30-day Cardiovascular Mortality Research Articles

Long-term outcome after unprotected left main percutaneous coronary intervention in patients with acute myocardial infarction complicated by cardiogenic shock: a landmark analysis

Abstract Funding Acknowledgements None. Background Early revascularization of culprit arteries has demonstrated to improve outcomes in patients with acute myocardial infarction (AMI) complicated by cardiogenic shock (CS), however, little is known about long-term outcome after unprotected left main (LM) percutaneous coronary intervention (PCI) in patients with AMI-CS. Methods We retrospectively investigated 2325 consecutive patients with AMI who underwent primary percutaneous coronary intervention (pPCI) in our institution from January 2004 to December 2017. The primary outcome was cardiovascular (CV) death up to 3yrs. Results Among the 2325 eligible patients, 272 AMI patients (11.7%) were complicated by CS on admission (AMI-CS). The mean age was 71 years, 75% of patients were male, STEMI was seen in 86%, and mechanical circulatory support was used in 61%. Of 272 AMI-CS, 35 (14.0%) patients were treated with PCI for LM and had significantly higher 30-day cardiovascular mortality (52.6%) compared with those treated with PCI for non-LM (24.8%) (p = 0.0001). Kaplan-Meier analysis showed that mortality up to 3 years was significantly higher in AMI-CS patients with LM compared those with non-LM (p < 0.0001). Multivariate Cox regression analysis showed LM was significantly associated with higher cardiovascular mortality (adjusted HR 1.90, 95%CI 1.18-3.07, p = 0.0088). Conclusions Primary PCI of the LM was performed in 14.0% of patients with AMI-CS. Short- and long-term CV mortality was significantly higher with LM AMI-CS than non-LM AMI-CS. Further studies should evaluate to improve both short- and long-term outcome among AMI-CS with LM.

Association of acute glycemic parameters at admission with cardiovascular mortality in the oldest old with acute myocardial infarction.

Stress-related glycemic indicators, including admission blood glucose (ABG), stress-hyperglycemia ratio (SHR), and glycemic gap (GG), have been associated with worse outcomes after acute myocardial infarction (AMI). However, data regarding their prognostic value in the oldest old with AMI are unavailable. Therefore, this study aimed to investigate the association of stress-related glycemic indicators with short- and long-term cardiovascular mortality (CVM) in the oldest old (≥ 80 years) with AMI. In this prospective study, a total of 933 consecutive old patients with AMI admitted to FuWai hospital (Beijing, China) were enrolled. On admission, ABG, SHR, and GG were assessed and all participants were classified according to their quartiles. Kaplan-Meier, restricted cubic splines (RCS), and multivariate Cox regression analyses were performed to evaluate the association between these glycemic indicators and CVM within 30 days and long-term follow-up. During an average of 1954 patient-years of follow-up, a total of 250 cardiovascular deaths were recorded. Kaplan-Meier analyses showed the lowest CVM in quartile 1 of ABG and in quartile 2 of SHR and GG. After adjusting for potential covariates, patients in quartile 4 of ABG, SHR, and GG had a respective 1.67-fold (95% CI: 1.03-2.69; P = 0.036), 1.80-fold (95% CI: 1.16-2.79; P = 0.009), and 1.78-fold (95% CI: 1.14-2.79; P = 0.011) higher risk of long-term CVM risk compared to those in the reference groups (quartile 1 of ABG and quartile 2 of SHR and GG). Furthermore, RCS suggested a J-shaped relationship of ABG and a U-shaped association of SHR and GG with long-term CVM. Additionally, we observed similar associations of these acute glycemic parameters with 30-day CVM. Our data first indicated that SHR and GG consistently had a U-shaped association with both 30-day and long-term CVM among the oldest old with AMI, suggesting that they may be useful for risk stratification in this special population.

Gender differences in clinical features and outcomes of patients over 75 years presenting with acute heart failure. Results of a nationwide study (2016-2019).

Heart failure (HF) is a major health problem in Western countries, and a leading cause of hospitalizations and death. There is a scarcity of data on the influence of sex on HF outcomes in elderly patients. The aim of the present study was to analyze differences between men and women in clinical characteristics, in-hospital mortality, 30-day HF readmission rates, cardiovascular mortality and HF readmission rates at 1 year after discharge in patients older than 75 years hospitalized for HF in Spain. Retrospective analysis of patients discharged with a main diagnosis of HF from all Spanish public hospitals between 2016 and 2019. Patients aged 75 years or older were selected, and a comparison was made between male and female patients. From 2016 to 2019, a total of 354,786 episodes of HF in this age subgroup were identified, 59.2% being women. The overall mean age was 85.2 ± 5.4 years, being higher in women (85.9 ± 5.5 vs. 84.2 ± 5.3 years, p < 0.001). Risk-adjusted in-hospital mortality was lower in women (odds ratio [OR]: 0.96, 95% confidence interval [CI]: 0.92-0.97; p < 0.001). Female sex also showed a protective effect for 30-day readmissions, with an OR of 1.06 (95% CI: 1.04-1.09; p < 0.001). One-year cardiovascular mortality (24.1% vs. 25.0%; p < 0.001) and one-year HF readmission rates (30.8% vs. 31.6%; p = 0.001) were lower in women. Almost 60% of hospital admissions for HF in people aged 75 years or older between 2016 and 2019 in Spain were female patients. Female sex seems to play a protective role on in-hospital mortality and the rate of admissions and mortality at 1 year after discharge.

Real-World Evaluation of a Pharmacoinvasive Strategy for STEMI in Latin America: A Cost-Effective Approach with Short-Term Benefits.

While pharmacoinvasive strategy (PI) is a safe and effective approach whenever access to primary percutaneous intervention (pPCI) is limited, data on each strategy's economic cost and impact on in-hospital stay are scarce. The objective is to compare the cost-effectiveness of a PI with that of pPCI for the treatment of ST-elevation myocardial infarction (STEMI) in a Latin-American country. A total of 1747 patients were included, of whom 470 (26.9%) received PI, 433 (24.7%) pPCI, and 844 (48.3%) NR. The study's primary outcome was the incremental cost-effectiveness ratio (ICER) for PI compared with those for pPCI and non-reperfused (NR), calculated for 30-day major cardiovascular events (MACE), 30-day mortality, and length of stay. For PI, the ICER estimates for MACE showed a decrease of $-35.81/per 1% (95 confidence interval, -114.73 to 64.81) compared with pPCI and a decrease of $-271.60/per 1% (95% CI, -1086.10 to -144.93) compared with NR. Also, in mortality, PI had an ICER decrease of $-129.50 (95% CI, -810.57, 455.06) compared to pPCI and $-165.27 (-224.06, -123.52) with NR. Finally, length of stay had an ICER reduction of -765.99 (-4020.68, 3141.65) and -283.40 (-304.95, -252.76) compared to pPCI and NR, respectively. The findings of this study suggest that PI may be a more efficient treatment approach for STEMI in regions where access to pPCI is limited or where patient and system delays are expected.

Urgent versus Non-Urgent Transcatheter Aortic Valve Implantation Outcomes

Introduction: There are limited data about the outcomes of nonelective transcatheter aortic valve implantation (TAVI). Some studies suggest that these patients (pts) have worst results. Our purpose was to compare outcomes in pts submitted to urgent versus elective TAVI. Methods: Retrospective analysis of 298 consecutive pts submitted to TAVI between 2018 and 2021 in a single tertiary center. Baseline characteristics and outcomes were collected and compared between elective and nonelective TAVI. Results: Pts submitted to urgent TAVI (79 pts) had worse baseline characteristics, with higher EuroScore risk (9.26 vs. 5.17%, p < 0.0001), STS score (7.09 vs. 4.4%, p < 0.0001), and NT pro-natriuretic peptide B (10,168 vs. 3,241 pg/mL, p = 0.001), lower left ventricle ejection fraction (45 vs. 52%, p = 0.003), more diabetes (46.8 vs. 32.4%, p = 0.0.22), peripheral artery disease (21.5 vs. 6.8%, p < 0.0001), and poor vascular accesses (18.4 vs. 7.4%, p = 0.007). Urgent TAVI was associated with higher mortality (25.3 vs. 15.1%, p = 0.043), 30-day cardiovascular mortality (17.5 vs. 4%, p = 0.001), life-threatening bleeding (11.5 vs. 4.1%, p = 0.018), vascular complications (11.5 vs. 4.6%, p = 0.031), and longer hospital stay (28 vs. 12 days, p < 0.0001), but not with intensive care unit or post-TAVI hospital stay (5 vs. 4 days, p = 0.197 and 11 vs. 10 days, p = 0.572). When adjusted to differences in baseline characteristics, urgent TAVI was only associated with longer hospital stay (p < 0.0001). Conclusion: Pts submitted to urgent TAVI have worse short-term outcomes, but this seems to be attributable to the worse baseline characteristics instead of the urgent nature of the procedure.

Outcomes and predictors of periprocedural stroke after transcatheter aortic valve implantation

BackgroundRisk factors for stroke after transcatheter aortic valve implantation (TAVI) are currently incompletely understood. PurposeTo identify possible predictors of early post-TAVI stroke and explore its short-term outcomes. MethodsRetrospective analysis of consecutive patients (pts) submitted to TAVI between 2009 and 2020 in a tertiary center. Baseline characteristics, procedural information and stroke in first 30 days after TAVI were collected. In-hospital and 12 months outcomes were analyzed. ResultsA total of 512pts (56,1% female, mean age of 82 ± 6years.) were included. In the first 30 days after TAVI 19pts (3,7%) had a stroke. In univariate analysis stroke was associated with higher body mass index (29 vs 27kg/m2, p=0.035), higher triglyceridemia (> 117,5mg/dL, p=0,002), lower high-density lipoprotein (< 38,5mg/dL, p=0,009) and porcelain aorta (36,8% vs 15,5%, p=0,014) and more frequent use of post-dilatation (58,8% vs 32%, p=0,021). In multivariate analysis, triglycerides > 117,5mg/dL (p=0,032, OR = 3,751) and post-dilatation (p=0,019, OR = 3,694) were the independent predictors. Stroke after TAVI was associated with longer intensive care unit stay (12 vs 4 days, p<0,001) and post-TAVI hospital stay (25 vs 10 days, p<0,0001), higher intra-hospital mortality (21,1% vs 4,3%, p=0,003), cardiovascular 30-day mortality (15,8% vs 4,1%, p=0,026) and 1-year stroke (13,2% vs 1,1%, p=0,003). ConclusionPeriprocedural and 30-day stroke is a relatively uncommon but potentially devastating complication after TAVI. In this cohort, 30-day stroke rate after TAVI was 3.7%. Hypertriglyceridemia and post-dilatation were found to be the only independent risk predictors. Outcomes after stroke, including 30-day mortality, were significantly worse.

A Retrospective Study to Evaluate the Association Between the Glasgow Prognostic Score and Atrial Fibrillation, Stroke, and Mortality at 30 Days and at 1 Year After Coronary Artery Bypass Graft Surgery.

BACKGROUND The Glasgow prognostic score (GPS) consists of a combination of serum C-reactive protein and albumin levels as indicators of systematic inflammatory response and nutritional status, respectively. The present retrospective study aimed to evaluate the association between the GPS and atrial fibrillation, stroke, and mortality at 30 days and 1 year after coronary artery bypass graft (CABG) surgery. MATERIAL AND METHODS Patients with chronic coronary syndromes who underwent CABG surgery between 2012 and 2019 in a single center were included. Preoperative GPS was calculated. Then, patients were grouped according to postoperative atrial fibrillation (POAF) development. Further, groups were formed to evaluate the relationship between GPS and 30-day and 1-year cardiovascular mortality as well as stroke development. RESULTS Patients who developed POAF had higher GPS, higher European System for Cardiac Operative Risk Evaluation (EuroSCORE II) score, advanced age, lower angiotensin converting enzyme inhibitor/angiotensin receptor blocker (ACEI/ARB) use, lower left ventricular ejection fraction, and were more likely to be female and to have a history of carotid artery disease (P<0.05, for all). Additionally, GPS, EuroSCORE II, advanced age, and lower left ventricular ejection fraction were detected as independent risk factors for POAF development. When adverse outcomes were assessed, cardiovascular mortality at 30 days or 1 year, and stroke development at 1 year, were more frequent in patients with POAF. Moreover, POAF development was found to be an independent risk factor for adverse outcomes. Also, GPS was established as an independent risk factor both for 30-day and 1-year cardiovascular mortality (P<0.0001 and P=0.001, respectively). CONCLUSIONS GPS is an easy-to-calculate score that has reasonable diagnostic accuracy in determining the risk of POAF and stroke as well as 30-day and 1-year cardiovascular mortality.

Abstract 15248: Clinical Outcomes of Transcatheter Aortic Valve Replacement With and Without Percutaneous Coronary Intervention - An Updated Meta-Analysis and Systematic Review

Hypothesis: Transcatheter aortic valve replacement (TAVR) serves as a less-invasive treatment option for high-risk patients with severe aortic stenosis. Given the coexistence of obstructive coronary artery disease in patients with high-grade aortic stenosis (estimated to be 40-75%), there is inconsistent clinical data regarding potential mortality benefits of paired percutaneous coronary intervention (PCI) with TAVR procedures. Methods: We performed a literature search using PubMed, Embase, and Cochrane Library from inception through April 2022 to assess the mortality impact of preceding/concomitant PCI in patients undergoing transcatheter aortic valve replacement. The primary outcomes were 30-day all-cause mortality, 30-day cardiovascular mortality, and 6 months-1 year all-cause mortality. Secondary outcomes included 30-day myocardial infarction, stroke, major bleeding/vascular complications, and acute kidney injury. Results: 11 studies (10 retrospective cohort studies, 1 randomized control trial) involving 2791 patients were included in the meta-analysis. Compared to patients undergoing TAVR alone, the TAVR+PCI group showed no significant difference in 30-day all-cause mortality (RR 0.90, CI 0.66, 1.22, p =0.49), 30-day cardiovascular mortality (RR 0.71 CI 0.44, 1.14, p =0.16), or 6 months-1 year all-cause mortality (RR 0.94, CI 0.75, 1.18, p =0.57). Regarding secondary outcomes, 30-day myocardial infarction was higher in the TAVR+PCI group compared to the TAVR group (RR 3.09, CI 1.26, 7.57, p =0.01), while no significant differences were found in rates of 30-day stroke (RR 1.14, CI 0.56, 2.33, p =0.72), major bleeding/vascular complications (RR 1.11, CI 0.79, 1.56, p =0.55), and acute kidney injury (RR 1.07, CI 0.75, 1.54, p =0.71). Conclusion: Concomitant/preceding percutaneous coronary intervention does not confer any additional mortality benefit, and may increase the risk of 30-day myocardial infarction, in patients with high-grade aortic stenosis undergoing transcatheter aortic valve replacement. Further trials with large sample sizes are needed to confirm our findings.

Abstract 10721: Pharmacologic Management of Bradycardia During Rotational Atherectomy: A 10-Year Veterans Affairs Experience

Introduction: Rotational atherectomy (RA) is frequently used for plaque modification in patients with calcified coronary lesions. RA use in dominant artery lesions is often associated with transient bradyarrhythmias, thought to be due to adenosine release from injured erythrocytes. As such, prophylactic transvenous pacemakers (TVP) are often placed, increasing risk of bleeding and tamponade. We hypothesize that patients undergoing RA at risk for bradyarrhythmias can be safely managed with non-selective adenosine receptor antagonists without routine prophylactic TVP use. Methods: We retrospectively identified 384 consecutive patients who underwent RA at the Ralph H. Johnson VA Medical Center between January 2011 and September 2020. Patients were divided into those pretreated with aminophylline or theophylline (n=147) and those who were not. Primary and secondary endpoints were breakthrough bradyarrhythmia requiring acute pharmacologic or TVP rescue and a composite of 30-day cardiovascular mortality, readmission, and permanent pacemaker implantation. Results: A total of 319 patients who underwent 358 RA procedures met our inclusion criteria. None of the patients had a prophylactic TVP. Overall, 25 patients (6.9%) developed bradycardia, all successfully managed pharmacologically without TVP rescue. Of those pretreated, significantly more patients (12.2%) developed breakthrough bradycardia compared to the 3.3% that did not receive pretreatment (P value 0.001). RA on a dominant vessel was the only significant risk factor among those who developed bradycardia. There was no difference in the secondary endpoint between those pretreated with a non-selective adenosine receptor antagonist compared to those that were not (P value 0.09). Conclusion: Plaque modification with RA can be safely done without routine prophylactic TVP use with favorable acute procedural and short-term outcomes with aminophylline or theophylline pretreatment. There is a significant risk of breakthrough bradycardia with RA on a dominant vessel that can be easily managed medically.

Transcatheter Aortic Valve Implantation Versus Surgical Aortic Valve Replacement in Low-risk Patients: A Meta-Analysis Based on a 2-Year Follow-Up.

Previous studies have shown that transcatheter aortic valve implantation is the best alternative therapy to surgical aortic valve replacement in high-risk surgical patients with aortic stenosis. However, it is not clear whether transcatheter aortic valve implantation can be utilized in low-risk surgical patients with aortic stenosis. This studyaimed to evaluate the safety and efficacy of transcatheter aortic valve implantation in low-risk patients. From the outset of our initiative until April 2022, PubMed, EMBASE, and the Cochrane database were thoroughly searched, yielding the selection of 3 randomized controlled trials including 2644 patients with aortic stenosis, to assess outcome measures at distinct follow-up time. The mean Society of Thoracic Surgeons Predicted Risk of Mortality score of patients was 2.2. At the 30-day and 1-year follow-up, transcatheter aortic valve implan- tation was associated with a lower incidence of all-cause mortality, cardiovascular mor- tality, acute kidney injury (stage 2 or 3), life-threatening or significant bleeding, and new atrial fibrillation but an increased risk of permanent pacemaker implantation. At the 2-year follow-up, transcatheter aortic valve implantation only had an advantage in new atrial fibrillation (relative risk, 0.27; 95% CI, 0.14-0.51; P &lt; .0001), with no significant differ- ence in all-cause mortality or cardiovascular mortality. For low-risk surgical patients with aortic stenosis, compared to surgical aortic valve replacement, transcatheter aortic valve implantation was associated with lower all-cause mortality at 30-day follow-up and lower cardiovascular mortality at 1-year follow-up. Except for the advantages in new atrial fibrillation, transcatheter aor- tic valve implantation had no significant impact on mortality at 2-year follow-up.

Peripheral artery disease, abnormal ankle-brachial index, and prognosis in patients with acute coronary syndrome.

ObjectivesAnkle-brachial index (ABI) is an independent prognostic marker of cardiovascular events among patients with coronary artery disease (CAD). We aimed to investigate the outcome of patients hospitalized with acute coronary syndrome (ACS) and abnormal ABI.Approach and resultsABI was prospectively measured in 1,047 patients hospitalized due to ACS, who were stratified into three groups, namely, those with clinical peripheral artery disease (PAD) (N = 132), those without clinical PAD but with abnormal (< 0.9) ABI (subclinical PAD; N = 148), and those without clinical PAD with normal ABI (no PAD; N = 767). Patients were prospectively followed for 30-day major adverse cardiovascular event (MACE) and 1-year all-cause mortality. The mean age was 64 years. There was a significant gradual increase throughout the three groups in age, i.e., the incidence of prior stroke, diabetes mellitus, and hypertension (p for trend = 0.001 for all). The in-hospital course showed a gradual rise in the incidence of complications with an increase in heart failure [2.5, 6.1, and 9.2%, (p for trend = 0.001)] and acute kidney injury [2, 4.1, and 11.5%, (p for trend = 0.001)]. At day 30, there was a stepwise increase in MACE, such that patients without PAD had the lowest rate, followed by subclinical and clinical PADs (3.5, 6.8, and 8.1%, respectively, p for trend = 0.009). Similarly, there was a significant increase in 1-year mortality from 3.4% in patients without PAD, through 6.8% in those with subclinical PAD, to 15.2% in those with clinical PAD (p for trend = 0.001).ConclusionSubclinical PAD is associated with poor outcomes in patients with ACS, suggesting that routine ABI screening could carry important prognostic significance in these patients regardless of PAD symptoms.

Clinical significance and change in the degree of mitral insufficiency after TAVI

Introduction: Hemodynamically signifi cant mitral regurgitation (MR) occurs in up to 20-30% of patients with high-grade aortic stenosis (AC) indicated for transcatheter aortic valve implantation (TAVI). Despite the establishment of the method as a standard in the treatment of high-risk patients for surgery worldwide and the growing number of patients treated interventionally, behavior in concomitant signifi cant MR continues to be a diagnostic and therapeutic challenge. The decision to intervene on multiple valves must take into account the additional surgical risk of the combined procedures. Signifi cant MR is associated with a worse prognosis in both surgical and interventional treatment. With high operative risk and signifi cant MR, TAVI is a possible solution due to the proven reduction in severity in a signifi cant proportion of patients.&amp;nbsp;The aim of this paper is to evaluate the impact of signifi cant secondary MR on mortality and rate change after TAVI. Material and methods: The article is a retrospective analysis of 50 patients with high-grade symptomatic aortic stenosis who underwent successful TAVI. Patients were followed for a period of 1 year and were divided into two major groups &amp;ndash; no signifi cant MR (0.1 degree) and those with signifi cant secondary MR (&amp;ge; grade 2). Overall mortality, cardiovascular mortality, functional class of heart failure according to the NYHA classifi cation, ejection fraction and need for rehospitalizations weremonitored. Conclusions: Hemodynamically signifi cant secondary MR, concomitant high-grade AC before TAVI undergoes positive dynamics in a signifi cant proportion of patients postprocedurally and should be considered when deciding on a therapeutic strategy by the Heart team. The worsening of signifi cant secondary MI in the studied patients is associated with 30-day and one-year cardiovascular mortality and the need for rehospitalization, which is consistent with data that the prognosis is important not only the presence of signifi cant secondary MR, but its dynamics after TAVI.

The Systemic Immune-Inflammation Index Predicts Impaired Myocardial Perfusion and Short-Term Mortality in ST-Segment Elevation Myocardial Infarction Patients.

In this study, we aimed to evaluate the utility of the immune-inflammation index (SII) in estimating the no-reflow phenomenon and short-term cardiovascular prognosis in patients with ST-segment elevation myocardial infarction (STEMI). 723 consecutive patients with STEMI who underwent primary percutaneous coronary intervention (PCI) were enrolled in our study. The receiver-operating characteristics (ROC) curve was used to determine the cut-off value of SII to predict the no-reflow. The multivariate regression analysis analyzed the correlation between no-reflow and SII. The median value of SII was significantly higher in patients with no-reflow in comparison with normal reperfusion [1466 (939-2409) vs 905 (566-1379), p < .001]. The optimal threshold for SII in predicting the no-reflow phenomenon was 1036, with sensitivity and specificity of 70% and 59%, respectively. The area under the ROC curve (AUC) was 0.71 (95% CI, 0.66-0.75, p < .001). In multivariate analysis, SII ≥ 1036 value showed an independent predictive value for the no-reflow (OR = 0.51, 95% CI: 0.29-0.92, p = .02) and the 30-day cardiovascular mortality (OR = 2.37, 95% CI: 1.34-4.19, p = .003). Our results suggest that higher SII levels are independently associated with the no-reflow phenomenon and 30-day mortality in STEMI patients undergoing primary PCI.

Early and midterm outcomes of transcatheter aortic-valve replacement with balloon-expandable versus self-expanding valves: A meta-analysis

BackgroundCurrent guidelines provide recommendation for transcatheter aortic-valve replacement (TAVR) in severe aortic stenosis without emphasis on valve systems. The comparative performances of balloon-expandable valves (BEV) and self-expanding valves (SEV) remain unclear. We aim to compare the early (30-day) and midterm (1-year) mortality and cardiovascular outcomes of BEV with SEV. MethodsPubMed, CENTRAL, and EMBASE were searched from inception to February 13, 2020 for randomized controlled trials (RCTs) and propensity-score matched (PSM) studies. Odds ratios (ORs) for binary outcomes and mean differences for continuous outcomes were pooled using random-effect models (DerSimonian–Laird method) with Hartung-Knapp-Sidik-Jonkman variance correction. Primary outcomes were early and midterm all-cause mortality. ResultsWe included 3 RCTs (1418 patients) and 12 PSM studies (36,540 patients). Compared with SEV, BEV was associated with significantly lower mortality at 30 days (OR 0.76, 95% CI 0.67–0.85, p < 0.001, I2 = 0) and 1 year (OR 0.87, 95% CI 0.77–0.99, p = 0.04, I2 = 20.4%) in PSM studies, but not RCTs with insufficient power. Similar findings were found in subgroups analysis based on valve generations and SEV types. The 30-day and 1-year cardiovascular mortality, 30-day incidences of moderate to severe paravalvular leak, procedural contrast agent volume, and procedure time were lower, but transvalvular pressure gradient was higher in BEV than SEV in PSM studies. The 30-day incidences of permanent pacemaker implantation (PPI), acute kidney injury, stroke, major bleeding, major vascular complications, and rehospitalization were not statistically different between BEV and SEV. Early-generation SEV was associated with a higher 30-day PPI risk than corresponding BEV comparators. PPI risk was lower in ACURATE neo (Boston Scientific, Natick, MA) but higher in Evolut R SEV (Medtronic Inc., Minneapolis, MN), both compared with SAPIEN 3 BEV (Edwards Lifesciences, Irvine, CA). ConclusionsPSM studies suggest lower early and midterm mortality in BEV than SEV, but the contribution of unmeasured confounders cannot be excluded. Results from adequately powered RCTs with long-term follow-up are critically needed to confirm these findings.

Prognostic Outcomes in Acute Myocardial Infarction Patients Without Standard Modifiable Risk Factors: A Multiethnic Study of 8,680 Asian Patients.

BackgroundAn increasing proportion of patients with acute myocardial infarction (AMI) are presenting without standard modifiable risk factors (SMuRFs) of hypertension, hypercholesterolemia, diabetes, and smoking, but with an unexpectedly increased mortality. This study examined the SMuRF-less patients presenting with AMI in a multiethnic Asian population.MethodsWe recruited patients presenting with AMI from 2011 to 2021 and compared the prevalence, clinical characteristics, and outcomes of SMuRF-less and SMuRF patients. Multivariable analysis was used to compare the outcomes of 30-day cardiovascular mortality, all-cause mortality, readmission, cardiogenic shock, stroke, and heart failure. Kaplan–Meier curves were constructed for 30-day cardiovascular mortality, with stratification by ethnicity, gender and AMI type, and 10-year all-cause mortality.ResultsStandard modifiable risk factor-less patients, who made up 8.6% of 8,680 patients, were significantly younger with fewer comorbidities that include stroke and chronic kidney disease, but higher rates of ventricular arrhythmias and inotropic or invasive ventilation requirement. Multivariable analysis showed higher rates of cardiovascular mortality (HR 1.48, 95% CI: 1.09–1.86, p = 0.048), cardiogenic shock (RR: 1.31, 95% CI: 1.09–1.52, p = 0.015), and stroke (RR: 2.51, 95% CI: 1.67–3.34, p = 0.030) among SMuRF-less patients. A 30-day cardiovascular mortality was raised in the SMuRF-less group, with similar trends in men, patients with ST-segment elevation myocardial infarction (STEMI), and the three Asian ethnicities. All-cause mortality remains increased in the SMuRF-less group for up to 5 years.ConclusionThere is a significant proportion of patients with AMI without standard risk factors in Asia, who have worse short-term mortality. This calls for greater focus on the management of this unexpectedly high-risk subgroup of patients.

Transcatheter aortic valve implantation in patients with rheumatic aortic stenosis

BackgroundRheumatic heart disease (RHD) accounts for the highest number of deaths from valvular heart disease globally. Yet, rheumatic aortic stenosis (AS) was excluded from landmark studies investigating the safety and...

Procedural, Short-Term, and Intermediate-Term Outcomes in Propensity-Matched Patients With Severe Mitral Valve Regurgitation Undergoing Urgent Versus Elective MitraClip Percutaneous Mitral Valve Repair

The study authors sought to compare outcomes in patients with severe mitral valve regurgitation (MR) undergoing urgent, as compared to elective, mitral valve repair employing MitraClip. They hypothesized that, compared to elective cases, MitraClip procedures performed for urgent indications would be associated with increased intraoperative and postoperative complications but have similar long-term outcomes. A retrospective chart review with 3:1 propensity score matching of elective-to-urgent cases. A single, large-volume tertiary care academic medical center. All consecutive patients with severe MR who underwent elective or urgent MitraClip procedures between December 15, 2015, and October 26, 2020. MR repair with MitraClip. As expected, patients in the urgent MitraClip group required a higher level of preprocedural care, and there were significant differences in baseline demographic and clinical variables as compared to the elective group. To reduce baseline characteristics heterogeneity, propensity matching was performed for age, left ventricular systolic dysfunction, congestive heart failure, chronic obstructive pulmonary disease, and smoking histories, using the nearest-neighbor matching with a caliper of 0.2 and with replacement. The final study cohort included 89 urgent and 252 matched elective cases, with a suitable alignment between the treatment groups. Propensity-matched urgent MitraClip patients experienced a longer hospital length of stay (p < 0.001), increased intensive care unit admissions (19% v 4%, p < 0.001) and mechanical ventilation (6.7% v 1.6%, p=0.023), postprocedural atrial fibrillation (11% v 4.4%, p=0.036), pericardial effusion (10% v 2.4%, p=0.005), and acute kidney injury (7.9% v 2%, p=0.016). Furthermore, patients in the urgent cohort incurred significantly higher 30-day cardiovascular mortality (6.7% v 2%, p=0.039), increased 30-day (16% v 5.6%, p=0.006), and 1-year (33% v 20%, p=0.021) readmission rates. However, there were no statistically significant differences in 30-day and 1-year overall and 1-year cardiovascular mortality. Urgent MitraClip repairs can be performed successfully, when needed, in critically ill patients with severe MR. Despite the procedural success, patients undergoing urgent MitraClip repair remain at high risk for adverse outcomes in the short- and intermediate-term and incur increased cardiovascular mortality and morbidity. Further efforts are required to develop strategies to optimize short and intermediate outcomes in this vulnerable group of patients.

Acute Kidney Injury Following Admission with Acute Coronary Syndrome: The Role of Diabetes Mellitus.

Purpose: To evaluate the role of diabetes mellitus in the incidence, risk factors, and outcomes of AKI (acute kidney injury) in patients admitted with ACS (acute coronary syndrome). Methods: We performed a comparative evaluation of ACS patients with vs. without DM who developed AKI enrolled in the biennial ACS Israeli Surveys (ACSIS) between 2000 and 2018. AKI was defined as an absolute increase in serum creatinine (≥0.5 mg/dL) or above 1.5 mg/dL or new renal replacement therapy upon admission with ACS. Outcomes included 30-day major adverse cardiovascular events (MACE) and 1-year all-cause mortality. Results: The current study included a total of 16,879 patients, median age 64 (IQR 54–74), 77% males, 36% with DM. The incidence of AKI was significantly higher among patients with vs. without DM (8.4% vs. 4.7%, p < 0.001). The rates of 30-day MACE (40.8% vs. 13.4%, p < 0.001) and 1-year mortality (43.7% vs. 10%, p < 0.001) were significantly greater among diabetic patients who developed vs. those who did not develop AKI respectively, yet very similar among patients that developed AKI with vs. without DM (30-day MACE 40.8% vs. 40.3%, p = 0.9 1-year mortality 43.7 vs. 44.8%, p = 0.8, respectively). Multivariate analyses adjusted to potential confounders, showed similar independent predictors of AKI among patients with and without DM, comprising; older age, chronic kidney disease, congestive heart failure, and peripheral arterial disease. Conclusions: Although patients with DM are at much greater risk for AKI when admitted with ACS, the independent predictors of AKI and the worse patient outcomes when AKI occurs, are similar irrespective to DM status.

Periprocedural and short-term stroke after transcatheter aortic valve implantation – what are the outcomes and how can we predict it

Abstract Background Stroke is a known complication after transcatheter aortic valve implantation (TAVI). Although risk factors for its occurrence are being suggested, we still don't have clear tools to predict which patients will most probably have it and how to prevent it. Purpose To identify possible clinical and procedural predictors of early post-TAVI stroke. Methods Retrospective analysis of consecutive patients (P) submitted to TAVI between 2009 and 2020 in a tertiary center. Baseline characteristics, procedural information and stroke in first 30 days after TAVIwere collected. Results A total of 494P (56,1% female) were included, with a mean age of 82±6 years (minimum 45 and maximum 95 years- old). The majority (98,4%) had at least one cardiovascular risk factor (83,2% hypertension, 67,6% dyslipidemia, 64% excess weight, 36,8% diabetes, 11,9% smoking). Half patients had chronic kidney disease, 34,8% atrial fibrillation, 16,4% peripheral artery disease, 15,4% porcelain aorta, and 12,3% a previous stroke. The procedure was done via transfemoral access in 460P (93,1%), subclavian artery in 16P (3,2%), transcava in 10P (2%) and transaortic in 7P (1,4%). Aortic valve pre-dilation was done in 35,6% and post-dilation in 31,2%. In the first 30 days after TAVI 19P (3,8%) had a stroke (11P with a major and 8P with a minor stroke). Patients with stroke had more hypertension (100% vs 82,4%, p=0.045), higher BMI (29 vs 27, p=0.039) and more frequently porcelain aorta (36,8% vs 15,5%, p=0,014). They also tended to have more peripheral artery disease (31,6% vs 15,7%, p=0,066). There weren't other differences in baseline characteristics between the two groups. Considering the aspects related to the procedure, post-dilation was the only predictor of events (58,8% vs 32%, p=0,021). In a multivariable analysis including clinical and procedural predictors, porcelain aorta (p=0,048, OR = 2,895) and post-dilation (p=0,042, OR = 2,844) were the independent predictors. Stroke after TAVI was associated with longer hospital stay (36 vs 15days, p&amp;lt;0,001) and intensive care unit stay (12 vs 3 days, p&amp;lt;0,001), higher intra-hospital mortality (14,8% vs 3,2%, p=0,002), global 30-day mortality (12,1% vs 3,3%, p=0,0011) and cardiovascular 30-day mortality (11,5% vs 3,4%, p=0,038). Conclusion Periprocedural and 30-day stroke is a relatively uncommon but potentially devastating complication after TAVI. There are clinical and procedural characteristics that are associated with a higher risk and should be considered when selecting patients for treatment and strategies to prevent events. Funding Acknowledgement Type of funding sources: None.

B-PO05-198 IMPLEMENTATION OF AN ATRIAL FIBRILLATION TREATMENT PATHWAY IN THE EMERGENCY DEPARTMENT REDUCES ATRIAL FIBRILLATION HOSPITALIZATIONS

Hospitalization rates for atrial fibrillation (AF) patients have steadily risen over two decades. An AF treatment pathway in the Emergency Department (ED) with early follow-up of appropriate patients in an AF specialty clinic may reduce unnecessary hospitalizations and repeat ED visits. To evaluate the impact of an ED AF treatment pathway based on hemodynamic stability and symptom severity on AF discharge rate, repeat ED visits, and cardiovascular mortality at the University of North Carolina Medical Center (UNCMC), compared to usual care at Pardee Hospital (PRDH), another hospital of comparable size within the University of North Carolina network of hospitals. An AF treatment pathway was developed and implemented through education and electronic medical record system integration. Between 2016 and 2020, 4,487 patients presented to the ED of two hospitals with a diagnosis of AF. Rates of admission, discharge, 30-day repeat hospitalizations, and cardiovascular mortality were tallied and compared between the two hospitals (Wilcoxon Rank Sum). Utilization of an ED AF treatment pathway was associated with a significantly increased discharge rate in comparison with usual care (67.1% vs. 55.4%, p<0.001; Figure). There was no significant difference in 30-day repeat ED visits (2.2% vs. 2.7%; p=0.739) or overall cardiovascular mortality (2.3% vs. 1.9%; p=0.226) between the two hospitals. Implementation of an AF treatment pathway can significantly decrease admission rate in the ED without affecting 30-day repeat ED presentation or cardiovascular mortality rate.