ABSTRACT
Veno-venous extracorporeal membrane oxygenation (VV ECMO) has been used as a life-supporting modality for patients with severe respiratory failure because of coronavirus disease 2019 (COVID-19). We aim to evaluate the performance of the RESP score in predicting the hospital survival of COVID-19 patients undergoing VV ECMO. We performed retrospective analysis of the extracorporeal life support organization (ELSO) dataset for COVID-19 patients requiring ECMO support to evaluate the performance of RESP score in predicting in hospital survival. All adult (age ≥18) COVID-19 patients receiving VV ECMO for acute respiratory failure enrolled in the ELSO database from March to August 2020 were included in the analysis. A total of 1985 patients from the ELSO registry were identified and analyzed based on pre-ECMO variables. Median RESP score of survivors was 3 (IQR 1-5) compared to 2 (IQR 0-4) in deceased. A logistic model including RESP score variables poorly discriminated survival and death with AUC (area under curve) 0.61 (95% confidence interval: 0.59-0.64). In-hospital survival for COVID-19 patients based on RESP score class from I to V was 69.7%, 59.3%, 45.7%, 42.5%, and 32.3%, respectively. Patients with immunosuppression (relative risk = 0.43) and pre-ECMO cardiac arrest (relative risk = 0.48) had lower survival. RESP score is a poor predictor of survival in COVID-19 patients undergoing ECMO. Compared to the original cohort used for RESP score creation, COVID-19 patients in RESP class I-III had worse survival whereas the patients in RESP class IV-V had better survival.
Subject(s)
COVID-19 , Extracorporeal Membrane Oxygenation , Respiratory Distress Syndrome , Respiratory Insufficiency , Adult , COVID-19/therapy , Humans , Respiratory Insufficiency/therapy , Retrospective StudiesABSTRACT
BACKGROUND: Low voltage electrocardiography (ECG) coupled with increased ventricular wall thickness is the hallmark of cardiac amyloidosis. However, patient characteristics influencing voltage in the general population, including bundle branch block, have not been evaluated in amyloid heart disease. METHODS: A retrospective analysis was performed of patients with newly diagnosed cardiac amyloidosis from 2002 to 2014. ECG voltage was calculated using limb (sum of QRS complex in leads I, II and III) and precordial (Sokolow: S in V1 plus R in V5-V6) criteria. The associations between voltage and clinical variables were tested using multivariable linear regression. A Cox model assessed the association of voltage with mortality. RESULTS: In 389 subjects (transthyretin ATTR 186, light chain AL 203), 30% had conduction delay (QRS >120ms). In those with narrow QRS, 68% met low limb, 72% low Sokolow and 57% both criteria, with lower voltages found in AL vs ATTR. LV mass index as well as other typical factors that impact voltage (age, sex, race, hypertension, BSA, and smoking) in the general population were not associated with voltage in this cardiac amyloidosis cohort. Patients with LBBB and IVCD had similar voltages when compared to those with narrow QRS. Voltage was significantly associated with mortality (p<0.001 for both criteria) after multivariable adjustment. CONCLUSION: Classic predictors of ECG voltage in the general population are not valid in cardiac amyloidosis. In this cohort, the prevalence estimates of ventricular conduction delay and low voltage are higher than previously reported. Voltage predicts mortality after multivariable adjustment.
Subject(s)
Amyloidosis/complications , Electrocardiography/methods , Heart Diseases/diagnosis , Aged , Aged, 80 and over , Female , Heart Diseases/physiopathology , Humans , Male , Middle Aged , Proportional Hazards Models , Retrospective Studies , Risk FactorsABSTRACT
BACKGROUND: Light chain (AL) and transthyretin (ATTR) amyloidosis have a similar effect on myocardial function but very different disease trajectories and survival. However, limited data are available evaluating subtype-specific predictors of outcomes in a large contemporary cohort. METHODS AND RESULTS: We retrospectively investigated 360 patients at the time of initial diagnosis of cardiac amyloidosis (191 AL and 169 ATTR) from 2002 to 2014. Clinical, laboratory, electrical, and morphologic covariates were evaluated based upon amyloid subtype. ATTR etiology was associated with older age, more chronic medical conditions, and the use of standard heart failure medical therapy. Left ventricular mass index and electrocardiographic voltage were higher in ATTR, while there was no difference in ejection fraction or markers of diastology between subtypes. A multivariable Cox model was generated using previously identified predictors of negative outcomes in cardiac amyloidosis and analyzed after stratification for subsequent amyloid-specific treatment. An AL etiology was the most predictive variable (hazard ratio 3.143, P<0.001) of 3-year all-cause mortality. The only covariate that showed a significantly greater magnitude of effect on mortality in 1 amyloid subtype versus the other was amyloid-specific treatment in AL (P=0.015). The magnitude of effect of other variables on mortality did not significantly differ between subtypes. CONCLUSIONS: Clinical, morphological, electrical, and biomarker data do not significantly interact with amyloid subtype in its association with mortality, despite the fact that the prognosis in each subtype differs greatly. This suggests an additional factor or factors (such as light chain toxicity) contributing to poorer outcomes in AL amyloid.
