Cardiac Intensive Care Unit Mortality Research Articles

Standardizing the diagnosis of necrotizing enterocolitis in infants with congenital heart disease.

This quality improvement initiative aimed to standardize the diagnosis of necrotizing enterocolitis (NEC) in infants with congenital heart disease (CHD). A multidisciplinary team developed clinical practice guidelines for thediagnosis and treatment of NEC within the Cardiac Intensive Care Unit (CICU). The diagnosis rate of NEC per 100 at-risk admissions was the primary outcome measure. NEC order set usage was employed as a process measure, and the balancing measures monitored were CICU length of stay (LOS) and mortality. After guideline development and implementation, the diagnosis rate of NEC decreased from 3% to 1%, sustained over three years. The EMR order set enabled guideline integration into daily workflow. No change was noted in CICU LOS or mortality. Guideline implementation standardized the diagnosis of NEC in infants with CHD. Establishing a standardized definition and subsequent treatment regimen has enabled us to provide more consistent and appropriate care.

Global longitudinal strain as a predictor of mortality in patients with cardiogenic shock

Abstract Funding Acknowledgements Type of funding sources: Foundation. Main funding source(s): Aarhus University Dagmar Marshalls Fond. Background The assessment of left ventricular (LV) function through transthoracic echocardiography (TTE) is essential for guiding diagnosis and treatment in cases of cardiogenic shock (CS). Myocardial global longitudinal strain (GLS) provides an objective and reproducible measure of systolic function, independently predicting outcomes in acute heart failure, regardless of left ventricular ejection fraction (LVEF). However, whether assessment of GLS can predict mortality in patients with CS remains unknown. Purpose In this study, we aimed to evaluate the prognostic significance of GLS in patients with CS. Methods Data from cardiac intensive care unit (CICU) patients admitted between 2007 and 2018 with CS who received vasoactive agents and/or mechanical circulatory support were analysed. GLS (as absolute values) and biplane LVEF were measured via TTE performed within 24 hours of CICU admission. Patients with CS were categorised based on the GLS quartile: mild (GLS >9.7%), moderate (7.0% < GLS <9.6%), severe (5.0% < GLS < 6.9%), and very severe (GLS ≤ 4.9%). CICU and in-hospital mortality were compared across GLS categories, and the relationship between GLS and mortality was assessed using multivariable logistic regression. Results The study included 626 patients with a median age of 68.6 years, a median LVEF of 31% (IQR 24 to 40%), and a median GLS of 7.0% (IQR 5.0 to 9.7%). In-hospital mortality was 29.1%. As GLS deteriorated, there was an increasing need for vasopressors (P<0.001). Patients with progressively lower GLS exhibited significantly higher CICU and in-hospital mortality across the GLS quartiles (Figure A; P<0.001). Patients in the severe (adjusted OR 2.67; p<0.001) and very severe category (adjusted OR 3.54; P<0.001) had significantly increased risk of in-hospital death compared with mild category. In multivariable analysis, every 1% decrease in GLS corresponded to a 14% higher risk of in-hospital mortality (P<0.001). Finally, GLS outperformed LVEF for discrimination of in-hospital mortality (P=0.002), and when both measurements were included in the same multivariable model, only GLS remained significant. When patients were divided according to whether they had GLS and/or LVEF below the median value, patients with low GLS had higher mortality irrespective of the LVEF (Figure B). Conclusion In patients with CS, GLS assessment surpasses LVEF in its prognostic value and improves risk stratification. Routine evaluation of GLS should be considered for patients with CS.Figure AFigure B

Higher mortality among off-hours versus regular-hours admissions to the cardiac intensive care unit (CICU): insights from the critical care cardiology trials network registry (CCCTN)

Abstract Funding Acknowledgements None. Background The outcomes of patients admitted to general intensive care units vary significantly according to the time of admission. Whether this applies to the CICU setting is unknown. Purpose We sought to determine if patient characteristics, admission source, critical care therapy utilization, and clinical outcomes differ according to whether CICU admission occurred during regular-hours or off-hours. Methods CCCTN is a multicenter prospective registry of consecutive admissions to CICUs in North America coordinated by the TIMI Study Group. For this analysis of admissions during calendar year 2022, "regular-hours" was defined as 7 a.m.- 7 p.m. Monday-Friday, and "off-hours" was defined as 7 p.m.- 7 a.m. on weekdays or at any time on Saturday or Sunday. Logistic regression analysis was used to adjust in-hospital mortality rates for admission time (on-hours vs. off-hours), age, sex, SOFA score, and cardiac arrest. Results Among 5238 CICU admissions, 2956 (56.4%) occurred during off-hours. Patient demographics (mean age: 67.0 years, 35.7% female, 51.1% white) and comorbidities were generally similar among off-hours and regular-hours admissions. The median SOFA score was 3.0 in both groups. Compared to regular-hours admissions, off-hours admissions were more likely to originate from the ED (39.9% vs. 29.4%, p<0.0001) and less likely to originate from a procedural area (24.5% vs. 41.8%, p<0.0001). ST-elevation MI was a more common admission diagnosis among off-hours vs. regular-hours admissions (19.2% vs. 16.4%, p=0.009). Primary CICU indications of respiratory insufficiency, unstable arrhythmia, cardiac arrest, and distributive/mixed shock were more common among off-hours admissions (Table). Mechanical ventilation, IV vasoactive therapy, and targeted temperature management (TTM) were utilized more frequently among patients admitted during off-hours. Median ICU (2.5 vs. 2.0d) and hospital length of stay (6.2 vs. 5.8d) were longer for off-hours admissions (both p<0.0001). Crude CICU mortality (11.4% vs. 8.5%, p=0.0005) and in-hospital mortality (15.6% vs. 11.7%, p<0.0001) were significantly higher among off-hours admissions (Figure). After adjustment, off-hours admission remained significantly associated with higher in-hospital mortality (OR 1.2, 95% CI 1.02 – 1.49, p=0.03). Conclusions Off-hours and regular-hours admissions to the CICU had similar baseline characteristics but differed significantly regarding source of admission, indication for admission, and utilization of critical care therapies. These differences were associated with worse clinical outcomes among off-hours admissions, which may suggest the need for more intensive staffing in CICUs during these times.FigureTable

Early Serial Assessment of Aggregate Vasoactive Support and Mortality in Cardiogenic Shock: Insights From the Critical Care Cardiology Trials Network Registry.

Associations of early changes in vasoactive support with cardiogenic shock (CS) mortality remain incompletely defined. The Critical Care Cardiology Trials Network is a multicenter registry of cardiac intensive care units. Patients admitted with CS (2018-2023) had vasoactive dosing assessed at 4 and 24 hours from cardiac intensive care unit admission and quantified by the vasoactive-inotropic score (VIS). Prognostic associations of VIS at both time points, as well as change in VIS from 4 to 24 hours, were examined. Interaction testing was performed based on mechanical circulatory support status. Among 3665 patients, 82% had a change in VIS <10, with 7% and 11% having a ≥10-point increase and decrease from 4 to 24 hours, respectively. The 4 and 24-hour VIS were each associated with cardiac intensive care unit mortality (13%-45% and 11%-73% for VIS <10 to ≥40, respectively; Ptrend <0.0001 for each). Stratifying by the 4-hour VIS, changes in VIS from 4 to 24 hours had a graded association with mortality, ranging from a 2- to >4-fold difference in mortality comparing those with a ≥10-point increase to ≥10-point decrease in VIS (Ptrend <0.0001). The change in VIS alone provided good discrimination of cardiac intensive care unit mortality (C-statistic, 0.72 [95% CI, 0.70-0.75]) and improved discrimination of the 24-hour Sequential Organ Failure Assessment score (0.72 [95% CI, 0.69-0.74] to 0.76 [95% CI, 0.74-0.78]) and the clinician-assessed Society for Cardiovascular Angiography and Interventions shock stage (0.72 [95% CI, 0.70-0.74] to 0.77 [95% CI, 0.75-0.79]). Although present in both groups, the mortality risk associated with VIS was attenuated in patients managed with versus without mechanical circulatory support (odds ratio per 10-point higher 24-hour VIS, 1.36 [95% CI, 1.23-1.49] versus 1.84 [95% CI, 1.69-2.01]; Pinteraction <0.0001). Early changes in the magnitude of vasoactive support in CS are associated with a gradient of risk for mortality. These data suggest that early VIS trajectory may improve CS prognostication, with the potential to be leveraged for clinical decision-making and research applications in CS.

Abstract 12925: MICU Overflow Patients in the Cardiac Intensive Care Unit: Insights From the Critical Care Cardiology Trials Network Registry

Background: The cardiac intensive care unit (CICU) is designed to manage critically ill patients (pts) with acute cardiovascular (CV) conditions, but may be the site of care for pts with non-CV critical illness when medical ICU (MICU) beds are unavailable. Methods: The Critical Care Cardiology Trials Network (CCCTN) is a multicenter registry of consecutive admissions to CICUs in North America coordinated by the TIMI Study Group. Pts with no acute or major cardiac issues were designated as MICU overflow and were compared to those admitted with acute CV illness. A generalized mixed-effect regression model was used to adjust for age, sex, Sequential Organ Failure Assessment (SOFA) score and cardiac arrest while accounting for variability among centers. Results: Among 18,006 CICU admissions, 778 (4.3%) were MICU overflow, with a range of 0% to 26% among centers. MICU overflow rates trended lower over time (Fig-A) . In comparison to admissions with acute CV illness, MICU overflow patients were younger (60.0 vs 67.0 y, p&lt;0.001) and more likely to be female (45.6 vs 36.7%, p&lt;0.001). Comorbidities differed markedly between the 2 groups (Fig-B) . Presentation with cardiac arrest was more common among admissions with acute CV illness (12.9% vs 4.5%, p&lt;0.001). MICU overflow admissions had higher SOFA scores than those with acute CV illness (5.0 vs 3.0, p&lt;0.001). Resource utilization is shown in Fig-C . ICU LOS was similar (2.0 vs 2.2d, p=0.4). MICU overflow status was associated with a trend in CICU mortality (adj-OR 1.19, 95% CI 0.93-1.53, p=0.16) and significantly higher hospital mortality (adj-OR 1.69, 95% CI 1.36-1.73, p&lt;0.001) (Fig-D) . Conclusions: MICU overflow pts constitute a meaningful number of admissions to CICUs. These pts have more multi-system disease, greater baseline organ dysfunction, and higher hospital mortality than pts with acute CV illness. These findings reinforce the need for multidisciplinary CICU teams with expertise in all facets of critical care.

Characteristics, therapies, and outcomes of In-Hospital vs Out-of-Hospital cardiac arrest in patients presenting to cardiac intensive care units: From the critical care Cardiology trials network (CCCTN)

BackgroundCardiac arrest (CA) is a common reason for admission to the cardiac intensive care unit (CICU), though the relative burden of morbidity, mortality, and resource use between admissions with in-hospital (IH) and out-of-hospital (OH) CA is unknown. We compared characteristics, care patterns, and outcomes of admissions to contemporary CICUs after IHCA or OHCA. MethodsThe Critical Care Cardiology Trials Network is a multicenter network of tertiary CICUs in the US and Canada. Participating centers contributed data from consecutive admissions during 2-month annual snapshots from 2017 to 2021. We analyzed characteristics and outcomes of admissions by IHCA vs OHCA. ResultsWe analyzed 2,075 admissions across 29 centers (50.3% IHCA, 49.7% OHCA). Admissions with IHCA were older (median 66 vs 62 years), more commonly had coronary disease (38.3% vs 29.7%), atrial fibrillation (26.7% vs 15.6%), and heart failure (36.3% vs 22.1%), and were less commonly comatose on CICU arrival (34.2% vs 71.7%), p < 0.001 for all. IHCA admissions had lower lactate (median 4.3 vs 5.9) but greater utilization of invasive hemodynamics (34.3% vs 23.6%), mechanical circulatory support (28.4% vs 16.8%), and renal replacement therapy (15.5% vs 9.4%); p < 0.001 for all. Comatose IHCA patients underwent targeted temperature management less frequently than OHCA patients (63.3% vs 84.9%, p < 0.001). IHCA admissions had lower unadjusted CICU (30.8% vs 39.0%, p < 0.001) and in-hospital mortality (36.1% vs 44.1%, p < 0.001). ConclusionDespite a greater burden of comorbidities, CICU admissions after IHCA have lower lactate, greater invasive therapy utilization, and lower crude mortality than admissions after OHCA.

C52 THE BIG FOUR: RESPIRATORY FAILURE, RENAL INSUFFICIENCY, HAEMORRHAGE AND SEPSIS, HOW DO THEY IMPACT ON CICU PATIENT?

Abstract Background The current rise in life expectancy in the general population leads to changes in baseline characteristics of Cardiac Intensive Care Unit (CICU) patients, increasing the risk of non–cardiac complications during the hospitalization. Objectives Evaluate epidemiology and prognostic impact of major non–cardiac complications (respiratory failure, renal insufficiency, haemorrhage and sepsis) during CICU stay. Methods: Retrospective analysis of CICU patients at Ospedale Maggiore of Bologna between March and November 2021. Results Baseline characteristics, cardiovascular risk factors and comorbidities of the patients are reported in Table 1. During the CICU stay, 19.7% of patients suffered from acute respiratory failure, needing for ventilation; 15.0% had renal insufficiency (considered as need for haemodialysis, glomerular filtration rate according to Cockcroft–Gault &amp;lt; 60 ml/min, serum creatinine rise &amp;gt; 25% from baseline); 1.8% reported major haemorrhages (defined as serum haemoglobin &amp;lt; 8 g/dl or need for blood transfusion); 1.7% developed sepsis (positive blood cultures). Mean CICU stay for complicated patients was 6 days, intra–CICU mortality was 1.7% (8 deaths) and 30–days mortality was 7.0% (32 deaths). At univariate logistic regression analysis, acute respiratory failure was the only complication associated with a statistically relevant increase in 30–days mortality (OR 2.37, CI 95%, 1.05–5.34; p = 0.038), although, also the other complications had a negative prognostic effect: haemorrhage (OR 1.58, CI 95%, 1.77–14.16; p = 0.681), renal insufficiency (OR 1.47, CI 95%, 0.56–3.87; p = 0.432) and sepsis (OR 1.25, CI 95%, 0.33–5.87, p = 0.850). Conclusions Epidemiology and baseline characteristics of CICU patients are changing. Older age and frailty make non–cardiac complications more likely to happen. Acute respiratory failure has the worst prognostic effect on mortality. This fact suggests that CICU Cardiologists should improve their management of these major non–cardiac complications.

Shifting the Paradigm: A Quality Improvement Approach to Proactive Cardiac Arrest Reduction in the Pediatric Cardiac Intensive Care Unit.

Children with cardiac conditions are at higher risk of in-hospital pediatric cardiopulmonary arrest (CA), resulting in significant morbidity and mortality. Despite the elevated risk, proactive cardiac arrest prevention programs in the cardiac intensive care unit (CICU) remain underdeveloped. Our team developed a multidisciplinary program centered on developing a quality improvement (QI) bundle for patients at high risk of CA. This project occurred in a 26-bed pediatric CICU of a tertiary care children's hospital. Statistical process control methodology tracked changes in CA rates over time. The global aim was to reduce CICU mortality; the smart aim was to reduce the CA rate by 50% over 12 months. Interprofessional development and implementation of a QI bundle included visual cues to identify high-risk patients, risk mitigation strategies, a new rounding paradigm, and defined escalation algorithms. Additionally, weekly event and long-term data reviews, arrest debriefs, and weekly unit-wide dissemination of key findings supported a culture change. After bundle implementation, CA rates decreased by 68% compared to baseline and 45% from the historical baseline. Major complications decreased from 17.1% to 12.6% (P < 0.001) and mortality decreased from 5.7% to 5.0% (P = 0.048). These results were sustained for 30 months. Cardiac arrest is a modifiable, rather than inevitable, metric in the CICU. Reduction is achievable through the interprofessional implementation of bundled interventions targeting proactive CA prevention. Once incorporated into widespread efforts to engage multidisciplinary CICU stakeholders, these patient-focused interventions resulted in sustained improvement.

Cardiac Intensive Care Unit Admissions during COVID-19 Pandemic-A Single Center Experience.

AimThe impact of coronavirus disease 2019 (COVID-19) lockdown on cardiac emergency admissions to hospitals has been reported previously. We aimed to study the emergency room (ER) admissions to cardiac intensive care unit (CICU) at a tertiary care center during that period and compare this with admissions during the same time frame in the previous years.Materials and methodsThis is a retrospective observational study of patients admitted to the CICU during the pandemic period from March 22 to August 1 (inclusive) of 2020 and compared this with CICU admissions in the same time frame in the previous 2 years (2018 and 2019).ResultsDuring the study period in 2020, a total of 216 patients (age 59 ± 14 years) were admitted via ER, which is a 33% and 30% decline in admissions compared to 2019 (n = 322, age 63 ± 12 years) and 2018 (n = 307, age 62 ± 13), respectively. The decline in admissions with the primary diagnosis of acute coronary syndrome (ACS), acute decompensated heart failure, arrhythmia, and other diagnoses during the study period in 2020 were 27%, 38%, 62%, and 59%, respectively, while there was a 50% increase in acute pulmonary embolism admission compared to the mean admission in 2018 and 2019. Weekly admission rates gradually increased from less than 10 per week in the first 3 weeks to >15 by eighth week of the study period in 2020, while the trend was same throughout the study period in the previous 2 years. The CICU mortality rate in 2020 study period was 4.6% compared to 3.9% in 2018 (p = 0.83) and 5.6% in 2019 (p = 0.70). The in-hospital mortality of these patients was also similar in all 3 years (6.5%, 7.8%, and 7.9% in 2018, 2019, and 2020, respectively; p = 0.61).ConclusionOur study showed that CICU admissions during COVID-19 lockdown had declined compared to the previous years in a large tertiary center in India. Government and health organizations should educate the public early on during the pandemic about the consequences of ignoring other acute medical problems such as ACS, provide various measures for them to reach hospital early, and give reassurance with the best practices adopted in hospitals to avoid contracting the virus from the hospital environment.How to cite this articleYalamanchi R, Dasari BC, Narra L, Oomman A, Kumar P, Nayak R, et al. Cardiac Intensive Care Unit Admissions during COVID-19 Pandemic—A Single Center Experience. Indian J Crit Care Med 2020;24(11):1103–1105.

Sex differences in crude mortality rates and predictive value of intensive care unit-based scores when applied to the cardiac intensive care unit.

Limited data exists regarding sex differences in outcome and predictive accuracy of intensive care unit-based scoring systems when applied to cardiac intensive care unit patients. We reviewed medical records of patients admitted to cardiac intensive care unit from 1 January 2011-31 December 2016. Sex differences in mortality rates and the performance of intensive care unit-based scoring systems in predicting in-hospital mortality were analyzed. Calibration was assessed by the Hosmer-Lemeshow test and locally weighted scatterplot smoothing curves. Discrimination was assessed using the c statistic and receiver-operating characteristic curve. Among 6963 patients, 2713 (39%) were women. Overall in-hospital and cardiac intensive care unit mortality rates were similar in women and men (9.1% vs 9.4%, p=0.67 and 5.9% vs 6%, p=0.88, respectively) and in age and major diagnosis subgroups. Of the scoring systems, Acute Physiology and Chronic Health Evaluation III and Sequential Organ Failure Assessment had poor calibration (Hosmer-Lemeshow p value <0.001), while Simplified Acute Physiology Score II performed better (Hosmer-Lemeshow p value 0.09), in both women and men. All scores had good discrimination (C statistics >0.8). In the subgroups of acute myocardial infarction and heart failure patients, all scores had good calibration (Hosmer-Lemeshow p>0.001) and discrimination (C statistic >0.8) while in diagnosis subgroups with highest mortality, the calibration varied among scores and by sex, and discrimination was poor. No sex differences in mortality were seen in cardiac intensive care unit patients. The mortality predictive value of intensive care unit-based scores is limited in both sexes and variable among different subgroups of diagnoses.

Abstract 17185: Burden and Prognostic Significance of Thrombocytopenia in the Cardiac Intensive Care Unit: Insights From the Critical Care Cardiology Trials Network (CCCTN) Registry

Introduction: Thrombocytopenia is associated with poor outcomes in general medical intensive care unit (ICU) populations; however, the burden and prognostic significance of thrombocytopenia in cardiac ICU (CICU) populations have not been rigorously studied. Methods: The Critical Care Cardiology Trials Network (CCCTN) is an investigator-initiated multicenter network of CICUs (n=25) in North America. Consecutive admissions to the CICU during annual snapshots (mostly 2 months) were submitted to the coordinating center (TIMI Study Group, Boston, MA) between September 2017 and September 2019. Patients were stratified by platelet counts on admission to the CICU and nadir platelet counts. Thrombocytopenia was classified as mild (100-149 K/uL), moderate (50-99 K/uL), or severe (&lt;50 K/uL). Results: Of 8206 CICU admissions with complete laboratory data, 21.7% had thrombocytopenia (platelets &lt;150 K/uL) on admission and 38.4% had thrombocytopenia at any point during their CICU course ( Fig-left ). Among those with normal platelet counts on admission (n=6423), 21.3% developed thrombocytopenia during their CICU course. Patients with thrombocytopenia on admission were more likely to have active cancer, underlying liver disease, and CKD as compared to those who did not (each p&lt;0.001). Among patients with cardiogenic shock (n=1478), 56.8% had thrombocytopenia (mild: 28.6%; moderate: 19.4%; severe: 8.9%). Among patients managed with mechanical circulatory support (MCS) (n=926), 65.0% had thrombocytopenia (mild: 27.0%; moderate: 24.3%; severe: 13.7%). There were stepwise gradients of increasing CICU and in-hospital mortality associated with lower nadir platelet counts (p-trend &lt;0.001) ( Fig-right ). Conclusions: Thrombocytopenia is common in CICU patients, including more than half of patients with cardiogenic shock and those managed with MCS. Thrombocytopenia is an adverse prognostic marker in CICU patients.

Multidisciplinary team approach in acute myocardial infarction patients undergoing veno-arterial extracorporeal membrane oxygenation

BackgroundLimited data are available on the impact of a specialized extracorporeal membrane oxygenation (ECMO) team on clinical outcomes in patients with acute myocardial infarction (AMI) complicated by cardiogenic shock (CS). This study evaluated whether specialized ECMO team is associated with improved in-hospital mortality in AMI patients undergoing veno-arterial (VA) ECMO.MethodsA total of 255 AMI patients who underwent VA-ECMO were included. In January 2014, a multidisciplinary ECMO team was founded at our institution. Eligible patients were classified into a pre-ECMO team group (n = 131) and a post-ECMO team group (n = 124). The primary outcome was in-hospital mortality.ResultsIn-hospital mortality (pre-ECMO team vs. post-ECMO team, 54.2% vs. 33.9%; p = 0.002) and cardiac intensive care unit mortality (pre-ECMO team vs. post-ECMO team, 51.9% vs. 30.6%; p = 0.001) were significantly lower after the implementation of a multidisciplinary ECMO team. On multivariable logistic regression model, implementation of the multidisciplinary ECMO team was associated with reduction of in-hospital mortality [odds ratio: 0.37, 95% confidence interval (CI) 0.20–0.67; p = 0.001]. Incidence of all-cause mortality [58.3% vs. 35.2%; hazard ratio (HR): 0.49, 95% CI 0.34–0.72; p < 0.001) and readmission due to heart failure (28.2% vs. 6.4%; HR: 0.21, 95% CI 0.08–0.58; p = 0.003) at 6 months of follow-up were also significantly lower in the post-ECMO team group than in the pre-ECMO team group.ConclusionsImplementation of a multidisciplinary ECMO team was associated with improved clinical outcomes in AMI patients complicated by CS. Our data support that a specialized ECMO team is indispensable for improving outcomes in patients with AMI complicated by CS.

Epidemiology and Outcomes of Acute Decompensated Heart Failure in Children.

Acute decompensated heart failure (ADHF) is a highly morbid condition among adults. Little is known about outcomes in children with ADHF. We analyzed the Pediatric Cardiac Critical Care Consortium registry to determine the epidemiology, contemporary treatments, and predictors of mortality in critically ill children with ADHF. Cardiac intensive care unit (CICU) patients ≤18 years of age meeting Pediatric Cardiac Critical Care Consortium criteria for ADHF were included. ADHF was defined as systolic or diastolic dysfunction requiring continuous vasoactive or diuretic infusion, respiratory support, or mechanical circulatory support. Demographics, diagnosis, therapies, complications, and mortality are described for the cohort. Predictors of CICU mortality were identified using logistic regression. Among 26 294 consecutive admissions (23 centers), 1494 (6%) met criteria for analysis. Median age was 0.93 years (interquartile range, 0.1-9.3 years). Patients with congenital heart disease (CHD) comprised 57% of the cohort. Common therapies included the following: vasoactive infusions (88%), central venous catheters (86%), mechanical ventilation (59%), and high flow nasal cannula (46%). Common complications were arrhythmias (19%), cardiac arrest (10%), sepsis (7%), and acute renal failure requiring dialysis (3%). Median length of CICU stay was 7.9 days (interquartile range, 3-18 days) and the CICU readmission rate was 22%. Overall, CICU mortality was 15% although higher for patients with CHD versus non-CHD (19% versus 11%; P<0.001). Independent risk factors associated with CICU mortality included age <30 days, CHD, vasoactive infusions, ventricular tachycardia, mechanical ventilation, sepsis, pulmonary hypertension, extracorporeal membrane oxygenation, and cardiac arrest. ADHF in children is characterized by comorbidities, high mortality rates, and frequent readmission, especially among patients with CHD. Opportunities exist to determine best practices around appropriate use of mechanical support, cardiac arrest prevention, and optimal heart transplantation candidacy to improve outcomes for these patients.

Influence of cardiac arrest and SCAI shock stage on cardiac intensive care unit mortality.

Patients with concomitant cardiac arrest (CA) and shock are at increased risk of mortality, even when stratified according to shock severity. We sought to determine whether the presence of ventricular fibrillation (VF) modified the relationship between CA and mortality in cardiac intensive care unit (CICU) patients. We retrospectively analyzed unique Mayo Clinic CICU patients admitted between 2007 and 2015. Society for Cardiovascular Angiography and Intervention (SCAI) shock stages A through E were classified at admission. Hospital mortality in each SCAI shock stage was stratified by the presence of CA, VF CA, or non-VF CA. We included 9,898 patients with a mean age of 68 years (38% females). CA was present in 12%, including 53% with VF CA and 47% with non-VF CA. Hospital mortality was higher in patients with CA compared to patients without CA (34% vs. 6%; adjusted odds ratio [OR] = 3.1, 95% CI [2.4, 4.0], p < .001), and patients with non-VF CA had higher hospital mortality than patients with VF CA (44% vs. 25%; adjusted OR = 2.1, 95% CI [1.4, 3.0], p < .001). After adjustment, patients with any CA or non-VF CA had higher hospital mortality at each SCAI stage, except stage E (all other p < .05), whereas patients with VF CA did not (all p > .1). CA rhythm modifies the relationship between CA and mortality in CICU patients, when accounting for coma, shock, and organ failure. Outcome studies examining CA in patients with cardiogenic shock need to account for important differences such as CA rhythm.

Abstract 417: The Prognostic Value of Lactate in Cardiac Intensive Care Unit Patients With and Without Cardiac Arrest

Introduction: Lactate is a known prognostic marker in critically ill patients, including patients with shock and cardiac arrest (CA). We sought to describe the association between admission lactate and hospital mortality in cardiac intensive care unit (CICU) patients, particularly those with CA. Methods: We retrospectively evaluated adult patients admitted to a tertiary care CICU from January 1, 2007, to April 30, 2018, with measured lactate on admission. We examined hospital mortality as a function of admission lactate level in patients with and without CA. Multivariable logistic regression was used to determine predictors of hospital mortality in the overall cohort, after adjustment for clinical characteristics, therapies, and illness severity. Results: We included 3,042 patients with a median age of 70 years (IQR 60-80), including 40.5% (n=1,233) females. There were 789 patients (26.1%) with a diagnosis of CA. The median APACHE-4 predicted mortality was 24.2% (IQR 10.9-50.7), and 50.8% (n=1546) were treated with vasoactive infusions. The median lactate on admission was 1.8 mmol/L (IQR 1.1-3.0). CICU mortality occurred in 478 (15.7%) patients) and hospital mortality occurred in 706 (23.2%) patients. Hospital mortality rose progressively as a function of admission lactate ( Figure ). On univariable analysis, lactate was associated with increased hospital mortality among the overall cohort (OR 1.36, CI 1.31-1.42, P &lt; .001; AUROC 0.71), patients with CA (OR 1.33 (95% CI 1.25-1.41, P &lt; .01; AUROC 0.73), and patients without CA (OR 1.27, CI 1.21-1.34, P &lt; .01; AUROC 0.64). On multivariable analysis, lactate was one of the most significant predictors of hospital mortality (adjusted OR 1.13 per mmol/L, 95% CI 1.08-1.18, P &lt; .001). Conclusions: Admission lactate levels are strongly associated with increased hospital mortality among CICU patients, especially those with CA. The prognostic value of lactate levels may help inform clinicians caring for CICU patients.

P1711The association of multidisciplinary team approach with clinical outcomes in patients with acute myocardial infarction underwent veno-arterial extracorporeal membrane oxygenation

Abstract Background Multidisciplinary team approach is necessary for the management of critically-ill patients. However, limited data are available on the impact of specialized extracorporeal membrane oxygenation (ECMO) team on clinical outcomes in patients with acute myocardial infarction (AMI) complicated by cardiogenic shock. Objectives This study aimed to identify whether specialized ECMO team is associated with improved in-hospital mortality in AMI patients underwent venoarterial ECMO. Methods A total of 255 AMI patients underwent venoarterial ECMO from May 2004 to July 2018 were enrolled. In January 2014, multidisciplinary ECMO team was founded at our institution. Eligible patients were classified into pre-ECMO team group (n=131) and post-ECMO team group (n=124). The primary outcome was in-hospital mortality. Results In-hospital mortality (54.2% vs. 33.9%, p=0.002) and cardiac intensive care unit mortality (45.0% vs. 25.0%, p=0.001) were significantly lower after the implantation of multidisciplinary ECMO team (pre ECMO team vs. post-ECMO team). On binary logistic regression model, the multidisciplinary ECMO team approach was associated with lower risk of in-hospital mortality (odds ratio 0.36, 95% confidence interval 0.19–0.67, p=0.001). Incidence of all-cause mortality (58.3% vs. 35.2%, p&lt;0.001) and rehospitalization due to heart failure (28.2% vs. 6.4%, p=0.001) at 6-months follow-up were also significantly lower in the post-ECMO team group than in the pre-ECMO team group. Clinical outcomes Variables Total (N=255) Pre-ECMO team (N=131) Post-ECMO team (N=124) P value In-hospital mortality 113 (44.3) 71 (54.2) 42 (33.9) 0.002 Cardiovascular death 90 (35.3) 59 (45.0) 31 (25.0) 0.001 Noncardiovascular death 23 (9.0) 12 (9.2) 11 (8.9) &gt;0.99 Cardiac intensive care unit mortality 106 (41.6) 68 (51.9) 38 (30.6) 0.001 Successful weaning of ECMO 169 (66.3) 75 (57.3) 94 (75.8) 0.002 Data are presented as n (%). Abbreviations: ECMO, extracorporeal membrane oxygenation. Incidence of death, readmission for HF Conclusions The multidisciplinary ECMO team approach was associated with improved clinical outcomes in AMI patients complicated by cardiogenic shock. Our data support that specialized ECMO team is indispensable to improve outcomes in patients with AMI with refractory cardiogenic shock.

Demographics, Care Patterns, and Outcomes of Patients Admitted to Cardiac Intensive Care Units

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. To characterize patients admitted to contemporary, advanced CICUs. 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. Demographics, diagnoses, management, and outcomes. 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%. 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.

Prognostic Value of Admission Blood Glucose Level in Critically Ill Patients Admitted to Cardiac Intensive Care Unit according to the Presence or Absence of Diabetes Mellitus.

BackgroundAdmission blood glucose (BG) level is a predictor of mortality in critically ill patients with various conditions. However, limited data are available regarding this relationship in critically ill patients with cardiovascular diseases according to diabetic status.MethodsA total of 1,780 patients (595 with diabetes) who were admitted to cardiac intensive care unit (CICU) were enrolled from a single center registry. Admission BG level was defined as maximal serum glucose level within 24 hours of admission. Patients were divided by admission BG level: group 1 (< 7.8 mmol/L), group 2 (7.8–10.9 mmol/L), group 3 (11.0–16.5 mmol/L), and group 4 (≥ 16.6 mmol/L).ResultsA total of 105 patients died in CICU (62 non-diabetic patients [5.2%] and 43 diabetic patients [7.9%]; P = 0.105). The CICU mortality rate increased with admission BG level (1.7%, 4.8%, 10.3%, and 18.8% from group 1 to group 4, respectively; P < 0.001). On multivariable analysis, hypertension, mechanical ventilator, continuous renal replacement therapy, acute physiology and chronic health evaluation II (APACHE II) score, and admission BG level significantly influenced CICU mortality in non-diabetic patients (group 1 vs. group 3: hazard ratio [HR], 3.31; 95% confidence interval [CI], 1.47–7.44; P = 0.004; group 1 vs. group 4: HR, 6.56; 95% CI, 2.76–15.58; P < 0.001). However, in diabetic patients, continuous renal replacement therapy and APACHE II score influenced CICU mortality but not admission BG level.ConclusionAdmission BG level was associated with increased CICU mortality in critically ill, non-diabetic patients admitted to CICU but not in diabetic patients.

Length of Stay, Mortality, Cost, and Perceptions of Care Associated With Transition From an Open to Closed Staffing Model in the Cardiac Intensive Care Unit.

Organizational models in the intensive care unit (ICU) have classically been described as either closed or open, depending on the presence or absence of a dedicated ICU team. Although a closed model has been shown to improve patient outcomes in medical and surgical ICUs, the merits of various care models have not been previously explored in the cardiac ICU (CICU) setting. From November 2012 to March 2014, data were prospectively collected on all admissions before and after transition from an open to closed CICU at our institution. Baseline clinical variables, illness severity, admission and discharge diagnoses, resource use, and outcomes were recorded. Anonymous surveys were also collected from nursing and resident trainee participants to evaluate the influence of unit structure on perceptions of care. Descriptive statistics were used, and logistic regression modeling was performed to examine the impact of unit structure on mortality. The study consisted of 670 patients, 332 (49.6%) of whom were admitted to the open CICU model and 338 (50.4%) of whom were admitted to the closed model. Neither CICU nor hospital mortality differed between the open and closed units, though length of stay was shorter in the closed CICU. Additionally, nurses and resident trainees reported that the closed CICU allowed for better communication, collaboration, and education. Although there was no significant impact of unit structure on patient outcomes in this single-center study, the closed CICU model was associated with better perceptions of care.

Association Between Presence of a Cardiac Intensivist and Mortality in an Adult Cardiac Care Unit

BackgroundDedicated intensive care unit (ICU) physician staffing is associated with a reduction in ICU mortality rates in general medical and surgical ICUs. However, limited data are available on the role of a cardiac intensivist in the cardiac intensive care unit (CICU). ObjectivesThis study investigated the association of cardiac intensivist–directed care with clinical outcomes in adult patients admitted to the CICU. MethodsThis study analyzed 2,431 patients admitted to the CICU at Samsung Medical Center in Seoul, South Korea, from January 2012 to December 2015. In January 2013 the CICU was changed from a low-intensity staffing model to a high-intensity staffing model managed by a dedicated cardiac intensivist. Eligible patients were divided into either a low-intensity management group (n = 616) or a high-intensity management group (n = 1,815). One-to-many (1:N) propensity score matching with variable matching ratios was also performed. The primary outcome was death in the CICU. ResultsDeath in the CICU occurred in 55 patients (8.9%) in the low-intensity group versus 74 patients (4.1%) in the high-intensity group (p < 0.001). Of 135 patients who underwent extracorporeal membrane oxygenation, the CICU mortality rate in the high-intensity group was also lower than that in the low-intensity group (54.5% vs. 22.5%; p = 0.001). On propensity score matching, high-intensity staffing was found associated with a lower CICU mortality rate in the matched cohort of patients (7.5% vs. 3.7%; adjusted odds ratio: 0.53; 95% confidence interval: 0.32 to 0.86; p = 0.010). In overall and propensity-matched patients, there were no substantive differences in either median length of CICU stay or readmission rates between the 2 groups. ConclusionsThe presence of a dedicated cardiac intensivist was associated with a reduction in CICU mortality rates in patients with cardiovascular disease who required critical care.