Permanent Pacemaker Insertion Research Articles

Predictors of pacemaker requirement in patients receiving implantable loop recorders for unexplained syncope: A systematic review and meta-analysis

BackgroundImplantable loop recorders (ILRs) are increasingly used to evaluate patients with unexplained syncope. Identification of all predictors of bradycardic syncope and consequent permanent pacemaker (PPM) insertion is of substantial clinical interest as patients in the highest risk category may benefit from upfront pacemaker insertion. ObjectiveWe performed a systematic review and meta-analysis to identify risk predictors for PPM insertion in ILR recipients with unexplained syncope. MethodsAn electronic database search (MEDLINE, Embase, Scopus, Cochrane) was performed in June 2023. Studies evaluating ILR recipients with unexplained syncope and recording risk factors for eventual PPM insertion were included. A random effects model was used to calculate the pooled odds ratio (OR) for clinical and electrocardiographic characteristics with respect to future PPM requirement. ResultsEight studies evaluating 1007 ILR recipients were included; 268 patients (26.6%) underwent PPM insertion during study follow-up. PPM recipients were older (mean age, 70.2 ± 15.4 years vs 61.6 ± 19.7 years; P < .001). PR prolongation on baseline electrocardiography was a significant predictor of PPM requirement (pooled OR, 2.91; 95% confidence interval, 1.63–5.20). The presence of distal conduction system disease, encompassing any bundle branch or fascicular block, yielded a pooled OR of 2.88 for PPM insertion (95% confidence interval, 1.53–5.41). Injurious syncope and lack of syncopal prodrome were not significant predictors of PPM insertion. Sinus node dysfunction accounted for 62% of PPM insertions, whereas atrioventricular block accounted for 26%. ConclusionApproximately one-quarter of ILR recipients for unexplained syncope require eventual PPM insertion. Advancing age, PR prolongation, and distal conduction disease are the strongest predictors for PPM requirement.

Review of the Association Between Long-Term and Current Systemic Steroid Use With Electromechanical Complications and Inpatient Mortality After ST-Elevation Myocardial Infarction.

Background The impact of long-term systemic steroid use on electrical and mechanical complications following ST-segment elevation myocardial infarction (STEMI) has not been extensively studied. Methods In a retrospective cohort study of the National Inpatient Sample (NIS) from 2018 to 2020, adults admitted with STEMI were dichotomized based on the presence of long-term (current) systemic steroid (LTCSS) use. The primary outcome was all-cause mortality. Secondary outcomes included a composite of mechanical complications, electrical, hemodynamic, and thrombotic complications, as well as revascularization complexity, length of stay (LOS), and total charge. Multivariate linear and logistic regressions were used to adjust for confounders. Results Out of 608,210 admissions for STEMI, 5,310 (0.9%) had LTCSS use. There was no significant difference in the odds of all-cause mortality (aOR: 0.89, 95%CI: 0.74-1.08, p-value: 0.245) and the composite of mechanical complications (aOR: 0.74, 95%CI: 0.25-2.30, p-value: 0.599). LTCSS use was associated with lower odds of ventricular tachycardia, atrioventricular blocks, new permanent-pacemaker insertion, cardiogenic shock, the need for mechanical circulatory support, mechanical ventilation, cardioversion, a reduced LOS by 1 day, and a reduced total charge by 34,512 USD (all p-values: <0.05). There were no significant differences in the revascularization strategy (coronary artery bypass graft (CABG) vs. percutaneous coronary interventions (PCI)) or in the incidence of composite thrombotic events. Conclusion LTCSS use among patients admitted with STEMI was associated with lower odds of electrical dysfunction and hemodynamic instability but no difference in the odds of mechanical complications, CABG rate, all-cause mortality, cardiac arrest, or thrombotic complications. Further prospective studies are needed to evaluate these findings further.

Right anterior mini-thoracotomy aortic valve replacement versus transcatheter aortic valve implantation in octogenarians: a single-center retrospective study.

The aim of this study was to compare the early outcomes of octogenarians undergoing minimally invasive right anterior mini-thoracotomy aortic valve replacement (RAT-AVR) with those undergoing transcatheter aortic valve implantation (TAVI) for aortic valve disease. In this single-center retrospective study, data were collected from octogenarians before and after RAT-AVR and TAVI between January 2021 and July 2022. Short-term outcomes, including the length of hospital stay, in-hospital mortality, all-cause mortality, and other major postoperative complications, were compared and analyzed. There were no significant differences in in-hospital mortality, stroke, acute kidney dysfunction requiring renal replacement therapy, length of intensive care unit stay, or length of hospital stay. However, the TAVI group had a higher incidence of permanent pacemaker insertion (10% vs. 0%, p=0.54) and paravalvular leaks (75% vs. 0%, p<0.001). In the present study on octogenarians, both TAVI and RAT-AVR showed comparable short-term results. Although both procedures were considered safe and effective in the selected group, RAT-AVR had a lower incidence of complete atrioventricular block and paravalvular regurgitation.

Use of Sutureless Valve in Aortic Root Enlargement

The small aortic annulus is a surgical challenge in patients undergoing aortic valve replacement which may lead to patient prosthesis mismatch. Management options include aortic root enlargement, aortic root replacement, and the use of sutureless valves. In this case series, we report our results with aortic root enlargement, sutureless valve implantation, and benchtop modelling of the radial forces exerted. Five patients underwent aortic root enlargement and insertion of the Perceval valve as part of the management strategy to enlarge their effective orifice area. We further investigate this strategy with a benchtop model to quantify the radial forces exerted by the Perceval valve on the aortic annulus. Radial and hoop forces on the aortic annulus and inner ring of the Perceval valve were recorded using a Mylar force tester. Five female patients with native annulus between 18mm-20mm underwent root enlargement and insertion of a Perceval S valve. The postoperative course was uncomplicated for all patients except for one who required a permanent pacemaker insertion. Transvalvular pressure gradients remained low at up to 4 years of follow-up (12 mmHg-21 mmHg), with no evidence of paravalvular leak. Benchtop testing demonstrated radial forces exerted at the annulus in all-size Perceval S valves to be within physiological variables, whereas compressive forces required to deform the valves were supraphysiological. The deployment of a sutureless valve within a surgical enlarged aortic root is a feasible solution in patients with a small aortic root.

Balloon-Expandable Versus Self-Expandable Valve in Transcatheter Aortic Valve Replacement: A Nation-Wide Study

A few studies have reported comparative analysis of clinical outcomes between balloon-expandable valve (BEV) and self-expandable valve (SEV) after transcatheter aortic valve replacement (TAVR) in patients with severe aortic stenosis using newer-generation devices. However, those reports were mostly limited to short-term outcomes and Western populations. In the present study, data of patients with severe aortic stenosis who underwent TAVR between March 2016 and December 2018 were obtained from the National Health Insurance Service in Korea. The primary end point, defined as all-cause mortality, was compared in BEV (SAPIEN 3, Edwards Lifesciences, Irvine, California) and SEV (Evolut R, Medtronic, Minneapolis, MN) groups using a propensity-score matching analysis. Cumulative event rates of ischemic stroke, repeat procedures, and permanent pacemaker insertion (PPI) were evaluated as secondary outcomes. All events were followed up to a maximum of 3 years. A total of 1,172 patients underwent transfemoral TAVR, of whom 707 (60.3%) were treated with BEV and 452 (38.6%) with SEV. After 1:1 propensity-score matching, the BEV group showed lower all-cause mortality after a median follow-up of 12.0 months (mean: 13.1 ± 9.3 months) based on Cox proportional hazard model analysis (hazard ratio [HR] 0.67, 95% confidence interval [CI] 0.45 to 0.99, p=0.04). Cumulative incidence of ischemic stroke was not statistically different between the 2 groups (HR 0.68, 95% CI 0.29 to 1.59, p=0.37). PPI occurred less frequently in the BEV group (HR 0.4, 95% CI 0.25 to 0.64, p < 0.01). Repeat procedures were rare (1 patient in BEV and 2 patients in SEV group). In conclusion, Korean nation-wide data analysis showed that BEV was associated with less all-cause death and incidence of PPI after TAVR than was SEV using a newer-generation device.

Cardiac Catheterization in Port Harcourt: Initial Two Years’ Experience

Introduction: Cardiac catheterization for diagnostic and therapeutic purposes is now routinely done at the Save a Life Port Harcourt, since last two years. Also included are cardiac devices which include pacemakers, Implantable Cardiac Defibrillators and Cardiac Resynchronization Therapy. In this retrospective study, we review our initial two years’ experience of Cardiac Catheterization at the Save a Life Mission Hospital, Port Harcourt. Methods: This is a retrospective study over a period of two years, form 1st February, 2021 to 31st March, 2023. A total of 216 consecutive diagnostic and therapeutic cardiac catheterization including cardiac devices performed in Save a life Mission Hospital between 1st February 2021 to 31st March 2023 were evaluated. Among them 88; (40.7%) were coronary angiogram, 41 (18.98%) percutaneous transluminal coronary angioplasty (PTCA) and stenting, 59(27.3%) permanent pacemaker insertion, 29 (13.4%) Implantable cardioverter defibrillators, 14 (6.5%) cardiac resynchronization therapy and 26 (12.1%) with peripheral angiography. Six patients were referred for coronary artery bypass surgery. Vascular complications [groin hematoma] occurred in two patients (0.9%). Conclusion: Both diagnostic and therapeutic cardiac catheterization procedures are safe with very low risk of complications even in its initial experience. The optimate goal of these procedures is to ensure the safety of the patients.

The impact of chronic kidney disease on healthcare utilization and costs associated with pacemaker infection

Abstract Background Patients with CKD are at increased risk of bleeding and device-related infections due to their chronic illness. CKD complicates treatment which could lead to an increase in duration of hospitalizations and higher costs. Purpose The goal of this study is to compare hospitalizations and the total costs associated with permanent pacemaker (PPM) infection in patients with and without CKD. Methods This retrospective analysis used Medicare Fee for service (FFS) claims to identify patients implanted with a transvenous PPM from June 2016-December 2020. Device infections, hospitalizations and costs were identified in a 12-month follow-up period post-device implant. Costs include all inpatient and outpatient hospital costs. Patients with CKD and infections were identified based on ICD-10 diagnostic codes. A generalized linear model was utilized to calculate non-infection and infection costs by CKD status. The simple differences between these cohorts represent the total infection cost with CKD and total infection cost without CKD highlighting the incremental cost of infected patients with CKD. Results A total of 439,679 Medicare FFS patients had PPM insertion from June 2016-December 2020, of which 13% had CKD and 1.2% had a device infection within 12-months post-implant. Infected patients with CKD incurred two admissions on average (p-value = &amp;lt;0.001), versus 1.4 (p-value = &amp;lt;0.001) for an infected patient without CKD. The total days in hospital for infected patients with CKD were 32 days (p-value = &amp;lt;0.001) versus 22 days (p-value=&amp;lt;0.001) for infected patients without CKD (Figure 1). The average cost of an infection in the US for a CKD patient was $176,483 (p-value = &amp;lt;0.001) versus $65,792 (p-value =&amp;lt;0.001) for a patient without CKD. The incremental costs of an infection in CKD as compared to no CKD was $110,691 (p-value of interaction = 0.0160). Conclusion In our analysis PPM-related infection in patients with CKD were characterized by more health care utilizations and higher costs compared to patients without CKD.Figure 1

Permanent pacemaker implantations among patients with spinal cord injury in the United States

Abstract Background Acute spinal cord injury (SCI) is associated with severe cardiovascular complications. Information regarding the need for permanent cardiac pacing in SCI patients is scarce and based on case reports and small case series. We aimed to investigate the extent of permanent pacemaker (PPM) implantation procedures as well as to identify predictors for PPM insertion among SCI patients in a U.S contemporary, nationwide, all-comer registry. Methods Using the National Inpatient Sample (NIS) database, patients hospitalized with a primary diagnosis of SCI in the US between 2016-2019 and underwent PPM implantation were identified. Patients with cardiac implantable electronic device in-situ were excluded. Baseline demographics, clinical characteristics, injury type, in-hospital procedures and outcomes including time to PPM implantation, length of stay and mortality were collected. Outcome analysis performed after propensity score matching (PSM). Predictors of PPM implantation were identified via a multivariable logistic regression model. Results A total of 35880 patients, were hospitalized with a primary diagnosis of SCI during the study period, and 240 (0.7%) received a PPM. Median age of patients receiving PPM was 69 years, 75% were males, and 67% had high level SCI injury (level C1-5). Time to PPM implantation was 9 days (IQR 4-19). PPM implantation was associated with higher rates of cervical spine injuries, traumatic brain injury (TBI), chest and upper limbs injuries, respiratory failure and other signs of severe illness. Longer hospital stay and higher in-hospital mortality rate was observed in patients receiving a PPM. Multivariate analysis identified the following independent risk factors for PPM implantation: cervical SCI [OR 77.07 (11.13-553.42), p&amp;lt;0.001], TBI [OR 3.84(1.59-9.28), p=0.003] and tracheostomy/respiratory ventilation&amp;gt; 96 h [OR 31.766(7.91-127.54), p=&amp;lt;0.001]. Conclusion Cervical SCI, need for tracheostomy and prolonged mechanical ventilation were the strongest predictors for PPM implantation in patients hospitalized for SCI in a nationwide registry.

Abstract 13737: Two Episodes of Intermittent Complete Heart Block Following Elective Procedures

Background: Iatrogenic bradycardia and complete heart block can occur with medications commonly administered during general anesthesia. Case: A 79-year-old male with past medical history of coronary artery disease, hypertension, paroxysmal atrial fibrillation and a left bundle branch block, underwent elective lithotripsy procedure, baseline ECG demonstrated in Figure A. Post-operatively, he developed asymptomatic complete heart block approximately 3 minutes after receiving sugammadex, a paralytic reversal agent (see Figure B). He was admitted for monitoring and spontaneously converted to sinus rhythm after 10 hours. The patient was discharged home with a 30-day event monitor; no pauses or high-grade atrioventricular block was noted during the monitoring period. Three months later, he underwent ureteroscopy stent exchange; during the induction with propofol he developed asystole followed by cardiac arrest. CPR was initiated and had return to spontaneous circulation after 3 minutes. The patient was transferred to the ICU, however, once again complete heart block was observed. Clinical decision-making: This case highlights recurrent episodes of transient complete heart block in the setting of an underlying left bundle branch and first-degree AV block that were exacerbated by medications during general anesthesia. Because of his underlying conduction disease and recurrent complete heart block and subsequent cardiac arrest, he ultimately underwent insertion of permanent dual chamber pacemaker. Conclusion: Iatrogenic transient complete heart block is a rare but potentially fatal complication. Prompt diagnosis and clinical suspicion of reversible causes are warranted. Significant underlying conduction disease should be considered to decide the ideal therapeutic option.

Surgery for paravalvular abscess in children

ObjectiveTo investigate the outcomes of surgery in children with paravalvular abscess at our institution. MethodsA retrospective review of all patients who underwent surgery for paravalvular abscess was performed. ResultsBetween 1989 and 2020, 30 patients underwent surgery for paravalvular abscess, of whom 5 (16.7%) had an intracardiac fistula and 6 (20.0%) had a pseudoaneurysm. Aortic annulus abscesses were most common, occurring in 23 patients (76.7%). Aortic root replacement was performed in 17 patients (56.7%), root reconstruction was performed in 4 (13.3%), and reconstruction of the central fibrous body was required in 5 (16.7%). Postoperatively, 7 patients (23.3%) required extracorporeal membrane oxygenation (ECMO) support, and 1 patient (3.3%) required permanent pacemaker insertion. There were 6 early deaths, 5 of whom were on ECMO, and no late deaths, with a 15-year survival of 79.7% (95% confidence interval [CI], 60.2%-90.3%). Deaths were from sudden cardiac arrest resulting in brain death in 3 patients, inability to wean from ECMO due to severe cardiac dysfunction in 2 patients, and cerebral mycotic aneurysm and hemorrhage in 1 patient. Freedom from reoperation was 40.0% (95% CI, 17.0%-62.3%) at 15 years Reoperation due to recurrence was rare, occurring in only 2 patients (6.7%). Streptococcus pneumoniae (hazard ratio [HR], 9.2; 95% CI, 1.6-51.7) and preoperative shock (HR, 6.4; 95% CI, 1.3-32.0) were associated with mortality. Central fibrous body reconstruction was associated with reoperation (HR, 4.4; 95% CI, 1.2-16.1). ConclusionsAlthough paravalvular abscess in children is associated with high early mortality, hospital survivors have good long-term survival. Reoperation is frequent, but is rarely due to recurrence of endocarditis.

Complete heart block is a significant predictor of mortality in immune checkpoint inhibitor myocarditis

BackgroundImmune checkpoint inhibitor (ICI) myocarditis is associated with significant mortality risk. Electrocardiogram (ECG) changes in ICI myocarditis have strong prognostic value. However the impact of complete heart block (CHB) is not well defined. This study sought to evaluate the impact of CHB on mortality in ICI myocarditis, and to identify clinical predictors of mortality and CHB incidence.MethodsWe conducted a retrospective cohort study of patients with ICI myocarditis at three Mayo Clinic sites from 1st January 2010 to 31st September 2022 to evaluate mortality rates at 180 days. Clinical, laboratory, ECG, echocardiographic, and cardiac magnetic resonance imaging (CMR) characteristics were assessed. Cox and logistic regression were performed for associations with mortality and CHB respectively.ResultsOf 34 identified cases of ICI myocarditis, 7 (20.6%) had CHB. CHB was associated with higher mortality (HR 7.41, p = 0.03, attributable fraction 86.5%). Among those with CHB, troponin T (TnT) < 1000 ng/dL, low white blood cell count and high ventricular rate at admission were protective. There was trend towards increased survival among patients who underwent permanent pacemaker insertion (p = 0.051), although most experienced device lead complications. Factors associated with development of CHB included prolonged PR and QRS intervals and low Sokolow Lyon Index. Where these were normal and TnT was < 1000 ng/dL, no deaths occurred. Impaired myocardial longitudinal strain was sensitive for ICI myocarditis but was not prognostically significant.ConclusionThere is a strong temporal association between CHB and early mortality in people with ICI myocarditis. Focusing on arrhythmogenic complications can be helpful in predicting outcomes for this group of critically ill individuals.

Mechanical atrioventricular valve replacement in patients with single ventricle palliation.

Atrioventricular valve (AVV) replacements in patients with single-ventricle circulations pose significant surgical risks and are associated with high morbidity and mortality. From 1997 to 2021, 16 consecutive patients with functionally single-ventricle physiology underwent mechanical AVV replacement. Primary outcome was transplant-free survival. Secondary outcomes included major postoperative morbidity. The median age of AVV replacement was 2 years old (interquartile range 0.6-3.8 years). All AVV replacements were performed with a St. Jude Medical mechanical valve, median 24 mm (range, 19-31mm). Extracorporeal membrane oxygenation (ECMO) was required in 4 patients. Operative mortality was 38% (6/16). There were 2 late deaths and 3 transplants. Transplant-free survival was 50% at 1 year, 37.5% at 5 years, and 22% at 10 years. Transplant-free survival was higher for patients with preserved ventricular function (P = 0.01). Difference in transplant-free survival at 1 year was 75% vs 25%, at 5 years was 62.5% vs 12.5% and at 10 years was 57% vs 0%. Three (19%) patients had complete heart block requiring permanent pacemaker insertion. 6 of 13 patients (46%) patients reached Fontan completion (3 patients operated at/after Fontan). Significant bleeding events occurred in 8 patients (50%) with 3 patients suffering major cerebrovascular accidents. There were 6 events of valve thrombosis in 5 patients, resulting in 2 deaths and 2 heart transplants. Mechanical valve replacement carries significant morbidity and mortality risk. While it successfully salvages about half of patients with preserved ventricular function, careful consideration of alternative options should be made before embarking upon mechanical valve replacement.

Complications following cardiac pacemaker insertions

Context: Permanent pacemaker insertion is a recognised mode of therapy for cardiac arrhythmias. The procedure is carried our regularly at the Cardiac Catheterization laboratory of Madras Medical Mission India.&#x0D; Aims: This study reviewed the associated morbidity and complications of cardiac pacemaker insertions carried out over fifteen years. &#x0D; Settings and Design: This study was carried out in the Cardiac Electrophysiology department, of the Institute of Cardiovascular diseases, Madras Medical Mission, India. The study was retrospective. &#x0D; Material and methods: Data was collected when previously paced patients presented for cardiac interrogation between January to July of 2013. The patients had undergone implantation over the preceding fifteen years. 501 consecutive cases were chosen for analysis.The data obtained was analysed using SPSS statistical software version 15.&#x0D; Results: The 501 patients had been on pacemaker for variable durations. They comprised 321 males and 180 females. A variety of complications were observed in 33 (6.58%) patients but there was no procedure-related mortality. &#x0D; Conclusions: Pacemakers were generally well tolerated. Majority of patients were asymptomatic and the rate of complications is 6.58%.

The Outcome of Congenital Cardiac Surgery in Patients with Down Syndrome: Single-Center Experience.

This study aimed to describe the outcomes of Down syndrome patients who underwent cardiac surgery for congenital heart defects and to develop risk prediction models for in-hospital mortality, recurrent hospital admission, and the need for catheter intervention among a cohort of patients. This single-centre retrospective cohort study included consecutive Down syndrome patients who underwent cardiac surgery for congenital heart defects between January 2018 and December 2021. We reviewed the electronic medical records. Two hundred patients fulfilled the eligibility criteria with complete data reporting. The patients' perioperative data and outcomes were recorded. Females constituted 56.5%. Most (78.5%) patients showed accepted recovery. The incidence of all-cause in-hospital mortality was 3.0%. The rates of the need for a second operation, heart failure management, and permanent pacemaker insertion were 3.0%, 2.0%, and 2.5%, respectively. Only 8 (4.0%) patients stayed in the hospital for a long duration after chylothorax or tracheostomy (if intubated more than 2 weeks). The model had an accuracy of 99% and included the intraoperative transesophageal echocardiography (TEE) abnormalities (residual heart lesions) (adjusted odds ratio [AOR]: 26.541, p = 0.033), the duration of mechanical ventilation following the operation (AOR: 1.152, p = 0.009), and the occurrence of postoperative heart block (AOR: 76.447, p = 0.005). Surgical treatment of congenital heart defects in Down syndrome patients had good outcomes with accepted recovery (without intra-hospital or during follow-up mortality or morbidity) of 78.5% and a 3% incidence of in-hospital mortality. Though, the occurrence of chylothorax was considerably high, and resulted in a long hospital stay (more than 10 days). Repair of tetralogy of Fallot and coarctation of the aorta were associated with an increased likelihood of catheter intervention following the operation.

Outcomes of transcatheter aortic valve replacement in patients with and without amyloidosis: A nationwide analysis from the United States

BackgroundAmyloidosis is a common comorbidity in elderly patients with aortic stenosis (AS) referred for transcatheter aortic valve replacement (TAVR). This study aims to assess the impact of amyloidosis on the clinical outcomes of TAVR. MethodsThis is a retrospective study of the National Inpatient Sample database that identified adult patients (≥18 years) with AS hospitalized for TAVR from 2016 through 2020 to compare outcomes in those with versus without amyloidosis. Our primary outcome was in-hospital mortality. Secondary outcomes included procedural complications, hospital length of stay (LOS), and total costs. TAVR trends in both cohorts were also evaluated. ResultsThe total cohort included 304,710 patients with AS undergoing TAVR, of whom 410 had amyloidosis. Over the study period, TAVR trends increased significantly in patients with and without amyloidosis (both ptrend < 0.01). Patients with amyloidosis were more likely to be older males with atrial fibrillation/flutter, congestive heart failure, renal disease, and dementia compared to non-amyloidosis patients. After adjustment for baseline characteristics, patients with amyloidosis had similar odds of in-hospital mortality (adjusted odds ratio [aOR] 1.66, 95 % confidence interval [CI] 0.34–3.63), heart block (aOR 1.33, 95 % CI 0.84–2.10), permanent pacemaker insertion (aOR 0.67, 95 % CI 0.27–1.66), stroke (aOR 0.90, 95 % CI 0.32–3.13), acute kidney injury, major bleeding, blood transfusion, vascular complications, in addition to similar LOS (p = 0.21) and total costs (p = 0.18) compared to patients without amyloidosis. ConclusionIn patients with AS undergoing TAVR, comorbid amyloidosis is associated with similar in-hospital mortality and procedural complications compared to patients without amyloidosis.

Cardiac Rehabilitation in Patients with Pacemakers Implantation

Total AV block is a condition when the impulses from the atrium cannot reach the ventricles. Indications for the implantation of a permanent pacemaker are symptomatic bradycardia and high-risk conditions such as total AV block. The following case discusses a patient with total AV block post implantation of permanent pacemaker (PPM). Cardiac rehabilitation program started when the patient is hemodynamically stable. In bed exercises are carried out to prevent bed rest complications such as joint range of motion exercises and breathing exercises. After the patient underwent PPM insertion, the first phase of cardiac rehabilitation with mobilization program started 24 hours after implantation. More intensive mobilization was carried out and a six-minute walking test was carried out before discharge. In the next phase, a second phase of cardiac rehabilitation (outpatient) is carried out for 4-8 weeks considering the healing time after implantation after 1 weeks.

Outcomes of Transcatheter Aortic Valve Implantation in Nonagenarians and Octogenarians (Analysis from the National Inpatient Sample Database)

Risks among nonagenarian (age ≥90 years) and octogenarian (age 80 to 89 years) patients who underwent transcatheter aortic valve implantation (TAVI) compared with clinically similar septuagenarian (age 70 to 79 years) patients remain unclear. This study aimed to assess the outcomes of TAVI in nonagenarians and octogenarians compared with septuagenarians. We conducted a retrospective cohort study using the National Inpatient Sample database to identify patients aged ≥70 years hospitalized for TAVI from 2016 to 2020 and to compare outcomes in nonagenarians and octogenarians versus septuagenarians. The primary outcome was in-hospital mortality. Secondary outcomes included procedural complications, length of stay (LOS), and total costs. The trends in in-hospital outcomes were evaluated. Results were adjusted for demographic/clinical factors. The total cohort included 263,325 patients hospitalized for TAVI, of whom 11.9% were nonagenarians, 51.1% octogenarians, and 37.0% septuagenarians. After adjustment, nonagenarians and octogenarians had higher odds of in-hospital mortality (adjusted odds ratio 1.80, 95% confidence interval 1.34 to 2.41 for nonagenarians; adjusted odds ratio 1.65, 95% confidence interval 1.35 to 2.01 for octogenarians), heart block, permanent pacemaker insertion, stroke, major bleeding, blood transfusion, and palliative care consultation than septuagenarians (all p <0.01). LOS was longer and the total costs were higher for nonagenarians and octogenarians (both p <0.01). Over the study period, in-hospital mortality decreased in nonagenarians (ptrend=0.04), and major bleeding, permanent pacemaker insertion, LOS, and costs decreased in all patients aged ≥70years (ptrend <0.01). In conclusion, nonagenarians and octogenarians who underwent TAVI have higher rates of mortality and procedure-related complications than clinically similar septuagenarians. Further research is necessary to optimize outcomes in this frail population.

Immune checkpoint inhibitor myocarditis with complete heart block: a case series

Abstract Funding Acknowledgements Type of funding sources: None. Background/Introduction Immune checkpoint inhibitor (ICI) myocarditis is a life-threatening condition characterized by lymphocytic myocardial infiltration[1]. Complete heart block (CHB) occurs in 15% of cases and is often fatal[2-4]. The nature and optimal management of this often-malignant condition is poorly understood[5]. Purpose This case series assesses prognostic factors associated with survival at 90 days among people with ICI myocarditis and CHB. Methods The electronic patient record system was used to identify patients admitted with ICI myocarditis. A two-physician review was used to assess the presence of ICI-associated CHB. Wilcoxon rank sum and Spearman’s rank correlation were used for categorical and quantitative variables respectively. Data was analysed using STATA/IC 16.1. The primary outcome was person-day survival 90 days after presenting symptom onset. Results Six patients were included in the final analysis. Mean survival was 47 person days. All had metastatic disease and presented 15 to 32 days after the first ICI infusion. All had muscle weakness. Other common self-symptoms were shortness of breath (4), blurred vision (4), double vision (3), collapse (3), and leg swelling (1). Proximal myopathy (2), fatigable myopathy (1), ptosis (3), and peripheral oedema (1) were present on examination. Raised troponin T and white blood cell count (WBC) were associated with 90-day survival (see Table 1). Nt-pro BNP, AST, and CK levels were raised in all patients. Two patients were tested for anti-striated muscle antibody titres, and both were strongly positive. Increase in QRS duration compared to baseline ECG was associated with lower survival at 90 days. Only one patient had CHB on admission. Steroid dose, IVIG, and plasmapheresis weren’t associated with survival. One patient declined device therapy. One declined permanent pacemaker (PPM) after insertion of transvenous pacemaker (TVP). Both died within 2 weeks. Three people underwent insertion of a transvenous pacemaker (TVP) followed by PPM insertion (table 2). All three eventually died within 100 days. One person received isoproterenol and immunosuppression as a bridge to PPM and survived. One patient was managed initially with TVP but subsequently declined PPM insertion. TVP removal resulted in CHB recurrence, and they died shortly after discharge. One person declined device therapy and died while receiving comfort care. Lead malfunction was frequent. One patient experienced bradycardia arrest with failure of a TVP lead to capture, while another experienced lead dislodgement. Conclusion CHB secondary to ICI is often fatal. It should be considered in patients presenting with symptoms of myositis, raised troponin and increased QRS duration. Despite a small sample size, this study identifies several prognostic factors which can guide both patients and physicians with decision-making. Larger studies are needed to better understand the role of device therapy in this population.

A primer for the student joining the adult cardiac surgery service tomorrow: Primer 1 of 7

A primer for the student joining the adult cardiac surgery service tomorrow: Primer 1 of 7

Race and Socioeconomic Disparities in Proximal Aortic Surgery

BackgroundSubstantial socioeconomics-based disparities exist in cardiac surgery. Although there are robust data for revascularization and valve procedures, the effect of race and socioeconomic status on proximal aortic surgery is not well studied. This study analyzed the impact of race and socioeconomic status on in-hospital outcomes after proximal aortic surgery. MethodsAll adult patients who underwent proximal aortic surgery for aortic dissection or thoracic aneurysm from the 2016 to 2018 National Inpatient Sample were included. Primary outcomes included in-hospital mortality and in-hospital composite morbidity (stroke, pulmonary embolus, major bleeding, acute kidney injury, or permanent pacemaker insertion). Adjusted outcomes were assessed with multivariable analysis. ResultsA weighted total of 32,895 patients were included; 25,461 (77.4%) classified as White, 3224 (9.8%) Black, 2039 (6.2%) Hispanic, and 2171 (6.6%) other. Black and Hispanic patients had significantly lower median household income, higher proportion of self-pay insurance status, younger age, higher comorbidity burden, and a higher proportion of urgent or emergency procedures compared with White patients. There was no significant difference in observed in-hospital mortality by patient race, but non-White patients had significantly higher composite morbidity. On adjusted analysis, there was no difference in in-hospital mortality, but non-White race was an independent predictor of in-hospital morbidity (adjusted odds ratio, 1.6; 95% CI, 1.4-1.8; P < .001). ConclusionsPatients of non-White race who undergo proximal aortic surgery have less insurance coverage, more urgent procedures, and a higher comorbidity burden than White patients, disparities that translate to significantly higher morbidity in non-White. A greater focus on nonfatal outcome differentials and improving access to care likely will improve aortic surgery disparities.