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There are minimal data describing outcomes in ambulatory pediatric and young adult ventricular assist device (VAD)-supported patient populations. We performed a retrospective analysis of encounter-level data from 2006 to 2017 Nationwide Emergency Department Sample (NEDS) to compare emergency department (ED) resource utilization and outcomes for pediatric (≤18 years, n = 494) to young adult (19-29 years, n = 2,074) VAD-supported patient encounters. Pediatric encounters were more likely to have a history of congenital heart disease (11.3% vs. 4.8%). However, Pediatric encounters had lower admission/transfer rates (37.8% vs. 57.8%) and median charges ($3,334 (IQR $1,473-$19,818) vs. $13,673 ($3,331-$45,884)) (all p < 0.05). Multivariable logistic regression modeling revealed that age itself was not a predictor of admission, instead high acuity primary diagnoses and medical complexity were: (adjusted odds ratio; 95% confidence intervals): cardiac (3.0; 1.6-5.4), infection (3.4; 1.7-6.5), bleeding (3.9; 1.7-8.8), device complication (7.2; 2.7-18.9), and ≥1 chronic comorbidity (4.1; 2.5-6.7). In this largest study to date describing ED resource use and outcomes for pediatric and young adult VAD-supported patients, we found that, rather than age, high acuity presentations and comorbidities were primary drivers of clinical outcomes. Thus, reducing morbidity in this population should target comorbidities and early recognition of VAD-related complications.

There are limited data describing the prevalence of mental health disorders (MHDOs) in patients with ventricular assist devices (VADs), or associations between MHDOs and resource use or outcomes. We used the Nationwide Emergency Department Sample administrative database to analyze 44,041 ED encounters for VAD-supported adults from 2010 to 2017, to assess the relationship between MHDOs and outcomes in this population. MHDO diagnoses were present for 23% of encounters, and were associated with higher charges and rates of admission, but lower mortality.

Background With a growing population of patients supported by ventricular assist devices (VADs) and the improvement in survival of this patient population, understanding the healthcare system burden is critical to improving outcomes. Thus, we sought to examine national estimates of VAD‐related emergency department (ED) visits and characterize their demographic, clinical, and outcomes profile. Additionally, we tested the hypotheses that resource use increased and mortality improved over time. Methods and Results This retrospective database analysis uses encounter‐level data from the 2010 to 2017 Nationwide Emergency Department Sample. The primary outcome was mortality. From 2010 to 2017, >880 million ED visits were evaluated, with 44 042 VAD‐related ED visits identified. The annual mean visits were 5505 (SD 4258), but increased 16‐fold from 2010 to 2017 (824 versus 13 155). VAD‐related ED visits frequently resulted in admission (72%) and/or death (3.0%). Median inflation‐adjusted charges were $25 679 (interquartile range, $7450, $63 119) per encounter. The most common primary diagnoses were cardiac (22%), and almost 30% of encounters were because of bleeding, stroke, or device complications. From 2010 to 2017, admission and mortality decreased from 82% to 71% and 3.4% to 2.4%, respectively ( P for trends Conclusions We present the first study using national‐level data to characterize the growing ED resource use and financial burden of patients supported by VAD. During the past decade, admission and mortality rates decreased but remain substantial; in 2017 ≈1 in every 40 VAD ED encounters resulted in death, making it critical that clinical decision–making be optimized for patients with VAD to maximize good outcomes.

Introduction: The past decade has seen tremendous growth in ambulatory ventricular assist device (VAD) patients. We sought to identify patients that present to the emergency department (ED) who are at the highest risk of death. Methods: We performed a retrospective analysis of ED encounters of VAD patients using data from the Nationwide Emergency Department Sample (NEDS) from 2010-2017. Demographic and clinical variables significantly associated with mortality (p < 0.2) in a univariate analysis were evaluated in a multivariate model. Using a random sampling of patient encounters, 80% were assigned to development and 20% to validation cohorts. A risk model was derived from independent predictors of mortality, which were weighted using integer-normalized beta coefficients. Each patient encounter was assigned to one of three groups based on risk score. Results: A total of 44,042 ED encounters of VAD patients were included in the study. The majority of patients were male (73.6%), Conclusions: We present a novel risk score and its validation for predicting mortality of VAD patients who present to the ED, which can serve as useful tool for clinicians caring for this high-risk, and growing, population.

Introduction: Outcomes of mechanical circulatory support (MCS) to treat myocarditis are not well described. Hypothesis: We hypothesize that MCS is increasingly utilized for the treatment of myocarditis and is associated with high morbidity and mortality. Methods: This study utilized admissions from the National Inpatient Sample (NIS) from 2012-2016. Patient-encounters with myocarditis were identified using ICD-9/10 codes. Weighted population estimate outcomes comparing encounters with MCS or without MCS were calculated. Mode of MCS was examined and trends in MCS treatment, mortality and morbidity were assessed using logistic regression models. Results: Of the 48,965 encounters for myocarditis between 2012 and 2016, 1,910 patients died (3.9%) and 255 (0.5%) underwent transplant. MCS was used in 2,215 patients (4.5%): extra corporeal membrane oxygenation (ECMO) in 590, durable ventricular assist device (VAD) in 150, temporary VAD (tVAD) in 320, and intra-aortic balloon pump (BP) in 770. Over 5 years there was no change in the frequency of MCS and mortality in MCS patients remained stable (p for trends >0.3 ). However, the use of ECMO increased from 23.2% in 2012 to 38.5% in 2016 while BP use decreased from 60.9% to 26.4% (p trend for both Conclusion: MCS is utilized in 5% of patients with myocarditis. ECMO has become the most common support modality, but its use is associated with significant morbidity and mortality. Further evaluation of how patient characteristics influence the MCS type utilized and their impact on outcomes is needed.

OBJECTIVE: To evaluate the effect of a standardized feeding approach using a clinical nutrition pathway on weight-for-age Z score (WAZ) over hospital length of stay (HLOS) for infants with congenital heart disease (CHD). STUDY DESIGN: A ten-year retrospective cohort study examined eligible infants who underwent neonatal cardiac surgery between July 2009 through December 2018 (n=987). Eligibility criteria included infants born at least 37 weeks gestation and a minimum birth weight of 2 kilograms who underwent cardiac surgery for CHD within the first 30 days of life. Using the best linear unbiased predictions (BLUP) from a linear mixed effects model, WAZ change over HLOS was estimated before and after January 2013, when the standardized feeding approach was initiated. BLUP model included adjustment for patient characteristics including sex, race, HLOS, and class of cardiac defect. RESULTS: Change in WAZ over HLOS was significantly higher during the period 2013–2018 than during the period 2009–2012 (β(SE)=0.16 (0.02), P < .001), after controlling for sex, race, HLOS, and CHD category, indicating that infants experienced decreased WAZ loss over HLOS after the standardized feeding approach was initiated. Additionally, differences were found in WAZ loss over HLOS between infants with single ventricle CHD (β(SE)=0.26 (0.04), p

Purpose Myocarditis is a common cause of pediatric heart failure and may require treatment with mechanical circulatory support (MCS). The purpose of this study is to describe the frequency of MCS use in pediatric myocarditis, types of MCS used, and outcomes of patients who receive MCS. Methods This study utilized the administrative Kids’ Inpatient Database (KID), a nationally representative sample of discharge data. Five years of KID admissions (2003, 2006, 2009, 2012 and 2016) were queried using ICD-9/10 codes to identify those with a diagnosis of myocarditis. MCS strategies and outcomes were calculated and compared using logistic regression. Results Of 5,661 admissions for myocarditis, MCS was used in 194 (3.4%). ECMO was used in 82 (42.3%), a temporary ventricular assist device (tVAD) in 38 (19.6%), a durable VAD (dVAD) in 53 (27.3%) and combination MCS (cMCS) in 22 (11.3%). Half of admissions (n=2854, 50.4%), occurred in patients age 13-18 years, however teenagers were less likely than children Conclusion MCS is used in 1 in 30 pediatric myocarditis cases and patients who require MCS have higher morbidity and mortality. ECMO is the most commonly used MCS modality in pediatric myocarditis but there is no significant difference in mortality based on MCS modality.

Introduction Studies regarding sex differences in patients with LVADs have demonstrated variable characteristics and outcomes in terms of frequency of adverse events and mortality by sex. There are limited data regarding differences in LVAD-related emergency department (ED) visits between women and men. Hypothesis Comorbidity burden and clinical outcomes of LVAD patients vary by sex. Methods We performed a retrospective analysis of 44,042 LVAD-related ED encounters from the 2010-2017 Nationwide Emergency Department Sample (NEDS). ICD-9/10 codes were used to identify patients with LVADs and their associated primary and comorbidity diagnoses. Demographics, clinical characteristics, and outcomes (death, hospital admission, and rates of LVAD-related procedures) were compared via Chi-square tests. Results Women comprised 26% (n=11654) of LVAD-related ED visits. Compared to men, women were younger (58.1 years [IQR 46.59, 67.13] vs. 61.5 [IQR 51.66, 69.31]; p 0.05). Women underwent endoscopy less frequently than men (5.1% vs. 6.8%, p = 0.006), but there were no differences in blood transfusion, catheterization, device exchange, and heart transplantation (p for all ≥ 0.05). Despite being less likely than men to be admitted to the hospital (61.6% vs. 67.6%, p Conclusions Compared to men, the comorbidity profiles and clinical outcomes of women with LVADs who seek ED evaluation significantly differ. Future analyses will further explore the disparity in hospital admission by sex despite similar mortality rates. Understanding these sex differences among VAD patients is a critical step in the effort to improve long-term outcomes. Figure 1. Comorbidities (A), Primary Diagnosis (B), ED or Hospital Procedures Performed (C), and Outcomes (D) of LVAD-related ED Encounters by Sex

Purpose Although the risk of bleeding complications is well known for patients with ventricular assist devices (VADs), there is minimal data describing how bleeding events impacts the ambulatory VAD population's emergency department (ED) resource utilization or outcomes. Methods We utilized ED-encounter level data from the Nationwide Emergency Department Sample (NEDS). Patients age ≥19 years with VADs from 2006 to 2014 were identified via ICD-9 diagnoses. Primary diagnoses were queried for bleeding events. Encounters were also queried for ED and inpatient bleeding driven procedures. Overall inpatient and ED charges and mortality were assessed. Results Over a nine-year period, 17,356 VAD-related ED visits were identified, of which bleeding events were the second most common primary diagnosis (25%). Bleeding events were less common in young adults (19 to 44 years) compared to middle (45 to 64 years) and older (≥65 years) adults (16% vs. 25% vs. 29%, p Conclusion This is the largest study to date investigating resource utilization and outcomes among ambulatory VAD patients presenting to the ED with a bleeding event. A bleeding event was the primary diagnosis for 1 in 4 ED encounters, representing the second most common primary diagnosis in this population. Bleeding events were associated with older age, frequent procedures, trend towards higher charges, and—when requiring a blood transfusion—higher mortality.

Purpose Data related to the epidemiology and resource utilization of ventricular assist device (VAD) related emergency department (ED) visits are limited. However, an improved understanding of the burden of VADs on the healthcare system is critical to designing interventions that improve outcomes. We examined national estimates of VAD-related ED visits and described medical complexity, admissions, resource utilization, and mortality. Methods This study utilizes data from ED encounter-level data via the 2006-2014 Nationwide Emergency Department Sample (NEDS). ICD-9 codes were used to identify patient-encounters with VADs. Demographic and clinical factors are reported via descriptive statistics. The primary outcome was death; secondary outcomes included median inflation-adjusted charge and hospital admission. Results From 2006 to 2014, over 900 million ED visits were evaluated, of which 17,356 (.002%) VAD-related ED visits were identified, for a median of 1,028 (SD 1,489) visits per year. Most VAD ED encounters were represented by patients that were male (74%), ≥ 45 years old (73%), and living in an urban environment (85%). 73% of VAD related ED visits resulted in inpatient admission and the median inflation-adjusted charge was $23,862 (IQR 7,129; 58,265) per visit. Mortality, either in the ED or during an associated admission, was 4.7%. The most common primary diagnoses were cardiac (32%) followed by bleeding (25%) and infection (18%). More than half of the encounters were with patients with ≥1 chronic medical condition, with diabetes (34%) and hypertension (31%) the most prevalent. Conclusion This is the first study to use national level data to describe the clinical characteristics and outcomes of patients with VADs who present to the ED. With nearly 1 in 20 VAD ED encounters resulting in death, strategies to reduce mortality are urgently needed.

Purpose There are minimal data on emergency department (ED) resource utilization for pediatric patients with ventricular assist devices (VADs), and it is unclear if adult data can be extrapolated to children. Methods This analysis of national estimates of ED-visit level encounters uses the Nationwide Emergency Department Sample (NEDS). Patients from 2006 to 2014 with VADs were identified using ICD-9 codes and categorized as pediatric (≤18y), young adult (19-44y), middle adult (45-64y) and older adult (≥65y). The primary outcome was death; secondary outcomes included median inflation adjusted charge, admission/transfer rate, and primary encounter diagnoses. Results Over the 9 years studied, a total of 254 (95% CI 190-318) pediatric, 3,003 (95% CI 2424-3582) young adult, 7,590 (95% CI 6220-8961) middle adult, and 6,857 (95% CI 5604-8110) older adult ED encounters were identified. Compared to all other age groups, the pediatric VAD ED encounters were more likely to occur at a non-teaching or non-metropolitan ED, to have private insurance as a primary payer, and have a higher proportion of female patients (p ≤ 0.0003 for all). The two most frequent primary encounter diagnoses in pediatric patients were acute gastrointestinal (19%) and respiratory complaints (14%), both of which were uncommon in all adult age groups (p 0.2 for all). Conclusion In this study evaluating ED resource utilization of VAD patients, pediatric patients had much lower admission rate and charges compared to their adult counterparts—likely reflecting generally lower acuity complaints or potentially less medical complexity. Still, high mortality rates across all ages highlights the ubiquitous fragility of patients with VADs presenting to the ED and the need for strategies to reduce morbidity and mortality.

Purpose With advances in mechanical circulatory support and orthotopic heart transplants (OHT) remaining a limited resource, there has been a dramatic increase in Ventricular Assist Device (VAD) implantation. There is minimal data comparing emergency department (ED) resource utilization and outcomes between these populations. We examined national estimates of VAD and OHT-related ED visits and evaluated admissions, resource utilization, and mortality. Methods This study is an epidemiological analysis comparing national estimates of ED visit-level data from the 2006-2014 Nationwide Emergency Department Sample (NEDS) in patients with VADs vs OHT, identified using ICD-9 codes. The primary outcome was death; secondary outcomes included median inflation-adjusted charge and hospital admission. We tested the hypothesis that resource utilization and mortality are higher in ED visits for VAD patients compared to OHT patients. Results 17,356 VAD-related ED, and 138,133 OHT-related visits were identified. Patients with VADs were more likely to be male (74% vs 70%, p=0.001) and ≥ 65 yo (39% vs 38%, p=0.0004). VADs were more likely to have a primary diagnosis of bleeding (25% vs 2%) and less likely to have acute respiratory disease (6% vs 20%, p Conclusion Patients with VADs presenting to the ED represent a population with greater morbidity, mortality and resource utilization compared to OHT. A more developed understanding of those factors that drive mortality and resource use is imperative for improving outcomes in this high-risk population.