Comparing the Mutual Interchangeability of ECOM, FloTrac/Vigileo, 3D-TEE, and ITD-PAC Cardiac Output Measuring Systems in Coronary Artery Bypass Grafting.

OBJECTIVE: The aim of this study was to compare the mutual interchangeability of 4 cardiac output measuring devices by comparing their accuracy, precision, and trending ability. DESIGN: A single-center prospective observational study. DESIGN: Nonuniversity teaching hospital, single center. PARTICIPANTS: Forty-four consecutive patients scheduled for elective, nonemergent coronary artery bypass grafting (CABG). INTERVENTIONS: The cardiac output was measured for each participant using 4 methods: intermittent thermodilution via pulmonary artery catheter (ITD-PAC), Endotracheal Cardiac Output Monitor (ECOM), FloTrac/Vigileo System (FLOTRAC), and 3-dimensional transesophageal echocardiography (3D-TEE). MEASUREMENTS AND MAIN RESULTS: Measurements were performed simultaneously at 5 time points: presternotomy, poststernotomy, before cardiopulmonary bypass, after cardiopulmonary bypass, and after sternal closure. A series of statistical and comparison analyses including ANOVA, Pearson correlation, Bland-Altman plots, quadrant plots, and polar plots were performed, and inherent precision for each method and percent errors for mutual interchangeability were calculated. For the 6 two-by-two comparisons of the methods, the Pearson correlation coefficients (r), the percentage errors (% error), and concordance ratios (CR) were as follows: ECOM_versus_ITD-PAC (r = 0.611, % error = 53%, CR = 75%); FLOTRAC_versus_ITD-PAC (r = 0.676, % error = 49%, CR = 77%); 3D-TEE versus ITD-PAC (r = 0.538, % error = 64%, CR = 67%); FLOTRAC_versus_ECOM (r = 0.627, % error = 51%, CR = 75%); 3D-TEE_versus ECOM (r = 0.423, % error = 70%, CR = 60%), and 3D-TEE_versus_FLOTRAC (r = 0.602, % error = 59%, CR = 61%). CONCLUSIONS: Based on the recommended statistical measures of interchangeability, ECOM, FLOTRAC, and 3D-TEE are not interchangeable with each other or to the reference standard invasive ITD-PAC method in patients undergoing nonemergent cardiac bypass surgery. Despite the negative result in this study and the majority of previous studies, these less-invasive methods of CO have continued to be used in the hemodynamic management of patients. Each device has its own distinct technical features and inherent limitations; it is clear that no single device can be used universally for all patients. Therefore, different methods or devices should be chosen based on individual patient conditions, including the degree of invasiveness, measurement performance, and the ability to provide real-time, continuous CO readings.

Invasive Hemodynamic Monitoring in Cardiogenic Shock Is Associated With Lower In-Hospital Mortality.

Background There is increasing utilization of cardiogenic shock treatment algorithms. The cornerstone of these algorithms is the use of invasive hemodynamic monitoring (IHM). We sought to compare the in-hospital outcomes in patients who received IHM versus no IHM in a real-world contemporary database. Methods and Results Patients with cardiogenic shock admitted during October 1, 2015 to December 31, 2018, were identified from the National Inpatient Sample. Among this group, we compared the outcomes among patients who received IHM versus no IHM. The primary end point was in-hospital mortality. Secondary end points included vascular complications, major bleeding, need for renal replacement therapy, length of stay, cost of hospitalization, and rate of utilization of left ventricular assist devices and heart transplantation. Propensity score matching was used for covariate adjustment. A total of 394 635 (IHM=62 565; no IHM=332 070) patients were included. After propensity score matching, 2 well-matched groups were compared (IHM=62 220; no IHM=62 220). The IHM group had lower in-hospital mortality (24.1% versus 30.6%, P<0.01), higher percentages of left ventricular assist devices (4.4% versus 1.3%, P<0.01) and heart transplantation (1.3% versus 0.7%, P<0.01) utilization, longer length of hospitalization and higher costs. There was no difference between the 2 groups in terms of vascular complications, major bleeding, and the need for renal replacement therapy. Conclusions Among patients with cardiogenic shock, the use of IHM is associated with a reduction in in-hospital mortality and increased utilization of advanced heart failure therapies. Due to the observational nature of the current study, the results should be considered hypothesis-generating, and future prospective studies confirming these findings are needed.

The Mayo Cardiac Intensive Care Unit Admission Risk Score is Associated with Medical Resource Utilization During Hospitalization.

OBJECTIVE: To determine whether the Mayo Cardiac Intensive Care Unit (CICU) Admission Risk Score (M-CARS) is associated with CICU resource utilization. PATIENTS AND METHODS: Adult patients admitted to our CICU from 2007 to 2018 were retrospectively reviewed, and M-CARS was calculated from admission data. Groups were compared using Wilcoxon test for continuous variables and χ2 test for categorical variables. RESULTS: We included 12,428 patients with a mean age of 67±15 years (37% female patients). The mean M-CARS was 2.1±2.1, including 5890 (47.4%) patients with M-CARS less than 2 and 644 (5.2%) patients with M-CARS greater than 6. Critical care restricted therapies were frequently used, including mechanical ventilation in 28.0%, vasoactive medications in 25.5%, and dialysis in 4.8%. A higher M-CARS was associated with greater use of critical-care therapies and longer CICU and hospital length of stay. The low-risk cohort with M-CARS less than 2 was less likely to require critical-care-restricted therapies, including invasive or noninvasive mechanical ventilation (8.0% vs 46.1%), vasoactive medications (10.1% vs 38.8%), or dialysis (1.0% vs 8.2%), compared with patients with M-CARS greater than or equal to 2 (all P<.001). CONCLUSION: Patients with M-CARS less than 2 infrequently require critical-care resources and have extremely low mortality, suggesting that the M-CARS could be used to facilitate the triage of critically ill cardiac patients.