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Hospitalization-Related Resource Utilization in Congenital Heart Disease with Advanced Heart Failure
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The Journal of Heart and Lung Transplantation, Vol 36, No 4S, April 2017
6( 90) Ventricular Arterial Coupling: A Novel Echocardiographic Risk Factor for Poor Outcome in PAtients with Acute Decompensated Heart Failure C.A. Capone , J. Lorenzo, B. Tria, S.S. Medar, S.I. Aydin, J.M. Lamour, D.T. Hsu, J. Mahgerefteh. The Children's Hospital of Montefiore-Albert Einstein College of Medicine, Bronx, NY. Purpose: A higher (VA) coupling ratio measured non-invasively has been well described in adult heart failure patients and is associated with worse heart failure prognosis and response to treatment, largely due to increases in arterial elastance. There is no data regarding the importance of VA coupling in pediatric patients with heart failure. Hypothesis: A higher VA coupling ratio will be associated with worse outcomes in pediatric patients admitted with acute decompensated heart failure (ADHF) on inotropes. Methods: Demographic, clinical and echocardiographic (echo) data (including ventricular volumes, arterial elastance and LV elastance) were obtained for children with ADHF and compared to a group of normal controls. The association of VA coupling ratio with worse outcome (mechanical circulatory support, transplant, or death) and inotrope score was assessed. Results: Echos from 15 patients with ADHF (7 DCM, 8 myocarditis) on inotropes were reviewed. Mean age at presentation was 7±7 years. At time of echo, mean NYHA class was 3.6±7.4 mean inotrope score was 6.8±4.6. Outcome events occurred in 8/15 patients (53%). Patients with ADHF, compared to normal controls, had a significantly lower LV elastance (1.3 ± 0.79 vs. 4.3 ±1.22, respectively p= 0.001) and higher VA coupling ratio (4.3±3.1 vs 0.7±0.2, respectively p= 0.001). There was no difference in arterial elastance between patients with ADHF and normal controls (4.1±2.44 vs 2.9±0.8 respectively p= 0.09). Among ADHF patients, those with poor outcomes had a lower LV elastance (0.9±0.51 vs. 1.7±0.84, respectively p= 0.06) and a higher VA coupling ratio (5.9±3.45 vs. 2.5±1.3, respectively p= 0.02). There was no difference in arterial elastance among those with poor outcomes (4.5±3.1 vs. 3.6±1.49, respectively p= 0.47). There was no correlation between arterial elastance or LV elastance with inotrope score (r= 0.17 and r= 0.56 respectively). Conclusion: A higher VA coupling ratio is significantly associated with worse outcome in pediatric ADHF patients. Unlike adult data, this mechanism is driven not by an increase in arterial elastance but a decrease in ventricular elastance. Arterial elastance is unchanged in ADHF and is unrelated to inotrope score. VA coupling may provide insight into the mechanisms of heart failure in pediatric heart failure and identify potential targets for therapy. 6( 91) Hospitalization-Related Resource Utilization in Congenital Heart Disease with Advanced Heart Failure D.S. Burstein ,1 P. Shamszad,1 C.S. Almond,2 J.F. Price,3 K.Y. Lin,1 M.J. O'Connor,1 R.E. Shaddy,1 C.E. Mascio,1 J.W. Rossano.1 1Pediatric Cardiology, Children's Hospital of Philadelphia, Philadelphia, PA; 2Pediatric Cardiology, Stanford Childrens Hospital, Palo Alto, CA; 3Pediatric Cardiology, Texas Children's Hospital, Houston, TX. Purpose: While advancements in the management of congenital heart disease (CHD) have improved overall mortality, advanced heart failure (AHF) remains a risk. Resource utilization associated with CHD-related AHF is unknown. We sought to test the hypothesis that resource utilization is high among pediatric patients with CHD and AHF and associated with comorbidities and advanced therapies. Methods: All hospitalizations in the Pediatric Health Information System database involving a CHD diagnosis between 2004 and 2015 were queried. Patients with AHF, defined as a diagnosis of heart failure and at least 7 days of continuous inotropic support, were identified. Results: Of 476,905 CHD hospitalizations, AHF was present in 6131 (1.3%) hospitalizations (72% infant, 55% male, 54% underwent cardiac surgery). Hospital length of stay (LOS) was longer in AHF than non-AHF (median 42d [IQR 23-79] vs. 6d [IQR 3-17]; p< 0.001), as was ICU LOS (30d [IQR 15-60] vs. 6d [2-19]; p< 0.001). Hospital charges were also higher in AHF (median $658k vs. $100k, p< 0.001) with the highest quartile of hospitalizations resulting in > $1.2m in charges per AHF hospitalization. Compared to non-AHF hospitalizations, laboratory charges were 40% higher, clinical charges were 62% higher and pharmacy charges were 77% higher in AHF hospitalizations. Among AHF hospitalizations, extracorporeal membrane
oxygenation was utilized in 18% with median charges of $1.2m (IQR $719k$2m) per hospitalization, cardiac transplantation was performed in 9% with median charges of $1.2m (IQR $715k-$2.1m) and a ventricular assist device was utilized in 3% with median charges of $1.9m (IQR $1.2m-$2.8m). Comorbidities in AHF also contributed to higher charges, including respiratory failure occuring in 32% (median charges $890k [IQR $471k-$1.7m]), sepsis in 31% (median charges $1.0m [IQR $583k-$1.8m]), acute renal failure in 24% (median charges $1.1m [IQR $608k-$1.9m]), and stroke in 8% (median charges $1.2m [IQR $640k-$2.3m]). Conclusion: CHD-related AHF is a high resource utilization cohort with most hospitalizations exceeding 1 month in duration and generating hospital charges in excess of $600,000, a more than 6-fold increase over the non-AHF cohort. As cost-effectiveness becomes an increasing driver in high-value care, ongoing study is needed to help optimize resource utilization. 6( 92) Peak Troponin I Is Associated with Death and Extracorporeal Membrane Oxygenation in Pediatric Myocarditis A. Butto ,1 J. Rossano,1 D. Nandi,2 C. Ravishankar,1 K.Y. Lin,1 M.J. O'Connor,1 R.E. Shaddy,1 P. Shamszad.1 1Division of Cardiology, Children's Hospital of Philadelphia, Philadelphia, PA; 2Cardiology, The Heart Center, Nationwide Children's Hospital, Columbus, OH. Purpose: Serum troponin (Tn) is often elevated in viral myocarditis (VM); however, its prognostic significance is unknown. We tested the hypothesis that abnormal serum Tn is associated with mortality or extracorporeal membrane oxygenation (ECMO) use in children hospitalized with VM. Methods: We retrospectively studied data from six large children’s hospitals participating in the Pediatric Health Information System Plus (PHIS+) database. Analysis was performed on patients hospitalized with VM between 2007 and 2013, in whom at least one Tn was recorded within 72 hours of admission. Abnormal Tn was defined as any value outside hospital-reported reference range. Outcome measures included mortality, ECMO, mechanical ventilation, and inotrope use. The relationship between outcome measures and abnormal or peak Tn were assessed by chi-squared test, Mann-Whitney U test, and logistic regression, as appropriate. Results: A total of 152 VM patients (58% male, 16% infant) across all six PHIS+ centers had TnI (n= 116) or TnT (n= 36) recorded. Median baseline and peak TnI were 1.76 ng/dl (IQR 0.33-11.03) and 2.84 ng/dl (IQR 0.4614.70), respectively. Mean time to peak TnI was 2.0 +/- 9.5 days. Median baseline and peak TnT were 0.27 ng/dl (IQR 0.02-1.08) and 0.41 ng/dl (IQR 0.02-1.20), respectively. Mean time to peak TnT was 1.2 +/- 2.0 days. Overall mortality was 7% and ECMO was used in 22%. At least one abnormal TnI or TnT was present in 81% of cases and was associated with higher use of ECMO (OR 4.5, 95% CI 1.02-20.24) and intravenous immunoglobulin (OR 4.4, 95%CI 1.9-10.6). Abnormal TnI or TnT was not associated with mechanical ventilation (p= 0.83) or inotrope use (p= 0.25). Peak TnI was greater among patients who either died or were supported with ECMO (median 4.35 ng/dl, IQR 1.28-30.24 vs. 2.08 ng/dl, IQR 0.37-12.37; p< 0.001). After adjusting for infant age and gender, there was a 1% increase in odds of mortality (OR 1.01, 95% CI 1.01-1.03) and a 1% increase in odds of ECMO use (OR 1.01, 95%CI 1.01-1.02) for each 1 ng/dl-unit increase in peak TnI. Peak TnT was not associated with death (p= 0.23) or ECMO (p= 0.09); however, small sample size limits interpretation of this data. Conclusion: Higher peak serum troponin I was associated with mortality and ECMO use in children hospitalized with viral myocarditis. This finding may help risk stratify this population if it can be prospectively validated. 6( 93) The Association of Carvedilol Use on Transplant Free Survival in Pediatric Patients with Dilated Cardiomyopathy: An Analysis from the Pediatric Cardiomyopathy Registry J.W. Rossano ,1 L.J. Addonizio,2 C.E. Canter,3 S.D. Colan,4 D.A. Dodd,5 M.D. Everitt,6 B. Harty,7 D. Hsu,8 J.L. Jefferies,9 P.F. Kantor,10 A. Lal,11 J.M. Lamour,8 T.M. Lee,2 E. Pahl,12 L. Shi,7 J.A. Towbin,13 S.M. Ware,14 S.A. Webber,5 J.D. Wilkinson,15 S.E. Lipshultz.15 1Cardiology, The Children 's Hospital of Philadelphia, Philadelphia, PA; 2Morgan Stanley Children’s Hospital, New York, NY; 3Washington University School of Medicine, St. Louis, MO; 4Boston Children’s Hospital, Boston, MA; 5Vanderbilt University, Nashville, TN; 6Children’s Hospital Colorado, Denver, CO;
The Journal of Heart and Lung Transplantation, Vol 36, No 4S, April 2017
6( 90) Ventricular Arterial Coupling: A Novel Echocardiographic Risk Factor for Poor Outcome in PAtients with Acute Decompensated Heart Failure C.A. Capone , J. Lorenzo, B. Tria, S.S. Medar, S.I. Aydin, J.M. Lamour, D.T. Hsu, J. Mahgerefteh. The Children's Hospital of Montefiore-Albert Einstein College of Medicine, Bronx, NY. Purpose: A higher (VA) coupling ratio measured non-invasively has been well described in adult heart failure patients and is associated with worse heart failure prognosis and response to treatment, largely due to increases in arterial elastance. There is no data regarding the importance of VA coupling in pediatric patients with heart failure. Hypothesis: A higher VA coupling ratio will be associated with worse outcomes in pediatric patients admitted with acute decompensated heart failure (ADHF) on inotropes. Methods: Demographic, clinical and echocardiographic (echo) data (including ventricular volumes, arterial elastance and LV elastance) were obtained for children with ADHF and compared to a group of normal controls. The association of VA coupling ratio with worse outcome (mechanical circulatory support, transplant, or death) and inotrope score was assessed. Results: Echos from 15 patients with ADHF (7 DCM, 8 myocarditis) on inotropes were reviewed. Mean age at presentation was 7±7 years. At time of echo, mean NYHA class was 3.6±7.4 mean inotrope score was 6.8±4.6. Outcome events occurred in 8/15 patients (53%). Patients with ADHF, compared to normal controls, had a significantly lower LV elastance (1.3 ± 0.79 vs. 4.3 ±1.22, respectively p= 0.001) and higher VA coupling ratio (4.3±3.1 vs 0.7±0.2, respectively p= 0.001). There was no difference in arterial elastance between patients with ADHF and normal controls (4.1±2.44 vs 2.9±0.8 respectively p= 0.09). Among ADHF patients, those with poor outcomes had a lower LV elastance (0.9±0.51 vs. 1.7±0.84, respectively p= 0.06) and a higher VA coupling ratio (5.9±3.45 vs. 2.5±1.3, respectively p= 0.02). There was no difference in arterial elastance among those with poor outcomes (4.5±3.1 vs. 3.6±1.49, respectively p= 0.47). There was no correlation between arterial elastance or LV elastance with inotrope score (r= 0.17 and r= 0.56 respectively). Conclusion: A higher VA coupling ratio is significantly associated with worse outcome in pediatric ADHF patients. Unlike adult data, this mechanism is driven not by an increase in arterial elastance but a decrease in ventricular elastance. Arterial elastance is unchanged in ADHF and is unrelated to inotrope score. VA coupling may provide insight into the mechanisms of heart failure in pediatric heart failure and identify potential targets for therapy. 6( 91) Hospitalization-Related Resource Utilization in Congenital Heart Disease with Advanced Heart Failure D.S. Burstein ,1 P. Shamszad,1 C.S. Almond,2 J.F. Price,3 K.Y. Lin,1 M.J. O'Connor,1 R.E. Shaddy,1 C.E. Mascio,1 J.W. Rossano.1 1Pediatric Cardiology, Children's Hospital of Philadelphia, Philadelphia, PA; 2Pediatric Cardiology, Stanford Childrens Hospital, Palo Alto, CA; 3Pediatric Cardiology, Texas Children's Hospital, Houston, TX. Purpose: While advancements in the management of congenital heart disease (CHD) have improved overall mortality, advanced heart failure (AHF) remains a risk. Resource utilization associated with CHD-related AHF is unknown. We sought to test the hypothesis that resource utilization is high among pediatric patients with CHD and AHF and associated with comorbidities and advanced therapies. Methods: All hospitalizations in the Pediatric Health Information System database involving a CHD diagnosis between 2004 and 2015 were queried. Patients with AHF, defined as a diagnosis of heart failure and at least 7 days of continuous inotropic support, were identified. Results: Of 476,905 CHD hospitalizations, AHF was present in 6131 (1.3%) hospitalizations (72% infant, 55% male, 54% underwent cardiac surgery). Hospital length of stay (LOS) was longer in AHF than non-AHF (median 42d [IQR 23-79] vs. 6d [IQR 3-17]; p< 0.001), as was ICU LOS (30d [IQR 15-60] vs. 6d [2-19]; p< 0.001). Hospital charges were also higher in AHF (median $658k vs. $100k, p< 0.001) with the highest quartile of hospitalizations resulting in > $1.2m in charges per AHF hospitalization. Compared to non-AHF hospitalizations, laboratory charges were 40% higher, clinical charges were 62% higher and pharmacy charges were 77% higher in AHF hospitalizations. Among AHF hospitalizations, extracorporeal membrane
oxygenation was utilized in 18% with median charges of $1.2m (IQR $719k$2m) per hospitalization, cardiac transplantation was performed in 9% with median charges of $1.2m (IQR $715k-$2.1m) and a ventricular assist device was utilized in 3% with median charges of $1.9m (IQR $1.2m-$2.8m). Comorbidities in AHF also contributed to higher charges, including respiratory failure occuring in 32% (median charges $890k [IQR $471k-$1.7m]), sepsis in 31% (median charges $1.0m [IQR $583k-$1.8m]), acute renal failure in 24% (median charges $1.1m [IQR $608k-$1.9m]), and stroke in 8% (median charges $1.2m [IQR $640k-$2.3m]). Conclusion: CHD-related AHF is a high resource utilization cohort with most hospitalizations exceeding 1 month in duration and generating hospital charges in excess of $600,000, a more than 6-fold increase over the non-AHF cohort. As cost-effectiveness becomes an increasing driver in high-value care, ongoing study is needed to help optimize resource utilization. 6( 92) Peak Troponin I Is Associated with Death and Extracorporeal Membrane Oxygenation in Pediatric Myocarditis A. Butto ,1 J. Rossano,1 D. Nandi,2 C. Ravishankar,1 K.Y. Lin,1 M.J. O'Connor,1 R.E. Shaddy,1 P. Shamszad.1 1Division of Cardiology, Children's Hospital of Philadelphia, Philadelphia, PA; 2Cardiology, The Heart Center, Nationwide Children's Hospital, Columbus, OH. Purpose: Serum troponin (Tn) is often elevated in viral myocarditis (VM); however, its prognostic significance is unknown. We tested the hypothesis that abnormal serum Tn is associated with mortality or extracorporeal membrane oxygenation (ECMO) use in children hospitalized with VM. Methods: We retrospectively studied data from six large children’s hospitals participating in the Pediatric Health Information System Plus (PHIS+) database. Analysis was performed on patients hospitalized with VM between 2007 and 2013, in whom at least one Tn was recorded within 72 hours of admission. Abnormal Tn was defined as any value outside hospital-reported reference range. Outcome measures included mortality, ECMO, mechanical ventilation, and inotrope use. The relationship between outcome measures and abnormal or peak Tn were assessed by chi-squared test, Mann-Whitney U test, and logistic regression, as appropriate. Results: A total of 152 VM patients (58% male, 16% infant) across all six PHIS+ centers had TnI (n= 116) or TnT (n= 36) recorded. Median baseline and peak TnI were 1.76 ng/dl (IQR 0.33-11.03) and 2.84 ng/dl (IQR 0.4614.70), respectively. Mean time to peak TnI was 2.0 +/- 9.5 days. Median baseline and peak TnT were 0.27 ng/dl (IQR 0.02-1.08) and 0.41 ng/dl (IQR 0.02-1.20), respectively. Mean time to peak TnT was 1.2 +/- 2.0 days. Overall mortality was 7% and ECMO was used in 22%. At least one abnormal TnI or TnT was present in 81% of cases and was associated with higher use of ECMO (OR 4.5, 95% CI 1.02-20.24) and intravenous immunoglobulin (OR 4.4, 95%CI 1.9-10.6). Abnormal TnI or TnT was not associated with mechanical ventilation (p= 0.83) or inotrope use (p= 0.25). Peak TnI was greater among patients who either died or were supported with ECMO (median 4.35 ng/dl, IQR 1.28-30.24 vs. 2.08 ng/dl, IQR 0.37-12.37; p< 0.001). After adjusting for infant age and gender, there was a 1% increase in odds of mortality (OR 1.01, 95% CI 1.01-1.03) and a 1% increase in odds of ECMO use (OR 1.01, 95%CI 1.01-1.02) for each 1 ng/dl-unit increase in peak TnI. Peak TnT was not associated with death (p= 0.23) or ECMO (p= 0.09); however, small sample size limits interpretation of this data. Conclusion: Higher peak serum troponin I was associated with mortality and ECMO use in children hospitalized with viral myocarditis. This finding may help risk stratify this population if it can be prospectively validated. 6( 93) The Association of Carvedilol Use on Transplant Free Survival in Pediatric Patients with Dilated Cardiomyopathy: An Analysis from the Pediatric Cardiomyopathy Registry J.W. Rossano ,1 L.J. Addonizio,2 C.E. Canter,3 S.D. Colan,4 D.A. Dodd,5 M.D. Everitt,6 B. Harty,7 D. Hsu,8 J.L. Jefferies,9 P.F. Kantor,10 A. Lal,11 J.M. Lamour,8 T.M. Lee,2 E. Pahl,12 L. Shi,7 J.A. Towbin,13 S.M. Ware,14 S.A. Webber,5 J.D. Wilkinson,15 S.E. Lipshultz.15 1Cardiology, The Children 's Hospital of Philadelphia, Philadelphia, PA; 2Morgan Stanley Children’s Hospital, New York, NY; 3Washington University School of Medicine, St. Louis, MO; 4Boston Children’s Hospital, Boston, MA; 5Vanderbilt University, Nashville, TN; 6Children’s Hospital Colorado, Denver, CO;