Journal of Cardiac Failure Vol. 18 No.

6 2012

Clinical Investigations

Prevalence, Morbidity, and Mortality of Heart

FailureeRelated Hospitalizations in Children in the United
States: A Population-Based Study
JOSEPH W. ROSSANO, MD,1 JEFFREY J. KIM, MD,2 JAMIE A. DECKER, MD,2 JACK F. PRICE, MD,2 FARHAN ZAFAR, MD,3
DANIEL E. GRAVES, PhD,4 DAVID L. S. MORALES, MD,3 JEFFREY S. HEINLE, MD,3 BIYKEM BOZKURT, MD,5
JEFFREY A. TOWBIN, MD,6 SUSAN W. DENFIELD, MD,2 WILLIAM J. DREYER, MD,2 AND JOHN L. JEFFERIES, MD6
Philadelphia, Pennsylvania; Houston, Texas; and Cincinnati, Ohio

ABSTRACT
Background: Few data exist on prevalence, morbidity, and mortality of pediatric heart failure hospitalizations. We tested the hypotheses that pediatric heart failureerelated hospitalizations increased over time
but that mortality decreased. Factors associated with mortality and length of stay were also assessed.
Methods and Results: A retrospective analysis of the Healthcare Cost and Utilization Project Kids Inpatient Database was performed for pediatric (age #18 years) heart failureerelated hospitalizations for the years
1997, 2000, 2003, and 2006. Hospitalizations did not significantly increase over time, ranging from 11,153
(95% confidence interval [CI] 8,898e13,409) in 2003 to 13,892 (95% CI 11,528e16,256) in 2006. Hospital
length of stay increased from 1997 (mean 13.8 days, 95% CI 12.5e15.2) to 2006 (mean 19.4 days, 95% CI
18.2 to 20.6). Hospital mortality was 7.3% (95% CI 6.9e8.0) and did not vary significantly between years;
however, risk-adjusted mortality was less in 2006 (odds ratio 0.70, 95% CI 0.61 to 0.80). The greatest risk
of mortality occurred with extracorporeal membrane oxygenation, acute renal failure, and sepsis.
Conclusions: Heart failureerelated hospitalizations occur in 11,000e14,000 children annually in the
United States, with an overall mortality of 7%. Many comorbid conditions influenced hospital mortality.
(J Cardiac Fail 2012;18:459e470)
Key Words: Heart failure, pediatrics, epidemiology.

Inpatient treatment for acute heart failure is now one of

the most common reasons for hospital admission in adults,
with O3 millions hospitalizations annually.1 The number

of adults hospitalized for heart failure has steadily increased over the past 3 decades.1e3 The cost associated
with this is dramatic, not only in health care expenditures,
which is now estimated to be O$30 billion annually,4 but
also in terms of morbidity and mortality. The in-hospital
mortality for adults hospitalized with heart failure is 3%
e7%,1,5 and the median survival after the first admission
for heart failure in adult patients is !3 years.6
Although there are an increasing number of studies on
acute heart failure in adults, there are only limited data
on the incidence, etiology, or outcome of inpatient admissions for heart failure in pediatric patients.7,8 Andrews
et al. described the incidence of heart failure admission
from cardiomyopathy in the United Kingdom as 0.87/
100,000 in patients !16 years old.7 In that cohort, 34%
died or underwent heart transplantation within 1 year of
hospital admission. Other etiologies of heart failure, such
as congenital heart disease (CHD), valvar disease, or
complications of heart transplantation, were not included
in that study. These other etiologies are important, because

From the 1Department of Pediatrics, Division of Cardiology, The

Childrens Hospital of Philadelphia, Perelman School of Medicine at the
University of Pennsylvania, Philadelphia, Pennsylvania; 2Department of
Pediatrics, Lillie Frank Abercrombie Section of Pediatric Cardiology,
Baylor College of Medicine, Houston, Texas; 3Michael E. DeBakey
Department of Surgery, Baylor College of Medicine, Houston, Texas; 4Department of Physical Medicine and Rehabilitation, Baylor College of Medicine, Houston, Texas; 5Department of Medicine, Section of Cardiology,
Baylor College of Medicine, Houston, Texas and 6The Heart Institute,
Cincinnati Childrens Hospital, Department of Pediatrics, University of
Cincinnati, Cincinnati, Ohio.
Manuscript received December 15, 2011; revised manuscript received
March 1, 2012; revised manuscript accepted March 2, 2012.
Reprint requests: Joseph W. Rossano, MD, 34th and Civic Center
Boulevard, Philadelphia, PA 19104. Tel: 267-426-3063; Fax: 215-5904620. E-mail: rossanoj@email.chop.edu
See page 464 for disclosure information.
1071-9164/$ - see front matter
2012 Elsevier Inc. All rights reserved.
doi:10.1016/j.cardfail.2012.03.001

459

460 Journal of Cardiac Failure Vol. 18 No. 6 June 2012

currently almost 50% of pediatric heart transplants occur
for etiologies other than cardiomyopathy.9
Moreover, there are very limited data on the longitudinal
experience with pediatric heart failure. Although the number
of heart transplants performed annually in the United States
has remained stable at about 300 to 400 per year,10 it is
unknown whether the incidence of heart failure in children
is increasing, as is the case with adults. Additionally, there
are no data on the morbidity, hospital duration, or hospital
characteristics of children hospitalized with heart failure.
Knowledge of these is critical to devising therapies to improve the care and survival of these patients. Therefore, the
purpose of the present study was to test the hypothesis that
the prevalence of heart failure related hospitalizations
among children in the United States increased over the years
from 1997 to 2006. We also tested the hypothesis that mortality decreased over that time. Comorbidities and hospital
length of stay (LOS) were also assessed.

Methods
Data
The study was a retrospective review of the Kids Inpatient
Database (KID) for the years 1997, 2000, 2003, and 2006. The
KID is part of the Healthcare Cost and Utilization Project, managed by the Agency for Healthcare Research and Quality, which
is part of the Department of Health and Human Services. The
database was created to allow analyses of hospital utilization by
children across the United States.11
The KID consists of nationwide sampling of pediatric hospital
admissions. A systematic random sampling is used to select 80%
of pediatric hospital admissions and complicated in-hospital births
and 10% of uncomplicated in-hospital births. To further ensure
accurate representation of pediatric admissions, the discharges are
sorted by state, hospital, diagnostic-related group (DRG), and
a random number within each DRG.11 The hospitals included in
the database are specialty hospitals, public hospitals, and academic
medical centers. The KID contains data from 2e3 million hospital
discharges per year for children. There were 27 states that contributed data in the 2000 database, 36 states in the 2003 database, and
38 states in the 2006 database. The large sample size of the KID
enables analyses of even rare diagnoses and procedures.12e15 Additionally, the KID can be weighted to produce national estimates.16
For weights, hospitals are poststratified on hospital characteristics
including ownership/control, bed size, teaching status, rural/urban
location, and region of country.
The KID is composed of O100 clinical and nonclinical variables
for each hospital stay, including primary and subsequent diagnoses,
and primary and subsequent procedures. There are up to 15 diagnoses and procedures for each discharge. Heart failureerelated hospitalizations and other diagnoses and procedures were identified by
ICD-9 codes (Supplemental Table 1, available online). Additional
data in the database include admission and discharge status, and patient demographics (eg, sex, age, race), hospital LOS, and hospital
characteristics (eg, location, size, teaching status).11 The hospitals
location was determined by the American Hospital Association
Annual Survey of Hospitals. Designation of a childrens hospital
was assigned based on information provided by the National Association of Childrens Hospitals and Related Institutions (NACHRI).

A hospital was considered to not be a childrens hospital if was

identified as such by NACHRI.
Statistical Analyses
Descriptive statistics were used to describe the clinical characteristics of heart failure admissions. Hospitalization rates were
calculated using United States Census data for the estimated number of people #18 years old in the study year.17 A general linear
model was created to compare trends in continuous variables, and
a logistic regression model was used to compare differences in
years among categoric variables. For multivariable analysis, the
following variables were included in the model: calendar year,
hospital characteristics, sex, ethnicity, age, cardiomyopathy,
CHD, myocarditis, cardiac procedures, arrhythmias, pulmonary
hypertension, sepsis, acute cerebrovascular disease (CVD), respiratory failure, acute renal failure, hepatic impairment, ventricular
assist device (VAD), and extracorporeal membrane oxygenation
(ECMO). All variables had !5% missing values with the exception of ethnicity. For this variable, values were imputed for missing values with the most common value, as described previously.18
The results of the multivariable analysis were similar whether
imputation was performed or not. All analyses were performed
on weighted values with SPSS version 18.0 (SPSS, Chicago,
Illinois, USA). Statistical significance was defined as P ! .05.

Results
In 1997 there were 13,227 (95% confidence interval [CI]
10,539e15,915) pediatric heart failureerelated admissions
(Table 1). This number decreased to 11,153 (95% CI
8,898e12,409) in 2003 and increased again in 2006 to
13,892 (95% CI 11,528e16,256). From a population standpoint, admissions ranged from a low of 15.2 per 100,000
children in 2003 to a high of 17.9 per 100,000 children in
2006. The majority of patients were infants (!1 year) in
all years, and the proportion of infants increased from
54.7% in 1997 to 63.9% in 2006 (P ! .001). Additionally,
the vast majority of admissions occurred in urban and
teaching hospitals. Likewise, more patients were hospitalized in large hospitals compared with small or mediumsized hospitals, and this percentage significantly increased
from 48.5% in 1997 to 65.1% in 2006 (P ! .001).
There were many cardiac and noncardiac comorbidities in
this cohort. CHD was found in the majority of patients, and
the portion of patients with CHD increased over time from
60.6% in 1997 to 69.3% in 2006 (Table 2). Other cardiac
comorbidities included cardiomyopathy in 12.8%e13.6%,
myocarditis in 1.7%e2.1%, and arrhythmias in 12.2%
e15.2%. A cardiac surgical or interventional procedure
was performed in 30.6%e38.8% of patients. ECMO and
VAD use were uncommon, occurring in only 2.8% and
0.8% in 2006, respectively. Noncardiac comorbidities were
common and tended to increase during the study period,
including sepsis, which increased from 6.0% in 1997 to
13.2% in 2006, and acute renal failure, which increased
from 3.1% in 1997 to 5.9% in 2006 (P ! .001 for both).
The duration of hospitalization increased significantly
during the study. The mean LOS was 13.8 days in 1997

Heart Failure Hospitalizations in Children

Rossano et al

461

Table 1. Characteristics of Heart FailureeRelated Hospitalizations

1997
Hospitalizations
Hospitalization rate
Female
Nonwhite*
Childrens hospital*
Age, y*
!1
1e12
13e18
Urban location*

2000

2003

2006

13,227
17.7
50.6%
44.5%
67.7%

(10,539e15,915)
(14.1e21.3)
(48.8e52.4)
(39.4e49.8)
(58.7e75.6)

11,643
15.2
47.9%
50.5%
69.2%

(9,382e13,902)
(12.2e18.2)
(46.0e49.7)
(44.7e56.3)
(61.5e75.9)

11,153
14.5
49.2%
50.4%
75.6%

(8,898e13,409)
(11.5e17.4)
(47.7e50.8)
(44.7e56.0)
(69.1e81.1)

13,892
17.9
48.4%
49.8%
80.3%

(11,528e16,256)
(14.8e20.9)
(46.9e49.8)
(44.8e54.8)
(75.5e84.4)

54.7%
30.9%
14.4%
94.2%

(52.5e56.8)
(29.0e32.9)
(12.9e16.1)
(92.3e95.7)

58.7%
26.9%
14.4%
94.8%

(56.2e61.2)
(24.5e29.5)
(12.4e16.6)
(92.3e96.5)

56.5%
26.6%
16.9%
96.8%

(54.4e58.5)
(25.1e28.2)
(15.0e19.0)
(95.2e97.8)

63.9%
21.7%
14.4%
98.0%

(61.8e65.9)
(20.0e23.5)
(13.0e15.9)
(96.9e98.8)

95% confidence intervals are presented in parentheses.

*P ! .05 across years.

and increased to 19.4 days in 2006 (P ! .001). This corresponded to total hospital days for 2006 of 269,615 (95% CI
220,174e319,056). Many factors were associated with increased hospital LOS including nonwhite ethnicity, cardiomyopathy, sepsis, acute renal failure, undergoing a cardiac
surgical or interventional procedure, and ECMO (Fig. 1).
The overall unadjusted hospital mortality for patients with
a diagnosis of heart failure was 7.4%, which was significantly higher than for children without heart failure at
0.4% (odds ratio 20.60, 95% CI 18.85e22.51). Mortality
did not vary significantly over the study years and ranged
from 7.2% to 7.9%. The crude mortality ranged from 6.2%
in patients with congenital heart disease to 48.4% in patients
undergoing ECMO (Fig. 2). On univariable analysis, factors
associated with the greatest increase in the risk of hospital
mortality included ECMO, acute renal failure, VAD, and
hepatic impairment (Table 3). The contribution of these
factors remained after adjustment of multivariable analysis,
although the adjusted odds ratios were less. Infants and nonwhite ethnicity were significantly associated with mortality
after adjustment with adjusted odds ratios of 1.32 and 1.16,
respectively. Factors associated with an increased likelihood
of hospital survival included later calendar year (2006 vs all

other years), congenital heart disease, myocarditis, and

undergoing a cardiac surgical or interventional procedure.

Discussion
This study represents the largest population-based study
of childhood heart failureerelated hospitalizations from
all etiologies to date. A number of important observations
merit special note. The total number of hospitalizations
annually over the 10-year time period of the study ranged
from 11,000 to almost 14,000. Although it was our hypothesis that heart failure admissions would have increased over
time, the observed differences were not statistically significant. The precise reason for this is unknown; it may be that
the time period of the study was not of sufficient length to
observe significant differences. Alternatively, it is possible
that the prevalence and outcome of conditions such as
pediatric cardiomyopathy and myocarditis has not varied
significantly over time, thus contributing to the stable
number of pediatric heart failure admissions observed.
Although the absolute number of heart failure admissions
in children is far less than in adult patients in the United

Table 2. Comorbidites and Procedures in Patients With a Diagnosis of Heart Failure

1997
Comorbidity
Cardiomyopathy
Congenital heart disease*
Myocarditis
Arrhythmias*
Pulmonary hypertension
Sepsis*
Acute cerebrovascular disease
Respiratory failure*
Acute renal failure*
Hepatic impairment
Procedure
Cardiac procedure
ECMO*
VAD

12.8%
60.6%
1.7%
13.2%
10.6%
6.0%
1.2%
5.9%
3.1%
2.3%

(11.4e14.3)
(55.3e65.6)
(1.3e2.3)
(12.2e14.4)
(8.7e12.7)
(5.1e7.1)
(0.9e1.5)
(4.8e7.2)
(2.4e4.0)
(1.8e2.9)

30.6% (23.3%e38.9%)
1.1% (0.8e1.4)
0.3% (0.2 0.6)

2000
13.6%
64.9%
2.1%
12.1%
9.7%
7.4%
0.9%
8.9%
3.9%
2.0%

(11.6e15.8)
(60.1e69.5)
(1.7e2.7)
(10.7e13.6)
(8.3e11.4)
(6.4e8.5)
(0.7e1.3)
(7.2e10.9)
(3.1e4.8)
(1.4e2.7)

32.3% (25.9e39.3)
1.5% (1.1e2.0)
0.6% (0.4e0.9)

ECMO, extracorporeal membrane oxygenation; VAD, ventricular assist device.

95% confidence intervals are presented in parentheses.
*P ! .05 across years.

2003
15.0%
65.4%
2.2%
13.8%
9.8%
9.4%
1.2%
12.0%
4.6%
2.2%

(12.8e17.4)
(60.5e70.0)
(1.8e2.7)
(12.7e15.1)
(8.7e11.1)
(8.3e10.8)
(0.9e1.5)
(10.0e14.5)
(3.7e5.5)
(1.7e2.7)

37.6% (30.6e45.2)
2.0% (1.6e2.5)
0.6% (0.4e0.9)

2006
13.6%
69.3%
2.1%
15.2%
10.0%
13.2%
1.2%
12.0%
5.9%
2.6%

(12.3e15.1)
(66.7e71.7)
(1.7e2.4)
(14.0e16.6)
(9.1e11.0)
(12.2e14.3)
(1.0e1.5)
(10.5e13.5)
(5.0e6.9)
(2.1e3.0)

38.8% (34.5%e43.3%)
2.8% (2.4e3.3)
0.8 (0.6e1.1)

462 Journal of Cardiac Failure Vol. 18 No. 6 June 2012

Fig. 1. Mean hospital length of stay for children with heart failureerelated hospitalizations. CHD, congenital heart disease; CVD, cerebrovascular disease; ECMO, extracorporeal membrane oxygenation; HTN, hypertension; VAD, ventricular assist device. *Factor associated
with increased hospital length of stay (P ! .05).

States, which at O3.5 million hospitalizations annually

is O250-fold higher than in children,1 it represents an
increasingly important disorder in children and in health
care costs. This discrepancy between adults and children,
however, is less when looking at a population level. In
a large series from Scotland, the age-adjusted rate for first
heart failure hospitalization peaked at 162 per 100,000
and decreased to 101 per 100,000 in 2003.6 When looking
at the United States, the age-adjusted rate for any heart

failureerelated hospitalizations has been increasing over

time and was O900 per 100,000 in 2004.1 In the present
study, there were 14.5e17.9 heart failureerelated hospitalizations per 100,000 children. This is similar to what has
been reported for other serious acute diseases in children,
such as severe sepsis, with a reported prevalence of 56
cases per 100,000 children and an overall mortality of
10%.19 Thus, in the context of overall child health, the
burden of disease is significant.

Fig. 2. Hospital mortality for children with heart failure related hospitalizations. Abbrreviations as in Fig. 1. *Factor associated with
increased hospital mortality (P ! .05).

Heart Failure Hospitalizations in Children

Table 3. Factors Associated With Mortality Among
Patients With a Diagnosis of Heart Failure
Univariable

Multivariable

Factor

Odds
Ratio

95%
CI

Odds
Ratio

95%
CI

Year 2006 vs all others

Urban hospital
Childrens hospital
Female
Nonwhite
Infants
Cardiomyopathy
Congenital heart disease
Myocarditis
Cardiac procedure
Arrhythmias
Pulmonary hypertension
Sepsis
Stroke
Respiratory failure
Acute renal failure
Hepatic impairment
ECMO
VAD

0.97
1.57
1.32
1.06
1.27
0.94
1.30
0.62
1.30
0.87
1.55
1.30
4.26
4.59
4.65
8.37
5.70
13.16
6.53

0.85e1.13
1.10e2.24
1.12e1.56
0.96e1.18
1.12e1.43
0.84e1.05
1.13e1.49
0.55e0.71
0.97e1.74
0.73e1.05
1.35e1.77
1.11e1.51
3.75e4.84
3.46e6.08
4.07e5.30
7.09e9.88
4.59e7.08
11.02e15.71
4.66e9.15

0.70
0.99
1.18
1.11
1.16
1.32
0.94
0.74
0.45
0.81
1.47
1.33
2.71
2.13
2.92
4.46
3.16
8.50
1.93

0.61e0.80
0.67e1.48
0.99e1.41
0.99e1.25
1.04e1.31
1.16e1.52
0.78e1.12
0.64e0.86
0.30e0.68
0.67e0.97
1.27e1.71
1.14e1.57
2.35e3.14
1.46e3.10
2.52e3.40
3.70e5.37
2.45e4.09
6.71e10.79
1.18e3.16

Abbreviations as in Table 2.

Heart failure in children, as in adults, is a morbid condition. A significant minority of patients had arrhythmias,
pulmonary hypertension, sepsis, or respiratory failure. Importantly, these morbidities tended to increase over time.
Likewise, the patients were hospitalized for prolonged periods, and the duration of hospitalization increased O40%
during the study years. The total number of hospitalized
days for children with heart failure in 2006 was just under
270,000. The full impact of this is difficult to measure, but
would certainly be immense in terms of cost to society and
detriment to families. The full economic, societal, and
family burden of pediatric heart failure cannot be gleaned
from this study, but there is reason to infer that the burden
is great.
Some other important trends also merit discussion. CHD
was seen in the majority of patients, and the frequency
increased from just over 60% in 1997 to almost 70% in
2006. Because most serious CHD presents in infancy, it is
not surprising that infants composed the majority of patients,
which increased throughout the study years, peaking in 2006
at 64%. In addition, the largest percentage of children with
cardiomyopathies present in the first year of life.20 In the
case of CHD-related heart failure, many of these patients underwent a cardiac surgical or interventional procedure, and
having CHD or undergoing a cardiac procedure was independently associated with a decreased risk of death. Clearly,
CHD is a diverse entity that encompasses simple lesions,
such as a ventricular septal defect, to complex lesions,
such a hypoplastic left heart syndrome or other functional
single ventricle variants. The risk of these lesions would
not be expected to be similar, and the improved outcome
of the CHD group overall is very likely skewed by the
more prevalent simple lesions.21 The impact of different

Rossano et al

463

lesions on outcome in patients with heart failure certainly

warrants further study and scrutiny.
Most children were hospitalized in urban and childrens
hospitals, and the proportion of patients hospitalized in
these hospitals increased over time. The precise reasons
for these numbers are unknown, but it may be that providers
in small and rural hospitals recognized the severity of
illness in children with heart failure and transfered to larger
centers with expertise in heart failure appropriately. It is
notable that on multivariable analysis, hospital characteristics were not associated with survival.
Among adult heart failure patients, important sex,22,23
ethnic,22,24,25 and socioeconomic26,27 differences regarding
quality of care and outcomes have also been identified. It is
important to note that nonwhite children had a 16%
increase in the risk of death compared with white children,
after adjustment. It is unclear what other socioeconomic
factors, such as parental income or education level, would
have on outcomes of these children. Whether these factors
would strengthen or weaken the association of ethnicity on
mortality is unknown and merits further inquiry.
The use of mechanical circulatory support, especially
VAD therapy, was uncommon in all years. The use of
ECMO increased over time, yet was still uncommonly
used, being used in !3% of hospitalizations in 2006.
Survival after ECMO was poor, and the use of ECMO
had the greatest influence on hospital mortality. This is
consistent with several reports which have described the
high mortality in heart failure patients where ECMO is
used as bridge to heart transplantation.28,29 Although there
has been an increase in the use of mechanical circulatory
support including the Berlin Heart Excor VAD in pediatric
patients as a bridge to transplantation,30 the impact of this
device and others suitable for some pediatric patients awaits
further study.31
Perhaps the most striking finding of the study was the
overall mortality seen. More than 7% of children with heart
failure died during their hospitalization. This is in stark
contrast to the 0.4% mortality in children without heart
failure. It is important to note that while the unadjusted
mortality was similar in all years, comorbidities were
more common in later years. When these comorbidities
were factored into the multivariable analysis, there was
an improvement in mortality evident in the later study
years. The mortality seen in children with heart failure
also appears to be greater than currently seen in adult
patients, with the overall inpatient mortality rate ranging
from 3% to 7% in many recent reports.1,5 Mortality was
influenced by many factors, including comorbid conditions.
Children with the diagnosis of CHD had an overall mortality of 6.2%, whereas children with acute renal failure had
an overall mortality of 35.4%. Cardiac comorbidities
associated with an increased risk of death in the present
study included pulmonary hypertension and arrhythmias.
Interestingly, a greater impact was seen from noncardiac
comorbidities, including sepsis, acute CVD, hepatic
impairment, and acute renal failure. This is similar to

464 Journal of Cardiac Failure Vol. 18 No. 6 June 2012

findings in adult heart failure patients, in whom noncardiac
morbidities are common and are associated with increased
mortality.1,8,32e35 In particular, respiratory failure, renal
disease, and CVD have been strongly correlated with an
increase risk of death among heart failure patients.6,32,34e38
Limitations

The present study has several limitations. It is a retrospective analysis of a large administrative database. Identification of patients was by ICD-9 codes, and there exists no
gold standard for the diagnosis of heart failure. Likewise,
all comorbidities identified are subject to the same limitation. Although there are quality control measures instituted
by the Department of Health and Human Services, which
oversees the database, there is no panel of heart failure
specialists that adjudicates cases. Also, there are no clinical
data such as vital signs, laboratory results, echocardiogram
reports, or medication use and timing. Additionally, only
hospital data are available, and the data are deidentified.
This precludes determining outcomes such as death after
discharge and readmission rates. Although the 10-year
time period of the study does provide some significant
duration to evaluate trends, that time period is still
relatively short. Further follow-up studies are needed to
determine if the trends observed continue over time.
Conclusion
Heart failureerelated hospitalizations occur in
11,000e14,000 children yearly in the United States with
an overall mortality of 7%. From 1997 to 2006, hospital
LOS increased 40%, corresponding to O250,000 total
hospital days in 2006. Many comorbid conditions influenced hospital mortality. Ongoing study of management
strategies is needed to improve the morbidity and mortality
of caring for this complex group of patients.
Disclosures
None.

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predictors of incident heart failure. J Card Fail 2006;12:540e5.
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Dobbels F, et al. The registry of the International Society for Heart
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Massicotte MP, et al. Bridging children of all sizes to cardiac transplantation: The initial multicenter north american experience with
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Heart failure survival among older adults in the united states: a poor
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Fonarow GC, Adams KF Jr, Abraham WT, Yancy CW, Boscardin WJ.
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fraction. Am J Cardiol 2011;107:79e84.

466 Journal of Cardiac Failure Vol. 18 No. 6 June 2012

Supplemental Table 1. ICD-9 Codes for Diagnoses and Procedures
ICD-9 Code
Heart Failure
402.01
402.11
402.91
404.01
404.03
404.11
404.13
404.91
404.93
428.00
428.01
428.20
428.21
428.22
428.23
428.30
428.31
428.32
428.33
428.40
428.41
428.42
428.43
428.9
398.91
Congenital heart disease
745.0
745.10
745.11
745.12
745.19
745.2
745.3
745.4
745.5
745.60
745.61
745.69
746.00
746.01
746.02
746.09
746.1
746.2
746.3
746.6
746.6
746.7
746.81
746.82
746.83
746.84
746.85
746.86
746.87
746.89
746.9
747.0
747.10
747.11
747.20
747.11
747.22
747.29
747.3
747.40
747.41
747.42
747.49

Description
Malignant hypertensive heart disease with heart failure
Benign hypertensive heart disease with heart failure
Unspecified hypertensive heart disease with heart failure
Malignant hypertensive heart and renal disease with heart failure
Malignant hypertensive heart and renal disease with heart failure and renal failure
Benign hypertensive heart and renal disease with heart failure
Benign hypertensive heart and renal disease with heart failure and renal failure
Unspecified hypertensive heart and renal disease with heart failure
Unspecified hypertensive heart and renal disease with heart failure and renal failure
Unspecified congestive heart failure
Left heart failure
Unspecified systolic heart failure
Acute systolic heart failure
Chronic systolic heart failure
Acute or chronic systolic heart failure
Unspecified diastolic heart failure
Acute diastolic heart failure
Chronic diastolic heart failure
Acute or chronic diastolic heart failure
Unspecified combined systolic and diastolic heart failure
Acute combined systolic and diastolic heart failure
Chronic combined systolic and diastolic heart failure
Acute or chronic combined systolic and diastolic heart failure
Unspecified heart failure
Rheumatic heart failure
Common truncus
Complete transposition of the great vessels
Double-outlet right ventricle
Corrected transposition of the great vessels
Other transposition of the great vessels
Tetralogy of Fallot
Common ventricle
Ventricular septal defect
Ostium secundum type atrial septal defect
Unspecified endocardial cushion defect
Ostium primum defect
Other endocardial cushion defect
Unspecified pulmonary valve anomaly
Congenital pulmonary valve atresia
Congenital pulmonary valve stenosis
Other pulmonary valve anomaly
Congenital tricuspid atresia and stenosis
Ebstein anomaly
Congenital stenosis of the aortic valve
Congenital insufficiency of aortic valve
Congenital mitral stenosis
Hypoplastic left heart syndrome
Subaortic stenosis
Cor triatriatum
Infundibular pulmonic stenosis
Obstructive anomalies of heart, not elsewhere classified
Coronary artery anomaly
Congenital heart block
Malposition of heart and cardiac apex
Other specified anomalies of heart
Unspecified anomalies of heart
Patent ductus arteriosus
Coarctation of aorta
Interruption of aortic arch
Unspecified anomaly of aorta
Anomalies of aortic arch
Atresia and stenosis of aorta
Other anomalies of aorta
Anomalies of pulmonary artery
Unspecified anomaly of great veins
Total anomalous pulmonary venous connection
Partial anomalous pulmonary venous connection
Other anomalies of great veins
(continued on next page)

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Rossano et al

467

Supplemental Table 1. (Continued )

ICD-9 Code
Cardomyopathy
425.00
425.10
425.20
425.30
425.40
425.50
425.70
425.80
425.90
Myocarditis
032.82
036.40
036.43
074.20
074.23
130.3
391.2
398.0
422.0
422.90
422.91
422.92
422.93
422.99
429.0
Cardiac Procedures
35.0
35.00
35.01
35.02
35.03
35.04
35.1
35.10
35.11
35.12
35.13
35.14
35.20
35.21
35.22
35.23
35.24
35.25
35.26
35.27
35.28
35.31
35.32
35.33
35.34
35.35
35.39
35.41
35.42
35.50
35.51
35.52
35.53
35.54
35.55
35.60
35.61
35.62
35.63
35.70
35.71
35.72
35.73
35.81

Description
Endomyocardial fibrosis
Hypertrophic obstructive cardiomyopathy
Obscure cardiomyopathy of Africa
Endocardial fibroelastosis
Other primary cardiomyopathies
Alcoholic cardiomyopathy
Nutritional and metabolic cardiomyopathy
Cardiomyopathy in other diseases classified
Secondary cardiomyopathy, unspecified
Diptheric myocarditis
Unspecified meningococcal carditis
Meningococcal myocarditis
Unspecified Coxsackie carditis
Coxsackie myocarditis
Myocarditis due to toxoplasmosis
Acute rheumatic myocarditis
Rheumatic myocarditis
Acute myocarditis in diseases classified elsewhere
Other and unspecified acute myocarditis
Idiopathic myoarditis
Septic myocarditis
Toxic myocarditis
Other acute and unspecified acute myocarditis
Unspecified myocarditis
Closed heart valvotomy (excludes percuteaneous balloon valvuloplasty)
Closed heart valvotomy, unspecified valve
Closed heart valvotomy, aortic valve
Closed heart valvotomy, mitral valve
Closed heart valvotomy, pulmonary vavle
Closed heart valvotomy, tricuspid valve
Open heart valvuloplasty without replacement
Open heart valvuloplasty without replacement, unspecified valve
Open heart valvuloplasty of aortic valve without replacement
Open heart valvuloplasty of mitral valve without replacement
Open heart valvuloplasty of pulmonary valve without replacement
Open heart valvuloplasty of tricuspid valve without replacement
Replacement of unspecified heart valve
Replacement of aortic valve with tissue graft
Other replacement of mitral valve with tissue graft
Replacement of mitral valve with tissue graft
Other replacement of mitral valve
Replacement of pulmonary valve with tissue graft
Other replacement of pulmonary valve
Replacement of tricuspid valve with tissue graft
Other replacement of tricuspid valve
Operations on papillary muscles
Operations on chordae tendineae
Annuloplasty
Infundibulectomy
Operations on trabeculae careae cordis
Operations on other structures adjacent to valves of heart
Enlargement of existing atrial septal defect
Creation of septal defect in heart
Repair of unspecified septal defect of heart with prosthesis
Repair of atrial septal defect with prosthesis, open technique
Repair of atrial septal defect with prosthesis, closed technique
Repair of ventricular septal defect with prosthesis
Repair of endocardial cushing defect with prosthesis
Repair of ventricular septal defect with prosthesis, closed technique
Repair of unspecified septal defect of heart with tissue graft
Repair of atrial septal defect with tissue graft
Repair of ventricular septal defect with tissue graft
Repair of endocardial cushion defect with tissue graft
Other and unspecified repair of unspecified septal defect of heart
Other and unspecified repair of atrial septal defect
Other and unspecified repair of ventricualr septal defect
Other and unspecified repair of endocardial cushion defect
Repair of tetralogy of Fallot
(continued on next page)

468 Journal of Cardiac Failure Vol. 18 No. 6 June 2012

Supplemental Table 1. (Continued )
ICD-9 Code
35.82
35.83
35.84
35.91
35.92
35.93
35.94
35.95
35.96
35.98
35.99
36.03
36.09
36.1
36.10
36.11
36.12
36.13
36.14
36.15
36.16
36.17
36.19
36.2
36.31
36.32
36.33
36.39
36.91
36.99
37.0
37.10
37.11
37.12
37.24
37.31
37.32
37.33
37.35
37.41
37.49
37.67
37.70
37.71
37.72
37.73
37.74
37.75
37.76
37.77
37.78
37.79
37.80
37.81
37.82
37.83
37.85
37.86
37.87
37.89
37.90
37.91
37.92
37.93
37.94
37.95
37.96
37.97

Description
Total repair of total anomalous pulmonary venous connection
Total repair of truncus arteriosus
Total correction of transposition of the great vessels, not elsewhere classified
Interatrial transposition of venous return
Creation of conduit between right ventricle and pulmonary artery
Creation of conduit between left venticle and aorta
Creation of conduit between atrium and pulmonary artery
Revisioun of corrective procedure on heart
Percutaneous valvuloplasty
Other operations on septa of heart
Other operations on valves of heart
Open chest coronary angioplasty
Other removal of coronary artery obstruction (excludes that by open angioplasty
or percutaneous transluminal coronary angioplasty or artherectomy)
Bypass anastomosis for heart revascularization
Aortocoronary bypass for heart revascularization, not otherwise specified
Aortocoronary bypass of one coronary artery
Aortocoronary bypass of two coronary arteries
Aortocoronary bypass of three coronary arteries
Aortocoronary bypass of four or more coronary arteries
Single internal mammary-coronary artery bypass
Double internal mammary-coronary artery bypass
Abdominal-coronary artery bypass
Other bypass anastomosis for heart revascularization
Heart revascularization by arterial implant
Open chest transmuocardial revascularization
Other transmyocardial revascularization
Endoscopic transmyoardial revascularizaiton
Other heart revascularization
Repair of aneurysm of coronary vessel
Other operations on vessels of heart
Pericardiocentesis
Incision of the heart, not otherwise specified
Cardiotomy
Pericardiotomy
Biopsy of pericardium
Pericardiectomy
Excision of aneurysm of heart
Excision or destruction of other lesion or tisssue of heart, open approach
Parial ventriculectomy
Implantation of prosthetic cardiac support device around the heart
Other repair of heart and pericardium
Inplantation of cardiomyostimulation system
Initial insertion of lead, not otherwise specified
Initial insertion of transvenous lead into ventricle
Initial insertion of transvenous leads into atrium and ventricle
Initial insertion of transvenous lead into atrium
Insert/replace epicardial lead into epicardium
Revision of lead
Replacemnt of transvenous atrial and/or ventricular leads
Removal of leads without replacement
Insertion of temporary transvenous pacemaker system
Revision or relaocation of pacemaker pocket
Insertion of permanent pacemaker, inial or replacement, type of device not specified
Initial insertion of single-chamber device, not specified as rate response
Initial insertion of a single-chamber device, rate responsive
Initial insertion of dual-chamber device
Replacement of any type pacemaker device with single-chamber device, not
specified as rate responsive
Replacement of any type pacemaker device with single-chamber device,
rate responsive
Replacement of any type pacemaker device with dual-chamber device
Revision or removal of pacemaker device
Insertion of left atrial appendage device
Open cardiac massage
Injection of therapeutic substance into heart
Injection of therapeutic substance into pericardium
Implantation or replacement of automatic cardioverter/defibrillator, total system
Implantation of automatic cardioverter/defibrillator leads only
Implantation of automatic cardioverter/defibrillator pulse generator only
Replacement of automatic cardioverter/defibrillator leads only
(continued on next page)

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469

Supplemental Table 1. (Continued )

ICD-9 Code
37.98
37.99
38.04
38.05
38.14
38.15
38.34
38.35
38.44
38.45
38.65
38.7
38.85
39.0
39.21
39.22
39.23
39.54
39.57
39.58
39.64
Pulmonary Hypertension
415.0
416.0
416.8
416.9
Arrhythmias
426.0
426.54
426.7
426.81
426.82
427.0
427.1
427.2
427.31
427.32
427.41
427.42
427.81
427.89
427.9
785.0
Acute Renal Failure
584.5
584.6
584.7
584.8
584.9
Respiratory Failure
518.81
518.83
518.84
799.1
Acute Cerebrovascular Disease
430
431
432.0
432.1
432.9
433.01
433.11
433.21
433.31
433.81
433.91
434.00
434.01
434.10
434.11
434.90

Description
Replacement of automatic cardioverter/defibrillator pulse generatory only
Other cardiac procedures
Incision of vessels, aorta
Incision of vessels, orther thoracic vessels
Endarectomy, aorta
Endarectomy, other thoracic vessels
Resection of vessel with anastomosis, aorta
Resection of vessel with anastomosis, other thoracic vessels
Resection of vessel with replacement, aorta
Resection of vessel with replacement, other thoracic vessels
Other excision of vessels, thoracic vessels
Interruption of vena cava
Other surgical occlusion of vessels, thoracic vessel
Systemic to pulmonary artery shunt
Caval-pulmonary anastomosis
Aortaesubclavian artery bypass
Other intrathoracic vascular shunt or bypass
Reentry operation (aorta)
Repair of blood vessel with synthetic patch graft
Repair of blood vessel with uspecified type of patch graft
Intraoperative cardiac pacemaker
Acute cor pulmonale
Primary pulmonary hypertension
Other chronic pulmonary heart diseases
Unspecified chronic pulmonary heart disease
Third-degree atrioventricular block
Trifascicular block
Anomalous atrioventricular excitation
Lown-Ganong-Levine syndrome
Long QT syndrome
Paroxysmal supraventricular tachycardia
Paroxysmal ventricular tachycardia
Unspecified paroxysmal tachycardia
Atrial fibrillation
Atrial flutter
Ventricular fibrillation
Ventricular flutter
SA node dysfunction
Other specified cardiac dysrhythmias
Unspecified cardiac dysrhythmia
Unspecified tachycardia
Acute renal failure (ARF) with tubular necrosis
ARF with lesion of renal cortical necrosis
ARF with lesion of renal medullary necrosis
ARF with other specified pathologic lesion in kidney
Unspecified ARF
Acute respiratory failure
Chronic respiratory failure
Acute and chronic respiratory failure
Respiratory arrest
Subarachnoid hemorrhage
Intracerebral hemorrhage
Nontraumatic extradural hemorrhage
Subdural hemorrhage
Intracranial hemorrhage, not otherwise specificed
Basilar artery occlusion with cerebrovascular accident (CVA)
Carotid artery occlusion with CVA
Vertebral artery occlusion with CVA
Multiple and bilateral arterial occlusion with CVA
Other specified precerebral artery occlusion and CVA
Unspecified precerebral artery occlusion and CVA
Cerebral thrombosis without mention of CVA
Cerebral thrombosis with CVA
Cerebral embolism without mention of CVA
Cerebral embolism with CVA
Unspecified cerebral artery occlusion without mention of CVA
(continued on next page)

470 Journal of Cardiac Failure Vol. 18 No. 6 June 2012

Supplemental Table 1. (Continued )
ICD-9 Code
434.91
437.1
438.9
997.02
Hepatic Impairment
570
571.0
571.1
571.2
571.3
571.40
571.41
571.42
571.49
571.5
571.6
571.8
571.9
572.0
572.2
572.3
572.4
572.8
573.0
573.3
573.4
573.8
573.9
Sepsis/Systemic Inflammatory Response Syndrome (SIRS)
995.90
995.91
995.92
995.93
995.94
038.0
038.10
038.11
038.12
038.19
038.2
038.3
038.40
038.41
038.42
038.43
038.44
038.49
038.8
038.9
054.5
790.7
771.81
771.83
Extracorporeal membrane oxygenation (ECMO)
39.65
Ventricular Assist Device
37.60
37.62
37.65
37.66
37.68
37.52
37.61

Description
Unspecified cerebral artery occlusion with CVA
Other generalized ischemic cerebrovascular disease
Unspecified CVA, late effect
Iatrogenic cebrovasuclar infarction or hemorrhage
Acute and subacute necrosis of liver
Alcoholic fatty liver
Acute alcoholic hepatitis
Alcoholic liver cirrhosis
Unspecified alcoholic liver damage
Unspecified chronic hepatitis
Chronic persistent hepatitis
Autoimmune hepatitis
Other chronic hepatitis
Cirrhosis, not otherwise specified
Primary biliary cirrhosis
Other chronic nonalcoholic liver disease
Unspecified chronic liver disease
Liver abscess and sequelae of chronic liver disease
Hepatic coma
Portal hypertension
Hepatorenal syndrome
Other sequelae of chronic liver disease
Chronic passive congestion of liver
Hepatitis, unspecified
Hepatic infarction
Other specified disorders of liver
Unspecified disorder of liver
Unspecified SIRS
Sepsis
Severe sepsis
SIRS due to noninfectious process without acute organ dysfunction
SIRS due to noninfectious process with acute organ dysfunction
Streptococcal septicemia
Unspecified staphylococcal septicemia
Methicillin-sensitive staphylococcal septicemia
Methicillin-resistant staphylococcal septicemia
Other staphylococcal septicemia
Pneumococcal septicemia
Septicemia due to anaerobes
Unspecified gram-negative septicemia
Haemophilus influenzae septicemia
Escherichia coli septicemia
Pseudomonas septicemia
Serratia septicemia
Other septicemia
Other specified septicemias
Septicemia, not otherwise specified
Herpetic septicemia
Bacteremia
Septicemia of the newborn
Bacteremia of the newborn
ECMO
Implantation of heart and circulatory assist system
Insertion of temporary nonimplantable extracorporeal circulatory assist system
Implant of single ventricular (extracorporeal) external heart assist system
Insertion of implantable heart assist system
Insertion of percutaneous external heart assist device
Implantation of total replacement heart system
Implantation of pulsation balloon