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1.
Intensive Care Med ; 48(1): 1-15, 2022 Jan.
Article in English | MEDLINE | ID: covidwho-1800370

ABSTRACT

Rates of survival with functional recovery for both in-hospital and out-of-hospital cardiac arrest are notably low. Extracorporeal cardiopulmonary resuscitation (ECPR) is emerging as a modality to improve prognosis by augmenting perfusion to vital end-organs by utilizing extracorporeal membrane oxygenation (ECMO) during conventional CPR and stabilizing the patient for interventions aimed at reversing the aetiology of the arrest. Implementing this emergent procedure requires a substantial investment in resources, and even the most successful ECPR programs may nonetheless burden healthcare systems, clinicians, patients, and their families with unsalvageable patients supported by extracorporeal devices. Non-randomized and observational studies have repeatedly shown an association between ECPR and improved survival, versus conventional CPR, for in-hospital cardiac arrest in select patient populations. Recently, randomized controlled trials suggest benefit for ECPR over standard resuscitation, as well as the feasibility of performing such trials, in out-of-hospital cardiac arrest within highly coordinated healthcare delivery systems. Application of these data to clinical practice should be done cautiously, with outcomes likely to vary by the setting and system within which ECPR is initiated. ECPR introduces important ethical challenges, including whether it should be considered an extension of CPR, at what point it becomes sustained organ replacement therapy, and how to approach patients unable to recover or be bridged to heart replacement therapy. The economic impact of ECPR varies by health system, and has the potential to outstrip resources if used indiscriminately. Ideally, studies should include economic evaluations to inform health care systems about the cost-benefits of this therapy.


Subject(s)
Cardiopulmonary Resuscitation , Extracorporeal Membrane Oxygenation , Out-of-Hospital Cardiac Arrest , Adult , Cardiopulmonary Resuscitation/methods , Cost-Benefit Analysis , Extracorporeal Membrane Oxygenation/methods , Humans , Out-of-Hospital Cardiac Arrest/therapy
2.
J Card Fail ; 27(3): 327-337, 2021 03.
Article in English | MEDLINE | ID: covidwho-1024961

ABSTRACT

BACKGROUND: Venoarterial extracorporeal membrane oxygenation (VA-ECMO) is increasingly used as a life-saving therapy for patients with cardiovascular collapse, but identifying patients unlikely to benefit remains a challenge. METHODS AND RESULTS: We created the RESCUE registry, a retrospective, observational registry of adult patients treated with VA-ECMO between January 2007 and June 2017 at 3 high-volume centers (Columbia University, Duke University, and Washington University) to describe short-term patient outcomes. In 723 patients treated with VA-ECMO, the most common indications for deployment were postcardiotomy shock (31%), cardiomyopathy (including acute heart failure) (26%), and myocardial infarction (17%). Patients frequently suffered in-hospital complications, including acute renal dysfunction (45%), major bleeding (41%), and infection (33%). Only 40% of patients (n = 290) survived to discharge, with a minority receiving durable cardiac support (left ventricular assist device [n = 48] or heart transplantation [n = 7]). Multivariable regression analysis identified risk factors for mortality on ECMO as older age (odds ratio [OR], 1.26; 95% confidence interval [CI], 1.12-1.42) and female sex (OR, 1.44; 95% CI, 1.02-2.02) and risk factors for mortality after decannulation as higher body mass index (OR 1.17; 95% CI, 1.01-1.35) and major bleeding while on ECMO support (OR, 1.92; 95% CI, 1.23-2.99). CONCLUSIONS: Despite contemporary care at high-volume centers, patients treated with VA-ECMO continue to have significant in-hospital morbidity and mortality. The optimization of outcomes will require refinements in patient selection and improvement of care delivery.


Subject(s)
Extracorporeal Membrane Oxygenation , Heart Failure , Adult , Aged , Extracorporeal Membrane Oxygenation/adverse effects , Female , Humans , Registries , Retrospective Studies , Shock, Cardiogenic/epidemiology , Shock, Cardiogenic/therapy
3.
Vasc Med ; 26(4): 426-433, 2021 08.
Article in English | MEDLINE | ID: covidwho-1166685

ABSTRACT

Coronavirus disease 2019 (COVID-19) may predispose patients to venous thromboembolism (VTE). Limited data are available on the utilization of the Pulmonary Embolism Response Team (PERT) in the setting of the COVID-19 global pandemic. We performed a single-center study to evaluate treatment, mortality, and bleeding outcomes in patients who received PERT consultations in March and April 2020, compared to historical controls from the same period in 2019. Clinical data were abstracted from the electronic medical record. The primary study endpoints were inpatient mortality and GUSTO moderate-to-severe bleeding. The frequency of PERT utilization was nearly threefold higher during March and April 2020 (n = 74) compared to the same period in 2019 (n = 26). During the COVID-19 pandemic, there was significantly less PERT-guided invasive treatment (5.5% vs 23.1%, p = 0.02) with a numerical but not statistically significant trend toward an increase in the use of systemic fibrinolytic therapy (13.5% vs 3.9%, p = 0.3). There were nonsignificant trends toward higher in-hospital mortality or moderate-to-severe bleeding in patients receiving PERT consultations during the COVID-19 period compared to historical controls (mortality 14.9% vs 3.9%, p = 0.18 and moderate-to-severe bleeding 35.1% vs 19.2%, p = 0.13). In conclusion, PERT utilization was nearly threefold higher during the COVID-19 pandemic than during the historical control period. Among patients evaluated by PERT, in-hospital mortality or moderate-to-severe bleeding were not significantly different, despite being numerically higher, while invasive therapy was utilized less frequently during the COVID-19 pandemic.


Subject(s)
COVID-19/therapy , Health Resources/trends , Health Services Needs and Demand/trends , Patient Care Team/trends , Practice Patterns, Physicians'/trends , Pulmonary Embolism/therapy , Thrombolytic Therapy/trends , Venous Thromboembolism/therapy , Adult , Aged , Aged, 80 and over , COVID-19/complications , COVID-19/diagnosis , COVID-19/mortality , Female , Hemorrhage/etiology , Hemorrhage/mortality , Hospital Mortality , Humans , Male , Middle Aged , Pulmonary Embolism/diagnosis , Pulmonary Embolism/etiology , Pulmonary Embolism/mortality , Retrospective Studies , Risk Assessment , Risk Factors , Time Factors , Treatment Outcome , Venous Thromboembolism/diagnosis , Venous Thromboembolism/etiology , Venous Thromboembolism/mortality
4.
ASAIO J ; 67(3): 245-249, 2021 03 01.
Article in English | MEDLINE | ID: covidwho-1005536

ABSTRACT

The coronavirus disease 2019 (COVID-19) pandemic has placed extraordinary strain on global healthcare systems. Use of extracorporeal membrane oxygenation (ECMO) for patients with severe respiratory or cardiac failure attributed to COVID-19 has been debated due to uncertain survival benefit and the resources required to safely deliver ECMO support. We retrospectively investigated adult patients supported with ECMO for COVID-19 at our institution during the first 80 days following New York City's declaration of a state of emergency. The primary objective was to evaluate survival outcomes in patients supported with ECMO for COVID-19 and describe the programmatic adaptations made in response to pandemic-related crisis conditions. Twenty-two patients with COVID-19 were placed on ECMO during the study period. Median age was 52 years and 18 (81.8%) were male. Twenty-one patients (95.4%) had severe ARDS and seven (31.8%) had cardiac failure. Fifteen patients (68.1%) were managed with venovenous ECMO while 7 (31.8%) required arterial support. Twelve patients (54.5%) were transported on ECMO from external institutions. Twelve patients were discharged alive from the hospital (54.5%). Extracorporeal membrane oxygenation was used successfully in patients with respiratory and cardiac failure due to COVID-19. The continued use of ECMO, including ECMO transport, during crisis conditions was possible even at the height of the COVID-19 pandemic.


Subject(s)
COVID-19/therapy , Extracorporeal Membrane Oxygenation/methods , Adolescent , Adult , Aged , COVID-19/mortality , Extracorporeal Membrane Oxygenation/mortality , Female , Humans , Male , Middle Aged , Retrospective Studies , SARS-CoV-2 , Standard of Care , Treatment Outcome , Young Adult
6.
J Thorac Cardiovasc Surg ; 162(1): 137-138, 2021 07.
Article in English | MEDLINE | ID: covidwho-783339
7.
Circ Heart Fail ; 13(9): e007516, 2020 09.
Article in English | MEDLINE | ID: covidwho-748835

ABSTRACT

The coronavirus disease 2019 (COVID-19) pandemic imposed severe restrictions on traditional methods of patient care. During the pandemic, the heart failure program at New York-Presbyterian Hospital in New York, NY rapidly and comprehensively transitioned its care delivery model and administrative organization to conform to a new healthcare environment while still providing high-quality care to a large cohort of patients with heart failure, heart transplantation, and left ventricular assist device. In addition to the widespread adoption of telehealth, our program restructured outpatient care, initiating a shared clinic model and introducing a comprehensive remote monitoring program to manage patients with heart failure and heart transplant. All conferences, including administrative meetings, support groups, and educational seminars were converted to teleconferencing platforms. Following the peak of COVID-19, many of the new changes have been maintained, and the program structure will be permanently altered as a lasting effect of this pandemic. In this article, we review the details of our program's transition in the face of COVID-19 and highlight the programmatic changes that will endure.


Subject(s)
Cardiology/organization & administration , Coronavirus Infections/epidemiology , Delivery of Health Care/organization & administration , Heart Failure/therapy , Pneumonia, Viral/epidemiology , Telemedicine/organization & administration , Advance Care Planning , Ambulatory Care/organization & administration , Betacoronavirus , COVID-19 , Heart Transplantation , Heart-Assist Devices , Humans , New York City/epidemiology , Nurse Practitioners , Pandemics , Physicians , Professional Role , SARS-CoV-2 , Self-Help Groups , Telecommunications , Tertiary Care Centers/organization & administration , Videoconferencing
8.
J Thorac Cardiovasc Surg ; 160(4): 937-947.e2, 2020 10.
Article in English | MEDLINE | ID: covidwho-649605

ABSTRACT

BACKGROUND: The onset of the coronavirus disease 2019 (COVID-19) pandemic has forced our cardiac surgery program and hospital to enact drastic measures that has forced us to change how we care for cardiac surgery patients, assist with COVID-19 care, and enable support for the hospital in terms of physical resources, providers, and resident training. METHODS: In this review, we review the cardiovascular manifestations of COVID-19 and describe our system-wide adaptations to the pandemic, including the use of telemedicine, how a severe reduction in operative volume affected our program, the process of redeployment of staff, repurposing of residents into specific task teams, the creation of operation room intensive care units, and the challenges that we faced in this process. RESULTS: We offer a revised set of definitions of surgical priority during this pandemic and how this was applied to our system, followed by specific considerations in coronary/valve, aortic, heart failure and transplant surgery. Finally, we outline a path forward for cardiac surgery for the near future. CONCLUSIONS: We recognize that individual programs around the world will eventually face COVID-19 with varying levels of infection burden and different resources, and we hope this document can assist programs to plan for the future.


Subject(s)
Academic Medical Centers/organization & administration , Betacoronavirus , Cardiac Surgical Procedures , Coronavirus Infections , Health Care Rationing , Health Services Accessibility/organization & administration , Pandemics , Perioperative Care/methods , Pneumonia, Viral , Adult , Betacoronavirus/isolation & purification , COVID-19 , Cardiac Surgical Procedures/trends , Cardiovascular Diseases/diagnosis , Cardiovascular Diseases/therapy , Cardiovascular Diseases/virology , Coronavirus Infections/complications , Coronavirus Infections/diagnosis , Coronavirus Infections/epidemiology , Coronavirus Infections/therapy , Female , Health Care Rationing/methods , Health Care Rationing/organization & administration , Humans , Infection Control/methods , Infection Control/organization & administration , Intensive Care Units/organization & administration , Male , Middle Aged , New York City/epidemiology , Operating Rooms/organization & administration , Patient Care Team/organization & administration , Personnel Staffing and Scheduling/organization & administration , Pneumonia, Viral/complications , Pneumonia, Viral/diagnosis , Pneumonia, Viral/epidemiology , Pneumonia, Viral/therapy , SARS-CoV-2 , Telemedicine/methods , Telemedicine/organization & administration
10.
Circ Heart Fail ; 13(7): e007220, 2020 07.
Article in English | MEDLINE | ID: covidwho-546317

ABSTRACT

The novel coronavirus disease 2019, otherwise known as COVID-19, is a global pandemic with primary respiratory manifestations in those who are symptomatic. It has spread to >187 countries with a rapidly growing number of affected patients. Underlying cardiovascular disease is associated with more severe manifestations of COVID-19 and higher rates of mortality. COVID-19 can have both primary (arrhythmias, myocardial infarction, and myocarditis) and secondary (myocardial injury/biomarker elevation and heart failure) cardiac involvement. In severe cases, profound circulatory failure can result. This review discusses the presentation and management of patients with severe cardiac complications of COVID-19 disease, with an emphasis on a Heart-Lung team approach in patient management. Furthermore, it focuses on the use of and indications for acute mechanical circulatory support in cardiogenic and/or mixed shock.


Subject(s)
Acute Coronary Syndrome/therapy , Arrhythmias, Cardiac/therapy , Coronavirus Infections/therapy , Heart Failure/therapy , Myocarditis/therapy , Pneumonia, Viral/therapy , Acute Coronary Syndrome/complications , Anti-Bacterial Agents/adverse effects , Antiviral Agents/therapeutic use , Arrhythmias, Cardiac/chemically induced , Arrhythmias, Cardiac/complications , Azithromycin/adverse effects , Betacoronavirus , COVID-19 , Cardiotonic Agents/therapeutic use , Chronic Disease , Coronavirus Infections/complications , Cytokine Release Syndrome/complications , Cytokine Release Syndrome/therapy , Enzyme Inhibitors/adverse effects , Extracorporeal Membrane Oxygenation , Heart Failure/etiology , Heart-Assist Devices , Humans , Hydroxychloroquine/adverse effects , Intra-Aortic Balloon Pumping , Myocardial Infarction/complications , Myocardial Infarction/therapy , Myocarditis/complications , Pandemics , Percutaneous Coronary Intervention , Pneumonia, Viral/complications , SARS-CoV-2 , Shock, Cardiogenic/etiology , Shock, Cardiogenic/therapy , Thromboembolism
11.
JACC Case Rep ; 2(9): 1391-1396, 2020 Jul 15.
Article in English | MEDLINE | ID: covidwho-436820

ABSTRACT

Severe acute respiratory syndrome coronavirus 2 is associated with a prothrombotic state in infected patients. After presenting a case of right ventricular thrombus in a patient with coronavirus disease-2019 (COVID-19), we discuss the unique challenges in the evaluation and treatment of COVID-19 patients, highlighting our COVID-19-modified pulmonary embolism response team algorithm. (Level of Difficulty: Beginner.).

12.
JAMA Cardiol ; 5(10): 1165-1169, 2020 10 01.
Article in English | MEDLINE | ID: covidwho-246328

ABSTRACT

Importance: Recipients of heart transplant (HT) may be at increased risk of adverse outcomes attributable to infection with coronavirus disease 2019 (COVID-19) because of multiple comorbidities and clinically significant immunosuppression. Objective: To describe the characteristics, treatment, and outcomes of recipients of HT with COVID-19. Design, Setting, and Participants: This case series from a single large academic heart transplant program in New York, New York, incorporates data from between March 1, 2020, and April 24, 2020. All recipients of HT followed up by this center who were infected with COVID-19 were included. Interventions: Heart transplant and a confirmed diagnosis of COVID-19. Main Outcomes and Measures: The primary measure was vital status at end of study follow-up. Secondary measures included patient characteristics, laboratory analyses, changes to immunosuppression, and treatment administered for COVID-19. Results: Twenty-eight patients with HT received a confirmed diagnosis of COVID-19. The median age was 64.0 (interquartile range [IQR], 53.5-70.5) years, 22 (79%) were men, and the median time from HT was 8.6 (IQR, 4.2-14.5) years. Comorbid conditions included hypertension in 20 patients (71%), diabetes in 17 patients (61%), and cardiac allograft vasculopathy in 16 patients (57%). Twenty-two participants (79%) were admitted for treatment, and 7 (25%) required mechanical ventilation. Most (13 of 17 [76%]) had evidence of myocardial injury (median high-sensitivity troponin T, 0.055 [IQR, 0.0205-0.1345] ng/mL) and elevated inflammatory biomarkers (median peak high-sensitivity C-reactive protein, 11.83 [IQR, 7.44-19.26] mg/dL; median peak interleukin 6, 105 [IQR, 38-296] pg/mL). Among patients managed at the study institution, mycophenolate mofetil was discontinued in 16 patients (70%), and 6 (26%) had a reduction in the dose of their calcineurin inhibitor. Treatment of COVID-19 included hydroxychloroquine (18 patients [78%]), high-dose corticosteroids (8 patients [47%]), and interleukin 6 receptor antagonists (6 patients [26%]). Overall, 7 patients (25%) died. Among 22 patients (79%) who were admitted, 11 (50%) were discharged home, 4 (18%) remain hospitalized at the end of the study, and 7 (32%) died during hospitalization. Conclusions and Relevance: In this single-center case series, COVID-19 infection was associated with a case fatality rate of 25% in recipients of HT. Immunosuppression was reduced in most of this group of patients. Further study is required to evaluate the optimal approach to management of COVID-19 infection in the HT population.


Subject(s)
COVID-19/mortality , Heart Transplantation , Hospitalization/statistics & numerical data , Transplant Recipients , Aged , Biomarkers/blood , C-Reactive Protein/analysis , COVID-19/therapy , Comorbidity , Female , Glucocorticoids/therapeutic use , Humans , Hydroxychloroquine/therapeutic use , Immunosuppressive Agents/administration & dosage , Interleukin-6/blood , Male , Middle Aged , New York City/epidemiology , Receptors, Interleukin-6/antagonists & inhibitors , Respiration, Artificial/statistics & numerical data , Retrospective Studies , Troponin T/blood
13.
Circulation ; 141(23): 1930-1936, 2020 06 09.
Article in English | MEDLINE | ID: covidwho-32308
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