Special Considerations in Critical Care of the Congenital Heart Disease Patient

Clinical Profiles and Outcomes of Adult Congenital Heart Disease Patients in the Cardiac Intensive Care Unit

BACKGROUND

There is limited evidence to guide care and improve outcomes among critically ill adult congenital heart disease (ACHD) patients.

OBJECTIVES

The purpose of this study was to examine the clinical profile and outcomes of ACHD patients admitted to an academic cardiac intensive care unit (CICU).

METHODS

Retrospective cohort study of Mayo Clinic CICU admissions (2007-2018), including those who had been evaluated in our ACHD clinic. Critical care diagnoses (CCD) at the time of admission and critical care therapies (CCT) during the CICU stay were examined. Logistic regression and Cox proportional hazards regression were used to evaluate in-hospital and 1-year mortality, respectively.

RESULTS

Among 12,428 unique CICU admissions, 253 (2.0%) had ACHD (52.6% female, median age 41.5 [IQR: 31.5-53.5] years), classified as severe in 103 (40.9%); 49.0% had a CCD or CCT. Compared to non-ACHD, ACHD patients were more likely to have heart failure, atrial and ventricular arrhythmias. In-hospital mortality occurred in 22 (8.7%) ACHD patients and was higher among patients with CCD or requiring CCT, especially severe ACHD. One-year survival was lower for those with CCD (64.1% vs 87.5%, P < 0.001) or CCT (68.5% vs 84.5%; P = 0.001). Following multivariable adjustment, ACHD patients had higher in-hospital mortality (adjusted OR: 1.76; 95% CI: 1.01-2.94; P = 0.04) and higher risk of 1-year mortality (adjusted HR: 1.42; 95% CI: 1.06-1.89; P = 0.02). A total of 101 (43.9%) hospital survivors were readmitted within 1 year.

CONCLUSIONS

ACHD patients in the CICU experience high readmission rates and mortality. Tailored treatment strategies are needed to improve outcomes for critical ACHD patients.

Toronto ACHD program: A 65 year legacy

The Toronto Adult Congenital Heart Disease (ACHD) Program at the University Health Network, University of Toronto, began in 1959. It traces its origins to a Paul Wood protégé, Dr. John Evans, and to a long-standing and supportive relationship with Hospital for Sick Children (SickKids), located just across the street. Over the decades, the program has grown to become a major center for training and research in ACHD and one of the largest clinical programs for ACHD care globally. This paper recounts the 65-year history of the program, including some of its key individuals, challenges, milestones, innovations, discoveries, and future aspirations.

Intraoperative Hemodynamic Instability in a Patient With Ebstein's Anomaly Complicated With Eisenmenger Syndrome

Ebstein's anomaly is a rare congenital displacement of the tricuspid valve resulting in atrialization of the right ventricle. About half of the patients with Ebstein's anomaly also have atrial septal defects, which may lead to chronic shunting and development of Eisenmenger syndrome. We describe a case of a sexagenarian male patient with a history of Ebstein's anomaly complicated with Eisenmenger syndrome undergoing robotic laparoscopic adrenalectomy who presented hemodynamic instability, hypoxemia, and likely right-to-left shunting intraoperatively, as well as the actions taken to correct it and have a successful outcome. Perioperative management of adult patients with congenital heart defects is complex and requires careful monitoring. When available, intraoperative transesophageal echocardiography is strongly recommended. To prevent right-to-left shunting, maintaining elevated systemic vascular resistance with the use of vasopressors and low positive end-expiratory pressure (PEEP) ventilation is critical.

Optimizing outcomes: Impact of palliative care consultation timing in the cardiovascular intensive care unit

BACKGROUND

ICU patients and their families experience significant stress due to illness severity and prognostic uncertainty, making palliative care (PC) integral for symptom management, family support, and end-of-life care goals. The impact of PC in the Cardiac Intensive Care Unit (CICU) remains unstudied.

OBJECTIVE

We explore the impact of early palliative care consultation (PCC) on patient outcomes in the CICU, including mortality, length of stay, and family meeting frequency.

METHODS

This retrospective study at MedStar Washington Hospital Center included 209 adult patients admitted to the CICU between December 2021 and June 2022 receiving PCC. We compared outcomes between those receiving early (<72 h) and late (>72 h) PCC, including mortality, length of stay, and family meeting frequency. Statistical analysis included Wilcoxon rank sum tests, Chi-squared tests, Fisher's exact test, and Poisson regression models.

RESULTS

The study included 209 patients admitted to the (M age = 68 years, SD = 14; 45 % female; 62 % Black, 30 % White) who received PCC, most (79 %) within 72 h. Early PCC was associated with shorter CICU stays (median, 3 vs. 5.5 days; p = 0.005). Early PCC patients had higher odds of family meetings (IRR=3.59; p < 0.001) and experienced a change in code status sooner (median 1 day vs. 3 days, p < 0.001). Late PCC patients were more likely to undergo tracheostomy (13.6% vs. 2.4 %; p = 0.007), cardioversion (9.1% vs. 1.8 %; p = 0.037), and have PEG tubes placed (13.6% vs. 2.4 %; p = 0.007).

CONCLUSIONS

Early PCC in the CICU is associated with shorter CICU stays, fewer procedures, and more frequent family meetings.