In-hospital Heart Research Articles

Outcomes in ST-segment elevation myocardial infarction treated with primary percutaneous coronary intervention or pharmacoinvasive strategy in a Latin American country

ObjectiveThe primary percutaneous coronary intervention (PPCI) is the preferred reperfusion strategy for ST-segment elevation myocardial infarction (STEMI). The pharmacoinvasive strategy (PIs) is a reasonable alternative when prompt PPCI is not possible, especially in resource-limited regions. We aimed to compare PPCI versus PIs outcomes in Peru.MethodsThis was a retrospective cohort study based on the second Peruvian Registry of STEMI (PERSTEMI II). We compared the characteristics, in-hospital outcomes and 30-day mortality of patients undergoing PPCI during the first 12 h and those receiving a PIs. A propensity score-matched analysis was conducted to compare the effects of each treatment strategy on clinical outcomes.ResultsPIs patients were younger than PPCI patients, had a shorter first medical contact time, first medical contact to reperfusion time, and total ischemic time until reperfusion. Successful PCI was more frequent in the PIs group (84.4% vs. 71.1%, p = 0.035). There were no differences between PIs and PPCI in terms of total in-hospital mortality (5.2% vs. 6.6%, p = 0.703), cardiovascular mortality (4.2% vs. 5.3%, p = 0.735), cardiogenic shock (8.3% vs. 13.2%, p = 0.326), heart failure (19.8% vs. 30.3%, p = 0.112), or major bleeding (0% vs. 2.6%, p = 0.194). In the propensity score-matched analysis, the rates of cardiovascular mortality, postinfarction heart failure and successful reperfusion were similar.ConclusionsIn this real-world study, no differences were found in the in-hospital outcomes between patients with STEMI who received PIs or PPCI.

Short- and long-term outcomes in patients with right ventricular infarction according to modalities of reperfusion strategies in China: data from China Acute Myocardial Infarction (CAMI) Registry

Abstract Funding Acknowledgements Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Twelfth Five-Year Planning Project of the Scientific and Technological Department of China Purpose We sought to investigate the short- and long-term outcomes in patients with right ventricular infarction in China. Methods Data from China Acute Myocardial Infarction (CAMI) Registry for patients with right ventricular infarction between January 2013 and September 2014 were analyzed. Results Of the 1,988 patients with right ventricular infarction, 733 patients did not receive reperfusion therapy, 281 patients received thrombolysis therapy, and 974 patients underwent primary PCI. Primary PCI and thrombolysis were all associated with lower risks of in-hospital (3.1% vs 12.6%; adjusted OR: 0.48; 95% CI: 0.27–0.87; P = 0.0151 and 5.7% vs 12.6%; adjusted OR: 0.43; 95% CI: 0.22–0.85; P = 0.0155, respectively) and two-year all-cause mortality (6.3% vs 20.9%; adjusted HR: 0.50; 95% CI: 0.34–0.73; P = 0.0003 and 11.0% vs 20.9%; adjusted HR: 0.59; 95% CI: 0.38–0.92; P = 0.0189, respectively) compared with no reperfusion therapy. Meanwhile, primary PCI was superior to thrombolysis in reducing the risks of in-hospital atrial-ventricular block (4.2% vs 8.9%; adjusted OR: 0.46; 95% CI: 0.23–0.91; P = 0.0257), cardiogenic shock (5.3% vs 13.9%; adjusted OR: 0.43; 95% CI: 0.23–0.83; P = 0.0115), and heart failure (8.5% vs 23.5%; adjusted OR: 0.35; 95% CI: 0.22–0.56; P < 0.0001). Primary PCI could reduce the risk of two-year major adverse cardiac and cerebrovascular event (19.1% vs 33.3%; adjusted HR: 0.72; 95% CI: 0.56–0.92; P = 0.0092) relative to no reperfusion therapy, whereas thrombolysis may increase the risk of two-year revascularization (15.5% vs 8.7%; adjusted HR: 1.90; 95% CI: 1.15–3.16; P = 0.0124) compared with no reperfusion therapy. Conclusions Timely reperfusion therapy is essential for patients with right ventricular infarction. Primary PCI should be considered as the default treatment strategy for patients with right ventricular infarction in the contemporary primary PCI era.

Post-operative Morbidity and Mortality After Fontan Procedure in Patients with Heterotaxy and Other Situs Anomalies

Heterotaxy is a complex, multisystem disorder associated with single ventricle heart disease and decreased survival. Ciliary dysfunction is common in heterotaxy and other situs abnormalities (H/SA) and may increase post-operative complications. We hypothesized that patients with H/SA have increased respiratory and renal morbidities and increased in-hospital mortality after Fontan procedure. We queried the Pediatric Health Information System database for hospitalizations with ICD-9/10 codes for Fontan procedure in patients aged 1 through 11years from 2004 to 2019. H/SA was identified by codes for dextrocardia, situs inversus, asplenia/polysplenia, or atrial isomerism and compared to non-H/SA controls. Outcomes were in-hospital mortality or heart transplantation, ECMO, hemodialysis, length of stay (LOS), and mechanical ventilation or vasoactive medication use ≥ 4days. We adjusted estimates with multivariable logistic regression. Of 7897 patients at 50 centers, 1366 (17%) met criteria for H/SA. H/SA had worse outcomes for all study measures: death/transplantation (1.9 vs 1.1%, OR 1.74 (95% CI 1.01-3.03); p = 0.047), ECMO (3.7 vs 2.3%, OR 1.74 (1.28-2.35); p < 0.001), hemodialysis (2.1 vs 1.2%, OR 1.66 (1.06-2.59); p = 0.026), prolonged mechanical ventilation (13.2% vs 7.6%, OR 1.85 (1.53-2.25); p < 0.001) and vasoactive medication use (29.4 vs 19.7%, OR 1.65 (1.43-1.90), and longer LOS (11 (8-17) vs 9 (7-14) days; p < 0.001). H/SA is associated with increased cardiovascular, renal, and respiratory morbidity, as well as in-hospital mortality after Fontan procedure. Attention to renal and respiratory needs may improve outcomes in this difficult population. The relationship between ciliary dysfunction and lung and renal morbidity should be explored further.

Comparison of GRACE and TIMI risk scores in the prediction of in-hospital and long-term outcomes among East Asian non-ST-elevation myocardial infarction patients

BackgroundRisk stratification in non-ST segment elevation myocardial infarction (NSTEMI) determines the intervention time. Limited study compared two risk scores, the Thrombolysis in Myocardial Infarction (TIMI) and Global Registry of Acute Coronary Events (GRACE) risk scores in the current East Asian NSTEMI patients.MethodsThis retrospective observational study consecutively collected patients in a large academic hospital between 01/01 and 11/01/2017 and followed for 4 years. Patients were scored by TIMI and GRACE scores on hospital admission. In-hospital endpoints were defined as the in-hospital composite event, including mortality, re-infarction, heart failure, stroke, cardiac shock, or resuscitation. Long-term outcomes were all-cause mortality and cardiac mortality in 4-year follow-up.ResultsA total of 232 patients were included (female 29.7%, median age 67 years), with a median follow-up of 3.7 years. GRACE score grouped most patients (45.7%) into high risk, while TIMI grouped the majority (61.2%) into medium risk. Further subgrouping the TIMI medium group showed that half (53.5%) of the TIMI medium risk population was GRACE high risk (≥ 140). Compared to TIMI medium group + GRACE < 140 subgroup, the TIMI medium + GRACE high-risk (≥ 140) subgroup had a significantly higher in-hospital events (39.5% vs. 9.1%, p < 0.05), long-term all-cause mortality (22.2% vs. 0% p < 0.001) and cardiac death (11.1% vs. 0% p = 0.045) in 4-year follow-up. GRACE risk scores showed a better predictive ability than TIMI risk scores both for in-hospital and long-term outcomes. (AUC of GRACE vs. TIMI, In-hospital: 0.82 vs. 0.62; long-term mortality: 0.89 vs. 0.68; long-term cardiac mortality: 0.91 vs. 0.67, all p < 0.05). Combined use of the two risk scores reserved both the convenience of scoring and the predictive accuracy.ConclusionGRACE showed better predictive accuracy than TIMI in East Asian NSTEMI patients in both in-hospital and long-term outcomes. The sequential use of TIMI and GRACE scores provide an easy and promising discriminative tool in predicting outcomes in NSTEMI East Asian patients.

Abstract 10214: Stress Testing Prior to Abdominal Aortic Aneurysm Repair: What is Our Return on Investment?

Introduction: The use of stress testing prior to abdominal aortic aneurysm (AAA) repair is highly variable. We examined the financial implications of this variation and its impact on postoperative cardiac events. Methods: We studied patients who underwent elective endovascular (EVAR) or open AAA repair at Vascular Quality Initiative participating centers from 2015–2019. We grouped centers into quintiles by their frequency of preoperative stress testing. We calculated rates of major adverse cardiovascular events (MACE), a composite of in-hospital myocardial infarction, stroke, heart failure, or death, for each quintile. We applied the charges for electrocardiographic, echocardiographic, and nuclear stress tests at our institution in 2019 to the study population to calculate expected charges per 1,000 patients. Results: We studied 27,978 patients who underwent EVAR (mean age: 73.5 ±8.5 years, 81.7% male) and 4,481 who underwent open AAA repair (mean age: 69.5 ±8.1 years, 75.1% male). Stratifying by quintile, stress test frequency ranged from 13.0% to 68.6% (mean: 37.9%) among EVAR patients and 15.9% to 85.0% (mean: 52.8%) among open AAA repair (Figure). The rate of MACE was 1.4% after EVAR and 10.2% after open AAA repair. MACE after EVAR increased with the frequency of stress testing and was 0.9% at 1 st quintile centers vs 1.7% at 5 th quintile centers (p-trend=0.033). There was no association between MACE and stress testing for open AAA repair (p-trend=0.192). The estimated charges for stress testing prior to EVAR was $125,806 per 1,000 patients at 1 st quintile centers, and $664,975 at 5 th quintile centers, while charges prior to open AAA repair were $153,861 per 1,000 patients at 1 st quintile centers, and $825,473 at 5 th quintile centers. Conclusions: More frequent stress testing is associated with high cost without a reduction in MACE. This lack of return on investment highlights the need for more judicious stress test use prior to AAA surgery.

Declines in in- and out-of-hospital coronary mortality from 2000 to 2016: results from the French MONICA registries

Abstract Background In the past decades, improvements in the management of acute coronary events (ACE) have dramatically reduced in-hospital Coronary Heart Disease (CHD) mortality. Little is known on recent evolutions in out-of-hospital mortality and its contribution to overall ACE mortality. Purpose To estimate trends of in- and out-of-hospital ACE mortality rates from 2000 to 2016 and their respective contribution to total CHD mortality. Methods Using data from the three CHD MONICA registries, all fatal myocardial infarctions, coronary deaths and sudden deaths occurring between January 1st, 2000 and December 31st, 2016 in patients age 35 to 74 were recorded. Age-standardized mortality rates (SMRs) were estimated by gender and calendar year. Crude mortality rates (CMRs) were estimated by 20-years age group. Trends were expressed as annual percentage changes (APCs). Results During the study period, 20,822 fatal events were recorded, of which 69.4% took place out-of hospital (Figure 1). Almost 90% of out-of-hospital deaths occurred at home. Standardized ACE mortality rates decreased more steeply in women as compared to men, with an APC of −4.4%, versus −3.5% in men. Decreases in ACE mortality were more pronounced inside than outside the hospital (APC: −4.6% versus −3.1% in men; −5.9% versus −3.7% in women), with an increase in the contribution of out-of-hospital mortality to overall ACE mortality from 64.7% to 71.1% in men, and from 64.4% to 71.4% in women. Decreases in CMRs were more pronounced for people age 55–74 compared to those age 35–54. In the 55–74 age group, in-hospital SMRs decreased more steeply inside than outside the hospital (APC −5.2% versus −3.6% in men; −6.3% versus −3.9% in women, Figure 2). This was not observed among the youngest subjects, in whom the decreases for in- and out-of-hospital CMRs were similar (APC −1.5% versus −1.6% in men; −3.6% versus −3.1% in women). Conclusions Over the study period, out-of-hospital mortality accounted for more than two-thirds of overall ACE mortality. Declines were more pronounced for in-hospital mortality than for out-of hospital, except in the youngest subjects, in whom they were similar. These results highlight the need to strengthen primary prevention. Funding Acknowledgement Type of funding sources: Public Institution(s). Main funding source(s): - Santé Publique France (SPF) - Institut national de la santé et de la recherche médicale (Inserm)

Prognostic value of anemia in patients with ST-elevation myocardial infarction

Abstract Introduction Haemoglobin (Hb) levels are an important outcome predictor in several diseases. Purpose We aimed to evaluate Hb at hospital admission in patients with ST-segment elevation myocardial infarction (STEMI) as a predictor of in-hospital complications, mortality and heart failure (HF) during follow-up. Methods We retrospectively studied consecutive STEMI patients treated with primary percutaneous coronary intervention between January 2010 and December 2016. Clinical data was retrieved by review of patients' clinical records. Severity of anaemia was defined according World Health Organization cut-offs. Results Of 864 patients with mean age of 63±13 years, 646 (75%) were male. Mean Hb at hospital admission was 14±2g/dL, 682 (81%) with normal Hb, 118 (14%) with mild anaemia, 45 (5%) with moderate anaemia and 2 (0.2%) with severe anaemia. Female gender, smoking, diabetes, hypertension, previous myocardial infarction and peripheral artery disease were associated to higher incidence of anaemia at hospital admission. Anaemia was also associated to Killip-Kimball (KK) class ≥II at hospital admission. They also had higher incidence of in-hospital stroke, advanced atrioventricular block, gastrointestinal bleeding and blood transfusion. In-hospital mortality was 9%, higher patients with anaemia (13% vs 7%, p=0.022). Median follow-up was 43 (26–66) months. All-cause mortality was 14%, higher in patients with anaemia (27% vs 11%, p&amp;lt;0.001, Log rank test p&amp;lt;0.001). In multivariate analysis, age (HR 1.1, 95% CI 1.0–1.1), diabetes (HR 1.9, 95% CI 1.1–3.4), left ventricular ejection fraction (LVEF) at discharge (if &amp;lt;50%, HR 3.4, 95% CI 1.6–7.2), and anaemia at admission (HR 1.8, 95% CI 1.0–3.2) were independent predictors of all-cause death during follow-up. Incidence of de novo HF, clinical worsening or hospitalization was 18%, higher in patients with anaemia (27% vs 17%, p=0.007, Log rank test p=0.007). In multivariate analysis, age (HR 1.1, 95% CI 1.0–1.1), KK class (if II, HR 2.1, 95% CI 1.3–3.5; if III, HR 4.0, 95% CI 1.8–8.9; if IV, HR 2.1, 95% CI 1.2–3.9), body mass index (if obese, HR 2.5, 95 CI 1.4–4.4) and LVEF at discharge (if &amp;lt;50%, HR 4.2, 95% CI 2.2–7.7), but not anaemia at admission (p=0.633) were independent predictors HF. Conclusion In our contemporary cohort of STEMI patients, the presence of anaemia at hospital admission was not only associated to in-hospital complications, but also all-cause mortality during follow-up. Funding Acknowledgement Type of funding sources: None.

Importance of In-Hospital Prospective Registry and Infectious Endocarditis Heart Team to Monitor and Improve Quality of Care in Patients with Infectious Endocarditis.

Aim: To investigate the value of prospective in-hospital registry data and the impact of an infectious endocarditis heart team approach (IEHT) on improvement in quality of care and monitor outcomes in hospitalized patients with IE. Methods: Between December 2014 and the end of 2019, 160 patients were hospitalized in one centre with the definite diagnosis of infectious endocarditis (IE) and entered in a prospective registry. From 2017, an IEHT was introduced. Propensity score matching was used to assess the impact of an IEHT approach on clinical outcomes. Results: Median age was 72.5 y (62.75–80.00), diabetes was present in 33.1%, chronic kidney disease in 27.5%, COPD in 17.5%, and a history of ischaemic heart disease in 30.6%. Prosthetic valve IE was observed in 43.8% and device-related IE in 16.9% of patients. Staphylococcus (37.5%) was the most frequent pathogen followed by streptococcus (24.4%) and enterococcus (23.1%). Overall, 30-day and 1-year mortality were 19.4% and 37.5%, respectively. The introduction of prospective data collection and IE heart team was associated with a trend towards reduction of adjusted 1-year mortality (26.5% IEHT vs. 41.2% controls, p = 0.0699). An IEHT clinical decision-making approach was independently associated with a shorter length of stay (p = 0.04). Conclusions: Use of a prospective registry of IE coupled with a heart team approach was associated with more efficient patient management and a trend towards lower mortality. Prospective data collection and dedicated IEHT have the potential to improve patient care and clinical outcomes.

In-hospital complications in acute ST-elevation myocardial infarction depending on renal function.

To analyze in-hospital complications in patients with acute ST-elevation myocardial infarction (STEMI) depending on renal function. Observational study in patients with STEMI. The study included 169patients undergoing primary percutaneous coronary intervention. In all patients glomerular filtration rate (GRF) was calculated using the Modification of Diet in Renal Disease Study (MDRD) equation. Of these patients, 84had aGFR ≥ 90 ml/min/1.73 m2 (Group1) and 85 < 90 ml/min/1.73 m2 (Group2). Other parameters in both groups were comparable. Study groups were followed to compare Killip class > 2acute heart failure, in-hospital pneumonia, pulseless ventricular tachycardia or ventricular fibrillation, new onset atrial fibrillation, and high grade atrioventricular block. All patients were treated according to European Society of Cardiology (ESC) guidelines for the management of acute myocardial infarction in patients presenting with ST elevation. Mean GFR in Group1 was 107.6 [Formula: see text] and in Group2 75.3 [Formula: see text] 11.2 (p < 0.0001). The incidence of atrial fibrillation was higher in Group2: in Group1 and Group2 the atrial fibrillation rate was 1.12% (one of 84) vs 8.24% (seven of 85) (p = 0.031), respectively. Group1 revealed significantly lower rates of acute heart failure (Killip class > 2): in Group1 and Group2 0% (0of 84patients) vs 5.88% (five of 85patients) (p = 0.024), respectively. The authors found no significant differences for other complications: in Group1 and Group2 ventricular tachycardia or ventricular fibrillation was 4.76% (four of 84patients) vs 5.89% (five of 85patients) (p = 0.75), high grade atrioventricular block was 2.38% (two of 84patients) vs 4.71% (four of 85patients) (p = 0.41), and the in-hospital pneumonia rate was 2.38% (two of 84patients) vs 4.71% (four of 85patients) (p = 0.41), respectively. Patients with lower GFR were more likely to suffer from in-hospital acute heart failure (Killip class > 2) and atrial fibrillation in STEMI despite primary percutaneous coronary intervention. Renal function did not affect in-hospital pneumonia, pulseless ventricular tachycardia or ventricular fibrillation rates. The evaluation of kidney function through GFR in STEMI patients may make in-hospital complications more predictable.

Abstract 15410: Post-operative Outcomes After Fontan Procedure in Patients With Heterotaxy and Other Situs Anomalies

Background: Heterotaxy is a multisystem disorder of situs often associated with cardiac, immune, and gastrointestinal abnormalities. Heterotaxy and other situs abnormalities (H/SA) may share ciliary dysfunction as an embryologic origin. Extracardiac manifestations of H/SA may contribute to increased morbidity and mortality after total cavopulmonary connection (Fontan) procedure. We hypothesized that patients with H/SA have worse postoperative outcomes after Fontan than patients without H/SA. Methods: We queried the Pediatric Health Information System (PHIS) database for hospitalizations with ICD-9/10 codes for Fontan procedure in patients aged 1 to 12 years from 2004 to 2019. Those coded for dextrocardia, situs inversus, asplenia/polysplenia, and atrial isomerism were defined as H/SA. Outcomes were in-hospital all-cause mortality or heart transplantation, post-operative ECMO, dialysis, postsurgical length of stay (LOS), and mechanical ventilation &gt;4 days. Outcomes were compared between H/SA and non-H/SA controls with chi-squared or rank-sum test (reported as median (IQR)), and statistically adjusted for surgical center, age, sex, race, genetic anomaly, and pre-operative support with multivariate logistic regression (reported as adjusted odds-ratio (95% CI)). Results: Of 7,897 patients who underwent Fontan at 50 PHIS centers, 1,366 (17%) met criteria for H/SA. Patients with H/SA versus non-H/SA were older (3.7 (2.9-4.8) vs 3.4 (2.7-4.2) years; p&lt;0.001), more female (44 vs 40%, p=0.005), and Asian or Hispanic (35% vs 24%, p&lt;0.001). H/SA had higher rates of discharge death/transplantation (1.9 vs 1.1%, aOR 1.76 (1.02-3.04); p=0.042), post-operative ECMO (3.7 vs 2.3%, aOR 1.73 (1.28-2.33); p&lt;0.001), dialysis (2.1 vs 1.2%, aOR 1.66 (1.06-2.59); p=0.026), prolonged intubation (13.2% vs 7.6%, aOR 1.86 (1.53-2.25); p&lt;0.001), and longer LOS (11 (8-17) vs 9 (7-13) days; p&lt;0.001). Conclusions: We observed increased mortality and postoperative complications in this largest report to date on patients with H/SA after Fontan. We postulate that ciliary dysfunction may contribute to increased lung and renal morbidity, and should be explored further. Adjustment for anatomic complexity and hemodynamics are required for further study .

Impact of concurrent right ventricular myocardial infarction on outcomes among patients with left ventricular myocardial infarction

To compare in-hospital outcomes between left ventricular myocardial infarction (LVMI) patients with and without right ventricular myocardial infarction (RVMI). Patients with acute ST-segment elevation MI (STEMI) undergoing primary percutaneous coronary intervention (PCI) were enrolled and divided into LVMI with and without RVMI groups. Between-group differences and in-hospital outcomes were compared. Compared to patients without RVMI, patients with RVMI were more likely to be male, have higher body mass index, serum levels of C-reactive protein (8.9 ± 2.4 vs 6.2 ± 2.1 mg/dL), B-type natriuretic peptide (1295 ± 340 vs 872 ± 166 pg/mL) and cardiac troponin-I (8.6 ± 2.9 vs 5.2 ± 2.1 ng/mL), and have diabetes (36.3% vs 3.4%) and dyslipidemia (53.4% vs 48.1%). Patients with RVMI had lower left and right ventricular ejection fraction (50.5 ± 5.6% vs 53.4 ± 3.8% and 33.6 ± 2.9% vs 45.7 ± 2.0%), but had higher mean pulmonary artery pressure (30.6 ± 3.3 vs 23.8 ± 3.1 mm Hg). Compared to patients without RVMI, patients with RVMI had higher odds of in-hospital all-cause mortality (4.1% vs 1.0%) and new onset acute heart failure (3.4% vs 1.0%). After adjusted for confounding factors, LVMI with RVMI remained independently associated with composite outcomes, with odds ratio 1.66 (95% confidence interval 1.39–2.04). Compared to isolated LVMI patients, those with concomitant RVMI have higher odds of in-hospital complications, particularly all-cause mortality and new onset acute heart failure.

Marijuana use and mortality following orthopedic surgical procedures

ABSTRACTBackground: The association between marijuana use and surgical procedures is a matter of increasing societal relevance that has not been well studied in the literature. The primary aim of this study is to evaluate the relationship between marijuana use and in-hospital mortality, as well as to assess associated comorbidities in patients undergoing commonly billed orthopedic surgeries. Methods: The National Inpatient Sample (NIS) database from 2010 to 2014 was used to determine the odds ratios for the associations between marijuana use and in-hospital mortality, heart failure (HF), stroke, and cardiac disease (CD) in patients undergoing 5 common orthopedic procedures: total hip (THA), total knee (TKA), and total shoulder (TSA) arthroplasties, spinal fusion, and traumatic femur fracture fixation. Results: Of 9,561,963 patients who underwent one of the 5 selected procedures in the 4-year period, 26,416 (0.28%) were identified with a diagnosis of marijuana use disorder. In hip and knee arthroplasty patients, marijuana use was associated with decreased odds of mortality compared with no marijuana use (P < .0001) and increased odds of HF (P = .018), stroke (P = .0068), and CD (P = .0123). Traumatic femur fixation patients had the highest prevalence of marijuana use (0.70%), which was associated with decreased odds of mortality (P = .0483), HF (P = .0076), and CD (P = .0003). For spinal fusions, marijuana use was associated with increased odds of stroke (P < .0001) and CD (P < .0001). Marijuana use in patients undergoing total shoulder arthroplasty was associated with decreased odds of mortality (P < .001) and stroke (P < .001). Conclusions: In this study, marijuana use was associated with decreased mortality in patients undergoing THA, TKA, TSA, and traumatic femur fixation, although the significance of these findings remains unclear. More research is needed to provide insight into these associations in a growing surgical population.

Impact of Regional Cerebral Perfusion on Outcomes Among Neonates Undergoing Norwood Operation.

To evaluate the impact of regional cerebral perfusion (RCP) during heart operation on outcomes in neonates undergoing Norwood operation. We performed a retrospective cohort study using data from the Single Ventricle Reconstruction trial data set. The adjusted effect of RCP use on each outcome was studied using a penalized logistic regression model with bootstrap validation. Of 549 patients included in the study, 252 patients (45.9%) received RCP during their heart operation. In univariate comparisons, the majority of the baseline characteristics and preoperative risk factors were similar in the RCP and No RCP group. The total cardiopulmonary bypass (CPB) time and the total cross-clamp (CC) time were longer in the RCP group (RCP vs No RCP, median CPB time: 161 minutes vs 109 minutes; median CC time: 63 minutes vs 43 minutes). In adjusted models, the use of RCP was not associated with decreased mortality and/or need for heart transplant at hospital discharge (odds ratio [OR]: 0.73; 95% confidence interval [CI]: 0.43-1.25) or prolonged mechanical ventilation (OR: 1.20, 95% CI: 0.62-2.28) or prolonged hospital length of stay (OR: 1.30, 95% CI: 0.73-2.30). We demonstrated that use of RCP was associated with longer CPB times, increased use of ultrafiltration, and higher probability of open chest after Norwood operation. This study did not demonstrate any impact of RCP on in-hospital mortality and/or heart transplantation, prolonged mechanical ventilation, and prolonged hospital length of stay among neonates undergoing Norwood operation.

Influence of CYP2C9 and VKORC1 on Warfarin Dose and Complications in Kazakhstani Patients with Left Ventricular Assist Device

Purpose The use of anti-platelet and anti-thrombotic therapy is a main stay in left ventricular assist devises (LVAD) to mitigate complicationssuch as pump thrombosis or systemic thromboembolism. Although multiple reports have documented the influence of CYP2C9 and VKORC1 variants on warfarin dose, risk of over-anticoagulation and hemorrhage, their influence on anticoagulation maintenance is limited. The purpose of this study is to evaluate the influence of CYP2C9 and VKORC1 polymorphisms on warfarin response and dosing algorithms in LVAD patients. Methods 100 patients implanted the HW, HM2, HM3 LVAD, irrespective of intended goal of therapy (either bridge to transplantation or destination therapy) after December 2011 at a single clinic - National Research Center for Cardiac Surgery, Astana, Kazakhstan with genotype data available for CYP2C9 (*1, *2, and *3 [rs1799853 and rs1057910]) and VKORC1 (-1639 G>A [rs9923231]) variants were included into study after institutional ethics committee approved the protocol. Postoperative warfarin dose, international normalized ratio (INR), and bleeding events were measured until discharge, 6 months, or composite end point (in-hospital MCS recovery, heart transplant, or death). Results 32.0% of patients with implanted LVADs had at least one polymorphism: VKORC1 (14.0%), CYP2C9*2 (15.0%), CYP2C9*2 and VKORC1 (3.0%). At discharge or before composite end point, patients with any polymorphism received a lower mean warfarin dosage than patients having no polymorphism (3.2±1.5 vs. 5.5±3.7 mg, p = 0.015) and achieved a similar mean INR (2.20±0.67 vs. 2.19±0.69, p = 0.96). There was no significant difference in bleeding rates within 6 months or before composite end point (6.13 vs. 8.02 events/patient-year, p = 0.13). Neither CYP2C9 nor VKORC1 influenced the risk of minor hemorrhage. CYP2C9 and VKORC1 explained 6.3% of the variance in dose change over the first days of therapy demonstrating that the usefulness of genotype-guided dosing may extend beyond first days of therapy. Conclusion This study confirms the importance of VKORC1/CYP2C9 genotypes for warfarin dosing in LVAD patients and demonstrates an impact of genetic factors on clinical outcomes and proof of concept that genotype data could be incorporated into Warfarin dosing algorithm in LVAD patients.

Epidural Analgesia Reduces Total Inhospital Morphine Requirements Post Heart Lung / Lung Transplant in Paediatric Population

Purpose Patients undergoing heart lung / lung transplantation utilise extensive hospital resources. Pain management is an important factor in post surgery recovery, influencing respiratory and other health outcomes and hospital resource burden. To our knowledge, no previous study has evaluated analgesic practices in the paediatric heart lung / lung transplant population. Methods We conducted a retrospective analysis of all paediatric patients (age less than 18 years) who underwent heart / lung transplant at a single tertiary centre between January 2006 and January 2018. Results 39 subjects were identified, of whom 30 had epidural analgesia (plus / minus adjunctive systemic analgesia). All epidurals were ceased by day 5. Mean age of epidural analgesia patients was 12.6 years; mean age of systemic analgesia patients was 11.6. Epidural analgesia, when compared with systemic analgesia, was associated with a significantly reduced total in-hospital morphine requirement (mean 1.65 vs 2.74mg/kg/24 hours) (p = 0.02). There were no epidural-related or opioid-related episodes of harm CTCAE grade 4 or greater (nil life threatening events). There was no meaningful correlation between total in-hospital morphine requirements and CTCAE grades of harm (correlation coefficient = 0.15). In addition, both epidural and systemic analgesia had similar endotracheal tube days (p = 0.56) and ICU days (p = 0.90). In all patients, opioid requirements during day 5 postoperative correlated with total hospital morphine requirements (correlation coefficient = 0.46). Conclusion Epidural analgesia reduces total in-hospital morphine requirements post heart lung / lung transplant in paediatric population. Epidural analgesia and systemic analgesia both appear safe in this setting.

Abstract 19842: Microvascular Dysfunction in Patients with ST-Elevation Myocardial Infarction after Primary Percutaneous Coronary Intervention: No Sex Disparity

Background: Microvascular dysfunction is highly prevalent in women and presumed secondary to hormonal fluctuations, increased vascular tone, and endothelial dysfunction. Its contribution has never been examined in the acute setting. Patients with ST-elevation myocardial infarction (STEMI) with persistent ST-elevation (ST-E) post successful primary percutaneous coronary intervention (PPCI) are at risk of in-hospital cardiac events. We used ST-E recovery on ECGs pre and post PPCI to study potential sex differences in microvascular dysfunction, in conjunction with cardiac events in a STEMI population. Methods: Retrospective analysis was conducted on consecutive STEMI patients undergoing PPCI in Vancouver between May 2007 and September 2010 with evaluable ECGs pre and post PPCI. Patients with bundle branch block were excluded. Quantification of ST-E in each lead was done by electronic calipers by investigators blinded to clinical outcomes. Univariate analysis was performed by sex, for the association between ST-E recovery in the lead with maximal ST-E and the composite of in-hospital mortality, heart failure, cardiogenic shock, and reinfarction. Results: Of our 413 patients, 23% were women. In comparing baseline characteristics, age was significantly different (mean age of females = 72 vs. males = 61, p&lt;0.001). More female than male patients had incomplete (&lt;50%) ST-E recovery (20.6% vs. 12.7%, p=0.052). Women with incomplete recovery had an odds ratio of 2.3 for the primary outcome, compared with 1.4 in men, which was not statistically significant between sex. The primary outcome occurred more often in women (29.9% vs. 18.0%, p=0.012), but after adjusting for age, sex difference was no longer significant. Conclusions: Female STEMI patients are older, had more incomplete ST-E recovery after PPCI and had more in-hospital cardiac events, although significance was lost after adjusting for age. The higher prevalence of microvascular dysfunction in stable women may not be a large contributor of persistent ST-E in the acute setting. The higher incidence of incomplete ST-elevation in women may be attributable to the increasing prevalence of endothelial dysfunction with age. This novel interaction should be further examined with objective measures.

EVOLUTION OF A REGIONAL STEMI REPERFUSION MODEL: THE 6-YEAR VANCOUVER COASTAL HEALTH AUTHORITY EXPERIENCE

BACKGROUND: Guidelines strongly recommend that regional systems of STEMI care include the assessment and continuous quality improvement of EMS and hospitalbased activities. We describe the evolution of the Vancouver Coastal Health Authority (VCHA) STEMI program, including the impact of individual care components on reperfusion times and clinical outcomes over a 75-month period. METHODS: All patients with confirmed STEMI presenting within the VCHA from June 2007 to September 2013 were included (n 1⁄4 2041). Primary analysis was performed by care component phase: Phase 1, regionalization of the STEMI program (n 1⁄4 278, June 2007 to May 2008); Phase 2, introduction of pre-hospital ECGs (n 1⁄4 979, May 2008 to May 2011); and Phase 3, implementation of an inter-facility transfer protocol for primary PCI (pPCI) (n 1⁄4 784, May 2011 to September 2013)). A total of 1353 patients received pPCI across all phases. RESULTS: Baseline clinical characteristics were similar between phases. Amongst patients receiving pPCI, median first medical contact-to-device times decreased over the 3 phases, whether the initial presentation was at a PCI capable hospital (116 min, 92 min, 95 min; p < 0.001 for trend) or PCI non-capable hospital (174 min, 146 min, 123 min; p < 0.001 for trend) (Figure). Moreover, the proportion of STEMI patients receiving successful pPCI increased across each phase (44.2%, 63.8%, 74.5%; p < 0.001). Overall in-hospital mortality was not significantly different across each phase (9.4%, 8.8%, 10.6%; p 1⁄4 0.44). However, overall rates of in-hospital congestive heart failure (15.8%, 19.7%, 23.9%; p 1⁄4 0.008) and major bleeding (9.0%, 16.0%, 14.8%; p 1⁄4 0.014) increased over time. CONCLUSION: Within a geographically defined cohort of STEMI patients, a phased roll out of regional pPCI significantly reduced reperfusion times and increased the proportion of patients receiving timely pPCI over a 6-year period. However, in-hospital mortality was unchanged during this same period despite improvements in pPCI performance and access, and both in-hospital congestive heart failure and major bleeding increased over this time period. This suggests that variables beyond receiving timely pPCI are important in determining clinical endpoints. Therefore, in addition to optimizing reperfusion strategies, further understanding and optimization of these variables will be critical to improve STEMI outcomes. 122 DELAYED EDUCATIONAL REMINDERS FOR LONG-TERM MEDICATION ADHERENCE IN ST-ELEVATION MYOCARDIAL INFARCTION (DERLA -STEMI)

Outcome of Percutaneous Coronary Intervention Following Recent Surgery

Outcome data regarding postoperative acute coronary syndrome treated with percutaneous coronary intervention (PCI) are limited. The objective of this study was to determine clinical outcomes of patients undergoing PCI within 7 days after a surgical procedure. We assessed outcomes of 517 patients who underwent PCI within 7 days after a surgery across 44 hospitals from January 2010 to December 2011 from the Blue Cross Blue Shield of Michigan Cardiovascular Consortium registry. Patients with postoperative PCI were compared with all other patients with PCI using propensity-matched analysis. Of the 65,175 patients who underwent PCI within the study period, 517 patients had undergone surgery within the previous 7 days. In unadjusted analysis, patients with postsurgical PCI had higher in-hospital mortality (6.96% vs 1.33%), stroke (0.96% vs 0.26%), bleeding events (6.96% vs 2.6%), heart failure (6.96% vs 2.36%), and cardiogenic shock (7.16% vs 1.95%). After propensity matching, mortality remained higher in postsurgical patients (6.5% vs 3.96%, odds ratio 1.7 [1.1 to 2.6], p = 0.02). The odds of mortality were especially high among patients who would otherwise be considered low risk (<1% of predicted mortality in a nonsurgical setting) in whom a recent surgery was strongly associated with death (odds ratio 5.7, p = 0.02). In conclusion, PCI performed within 7 days after a surgical procedure is associated with an increased risk of early mortality. Although some of this increased risk is related to an adverse clinical profile, higher mortality is also observed in patients otherwise considered low risk for PCI.

A new simple algorithm to stratify the risk of contrast-induced nephropathy in patients with acute coronary syndrome

Objectives and background: Previous studies on contrast-induced nephropathy (CIN) have identified contrast volume (CV) as a risk factor. The aim of our research was to define the safe dose of contrast media based on absolute CV, maximum allowable contrast dose (MACD) and estimated glomerular filtrate rate (eGFR). Methods and results: A total of 940 consecutive patients with acute coronary syndrome (ACS) were enrolled. Fifty-four patients developed CIN. MACD was defined as 5*body weight/serum creatinine. When using a CV higher than MACD, CIN-risk was increased 19-fold (OR 9.810—39.307, p<0.001). For the CV/eGFR ratio, we found that for every increase of one-tenth, CIN-risk increased by 4.9% (OR 1.037–1.061, p<0.001). The discriminative ability of CV (C statistic=0.626±0.038) was significantly lower than for the CV/MACD (C statistic=0.782±0.036, p=0.003) and CV/eGFR (C statistics: 0.796±0.033 for MDRD-4, 0.796±0.034 for Cockcroft-Gault, and 0.803±0.033 for CKD-EPI; p<0.001). There were no differences in the discriminative ability to predict CIN between the three eGFR equations. The combination of CV/MACD and CV/eGFR in a single protocol increases the positive predictive value of the Mehran risk score (40.7% vs 8.8%) with the same sensitivity (90.7% vs 83.3%). High doses of relative CV (CV/MACD and CV/eGFR) were also significantly associated with higher in-hospital mortality, reinfarction, and heart failure. ![Figure][1] Prediction of CIN risk Conclusions: A sequential protocol based on CV/MACD and CV/eGFR appropriately identified those ACS patients who developed CIN, with predictive values similar to a Mehran score, reducing the false positive rate. It is also useful to predict risk of in-hospital cardiac events regardless of GRACE score. [1]: pending:yes

Abstract 268: Multidisciplinary Approach to the Heart Failure Patient Significantly Improves Adherence to Evidence-Based Medicine Beyond Core Measures

Background: Adherence to heart failure core measures has been a focus of all hospitals in the past several years and has become even more important with the advent of pay for performance. Core measures address basic heart failure care, but do not include utilization of all evidence-based therapies which improve long term outcomes. We hypothesized that an in-hospital multidisciplinary heart failure (HF) management program could improve adherence to evidence-based guidelines beyond core measures. Methods: As a quality improvement initiative, we formed a multidisciplinary team to improve compliance with HF evidence-based therapy. Interventions included multiple educational sessions, discharge and post-discharge transition improvements, concurrent and post-discharge chart abstraction, revised patient education, and real-time provider education. Charts were abstracted in 525 consecutive HF inpatients between Jul 2010 and Mar 2011. Data was collected in the GWTG-HF (Outcome Inc) Registry. Pre-intervention compliance data (Jul-Sep) was compared to post-intervention (Nov-Mar) data with a paired t test and the Mann-Whitney rank sum test. Direct variable cost was analyzed for defect-free cases versus cases with defects. Results: Baseline Demographics: Mean age was 69 years, 42% female, 20% black, 55% ischemic etiology, mean LVEF=37%. Prior to the multidisciplinary intervention, overall defect-free care was excellent at over 89% (see figure) but there was a relative underutilization of aldosterone antagonists, hydralazine/nitrate therapy, CRT-D and anticoagulation for AF. Post-intervention, adherence improved to over 90% for all 8 evidence based therapies including: evidence-based beta-blocker (p=0.002), aldosterone antagonist (p&lt;0.001), hydralazine nitrate (p=0.04), ICD placed or prescribed (p&lt;0.001), CRT-D (p=0.002), anticoagulation for afib (p=0.04), and DVT prophylaxis (p=0.04). Mean direct variable cost per case was higher at $8249 in defect cases versus $6951 in defect-free cases. Conclusions: In this single center experience, interventions led by a HF multidisciplinary team can significantly improve adherence to evidence-based therapies, beyond core HF measures. A multidisciplinary approach to inpatient HF care has the potential to decrease HF related costs.