija
- Department of Cardiovascular and Thoracic Surgery, West Virginia University, Morgantown, WV, USA
| | - Dylan Thibault
- Department of Cardiovascular and Thoracic Surgery, West Virginia University, Morgantown, WV, USA
| | - James Fugett
- Department of Cardiovascular and Thoracic Surgery, West Virginia University, Morgantown, WV, USA
| | - Heather K Hayanga
- Department of Cardiovascular and Thoracic Surgery, West Virginia University, Morgantown, WV, USA
| | - Paul McCarthy
- Department of Cardiovascular and Thoracic Surgery, West Virginia University, Morgantown, WV, USA
| | - Vinay Badhwar
- Department of Cardiovascular and Thoracic Surgery, West Virginia University, Morgantown, WV, USA
| | - J W Awori Hayanga
- Department of Cardiovascular and Thoracic Surgery, West Virginia University, Morgantown, WV, USA
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Fessler J, Sage E, Roux A, Feliot E, Gayat E, Pirracchio R, Parquin F, Cerf C, Fischler M, Le Guen M. Is Extracorporeal Membrane Oxygenation Withdrawal a Safe Option After Double-Lung Transplantation? Ann Thorac Surg 2020; 110:1167-1174. [DOI: 10.1016/j.athoracsur.2020.03.077] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2019] [Revised: 02/24/2020] [Accepted: 03/23/2020] [Indexed: 01/04/2023]
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Salman J, Bernhard BA, Ius F, Poyanmehr R, Sommer W, Aburahma K, Alhadidi H, Siemeni T, Kuehn C, Avsar M, Haverich A, Warnecke G, Tudorache I. Intraoperative Extracorporeal Circulatory Support in Lung Transplantation for Pulmonary Fibrosis. Ann Thorac Surg 2020; 111:1316-1324. [PMID: 32890486 DOI: 10.1016/j.athoracsur.2020.06.083] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2019] [Revised: 05/10/2020] [Accepted: 06/23/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Venous-arterial extracorporeal membrane oxygenation (ECMO) is an established technique for intraoperative cardiopulmonary support in patients undergoing lung transplantation. Patients with pulmonary fibrosis have a higher risk to require it. The aim of this study was to identify risk factors for the need of intraoperative ECMO use. METHODS Records of patients undergoing lung transplantation for pulmonary fibrosis at our institution between January 2010 and May 2018 were retrospectively reviewed. Univariate logistic regression analysis was used for statistical identification of risk factors. RESULTS There were 105 patients (34%) who required intraoperative ECMO support (ECMO+ group), and 203 (66%) did not (ECMO- group). Preoperative proof of pulmonary hypertension was identified as a risk factor for intraoperative ECMO support (odds ratio [OR], 3.8; 95% confidence interval [CI], 2.2-6.5; P < .01). Revealed mean pulmonary arterial pressure values exceeding 50 mm Hg and pulmonary vascular resistance values exceeding 9.4 Wood units were identified as risk factors for the need of intraoperative ECMO use with a prediction probability of 70%. Increased recipient body surface area (OR, 0.2; 95% CI, 0.1-0.5; P < .01) emerged as a protective factor against intraoperative ECMO (Hosmer-Lemeshow statistic, P = .71) as well as higher cardiac output (OR, 0.7; 95% CI, 0.6-0.9; P < .01). The postoperative course was more complicated in the ECMO+ group, whereas survival at 5 years did not differ among groups (70% vs 69%, P = .79). CONCLUSIONS Pulmonary hypertension with elevated pulmonary vascular resistance values predicts the need of intraoperative ECMO in patients receiving lung transplantation for pulmonary fibrosis. Although the postoperative course was more complicated in the ECMO+ group, long-term survival did not differ significantly.
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Affiliation(s)
- Jawad Salman
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany.
| | - Beeke-Alina Bernhard
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Fabio Ius
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Reza Poyanmehr
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Wiebke Sommer
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany; German Centre for Lung Research (DZL/BREATH), Hannover, Germany
| | - Khalil Aburahma
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Hani Alhadidi
- Division of Thoracic Surgery, King Hussein Medical Center, Amman, Jordan
| | - Thierry Siemeni
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Christian Kuehn
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Murat Avsar
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Axel Haverich
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Gregor Warnecke
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany; German Centre for Lung Research (DZL/BREATH), Hannover, Germany
| | - Igor Tudorache
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany; German Centre for Lung Research (DZL/BREATH), Hannover, Germany
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13
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Fessler J, Davignon M, Sage E, Roux A, Cerf C, Feliot E, Gayat E, Parquin F, Fischler M, Guen ML. Intraoperative Implications of the Recipients' Disease for Double-Lung Transplantation. J Cardiothorac Vasc Anesth 2020; 35:530-538. [PMID: 32741611 DOI: 10.1053/j.jvca.2020.07.039] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2020] [Revised: 07/09/2020] [Accepted: 07/10/2020] [Indexed: 01/03/2023]
Abstract
OBJECTIVES To compare intraoperative patterns among patients based on their primary pulmonary disease (cystic fibrosis [CF], chronic obstructive pulmonary disease [COPD]/emphysema [CE], and pulmonary fibrosis [PF]) during double- lung transplantation. The following 3 major outcomes were reported: blood transfusion, extracorporeal membrane oxygenation (ECMO) management, and the possibility of immediate extubation at the end of surgery. DESIGN Retrospective analysis of a prospectively maintained database, including donor and recipient characteristics and intraoperative variables. SETTING Foch Hospital, Suresnes, France (academic center performing 60-80 lung transplantations per year). PARTICIPANTS Patients who underwent double- lung transplantation from 2012-2019. Patients with retransplantation, multiorgan transplantation, or surgery performed with cardiopulmonary bypass were excluded. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Two hundred forty-six patients had CF, 117 had CE, and 66 had PF. No patient had primary pulmonary arterial hypertension. Blood transfusion was higher in the CF group than in the other 2 groups (red blood cells [p < 0.001], fresh frozen plasma [p = 0.004]). The CF and CE groups were characterized by a lower intraoperative requirement of ECMO (p = 0.002), and the PF group more frequently required postoperative ECMO (p < 0.001). CF and CE patients were more frequently extubated in the operating room than were PF patients (37.4%, 50.4%, and 13.6%, respectively; p < 0.001). CONCLUSIONS Intraoperative outcomes differed depending on the initial pathology. Such differences should be taken into account in specific clinical studies and in intraoperative management protocols.
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Affiliation(s)
- Julien Fessler
- Department of Anesthesiology, Hôpital Foch, 9250 Suresnes, France; Université Versailles-Saint-Quentin-en-Yvelines, 78646 Versailles, France
| | - Maxime Davignon
- Department of Anesthesiology, Hôpital Foch, 9250 Suresnes, France; Université Versailles-Saint-Quentin-en-Yvelines, 78646 Versailles, France
| | - Edouard Sage
- Université Versailles-Saint-Quentin-en-Yvelines, 78646 Versailles, France; Department of Thoracic Surgery, Hôpital Foch, 9250 Suresnes, France
| | - Antoine Roux
- Université Versailles-Saint-Quentin-en-Yvelines, 78646 Versailles, France; Department of Pneumology, Hôpital Foch, 9250 Suresnes, France
| | - Charles Cerf
- Department of Intensive Care, Hôpital Foch, 9250 Suresnes, France
| | - Elodie Feliot
- Department of Anesthesiology and Critical Care Medicine, Hôpital Saint Louis - Lariboisière, 75010 Paris, France; Institut National de la Santé et de la Recherche Médicale, 75654 Paris, France
| | - Etienne Gayat
- Department of Anesthesiology and Critical Care Medicine, Hôpital Saint Louis - Lariboisière, 75010 Paris, France; Institut National de la Santé et de la Recherche Médicale, 75654 Paris, France
| | - Francois Parquin
- Université Versailles-Saint-Quentin-en-Yvelines, 78646 Versailles, France; Department of Thoracic Surgery, Hôpital Foch, 9250 Suresnes, France
| | - Marc Fischler
- Department of Anesthesiology, Hôpital Foch, 9250 Suresnes, France; Université Versailles-Saint-Quentin-en-Yvelines, 78646 Versailles, France.
| | - Morgan Le Guen
- Department of Anesthesiology, Hôpital Foch, 9250 Suresnes, France; Université Versailles-Saint-Quentin-en-Yvelines, 78646 Versailles, France
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14
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Zhang R, Xu Y, Sang L, Chen S, Huang Y, Nong L, Yang C, Liu X, Liu D, Xi Y, He W, Wei B, He J, Li Y, Liu X. Factors associated with intraoperative extracorporeal membrane oxygenation support during lung transplantation. Respir Res 2020; 21:85. [PMID: 32293451 PMCID: PMC7160893 DOI: 10.1186/s12931-020-01355-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Accepted: 04/03/2020] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Intraoperative Extracorporeal membrane oxygenation (ECMO) is increasingly being applied as life-support for lung transplantation patients. However, factors associated with this procedure in lung transplantation patients have not yet been characterized. The aim of this study was to identify preoperative factors of intraoperative ECMO support during lung transplantation and to evaluated the outcome of lung transplantation patients supported with ECMO. METHODS Patients underwent lung transplantation treated with and without ECMO in Guangzhou Institute of Respiratory Diseases between January 2015 to August 2018 were retrospectively reviewed. Patient demographics and clinical variables were collected and analyzed. Multivariate logistic regression was performed to identify factors independently associated with intraoperative extracorporeal membrane oxygenation support during lung transplantation. RESULTS During the study period, 138 patients underwent lung transplantation at our institution, the mean LAS was (56.63 ± 18.39) (range, 32.79 to 88.70). Fourty four patients were treated with veno-venous/veno-arterial ECMO. Among the patients, 32 patients wean successfully ECMO after operation, 12 patients remain ECMO after operation, and 32 patients (62.74%) survived to hospital discharge. In multiple analysis, the following factors were associated with intraoperative ECMO support: advanced age, high PAP before operation, duration of mechanical ventilation before operation, a higher APACHE II and primary diagnosis for transplantation. The overall survival rates at 1, 3, and 12 months were 90.91, 72.73, and 56.81% in the ECMO group, and 95.40, 82.76, and 73.56% in the non-ECMO group, respectively (log-rank P = 0.081). Patients who underwent single lung transplant had a lower survival rates in ECMO group as compared with non-ECMO group at 1, 3, and 12 months (90.47% vs 98.25, 71.43% vs 84.21, and 52.38% vs 75.44%) (log-rank P = 0.048). CONCLUSIONS The preoperative factors of intraoperative ECMO support during lung transplantation included age, high PAP before operation, preoperative mechanical ventilation, a higher APACHE II and primary diagnosis for transplantation based on multivariate analysis.
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Affiliation(s)
- Rong Zhang
- The State Key Laboratory of Respiratory Diseases, Guangzhou Institute of Respiratory Health, The First Affiliated Hospital of Guangzhou Medical University, 151 Yanjiang Street West, Guangzhou, 510120, Guangdong, China
| | - Yonghao Xu
- The State Key Laboratory of Respiratory Diseases, Guangzhou Institute of Respiratory Health, The First Affiliated Hospital of Guangzhou Medical University, 151 Yanjiang Street West, Guangzhou, 510120, Guangdong, China
| | - Ling Sang
- The State Key Laboratory of Respiratory Diseases, Guangzhou Institute of Respiratory Health, The First Affiliated Hospital of Guangzhou Medical University, 151 Yanjiang Street West, Guangzhou, 510120, Guangdong, China
| | - Sibei Chen
- The State Key Laboratory of Respiratory Diseases, Guangzhou Institute of Respiratory Health, The First Affiliated Hospital of Guangzhou Medical University, 151 Yanjiang Street West, Guangzhou, 510120, Guangdong, China
| | - Yongbo Huang
- The State Key Laboratory of Respiratory Diseases, Guangzhou Institute of Respiratory Health, The First Affiliated Hospital of Guangzhou Medical University, 151 Yanjiang Street West, Guangzhou, 510120, Guangdong, China
| | - Lingbo Nong
- The State Key Laboratory of Respiratory Diseases, Guangzhou Institute of Respiratory Health, The First Affiliated Hospital of Guangzhou Medical University, 151 Yanjiang Street West, Guangzhou, 510120, Guangdong, China
| | - Chun Yang
- The State Key Laboratory of Respiratory Diseases, Guangzhou Institute of Respiratory Health, The First Affiliated Hospital of Guangzhou Medical University, 151 Yanjiang Street West, Guangzhou, 510120, Guangdong, China
| | - Xuesong Liu
- The State Key Laboratory of Respiratory Diseases, Guangzhou Institute of Respiratory Health, The First Affiliated Hospital of Guangzhou Medical University, 151 Yanjiang Street West, Guangzhou, 510120, Guangdong, China
| | - Dongdong Liu
- The State Key Laboratory of Respiratory Diseases, Guangzhou Institute of Respiratory Health, The First Affiliated Hospital of Guangzhou Medical University, 151 Yanjiang Street West, Guangzhou, 510120, Guangdong, China
| | - Yin Xi
- The State Key Laboratory of Respiratory Diseases, Guangzhou Institute of Respiratory Health, The First Affiliated Hospital of Guangzhou Medical University, 151 Yanjiang Street West, Guangzhou, 510120, Guangdong, China
| | - Weiqun He
- The State Key Laboratory of Respiratory Diseases, Guangzhou Institute of Respiratory Health, The First Affiliated Hospital of Guangzhou Medical University, 151 Yanjiang Street West, Guangzhou, 510120, Guangdong, China
| | - Bing Wei
- The State Key Laboratory of Respiratory Diseases, Guangzhou Institute of Respiratory Health, The First Affiliated Hospital of Guangzhou Medical University, 151 Yanjiang Street West, Guangzhou, 510120, Guangdong, China
| | - Jianxing He
- The State Key Laboratory of Respiratory Diseases, Guangzhou Institute of Respiratory Health, The First Affiliated Hospital of Guangzhou Medical University, 151 Yanjiang Street West, Guangzhou, 510120, Guangdong, China
| | - Yimin Li
- The State Key Laboratory of Respiratory Diseases, Guangzhou Institute of Respiratory Health, The First Affiliated Hospital of Guangzhou Medical University, 151 Yanjiang Street West, Guangzhou, 510120, Guangdong, China
| | - Xiaoqing Liu
- The State Key Laboratory of Respiratory Diseases, Guangzhou Institute of Respiratory Health, The First Affiliated Hospital of Guangzhou Medical University, 151 Yanjiang Street West, Guangzhou, 510120, Guangdong, China.
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15
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Hayanga JA, Aboagye J, Bush E, Canner J, Hayanga HK, Klingbeil A, McCarthy P, Fugett J, Abbas G, Badhwar V. Contemporary analysis of charges and mortality in the use of extracorporeal membrane oxygenation: A cautionary tale. ACTA ACUST UNITED AC 2020; 1:61-70. [PMID: 36003198 PMCID: PMC9390409 DOI: 10.1016/j.xjon.2020.02.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Revised: 02/07/2020] [Accepted: 02/20/2020] [Indexed: 11/06/2022]
Abstract
Objective The use of extracorporeal membrane oxygenation (ECMO) has increased exponentially. Costs and outcomes, however, vary considerably by indication. We sought to elucidate and quantify these differences. Methods Adult patients supported on ECMO between 2008 and 2016 were analyzed using the Nationwide Inpatient Sample. We divided the study period into an early (2008-2013) and late period (2013-2016). The primary outcome was hospital charges, and the secondary outcomes were mortality, length of stay (LOS), and duration of ECMO support. These were stratified by the 5 most common indications: postcardiotomy shock (PCS), cardiogenic shock (CS), severe acute respiratory failure (SARF), heart (HT), and lung transplantation (LT). Both patient and hospital characteristics were assessed. Charges were adjusted for inflation and analyzed using a generalized linear model with gamma distribution. Pairwise comparison with Bonferroni correction was used to evaluate the cost and multivariate logistic regression to assess the risk of mortality. Results Data pertaining to 15,829 adult patients were evaluated. Mean age of the entire cohort was 52.8 years, 8895 (56%) were white, and 10,278 (65%) were male. PCS was the predominant indication for ECMO (39%), followed by CS (37%). SARF accounted for 15% and HT and LT accounted for 3.9% and 5.4%, respectively. Mean LOS and duration of ECMO support were 23.4 days and 5.3 days respectively. Mean hospital charges per hospitalization for the entire cohort were USD 731,914 per patient. Charges per patient pertaining to hospitalizations in which ECMO was used in transplant patients were the highest: USD 1,448,931 and USD 1,574,378 (P = .99) for HT and LT, respectively. Charges were lower for the other indications: PCS USD 798,909, CS USD 655,099, and SARF USD 824,852. Overall mortality for the entire cohort was 55%. PCS and CS (53% vs 58%, P = .34) had similar survival, whereas SARF was 45%, LT was 39% and HT 32%. There were no differences in survival in these latter indications (SARF, LT and HT). The cumulative charges (proportion × hospital charges) reveal that PCS and CS (39% and 37%) account for both the majority of charges as well as the greatest mortality. Conversely, SARF and transplantation accounted for the smaller proportion of charges and the lower mortality. Patients undergoing HT had the longest LOS (51.7 days) and duration on ECMO (15.9 days), followed by LT (35.4 and 8.8 days respectively), and patients with SARF (28.6 and 6.6 respectively). LOS and duration of ECMO for those with PCS were 18.7 days and 4.8 days, respectively. Those on ECMO for CS were hospitalized for 19.7 days and spent an average of 3.8 days on ECMO. Mortality decreased, whereas charges increased in the late era. Conclusions The use of ECMO is associated with high hospital charges and a wide variation in outcomes. Hospitalizations, in which ECMO is used to support patients with cardiogenic shock (PCS and CS), are individually associated with lower LOS and charges. Cumulatively, however, these account for greater charges and greater mortality. Although mortality may be decreasing, overall charges are increasing with time. These variations may influence reimbursement decisions in value-based healthcare.
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16
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Hayanga JWA, Chan EG, Musgrove K, Leung A, Shigemura N, Hayanga HK. Extracorporeal Membrane Oxygenation in the Perioperative Care of the Lung Transplant Patient. Semin Cardiothorac Vasc Anesth 2020; 24:45-53. [PMID: 31893982 DOI: 10.1177/1089253219896123] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Lung transplantation (LT) is definitive therapy for end-stage lung disease. Donor allocation based on medical urgency has led to an increased trend in the transplantation of sicker and older patients. Mechanical ventilation (MV) formerly was the only method of bridging high-acuity patients to LT. When the physiological demands of ventilatory support exceeds the capability of MV, extracorporeal membrane oxygenation (ECMO) may become necessary. Recent improvements in ECMO technology and component design have led to a resurgence of interest in its use before, during, and after LT. Survival with ECMO as a bridge to LT has improved over time, now with many centers reporting little or no difference in outcomes, and some even reporting better outcomes, as compared with MV. Extracorporeal life support may also be used intraoperatively. In many studies to date, ECMO or cardiopulmonary bypass (CPB) has been reserved for patients who became hemodynamically unstable during the procedure or patients who could not tolerate single-lung ventilation. Both methods of support are fraught with potential complications. However, multiple studies comparing ECMO with CPB have shown that intraoperative use of ECMO resulted in improved outcomes and overall survival as well as lower rates of bleeding complications. In order to further reduce complications associated with ECMO, planned intraoperative ECMO use is occasionally reserved for high-risk patients who might otherwise require CPB. Future studies will need to improve patient selection to fully take advantage of the use of ECMO in LT while minimizing its costs.
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Affiliation(s)
| | - Ernest G Chan
- University of Pittsburgh Medical Center, Pittsburgh, PA, USA
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17
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Hayanga JA, Hayanga HK, Holmes SD, Ren Y, Shigemura N, Badhwar V, Abbas G. Mechanical ventilation and extracorporeal membrane oxygenation as a bridge to lung transplantation: Closing the gap. J Heart Lung Transplant 2019; 38:1104-1111. [DOI: 10.1016/j.healun.2019.06.026] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2018] [Revised: 06/05/2019] [Accepted: 06/28/2019] [Indexed: 11/26/2022] Open
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18
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Sanaiha Y, Kavianpour B, Mardock A, Khoury H, Downey P, Rudasill S, Benharash P. Rehospitalization and resource use after inpatient admission for extracorporeal life support in the United States. Surgery 2019; 166:829-834. [PMID: 31277884 DOI: 10.1016/j.surg.2019.05.013] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2019] [Revised: 03/22/2019] [Accepted: 05/09/2019] [Indexed: 01/22/2023]
Abstract
BACKGROUND With increasing dissemination and improved survival after extracorporeal life support, also called extracorporeal membrane oxygenation, the decrease in readmissions after hospitalization involving extracorporeal life support is an emerging priority. The present study aimed to identify predictors of early readmission after extracorporeal life support at a national level. METHODS This was a retrospective cohort study using the Nationwide Readmissions Database. All patients ≥18 years who underwent extracorporeal life support from 2010 to 2015 were identified. Patients were stratified into the following categories of extracorporeal life support: postcardiotomy, primary cardiogenic shock, cardiopulmonary failure, respiratory failure, transplantation, and miscellaneous. The primary outcome of the study was the rate of 90-day rehospitalization after extracorporeal life support admission. A multivariable logistic regression model was developed to predict the odds of unplanned 90-day readmission. Kaplan-Meier analyses were also performed. RESULTS An estimated 18,748 patients received extracorporeal life support with overall mortality of 50.2%. Of the patients who survived hospitalization, 30.2% were discharged to a skilled nursing facility, and 21.1% were readmitted within 90 days after discharge. After adjusting for patient and hospital characteristics, cardiogenic shock was associated with the greatest odds of mortality (adjusted odds ratio 1.6; 95% confidence interval, 1.09-1.46; C-statistic, 0.64). The cohort with respiratory failure had decreased odds of readmission (adjusted odds ratio 0.76; 95% confidence interval, 0.58-0.99). Discharge to skilled nursing facility (adjusted odds ratio 1.64; 95% confidence interval, 1.36-1.97) was independently associated with readmission. Cardiac and respiratory-related readmissions comprised the majority of unplanned 90-day rehospitalizations. CONCLUSION In this large analysis of readmissions after extracorporeal life support in adults, 21% of extracorporeal life support survivors were rehospitalized within 90 days of discharge. Disposition to a skilled nursing facility, but not advanced age nor female sex, was associated with readmission.
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Affiliation(s)
- Yas Sanaiha
- Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Cardiac Surgery, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA
| | - Behdad Kavianpour
- Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Cardiac Surgery, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA
| | - Alexandra Mardock
- Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Cardiac Surgery, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA
| | - Habib Khoury
- Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Cardiac Surgery, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA
| | - Peter Downey
- Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Cardiac Surgery, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA
| | - Sarah Rudasill
- Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Cardiac Surgery, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA
| | - Peyman Benharash
- Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Cardiac Surgery, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA.
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19
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Ius F, Natanov R, Salman J, Kuehn C, Sommer W, Avsar M, Siemeni T, Bobylev D, Poyanmehr R, Boethig D, Optenhoefel J, Schwerk N, Haverich A, Warnecke G, Tudorache I. Extracorporeal membrane oxygenation as a bridge to lung transplantation may not impact overall mortality risk after transplantation: results from a 7-year single-centre experience. Eur J Cardiothorac Surg 2019; 54:334-340. [PMID: 29444222 DOI: 10.1093/ejcts/ezy036] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2017] [Accepted: 01/17/2018] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVES Extracorporeal membrane oxygenation (ECMO) has an important role in bridging patients to lung transplantation. In this study, we present our experience with pretransplant ECMO during the last 7 years and investigate its impact on graft outcomes. METHODS Records of all lung-transplanted patients at our institution between January 2010 and April 2017 were retrospectively reviewed. Graft survival was compared between patients who required pretransplant ECMO (pre-Tx ECMO+) and patients who did not (pre-Tx ECMO-). Risk factors for in-hospital mortality and graft survival were identified using a binary logistic regression and the Cox regression analyses, respectively. RESULTS Among the 917 patients transplanted during the study period, 68 (7%) required ECMO as a bridge to transplantation [awake strategy, n = 57 (84%) patients]. Median bridging time was 9 days. Among pre-Tx ECMO+ patients, the need for haemodialysis at any point during bridging emerged as an independent risk factor for in-hospital mortality (odds ratio 7.79, 95% confidence interval 1.21-50.24; P = 0.031). Although in-hospital mortality was significantly higher in pre-Tx ECMO+ versus pre-Tx ECMO- patients (15% vs 5%, P = 0.003), overall graft survival did not differ between groups (79% vs 90% and 61% vs 68% at 1 and 5 years, respectively, P = 0.13). Pretransplant ECMO did not emerge as a risk factor for graft survival in the multivariable analysis. CONCLUSIONS If applied in selected patients in a high-volume centre, pretransplant ECMO as a bridge to transplantation results in impaired, but still high in-hospital, survival and does not impact graft survival.
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Affiliation(s)
- Fabio Ius
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Ruslan Natanov
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Jawad Salman
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Christian Kuehn
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Wiebke Sommer
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany.,German Center for Lung Research (DZL/BREATH), Giessen, Hannover, Germany
| | - Murat Avsar
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Thierry Siemeni
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Dmitry Bobylev
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Reza Poyanmehr
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Dietmar Boethig
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Joerg Optenhoefel
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Nicolaus Schwerk
- Department of Paediatrics, Hannover Medical School, Hannover, Germany
| | - Axel Haverich
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany.,German Center for Lung Research (DZL/BREATH), Giessen, Hannover, Germany
| | - Gregor Warnecke
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany.,German Center for Lung Research (DZL/BREATH), Giessen, Hannover, Germany
| | - Igor Tudorache
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany
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20
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Hayanga JWA, Hayanga HK, Holmes SD, Musgrove KA, Ren Y, Badhwar V, Abbas G. Lung transplantation and Affordable Care Act Medicaid expansion in the era of lung allocation score - a retrospective study. Transpl Int 2019; 32:762-768. [PMID: 30809843 DOI: 10.1111/tri.13420] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2018] [Revised: 01/14/2019] [Accepted: 02/22/2019] [Indexed: 11/28/2022]
Abstract
This study evaluated the impact of Medicaid eligibility expansion (ME) on lung transplant (LT) listings and Medicaid coverage. Data on LT candidates aged 18-64 were obtained from the Scientific Registry of Transplant Recipients (N = 9153). The impact of ME was evaluated by comparing LT listings in 2011-2013 with listings in 2014-2016, as well as comparing states that had and had not adopted ME in 2014. LT listings increased by 7.7% nationally post-ME. In ME states, LT listings increased by 15.2%, whereas nonexpansion states decreased by 1.5%. LT candidates with Medicaid increased after ME nationally (8.3% vs. 9.9%, P = 0.006) and in ME states (9.7% vs. 11.5%, P = 0.036), but not in nonexpansion states (6.6% vs. 7.7%, P = 0.170). Following multivariable adjustment, LT listings in ME states had 58% greater odds for Medicaid compared to nonexpansion states (P < 0.001). Expansion of Medicaid provided greater healthcare access and increased LT listings, but only within states that adopted eligibility expansion.
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Affiliation(s)
- J W Awori Hayanga
- Department of Cardiovascular and Thoracic Surgery, WVU Heart & Vascular Institute, West Virginia University, Morgantown, WV, USA
| | - Heather K Hayanga
- Division of Cardiovascular Anesthesia, WVU Heart & Vascular Institute, West Virginia University, Morgantown, WV, USA
| | - Sari D Holmes
- Department of Cardiovascular and Thoracic Surgery, WVU Heart & Vascular Institute, West Virginia University, Morgantown, WV, USA
| | - Kelsey A Musgrove
- Department of Cardiovascular and Thoracic Surgery, WVU Heart & Vascular Institute, West Virginia University, Morgantown, WV, USA
| | - Yue Ren
- Department of Cardiovascular and Thoracic Surgery, WVU Heart & Vascular Institute, West Virginia University, Morgantown, WV, USA
| | - Vinay Badhwar
- Department of Cardiovascular and Thoracic Surgery, WVU Heart & Vascular Institute, West Virginia University, Morgantown, WV, USA
| | - Ghulam Abbas
- Department of Cardiovascular and Thoracic Surgery, WVU Heart & Vascular Institute, West Virginia University, Morgantown, WV, USA
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21
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Trends in mortality and resource utilization for extracorporeal membrane oxygenation in the United States: 2008–2014. Surgery 2019; 165:381-388. [DOI: 10.1016/j.surg.2018.08.012] [Citation(s) in RCA: 47] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2018] [Revised: 07/19/2018] [Accepted: 08/12/2018] [Indexed: 11/23/2022]
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22
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Artificial Lungs for Lung Failure. J Am Coll Cardiol 2018; 72:1640-1652. [DOI: 10.1016/j.jacc.2018.07.049] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2018] [Revised: 06/13/2018] [Accepted: 07/03/2018] [Indexed: 12/20/2022]
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23
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Del Rio JM, Maerz D, Subramaniam K. Noteworthy Literature Published in 2017 for Thoracic Transplantation Anesthesiologists. Semin Cardiothorac Vasc Anesth 2018; 22:49-66. [DOI: 10.1177/1089253217749893] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Thoracic organ transplantation constitutes a significant proportion of all transplant procedures. Thoracic solid organ transplantation continues to be a burgeoning field of research. This article presents a review of remarkable literature published in 2017 regarding perioperative issues pertinent to the thoracic transplant anesthesiologists.
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Affiliation(s)
- J. Mauricio Del Rio
- Duke University, Durham, NC, USA
- Duke University Medical Center, Durham, NC, USA
| | - David Maerz
- University of Pittsburgh, Pittsburgh, PA, USA
- University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Kathirvel Subramaniam
- University of Pittsburgh, Pittsburgh, PA, USA
- University of Pittsburgh Medical Center, Pittsburgh, PA, USA
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