Association of COVID-19 Hospitalization Volume and Case Growth at US Hospitals with Patient Outcomes.

BACKGROUND: Whether the volume of coronavirus disease 2019 (COVID-19) hospitalizations is associated with outcomes has important implications for the organization of hospital care both during this pandemic and future novel and rapidly evolving high-volume conditions. METHODS: We identified COVID-19 hospitalizations at US hospitals in the American Heart Association COVID-19 Cardiovascular Disease Registry with ≥10 cases between January and August 2020. We evaluated the association of COVID-19 hospitalization volume and weekly case growth indexed to hospital bed capacity, with hospital risk-standardized in-hospital case-fatality rate (rsCFR). RESULTS: There were 85 hospitals with 15,329 COVID-19 hospitalizations, with a median hospital case volume was 118 (interquartile range, 57, 252) and median growth rate of 2 cases per 100 beds per week but varied widely (interquartile range: 0.9 to 4.5). There was no significant association between overall hospital COVID-19 case volume and rsCFR (rho, 0.18, P = .09). However, hospitals with more rapid COVID-19 case-growth had higher rsCFR (rho, 0.22, P = 0.047), increasing across case growth quartiles (P trend = .03). Although there were no differences in medical treatments or intensive care unit therapies (mechanical ventilation, vasopressors), the highest case growth quartile had 4-fold higher odds of above median rsCFR, compared with the lowest quartile (odds ratio, 4.00; 1.15 to 13.8, P = .03). CONCLUSIONS: An accelerated case growth trajectory is a marker of hospitals at risk of poor COVID-19 outcomes, identifying sites that may be targets for influx of additional resources or triage strategies. Early identification of such hospital signatures is essential as our health system prepares for future health challenges.

Minimally invasive fibrillating mitral valve replacement for patients with advanced cardiomyopathy: a safe and effective approach to treat a complex problem.

OBJECTIVE: The optimal management of mitral regurgitation (MR) in patients with cardiomyopathy has been controversial. Minimally invasive fibrillating mitral valve replacement (mini-MVR) might limit postoperative morbidity and mortality by minimizing recurrent MR. We hypothesized that mini-MVR with complete chordal sparing would offer low mortality and halt left ventricular (LV) remodeling in patients with severe cardiomyopathy and severe MR. METHODS: From January 2006 to August 2009, 65 patients with an LV ejection fraction (LVEF) of ≤35% underwent mini-MVR. The demographic, echocardiographic, and clinical outcomes were analyzed. RESULTS: The operative mortality compared with the Society of Thoracic Surgeons-predicted mortality was 6.2% versus 6.6%. It was 5.6% versus 7.4% for patients with an LVEF of ≤20% and 8.3% versus 17.9% among patients with a Society of Thoracic Surgeons-predicted mortality of ≥10%. At a median follow-up of 17 months, no recurrent MR or change in the LV dimensions or LVEF had developed, but the right ventricular systolic pressure had decreased (P=.02). At the first postoperative visit and latest follow-up visit, the New York Heart Association class had decreased from 3.0±0.6 to 1.7±0.7 and 2.0±1.0, respectively (P<.0001 for both). Patients with an LVEF of ≤20% and LV end-diastolic diameter of ≥6.5 cm were more likely to meet a composite of death, transplantation, or LV assist device insertion (P=.046). CONCLUSIONS: Our results have shown that mini-MVR is safe in patients with advanced cardiomyopathy and resulted in no recurrent MR, stabilization of the LVEF and LV dimensions, and a decrease in right ventricular systolic pressure. This mini-MVR technique can be used to address severe MR in patients with advanced cardiomyopathy.

Acute coronary syndrome pathways: alignment with a bundled care reimbursement model.

Changes in public policy, population demographics, and market dynamics are spurring innovative approaches to value-based care. Annually, hospitalizations for Acute Coronary Syndromes (ACS) account for a substantial proportion of healthcare expenditures in the United States. Vanderbilt University Medical Center has developed a framework to deliver comprehensive care incorporating inpatient and outpatient care teams for patients with ACS under an episode-based, bundled reimbursement model for a term of 6 months. As such, a value-oriented pathway was created with the goals of (1) optimizing patient outcomes following ACS; (2) minimizing complications from the treatment of ACS; and (3) reducing costs of healthcare related to the treatment of ACS. In a tertiary care academic medical system receiving patients from multiple facilities involving multiple providers, standardization of care by using practice guidelines and evidence-based data coupled with a robust computerized provider order entry system provides a unique opportunity to produce a "best practice" algorithm for treating patients presenting with ACS. Presented in this study are in-hospital and postdischarge care pathways for treating a diverse group of patients presenting with ACS to our institution.

Myocardial viability assessment by PET: (82)Rb defect washout does not predict the results of metabolic-perfusion mismatch.

UNLABELLED: PET is a sensitive technique for the identification of viable myocardial tissue in patients with coronary disease. Metabolic assessment with (18)F-FDG is considered the gold standard for assessment of viability before surgical revascularization. Prior research has suggested that viability may be assessed with washout of (82)Rb between early and late resting images. Our objective was to determine whether assessment of myocardial viability with (82)Rb washout is reliable when compared with PET using (18)F-FDG. METHODS: We performed PET for 194 patients referred for PET (18)F-FDG/(82)Rb to assess viability for clinical indications. We included 151 patients with resting defects >10% of the left ventricle (LV) (n = 159 defects). Patients with smaller resting (82)Rb defects (<10% LV) were excluded for the purpose of this study. PET images acquired with (82)Rb and (18)F-FDG defined viability by the mismatch between metabolism and perfusion ((18)F-FDG >125% of (82)Rb uptake in the (82)Rb defect). Evidence of viability with (82)Rb was assessed by the presence of (i) severity: (82)Rb counts in the defect >50% of (82)Rb in the normal zone of the resting PET images; (ii) washout: decrease of (82)Rb counts in the defect from early to late resting (82)Rb images <17% between the first 90-s image and the final 300-s image; or (iii) combined severity and washout criteria, which required positive criteria for (i) and (ii) to indicate viability. RESULTS: Prevalence of viability by (18)F-FDG/(82)Rb criteria was 50% (n = 79). Severity criteria yielded a sensitivity of 76% and a specificity of 17%, washout criteria yielded a sensitivity of 81% and a specificity of 23%, and both criteria had a sensitivity of 63% and a specificity of 32%. Positive and negative predictive values were poor for all criteria. No correlation existed between (82)Rb washout and (18)F-FDG-(82)Rb mismatch (r(2) = 0.00). Multiple receiver-operating-characteristic plots showed very poor discrimination despite varying criteria for viability by (82)Rb (severity from 50% to 60% of normal zone, washout from 12% to 17%). CONCLUSION: (82)Rb washout from early to late resting images, combined with quantitative severity of the resting (82)Rb defect, did not yield results equivalent to PET (18)F-FDG-(82)Rb mismatch and may not accurately assess myocardial viability.