Major In-hospital Outcomes Research Articles

Identification of Low- versus High-Risk Acute Coronary Syndrome for a Selective ECG Monitoring Strategy.

While admission of patients with acute coronary syndromes (ACS) in cardiology intensive care unit (CICU) is usual, in-hospital major outcomes in lower risk patients may be evaluated after early coronary angiography according to the European guidelines. Consecutive ACS patients were prospectively included after coronary angiography evaluation within 24 h and percutaneous coronary intervention (PCI), when required. Patients were classified as high- or low-risk according to hemodynamics, rhythmic state, ischemic and bleeding risks. Major in-hospital outcomes were assessed. From January to June 2021, 277 patients were enrolled (62.8% with ST-segment elevation myocardial infarction (STEMI) (n = 174); 37.2% with non-NSTEMI (NSTEMI) (n = 103). PCI was required for 260 patients (93.9%). Seventy-four patients (26.7%) were classified as low-risk (n = 47 NSTEMI; n= 27 STEMI) and 203 patients (73.3%) as high-risk of events. All patients were monitored in CICU. While 38 patients (18.7%) from the high-risk group reached the primary endpoint, mainly related to rhythmic or conduction disorder (n = 24, 11.8%) or unstable hemodynamics (n = 17; 8.4%), only 1 patient (1.3%) in the low-risk group had one major outcome (no fatal bleeding); p < 0.01. The negative predictive value of our patient stratification for the absence of major in-hospital outcome was 100% (CI95%: 100-100%) for STEMI and 97.9% [CI95%: 93.2-100%] for NSTEMI patients. Stratification of ACS patients after early coronary angiography and most of the time PCI, identify a population with very low risk of in-hospital events (1/4 of all ACS and 1/2 of NSTEMI) who may probably not require ECG monitoring and/or CICU admission. (NCT04378504).

Intermediate Follow-Up of Balloon-Expandable Versus Self-Expanding Transcatheter Aortic Valve Implantation in Patients With Small Aortic Annuli

The clinical impact of prosthesis-patient mismatch (PPM) in patients with small aortic annuli who underwent transcatheter aortic valve (AV) implantation with either balloon-expandable (BE) or self-expanding (SE) valves remains controversial. We assessed in-hospital and intermediate clinical outcomes in 573 patients with transfemoral transcatheter AV implantation with a small AV annulus, defined as an AV annulus area ≤430mm2. A total of 337 patients treated with a 23-mm BE valve (SAPIEN 3, Ultra) were compared with 236 patients treated with a 26-mm SE valve (Evolut series). Valve-in-valve cases were excluded, and late echo follow-up (mean 674 ± 438days) was assessed in a subset of 292 patients (51.0%). Well-matched BE and SE cohorts did not differ with respect to major in-hospital outcomes, other than a borderline increase in vascular complications and composite bleeding in patients with SE. Patients with BE had a higher incidence of severe PPM on discharge echocardiography (16.9% vs 6.8%, p <0.002). The mean AV gradient at 30days was higher for patients with BE (12.2 ± 4.2 vs 6.2 ± 7.9mm Hg, p <0.001) and at late follow-up (14.0 ± 8.2 vs 7.2 ± 3.5mm Hg, p <0.001). The follow-up left ventricular ejection fraction and incidence of >mild aortic insufficiency were similar. All-cause mortality for the 2 cohorts was similar, with an overall mean (95% confidence interval) survival time of 61.2months (57.8 to 64.5; p=0.98). There were no significant survival differences between combined patients with BE and SE with no, moderate, or severe PPM, with an overall mean (95% confidence interval) survival time of 32.5 (30.5 to 34.5)months combining valve types (p=0.23). In conclusion, despite an increased incidence of PPM with higher mean AV gradients that persist on late echocardiography in the BE cohort, patients with BE and SE with small aortic annuli have similar clinical outcomes at intermediate follow-up. Moderate and severe PPM had no impact on survival at a mean follow-up of 32.5months.

Abstract 14430: Sex Differences in Heart Transplantation - Analysis of the National Inpatient Sample 2012-2019

Introduction: Advanced heart failure therapies and heart transplantation (HTx) have been underutilized in women. Therefore, we aimed to explore the clinical characteristics and outcomes of HTx by sex. Methods: We conducted a retrospective analysis of adult discharges from the National Inpatient Sample (NIS) between 2012 and 2019. International Classification of Disease (ICD) procedure codes were used to identify those who underwent HTx. Results: A total of 20,180 HTx hospitalizations were identified from 2012-2019. Among them, 28% were female. Women undergoing HTx were younger (mean age 51 vs. 54.5 years, p&lt;0.001). HTx hospitalizations among men were more likely to have atrial fibrillation, diabetes, hypertension, renal failure, dyslipidemia, smoking, and ischemic heart disease. HTx hospitalizations among women were more likely to have hypothyroidism and valvular heart disease. HTx hospitalizations in women were associated with no significant difference in risk of in-hospital mortality (adjusted odds ratio [OR] 0.82; 95% confidence interval [CI] 0.58-1.16, p=0.271), no significant difference in length of stay or inflation-adjusted cost as shown in the Table. Men were more likely to develop acute kidney injury during HTx hospitalization (69.2% vs. 59.7%, adjusted OR 0.71, 95% CI 0.61-0.83, p&lt;0.001). Conclusions: HTx utilization is lower in women. However, most major in-hospital outcomes for HTx are similar between the sexes. Further studies are need to explore the causes of lower rates of HTx in women.

Abstract 14238: A Real-World Comparison of Percutaneous Coronary Intervention vs Coronary Artery Bypass in Patients With Chronic Total Occlusion

Introduction: There is a paucity of data comparing percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) in patients with chronic total occlusion (CTO) of the coronary arteries. Methods: The National Inpatient Sample (NIS) database was queried to identify all CTO related hospitalizations from 2002-2018. Patients undergoing PCI were compared with those having CABG for CTO using Cochran-Mantel-Haenszel statistics to determine unadjusted odds ratios (OR). A propensity matched analysis (PSM) was used to determine adjusted OR for major in-hospital outcomes. Results: A total of 404,563 patients with CTO were included in the analysis. Of these, 20,841 (5.6%) patients underwent CABG whereas 383,722 (94.8%) underwent PCI. Patients in the PCI group had a higher percentage of chronic obstructive pulmonary disease, diabetes, coagulopathy, obesity and renal failure. On an unadjusted analysis, the primary outcome of in-hospital mortality was comparable between the two groups. The odds of stroke, acute kidney injury, sepsis, major bleeding and need for IABP were higher with CABG, whereas the odds of cardiopulmonary arrest and coronary artery dissection were higher with PCI. On a propensity adjusted analysis, PCI was associated with a higher mortality and comparable rate of major bleeding and sepsis compared to CABG (Table). CABG, however, had a higher hospitalization cost ($ 156113.03 vs. $ 103078.48, p=&lt;0.0001), and a mean length of stay (8.93 vs. 4.82 days, p=&lt;0.0001) as compared to PCI. Conclusions: Our findings show that CABG has a lower inpatient mortality for CTO as compared to PCI, however it is associated with increased risk of complications, higher cost and increased length of hospitalization, highlighting the need for randomized data on the subject.

In-Hospital Outcomes in Patients Admitted to the Intensive Care Unit after a Return Visit to the Emergency Department.

Background: Intensive care unit (ICU) admission following a short-term emergency department (ED) revisit has been considered a particularly undesirable outcome among return-visit patients, although their in-hospital prognosis has not been discussed. We aimed to compare clinical outcomes between adult patients admitted to the ICU after unscheduled ED revisits and those admitted during index ED visits. Method: This retrospective study was conducted at two tertiary medical centers in Taiwan from 1 January 2016 to 31 December 2017. All adult non-trauma patients admitted to the ICU directly via the ED during the study period were included and divided into two comparison groups: patients admitted to the ICU during index ED visits and those admitted to the ICU during return ED visits. The outcomes of interest included in-hospital mortality, mechanical ventilation (MV) support, profound shock, hospital length of stay (HLOS), and total medical cost. Results: Altogether, 12,075 patients with a mean (standard deviation) age of 64.6 (15.7) years were included. Among these, 5.3% were admitted to the ICU following a return ED visit within 14 days and 3.1% were admitted following a return ED visit within 7 days. After adjusting for confounding factors for multivariate regression analysis, ICU admission following an ED revisit within 14 days was not associated with an increased mortality rate (adjusted odds ratio (aOR): 1.08, 95% confidence interval (CI): 0.89 to 1.32), MV support (aOR: 1.06, 95% CI: 0.89 to 1.26), profound shock (aOR: 0.99, 95% CI: 0.84 to 1.18), prolonged HLOS (difference: 0.04 days, 95% CI: −1.02 to 1.09), and increased total medical cost (difference: USD 361, 95% CI: −303 to 1025). Similar results were observed after the regression analysis in patients that had a 7-day return visit. Conclusion: ICU admission following a return ED visit was not associated with major in-hospital outcomes including mortality, MV support, shock, increased HLOS, or medical cost. Although ICU admissions following ED revisits are considered serious adverse events, they may not indicate poor prognosis in ED practice.

Learning Curve for Surgeons Adopting Transcarotid Artery Revascularization Based on the Vascular Quality Initiative-Transcarotid Artery Revascularization Surveillance Project

Transcarotid artery revascularization (TCAR) with flow reversal was recently introduced as a novel technique for carotid artery stenting (CAS). We examined the learning curve of surgeons adopting TCAR based on data from the Vascular Quality Initiative (VQI-TCAR Surveillance Project; TSP). We identified all patients in the TSP who underwent TCAR from September 2016 to December 2018. Cases were numbered in chronological order for each unique surgeon. Patients were then divided into 4 levels based on surgeon case number for comparison: cases 1 to 5 (novice), cases 6 to 20 (intermediate), cases 20 to 30 (advanced), and cases >30 (expert). During the study period, 3,456 TCAR procedures were performed by 417 unique surgeons from 178 centers. Of all procedures, 1,426 (41%) were performed at the novice level, 1,375 (40%) at the intermediate level, 307 (8.9%) at the advanced level, and 348 (10%) at the expert level. Cases performed at more advanced levels had lower operative times (novice 82 vs intermediate 73 vs advanced 62 vs expert 60 minutes, p < 0.001), fluoroscopy time (7 vs 6 vs 5 vs 5 minutes, p < 0.001), and flow reversal time (12 vs 11 vs 10 vs 10 minutes, p < 0.001). Cases done at more advanced levels had decreases in bleeding (3.9% vs 3.4% vs 1.6% vs 1.2%, p= 0.03). No differences in major in-hospital outcomes were found regardless of experience level including stroke (p= 0.99), death (p= 0.39), and composite stroke/death/myocardial infarction (p= 0.84). Transcarotid artery revascularization is being performed with excellent stroke and mortality rates in the TSP, even in the early stages of the surgeons' learning curve. Bleeding complications, operative, fluoroscopy, and flow reversal times all decrease with increasing TCAR experience.

463Temporal trends in latecomer ST-segment elevation myocardial infarction patients: Insights from the AMIS Plus Registry 1997–2017

Abstract Introduction A relevant proportion of patients experiencing ST-segment elevation myocardial infarction (STEMI) has a late presentation after symptoms onset. Temporal trends deriving from a large real-word scenario for this subgroup of patients are lacking. Purpose The aim of the present study was to provide a comprehensive analysis of temporal trends in latecomer STEMI patients, with particular regard to implementation of evidence-based treatments in this population and major in-hospital outcomes. Methods All STEMI patients included in the AMIS Plus Registry from January 1997 to December 2017 were included and patient-related delay was assessed: 27 231 patients were available for the final analysis. STEMI patients were classified as early or latecomers according to patient-related delay (≤ or &gt;12 hours, respectively). Results 22 928 patients were earlycomers (84%) and 4303 patients were classified as latecomers (16%). Across the study period we observed a significant decrease in prevalence of late presentation from 22% to 12.3% (p&lt;0.001, Figure 1). In latecomer STEMI patients there was a gradual uptake of evidence-based pharmacological treatments with an increase in discharge prescription of P2Y12 inhibitors from 6% to 90.7% (p&lt;0.001). Similarly, a marked increase in percutaneous coronary intervention (PCI) rate was observed (12.1–86.6%; p&lt;0.001). Across this 20-year period, in-hospital mortality was reduced to a third (to an absolute rate of 4.5%, p&lt;0.001) and a significant reduction in prevalence of both cardiogenic shock (14.6–4.3%) and re-infarction (5.4–0.2%) during the index hospitalisation was observed (p&lt;0.001 for both variables). Length of hospitalisation in acute care facilities significantly decreased from 10 (6,14) days to 4 (1,7) days (p&lt;0.001). At multivariate analysis, PCI had a strong independent protective effect toward in-hospital mortality (odds ratio 0.3, 95% confidence interval 0.187 to 0.480). Figure 1 Conclusion The present study provides a comprehensive picture of temporal trends in late presentation in STEMI over the last 20 years in Switzerland. During the study period in latecomer STEMI population there was a gradual uptake of evidence-based pharmacological treatments and a marked increase in PCI rate. In-hospital mortality was reduced to a third (to an absolute rate of 4.5%) and this reduction seems to be mainly associated with the increasing implementation of PCI.

Gender Differences in Outcomes After Implantation of Left Ventricular Assist Devices

Left ventricular assist device (LVAD) implantation has historically been underutilized in women compared with men. It was hypothesized that the introduction of continuous-flow LVADs would lead to more LVAD implantations in women and possibly narrow the gender gap. Patients who underwent LVAD implantation between 2009 and 2014 were identified using the national inpatient sample. A total of 3511 patients (17,251 when weighted) underwent LVAD implantation in the United States between 2009 and 2014. Mean age was 56 years and there were 817 women in the study sample (23.32%). LVAD implantations in women doubled from 2009 to 2014, but men continued to receive LVAD 3 times more than women. Inpatient mortality after LVAD placement was similar between men and women (13.42% women vs 12.85% men; odds ratio, 1.05; P= .16). Most common complications after LVAD implantation in both genders included acute kidney injury, bleeding requiring blood transfusion, and postoperative sepsis. There were no gender-specific differences in the incidence of periprocedural complications, including postoperative cardiac tamponade, postoperative thromboembolism, or sepsis. In addition, no significant difference was found in length of stay and median hospitalization cost. The use of extracorporeal membrane oxygenation did not differ between men and women. Subgroup analysis in patients older than 65 years of age showed higher in-hospital mortality but no differences between genders. The number of women undergoing LVAD implantation has increased with the introduction of continuous-flow LVADs, but a gender gap still exists. Most major in-hospital outcomes after LVAD implantation are similar between genders.

Clinical experience with trans-catheter aortic valve implantation at a tertiary hospital in the Republic of Ireland.

There is a paucity of published data on the clinical experience with trans-catheter aortic valve implantation (TAVI) in the Republic of Ireland. We sought to examine the clinical outcomes of patients with medium-term follow-up treated with TAVI at our institution. A prospective TAVI registry was used to assess the baseline demographics, procedural variables and clinical outcomes of patients treated with TAVI between the inception of the programme in 2008 and November 2017. A total of 354 patients (mean age 80.9 ± 8.1years, 58% male, mean STS score 6.1 ± 4.3%) were treated during the study period. Major in-hospital outcomes included in-lab death (n = 2, 0.6%), stroke (n = 8, 2.2%), device embolisation (n = 4, 1.2%), permanent pacemaker implantation (n = 22, 6.2%) and major vascular complication (n = 2, 0.6%). The median length of hospital stay was 4days (IQR 2-8days). The Kaplan-Meier estimate of freedom from death at 30days and 1year for the entire cohort was 97 ± 1% and 85.4 ± 2.3%, respectively. Trans-femoral access was associated with a significantly lower rate of death and/or stroke at 1year compared to trans-apical access (84.9 ± 2.4% versus 60 ± 8.9%, p = 0.0005). There was no significant difference in freedom from death and/or stroke at 1year between balloon-expandable and self-expanding valves (81.6 ± 2.6% versus 84.4 ± 7.4%, p = 0.63). This study documents low complication rates and favourable rates of survival following TAVI in a consecutive series of patients undergoing TAVI at a tertiary referral centre in the Republic of Ireland. These data support the application of this therapy in the Irish context.

Neutrophil to Lymphocyte Ratio as a Prognostic Predictor in Older People With Acute Coronary Syndrome

The neutrophil to lymphocyte ratio (NLR) at admission is a prognostic marker for acute coronary syndrome (ACS). However, no study was performed exclusively with older people. The present study evaluated the NLR in older people with ACS as a predictor of death, combined major in-hospital outcomes (death, stroke, reinfarction), hospital stay, ventricular ejection fraction, use of vasoactive drugs, and extent of coronary artery disease. We conducted a retrospective cohort study with in-hospital follow-up using data from a single center in Recife, Brazil. Patients aged 60 and older admitted with ACS were selected. The patients were followed until discharge or death. A total of 272 individuals were evaluated; 55.8% were men and the mean age was 73 years. The NLR was not a predictor of in-hospital death. A higher NLR upon admission was associated with a longer hospital stay (β = 0.131; 95% confidence interval [CI]: 0.017-0.246; P = .024) and an ejection fraction <50% (relative risk = 2.1; 95% CI: 1.19-3.57; P = .001). The other outcomes did not reach significance. The NLR was associated with a longer hospital stay and a left ventricular ejection fraction <50% in older people with ACS.

Effects of degree of pulmonary fissure completeness on major in-hospital outcomes after video-assisted thoracoscopic lung cancer lobectomy: a retrospective-cohort study.

BackgroundTo evaluate the clinical significance of degree of pulmonary fissure completeness (PFC) on major in-hospital outcomes following video-assisted thoracoscopic (VATS) lobectomy for non-small-cell lung cancer (NSCLC).Materials and methodsWe carried out a single-center retrospective analysis on the prospectively maintained database at our unit between August 2014 and October 2015. Patients were divided into two groups based on their fissure sum average (FSA). Patients with FSA >1 (1< FSA ≤3) were considered to have incomplete pulmonary fissures (group A), while patients with FSA of 0–1 were considered to have complete pulmonary fissures (group B). Demographic differences in perioperative characteristics and surgical outcomes between these two groups were initially assessed. Then, a multivariate logistic-regression analysis was further conducted to identify the independent predictors for major in-hospital outcomes.ResultsA total of 563 patients undergoing VATS lobectomy for NSCLC were enrolled. There were 190 patients in group A and 373 patients in group B. The overall morbidity and mortality rates of our cohort were 30.6% and 0.5%, respectively. Group A patients had a significantly higher overall morbidity rate than group B patients (42.1% vs 24.7%, P<0.001). Both minor morbidity (40.5% vs 22%, P<0.001) and major morbidity (11.1% vs 5.6%, P=0.021) rates in group A patients were also significantly higher than group B patients. No significant difference was observed in mortality rate between these two groups (1.1% vs 0.3%, P=0.26). The incomplete degree of PFC was significantly correlated with length of stay and chest-tube duration (log-rank P<0.001) after surgery. Finally, the incomplete degree of PFC was found to be predictive of overall morbidity (OR 2.08, P<0.001), minor morbidity (OR 2.39, P<0.001), and major morbidity (OR 2.06, P=0.031) by multivariate logistic-regression analyses.ConclusionDegree of PFC is an excellent categorical predictor for both major and minor morbidity after VATS lobectomy for NSCLC.

PCV20 - The Association Between Choice Of Balanced Intravenous Crystalloid And Subsequent Major In-Hospital Outcomes Among Adult Patients Undergoing Cardiac Surgery

PCV20 - The Association Between Choice Of Balanced Intravenous Crystalloid And Subsequent Major In-Hospital Outcomes Among Adult Patients Undergoing Cardiac Surgery

Diagnostic time course, treatment, and in-hospital outcomes for patients with ST-segment elevation myocardial infarction presenting with nondiagnostic initial electrocardiogram: A report from the American Heart Association Mission: Lifeline program

Prior studies indicate that a subset of patients diagnosed as having ST-segment elevation myocardial infarction (STEMI) will have an initial non-diagnostic electrocardiogram (ECG) during evaluation. However, the timing of diagnostic ECG changes in this group is unknown. Our primary aim was to describe the timing of ECG diagnosis of STEMI in patients whose initial ECG was non-diagnostic. Secondarily, we sought to compare the delivery of American College of Cardiology/American Heart Association guidelines-based care and in-hospital outcomes in this group compared with patients diagnosed as having STEMI on initial ECG. We analyzed data from 41,560 patients diagnosed as having STEMI included in the National Cardiovascular Data Registry ACTION Registry-GWTG from January 2007 to December 2010. We divided this study population into 2 groups: those diagnosed on initial ECG (N = 36,994) and those with an initial non-diagnostic ECG that were diagnosed on a follow-up ECG (N = 4,566). In general, baseline characteristics and clinical presentations were similar between the 2 groups. For patients with an initial non-diagnostic ECG, 72.4% (n = 3,305) had an ECG diagnostic for STEMI within 90 minutes of their initial ECG. There did not appear to be significant differences in the administration of guideline-recommended treatments for STEMI, in-hospital major bleeding (P = .926), or death (P = .475) between these groups. In a national sample of patients diagnosed as having STEMI, 11.0% had an initial non-diagnostic ECG. Of those patients, 72.4% had a follow-up diagnostic ECG within 90 minutes of their initial ECG. There did not appear to be clinically meaningful differences in guidelines-based treatment or major inhospital outcomes between patients diagnosed as having STEMI on an initial ECG and those diagnosed on a follow-up ECG.