Brandon M. Wiley

Predictive value of the Sequential Organ Failure Assessment score for mortality in a contemporary cardiac intensive care unit population

Background Optimal methods of mortality risk stratification in patients in the cardiac intensive care unit (CICU) remain uncertain. We evaluated the ability of the Sequential Organ Failure Assessment (SOFA) score to predict mortality in a large cohort of unselected patients in the CICU. Methods and Results Adult patients admitted to the CICU from January 1, 2007, to December 31, 2015, at a single tertiary care hospital were retrospectively reviewed. SOFA scores were calculated daily, and Acute Physiology and Chronic Health Evaluation (APACHE)‐III and APACHE‐IV scores were calculated on CICU day 1. Discrimination of hospital mortality was assessed using area under the receiver‐operator characteristic curve values. We included 9961 patients, with a mean age of 67.5±15.2 years; all‐cause hospital mortality was 9.0%. Day 1 SOFA score predicted hospital mortality, with an area under the receiver‐operator characteristic curve value of 0.83; area under the receiver‐operator characteristic curve values were similar for the APACHE‐III score, and APACHE‐IV predicted mortality (P>0.05). Mean and maximum SOFA scores over multiple CICU days had greater discrimination for hospital mortality (P<0.01). Patients with an increasing SOFA score from day 1 and day 2 had higher mortality. Patients with day 1 SOFA score <2 were at low risk of mortality. Increasing tertiles of day 1 SOFA score predicted higher long‐term mortality (P<0.001 by log‐rank test). Conclusions The day 1 SOFA score has good discrimination for short‐term mortality in unselected patients in the CICU, which is comparable to APACHE‐III and APACHE‐IV. Advantages of the SOFA score over APACHE include simplicity, improved discrimination using serial scores, and prediction of long‐term mortality.

Novel Use for Intracardiac Echocardiography: Evaluation of Patients With Continuous Flow Left Ventricular Assist Devices

A comprehensive evaluation of left ventricular assist device (LVAD) physiology requires concomitant hemodynamic and imaging assessment. Currently, transthoracic echocardiography (TTE) is the standard diagnostic modality for device interrogation. However, TTE imaging can be limited by poor acoustic

Integrated Cardiac and Lung Ultrasound (ICLUS) in the Cardiac Intensive Care Unit

Purpose of ReviewThis review highlights the use of basic lung ultrasound and introduces the concept of integrated cardiac and lung ultrasound (ICLUS) in the care of patients in the cardiac intensive care unit (ICU).Recent FindingsCardiac ultrasound is a fundamental imaging modality that is the gold standard for the diagnosis of cardiac pathology at the bedside. However, the demographics of the modern cardiac ICU are evolving to encompass patients with complex multi-organ system dysfunction in addition to acute cardiovascular disease. Therefore, a more comprehensive diagnostic approach is needed to allow the cardiologist to unravel the potential interplay of multiple pathologic processes. Literature on lung ultrasound has expanded dramatically in recent years as it has proven to be a feasible and accurate exam that provides rapid diagnosis of pulmonary pathology including pneumothorax, pleural effusion, pneumonia, and pulmonary edema. Furthermore, combined cardiac and lung sonography exposes the interaction of circulatory and pulmonary physiology that is central to the diagnosis and management of acute cardiovascular disease. ICLUS provides valuable information for the diagnosis and management of conditions such as respiratory failure, shock, and heart failure.SummaryNumerous studies in recent years have illustrated the utility of lung ultrasound in various clinical settings. Integration of lung and cardiac ultrasound provides the cardiologist with a more holistic examination of the medically complex patients that are admitted to the modern cardiac ICU.

Comparison of Mortality Risk Prediction among Patients ≥70 versus <70 Years of Age in a Cardiac Intensive Care Unit

Older adults account for an increasing number of cardiac intensive care unit (CICU) admissions. This study sought to determine the predictive value of illness severity scores for mortality in CICU patients ≥70 years of age. Adult patients admitted to the CICU from 2007 to 2015 at one tertiary care hospital were reviewed. Severity of illness scores were calculated on the first CICU day. Area under the receiver-operator characteristic curve (AUROC) values were used to assess discrimination for hospital mortality in patients ≥70 versus <70 years of age. We included 10,004 patients with a mean age of 67.4 ± 15.2 years (37.4% female); 4,771 patients (47.7%) were ≥70 years of age. Patients ≥70 years of age had greater illness severity and more extensive co-morbidities compared with patients <70 years of age. Patients ≥70 years of age had higher hospital mortality (11.6% vs 6.8%, odds ratio 1.80, 95% confidence interval 1.57 to 2.07, p <0.001), with a progressive increase in mortality as a function of decade. Severity of illness scores had lower AUROC values for hospital mortality in patients ≥70 years of age compared with patients <70 years of age (all p <0.05 by DeLong test). The Braden skin score on CICU admission predicted hospital mortality with an AUROC value only slightly lower than these scores. Increasing age decade was associated with decreased postdischarge survival by Kaplan-Meier analysis (p <0.001 by log-rank). In conclusion, contemporary CICU patients ≥70 years of age have greater illness severity, more co-morbidities and higher mortality than patients <70 years of age, yet severity of illness scores are less accurate for predicting mortality in CICU patients ≥70 years of age, emphasizing the need for more effective risk-stratification methods in this population.

Fusion Imaging for Procedural Guidance

The field of percutaneous structural heart interventions has grown tremendously in recent years. This growth has fueled the development of new imaging protocols and technologies in parallel to help facilitate these minimally-invasive procedures. Fusion imaging is an exciting new technology that combines the strength of 2 imaging modalities and has the potential to improve procedural planning and the safety of many commonly performed transcatheter procedures. In this review we discuss the basic concepts of fusion imaging along with the relative strengths and weaknesses of static vs dynamic fusion imaging modalities. This review will focus primarily on echocardiographic-fluoroscopic fusion imaging and its application in commonly performed transcatheter structural heart procedures.

Pneumonia and atrial flutter in a 71- year-old-man

A 71-year-old man with axa0medical history of hypertension and 80 pack-years of tobacco smokingxa0was presented with dyspnoea and coughofxa03-week duration. He was tachycardic, with heart rate 127 beats per minute. ECG revealed atrial flutter. Chest x-ray showed right upper lobe consolidation consistent with pneumonia.nnTransesophageal echocardiogram (TEE)-guided cardioversion was ordered. The echocardiogram revealed normal biventricular systolic function without significant valvular disease. The left atrial appendage was enlarged but no thrombus was present. Doppler pulsed-wave interrogation of the right superior pulmonary vein (RSPV) demonstrated increased velocity (1.2 m/s, …