Publications by authors named "Thomas Metkus"

58 Publications

Searching for the ideal antiplatelet therapy for CABG patients with kidney disease.

Authors:
Thomas S Metkus

Ann Thorac Surg 2021 May 19. Epub 2021 May 19.

Division of Cardiology, Department of Medicine, Johns Hopkins University, Blalock 524, D2 600 N Wolfe St, Baltimore, MD, 21287. Electronic address:

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http://dx.doi.org/10.1016/j.athoracsur.2021.04.088DOI Listing
May 2021

The role of sex and inflammation in cardiovascular outcomes and mortality in COVID-19.

Int J Cardiol 2021 May 8. Epub 2021 May 8.

Division of Cardiology, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA. Electronic address:

Objective: Higher mortality in COVID-19 in men compared to women is recognized, but sex differences in cardiovascular events are less well established. We aimed to determine the independent contribution of sex to stroke, myocardial infarction and death in the setting of COVID-19 infection.

Methods: We performed a retrospective cohort study of hospitalized COVID-19 patients in a racially/ethnically diverse population. Clinical features, laboratory markers and clinical events were initially abstracted from medical records, with subsequent clinician adjudication.

Results: Of 2060 patients, myocardial injury (32% vs 23%, p = 0.019), acute myocardial infarction (2.7% vs 1.6%, p = 0.114), and ischemic stroke (1.8% vs 0.7%, p = 0.007) were more common in men vs women. In-hospital death occurred in 160 men (15%) vs 117 women (12%, p = 0.091). Men had higher odds of myocardial injury (odds ratio (OR) 2.04 [95% CI 1.43-2.91], p < 0.001), myocardial infarction (1.72 [95% CI 0.93-3.20], p = 0.085) and ischemic stroke (2.76 [95% CI 1.29-5.92], p = 0.009). Despite adjustment for demographics and cardiovascular risk factors, male sex predicted mortality (HR 1.33; 95% CI:1.01-1.74; p = 0.041). While men had significantly higher markers of inflammation, in sex-stratified analyses, increase in interleukin-6, C-reactive protein, ferritin and d-dimer were predictive of mortality and myocardial injury similarly in both sexes.

Conclusions: Adjusted odds of myocardial injury, ischemic stroke and all-cause mortality, but not myocardial infarction, are significantly higher in men compared to women with COVID-19. Higher inflammatory markers are present in men but associated similarly with risk in both men and women. These data suggest that adverse cardiovascular outcomes in men vs. women are independent of cardiovascular comorbidities.
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http://dx.doi.org/10.1016/j.ijcard.2021.05.011DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8106202PMC
May 2021

Utilization and outcomes of transesophageal echocardiography in 1.3 million CABG procedures.

J Am Coll Cardiol 2021 Apr 28. Epub 2021 Apr 28.

Division of Thoracic and Cardiovascular Surgery, Department of Surgery, University of Florida, Gainesville, Florida.

Background: Utilization of intraoperative transesophageal echocardiography (TEE) at time of isolated coronary artery bypass grafting (CABG), impact on clinical decision making and associated outcomes are not well understood.

Objective: To determine the association of TEE with post-CABG mortality and changes to the operative plan.

Methods: We performed a retrospective cohort study of planned isolated CABG patients from the Society of Thoracic Surgeons Adult Cardiac Surgery Database between January 1, 2011 and June 30, 2019. The exposure variable of interest was use of intraoperative TEE during CABG, compared to no TEE. The primary outcome was operative mortality. We also assessed the association of TEE with unplanned valve surgery.

Results: Of 1,255,860 planned isolated CABG procedures across 1218 centers, 676,803 (53.9%) had intra-operative TEE. The proportion of patients receiving intra-operative TEE increased over time from 39.9% in 2011 to 62.1% in 2019 (Ptrend<0.0001). CABG patients undergoing intra-operative TEE had lower odds of mortality (adjusted OR 0.95, 95% CI 0.91-0.99, P=0.025), with heterogeneity across STS risk groups (Pinteraction 0.015). TEE was associated with increased odds of unplanned valve procedure in lieu of planned isolated CABG (adjusted OR 4.98, 95% CI 3.98-6.22, P<0.0001) CONCLUSION: Intra-operative TEE usage during planned isolated CABG is associated with lower operative mortality, particularly in higher risk patients, as well as greater odds of unplanned valve procedure. Our findings support usage of TEE to improve outcomes for isolated CABG for high risk patients.
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http://dx.doi.org/10.1016/j.jacc.2021.04.064DOI Listing
April 2021

The Range of Cardiogenic Shock Survival by Clinical Stage: Data From the Critical Care Cardiology Trials Network Registry.

Crit Care Med 2021 Apr 2. Epub 2021 Apr 2.

1 Peter Munk Cardiac Centre, University Health Network, Toronto, ON, Canada. 2 Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada. 3 Ted Rogers Centre for Heart Research, Toronto, ON, Canada. 4 Levine Cardiac Intensive Care Unit, TIMI Study Group, Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA. 5 Division of Cardiovascular Medicine, Duke University, Durham, NC. 6 Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN. 7 Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC. 8 Department of Cardiology, St. Vincent Hospital, Indianapolis, IN. 9 Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Mayo Clinic, Rochester, MN. 10 Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, OH. 11 John Hopkins University, Baltimore, MD. 12 Division of Cardiovascular Medicine, University of Utah School of Medicine, Salt Lake City, UT. 13 University of California San Diego, San Diego, CA. 14 Inova Heart and Vascular Institute, Inova Fairfax Medical Center, Falls Church, VA. 15 Department of Medicine, Stanford University School of Medicine, Stanford, CA. 16 Departments of Critical Care and Medicine (Cardiology), University of Alberta, Edmonton, AB, Canada.

Objectives: Cardiogenic shock presents with variable severity. Categorizing cardiogenic shock into clinical stages may improve risk stratification and patient selection for therapies. We sought to determine whether a structured implementation of the 2019 Society for Cardiovascular Angiography and Interventions clinical cardiogenic shock staging criteria that is ascertainable in clinical registries discriminates mortality in a contemporary population with or at-risk for cardiogenic shock.

Design: We developed a pragmatic application of the Society for Cardiovascular Angiography and Interventions cardiogenic shock staging criteria-A (at-risk), B (beginning), C (classic cardiogenic shock), D (deteriorating), or E (extremis)-and examined outcomes by stage.

Setting: The Critical Care Cardiology Trials Network is an investigator-initiated multicenter research collaboration coordinated by the TIMI Study Group (Boston, MA). Consecutive admissions with or at-risk for cardiogenic shock during two annual 2-month collection periods (2017-2019) were analyzed.

Patients: Patients with or at-risk for cardiogenic shock.

Measurements And Main Results: Of 8,240 CICU admissions reviewed, 1,991 (24%) had or were at-risk for cardiogenic shock. Distributions across the five stages were as follows: A: 33%; B: 7%; C: 16%; D: 23%; and E: 21%. Overall in-hospital mortality among patients with established cardiogenic shock was 39%; however, mortality varied from only 15.8% to 32.1% to 62.5% across stages C, D, and E (Cochran-Armitage ptrend < 0.0001). The Society for Cardiovascular Angiography and Interventions stages improved mortality prediction beyond the Sequential Organ Failure Assessment and Intra-Aortic Balloon Pumpin Cardiogenic Shock II scores.

Conclusions: Although overall mortality in cardiogenic shock remains high, it varies considerably based on clinical stage, identifying stage C as relatively lower risk. We demonstrate a pragmatic adaptation of the Society for Cardiovascular Angiography and Interventions cardiogenic shock stages that effectively stratifies mortality risk and could be leveraged for future clinical research.
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http://dx.doi.org/10.1097/CCM.0000000000004948DOI Listing
April 2021

Hospital variability in modifiable factors driving coronary artery bypass charges.

J Thorac Cardiovasc Surg 2021 Mar 9. Epub 2021 Mar 9.

Division of Cardiac Surgery, Department of Surgery, University of Maryland School of Medicine, Baltimore, Md; Adventist Healthcare White Oak Medical Center, Silver Spring, Md.

Objective: Coronary artery bypass grafting is associated with significant interhospital variability in charges. Drivers of hospital charge variability remain elusive. We identified modifiable factors associated with statewide interhospital variability in hospital charges for coronary artery bypass grafting.

Methods: Charge data were used as a surrogate for cost. Society of Thoracic Surgeons data from Maryland institutions and charge data from the Maryland Health Care Commission were linked to characterize interhospital charge variability for coronary artery bypass grafting. Multivariable linear regression was used to identify perioperative factors independently related to coronary artery bypass grafting charges. Of the factors independently associated with charges, we analyzed which factors varied between hospitals.

Results: A total of 10,337 patients underwent isolated coronary artery bypass grafting at 9 Maryland hospitals from 2012 to 2016, of whom 7532 patients were available for analyses. Mean normalized charges for isolated coronary artery bypass grafting varied significantly among hospitals, ranging from $30,000 to $57,000 (P < .001). Longer preoperative length of stay, operating room time, and major postoperative morbidity including stroke, renal failure, prolonged ventilation, reoperation, and deep sternal wound infection were associated with greater hospital charges. Incidence of major postoperative events, except stroke and deep sternal wound infection, was variable between hospitals. In a univariate linear regression model, patient risk profile only accounted for approximately 10% of statistical variance in charges.

Conclusions: There is significant charge variability for coronary artery bypass grafting among hospitals within the same state. By targeting variation in preoperative length of stay, operating room time, postoperative renal failure, prolonged ventilation, and reoperation, cardiac surgery programs can realize cost savings while improving quality of care for this resource-intense patient population.
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http://dx.doi.org/10.1016/j.jtcvs.2021.02.094DOI Listing
March 2021

Trends in Therapy and Outcomes Associated With Respiratory Failure in Patients Admitted to the Cardiac Intensive Care Unit.

J Intensive Care Med 2021 Mar 24:8850666211003489. Epub 2021 Mar 24.

Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Mayo Clinic, Rochester MN, USA.

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 ( < 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% ( < 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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http://dx.doi.org/10.1177/08850666211003489DOI Listing
March 2021

Incidence, predictors and prognosis of respiratory support in non-ST segment elevation myocardial infarction.

Eur Heart J Acute Cardiovasc Care 2020 Apr 23. Epub 2020 Apr 23.

Department of Medicine, Johns Hopkins University School of Medicine, USA.

Background: The incidences of invasive mechanical ventilation and non-invasive ventilation among patients with non-ST segment elevation myocardial infarction and associated prognosis are not well characterized.

Methods: We conducted a retrospective cohort study of patients with admission diagnosis of non-ST segment elevation myocardial infarction using the US National Inpatient Sample database between 2002-2014. The exposure variable was invasive mechanical ventilation or non-invasive ventilation within 24 h of admission, compared to no respiratory support. The primary outcome was in-hospital mortality. We determined the association between respiratory support and mortality using Cox proportional hazard models.

Results: A total of 4,152,421 non-ST segment elevation myocardial infarction hospitalizations were identified, among whom 1.3% required non-invasive ventilation and 1.9% required invasive mechanical ventilation. Non-invasive ventilation use increased over time (0.4% in 2002 to 2.4% in 2014, p<0.001) while there was no definite trend in invasive mechanical ventilation use. Revascularization was lower for non-ST segment elevation myocardial infarction hospitalizations including invasive mechanical ventilation (23.9%) and non-invasive ventilation (14.5%) compared to 36.5% of those without respiratory support (p<0.001). In-hospital mortality was 3.1% for non-ST segment elevation myocardial infarction without respiratory support compared to 9.2% with non-invasive ventilation (adjusted hazard ratio 1.86, 95% confidence interval 1.74-1.98) and 37.2% with invasive mechanical ventilation (adjusted hazard ratio 3.03, 95% confidence interval 2.88-3.19). Mortality for non-ST segment elevation myocardial infarction-non-invasive ventilation is improving over time while mortality for non-ST segment elevation myocardial infarction-invasive mechanical ventilation is increasing over time.

Conclusion: Mechanical respiratory support in non-ST segment elevation myocardial infarction is used in an important minority of cases, is increasing and is independently associated with mortality. Studies of the optimal management of acute coronary syndrome complicated by respiratory failure are needed to improve outcomes.
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http://dx.doi.org/10.1177/2048872620919947DOI Listing
April 2020

Association between Respiratory Failure and Clinical Outcomes in Patients with Acute Heart Failure: Analysis of 5 Pooled Clinical Trials.

J Card Fail 2021 May 5;27(5):602-606. Epub 2021 Feb 5.

Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, Connecticut.

Background: Despite a temporal increase in respiratory failure in patients hospitalized with acute heart failure (HF), clinical trials have largely not reported the incidence or associated clinical outcomes for patients requiring mechanical ventilation.

Methods And Results: After pooling 5 acute HF clinical trials, we used multivariable logistic regression adjusted for demographics, comorbidities, examinations, and laboratory findings to assess associations between mechanical ventilation and clinical outcomes. Among the 8296 patients, 210 (2.5%) required mechanical ventilation. Age, sex, smoking history, baseline ejection fraction, HF etiology, and the proportion of patients randomized to treatment or placebo in the original clinical trial were similar between groups (all, P > 0.05). Baseline diabetes mellitus was more common in the mechanical ventilation group (P = 0.02), but other comorbidities, including chronic lung disease, were otherwise similar (all P > 0.05). HF rehospitalization at 30 days (12.7% vs 6.6%, P < 0.001) and all-cause 60-day mortality (33.3% vs 6.1%, P < 0.001) was higher among patients requiring mechanical ventilation. After multivariable adjustment, mechanical ventilation use was associated with an increased 30-day HF rehospitalization (odds ratio 2.03; 95% confidence interval, 1.29-3.21, P = 0.002), 30-day mortality (odds ratio 10.40; 95% confidence interval, 7.22-14.98, P < 0.001), and 60-day mortality (odds ratio 7.68; 95% confidence interval, 5.50-10.74, P < 0.001). The influence of mechanical ventilation did not differ by HF etiology or baseline ejection fraction (both, interaction P > 0.20).

Conclusions: Respiratory failure during an index hospitalization for acute HF was associated with increased rehospitalization and all-cause mortality. The development of respiratory failure during an acute HF admission identifies a particularly vulnerable population, which should be identified for closer monitoring.
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http://dx.doi.org/10.1016/j.cardfail.2021.01.018DOI Listing
May 2021

Transition From an Open to Closed Staffing Model in the Cardiac Intensive Care Unit Improves Clinical Outcomes.

J Am Heart Assoc 2021 Feb 8;10(3):e018182. Epub 2021 Jan 8.

Section of Cardiovascular Medicine Yale School of Medicine New Haven CT.

Background Several studies have shown improved outcomes in closed compared with open medical and surgical intensive care units. However, very little is known about the ideal organizational structure in the modern cardiac intensive care unit (CICU). Methods and Results We retrospectively reviewed consecutive unique admissions (n=3996) to our tertiary care CICU from September 2013 to October 2017. The aim of our study was to assess for differences in clinical outcomes between an open compared with a closed CICU. We used multivariable logistic regression adjusting for demographics, comorbidities, and severity of illness. The primary outcome was in-hospital mortality. We identified 2226 patients in the open unit and 1770 in the closed CICU. The unadjusted in-hospital mortality in the open compared with closed unit was 9.6% and 8.9%, respectively (=0.42). After multivariable adjustment, admission to the closed unit was associated with a lower in-hospital mortality (odds ratio [OR], 0.69; 95% CI: 0.53-0.90, =0.007) and CICU mortality (OR, 0.70; 95% CI, 0.52-0.94, =0.02). In subgroup analysis, admissions for cardiac arrest (OR, 0.42; 95% CI, 0.20-0.88, =0.02) and respiratory insufficiency (OR, 0.43; 95% CI, 0.22-0.82, =0.01) were also associated with a lower in-hospital mortality in the closed unit. We did not find a difference in CICU length of stay or total hospital charges (>0.05). Conclusions We found an association between lower in-hospital and CICU mortality after the transition to a closed CICU. These results may help guide the ongoing redesign in other tertiary care CICUs.
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http://dx.doi.org/10.1161/JAHA.120.018182DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7955420PMC
February 2021

The role of timing in treatment of atrial fibrillation: An AFFIRM substudy.

Heart Rhythm 2021 May 28;18(5):674-681. Epub 2020 Dec 28.

Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, Maryland. Electronic address:

Background: In contrast to historical trials, the Early Treatment of Atrial Fibrillation for Stroke Prevention Trial (EAST-AFNET 4) suggests the superiority of early rhythm control over rate control in patients with recent-onset atrial fibrillation (AF). The relative contribution of timing vs improvement in AF therapeutics over time is unclear.

Objective: This study aimed to isolate the assessment of early intervention for AF from temporal changes in AF treatments through a secondary analysis of subjects from the Atrial Fibrillation Follow-up Investigation of Rhythm Management (AFFIRM) study.

Methods: We compared rate and rhythm control treatments in AFFIRM subjects stratified by time from their diagnosis of AF. Time-to-event analysis was performed to compare all-cause mortality, cardiovascular hospitalizations, stroke, and number of hospitalization days.

Results: Of the 4060 AFFIRM subjects, 2526 subjects (62.2%) had their first episode of AF within 6 months of study enrollment. Participants with "new" AF had a decreased risk of all-cause mortality (P = .001) than did those with prior AF diagnoses. Individuals previously diagnosed with AF were similar in age and demographic characteristics, but had more medical comorbidities, including myocardial infarction (P = .006), diabetes mellitus (P = .002), smoking (P = .003), and hepatic or renal comorbidities (P = .008). There were no differences in mortality, cardiovascular hospitalizations, or stroke between rate and rhythm control strategies in either AF subgroup.

Conclusion: AFFIRM subjects diagnosed with AF within 6 months of study enrollment showed no difference in survival, cardiovascular hospitalization, or ischemic stroke between rate and rhythm control strategies. Superiority of rhythm control strategies reported by newer AF trials may be more attributable to the refinement of AF therapies and less related to the timing of intervention.
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http://dx.doi.org/10.1016/j.hrthm.2020.12.025DOI Listing
May 2021

Advanced Respiratory Support in the Contemporary Cardiac ICU.

Crit Care Explor 2020 Sep 17;2(9):e0182. Epub 2020 Sep 17.

TIMI Study Group, Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA.

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.

Design: Prospective cohort study.

Setting: The Critical Care Cardiology Trials Network is a research collaborative of cardiac ICUs across the United States and Canada.

Patients: We included all medical cardiac ICU admissions at 25 cardiac ICUs during two consecutive months annually at each center from 2017 to 2019.

Measurements: We evaluated the use of advanced respiratory therapies including invasive mechanical ventilation, noninvasive ventilation, and high-flow nasal cannula versus no advanced respiratory support across admission diagnoses and the association with in-hospital mortality.

Main Results: Of 8,240 cardiac ICU admissions, 1,935 (23.5%) were treated with invasive mechanical ventilation, 573 (7.0%) with noninvasive ventilation, and 281 (3.4%) with high-flow nasal cannula. Admitting diagnoses among those with advanced respiratory support were diverse including general medical problems in patients with heart disease as well as primary cardiac problems. In-hospital mortality was higher in patients who received invasive mechanical ventilation (38.1%; adjusted odds ratio, 2.53; 2.02-3.16) and noninvasive ventilation or high-flow nasal cannula (8.8%; adjusted odds ratio, 2.25; 1.73-2.93) compared with patients without advanced respiratory support (4.6%). Reintubation rate was 7.6%. The most common variables associated with respiratory insufficiency included heart failure, infection, chronic obstructive pulmonary disease, and pulmonary vascular disease.

Conclusions: One-third of cardiac ICU admissions receive respiratory support with associated increased mortality. These data provide benchmarks for quality improvement ventures in the cardiac ICU, inform cardiac critical care training and staffing patterns, and serve as foundation for future studies aimed at improving outcomes.
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http://dx.doi.org/10.1097/CCE.0000000000000182DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7678799PMC
September 2020

Myocardial Injury in Severe COVID-19 Compared With Non-COVID-19 Acute Respiratory Distress Syndrome.

Circulation 2021 02 13;143(6):553-565. Epub 2020 Nov 13.

Divisions of Cardiology (T.S.M., A.S.B., M.J.C., A.G.H., C.J.L., E.D.M., W.S.P., J.R.R., D.R.T., J.C.T., R.K.H.), Johns Hopkins University School of Medicine, Baltimore, MD.

Background: Knowledge gaps remain in the epidemiology and clinical implications of myocardial injury in coronavirus disease 2019 (COVID-19). We aimed to determine the prevalence and outcomes of myocardial injury in severe COVID-19 compared with acute respiratory distress syndrome (ARDS) unrelated to COVID-19.

Methods: We included intubated patients with COVID-19 from 5 hospitals between March 15 and June 11, 2020, with troponin levels assessed. We compared them with patients from a cohort study of myocardial injury in ARDS and performed survival analysis with primary outcome of in-hospital death associated with myocardial injury. In addition, we performed linear regression to identify clinical factors associated with myocardial injury in COVID-19.

Results: Of 243 intubated patients with COVID-19, 51% had troponin levels above the upper limit of normal. Chronic kidney disease, lactate, ferritin, and fibrinogen were associated with myocardial injury. Mortality was 22.7% among patients with COVID-19 with troponin under the upper limit of normal and 61.5% for those with troponin levels >10 times the upper limit of normal (<0.001). The association of myocardial injury with mortality was not statistically significant after adjusting for age, sex, and multisystem organ dysfunction. Compared with patients with ARDS without COVID-19, patients with COVID-19 were older and had higher creatinine levels and less favorable vital signs. After adjustment, COVID-19-related ARDS was associated with lower odds of myocardial injury compared with non-COVID-19-related ARDS (odds ratio, 0.55 [95% CI, 0.36-0.84]; =0.005).

Conclusions: Myocardial injury in severe COVID-19 is a function of baseline comorbidities, advanced age, and multisystem organ dysfunction, similar to traditional ARDS. The adverse prognosis of myocardial injury in COVID-19 relates largely to multisystem organ involvement and critical illness.
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http://dx.doi.org/10.1161/CIRCULATIONAHA.120.050543DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7864609PMC
February 2021

Prevalence and Clinical Correlates of Echo-Estimated Right and Left Heart Filling Pressures in Hospitalized Patients With Coronavirus Disease 2019.

Crit Care Explor 2020 Oct 30;2(10):e0227. Epub 2020 Sep 30.

Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD.

Objectives: The prevalence of elevated right and left heart filling pressures in coronavirus disease 2019 is not well characterized. We aimed to characterize the prevalence of pulmonary hypertension and concurrent elevated left heart filling pressure in hospitalized patients with coronavirus disease 2019. We hypothesized that a significant proportion of coronavirus disease 2019 patients has evidence of pulmonary hypertension associated with elevated left heart filling pressure on transthoracic echocardiography.

Design: Retrospective cohort study.

Setting: Academic tertiary-care center.

Patients: Hospitalized coronavirus disease 2019 patients who underwent clinical transthoracic echocardiography.

Interventions: None.

Measurements And Main Results: The exposure variable of interest was right ventricular systolic pressure, calculated using the American Society of Echocardiography guidelines. Pulmonary hypertension was defined as right ventricular systolic pressure greater than 40 mm Hg. Left heart filling pressure was estimated with Nagueh's method for pulmonary artery occlusion pressure using E/e' ratio, and normal was considered pulmonary artery occlusion pressure less than 16 mm Hg. Clinical characteristics and outcomes were compared between the patients with and without pulmonary hypertension. A total of 73 patients (median age 66 yr [57-75 yr]; 46% women) were included. Median right ventricular systolic pressure was 39 mm Hg (interquartile range, 32-50 mm Hg), and 36 patients (49.3%) had evidence of pulmonary hypertension. Patients with pulmonary hypertension were more likely to require ICU admission (86% vs 65%; = 0.035) and have acute respiratory distress syndrome (72% vs 49%; = 0.0053) than those without. In-hospital mortality was 26% for those with pulmonary hypertension compared with 14% for those without ( = 0.19). Patients with pulmonary hypertension had higher median-estimated pulmonary artery occlusion pressure (17.4 mm Hg [12.7-21.3 mm Hg] vs 12.1 mm Hg [10.0-14.1 mm Hg]; = 0.0008), and elevated left heart filling pressure was present in 59% of those with pulmonary hypertension.

Conclusions: Pulmonary hypertension is common in hospitalized patients with coronavirus disease 2019 and is associated with poor clinical outcomes. Left ventricular filling pressure is elevated in over half of those with pulmonary hypertension and may represent a target to reduce right ventricular afterload and potentially improve outcomes in coronavirus disease 2019.
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http://dx.doi.org/10.1097/CCE.0000000000000227DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7531757PMC
October 2020

Diazoxide preserves myocardial function in a swine model of hypothermic cardioplegic arrest and prolonged global ischemia.

J Thorac Cardiovasc Surg 2020 Aug 26. Epub 2020 Aug 26.

Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Md. Electronic address:

Objective: Adenosine triphosphate potassium sensitive channels provide endogenous myocardial protection via coupling of cell membrane potential to myocardial metabolism. Adenosine triphosphate potassium sensitive channel openers, such as diazoxide, mimic ischemic preconditioning, prevent cardiomyocyte swelling, preserve myocyte contractility after stress, and provide diastolic protection. We hypothesize that diazoxide combined with hyperkalemic cardioplegia provides superior myocardial protection compared with cardioplegia alone during prolonged global ischemia in a large animal model.

Methods: Twelve pigs were randomized to global ischemia for 2 hours with a single dose of cold blood (4:1) hyperkalemic cardioplegia alone (n = 6) or with diazoxide (100 μmol/L) (n = 6) and reperfused for 1 hour. Cardiac output, myocardial oxygen consumption, left ventricular developed pressure, left ventricular ejection fraction, diastolic function, myocardial troponin, myoglobin, markers of apoptosis, and left ventricular infarct size were compared.

Results: Four pigs in the cardioplegia alone group could not be weaned from cardiopulmonary bypass. There were no differences in myoglobin, troponin, or apoptosis between groups. Diazoxide preserved cardiac output versus control (74.5 vs 18.4 mL/kg/min, P = .01). Linear mixed regression modeling demonstrated that the addition of diazoxide to cardioplegia preserved left ventricular developed pressure by 36% (95% confidence interval, 9.9-61.5; P < .01), dP/dt max by 41% (95% confidence interval, 14.5-67.5; P < .01), and dP/dt min by 33% (95% confidence interval, 8.9-57.5; P = .01). It was also associated with higher (but not significant) myocardial oxygen consumption (3.7 vs 1.4 mL O/min, P = .12).

Conclusions: Diazoxide preserves systolic and diastolic ventricular function in a large animal model of prolonged global myocardial ischemia. Diazoxide as an adjunct to hyperkalemic cardioplegia may allow safer prolonged ischemic times during increasingly complicated cardiac procedures.
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http://dx.doi.org/10.1016/j.jtcvs.2020.08.069DOI Listing
August 2020

Pulmonary and systemic hemodynamics are associated with myocardial injury in the acute respiratory distress syndrome.

Pulm Circ 2020 Jul-Sep;10(3):2045894020939846. Epub 2020 Jul 23.

Department of Emergency Medicine, University of Michigan Medical School, Ann Arbor, USA.

Background: Whether right and left heart hemodynamics are associated with myocardial injury in the acute respiratory distress syndrome (ARDS) is not known.

Methods: We performed a retrospective cohort study of subjects who had right heart catheterization within the ALVEOLI trial and Fluid and Catheter Treatment Trial. Myocardial injury was assessed using a highly sensitive troponin assay (hsTn; Abbot ARCHITECT). Hemodynamic variables included right atrial pressure, pulmonary artery wedge pressure, cardiac index and stroke volume, pulmonary vascular resistance, pulmonary arterial compliance, and pulmonary effective arterial elastance. We performed linear, logistic, and Cox regression to determine the association of hemodynamic variables with myocardial injury and to determine if hemodynamics mediated the association between myocardial injury and death.

Results: Among 252 ARDS patients, median day 0 troponin was 65.4 (13.8-397.8) ng/L. Lower cardiac index (β -0.23 SE 0.10; P < 0.001) and stroke volume (β -0.26 SE 0.005; P < 0.001), higher pulmonary vascular resistance (β 0.22 SE 0.11; P < 0.001), lower pulmonary arterial compliance (β -0.24 SE 0.06; P < 0.001), and higher arterial elastance (β 0.27 SE 0.43; P < 0.001) were associated with greater myocardial injury in univariable and adjusted models. Changes in stroke volume, cardiac index, pulmonary arterial compliance, pulmonary vascular resistance, and arterial elastance were all associated with progressive myocardial injury over three days. hsTn levels were associated with mortality; however, the association was attenuated after adjustment for each of stroke volume, pulmonary vascular resistance, pulmonary arterial compliance, and arterial elastance.

Conclusion: Pulmonary vascular hemodynamics are associated with myocardial injury in ARDS, while filling pressures are not. Pulmonary vascular disease may represent a treatable contributor to myocardial injury in ARDS.
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http://dx.doi.org/10.1177/2045894020939846DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7378723PMC
July 2020

Commentary: Acute kidney injury, a multi-billion-dollar issue.

J Thorac Cardiovasc Surg 2020 Jun 5. Epub 2020 Jun 5.

Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Md. Electronic address:

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http://dx.doi.org/10.1016/j.jtcvs.2020.05.070DOI Listing
June 2020

Incidence, Predictors, and Outcomes of Failure of Noninvasive Ventilation in Acute Heart Failure Hospitalization.

Respir Care 2020 Oct 12;65(10):1527-1533. Epub 2020 May 12.

Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland.

Some patients with acute heart failure (AHF) who are treated initially with noninvasive ventilation (NIV) will require endotracheal intubation, which indicates NIV failure. The incidence and prognosis of NIV failure in patients with AHF are not well characterized. Using the National In-Patient Sample (NIS), we conducted a retrospective cohort study of subjects hospitalized with AHF between 2008 and 2014 who were treated with NIV within 24 h of hospital admission. We determined predictors of NIV failure and determined the association between NIV failure and in-hospital mortality using Cox proportional hazard models. Of 279,534 subjects hospitalized with AHF and treated with NIV, 4,257 (1.52%) failed NIV and required intubation. Cardiogenic shock (odds ratio 8.79, 95% CI 6.89-11.2) and in-hospital arrest (odds ratio 24.9, 95% CI 18.71-33.14) were associated with NIV failure. In-hospital mortality was 26.5% for NIV failure compared to 5.6% for those without NIV ( < .001). After adjustment for demographics, comorbidities, cardiogenic shock, and in-hospital arrest, NIV failure was associated with nearly a 2-fold risk of in-hospital mortality (odds ratio 1.95, 95% CI 1.59-2.40). Intubation after initial NIV treatment was required in 1.5% of subjects hospitalized with AHF and treated with NIV, and was associated with high in-hospital mortality. These findings can guide future prospective interventional trials and quality improvement ventures.
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http://dx.doi.org/10.4187/respcare.07661DOI Listing
October 2020

Incidence, predictors and prognosis of respiratory support in non-ST segment elevation myocardial infarction.

Eur Heart J Acute Cardiovasc Care 2020 Apr 23:2048872620919947. Epub 2020 Apr 23.

Department of Medicine, Johns Hopkins University School of Medicine, USA.

Background: The incidences of invasive mechanical ventilation and non-invasive ventilation among patients with non-ST segment elevation myocardial infarction and associated prognosis are not well characterized.

Methods: We conducted a retrospective cohort study of patients with admission diagnosis of non-ST segment elevation myocardial infarction using the US National Inpatient Sample database between 2002-2014. The exposure variable was invasive mechanical ventilation or non-invasive ventilation within 24 h of admission, compared to no respiratory support. The primary outcome was in-hospital mortality. We determined the association between respiratory support and mortality using Cox proportional hazard models.

Results: A total of 4,152,421 non-ST segment elevation myocardial infarction hospitalizations were identified, among whom 1.3% required non-invasive ventilation and 1.9% required invasive mechanical ventilation. Non-invasive ventilation use increased over time (0.4% in 2002 to 2.4% in 2014, <0.001) while there was no definite trend in invasive mechanical ventilation use. Revascularization was lower for non-ST segment elevation myocardial infarction hospitalizations including invasive mechanical ventilation (23.9%) and non-invasive ventilation (14.5%) compared to 36.5% of those without respiratory support (<0.001). In-hospital mortality was 3.1% for non-ST segment elevation myocardial infarction without respiratory support compared to 9.2% with non-invasive ventilation (adjusted hazard ratio 1.86, 95% confidence interval 1.74-1.98) and 37.2% with invasive mechanical ventilation (adjusted hazard ratio 3.03, 95% confidence interval 2.88-3.19). Mortality for non-ST segment elevation myocardial infarction-non-invasive ventilation is improving over time while mortality for non-ST segment elevation myocardial infarction-invasive mechanical ventilation is increasing over time.

Conclusion: Mechanical respiratory support in non-ST segment elevation myocardial infarction is used in an important minority of cases, is increasing and is independently associated with mortality. Studies of the optimal management of acute coronary syndrome complicated by respiratory failure are needed to improve outcomes.
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http://dx.doi.org/10.1177/2048872620919947DOI Listing
April 2020

COVID-19 and Disruptive Modifications to Cardiac Critical Care Delivery: JACC Review Topic of the Week.

J Am Coll Cardiol 2020 07 16;76(1):72-84. Epub 2020 Apr 16.

Department of Critical Care and Division of Cardiology, Department of Medicine, University of Alberta Hospital, Alberta, Canada. Electronic address: https://twitter.com/seanvandiepen.

The COVID-19 pandemic has presented a major unanticipated stress on the workforce, organizational structure, systems of care, and critical resource supplies. To ensure provider safety, to maximize efficiency, and to optimize patient outcomes, health systems need to be agile. Critical care cardiologists may be uniquely positioned to treat the numerous respiratory and cardiovascular complications of the SARS-CoV-2 and support clinicians without critical care training who may be suddenly asked to care for critically ill patients. This review draws upon the experiences of colleagues from heavily impacted regions of the United States and Europe, as well as lessons learned from military mass casualty medicine. This review offers pragmatic suggestions on how to implement scalable models for critical care delivery, cultivate educational tools for team training, and embrace technologies (e.g., telemedicine) to enable effective collaboration despite social distancing imperatives.
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http://dx.doi.org/10.1016/j.jacc.2020.04.029DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7161519PMC
July 2020

Rationale and Design of the Aspirin Dosing-A Patient-Centric Trial Assessing Benefits and Long-term Effectiveness (ADAPTABLE) Trial.

JAMA Cardiol 2020 05;5(5):598-607

Minneapolis Heart Institute, Minneapolis Heart Institute Foundation, Minneapolis.

Importance: Determining the right dosage of aspirin for the secondary prevention treatment of atherosclerotic cardiovascular disease (ASCVD) remains an unanswered and critical question.

Objective: To report the rationale and design for a randomized clinical trial to determine the optimal dosage of aspirin to be used for secondary prevention of ASCVD, using an innovative research method.

Design, Setting, And Participants: This pragmatic, open-label, patient-centered, randomized clinical trial is being conducted in 15 000 patients within the National Patient-Centered Clinical Research Network (PCORnet), a distributed research network of partners including clinical research networks, health plan research networks, and patient-powered research networks across the United States. Patients with established ASCVD treated in routine clinical practice within the network are eligible. Patient recruitment began in April 2016. Enrollment was completed in June 2019. Final follow-up is expected to be completed by June 2020.

Interventions: Participants are randomized on a web platform in a 1:1 fashion to either 81 mg or 325 mg of aspirin daily.

Main Outcomes And Measures: The primary efficacy end point is the composite of all-cause mortality, hospitalization for nonfatal myocardial infarction, or hospitalization for a nonfatal stroke. The primary safety end point is hospitalization for major bleeding associated with a blood-product transfusion. End points are captured through regular queries of the health systems' common data model within the structure of PCORnet's distributed data environment.

Conclusions And Relevance: As a pragmatic study and the first interventional trial conducted within the PCORnet electronic data infrastructure, this trial is testing several unique and innovative operational approaches that have the potential to disrupt and transform the conduct of future patient-centered randomized clinical trials by evaluating treatments integrated in clinical practice while at the same time determining the optimal dosage of aspirin for secondary prevention of ASCVD.

Trial Registration: ClinicalTrials.gov Identifier: NCT02697916.
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http://dx.doi.org/10.1001/jamacardio.2020.0116DOI Listing
May 2020

Racial Disparity in Cardiac Surgery Risk and Outcome: Report From a Statewide Quality Initiative.

Ann Thorac Surg 2020 08 18;110(2):531-536. Epub 2020 Jan 18.

Division of Cardiothoracic Surgery, Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland.

Background: Racial disparities persist in health care. Our study objective was to evaluate racial disparity in cardiac surgery in Maryland.

Methods: A statewide database was used to identify patients. Demographics, comorbidities, and predicted risk of death were compared between races. Crude mortality and incidence of complications were compared between groups, as were risk-adjusted odds for mortality and major morbidity or mortality.

Results: The study included 23,094 patients. Most patients were white (75.8%), followed by African American (16.3%), Asian (3.8%), and other races (4.1%). African Americans had a higher preoperative risk for mortality based on The Society of Thoracic Surgeons predictive models compared with white patients (3.0% vs 2.3%, P < .001). African Americans also had higher prevalence of diabetes mellitus, hypertension, peripheral vascular disease, and cerebral vascular disease than white patients. After adjustment for preoperative risk, there was no difference in 30-day mortality between African Americans (odds ratio [OR], 1.26; 95% confidence interval [CI], 0.99-1.59), Asians (OR, 1.22; 95% CI, 0.75-1.97), and other races (OR, 1.18; 95% CI, 0.74-1.89) compared with whites. African Americans had lower risk-adjusted odds of major morbidity or mortality compared with whites (OR, 0.83; 95% CI, 0.75-0.93).

Conclusions: African American cardiac surgical patients have the highest preoperative risk in Maryland. Patients appeared to receive excellent cardiac surgical care, regardless of race, as risk-adjusted mortality did not differ between groups, and African American patients had lower risk-adjusted odds of major morbidity or mortality than white patients. Future interventions in Maryland should be aimed at reducing preoperative risk disparity in cardiac surgical patients.
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http://dx.doi.org/10.1016/j.athoracsur.2019.11.043DOI Listing
August 2020

Respiratory support in acute heart failure with preserved vs reduced ejection fraction.

Clin Cardiol 2020 Apr 11;43(4):320-328. Epub 2019 Dec 11.

Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland.

Background: There is little evidence addressing the use and differential impact of respiratory support in acute heart failure (AHF) patients with preserved (HFPEF) vs reduced (HFREF) ejection fraction. Therefore, our objective was to determine the usage and clinical outcomes of critical care respiratory support in AHF across the two populations.

Hypothesis: Respiratory support would be associated with adverse outcome in both HFPEF and HFREF.

Methods: We identified HFPEF, HFREF, invasive mechanical ventilation (IMV), and noninvasive ventilation (NIV) using International Classification of Disease-Ninth Edition codes in the National Inpatient Sample between January 1, 2008 and December 31, 2014. We determined rates of IMV and NIV use. We identified predictors of need for IMV and NIV and the association between ventilation strategies and in-hospital mortality in HFPEF vs HFREF.

Results: 1.3 million AHF-HFPEF and 1.7 million AHF-HFREF hospitalizations were included; 5.98% of AHF HFPEF hospitalizations included NIV and 0.57% included IMV. Among HFREF hospitalizations, fewer (4.1%) included NIV and more (0.93%) included IMV. In HFPEF hospitalization, NIV use was associated with 2.24-fold increased risk for death compared to no respiratory support in an adjusted model (HR 2.24 95% CI 2.05-2.44) and IMV use was associated with 2.85-fold increased risk for death (HR 2.85 95% CI 2.30-3.53). This increased risk of in-hospital mortality was similar among HFREF patients.

Conclusions: Use of respiratory support is increasing among patients with both HFPEF and HFREF and associated with substantially increased mortality in both heart failure subtypes.
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http://dx.doi.org/10.1002/clc.23317DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7144479PMC
April 2020

Clinical Practice Patterns in Temporary Mechanical Circulatory Support for Shock in the Critical Care Cardiology Trials Network (CCCTN) Registry.

Circ Heart Fail 2019 11 11;12(11):e006635. Epub 2019 Nov 11.

Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC (A.P.C., C.B.G., L.K.N.).

Background: Temporary mechanical circulatory support (MCS) devices provide hemodynamic assistance for shock refractory to pharmacological treatment. Most registries have focused on single devices or specific etiologies of shock, limiting data regarding overall practice patterns with temporary MCS in cardiac intensive care units.

Methods: The CCCTN (Critical Care Cardiology Trials Network) is a multicenter network of tertiary CICUs in North America. Between September 2017 and September 2018, each center (n=16) contributed a 2-month snapshot of consecutive medical CICU admissions.

Results: Of the 270 admissions using temporary MCS, 33% had acute myocardial infarction-related cardiogenic shock (CS), 31% had CS not related to acute myocardial infarction, 11% had mixed shock, and 22% had an indication other than shock. Among all 585 admissions with CS or mixed shock, 34% used temporary MCS during the CICU stay with substantial variation between centers (range: 17%-50%). The most common temporary MCS devices were intraaortic balloon pumps (72%), Impella (17%), and veno-arterial extracorporeal membrane oxygenation (11%), although intraaortic balloon pump use also varied between centers (range: 40%-100%). Patients managed with intraaortic balloon pump versus other forms of MCS (advanced MCS) had lower Sequential Organ Failure Assessment scores and less severe metabolic derangements. Illness severity was similar at high- versus low-MCS utilizing centers and at centers with more advanced MCS use.

Conclusions: There is wide variation in the use of temporary MCS among patients with shock in tertiary CICUs. While hospital-level variation in temporary MCS device selection is not explained by differences in illness severity, patient-level variation appears to be related, at least in part, to illness severity.
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http://dx.doi.org/10.1161/CIRCHEARTFAILURE.119.006635DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7008928PMC
November 2019

Demographics, Care Patterns, and Outcomes of Patients Admitted to Cardiac Intensive Care Units: The Critical Care Cardiology Trials Network Prospective North American Multicenter Registry of Cardiac Critical Illness.

JAMA Cardiol 2019 09;4(9):928-935

Clinical Center and Cardiology Branch, Critical Care Medicine Department, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland.

Importance: Single-center and claims-based studies have described substantial changes in the landscape of care in the cardiac intensive care unit (CICU). Professional societies have recommended research to guide evidence-based CICU redesigns.

Objective: To characterize patients admitted to contemporary, advanced CICUs.

Design, Setting, And Participants: This study established the Critical Care Cardiology Trials Network (CCCTN), an investigator-initiated multicenter network of 16 advanced, tertiary CICUs in the United States and Canada. For 2 months in each CICU, data for consecutive admissions were submitted to the central data coordinating center (TIMI Study Group). The data were collected and analyzed between September 2017 and 2018.

Main Outcomes And Measures: Demographics, diagnoses, management, and outcomes.

Results: Of 3049 participants, 1132 (37.1%) were women, 797 (31.4%) were individuals of color, and the median age was 65 years (25th and 75th percentiles, 55-75 years). Between September 2017 and September 2018, 3310 admissions were included, among which 2557 (77.3%) were for primary cardiac problems, 337 (10.2%) for postprocedural care, 253 (7.7%) for mixed general and cardiac problems, and 163 (4.9%) for overflow from general medical ICUs. When restricted to the initial 2 months of medical CICU admissions for each site, the primary analysis population included 3049 admissions with a high burden of noncardiovascular comorbidities. The top 2 CICU admission diagnoses were acute coronary syndrome (969 [31.8%]) and heart failure (567 [18.6%]); however, the proportion of acute coronary syndrome was highly variable across centers (15%-57%). The primary indications for CICU care included respiratory insufficiency (814 [26.7%]), shock (643 [21.1%]), unstable arrhythmia (521 [17.1%]), and cardiac arrest (265 [8.7%]). Advanced CICU therapies or monitoring were required for 1776 patients (58.2%), including intravenous vasoactive medications (1105 [36.2%]), invasive hemodynamic monitoring (938 [30.8%]), and mechanical ventilation (652 [21.4%]). The overall CICU mortality rate was 8.3% (95% CI, 7.3%-9.3%). The CICU indications that were associated with the highest mortality rates were cardiac arrest (101 [38.1%]), cardiogenic shock (140 [30.6%]), and the need for renal replacement therapy (51 [34.5%]). Notably, patients admitted solely for postprocedural observation or frequent monitoring had a mortality rate of 0.2% to 0.4%.

Conclusions And Relevance: In a contemporary network of tertiary care CICUs, respiratory failure and shock predominated indications for admission and carried a poor prognosis. While patterns of practice varied considerably between centers, a substantial, low-risk population was identified. Multicenter collaborative networks, such as the CCCTN, could be used to help redesign cardiac critical care and to test new therapeutic strategies.
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http://dx.doi.org/10.1001/jamacardio.2019.2467DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6659157PMC
September 2019

Predictors of operative mortality among cardiac surgery patients with prolonged ventilation.

J Card Surg 2019 Sep 3;34(9):759-766. Epub 2019 Jul 3.

Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland.

Background: Prolonged ventilation after cardiac surgery affects survival and increases morbidity. Previous studies have focused on predicting this complication preoperatively; however, indicators of poor outcome in those requiring prolonged ventilation remain ill-defined. We sought to identify predictors of operative mortality in cardiac surgery patients who experience prolonged mechanical ventilation.

Methods: 1698 patients who underwent cardiac surgery (CAB, aortic valve replacement ± CAB, or mitral valve repair/replacement ± CAB) required prolonged postoperative mechanical ventilation (>24 hours) between 2012 to 2016 in a statewide consortium. Perioperative factors were evaluated to identify the association with operative mortality. Covariates were selected through bootstrap aggregation to fit multivariable logistic regression models. The relative strength of association was determined by the Wald chi-square statistic.

Results: Median patient age was 68 years [IQR 61 to 76], 38% (644/1,698) were female, median duration of mechanical ventilation was 65 hours [IQR 38 to 143], median STS predicted risk of mortality was 3.1% [IQR 1.4 to 6.9%], and 15.7% (266/1698) suffered operative mortality. Among preoperative and operative characteristics, patient age and intraoperative initiation of extracorporeal membrane oxygenation (ECMO) were the strongest correlates of operative mortality on the multivariate analysis. Among postoperative factors, cardiac arrest and renal failure requiring dialysis were the strongest predictors of risk-adjusted operative mortality. Type of operation or surgical center had no association to mortality after risk adjustment.

Conclusion: Prolonged ventilation following cardiac surgery is associated with a five-fold increase in operative mortality. In these patients, operative mortality is associated with older age, intraoperative initiation of ECMO, postoperative cardiac arrest, and renal failure requiring dialysis.
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http://dx.doi.org/10.1111/jocs.14118DOI Listing
September 2019

Commentary: Nighttime stars: Intensivist coverage and cardiac surgical outcomes.

J Thorac Cardiovasc Surg 2020 04 16;159(4):1376-1377. Epub 2019 May 16.

Division of Cardiac Surgery, Department of Surgery, The Johns Hopkins Medical Institutions, Baltimore, Md. Electronic address:

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http://dx.doi.org/10.1016/j.jtcvs.2019.04.078DOI Listing
April 2020

Utilization and outcomes of early respiratory support in 6.5 million acute heart failure hospitalizations.

Eur Heart J Qual Care Clin Outcomes 2020 01;6(1):72-80

Department of Medicine, Johns Hopkins University School of Medicine, 4940 Eastern Ave, Baltimore, MD 21224, USA.

Aims: The incidence and outcomes of a requirement for non-invasive ventilation (NIV) or invasive mechanical ventilation (IMV) in acute heart failure (AHF) hospitalization are not clearly established. Thus, we aimed to characterize the incidence and trends in use of IMV and NIV in AHF and to estimate the magnitude of hazard for mortality associated with requiring IMV and NIV in AHF.

Methods And Results: We used the National Inpatient Sample (NIS) to identify AHF hospitalizations between 2008 and 2014. The exposure variable of interest was IMV or NIV use within 24 h of hospital admission compared to no respiratory support. We analysed the association between ventilation strategies and in-hospital mortality using Cox proportional hazards models adjusting for demographics and comorbidities. We included 6 534 675 hospitalizations for AHF. Of these, 271 589 (4.16%) included NIV and 51 459 (0.79%) included IMV within the first 24 h of hospitalization and rates of NIV and IMV use increased over time. In-hospital mortality for AHF hospitalizations including NIV was 5.0% and 27% for IMV compared with 2.1% for neither (P < 0.001 for both). In an adjusted model, requirement for NIV was associated with over two-fold higher risk for in-hospital mortality [hazard ratio (HR) 2.10, 95% confidence interval (CI) 2.01-2.19; P < 0.001] and requirement for IMV was associated with over three-fold higher risk for in-hospital mortality (HR 3.39, 95% CI 3.14-3.66; P < 0.001).

Conclusion: Respiratory support is used in many AHF hospitalizations, and AHF patients who require respiratory support are at high risk for in-hospital mortality. Our work should inform prospective intervention trials and quality improvement ventures in this high-risk population.
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http://dx.doi.org/10.1093/ehjqcco/qcz030DOI Listing
January 2020

Response.

Chest 2019 06;155(6):1315-1316

Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD.

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http://dx.doi.org/10.1016/j.chest.2019.03.002DOI Listing
June 2019

Epidemiology of Shock in Contemporary Cardiac Intensive Care Units.

Circ Cardiovasc Qual Outcomes 2019 03;12(3):e005618

Critical Care Medicine Department, National Institutes of Health Clinical Center and Cardiovascular Branch, National Heart, Lung, and Blood Institute, of the National Institutes of Health, Bethesda, MD (M.A.S.).

Background Clinical investigations of shock in cardiac intensive care units (CICUs) have primarily focused on acute myocardial infarction (AMI) complicated by cardiogenic shock (AMICS). Few studies have evaluated the full spectrum of shock in contemporary CICUs. Methods and Results The Critical Care Cardiology Trials Network is a multicenter network of advanced CICUs in North America. Anytime between September 2017 and September 2018, each center (n=16) contributed a 2-month snap-shot of all consecutive medical admissions to the CICU. Data were submitted to the central coordinating center (TIMI Study Group, Boston, MA). Shock was defined as sustained systolic blood pressure <90 mm Hg with end-organ dysfunction ascribed to the hypotension. Shock type was classified by site investigators as cardiogenic, distributive, hypovolemic, or mixed. Among 3049 CICU admissions, 677 (22%) met clinical criteria for shock. Shock type was varied, with 66% assessed as cardiogenic shock (CS), 7% as distributive, 3% as hypovolemic, 20% as mixed, and 4% as unknown. Among patients with CS (n=450), 30% had AMICS, 18% had ischemic cardiomyopathy without AMI, 28% had nonischemic cardiomyopathy, and 17% had a cardiac cause other than primary myocardial dysfunction. Patients with mixed shock had cardiovascular comorbidities similar to patients with CS. The median CICU stay was 4.0 days (interquartile range [IQR], 2.5-8.1 days) for AMICS, 4.3 days (IQR, 2.1-8.5 days) for CS not related to AMI, and 5.8 days (IQR, 2.9-10.0 days) for mixed shock versus 1.9 days (IQR, 1.0-3.6) for patients without shock ( P<0.01 for each). Median Sequential Organ Failure Assessment scores were higher in patients with mixed shock (10; IQR, 6-13) versus AMICS (8; IQR, 5-11) or CS without AMI (7; IQR, 5-11; each P<0.01). In-hospital mortality rates were 36% (95% CI, 28%-45%), 31% (95% CI, 26%-36%), and 39% (95% CI, 31%-48%) in AMICS, CS without AMI, and mixed shock, respectively. Conclusions The epidemiology of shock in contemporary advanced CICUs is varied, and AMICS now represents less than one-third of all CS. Despite advanced therapies, mortality in CS and mixed shock remains high. Investigation of management strategies and new therapies to treat shock in the CICU should take this epidemiology into account.
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http://dx.doi.org/10.1161/CIRCOUTCOMES.119.005618DOI Listing
March 2019

Complications and Outcomes of Temporary Transvenous Pacing: An Analysis of > 360,000 Patients From the National Inpatient Sample.

Chest 2019 04 10;155(4):749-757. Epub 2018 Dec 10.

Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD.

Background: The incidence of complications and the outcomes of temporary transvenous pacemaker (TTP) placement in the modern era are not well established.

Methods: To determine the current incidence of pericardial complications and the outcomes of patients undergoing TTP, we performed an analysis using the National Inpatient Sample (NIS), which is a US national database of hospital admissions. All patients who underwent TTP were identified by using International Classification of Diseases, Ninth Revision, Clinical Modification codes. A multivariate logistic regression model was constructed for a primary outcome of pericardial tamponade and another for a primary outcome of in-hospital mortality.

Results: A total of 360,223 patients underwent TTP placement in the United States between 2004 and 2014. In-hospital mortality was 14.1%, and 37.9% later underwent permanent pacemaker implantation. Potential procedural complications included pericardial tamponade in 0.6% of patients, pneumothorax in 0.9% of patients, and non-pericardial bleeding in 2.4% of patients. In adjusted models, female sex (OR, 1.33 [95% CI, 1.09-1.64]; P = .005), in-hospital cardiac arrest (OR, 3.52 [95% CI, 2.76-4.48]; P < .001), teaching hospital status (OR, 1.91 [95% CI, 1.53-2.40]; P < .001), and previous coronary artery bypass grafting (OR, 0.26 [95% CI, 0.14-0.49]; P < .001) were associated with tamponade. Following multivariate adjustment, pericardial tamponade complicating TTP insertion was associated with a fivefold increase in risk for in-hospital death (OR, 5.00 [95% CI, 2.51-9.96]; P < .001).

Conclusions: TTP placement is generally safe with low pericardial complication rates. Clinicians should be mindful of infrequent but serious complications of TTP, and strategies to mitigate pericardial tamponade and other complications should be sought and implemented.
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http://dx.doi.org/10.1016/j.chest.2018.11.026DOI Listing
April 2019