Lower Stroke Rates Research Articles

Abstract WP155: Epidemiology of Posterior Reversible Encephalopathy Syndrome (PRES) in the United States: A National Inpatient Sample Study

Introduction: Posterior reversible encephalopathy syndrome (PRES) is an increasingly recognized and potentially devastating cerebral dysregulation syndrome. The epidemiology of PRES and its associated manifestations have been underreported. We therefore sought to determine the prevalence and clinical severity of PRES among hospitalized patients in the United States (US). Methods: We conducted a retrospective cohort study using US data from the National Inpatient Sample (NIS) for the years 2016 to 2019. To identify patients with PRES, we used the ICD-10-CM diagnostic code I67.83, which was previously found to have a sensitivity of 100% (95% CI, 87%-100%) and a specificity of 88% (95% CI, 73%-97%) as compared to chart review. To characterize disease severity, we report the coincidence of any stroke (ischemic stroke, intracerebral hemorrhage [ICH], subarachnoid hemorrhage [SAH]) using previously validated ICD-10-CM codes, length of stay, need for mechanical ventilation, and discharge destination. Standard descriptive statistics with 95% CI are used to detail our findings. Results: We identified 39,460 hospitalizations for PRES among adults, which accounts for 0.03% of hospitalizations during the study period. The median age of PRES patients was 57 years (IQR, 41-67), 27,583 (69.9%) were female, and 26,399 (66.9%) were of White race. A total of 33,107 patients (83.9%) had a history of hypertension. Among patients with PRES, 3,950 (10.0%; 95% CI, 9.4-10.7%) had an ischemic stroke, 1,685 (4.3%; 95% CI, 3.8-4.7%) had ICH, and 995 (2.5%; 95% CI, 2.2-2.9%) had SAH during their index hospitalization. The median length of stay was 6 days (IQR 4-12), one quarter required mechanical ventilation, and half were discharged to home. Conclusion: In a representative US sample, we found that PRES is a rare disorder with relatively low rates of coincident ischemic and hemorrhagic stroke reported at index hospitalization.

Early Pharmacologic Therapy in Patients With Blunt Cerebrovascular Injury and TBI: Is it Safe and Effective? An EAST Multicenter Study.

Blunt cerebrovascular injury (BCVI) with concurrent traumatic brain injury (TBI) presents increased risk of both ischemic stroke and bleeding. This study investigated the safety and survival benefit of BCVI treatment (antithrombotic and/or anticoagulant therapy) in this population. We hypothesized that treatment would be associated with fewer and later strokes in patients with BCVI and TBI without increasing bleeding complications. Patients with head AIS >0 were selected from a database of BCVI patients previously obtained for an observational trial. A Kaplan-Meier analysis compared stroke survival in patients who received BCVI treatment to those who did not. Logistic regression was used to evaluate for confounding variables. Of 488 patients, 347 (71.1%) received BCVI treatment and 141 (28.9%) did not. BCVI treatment was given at a median of 31h post-admission. BCVI treatment was associated with lower stroke rate (4.9% vs 24.1%, P < .001 and longer stroke-free survival (P < .001), but also less severe systemic injury. Logistic regression identified motor GCS and BCVI treatment as the only predictors of stroke. No patients experienced worsening TBI because of treatment. Patients with BCVI and TBI who did not receive BCVI treatment had an increased rate of stroke early in their hospital stay, though this effect may be confounded by worse motor deficits and systemic injuries. BCVI treatment within 2-3days of admission may be safe for patients with mean head AIS of 2.6. Future prospective trials are needed to confirm these findings and determine optimal timing of BCVI treatment in TBI patients with BCVI.

The stroke rate influences performance, technique and core stability during rowing ergometer

ABSTRACT The aim of this study is to determine the effect of stroke rate on performance, technique and core stability during rowing ergometer. Twenty-four high-level rowers performed maximal intensity one-minute bouts at 20, 28 and 34 spm on a RowPerfect3 ergometer. Power at the handle, legs, trunk and arms levels were determined, and core kinematics and neuromuscular activations were measured. The power at the handle was enhanced with a higher stroke rate in the first half of the drive phase due to higher segment’s powers. This resulted in technical changes, as for instance greater mean to peak power ratio at each segment level. The higher trunk power preceded a delayed trunk extension but without significant increase in the erector spinae activation. This underlines the role of the core stability to transfer forces at a higher stroke rate. However, no co-activation parameters between trunk flexors and extensors helped further to understand this force transfer. Rowing at low stroke rate can be a training strategy to work on earlier trunk extension, while maintaining erectors spinae levels of activation. Training at higher stroke rate will induce a rowing technique closer to competition with greater neuromuscular activations, and maximise power production.

Outcomes of carotid endarterectomy in octogenarians compared to their younger counterparts: a retrospective observational study.

This study was performed to analyze the association between age and outcomes of carotid endarterectomy (CEA) by comparing postoperative outcomes between octogenarians and younger patients. From November 1994 to December 2022, 1,585 internal carotid arteries of 1,434 patients were enrolled. Patients were stratified into 2 groups: octogenarians (≥80 years old) and non-octogenarians (<80 years old). Primary endpoints were early (≤30 days) outcomes of ipsilateral stroke, any stroke, myocardial infarction, death, and major adverse cardiovascular events (MACE). We also compared overall any stroke and death between the 2 groups. One of 132 octogenarians (0.8%) and 17 of 1,453 non-octogenarians (1.1%) experienced ipsilateral stroke within 30 days. Thirty-day MACE occurred in 4 of 132 octogenarians (3%) and 44 of 1,453 non-octogenarians (3%). There were no significant differences in any early (≤30 days) outcomes. Symptomatic status was associated with increased 30-day MACE (odds ratio [OR], 2.610; 95% confidence interval [CI], 1.450-4.696; P = 0.003) and 30-day any stroke (OR, 3.999; 95% CI, 1.627-9.828; P = 0.003). Symptomatic status was also associated with overall any stroke (hazard ratio [HR], 2.885; 95% CI, 1.865-4.463; P < 0.001), but age of ≥80 years was not associated with 30-day MACE, 30-day any stroke, or overall stroke. Age of ≥80 years was only associated with overall survival (HR, 2.644; 95% CI, 1.967-3.555; P < 0.001). CEA would be a safe and effective treatment for octogenarians with low 30-day complications and long-term stroke rates, comparable with that of younger counterparts. Advanced age is not a contraindication for CEA.

Outcomes of Warfarin Home INR Monitoring vs Office-Based Monitoring: a Retrospective Claims-Based Analysis

BackgroundHome INR testing (patient self-testing) is feasible and effective for warfarin patients but little is known about real-world differences in outcomes for patients using PST versus laboratory-based INR monitoring.ObjectiveTo compare the safety/efficacy of patient self-testing of real-world warfarin therapy versus office/lab-based monitoring of therapy.Design/Setting/Participants/ExposureA retrospective claims-based analysis of warfarin patients enrolled in the MarketScan® Commercial Claims and Encounters and Medicare databases between January 1, 2013, and March 30, 2020. Stratification was based on INR testing method: patient self-testing versus testing at physicians’ offices/local laboratory. The probability of adverse events in each cohort was determined after adjusting for demographic and baseline clinical characteristics using a repeated measures analysis.Main MeasuresRates of all adverse events: deep venous thrombosis, pulmonary embolism, bleeding, and stroke. A secondary outcome of interest was emergency department visits.Key ResultsA total of 37,837 patients were included in the analysis: 1592 patients in the patient self-testing group and 36,245 in the office-based therapy group. After adjusting for demographic and baseline clinical characteristics, patients in the office-based group had statistically significantly higher rates of all adverse events (incidence rate ratio [IRR]=2.07, 95% CI [1.82, 2.36]), and specific adverse events including thromboembolism (IRR=4.38, 95% CI [3.29, 5.84]), major bleed (IRR=1.45, 95% CI [1.28, 1.64]), and stroke (IRR=1.30, 95% CI [1.05, 1.61]) than patients in the patient self-testing group. Office-based patients also had a statistically significant higher rate of emergency department visits than patient self-testing patients (IRR = 1.65, 95% CI [1.47, 1.84]).Conclusions/RelevanceThis analysis of real-world claims data shows lower rates of stroke, thromboembolism, and major bleeding, as well as fewer emergency department visits, with patient self-testing compared to office-based/lab INR monitoring. Our finding that PST is safe and effective among current users suggests that more patients may benefit from its use.

Intersection of sepsis, atrial fibrillation, and severe obesity: a population-based analysis in the United States.

Atrial fibrillation (AF) is an indicator of poor prognosis in patients with sepsis and can increase the risk of stroke and mortality. Data on the impact of severe obesity on the outcomes of sepsis complicated by AF remains poorly understood. National Inpatient Sample (2018) and ICD-10 CM codes were used to identify the principal sepsis admissions with AF. We assessed comorbidities and outcomes of sepsis in people without obesity (BMI < 30) vs. non-severe obesity (BMI 30-35) and severe obesity (BMI > 35) cohorts. We also did a subgroup analysis to further stratify obesity based on metabolic health and analyzed the findings. The primary outcomes were the prevalence and adjusted odds of AF, AF-associated stroke, and all-cause mortality in sepsis by obesity status. Multivariable regression analyses were adjusted for patient- and hospital-level characteristics and comorbidities. Our main analysis showed that of the 1,345,595 sepsis admissions, the severe obesity cohort was the youngest (median age 59 vs. non-severe 64 and people without obesity 68 years). Patients with obesity, who were often female, were more likely to have hypertension, diabetes, congestive heart failure, chronic pulmonary disease, and chronic kidney disease. The crude prevalence of AF was highest in non-severe obesity (19.9%). The adjusted odds of AF in non-severe obesity (OR 1.21; 95% CI:1.16-1.27) and severe obesity patients with sepsis (OR 1.49; 95% CI:1.43-1.55) were significantly higher than in people without obesity (p < 0.001). Paradoxically, the rates of AF-associated stroke (1%, 1.5%, and 1.7%) and in-hospital mortality (3.3%, 4.9%, and 7.1%) were lowest in the severe obesity cohort vs. the non-severe and people without obesity cohorts, respectively. On multivariable regression analyses, the all-cause mortality revealed lower odds in sepsis-AF patients with severe obesity (OR 0.78; 95% CI:0.67-0.91) or non-severe obesity (OR 0.63; 95% CI:0.54-0.74) vs. people without obesity. There was no significant difference in stroke risk. A higher prevalence of cardiovascular comorbidities can be linked to a higher risk of AF in people with obesity and sepsis. Paradoxically, lower rates of stroke and all-cause mortality secondary to AF in people with obesity and sepsis warrant further investigation.

Disparities in Outcomes Between Sexes in Type B Aortic Dissection Patients Treated with TEVAR

To evaluate differences in presentation and outcomes between sexes in patients who underwent thoracic endovascular aortic repair for type B aortic dissection (TBAD). Between January 1, 2012 and January 1, 2017 186 patients underwent thoracic endovascular aortic repair for TBAD at a single institution. Men (n=112) and women (n=74) were compared based on presenting demographics, comorbidities, and postoperative complications. Primary outcomes were survival and need for reintervention. Women were older (P=0.04) and had a lower body mass index (P=0.03). More women (F) presented with continued pain or refractory hypertension (51.0% F, 30.0% M), while more men (M) presented with acute complicated dissections (19.0% F, 39.0% M) (P=0.008). At presentation, women had statistically higher relative rates of chronic obstructive pulmonary disease (P=0.05), hyperlipidemia (P=0.03), and smoking (P=0.03). Significantly more women were on Medicare without Medicaid (55.0% F, 34.0% M), while men had private insurance (35.0% F, 13.0% M) (P=0.005). There was no significant difference in blood pressure control at presentation, discharge, or at 30days. When normalized by body surface area, women had larger ascending aortic diameters (19.2(3.10)F, 17.5(2.40)M, P=0.0002), as well as proportionally larger true lumens at the left subclavian artery (14.9(2.90)F, 13.4(2.50)M, P=0.0002), carina (12.6(5.80)F, 9.90(4.80)M, P=0.0009), and celiac (10.5(4.50)F, 8.50(4.10)M, P=0.006) levels, and at the largest point of dissection (11.6(6.50)F, 9.60(4.80)M, P=0.04), as well as proportionately smaller false lumens at the carina (5.90(5.60)F, 9.30(6.10)M, P=0.003). Despite not being statistically significant, women had lower rates of stroke (6.80% F, 8.00% M, P=0.7) and acute kidney injury (5.40% F, 11.6% M, P=0.2), as well fewer days in the intensive care unit (ICU) (3.20(4.30)F, 4.60(6.60)M, P=0.2) and an overall shorter length of stay (6.80(6.70)F, 8.00(8.20)M, P=0.5). Kaplan-Meier estimates for survival for women versus men were 96.0% vs. 92.0%, 90.0% vs. 79.0%, and 70.0% vs. 69.0% at 30 days, 1 year, and 3 years, respectively (P=0.042). Kaplan-Meier estimates for freedom from reintervention for women versus men were 89.0% vs. 90.0%, 58.0% vs. 72.0%, and 48.0% vs. 58.0% at 30 days, 1 year, and 3 years, respectively (P=0.13). Women present with TBAD at an older age, have more comorbidities, lower socioeconomic status, and have larger ascending aortic diameters for their size. Despite having less severe dissections as evidenced by smaller false lumens and wider true lumens, it does not appear that this correlates with improved outcomes for women when compared to men. It appears that this is one of the few, if not only, aortic pathologies that result in comparable outcomes between sexes.

Outcomes and Predictors of Morbidity after Carotid Body Tumor Resection

Carotid body tumors (CBTs) are uncommon neuroendocrine tumors at the carotid bifurcation treated with resection. The goal of this study was to examine patient outcomes after CBT resection and establish predictors of morbidity. Patients undergoing CBT resection were identified from the National Surgical Quality Improvement Program (NSQIP) database over 11years. Demographics, past medical history, preoperative labs, procedural details, morbidity and mortality were recorded. Multivariable logistic regression (MLR) analysis was performed to determine independent predictors of morbidity. From 2010 to 2020, 668 CBT resections were identified. The majority of patients were female (65%) and White (72%) with a mean age of 56 (standard deviation [SD]±16). Average body mass index (BMI) was 29.9 (SD±7.1). Arterial resection occurred in 81 patients (12%). 6% of patients experienced morbidity, most commonly re-operation (2.4%). Morbidity was more common in patients with higher BMI (33.1 vs. 29.7, P=0.005), chronic obstruction pulmonary disease (10% vs. 1.9%, P=0.012), higher American Society of Anesthesiologists (P=0.005), and lower albumin (3.7 vs. 4, P=0.016). Morbidity was not increased with arterial resection (P=1) or based on length of operation (P=0.169). Morbidity did not impact mortality (P=0.06) though led to longer length of stay [LOS] (8days vs. 2.4, P<0.001). On MLR, preoperative BMI was the only risk factor for morbidity (odds ratio 1.06, 95% confidence interval 1.02-1.1, P=0.005). CBT resection is very well tolerated with low stroke rates, morbidity, and mortality. Arterial resection leads to increased transfusion requirements and LOS but did not increase stroke rates, mortality, or overall morbidity. Within the NSQIP database, preoperative BMI was the only predictor of postoperative morbidity, which leads to significantly longer LOS.

Experimental investigation on slip conditions during thread rolling with flat dies

The process design of flat die rolling operations can be a tedious and costly process due to the challenges posed by small process windows. Within this work, an effort is made to closely investigate and understand the process limits caused by excessive slippage of the workpiece. Optical measurements are carried out to capture the characteristics of excessive slippage and the influence of the stroke rate and the tribological system on this process limit. Large differences in slippage were observed, depending on the tribological system. While systems with polymer based lubricants showed excessive slippage at low stroke rates, systems using oil or no lubricant endured higher stroke rates before process limits were reached. The optical measurements revealed three major forms of slippage: successful rolling without slippage, failure due to excessive slippage at process start, and failure due to excessive slippage at around one workpiece rotation.

Outcomes of repeat transcatheter aortic valve replacement with balloon-expandable valves: a registry study

With increasing numbers of patients undergoing transcatheter aortic valve replacement (TAVR), data on management of failed TAVR, including repeat TAVR procedure, are needed. The aim of this study was to assess the safety and efficacy of redo-TAVR in a national registry. This study included all consecutive patients in the Society of Thoracic Surgeons/American College of Cardiology Transcatheter Valve Therapy Registry from Nov 9, 2011, to Dec 30, 2022 who underwent TAVR with balloon-expandable valves in failed transcatheter heart valves (redo-TAVR) or native aortic valves (native-TAVR). Procedural, echocardiographic, and clinical outcomes were compared between redo-TAVR and native-TAVR cohorts using propensity score matching. Among 350 591 patients (1320 redo-TAVR; 349 271 native-TAVR), 1320 propensity-matched pairs of patients undergoing redo-TAVR and native-TAVR were analysed (redo-TAVR cohort: mean age 78 years [SD 9]; 559 [42·3%] of 1320 female, 761 [57·7%] male; mean predicted surgical risk of 30-day mortality 8·1%). The rates of procedural complications of redo-TAVR were low (coronary compression or obstruction: four [0·3%] of 1320; intraprocedural death: eight [0·6%] of 1320; conversion to open heart surgery: six [0·5%] of 1319) and similar to native-TAVR. There was no significant difference between redo-TAVR and native-TAVR populations in death at 30 days (4·7% vs 4·0%, p=0·36) or 1 year (17·5% vs 19·0%, p=0·57), and stroke at 30 days (2·0% vs 1·9%, p=0·84) or 1 year (3·2% vs 3·5%, p=0·80). Redo-TAVR reduced aortic valve gradients at 1 year, although they were higher in the redo-TAVR group compared with the native-TAVR group (15 mm Hg vs 12 mm Hg; p<0·0001). Moderate or severe aortic regurgitation rates were similar between redo-TAVR and native-TAVR groups at 1 year (1·8% vs 3·3%, p=0·18). Death or stroke after redo-TAVR were not significantly affected by the timing of redo-TAVR (before or after 1 year of index TAVR), or by index transcatheter valve type (balloon-expandable or non-balloon-expandable). Redo-TAVR with balloon-expandable valves effectively treated dysfunction of the index TAVR procedure with low procedural complication rates, and death and stroke rates similar to those in patients with a similar clinical profile and predicted risk undergoing TAVR for native aortic valve stenosis. Redo-TAVR with balloon-expandable valves might be a reasonable treatment for failed TAVR in selected patients. Edwards Lifesciences.

Safety and efficacy of enterprise stenting for symptomatic atherosclerotic severe posterior circulation stenosis

PurposeTo investigate the safety and efficacy of Enterprise stent angioplasty and risk factors for the prognoses in treating symptomatic severe posterior circulation atherosclerotic stenosis (SSPCAS).Materials and methodsPatients with SSPCAS who were treated with the Enterprise stent angioplasty were retrospectively enrolled. The clinical data, peri-procedural complications, postoperative residual stenosis, in-stent restenosis and recurrent stroke at follow-up were analyzed.Results262 patients with 275 stenotic lesions treated with the Enterprise stent angioplasty were enrolled. The stenosis degree was reduced from 86.3 ± 6.2% before to 19.3 ± 5.4% after stenting. Complications occurred in 14 (5.3%) patients. Clinical follow-up was performed in 245 (93.51%) patients for 16.5 ± 7.3 months. During 1 year follow-up, 7 patients (2.9%) had recurrent symptoms, including 4 patients with stenting in the intracranial vertebral artery and 3 in the basilar artery. Imaging follow-up was conducted in 223 (85.11%) patients. In-stent restenosis was present in 35 patients (15.7%), with the restenosis rate of 26.4% (n = 23) in the intracranial vertebral artery, which was significantly (P < 0.001) greater than in the basilar artery (8.8%). Six patients (17.1%) with in-stent restenosis were symptomatic. The stenotic length was the only significant (P = 0.026 and 0.024, respectively) independent risk factor for 1 year stroke or death events and in-stent restenosis.ConclusionThe Enterprise stent can be safely and efficaciously applied in the treatment of symptomatic severe posterior circulation atherosclerotic stenosis, with a relatively low rate of in-stent restenosis and recurrent stroke within 1 year. The stenotic length was the only significant independent risk factor for 1 year stroke or death events and in-stent restenosis.

Cost and Clinical Outcomes Evaluation Between the Endoaortic Balloon and External Aortic Clamp in Cardiac Surgery.

Endoaortic balloon occlusion facilitates cardioplegic arrest during minimally invasive surgery (MIS). Studies have shown endoclamping to be as safe as traditional aortic clamping. We compared outcomes and hospital costs of endoclamping versus external aortic occlusion in a large administrative database. There were 52,882 adults undergoing eligible cardiac surgery (October 2015 to March 2020) identified in the Premier Healthcare Database. Endoclamp procedures (n = 419) were 1:3 propensity score matched to similar procedures using external aortic occlusion (n = 1,244). Generalized linear modeling measured differences in in-hospital complications (major adverse renal and cardiac events, including mortality, new-onset atrial fibrillation, acute kidney injury [AKI], myocardial infarction [MI], postcardiotomy syndrome, stroke/transient ischemic attack [TIA], and aortic dissection) and length of stay (LOS). The mean age was 63 years, and 53% were male (n = 882). The majority (93%, n = 1,543) were mitral valve procedures, and 17% of procedures (n = 285) were robot-assisted. Total hospitalization costs were not statistically significantly different between the 2 groups ($52,158 vs $49,839, P = 0.06). The median LOS was significantly shorter in the endoclamp group (incident rate ratio = 0.87, P < 0.001). Mortality, atrial fibrillation, AKI, and stroke/TIA were similar between the 2 groups. MI and postcardiotomy syndrome were lower in the endoclamp group (odds ratio [OR] = 0.14, P = 0.006, and OR = 0.27, P = 0.005). There were no aortic dissections in the endoclamp group. Aortic endoclamping in MIS was associated with similar costs, shorter LOS, no dissections, and comparably low mortality and stroke rates when compared with external clamping in this hospital billing dataset. These results demonstrate the clinical safety and efficacy of endoaortic balloon clamping in a real-world setting. Further studies are warranted.

Statin Use and Stroke Rate in Older Adults With Atrial Fibrillation: A Population-Based Cohort Study.

Background Atherosclerotic disease is an important contributor to adverse outcomes in patients with atrial fibrillation (AF). There is limited recognition of the association between statin use and stroke rates in AF. We aimed to quantify the association between statin use and stroke rate in AF. Methods and Results Using linked administrative databases in Ontario, Canada, we conducted a population-based retrospective cohort study of patients, aged ≥66 years, diagnosed with AF between 2009 and 2019. We used cause-specific hazard regression to determine the association of statin use with stroke rate. We developed a second model to further adjust for lipid levels in the subset of patients with available measurements in the year before AF diagnosis. Both models adjusted for age, sex, heart failure, hypertension, diabetes, stroke/transient ischemic attack, vascular disease, and P2Y12 inhibitors at baseline, plus anticoagulation as a time-varying covariate. We studied 261 659 qualifying patients (median age, 78 years; 49% women). Statins were used in 142 834 (54.6%) patients, and 145 673 (55.7%) had lipid measurement(s) in the preceding year. Statin use was associated with lower stroke rates, with adjusted hazard ratios of 0.83 (95% CI, 0.77-0.88; P<0.001) in the full cohort and 0.87 (95% CI, 0.78-0.97; P=0.01) when adjusting for lipid data. Stroke rates increased in a near-linear manner as low-density lipoprotein values increased >1.5 mmol/L. Conclusions Statins were associated with lower stroke rates in patients with AF, whereas higher low-density lipoprotein levels were associated with higher stroke rates, highlighting the importance of vascular risk factor treatment in AF.

Edoxaban treatment in atrial fibrillation in routine clinical care: One-year outcomes of the prospective observational ETNA-AF study in South Korean patients.

The real-world outcomes of edoxaban treatment in patients with atrial fibrillation (AF) were analyzed in the ETNA-AF (Edoxaban Treatment in Routine Clinical Practice) study involving data from multiple regional registries. This report addresses effectiveness and safety of edoxaban in the Korean ETNA-AF population. One-year data from 1887 Korean ETNA-AF participants were analyzed according to edoxaban dose and patient age and compared with results of other ETNA-AF registries. Approximately 70% of patients received the recommended doses of edoxaban (60 mg/30 mg); non-recommended 60 mg and 30 mg doses were prescribed to 9.6% and 19.8% of the patients, respectively. The proportions of reference age (<65 years), youngest-old (65-74 years) and middle-old/oldest-old (≥75 years) groups were 21.4%, 40.2%, and 38.4%, respectively. Incidence of major or clinically relevant nonmajor bleeding was similar within dose (0.57%-1.71%) and age subgroups (1.26%-1.63%). Incidence of net clinical outcome, a composite of stroke, systemic embolic event, major bleeding, and all-cause mortality, was also comparable among dose subgroups (1.14%-3.10%) and age subgroups (2.28%-2.78%). The percentage of Korean patients receiving non-recommended 30 mg (19.8%) was over twice that of the European population (8.4%). However, the clinical outcomes were generally similar among different populations included in the ETNA-AF study. The outcomes in the Korean ETNA-AF population are like those in the global ETNA-AF population, with overall low event rates of stroke, major bleeding and all-cause mortality across age and dose subgroups. Edoxaban can be used effectively and safely in specific populations of Korean AF patients, including the elderly.

Anticoagulation therapy and clinical outcomes following transcatheter mitral valve repair for patients with mitral regurgitation: A meta-analysis.

Transcatheter mitral valve repair (TMVR) using MitraClip (MC) is now an established technique in the interventional treatment of mitral regurgitation. Common complications after MC procedure are bleeding and ischemic events. However, 2017 ESC/EACTS and 2020 ACC/AHA did not give a clear antithrombotic protocol, the policy has been based on clinical experience. Here, we performed a meta-analysis comparing outcomes with and without the addition of anticoagulants after TMVR.We searched the Cochrane Library, EMBASE, PubMed, and Web of Science from inception to October 6, 2022 to identify studies with or without the use of anticoagulants after TMVR. From each study, we extracted the number of people with bleeding, stroke, combined endpoints, and all-cause death.Five observational cohort studies were included, enrolling a total of 1892 patients undergoing TMVR who were assigned to either the anticoagulation group (n = 1209) or the no-anticoagulation group (n = 683). Pooled analysis showed a significantly lower stroke rate in the anticoagulated group (at least 4 weeks duration) compared with the non-anticoagulated group (RR[95% CI] = 0.14 [0.0-0.77], p = 0.02), and similar rates of bleeding, combined endpoints, and all-cause death in both groups (RR [95% CI] = 0.76 [0.48-1.22], p = 0.26), (RR[95% CI] = 0.52 [0.10-2.63], p = 0.43), and (RR[95% CI] = 0.89 [0.58-1.35], p = 0.58).We observed a reduced risk of stroke without elevated risk of bleeding, combined endpoints, or all-cause death in patients using anticoagulants (at least 4 weeks duration) after TMVR compared to no anticoagulants.

Left atrial appendage amputation concomitant with cardiac surgery in patients with sinus rhythm.

Since recent data demonstrated the benefit of the amputation of the left atrial appendage (LAA) in patients with atrial fibrillation, the long-term impact of LAA amputation on stroke rate and mortality in patients with no history of atrial fibrillation is still unknown. Patients with no history of atrial fibrillation who underwent coronary artery bypass grafting by the off-pump technique between 2014 and 2016 were examined retrospectively. Cohorts were divided by the concomitant execution of LAA amputation, and propensity score matching was applied by baseline characteristics. The stroke rate in a 5-year follow-up served as the primary end point. Secondary end points were the mortality rate and rehospitalization in the same time span. A total of 1,522 patients were enrolled, of whom 1,267 and 255 were included in the control group and in the LAA amputation group, respectively. These were matched to 243 patients in each group. In total, patients with an LAA amputation showed a significantly lower rate of stroke in a 5-year follow-up [7.0% vs 2.9%, hazard ratio, 0.41; 95% confidence interval (0.17; 0.98), p = 0.045]. However, there was no difference in all-cause mortality (P = 0.23) or rehospitalizations (P = 0.68). Subgroup analysis revealed LAA amputation in patients with a CHA2DS2VASc [congestive heart failure, hypertension, age ≥75 (doubled), diabetes, stroke (doubled), vascular disease, age 65 to 74 and sex category (female)] score of ≥3 to be associated with a reduction of stroke [9.4% vs 3.1%, hazard ratio, 0.33; 95% confidence interval [0.12; 0.92], P = 0.034]. LAA amputation concomitant with cardiac surgery reduces the stroke rate in patients with no history of atrial fibrillation and a high CHA2DS2VASc score (≥3) in a 5-year follow-up.

Early Stroke and Mortality After Percutaneous Left Atrial Appendage Occlusion in Patients With Atrial Fibrillation.

Percutaneous endocardial left atrial appendage occlusion (LAAO) is an alternative therapy for stroke prevention in patients with atrial fibrillation who are poor candidates for oral anticoagulants. Oral anticoagulation is generally discontinued 45 days following successful LAAO. Real-world data on early stroke and mortality following LAAO are lacking. Using International Classification of Diseases, Tenth Revision, Clinical-Modification codes, we performed a retrospective observational registry analysis to examine the rates and predictors of stroke, mortality, and procedural complications during index hospitalization and 90-day readmission among 42 114 admissions in the Nationwide Readmissions Database for LAAO between 2016 and 2019. Early stroke and mortality were defined as events occurring during index admission or 90-day readmission. Data on timing of early strokes post-LAAO were collected. Multivariable logistic regression modeling was used to ascertain predictors of early stroke and major adverse events. LAAO was associated with low rates of early stroke (0.63%), early mortality (0.53%), and procedural complications (2.59%). Among patients who had readmissions with strokes after LAAO, the median time from implant to readmission was 35 days (interquartile range, 9-57 days); 67% of readmissions with strokes occurred <45 days postimplant. Between 2016 and 2019, the rates of early stroke after LAAO significantly decreased (0.64% versus 0.46% P-for-trend <0.001), while early mortality and major adverse event rates were unchanged. Peripheral vascular disease and a history of prior stroke were independently associated with early stroke after LAAO. Early post-LAAO stroke rates were similar between low, medium, and high LAAO volume tertile centers. In this contemporary real-world analysis, the early stroke rate after LAAO was low, with the majority occurring within 45 days of device implantation. Despite an increase in LAAO procedures between 2016 and 2019, there with a significant decline in early strokes after LAAO during that period.

Contemporary outcomes after treatment of aberrant subclavian artery and Kommerell's diverticulum

ObjectiveAberrant subclavian artery (ASA) and Kommerell's diverticulum (KD) are rare vascular anomalies that may be associated with lifestyle-limiting and life-threatening complications. The aim of this study is to report contemporary outcomes after invasive treatment of ASA/KD using a large international dataset. MethodsPatients who underwent treatment for ASA/KD (2000-2020) were identified through the Vascular Low Frequency Disease Consortium, a multi-institutional collaboration to investigate uncommon vascular disorders. We report the early and mid-term clinical outcomes including stroke and mortality, technical success, and other operative outcomes including reintervention rates, patency, and endoleak. ResultsOverall, 285 patients were identified during the study period. The mean patient age was 57 years; 47% were female and 68% presented with symptoms. A right-sided arch was present in 23%. The mean KD diameter was 47.4 mm (range, 13.0-108.0 mm). The most common indication for treatment was symptoms (59%), followed by aneurysm size (38%). The most common symptom reported was dysphagia (44%). A ruptured KD was treated in 4.2% of cases, with a mean diameter of 43.9 mm (range, 18.0-100.0 mm). An open procedure was performed in 101 cases (36%); the most common approach was ASA ligation with subclavian transposition. An endovascular or hybrid approach was performed in 184 patients (64%); the most common approach was thoracic endograft and carotid-subclavian bypass. A staged operative strategy was employed more often than single setting repair (55% vs 45%). Compared with endovascular or hybrid approach, those in the open procedure group were more likely to be younger (49 years vs 61 years; P < .0001), female (64% vs 36%; P < .0001), and symptomatic (85% vs 59%; P < .0001). Complete or partial symptomatic relief at 1 year after intervention was 82.6%. There was no association between modality of treatment and symptom relief (open 87.2% vs endovascular or hybrid approach 78.9%; P = .13). After the intervention, 11 subclavian occlusions (4.5%) occurred; 3 were successfully thrombectomized resulting in a primary and secondary patency of 95% and 96%, respectively, at a median follow-up of 39 months. Among the 33 reinterventions (12%), the majority were performed for endoleak (36%), and more reinterventions occurred in the endovascular or hybrid approach than open procedure group (15% vs 6%; P = .02). The overall survival rate was 87.3% at a median follow-up of 41 months. The 30-day stroke and death rates were 4.2% and 4.9%, respectively. Urgent or emergent presentation was independently associated with increased risk of 30-day mortality (odds ratio [OR], 19.8; 95% confidence interval [CI], 3.3-116.6), overall mortality (OR, 3.6; 95% CI, 1.2-11.2) and intraoperative complications (OR, 8.3; 95% CI, 2.8-25.1). Females had a higher risk of reintervention (OR, 2.6; 95% CI, 1.0-6.5). At an aneurysm size of 44.4 mm, receiver operator characteristic curve analysis suggested that 60% of patients would have symptoms. ConclusionsTreatment of ASA/KD can be performed safely with low rates of mortality, stroke and reintervention and high rates of symptomatic relief, regardless of the repair strategy. Symptomatic and urgent operations were associated with worse outcomes in general, and female gender was associated with a higher likelihood of reintervention. Given the worse overall outcomes when symptomatic and the inherent risk of rupture, consideration of repair at 40 mm is reasonable in most patients. ASA/KD can be repaired in asymptomatic patients with excellent outcomes and young healthy patients may be considered better candidates for open approaches versus endovascular or hybrid modalities, given the lower likelihood of reintervention and lower early mortality rate.

Case Series of Early Structural Valve Deterioration of Trifecta Bioprosthesis - New Zealand Experience.

Structural valve deterioration (SVD) remains a limitation on the use of bioprosthetic valves, with patient and valve-related factors contributing to early SVD. The Trifecta valve has been reported to have excellent hemodynamics but studies have highlighted early failure. We present a review and case series at a New Zealand tertiary hospital defining early SVD as failure within 3 years of implant. A retrospective review from January 2015 to July 2019 included 525 patients undergoing surgical aortic valve replacement with 263 patients receiving an Abbott Trifecta or Trifecta Glide Technology (GT) valve. Our review found an acceptable safety profile for the valve with excellent hemodynamics, with a low mortality, stroke, and permanent pacemaker rate. Three patients out of 263 were identified from the study period as having early SVD requiring reintervention within 3 years of valve implantation leading to a 1.14% failure rate. One of the valves that had early SVD was a new generation Trifecta GT. An additional four patients were identified to have valves implanted prior to the study period and had valve failure at greater than 3 years post implantation. Five cases had cusp tears as their mechanism of failure, raising concerns about durability. The Trifecta valve has an acceptable safety profile and offers good hemodynamics due to the externally mounted leaflets. However, our experience of early SVD and failure is concerning for valve durability. Further comparison to other bioprosthetic valves and longer term follow-up are required to characterize the mechanism of failures.

Long-term outcome and factors associated with restenosis after combination therapy of balloon angioplasty and stenting for symptomatic intracranial stenosis

BackgroundThe optimal treatment for intracranial artery stenosis (ICAS) has not been established. We retrospectively examined the initial and long-term outcomes associated with restenosis of a combination therapy of balloon angioplasty and stenting for symptomatic atherosclerotic ICAS.MethodsConsecutive patients who underwent balloon angioplasty and/or stenting for ≥ 70% ICAS between 2006 and 2020 were analyzed. Patients within 48 h of stroke onset were excluded. The following procedures were established as standards at our institution: (1) primary balloon angioplasty alone was initially performed; (2) stenting for insufficient dilatation, recoiling, or dissection was conducted; and (3) stenting was considered for restenosis. Intracranial ischemic and hemorrhagic complications within 30 days after treatment were used to evaluate periprocedural safety. Recurrent ischemic events, restenosis and restenosis related factors were used to be evaluate the long-term outcome.ResultsA total of 160 patients were recruited. Initial treatment consisted of balloon angioplasty (n = 101) and stenting (n = 59). Intracranial complications within 30 days after treatment were ischemic in five (3.1%) and hemorrhagic in four patients (2.5%). The incidence of these complication was 3.1% in the stenting group and 2.5% in the balloon angioplasty group. The mean follow-up period was 53.9 months. Restenosis was found in 42 patients (26%). Recurrent ischemic events during follow-up were noted in 14 patients (8.8%), of which six patients had TIA and eight patients had ischemic stroke. Restenosis-associated factors included diabetes, coronary artery disease, percent stenosis after treatment, and balloon angioplasty in logistic univariate analysis. Multivariate Cox regression analysis showed that diabetes (HR: 2.084, CI: 1.039–4.180, p = 0.0386), length of lesion (HR; 1.358, CI: 1.174–1.571, p < 0.0001), and balloon angioplasty (HR: 4.194, CI: 1.083–16.239, p = 0.0379) were independent predictors for restenosis.ConclusionCombination therapy of balloon angioplasty and stenting for symptomatic ICAS had a low perioperative stroke rate and may improve long-term outcome. Balloon angioplasty, diabetes, and length of lesion were significantly associated with restenosis.