In-hospital Major Adverse Events Research Articles

#699 Diagnostic accuracy of the Modified Renal Angina Index (mRAI) for predicting acute kidney injury among critically ill Filipino adults

Abstract Background and Aims The proposed mRAI (modified renal angina index) (Fig. 1) predicts moderate to severe AKI within the first 7 days of ICU stay which outperforms serum creatinine and urine output. The use of the mRAI in AKI may be warranted to improve predicted performance of AKI biomarkers. The study aims to evaluate the diagnostic accuracy of modified renal angina index in predicting Acute Kidney Injury (AKI) among Critically ill Adult Filipino patient in a Tertiary Institution and its association with in hospital MAKE (Major Adverse Kidney Events). Method A retrospective cohort study including all adult critically ill patients, they were dichotomized into “low” (<10) or “high risk” (>10) based on the mRAI score upon the 1st ICU admission (Day 0-24 hr) during the hospital stay. Inclusion criteria: age >18 years old, ICU patients between 2019-2022. Exclusion criteria: Chronic Kidney Disease (Egfr <30 ml/min), Transplant recipients, HIV/Cancer, <48 hrs ICU stay, little changes in creatinine (<2x from baseline between Day 0-24 hr ICU admission). The composite outcome is achieved if at least one is met during the index of hospitalization: All-cause mortality prior to discharge or after ICU admission, New onset of renal replacement therapy (RRT), persistent renal dysfunction. The sensitivity, specificity, predictive values and area under the curve is used to determine diagnostic accuracy of the mRAI Scoring and its association with in Hospital MAKE. Simple and multiple logistic regression analysis is used to control the effect of confounders in determining the association of mRAI to AKI. SPSS version 20 will be used in the analysis. Results Using a cut off score of 10, the mRAI show 84.29% sensitivity, 76.06% specificity, 77.63%, PPV 83.08% NPV 80.14% and AUC 80.14% in predicting moderate to severe AKI (Fig. 2). A mRAI of >10 is associated with in hospital MAKE showing a 97.14% sensitivity, 67.61% specificity, 74.73% PPV, 96.0% NPV, and AUC 82.27% (Fig. 3). Among the high risk group there were 68 (97.1%) who had MAKE, 62 (88.6%) new onset RRT, 12% (17.1%) died within 7 days of ICU admission, 64 (91.4%) persistent renal dysfunction (Fig. 4). Conclusion The proposed score can be applied among critically ill adult Filipino patients which is an easy bedside tool for identification of moderate to severe AKI. mRAI constitutes a sensitive test with a high negative predictive, affirming its capability being a screening test, complementary to laboratory parameters and clinical judgement. We also found out that a mRAI score of >10 is associated with In-Hospital Major Adverse Kidney Events.

Pulsed-field vs cryoballoon vs radiofrequency ablation: Outcomes after pulmonary vein isolation in patients with persistent atrial fibrillation

BackgroundPulsed-field ablation (PFA) has shown promising data in terms of safety and procedural efficiency for pulmonary vein isolation (PVI), with similar long-term outcomes compared to radiofrequency ablation (RFA) and cryoballoon ablation (CBA) in patients with paroxysmal atrial fibrillation (AF). ObjectiveThe purpose of this study was to compare the procedural and long-term outcomes in patients with persistent AF undergoing PVI using PFA, CBA, or RFA. MethodsConsecutive patients with persistent AF undergoing first PVI with PFA, CBA, or RFA were included. Patients underwent 7-day Holter electrocardiography at 3, 6, and 12 months postablation. The primary outcome was recurrence of any atrial arrhythmia after a 90-day blanking period. Safety outcomes included the composite of in-hospital major adverse events. ResultsA total of 533 patients with persistent AF underwent PVI using PFA (n = 214), CBA (n = 190), or RFA (n = 129). Procedures with PFA guided by fluoroscopy were shorter than those with CBA (median 60 minutes; interquartile range [IQR] 53–80 minutes vs 84 minutes; IQR 68–101 minutes; P ≤ .001), and procedures with PFA in combination with 3-dimensional electroanatomic mapping were shorter than those with RFA (median 101 minutes; IQR 85–126 minutes vs 171 minutes; IQR 141–204 minutes; P < .001). Acute safety events occurred in 2.3%, 2.6%, and 0.8% in the PFA, CBA, and RFA groups, respectively (P = .545). The 1-year confounder-adjusted estimate for freedom from atrial arrhythmias was 62.1% for CBA, 55.3% for PFA, and 48.3% for RFA (CBA vs PFA: P = .79; CBA vs RFA: P = .009; PFA vs RFA: P = .010). ConclusionIn patients with persistent AF undergoing first PVI, 1-year confounder-adjusted outcomes are better with PFA and CBA than with RFA.

Predicting Major Adverse Events in Patients Undergoing Transcatheter Left Atrial Appendage Occlusion.

The National Cardiovascular Data Registry Left Atrial Appendage Occlusion Registry (LAAO) includes the vast majority of transcatheter LAAO procedures performed in the United States. The objective of this study was to develop a model predicting adverse events among patients undergoing LAAO with Watchman FLX. Data from 41 001 LAAO procedures with Watchman FLX from July 2020 to September 2021 were used to develop and validate a model predicting in-hospital major adverse events. Randomly selected development (70%, n=28 530) and validation (30%, n=12 471) cohorts were analyzed with 1000 bootstrapped samples, using forward stepwise logistic regression to create the final model. A simplified bedside risk score was also developed using this model. Increased age, female sex, low preprocedure hemoglobin, no prior attempt at atrial fibrillation termination, and increased fall risk most strongly predicted in-hospital major adverse events and were included in the final model along with other clinically relevant variables. The median in-hospital risk-standardized adverse event rate was 1.50% (range, 1.03%-2.84%; interquartile range, 1.42%-1.64%). The model demonstrated moderate discrimination (development C-index, 0.67 [95% CI, 0.65-0.70] and validation C-index, 0.66 [95% CI, 0.62-0.70]) with good calibration. The simplified risk score was well calibrated with risk of in-hospital major adverse events ranging from 0.26% to 3.90% for a score of 0 to 8, respectively. A transcatheter LAAO risk model using National Cardiovascular Data Registry and LAAO Registry data can predict in-hospital major adverse events, demonstrated consistency across hospitals and can be used for quality improvement efforts. A simple bedside risk score was similarly predictive and may inform shared decision-making.

Baseline risk factors of in-hospital mortality after surgery for acute type A aortic dissection: an ERTAAD study.

Surgery for type A aortic dissection (TAAD) is associated with high risk of mortality. Current risk scoring methods have a limited predictive accuracy. Subjects were patients who underwent surgery for acute TAAD at 18 European centers of cardiac surgery from the European Registry of Type A Aortic Dissection (ERTAAD). Out of 3,902 patients included in the ERTAAD, 2,477 fulfilled the inclusion criteria. In the validation dataset (2,229 patients), the rate of in-hospital mortality was 18.4%. The rate of composite outcome (in-hospital death, stroke/global ischemia, dialysis, and/or acute heart failure) was 41.2%, and 10-year mortality rate was 47.0%. Logistic regression identified the following patient-related variables associated with an increased risk of in-hospital mortality [area under the curve (AUC), 0.755, 95% confidence interval (CI), 0.729-0.780; Brier score 0.128]: age; estimated glomerular filtration rate; arterial lactate; iatrogenic dissection; left ventricular ejection fraction ≤50%; invasive mechanical ventilation; cardiopulmonary resuscitation immediately before surgery; and cerebral, mesenteric, and peripheral malperfusion. The estimated risk score was associated with an increased risk of composite outcome (AUC, 0.689, 95% CI, 0.667-0.711) and of late mortality [hazard ratio (HR), 1.035, 95% CI, 1.031-1.038; Harrell's C 0.702; Somer's D 0.403]. In the validation dataset (248 patients), the in-hospital mortality rate was 16.1%, the composite outcome rate was 41.5%, and the 10-year mortality rate was 49.1%. The estimated risk score was predictive of in-hospital mortality (AUC, 0.703, 95% CI, 0.613-0.793; Brier score 0.121; slope 0.905) and of composite outcome (AUC, 0.682, 95% CI, 0.614-0.749). The estimated risk score was predictive of late mortality (HR, 1.035, 95% CI, 1.031-1.038; Harrell's C 0.702; Somer's D 0.403), also when hospital deaths were excluded from the analysis (HR, 1.024, 95% CI, 1.018-1.031; Harrell's C 0.630; Somer's D 0.261). The present analysis identified several baseline clinical risk factors, along with preoperative estimated glomerular filtration rate and arterial lactate, which are predictive of in-hospital mortality and major postoperative adverse events after surgical repair of acute TAAD. These risk factors may be valuable components for risk adjustment in the evaluation of surgical and anesthesiological strategies aiming to improve the results of surgery for TAAD. https://clinicaltrials.gov, identifier NCT04831073.

In-hospital and 1-year outcomes of patients without modifiable risk factors presenting with acute coronary syndrome undergoing PCI: a Sex-stratified analysis.

A considerable proportion of patients admitted with acute coronary syndrome (ACS) have no standard modifiable cardiovascular risk factors (SMuRFs: hypertension, diabetes mellitus, dyslipidemia, and cigarette smoking). The outcomes of this population following percutaneous coronary intervention (PCI) are debated. Further, sex differences within this population have yet to be established. This retrospective cohort study included 7,847 patients with ACS who underwent PCI. The study outcomes were in-hospital mortality, all-cause mortality, and major adverse cardio-cerebrovascular events (MACCE). The association between the absence of SMuRFs (SMuRF-less status) and outcomes among all the patients and each sex was assessed using logistic and Cox proportional hazard regressions. Approximately 11% of the study population had none of the SMuRFs. During 12.13 [11.99-12.36] months of follow-up, in-hospital mortality (adjusted-odds ratio (OR):1.51, 95%confidence interval (CI): 0.91-2.65, P:0.108), all-cause mortality [adjusted-hazard ratio (HR): 1.01, 95%CI: 0.88-1.46, P: 0.731], and MACCE (adjusted-HR: 0.93, 95%CI:0.81-1.12, P: 0.412) did not differ between patients with and without SMuRFs. Sex-stratified analyses recapitulated similar outcomes between SMuRF+ and SMuRF-less men. In contrast, SMuRF-less women had significantly higher in-hospital (adjusted-OR: 3.28, 95%CI: 1.92-6.21, P < 0.001) and all-cause mortality (adjusted-HR:1.41, 95%CI: 1.02-3.21, P: 0.008) than SMuRF+ women. Almost one in 10 patients with ACS who underwent PCI had no SMuRFs. The absence of SMuRFs did not confer any benefit in terms of in-hospital mortality, one-year mortality, and MACCE. Even worse, SMuRF-less women paradoxically had an excessive risk of in-hospital and one-year mortality.

Machine-learning score to predict in-hospital outcomes in patients Hospitalized in Intensive Cardiac Care Unit

Abstract Background While few scores are available for risk stratification of patients hospitalized in Intensive Cardiac Care Unit (ICCU) using traditional statistical methods, the potential benefit of machine learning is not established. Purpose To investigate the feasibility and accuracy of machine-learning (ML) to predict in-hospital major adverse events (MAE) in patients hospitalized in ICCU and compare its performance with existing scores. Methods From April 7 to 22, 2021, a French nationwide, multicenter, prospective, study involving 39 centers included all consecutive patients admitted in ICCU (N=1499). The primary outcome was in-hospital MAE defined as a composite outcome including all-cause in-hospital mortality, cardiogenic shock and resuscitated cardiac arrest (severe ventricular arrhythmia requiring defibrillation or anti-arrhythmic agents). Twenty-eight clinical, biological, ECG, and echocardiographic variables were considered for the Boruta variable selection algorithm. Using 31 centers randomly as an index cohort, several ML algorithms (logistic regression, ridge regression, boosted cost-sensitive C5.0 and XGBoost. C5.0 ) were evaluated to build a ML-score to predict in-hospital MAE. The other 8 centers formed the external validation cohort of the ML-score. Results Among 1499 consecutive patients included (age 63.3±14.9 years, 69.6% male), 61 had in-hospital MAE (4.3%). Out of 28 variables included in the feature selection, seven were selected as of particular importance to predict MAE in the training set (N=844) including: illicit drug use, mean arterial pressure, Killip stage, exhaled CO level, left ventricular ejection fraction, TAPSE value and peak E/e’ ratio. Boosted cost-sensitive C5.0 technique showed the best performance compared with other ML-techniques (area under the curve [AUC]=0.90, PR-AUC=0.57, F1 score=0.5), using 5 of the 7 above mentioned variables: mean arterial pressure, exhaled CO level, left ventricular ejection fraction, TAPSE value and peak E/e’ ratio. Our ML-score exhibited a higher AUC compared with existing scores for MAE prediction (ML score: 0.90 vs TIMI-score: 0.56, GRACE-score: 0.52, Acute HF-score: 0.65; all p&amp;lt;0.001). ML-score also exhibited a good AUC in the external cohort (AUC 0.97). Conclusions Including five simple clinical and echocardiographic variables (mean arterial pressure, exhaled CO level, left ventricular ejection fraction, TAPSE value and peak E/e’ ratio) routinely assessed in patients admitted in ICCU, the ML score exhibited a better prognostic value to predict in-hospital outcomes compared with existing scores.ML model and existing scores: ROC curveML model and existing scores: PR curve

Machine learning to predict in-hospital outcomes in patients with acute heart failure

Abstract Background Acute heart failure (AHF) is a leading cause of mortality worldwide and a major public health issue with a still high rate of in-hospital outcomes. Physicians need more investigations and new tools to prevent those high-risk patients from major adverse events (MAE). While few scores are available for risk stratification of patients hospitalized for AHF using traditional statistical methods, the potential benefit of machine-learning (ML) is not established. Purpose To investigate the feasibility and accuracy of a machine-learning (ML) model using clinical, biological and echocardiographic data to predict in-hospital MAE in patients hospitalized for AHF and compare its performance with traditional models and existing scores. Methods The study cohort consists of consecutive patients admitted for AHF included in the French nationwide, multicenter, prospective, ADDICTO-USIC study involving 39 centers from 7 to 22 April 2021. Traditional clinical, biological, electrocardiographic and echographic data as well as a standardized exhaled carbon monoxide (CO) measurement and the presence of illicit drugs determined through an urine drug assay were recorded. Three ML models were developed using clinical and echocardiographic parameters to predict in-hospital MAE, including death, resuscitated cardiac arrest or cardiogenic shock requiring medical or mechanical hemodynamic support. Least absolute shrinkage and selection operator (LASSO) regression was used to select variables and prevent model overfitting. The ML models (LASSO, random forest and XGBoost) were then trained on 70% of patients and evaluated on the other 30% as internal validation. Their performance was compared against standard logistic regression model, using receiver operating characteristics (ROC) and precision-recall (PR) curves and area-under-the curves (AUC). Results Among 459 consecutive patients included (age 68±14 years, 68% male), 47 had in-hospital MAE (9.8%). Out of 28 clinical, biological, ECG, and echocardiographic variables, seven were selected as being the most important in predicting MAE in the training set (N=322): mean arterial pressure (MAP), ischemic cardiomyopathy etiology, sub-aortic velocity time integral (VTI), E/e’, tricuspid annular plane systolic excursion (TAPSE), illicit drugs and Carbon monoxide. The random forest model showed the best performance compared with the other ML models (AUROC=0.82, PR-AUC=0.48, F1 score=0.56). Our ML-score exhibited a higher AUC compared with an existing score for prediction of MAE (AUROC for ML score: 0.82 vs Acute HF-score: all p&amp;lt;0.001). Conclusions The random forest ML-model including seven clinical and echocardiographic variables, including carbon monoxide level and illicit drugs use, exhibited a better performance than traditional statistical methods or existing scores to predict in-hospital outcomes in patients admitted for AHF.Feature selection by LASSOPerformances of ML models on test set

Simplified bedside nomogram for predicting long-term mortality and major adverse cardio-cerebrovascular events following on-pump coronary artery bypass graft

Abstract Background When facing patients asking their physicians how their risk of mortality and morbidities will be in the distant future after their cardiac surgery, the lack of predictive models on long-term outcomes is noticed in the clinical practice. Current risk scores, such as the Society of Thoracic Surgeons (STS) and the European System for Cardiac Operative Risk Evaluation (EURO-Score), were designed to predict short-term mortality and need modifications to be used for long-term mortality. Furthermore, these scores involve several factors that might increase the prediction models' complexity. Simplified bedside-friendly models can overcome these complications and render the predictive model more feasible to be used by clinicians. Purpose This study aimed to determine predictors of in-hospital mortality, all-cause mortality, and major adverse cardio-cerebrovascular events (MACCE) among patients undergoing on-pump coronary artery bypass graft (CABG). Subsequently, we aimed to design a simplified bedside nomogram for each of the outcomes using pre-operative predictors. Methods From 2007 to 2017, this single-center, retrospective cohort included 22846 post-CABG patients. Predictors of in-hospital mortality and long-term outcomes were identified using logistic and Cox regression models, respectively. Subsequently, nomograms were established using pre-operative predictors based on parametric survival regression (multiple Weibull models) coefficient. Model performance was measured using the area under the curve (AUC), Harrell’s concordance index (C-index), and calibration curves. Results The study population aged 65.06±9.95 years (74% males). During a median follow-up of 96.85 [70.12-121.17] months, 249 in-hospital mortality, 4172 all-cause mortality, and 7508 MACCEs occurred. Predictors of each study outcome are demonstrated in Figure 1. In-hospital mortality nomogram included glomerular filtration rate (GFR) ≤60, hypertension, valvular heart disease, age, and diabetes (Figure 2) and demonstrated acceptable discrimination ability (AUC: 0.74, 95% confidence interval (CI): 0.70-0.77). Variables in all-cause mortality and MACCE nomograms were consistent, comprising age, heart failure with reduced ejection fraction, GFR≤60, and diabetes (Figure 2). The C-index for all-cause mortality and MACCE prediction was 0.71 (95%CI: 0.70-0.73) and 0.69 (95%CI: 0.68-0.72), respectively. Furthermore, visual assessment of calibration curves indicated good prognostic predictive accuracy for all the three nomograms. Conclusions The designed simplified nomograms had acceptable internal (according to C-index) and external (according to calibration curves) validity for predicting post-CABG in-hospital mortality, all-cause mortality, and MACCE. These nomograms could be implemented in the routine cardiovascular practice after validating in other centers.

In-hospital Prognostic Value of TAPSE/sPAP in Patients Hospitalized for Acute Heart Failure

Abstract Background Tricuspid annular plane systolic excursion over systolic pulmonary artery pressure (TAPSE/sPAP) assessed by echocardiography appears to be a good noninvasive approach for right ventricular to pulmonary artery coupling assessment. Yet, the in-hospital prognostic value of TAPSE/sPAP in patients hospitalized for acute heart failure (AHF) has never been explored. Purpose To assess TAPSE/sPAP prognostic value among patients hospitalized for AHF. Methods All consecutive major patients hospitalized for AHF across 39 French cardiology department, with TAPSE/sPAP measured by echocardiography within the 24 first hours of hospitalization were included in this prospective study. The primary outcome was in-hospital major cardiac adverse events (MACEs) defined as all-cause death, resuscitated cardiac arrest or cardiogenic shock. Results Three hundred and thirty-three patients with both AHF and TAPSE/sPAP measurement were included (mean age 68±14 years, 70% of male, 40% HFpEF, 18% HFmrEF, 42% HFrEF). In-hospital MACEs occurred in 50 (15%) of the patients. Using receiver operating characteristics curves analysis, the best threshold for in-hospital MACEs was 0.40 mm/mmHg. Patients with TAPSE/sPAP &amp;lt;0.40 mm/mmHg had more frequently atrial fibrillation (p=0.024), chronic kidney disease (p=0.001), higher NTproBNP level (p&amp;lt;0.001), and worse left and right ventricular function (p&amp;lt;0.01). TAPSE/sPAP &amp;lt;0.40 mm/mmHg was independently associated with in-hospital MACEs, even after adjustment with comorbidities (OR=3.75, 95%CI[1.87-7.93], p&amp;lt;0.001), clinical severity (OR=2.80, 95%CI[1.36-5.95], p=0.006), or using a propensity matched population analysis (OR=2.98, 95%CI[1.53-6.12], p=0.002, figure 1). Finally, TAPSE/sPAP showed incremental prognostic value for in-hospital MACEs over traditional risk factors, including left ventricular ejection fraction (figure 2). Conclusion Emphasizing the prognostic value of TAPSE/sPAP &amp;lt;0.40 mm/mmHg for in-hospital MACEs, over traditional risk factors, these results suggest embedding this parameter into clinical decision-making and risk stratification in patients hospitalized for AHF.

Abstract 17596: Association of Racial-Ethnic Disparities and Frailty on Adverse Outcomes in Geriatric Patients Undergoing Elective Percutaneous Left Atrial Appendage Closure With Watchman Device

Introduction: Use of left atrial appendage closure (LAAC) has become more widespread in the geriatric population. Frailty, a geriatric syndrome, is associated with significant morbidity and mortality. Hypothesis: Race/Ethnicity influences frailty status and may differentially impact adverse outcomes in elective LAAC procedure. Methods: Patients aged ≥65 years who underwent elective LAAC were identified using ICD-10 procedure code 02L73DK from 2016-2018 HCUP-NIS Database. Hospital Frailty Risk Score (HFRS) was calculated for each patient based on 109 ICD-10 diagnosis codes and classified into non-frail (HFRS &lt; 5) and frail (HFRS score ≥ 5) groups. Charlson comorbidity index (CCI) was used to assess comorbidity burden. In-hospital major adverse event (MAE) was defined as the composite of mortality, stroke (ischemic or hemorrhagic) or TIA, bleeding or transfusion, vascular complications, myocardial infarction, systemic embolization, and pericardial effusion or tamponade requiring pericardiocentesis or surgery. Outcome was in-hospital MAE. Multivariate regression analysis was used to assess the association of race/ethnicity and frailty on MAE. Results: 27,155 patients (Age = 77.3 ± 6.4 years; Female = 42.4%, White: 88%, Black: 3.4%, Hispanic:5.2%, Other: 3.4%) were included. Overall, the prevalence of frailty was 12.5% (White:12.4%, Black: 13.7%, Hispanic: 11.8%, Other: 13%). Overall, in-hospital MAE was 4.7%, with increased rates in frail patients (4% vs.9.6%; p&lt;0.001). Rates of in-hospital MAE were frail-White: 9.3%, frail-Black: 8%, frail-Hispanic:20.6%, and frail-Other: 4.2% (p&lt;0.001). On multivariate analysis, frail-White and frail-Hispanic patients were at increased risk of in-hospital MAE compared to non-frail patients (Figure). Conclusion: Further research is needed to highlight disparities by race/ethnicity and to identify potentially modifiable factors to mitigate adverse events in frail geriatric population undergoing LAAC.

Abstract 16504: Hospital Frailty Risk Score (HFRS) Predicts Adverse Events in Patients Undergoing Elective Percutaneous Left Atrial Appendage Closure (LAAC) With WATCHMAN Device

Introduction: Frailty and its association with adverse events are well-known in transcatheter aortic valve replacement. However, this association has not been well-studied in patients undergoing Left Atrial Appendage Closure (LAAC). Hypothesis: Frailty predicts adverse events in patients undergoing elective LAAC with WATCHMAN device. Methods: Patients aged ≥65 years who underwent elective LAAC with WATCHMAN device were identified using ICD-10 procedure code 02L73DK from the 2016-2018 HCUP-NIS Database. Hospital Frailty Risk Score (HFRS) was calculated for each patient based on 109 ICD-10 diagnosis codes and classified into non-frail (HFRS &lt; 5) and frail (HFRS score ≥ 5) groups. In-hospital major adverse event (MAE) was defined as the composite of mortality, stroke (ischemic or hemorrhagic) or TIA, bleeding or transfusion, vascular complications, myocardial infarction, systemic embolization, and pericardial effusion or tamponade requiring pericardiocentesis or surgery. Multivariate regression and receiver operating characteristic (ROC) analyses were used to assess the relationship between the HFRS and MAE. Results: 28,050 patients (Age = 77.3 ± 6.4 years; Female = 42.6%) were included, and 4.7% experienced in-hospital MAE. Frail patients (HFRS score ≥ 5) constituted 12.5% of the cohort. Frail patients were older and had a more significant proportion of women. Rates of MAE were significantly greater in frail patients (4% vs. 9.7%; p&lt;0.001). Increasing Hospital Frailty Risk Score was associated with a greater risk of in-hospital MAE. The AUC - ROC was 0.63 (Figures: A and B). Conclusions: HFRS predicts adverse events after LAAC. HFRS could be implemented in hospital information systems to facilitate the identification of at-risk patients.

Abstract 16630: Economic Impact of Frailty in Patients Undergoing Elective Percutaneous Left Atrial Appendage Closure (LAAC) With WATCHMAN Device

Introduction: Frailty is associated with significant morbidity and mortality in older adults. Currently, standard practice after percutaneous left atrial appendage closure involves monitoring patients overnight and discharging them the following day. Hypothesis: Frailty predicts increased hospital cost and length of stay (LOS) in patients undergoing elective LAAC with WATCHMAN device. Methods: Patients aged ≥65 years who underwent elective LAAC with WATCHMAN device were identified using ICD-10 procedure code 02L73DK from 2016-2018 HCUP-NIS Database. In-hospital major adverse event (MAE) was defined as the composite of mortality, stroke (ischemic or hemorrhagic) or TIA, bleeding or transfusion, vascular complications, myocardial infarction, systemic embolization, and pericardial effusion or tamponade requiring pericardiocentesis or surgery. Hospital Frailty Risk Score (HFRS) was calculated for each patient based on 109 ICD-10 diagnosis codes and classified into non-frail (HFRS &lt; 5) and frail (HFRS score ≥ 5) groups. Multivariate regression analysis was used to assess the relationship between the HFRS and hospital cost hospitalization (≥90 centile) and prolonged LOS (&gt;72 hours). Results: 28,050 patients (Age = 77.3 ± 6.4 years; Female = 42.6%) were included. Median hospitalization cost was $24,500 (inter-decile range: $14,000-37,100) and median LOS was 1 day (inter-decile range: 1-2 days) and 4.7% experienced in-hospital MAE. Frail patients (HFRS score ≥ 5) constituted 12.5% of the cohort. Increasing Hospital Frailty Risk Score was associated with a greater risk of high-cost hospitalization and LOS &gt; 72 hours (Figure). Conclusions: Increasing frailty is a significant predictor of increased hospital cost and LOS in elective LAAC. This effect is independent of age and in-hospital MAE.

Abstract 19153: In-Hospital Outcomes and Complications of Atrial Fibrillation Ablation: A Comparison Between Geriatric and Non-Geriatric Population

Introduction: Atrial fibrillation (AF) is the most common arrhythmia associated with significant morbidity and mortality. The availability of different types of ablation for the treatment of AF is improved patient mortality and mitigate the disease burden. However, there is limited data on comparing post ablation results for AF in the geriatric population on geriatric population. Hypothesis: To study the in-hospital outcomes and complication of AF ablation among the geriatric and non-geriatric population groups. Methods: The National Inpatient Sampling from October 2016 to December 2019, a nationally representative sample of US hospitalizations. Adult (&gt;18 years) inpatient admissions with AF and ablation were identified based on International Classification of Diseases-Tenth Revision. The patient population is divided into three groups based on age i.e., group A (18-64 years), group B (65-74 years), group C (&gt;75 years). Results: A total of 15,800 AF patients over the age of 18 undergoing ABLA were identified. Among them, Group A accounted for 36.8%, Group B for 34.2%, and Group C for 28.9% of the patients. The female population in Group A was 28.7%, in Group B it was 40%, and in Group C it was 54.3% (p=0.03). Group C had higher prevalence rates of CHF (53.5%), COPD (22%), and CKD (30%) compared to the other groups (p&lt;0.000). When comparing Group C with Group A and B, patients in Group C experienced higher in-hospital mortality (0.8% vs 0.3% vs 0.4%; p&lt;0.000), cardiac complications (13.4% vs 5.9% vs 7.5%; p&lt;0.000), AKI (17% vs 11% vs 11.8%; p&lt;0.000), and major adverse events (MI or non-fatal stroke or CV death) (28.5% vs 16.9% vs 19.2%; p&lt;0.000). The rates of ICD/pacemaker implantation differed among Group A, B, and C (5.9% vs 10% vs 20.5%; p=0.000). Conclusions: Among AF patients undergoing ablation, those aged over 75 demonstrated higher rates of CHF, COPD, and CKD compared to other age groups. This population also experienced increased in-hospital mortality, cardiac complications, AKI, major adverse events (MI or non-fatal stroke or CV death), and had a significantly higher rate of ICD/pacemaker implantation. These findings emphasize the need for tailored interventions and closer monitoring for AF patients aged over 75 to improve outcomes.

Intravascular lithotripsy compared to rotational atherectomy for the treatment of calcified distal left main coronary artery disease: A single center experience.

The safety and efficacy of intravascular lithotripsy (IVL) for the treatment of calcified distal left main (LM) disease remains unclear, especially compared to rotational atherectomy (RA). We retrospectively analyzed the baseline clinical, angiographic, intravascular ultrasound (IVUS) characteristics and procedural outcomes of 107 patients who underwent distal LM percutaneous coronary intervention (PCI) with IVL (with or without adjunct atherectomy) versus RA alone for plaque modification before stenting at a single center between 2020 and 2022. A total of 50 patients underwent calcium modification with IVL with or without adjunct atherectomy and 57 with RA only. The mean age was 73 years and with a high prevalence of diabetes (58.9%), chronic kidney disease (42.1%), prior revascularization (coronary artery bypass graft surgery [36.4%] or prior PCI [32.7%]). Acute coronary syndrome was the primary indication for PCI in over 50% of the patients in both groups. Medina 1-1-1 LM bifurcation disease was identified in 64% and 60% of the IVL and RA groups (p = 0.64) respectively. Final minimum stent area in distal LM (>8.2 mm2 ), ostial LAD (>6.3 mm2 ) and ostial LCX (>5.0 mm2 ) were achieved in 96%, 85% and 89% of cases treated with IVL respectively and 93%, 93% and 100% of cases treated with RA respectively (LM p = 1.00; LAD p = 0.62; LCX; p = 1.00 for difference between the two groups). Procedural success (technical success without in-hospital major adverse events) was achieved in 98% of the IVL group and 86% of the RA-only group (p = 0.04). There were eight procedural complications (flow-limiting dissection, perforation, or slow/no-reflow) in the RA group compared to four in the IVL group (NS), and one patient in the RA required salvaged mechanical support compared to none in the IVL group. Plaque modification with coronary IVL appears to be efficacious and safe for the treatment of severely calcified distal LM lesions compared to RA only. Larger randomized studies are needed to confirm these findings.

Prevalence and impact of recreational drug use in patients with acute cardiovascular events

ObjectiveWhile recreational drug use is a risk factor for cardiovascular events, its exact prevalence and prognostic impact in patients admitted for these events are not established. We aimed to assess...

Elevated High Sensitivity Cardiac Troponin T is Nonlinearly Associated with Poor Prognosis in Aging COVID-19 Patients: A Retrospective Study.

To evaluate the relationship between high-sensitivity cardiac troponin T (hs-cTnT) and prognosis in elderly patients with coronavirus disease 2019 (COVID-19). This study recruited 1399 COVID-19 patients aged 65 years or older admitted to Taizhou Hospital or Enze Hospital in Zhejiang Province from December 15, 2022, to January 4, 2023. The Cox regression model was used to evaluate the relationship between hs-cTnT level and in-hospital death. The logistic regression model was used to evaluate the relationship between hs-cTnT level and major adverse events. The restricted cubic spline (RCS) model is used for nonlinear analysis. The increase of peak hs-cTnT was associated with the increased risk of death (HR 9.49; 95% CI 1.19-75.48; trend p = 0.012) and major adverse events (OR 20.59; 95% CI 10.41-40.71; trend p < 0.001). RCS model showed the association between peak hs-cTnT and death and major adverse events were nonlinear (P for non-line < 0.001). Starting from the limit of quantification of hs-cTnT (3ng/L), the risk of death and major adverse events had a steep S-shaped increase until hs-cTnT reached the 90th percentile point (hs-cTnT = 131 ng/L), followed by a plateau period. Peak hs-cTnT has good predictive value for death and major adverse events, with AUC of 0.834 and 0.804, respectively. Peak hs-cTnT has high predictive value for the risk of in-hospital death and major adverse events in elderly patients with COVID-19. The association between peak hs-cTnT and death and major adverse events were nonlinear.

Right Ventricular Cardiac Power Index Predicts 1 Year Outcome After Transcatheter Edge-to-Edge-Repair for Severe Tricuspid Valve Regurgitation

Tricuspid transcatheter edge-to-edge repair (T-TEER) for severe tricuspid regurgitation (TR) emerged as a novel treatment option for patients not amenable to surgery. However, knowledge regarding independent risk factors for a worse prognosis is rarely available. The study sought to investigate the impact of right ventricular cardiac power index (RVCPi) on 1-year outcomes in patients with severe symptomatic TR who underwent T-TEER. Consecutive patients with severe TR who underwent T-TEER from August 2020 to March 2022 were included and followed prospectively. Baseline clinical and invasive hemodynamic variables, changes in echocardiographic parameters and New York Heart Association functional class, and periprocedural and in-hospital major adverse events were assessed. Primary end point was defined as a composite of all-cause mortality and heart failure hospitalization at 1 year after T-TEER. A multivariable Cox proportional-hazards regression analysis was performed to identify independent risk factors for combined primary end point. RVCPi was calculated as: (cardiac index×mean pulmonary pressure)×K (conversion factor 2.22×10-3)=W/m². Receiver operator characteristic analysis was used to determine discriminative capacity of RVCPi. The prognostic value of RVCPi threshold was tested using Kaplan-Meier analysis. In total, 102 patients (mean age 81±6years, 51% women) at high operative risk underwent T-TEER for severe TR. Primary end point occurred in 30 patients (32%). Receiver operator characteristic curve analysis demonstrated that RVCPi was associated with an area under the curve of 0.69 (95% confidence interval 0.56 to 0.82; p=0.003). With a RVCPi threshold of 0.17W/m² (maximally selected rank statistics), the event-free survival was significantly higher in the RVCPi <0.17W/m² group compared with those with RVCPi ≥0.17W/m² (71% vs 35%, log-rank p<0.001). In the multivariable Cox regression analysis, RVCPi was an independent predictor for the combined primary end point (hazard ratio 2.6, 95% confidence interval 1.4 to 5.1, p=0.003). In conclusion, RVCPi is associated with outcome in patients who underwent T-TEER for severe TR and this hemodynamic predictor is useful in risk stratification of T-TEER candidates.

Gender disparities related to clinical characteristics and outcomes of patients undergoing transseptal procedures

PurposeExplore gender disparities in patients undergoing transseptal puncture (TSP) for selected transcatheter cardiac intervention procedures. MethodsPatients who underwent TSP from January 2015 through September 2021 were reviewed. Primary outcomes were procedural and in-hospital major adverse events. Secondary endpoints were procedural success and hospitalization length of stay (LOS) >1 day. Unadjusted and multivariable-adjusted logistic regression analyses were performed to assess gender differences for in-hospital adverse events. ResultsThe study cohort comprised 510 patients (mean [SD] age, 74 [14.0] years); 246 women (48 %) underwent TSP for left atrial appendage occlusion (LAAO) or transcatheter edge-to-edge-repair (TEER). Compared with men, women were younger, had higher CHA2DS2-VASc scores, and were more likely to have had a prior ischemic stroke, but were less likely to have paroxysmal atrial fibrillation. After multivariable adjustment, there were no differences between genders in aborted or canceled procedures (odds ratio [OR]: 0.43; 95 % confidence interval [CI]: 0.10–1.96; p = 0.277), any adverse events (OR: 1.00; 95 % CI: 0.58–1.70; p = 0.98), major adverse events (OR: 1.60; 95 % CI: 0.90–2.80; p = 0.11), or death (OR: 1.00; 95 % CI: 0.20–5.00; p = 0.31). Subgroup analysis for LAAO procedures showed that at 30 days, women had higher rates of adverse events, major adverse cardiac events, and LOS >1 day. ConclusionsMen and women showed no differences in procedural success and in-hospital adverse outcomes in unadjusted analysis and after multivariable adjustment, despite women having a higher risk profile among patients undergoing TSP. However, compared with men, women undergoing LAAO experienced a higher rate of in-hospital adverse events irrespective of TSP.

A novel endovascular robotic-assisted system for endovascular aortic repair: first-in-human evaluation of practicability and safety

ObjectivesTo assess the practicability and safety of a novel endovascular robotic system for performing endovascular aortic repair in human.MethodsA prospective observational study was conducted in 2021 with 6 months post-operative follow-up. Patients with aortic aneurysms and clinical indications for elective endovascular aortic repair were enrolled in the study. The novel developed robotic system is applicable for the majority of commercial devices and various types of endovascular surgeries. The primary endpoint was technical success without in-hospital major adverse events. Technical success was defined as the ability of the robotic system to complete all procedural steps based on procedural segments.ResultsThe first-in-human evaluation of robot-assisted endovascular aortic repair was performed in five patients. The primary endpoint was achieved in all patients (100%). There were no device- or procedure-related complications or no in-hospital major adverse events. The operation time and total blood loss in these cases were equal to those in the manual procedures. The radiation exposure of the surgeon was 96.5% lower than that in the traditional position while the radiation exposure of the patients was not significantly increased.ConclusionsEarly clinical evaluation of the novel endovascular aortic repair in endovascular aortic repair demonstrated practicability, safety, and procedural effectiveness comparable to manual operation. In addition, the total radiation exposure of the operator was significantly lower than that of traditional procedures.Clinical relevance statementThis study applies a novel approach to perform the endovascular aortic repair in a more accurate and minimal-invasive way and lays the foundation for the perspective automation of the endovascular robotic system, which reflects a new paradigm for endovascular surgery.Key Points• This study is a first-in-human evaluation of a novel endovascular robotic system for endovascular aortic repair (EVAR).• Our system might reduce the occupational risks associated with manual EVAR and contribute to achieving a higher degree of precision and control.• Early evaluation of the endovascular robotic system demonstrated practicability, safety, and procedural effectiveness comparable to that of manual operation.

Predictive value of elevated neutrophil gelatinase-associated lipocalin levels for assessment of in-hospital adverse outcomes among myocardial infarction patients.

Inflammatory biomarkers are known to rise and have predictive value for adverse outcomes in patients with acute coronary ischemia. One of those biomarkers is neutrophil gelatinase-associated lipocalin (NGAL). To date, only very few studies have assessed the prognostic value of NGAL in this setting. We investigated the prognostic utility of elevated NGAL levels on clinical outcomes among ST-elevation myocardial infarction patients. High NGAL was defined as values within the 4th quartile. Patients were assessed for major in-hospital adverse clinical events (MACE). Multivariable logistic regression and area under the receiver operating characteristic curve (AUC) were used to further evaluate NGAL association for MACE and discrimination ability. A total of 273 patients were included. patients with high NGAL were at increased risk for MACE (62% vs. 19%; odds ratio 6.88, 95% confidence interval, 3.77-12.54, P < 0.001). After propensity score matching, the incidence of MACE was significantly higher in patients with high vs. low NGAL levels (69% vs. 6%, P = 0.002). In multivariable regression, high NGAL level was independently associated with MACE. The discrimination ability of NGAL to identify MACE (AUC 0.823), is significantly better than that of other inflammatory markers. Among ST-segment elevation myocardial infarction patients undergoing primary percutaneous coronary intervention, high NGAL levels are associated with adverse outcomes, independent of traditional inflammatory markers.