Recurrent Hospitalizations Research Articles

Pacing lead extraction in the management of tricuspid regurgitation: a case report

BackgroundPatients with a cardiac implantable electronic device (CIED)-induced tricuspid regurgitation (TR) have an increased mortality and morbidity. However, the impact of CIED-lead extraction and its indications are not well-defined.Case summaryA 69-year-old woman presented with recurrent hospital admissions for right heart failure refractory to medical therapy, on the background of a single-chamber permanent pacemaker (Biotronik) implanted 6 years ago for tachycardia–bradycardia syndrome. Transoesophageal echocardiography identified severe TR which was predominantly CIED-induced from a lead impingement of the posterior tricuspid valve (TV) leaflet preventing adequate leaflet coaptation. This had progressed to cause a degree of secondary functional TR. The patient underwent pacing lead extraction followed by epicardial lead placement via minithoracotomy, with significant symptomatic and echographic improvement of TR.DiscussionCIED-induced TR from a lead impingement of TV leaflets carries the highest risk of TR and its consequences. This case illustrates the significance of the relationship between CIED-leads and the TV, which impacts management strategy. We recommend a mechanistic approach and incorporating CIED-lead interaction with the TV apparatus as the underlying principle in developing future management guidelines for CIED-induced TR.

Schizoaffective Disorder: How long does it take to diagnose? A case report

Introduction: It is reported a case of a 57-year-old woman with multiple psychiatric hospitalizations, during which different diagnostic hypotheses and therapeutic procedures were proposed. Case repor t: After analyzing the patient’s clinical records, the medical team proposed a diagnosis of Schizoaffective Disorder. This disorder presents a high risk of recurrent hospitalizations and high costs associated with therapeutic and follow-up withdrawal, yet there is limited data to assess the post-discharge critical periods. Final considerations : Further research in this area is required to adopt effective therapeutic strategies, reduce the probability of hospital admissions, improve prognosis, and lessen associated financial costs

The demographic, psychosocial and clinical characteristics associated with cardiac risk factor control: an analysis of secondary prevention in adults with established coronary heart disease

Abstract Funding Acknowledgements Type of funding sources: None. Background and Purpose Achieving risk factor (RF) control in patients with established coronary heart disease (CHD) reduces the risk of CHD events.(1) Cross-sectional studies have shown that the implementation of current prevention guidelines is poor, with most patients failing to meet recommended targets.(2,3) This study aims to identify demographic, psychosocial and clinical characteristics associated with the non-achievement of RF targets in a population with CHD. Methods In this post-hoc cross-sectional analysis, multivariable logistic regression identified characteristics significantly associated with poor RF control in participants of the iASPIRE study which recently assessed secondary CHD prevention in Ireland. Results An unhealthy diet (Odds Ratio [OR] 1.6, 95% CI 1.1-2.4, p=0.015), male sex (OR 1.8, 95% CI 1.2-2.8, p=0.007) and type of acute coronary syndrome event (OR 0.6, 95% CI 0.4-0.9, p=0.012) were associated with failure to achieve blood pressure recommendations. Female sex (OR 2.3, 95% CI 1.4-3.8, p=0.002), lack of high-intensity statin (OR 2.4, 95% CI 1.5-3.8, p<0.001) and recurrent hospitalisation for CHD (OR 1.9, 95% CI 1.3-2.8, p=0.001) were associated with poor LDL-C control. Decreasing age (OR 0.9, 95% CI 0.9-1.0, p=0.018), marriage (OR 4.3, 95% CI 1.5-12.1, p=0.007) and insulin use (OR 9.7, 95% CI 1.9-50.4, p=0.007) were associated with a HbA1c of ≥53mmol/mol. The absence of a longstanding illness or disability and decreasing resting heart rate were associated with composite RF control. Conclusion Several demographic, psychosocial and clinical characteristics are associated with achieving guideline-recommended RF targets. These findings will support the development of targeted solutions that will improve guideline implementation and the practice of CHD prevention in a high-risk population.

Recurrent risk of hospitalization among older people with problematic alcohol use: a multiple failure-time analysis with a discontinuous risk model.

Background and aimsOlder people with problematic alcohol use vary in psychosocial functioning, age of onset for problem drinking and use of other drugs. The study measured the differential risks of all‐cause, alcohol‐, polydrug‐ and psychiatric‐related repeated hospitalizations among older people with problematic alcohol use.DesignA linked register‐based cohort study with discontinuous multiple‐failure (time‐to‐repeated‐event) data. Hospitalization and mortality were considered as failure.SettingSweden, March 2003–November 2017, using data from the Addiction Severity Index (ASI) register linked to National Inpatient Register and the Swedish cause of death register.ParticipantsParticipants aged 50 years and older (n = 1741; 28.2% women), with one or more alcohol problem days in the 30 days before an ASI assessment.MeasurementsFive mutually exclusive latent classes of problematic alcohol use, identified with 11 ASI items, were the independent variables: ‘late onset with fewer consequences (LO:FC; reference group)’; ‘early onset/prevalent multi‐dimensional problems (EO:MD)’; ‘late onset with co‐occurring anxiety and depression (LO:AD)’; ‘early onset with co‐occurring psychiatric problems (EO:PP)’; and ‘early onset with major alcohol problem (EO:AP)’. Covariates included socio‐demographic characteristics, previous hospitalization and Elixhauser comorbidity index. Outcome measurements included recurrent hospitalization and/or mortality due to: (a) all‐cause, (b) alcohol‐related disorders and diseases (c) polydrug use and (d) other psychiatric disorders.FindingsDuring the study period, more than 75% were hospitalized at least once or died. 57.3% were hospitalized with alcohol‐related, 8.5% with polydrug use and 18.5% with psychiatric‐related diagnoses. Compared with LO:FC, EO:PP had higher risk for all‐cause [adjusted hazard ratio (aHR) = 1.27, 95% confidence interval (CI) = 1.02–1.59] and alcohol‐related (aHR = 1.34, 95% CI = 1.02–1.75) hospitalizations. Adjusted risks for polydrug‐related hospitalization were 2.55, 95% CI = 1.04–6.27 for EO:MD and 2.62, 95% CI = 1.07–6.40 for EO:PP. Adjusted risk for psychiatric‐related hospitalization was higher for LO:AD (aHR = 1.78, 95% CI = 1.16–2.73 and EO:PP (aHR = 2.03, 95% CI = 1.22–3.38).ConclusionsOlder addiction service users in Sweden have varying risks of hospitalization due to alcohol use, polydrug use and psychiatric disorders. Older people with problematic alcohol use who have multiple needs and are assessed in social services may benefit from earlier interventions with an integrated focus on substance use and mental health.

FC098: Arteriovenous Access and Outcomes in Incident Hemodialysis Patients: Is Fistula First Approach Still Holding?

Abstract BACKGROUND AND AIMS Vascular access choice for patients with high risk of arteriovenous (AV) access failure has been sparking growing controversy as recent studies show similar survival and morbidity across patients receiving arteriovenous (AV) fistula or graft. We assessed hospitalization and mortality risks associated with access type in patients who started hemodialysis with a catheter without previous AV access creation in France, overall and by subgroups of age, sex and comorbidities. METHOD Longitudinal study of 18 800 incident hemodialysis patients from 2010 through 2018, based on the linkage of the French REIN registry of kidney replacement therapy (KRT) with the national health administrative database (SNDS). First-line AV access (fistula or graft) was ascertained from SNDS procedures codes. Hospitalizations were also identified through the SNDS, whereas mortality data was obtained from the REIN Registry. We used joint frailty models to estimate hazard ratios (HR) and 95% confidence intervals (CI) of recurrent hospitalization and death associated with AV grafts, compared with AV fistulæ. These models accounted for dependence between hospitalization and death. We further estimated propensity scores for first-line AV graft placement and used inverse probability weighting (IPW) to obtain weighted HR (wHR), accounting for potential indication bias. RESULTS Among studied patients, 35% were women, 45% had diabetes, 26% had history of heart failure and 19% had history of peripheral artery disease. More than half started dialysis urgently (52%). Patients with first-line AV graft (5%) were older than those with AV fistula (72 ± 14 versus 68 ± 15 years, respectively), and required more frequently assistance to walk (29% versus 17%). IPW resulted in covariate balance (absolute standardized difference <10%) within the overall population and the subgroups of interest (except for the timing of AV access creation in patients aged <70). Over a median follow-up of 48 months (IQR 27–48), hospitalization rates were 334 and 310 per 100 patient-years in the AV graft and fistula groups, respectively; mortality rates were 16 and 13 per 100 patient-years. Patients with AV graft had a 14% higher hazard of all-cause hospitalization (HR 1.14, 95% CI 1.08–1.20), which was only slightly attenuated in IPW analysis (wHR 1.11, 1.09–1.13). AV access type was not associated with mortality—HR 1.03 (0.89–1.19), wHR 1.11 (0.85–1.46). Results were consistent for most subgroups, except that the highest hazard of hospitalization with AV grafts compared to fistulæ was much attenuated in patients with diabetes, heart failure or peripheral artery disease with respect to patients without these comorbidities (Figure 1). CONCLUSION In patients starting hemodialysis with a catheter without previous AV access creation, the fistula first approach is associated with similar mortality, but lower risk of hospitalization compared to first-line AV graft. This may, however, not be the case for patients with a poor vascular condition, i.e. those with diabetes or peripheral artery disease, who have a similar hospitalization risk with either graft or fistula.

Impact of recurrent acute heart failure hospitalizations on prognosis of heart failure patients

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Hospitalizations for acute heart failure (AHF) are significant events for heart failure (HF) patients (pts) with each hospitalization portending a poor prognosis. Our aim was to compare pts with recurrent AHF admissions to those without and to study the impact of recurrent admissions on overall mortality. Methods Single centre retrospective study that included all pts followed at the HF Clinic of the Cardiology Department that had at least one visit during 2018. All data since their initial follow-up on HF Clinic was considered. Recurrent admissions were defined as 2 or more admissions for AHF in the same year, during the follow-up. Results A total of 138 pts were included (83% male, mean age 61±11years). Dilated cardiomyopathy (65;47%) and ischemic cardiomyopathy (62;45%) were the most frequent aetiologies and most pts had HF with reduced ejection fraction (131;95%). Mean left ventricular ejection fraction (LVEF) was 26±9% and right ventricular dysfunction was present in 27% of the cases. The majority of patients was on NYHA class II (80, 58%). A total of 84 (61%) pts was medicated with inhibitors of the renin-angiotensin system (iRAS), 45 (33%) with angiotensin receptor-neprilysin inhibitor (ARNI), 127 (92%) with beta-blockers (BB) and 116 (84%) with mineralocorticoid receptor antagonists (MRA). Ninety-seven (70%) pts had a cardiac electronic device implanted (47 CRT, 50 ICD). During a median follow-up of 40 months (IQR 32-58), 41 (30%) pts had hospitalizations for AHF and 21 (15%) had recurrent admissions. The median time to the first hospitalization was 16 months (IQR 6-29). Pts with recurrent admissions had a similar comorbidity profile and HF aetiology in comparison to pts with one or none admissions. Considering baseline echocardiographic parameters on first visit, they had a higher mean E/E’ ratio (22±8 vs 14±6, p= .012) and pulmonary systolic artery pressures (52±20 vs 38±14 mmHg, p= .026). No differences were found in LVEF, left ventricular volumes, presence of right ventricular dysfunction or mitral regurgitation. They were less frequently medicated with iRAS or ARNI (81% vs 96%, p=.012) and BB (81% vs 94%, p= .043) and had a higher mean diuretic dosage (87±47 vs 63±43 mg). During the follow-up a total of 31 (22%) pts died, 14 (10%) for cardiovascular reasons. Pts with recurrent AHF admissions were more likely to die from any cause (log rank =.01). On a multivariate analysis, recurrent AHF hospitalizations were an independent predictor of all-cause death (HR 2.4, IC95% 1.1-5.2, p=.03). Conclusion Recurrent AHF hospitalizations are associated with a worse long-term outcome of HF pts. Efforts should be made for an earlier identification of these pts. A higher baseline pulmonary systolic artery pressure and mean E/E’ ratio may identify a higher risk group who benefits from a closer follow-up.

Levosimendan increases time out-of-hospital in decompensated advanced heart failure

Abstract Funding Acknowledgements Type of funding sources: None. Background Advanced heart failure is associated with a high rate of hospitalization due to clinical decompensating. Adding Levosimendan (LVS), an inodilatador which metabolite has long-lasting effect, to intravenous diuretic therapy (standard therapy) is a therapeutic option in these patients, although the magnitude of the short and long-term benefit still remains controversial. Objective The aim of this study was to determine whether combination of LVS with standard therapy in patients with decompensated advanced heart failure (DAHF) increases time out-of-hospital compared to standard therapy alone. The secondary endpoint was duration of hospital stay for each type of hospitalization. Methods and Results Retrospective analysis of patients with advanced heart failure who met the following criteria: at least one hospitalization with standard therapy and at least one hospitalization with standard therapy plus LVS, separated less than 6 months from each other. From a total of 71 patients who took LVS in our cardiac care unit, 7 patients met the inclusion criteria. All these patients were male, mean age was 64,1 ± 10,6 years, mean left ventricular ejection fraction was 24,57 ± 7,3% and 71,4% had ischemic cardiomyopathy. A total of 22 hospitalizations were analysed (12 with standard therapy plus LVS and 10 with standard therapy), with 4 patients having more than two hospitalizations. The administration of LVS increased the time out-of-hospital until readmission compared to standard therapy alone (70.5 days vs 34.7 days, p = 0.023) (figure 1). The length of stay during LVS administration was longer (12.1 days vs 6.0 days, p <0.001). In 75% of cases after LVS infusion patients stay out-of-hospital more than 2 months while after standard therapy this event occurred only once (10%) (figure 2). 1-year mortality was 71,4%. Conclusion Use of Levosimendan increases time out-of-hospital in patients with DAHF. This is an opportunity to improve quality of life in patients with severe disease and recurrent hospitalizations.

Incidence, Treatment and Clinical Impact of Iron Deficiency in Chronic Heart Failure: A Longitudinal Analysis.

In patients with heart failure (HF), iron deficiency (ID) is a well-recognized therapeutic target; information about its incidence, patterns of iron repletion, and clinical impact is scarce. This single-centre longitudinal cohort study assessed the rates of ID testing and diagnosis in patients with stable HF, patterns of treatment with intravenous iron, and clinical impact of intravenous iron on HF rehospitalization risk. We included 711 consecutive outpatients (4400 visits) with stable chronic HF from 2014 to 2019 (median [interquartile range] visits per patient: 2 [2–7]. ID was defined as serum ferritin <100 µg/L, or 100–299 µg/L with transferrin saturation (TSAT) < 20%. During a median follow-up of 2.20 (1.11–3.78) years, ferritin and TSAT were measured at 2230 (50.7%) and 2183 visits (49.6%), respectively. ID was found at 846 (37.9%) visits, with ferritin and TSAT available (2230/4400), and intravenous iron was administered at 321/4400 (7.3%) visits; 233 (32.8%) patients received intravenous iron during follow-up. After multivariate analyses, iron repletion at any time during follow-up was associated with a lower risk of recurrent HF hospitalization (hazard ratio [HR] = 0.50, 95% confidence interval [CI] = 0.28–0.88; p = 0.016). Thus, ID was a frequent finding in patients with HF, and its repletion reduced the risk of recurrent HF hospitalizations.

Management of Multidrug-Resistant Infections in Cirrhosis.

The World Health Organization describes antimicrobial resistance as one of the biggest threats to global health, food security, and development with indiscriminate use of antimicrobials globally driving the emergence of multidrug-resistant bacteria, resistant to 60% of antimicrobials in some countries. Infections with multidrug-resistant organisms (MDROs) have increased in recent decades in patients with cirrhosis, who are frequently prescribed antibiotics, regularly undergo invasive procedures such as large volume paracentesis, and have recurrent hospitalizations, posing a particular risk in this already immunocompromised cohort of patients. In this review, we explore mechanisms underlying this vulnerability to MDRO infection; the effect of bacterial infections on disease course in cirrhosis; prevalence of MDROs in patients with cirrhosis; outcomes following MDRO infection; fungal infections; antibiotics and their efficacy; and management of MDRO infections in terms of detection, antimicrobial and nonantimicrobial treatments, prophylaxis, antibiotic stewardship, the gut microbiome, and technological interventions.

National trend in heart failure hospitalization and outcome under public health insurance system in Thailand 2008\u20132013

BackgroundThere are limited data on the burden, characteristics, and outcomes of hospitalized heart failure (HF) patients in Thailand. The aim of this study was to investigate national trend in HF hospitalization rate, in-hospital and 1-year mortality rate, and rehospitalization rate in Thailand.MethodsWe analyzed the claims data of hospitalized patients obtained from the three major Thailand public health reimbursement systems between 2008 and 2013. Patients aged ≥ 18 years with a principal diagnosis of HF by the International Classification of Diseases, Tenth Revision, Thai modification were included. Comorbidities were identified by secondary diagnosis codes. The annual rate of HF hospitalization was calculated per 100,000 beneficiaries. Records of subsequent hospitalization of discharged patients were retrieved. For 1-year mortality rate, vital status of each patient was obtained from Thai Civil Registration of Death database. All outcomes were tested for linear trends across calendar years.ResultsBetween 2008 and 2013, 434,933 HF hospitalizations were identified. The mean age was 65.3 years (SD 14.6), and 58.1% were female. The HF hospitalization rate increased from 138 in 2008 to 168 per 100,000 beneficiaries in 2013 (P for trend < 0.001). Nearly half (47.4%) had had a prior HF admission within 1 year. A small proportion of patients (7.4%) received echocardiography during hospitalization. The median length of hospital stay was 3 days. In-hospital mortality declined from 4.4 to 3.8% (P for trend < 0.001). The overall 30-day and 1-year rehospitalization rates were 34 and 73%, respectively, without significant trends over the study period. Most common cause of 30-day rehospitalization was HF (42%). One-year mortality decreased from 31.8% in 2008 to 28.5% in 2012 (P for trend < 0.001).ConclusionBetween 2008 and 2013, HF hospitalization rate in Thailand increased. The in-hospital and 1-year mortality rates decreased slightly. However, the rehospitalization rate remained high mainly due to recurrent HF hospitalization.

Influence of Neighborhood Conditions on Recurrent Hospital Readmissions in Patients with Heart Failure: A Cohort Study

PurposeThis study examined how certain aspects of residential neighborhood conditions (ie, observed built environment, census-based area-level poverty, and perceived disorder) affect readmission in urban patients with heart failure. MethodsA total of 400 patients with heart failure who were discharged alive from an urban-university teaching hospital were enrolled. Data were collected about readmissions during a 2-year follow-up. The impact of residential neighborhood conditions on readmissions was examined with adjustment for 7 blocks of covariates: 1) patient demographic characteristics; 2) comorbidities; 3) clinical characteristics; 4) depression; 5) perceived stress; 6) health behaviors; and 7) hospitalization characteristics. ResultsA total of 83.3% of participants were readmitted. Participants from high-poverty census tracts (≥20%) were at increased risk of readmission compared with those from census tracts with <10% poverty (hazard ratio [HR]: 1.53; 95% confidence interval: 1.03-2.27; P < .05) when adjusted for demographic characteristics. None of the built environmental or perceived neighborhood conditions were associated with the risk of readmission. The poverty-related risk of readmission was reduced to nonsignificance after including diabetes (HR: 1.33) and hypertension (HR: 1.35) in the models. ConclusionsThe effect of high poverty is partly explained by high rates of hypertension and diabetes in these areas. Improving diabetes and blood pressure control or structural aspects of impoverished areas may help reduce hospital readmissions.

Carboxyhemoglobin Does Not Predict the Need of Mechanical Ventilation and Prognosis during COPD Exacerbation.

Background Carboxyhemoglobin (COHb) is a complex formed by the binding of carbon monoxide to hemoglobin in blood. Higher COHb levels have been associated with poor prognosis in a variety of pulmonary disorders. However, little is known regarding the prognostic significance of COHb among individuals with chronic obstructive pulmonary disease (COPD) exacerbation. Methods In a retrospective study, we evaluated associations of venous COHb levels on hospital admission with the need for invasive mechanical ventilation, in-hospital mortality, and rehospitalization, among 300 patients hospitalized for COPD exacerbation in internal medical wards. Results Rates of in-hospital death and 1-year recurrent hospitalizations were 11.0% and 59.6%, respectively. COHb levels were not significantly associated with in-hospital mortality (OR = 0.82, P=0.25, 95% CI 0.59–1.15) or with 1-year rehospitalizations (OR = 0.91, P=0.18, 95% CI 0.79–1.04). The mean COHb level did not differ significantly between patients who needed invasive mechanical ventilation and those who were not invasively mechanically ventilated during the current hospitalization (2.01 ± 1.42% vs. 2.19 ± 1.68%, P=0.49). Conclusions Among patients hospitalized with COPD exacerbation in internal medicine wards, COHb levels on admission were not associated with invasive mechanical ventilation treatment, rehospitalizations, or mortality.

A Retrospective Cohort Study on Infant Respiratory Tract Infection Hospitalizations and Recurrent Wheeze and Asthma Risk: Impact of Respiratory Syncytial Virus.

Infant respiratory syncytial virus infection (RSV) has been associated with asthma later in life. We explored the risk of recurrent wheeze or asthma in children with infant RSV-associated hospitalization compared to other respiratory infections. We performed a retrospective cohort study using Danish national hospital discharge registers. Infants younger than 6 months, born between January 1995 and October 2018, and with a RSV hospital admission were compared to infants hospitalized for injuries, non-RSV acute upper respiratory tract infection (AURTI), pneumonia and other respiratory pathogens, nonpathogen-coded lower respiratory tract infections (LRTI), pertussis, or nonspecific respiratory infections. Infants were followed until recurrent wheeze or asthma diagnosis, death, migration, age 10 years, or study end. We estimated cumulative incidence rate ratios (CIRR) and hazard ratios (HR) adjusted for sex, age at inclusion, hospital length of stay (LOS), maternal smoking, 5-minute APGAR score (APGAR5), prematurity, and congenital risk factors (CRF). We included 68 130 infants, of whom 20 920 (30.7%) had RSV hospitalization. The cumulative incidence rate of recurrent wheeze or asthma was 16.6 per 1000 person-years after RSV hospitalization, higher than after injury (CIRR, 2.69; 95% confidence interval [CI], 2.48-2.92), AURTI (CIRR, 1.48; 95% CI, 1.34-1.58), or pertussis (CIRR, 2.32; 95% CI, 1.85-2.91), similar to pneumonia and other respiratory pathogens (CIRR, 1.15; 95% CI, .99-1.34) and LRTI (CIRR, 0.79; 95% CI, .60-1.04), but lower than nonspecific respiratory infections (CIRR, 0.79; 95% CI, .73-.87). Adjusted HRs for recurrent wheeze or asthma after RSV hospitalization compared to injuries decreased from 2.37 (95% CI, 2.08-2.70) for 0 to <1 year to 1.23 (95% CI, .88-1.73) for 6 to <10 years for term-born children, and from 1.48 (95% CI, 1.09-2.00) to 0.60 (95% CI, .25-1.43) for preterm-born children. Sex, maternal smoking, LOS, CRF, and APGAR5 were independent risk factors. Infant RSV hospitalization is associated with recurrent wheeze and asthma hospitalization, predominantly at preschool age. If causal, RSV prophylaxis, including vaccines, may significantly reduce disease burden of wheeze and asthma.

Pharmacological Treatment in Patients with Advanced Heart Failure: Recommendations and Challenges

Heart failure is a highly prevalent condition, and a series of new therapies have emerged over the past years, improving patients’ survival and quality of life, simultaneously making its management more complex. When treating patients with advanced heart failure, that is, with persistent limiting symptoms and recurrent hospitalizations, it is usually even more challenging to manage cases, given that, in addition to frequently having characteristics that would exclude them from most clinical studies, they pose a series of difficulties [...]

Non-Invasive Assessment of Congestion by Cardiovascular and Pulmonary Ultrasound and Biomarkers in Heart Failure.

Worsening chronic heart failure (HF) is responsible for recurrent hospitalization and increased mortality risk after discharge, irrespective to the ejection fraction. Symptoms and signs of pulmonary and systemic congestion are the most common cause for hospitalization of acute decompensated HF, as a consequence of increased cardiac filling pressures. The elevated cardiac filling pressures, also called hemodynamic congestion, may precede the occurrence of clinical congestion by days or weeks. Since HF patients often have comorbidities, dyspnoea, the main symptom of HF, may be also caused by respiratory or other illnesses. Recent studies underline the importance of the diagnosis and treatment of hemodynamic congestion before HF symptoms worsen, reducing hospitalization and improving prognosis. In this paper we review the role of integrated evaluation of biomarkers and imaging technics, i.e., echocardiography and pulmonary ultrasound, for the diagnosis, prognosis and treatment of congestion in HF patients.

Structural Inequities and Barriers to Accessing Kidney Healthcare Services in the United States: A Focus on Uninsured and Undocumented Children and Young Adults.

The population of children living in poverty and lacking healthcare insurance has increased in the United States of America in the last decade. Several factors have been responsible for this trend including illegal immigration, socioeconomic deprivation, young age, racial segregation, environmental degradation, and discriminatory housing policies. These systemic barriers have contributed to the exclusion of families from essential healthcare services. They are also contributory to the development of chronic illnesses (such as dialysis-dependent kidney disease) that are debilitating and frequently require considerable therapeutic resources. This unfortunate scenario creates a never-ending vicious cycle of poverty and diseases in a segment of society. For pediatric nephrologists, the challenges of caring for uninsured children with chronic kidney disease are all too familiar. Federally funded healthcare programs do not cover this patient population, leaving them the option of seeking care in emergency healthcare settings. Presentation with a critical illness often necessitates urgent placement of vascular catheters and the choice of acute hemodialysis. Adverse social environment influences the need for protracted chronic hemodialysis and a delay in kidney transplantation. Consequently, there is greater comorbidity, recurrent hospitalization, and a higher mortality rate. New policies should address the deficit in health insurance coverage while promoting social programs that will remove structural barriers to health care resources for undocumented children and young adults.

Assessing The Clinical Benefits Of Iv Iron-only In Heart Failure Patients: A Meta-analysis

<h3>Introduction</h3> The cost of heart failure (HF) continues to be a huge burden on the healthcare system, with recurrent hospitalizations and mortality being major contributors.¹ Iron deficiency (ID) is a commonly undertreated comorbidity in HF patients, despite research showing its association with increased mortality and hospitalization rates.² <h3>Objective</h3> We aim to perform a meta-analysis of randomized controlled trials (RCT) assessing the clinical benefits of treating iron deficiency in heart failure patients. <h3>Methods</h3> We searched Pubmed, Cochrane, EMBASE and NIH databases from 2005-2020. The result was limited to RCT's comparing intravenous (IV) iron-only to placebo, in HF patients with ID. We identified 7 RCT's for inclusion.^3-9 Intervention used in selected trials was IV iron (iron sucrose or ferric carboxymaltose). The primary outcome was the incidence of HF hospitalization, and the secondary outcome was all-cause mortality at maximum follow-up time. A random-effects model was used. The bias of included studies was assessed using the Cochrane bias assessment for RCT's. The analysis was performed using Cochrane Revman version 5.3. <h3>Results</h3> Seven studies were included, with 2,164 participants (1,167 IV Iron group, 997 Placebo group). There were no significant differences in the baseline characteristics of the groups. Follow-up time ranged from 12-52 weeks. Compared to placebo, IV iron significantly reduces the odds of HF hospitalization events in HF patients with ID (OR: 0.54; 95% CI: 0.32 to 0.91; p=0.02) [Figure 1]. Rates of all-cause mortality in the IV iron group were no different than in the placebo group (OR: 0.92; 95% CI: 0.68 to 1.24; p=0.60) [Figure 2]. <h3>Conclusion</h3> Treatment with IV iron compared to placebo significantly reduces the incidence of HF hospitalization in HF patients with ID. Conversely, there was no mortality benefit with using IV iron over placebo in HF patients with ID. Our study represents the largest number of meta-analyzed patients and expands on the recent meta-analysis by Osman et al.¹⁰ by including all types of HF (HFpEF and HFrEF) patients. Further study of the use of IV iron with longer follow-up time is needed to further explore the clinical benefits of IV iron in HF patients with ID.

Ventricular Assist Device (VAD) Implantation in a Patient with Complex Congenital Heart Disease (CHD)

<h3>Introduction</h3> VAD implantation in complex CHD patients presents physiologic and anatomic challenges. Few such cases have been described. <h3>Case Report</h3> We report a 41-year-old man with a history of dextrocardia, unbalanced atrioventricular (A-V) septal defect, single ventricle, heterotaxy with right atrial isomerism and asplenia, bilateral superior vena cava, pulmonic stenosis, and systemic hypertension. He had undergone surgical palliation including bilateral BT shunts (age 3 months and 7 years) and central aortopulmonary shunt at age 13 years. At age 14 years, he underwent bilateral bidirectional Glenn and extracardiac Fontan repair, followed by mechanical A-V valve replacement at age 21 years and epicardial pacemaker placement for paroxysmal atrial tachycardia (AT). He had recurrent heart failure hospitalizations requiring inotropes. Echocardiography now demonstrated moderate aortic regurgitation. Cardiac catheterization on milrinone and dobutamine found elevated Fontan pressures to 21 mmHg (panel A), reduced cardiac index to 1.4 L/min/m², normal pulmonary vascular resistance and no transhepatic gradient. An intra-aortic balloon pump was placed with improvement of his Fontan pressures to 17 mmHg. However, he subsequently developed refractory AT and cardiogenic shock. Due to cardiac deterioration, he underwent urgent HeartMate3 implantation and aortic valve repair with Park stitch (B: pre-op; C: post-op image) as a bridge to transplant. Surgical approach was an upper hemisternotomy and an anterior right thoracotomy at the 6th intercostal space. His course was complicated by postoperative bleeding requiring re-exploration of the chest, as well as acute kidney injury requiring temporary hemodialysis with subsequent renal recovery. He was transferred to acute rehab 3 weeks after surgery and was discharged home on guideline-directed medical therapy. <h3>Summary</h3> We report an adult patient with dextrocardia, Fontan repair, and single ventricle who underwent successful VAD implantation.

Association of Type of Oral Anticoagulant Dispensed With Adverse Clinical Outcomes in Patients Extending Anticoagulation Therapy Beyond 90 Days After Hospitalization for Venous Thromboembolism

Guidelines for managing venous thromboembolism (VTE) recommend at least 90 days of therapy with oral anticoagulants. Limited evidence exists about the optimal drug for continuing therapy beyond 90 days. To compare having prescriptions dispensed for apixaban, rivaroxaban, or warfarin after an initial 90 days of anticoagulation therapy for the outcomes of hospitalization for recurrent VTE, major bleeding, and death. This exploratory retrospective cohort study used data from fee-for-service Medicare (2009-2017) and from 2 commercial health insurance (2004-2018) databases and included 64 642 adults who initiated oral anticoagulation following hospitalization discharge for VTE and continued treatment beyond 90 days. Apixaban, rivaroxaban, or warfarin prescribed after an initial 90-day treatment for VTE. Primary outcomes included hospitalization for recurrent VTE and hospitalization for major bleeding. Analyses were adjusted using propensity score weighting. Patients were followed up from the end of the initial 90-day treatment episode until treatment cessation, outcome, death, disenrollment, or end of available data. Weighted Cox proportional hazards models were used to estimate hazard ratios (HRs) and 95% CIs. The study included 9167 patients prescribed apixaban (mean [SD] age, 71 [14] years; 5491 [59.9%] women), 12 468 patients prescribed rivaroxaban (mean [SD] age, 69 [14] years; 7067 [56.7%] women), and 43 007 patients prescribed warfarin (mean [SD] age, 70 [15] years; 25 404 [59.1%] women). The median (IQR) follow-up was 109 (59-228) days for recurrent VTE and 108 (58-226) days for major bleeding outcome. After propensity score weighting, the incidence rate of hospitalization for recurrent VTE was significantly lower for apixaban compared with warfarin (9.8 vs 13.5 per 1000 person-years; HR, 0.69 [95% CI, 0.49-0.99]), but the incidence rates were not significantly different between apixaban and rivaroxaban (9.8 vs 11.6 per 1000 person-years; HR, 0.80 [95% CI, 0.53-1.19]) or rivaroxaban and warfarin (HR, 0.87 [95% CI, 0.65-1.16]). Rates of hospitalization for major bleeding were 44.4 per 1000 person-years for apixaban, 50.0 per 1000 person-years for rivaroxaban, and 47.1 per 1000 person-years for warfarin, yielding HRs of 0.92 (95% CI, 0.78-1.09) for apixaban vs warfarin, 0.86 (95% CI, 0.71-1.04) for apixaban vs rivaroxaban, and 1.07 (95% CI, 0.93-1.24) for rivaroxaban vs warfarin. In this exploratory analysis of patients prescribed extended-duration oral anticoagulation therapy after hospitalization for VTE, prescription dispenses for apixaban beyond 90 days, compared with warfarin beyond 90 days, were significantly associated with a modestly lower rate of hospitalization for recurrent VTE, but no significant difference in rate of hospitalization for major bleeding. There were no significant differences for comparisons of apixaban vs rivaroxaban or rivaroxaban vs warfarin.

Revascularization in ischaemic heart failure with preserved ejection fraction: a nationwide cohort study.

Despite the common occurrence of coronary artery disease (CAD) and heart failure (HF) with preserved ejection fraction (HFpEF), there is limited evidence to guide revascularization. We investigated the long-term outcomes of coronary artery bypass grafting (CABG) in patients with HF and significant CAD across the spectrum of ejection fraction, using a large national cohort of patients from the Veteran Affairs (VA) Medical Centers in the US. Patients with HF were stratified into groups, HFpEF, HF with mid-range ejection fraction (HFmrEF), and HF with reduced ejection fraction (HFrEF) and compared to patients with no preoperative HF. We analysed 10 396 patients. Despite an increased hazard in the first year following revascularization, the long-term survival (median follow-up 6.6 years; interquartile range 3.7-10.1) of HFpEF post-CABG was similar to controls (hazard ratio 0.85, 95% confidence interval 0.68-1.06), but survival progressively declined with HFmrEF and HFrEF. Similar trends were seen with recurrent HF hospitalization with lower risk with baseline HFpEF (43.9 ± 6.9/100 patient-years) compared to HFmrEF (65.9 ± 3.8/100 patient-years) and HFrEF (93.4 ± 4.8/100 patient-years). Although HFpEF patients had lower mortality and HF hospitalization post-CABG compared to patients with a lower ejection fraction, they experienced the highest rates of future myocardial infarction. Although HFpEF patients with CAD have greater short-term risk post-CABG, their long-term survival is comparable to controls. However, they are at increased risk for HF hospitalizations and myocardial infarction. These data support the safety of CABG in HFpEF patients and suggest continuum of mortality risk for ischaemic HF when stratified by baseline ejection fraction before revascularization.