Significant Difference In In-hospital Mortality Research Articles

Effectiveness of pulmonary artery catheter monitoring for patients with cardiogenic shock of various causes: a systematic review and meta-analysis.

Cardiogenic shock is associated with significant morbidity and mortality. Invasive hemodynamic monitoring with pulmonary artery catheterization (PAC) can be useful in the assessment of changes in cardiac function and hemodynamic status; however, the benefits of PAC in the management of cardiogenic shock are not known well. We performed a systematic review and meta-analysis of observational studies and randomized controlled trials, comparing in-hospital mortality between PAC and non-PAC groups of cardiogenic shock patients with various underlying causes. Articles were obtained from MEDLINE, Embase, and Cochrane CENTRAL. We reviewed titles, abstracts, and full articles and evaluated the quality of evidence using the GRADE (Grading of Recommendations, Assessment, Development, and Evaluations) framework. We used a random-effects model to compare studies in terms of in-hospital mortality findings. We included twelve articles in our meta-analysis. Mortality among patients with cardiogenic shock was not significantly different between the PAC and the non-PAC groups [risk ratio (RR) 0.86, 95% confidence interval (CI): 0.73-1.02, I2=100%, P<0.01]. Two studies investigating cardiogenic shock caused by acute decompensated heart failure determined lower in-hospital mortality in the PAC group than in the non-PAC group (RR 0.49, 95% CI: 0.28-0.87, I2=45%, P=0.18). Six studies investigating cardiogenic shock of any cause determined lower in-hospital mortality in the PAC group than in the non-PAC group (RR 0.84, 95% CI: 0.72-0.97, I2=99%, P<0.01). There was no significant difference in in-hospital mortality between the PAC and non-PAC groups of patients with cardiogenic shock secondary to acute coronary syndrome (RR 1.01, 95% CI: 0.81-1.25, I2=99%, P<0.01). Overall, our meta-analysis demonstrated no significant association between PAC monitoring and in-hospital mortality among patients managed for cardiogenic shock. The use of PAC in the management of cardiogenic shock caused by acute decompensated heart failure was associated with lower in-hospital mortality, but there was no association between PAC monitoring and in-hospital mortality among patients with cardiogenic shock caused by acute coronary syndrome.

Outcomes of Transcatheter Aortic Valve Replacement in Patients With Concomitant Aortic Regurgitation

BackgroundThis study sought to evaluate outcomes of transcatheter aortic valve replacement (TAVR) in patients with moderate or greater aortic regurgitation (AR). MethodsThis was an observational study using an institutional database of TAVRs from November 2012 to April 2022. The study compared outcomes of TAVR in patients with isolated aortic stenosis (AS) vs patients with AS and concomitant AR (moderate or greater). Those patients with trace or mild AR were excluded. Clinical and echocardiographic outcomes were compared, with end points established by the Valve Academic Research Consortium 3. Kaplan-Meier survival estimation and Cox regression for mortality were performed. Competing-risk cumulative incidence estimates for heart failure readmissions were also compared. ResultsOf 3295 patients, 605 (53.4%) had severe AS with no AR and 529 (46.6%) had severe AS with moderate or severe AR. There were no significant differences in in-hospital mortality, length of stay, stroke, myocardial infarction, permanent pacemaker requirement, transfusion requirement, minor or major vascular complications, or 30-day readmissions between the 2 groups (P > .05). There were also no significant differences in annular dissection or rupture, coronary obstruction, or device embolization. Mean gradient and paravalvular leak rates at 30 days and 1 year were similar between the groups. Survival estimates were comparable, and, on multivariable Cox regression, mixed aortic valvular disease was not associated with an increased hazard of death as compared with isolated AS (hazard ratio, 1.01; 95% CI, 0.81-1.25; P = .962). Cumulative incidence estimates for heart failure readmissions were comparable between groups. ConclusionsTAVR can be safely performed in patients with mixed valvular disease, with outcomes comparable to those in isolated AS.

Demographics and Clinical Outcomes of Culture-Positive versus Culture-Negative Pyogenic Liver Abscess in an Asian Population.

Despite its high case-fatality risk, pyogenic liver abscess (PLA) lacks clear management guidelines in patients with negative microbial cultures. Our aim was to evaluate differences in clinical characteristics between patients with culture-negative liver abscess (CNLA) and those with culture-positive liver abscess (CPLA), and identify differences in the main causative pathogen. In this study, we retrospectively collected medical records of PLA patients admitted to a teaching hospital from January 2010 to December 2019. In total, 324 PLA patients were enrolled in this study. Of these, 202 (62.3%) cases were confirmed cultural positive, including 109 patients (54%) and 20 (9.9%) patients infected with Klebsiella pneumoniae (K. pneumoniae) and Escherichia coli (E.coli), respectively. Patients in the CPLA group were older (p=0.029) and had higher prevalence of abscesses larger than 5 cm in diameter (p = 0.003), gas-forming rate (p = 0.016), and percutaneous drainage (p < 0.001) compared with CNLA group. Patients with CPLA had significantly longer hospitalizations than those with CNLA (p = 0.010). Nevertheless, there was no significant difference in in-hospital mortality between the two groups (p = 0.415). Compared with patients with E. coli, those with K. pneumoniae had higher incidence of diabetes mellitus (p = 0.041), solitary abscess (p < 0.001), localization in the right hepatic lobe (p = 0.033), abscess size larger than 5 cm (p < 0.001) and percutaneous drainage (p = 0.002), but mortality was not significantly different (p = 1.000). No significant difference in in-hospital mortality was found between patients with CNLA and those with CPLA group. However, clinical characteristics and management were different between the main causative pathogens, including K. pneumoniae and E. coli.

USE OF CEMENTED FEMORAL COMPONENT FOR REVISION IN PERIPROSTHETIC FEMORAL FRACTURES (PFF) IN THE ELDERLY

PFFs are an increasing burden presenting to the acute trauma services. The purpose of this study is to show that cemented revision for Vancouver B2/B3 PFFs is a safe option in the geriatric population, allows early pain-free weight bearing and comparable to a control-group of uncemented stems with regard to return to theatre and revision surgery.A retrospective review was conducted of all PFFs treated in a Level 1 trauma centre from 2015-2020. Follow up x-rays and clinical course through electronic chart was reviewed for 78 cemented revisions and 49 uncemented revisions for PFF. Primary endpoints were all cause revision and return to theatre for any reason. Secondary endpoints recorded mobility status and all-cause mortality.In the cemented group there were 73 Vancouver B2, 5 Vancouver B3 PFF; the mean age was 79.7 years and mean radiological follow-up of 11.9 months. In the cementless group there were 32 Vancouver B2 and 17 Vancouver B3 PFFs; with all 49 patients undergoing distally bearing uncemented revision, the mean age was 72.7 years and mean radiological follow-up of 21.3 months.Patients treated with a cemented prosthesis had significantly higher ASA score (2.94 -v- 2.43, p&lt;0.001). The primary endpoints showed that there was no significant difference in all cause revision 3/78 and 5/49 p=0.077, or return to theatre 13/78 -v- 12/49 p=0.142.Secondary endpoints revealed no significant difference in in-hospital mortality. The cementless group were more likely to be mobilising without any aid at latest follow-up 35/49 -v- 24/78 p&lt;0.001.The use of cemented revision femoral component in the setting of PFFs is one option in the algorithm for management of unstable PFFs according to the Vancouver classification. Evidence from this case-control study, shows that the all-cause revision and return to theatre for any cause was comparable in both groups.

Transfer status may not be associated with worse outcomes in elderly trauma patients

PurposeTo compare outcomes of elderly patients who arrive directly to a lead trauma centre to those who are transferred from a peripheral hospital. MethodsThis study used a retrospective cohort design and data obtained from the local trauma registry. The study population was patients 65 years and older who presented with an Injury Severity Score (ISS) of 12 or greater, or for whom the trauma team was activated, over a 10-year period. Patients were excluded from the study if they arrived direct from the scene and died within 3 hours of arrival, they were found to have no injuries, or they were directly admitted more than 2 days from the time of injury. Following the use of multiple imputation, multivariable logistic regression analysis was used to evaluate the relationship between in-hospital mortality and directness of transport, while adjusting for potentially confounding variables. ResultsOf the 1619 patients included in the analyses over half (54.2%) were transported directly from the scene of injury to the lead trauma hospital (LTH). The remaining 45.8% initially presented to a non-tertiary hospital and were later transferred to the LTH. Crude mortality was 18.7% in the direct group and 14.0% in the transfer group (p = 0.015). The unadjusted odds of death for patients arriving to LTH by referral was 0.71 (95% confidence interval, 0.54, 0.93), compared to patients arriving to the LTH directly. After adjustment for age, ISS, presence of severe head injury, Charlson Comorbidity Index, shock, initial GCS, and ICU admission from the emergency department, the mortality risk did not differ significantly for transferred patients compared to those arriving directly (OR = 0.77 (95% confidence interval, 0.54, 1.09). ConclusionThere was no significant difference in in-hospital mortality between elderly patients transported directly to the trauma centre and those who were transferred from peripheral hospitals.

Analysis of Care and Outcomes for Epistaxis Weekend Admissions

To study differences in care of patients admitted for epistaxis during the weekend compared to the weekday. Retrospective database review. 2003 to 2014 National Inpatient Sample. Patients admitted for a primary diagnosis of epistaxis were extracted from the National Inpatient Sample from 2003 to 2014. Univariate and multivariate analyses were applied to assess differences in patient demographics, clinical characteristics, treatment, and outcomes between weekend and weekday admissions. A total of 39,329 cases were included in our study cohort, with 28,458 weekday admissions and 10,892 weekend admissions. There was no significant difference in patient race, gender, insurance status, hospital ownership status, or location between weekend and weekday admissions (p > .05). Most weekend admissions were emergent (82.2%) and were treated with packing (51.8%). Upon performing logistic regression, the likelihood of emergent admission (odds ratio [OR] 1.41, 95% confidence interval [CI] 1.32-1.51, p < .001) and prolonged length of stay (OR 1.11, 95% CI 1.05-1.17, p < .001) was higher for weekend admissions versus weekday admissions. Moreover, odds of packing for epistaxis were significantly higher (OR 1.14, 95% CI 1.09-1.19, p < .001) on the weekend, while odds of ligation (OR 0.88, 95% CI 0.80-0.97, p = .013) and endovascular arterial embolization (OR 0.74, 95% CI 0.65-0.84, p < .001) were lower. There were no significant differences in in-hospital mortality, patient discharge disposition, and total hospital charges (p > .05). Patients primarily admitted for epistaxis over the weekend were more likely to be emergent, experienced prolonged length of stay, and be treated nonoperatively with packing, than weekday admissions. No significant differences in patient insurance or hospital ownership were identified.

The Clinical Application of Ultra-Fast-Track Cardiac Anesthesia in Right-Thoracoscopic Minimally Invasive Cardiac Surgery: A Retrospective Observational Study

The purpose of this study was to investigate the effect of ultra-fast-track cardiac anesthesia (UFTCA) on rapid postoperative recovery in patients undergoing right-thoracoscopic minimally invasive cardiac surgery. A retrospective observational study. A single large teaching hospital. A total of 153 patients who underwent right-thoracoscopic minimally invasive cardiac surgery between January 2021 and August 2021 were enrolled. The inclusion criteria were American Society of Anesthesiologists grade I to III, New York Heart Association (NYHA) cardiac function class I to III, and age ≥18 years. The exclusion criteria were NYHA class IV, local anesthetic allergy, severe pulmonary hypertension (pulmonary arterial systolic pressure, PASP >70 mmHg), age ≤18 years or ≥80 years old, emergency surgery, and patients with incomplete or missing data. Finally, a total of 122 patients were included and grouped by different anesthesia strategies. Sixty patients received serratus anterior plane block-assisted ultra-fast- track cardiac anesthesia (UFTCA group), and 62 patients received conventional general anesthesia (CGA group). The primary outcomes were lengths of hospital stay and postoperative intensive care unit (ICU) stay. The secondary outcomes were postoperative pain scores, opioids use, postoperative chest tube drainage, and complications. The intraoperative dosages of sufentanil and remifentanil in the UFTCA group were significantly lower than those in the CGA group (66.25 ± 1.03 µg v 283.31 ± 11.36 µg, p < 0.001; and 1.94 ± 0.38 mg v 2.14 ± 0.99 mg, p < 0.001, respectively). The incidence of postoperative rescue analgesia in the UFTCA group was significantly lower than that in the CGA group (10 patients [16.67%] v 30 patients [48.38%], p < 0.001). In the postoperative ICU, there were fewer patients with pain score Numeric Rating Scale ≥3 in the UFTCA group than that in the CGA group (10 patients [16.67%] v 29 patients [46.78%], p < 0.001). The postoperative extubation time in the UFTCA group was shorter than that in the CGA group (0.3 hours [range, 0.25-0.4 hours] v 13.84 hours [range, 10.25-18.36 hours], p < 0.001). Lengths of ICU stay and hospital stay in the UFTCA group were shorter than those in the CGA group (27.73 ± 16.54 hours v 61.69 ± 32.48 hours, p < 0.001; and 8 days [range, 7-9] v 9 days [range, 8-12], p < 0.001, respectively). Compared with the CGA group, the patients in the UFTCA group had less chest tube drainage within 24 hours after surgery (197.67 ± 13.05 mL v 318.23 ± 160.10 mL, p < 0.001). There were no significant differences in in-hospital mortality, postoperative bleeding, or secondary surgery between the 2 groups. The incidences of postoperative nausea, vomiting, or atelectasis were comparable between the 2 groups. Serratus anterior plane block-assisted ultra-fast-track cardiac anesthesia can promote rapid postoperative recovery in patients with right-thoracoscopic minimally invasive cardiac surgery. This anesthesia regimen is clinically safe and feasible.

Extracorporeal Life Support for Cardiogenic Shock in Octogenarians: Single Center Experience.

The age limit for the use of extracorporeal membrane oxygenation (ECMO) support for post-cardiotomy cardiac failure is not defined. The aim of the study was to evaluate the outcomes of octogenarians supported with ECMO due to cardiogenic shock. A retrospective review of consecutive elderly patients supported with ECMO during a 13-year period in a tertiary care center. Patient's demographic variables, comorbidities, perioperative data and outcomes were collected from patient medical records. Data of octogenarian patients were compared with the septuagenarian group. The main outcomes of the study was in hospital mortality, 6-month survival and 1-year survival after hospital discharge and discharge options. Multivariate logistic regression analysis was performed to identify the factors associated with hospital survival. Eleven patients (18.3%) in the elderly group were octogenarians (aged 80 years or above), and forty-nine (81.7%) were septuagenarians (aged 70-79 years). There were no differences except age in demographic and preoperative variables between groups. Pre ECMO SAVE, SOFA, SAPS-II and inotropic scores were significantly higher in septuagenarians than octogenarians. There was no statistically significant difference in hospital mortality, 6-month survival, 1 year survival or discharge options between groups. ECMO could be successfully used in selected octogenarian patients undergoing cardiac surgery to support a failing heart. An early decision to initiate ECMO therapy in elderly post-cardiotomy shock patients is associated with favorable outcomes.

Impact of sex on in-hospital mortality and 90-day readmissions in patients undergoing transcatheter mitral valve replacement (TMVR): Analysis from the nationwide readmission database.

To evaluate sex differences in in-hospital mortality and 90-day readmission rates among patients undergoing transcatheter mitral valve replacement (TMVR) in the United States of America. Women have higher rates of mortality and rehospitalization than men following many cardiac procedures. TMVR has grown as an alternative to mitral valve surgery for patients at high surgical risk. The rates of TMVR mortality and rehospitalization by sex are unknown. We analyzed the Nationwide Readmissions Database (NRD) from 2016 to 2019 to identify hospitalizations for TMVR. Sex differences in in-hospital mortality and 90-day readmissions were determined using logistic regression models. Between 2016 and 2019, 4109 hospitalizations for TMVR were identified, comprised of 1758 (42.8%) men and 2351 (57.2%) women. The median age was 74 years for both men and women. There was no significant difference in in-hospital mortality during index hospitalization (6.51% vs. 6.69%;p = 0.852) and all-cause 90-day readmission (28.19% vs. 29.59%;p = 0.563) between men and women. Across the study period, trend analysis did not reveal a significant change in in-hospital mortality (men p = 0.087, women p = 0.194) or 90-day readmission rates (men p = 0.569, women p = 0.454). In patients undergoing TMVR, in-hospital mortalityand 90-day readmissions are similar between men and women. Between 2016 and 2019, TMVR in-hospital mortality and 90-day readmission rates remained unchanged. Further research is necessary to confirm these findings.

Urinary catheterization prior to PCI worsens clinical outcomes in patients with acute myocardial infarction

BackgroundIndwelling urethral catheters (IUCs) are used to measure urine volume, keep patients on bed rest, or keep the groin area clean in patients with acute myocardial infarction (AMI). However, the association between IUC use and in-hospital urinary-related complications is unknown. MethodsThis was a single-center retrospective analysis of 303 patients admitted to our hospital in 2018–2020 who had AMI without cardiogenic shock. An IUC was inserted in the emergency room upon initiation of invasive catheter treatment and removed as soon as possible. The primary outcome was in-hospital adverse urinary event (IHAUE), which consisted of in-hospital urinary tract infection and in-hospital gross hematuria. ResultsOf 303 patients, 243 patients (80.2 %) underwent IUC insertion. A lower proportion of patients with IUCs were male (72 % vs. 85 %, p = 0.044). A higher proportion had Killip classification 2 or 3 (13 % vs. 0 %, p = 0.003) or ST-elevation myocardial infarction (65 % vs. 32 %, p < 0.001). IHAUEs occurred significantly more commonly in patients with IUCs than without IUCs (11 % vs. 2 %, p = 0.023). Kaplan-Meier analysis showed that IHAUEs occurred more frequently in patients with IUCs than patients without IUCs (log-rank test p = 0.033). Furthermore, IUC use longer than the median of 2 days was associated with a higher odds ratio (OR) for IHAUE when compared with those without IUC use (OR, 3.65; 95 % confidence interval, 1.28–10.4; p = 0.015). There were no significant differences in in-hospital mortality by IUC status. ConclusionsIUC use is associated with a higher risk of IHAUEs in patients with uncomplicated AMI. Routine IUC use might not be recommended.

The obesity paradox in ST-segment elevation myocardial infarction patients: A meta-analysis.

The aim of this study was to investigate whether there was a difference in survival after initial percutaneous coronary intervention (PCI) among ST-segment elevation myocardial infarction (STEMI) patients with different body mass index (BMI). Literature retrieval was conducted on PubMed, Web of Science, Embase, CNKI, and Wanfang databases to obtain the published studies on the survival of STEMI patients with different BMI after initial PCI from the establishment of the database to 2022. All statistical analyses were performed using STATA16.0. Two hundred thirty-nine studies were retrieved, and 12 studies were eventually included. Meta-analysis showed that overweight patients [OR=0.66, 95% CI (0.58, 0.76), p < .001] and obese patients [OR=0.60, 95% CI (0.51, 0.72), p < .001] had lower in-hospital mortality than healthy-weight patients. Overweight patients [OR=0.66, 95% CI (0.58, 0.74), p < .001] and obese patients [OR=0.62, 95% CI (0.53, 0.72), p < .001] had lower short-term mortality than healthy-weight patients. In addition, overweight patients [OR=0.63, 95% CI (0.58, 0.69), p < .001] and obese patients [OR=0.59, 95% CI (0.52, 0.66), p < .001] also had lower long-term mortality than healthy-weight patients. There was no significant difference in in-hospital mortality [OR=1.06, 95% CI (0.89, 1.27), p > .05], short-term mortality [OR=1.04, 95% CI (0.89, 1.22), p > .05], and long-term mortality [OR=1.07, 95% CI (0.95, 1.20), p > .05] between overweight and obese patients. This meta-analysis confirmed an obesity paradox in STEMI patients following PCI. The obesity paradox exists in in-hospital, short-term, and long-term conditions.

253. Clinical Presentations of Hospitalized Adult Patients Infected with SARS-CoV-2 during the Omicron Variant Surge in South Florida

Abstract Background Patients infected with COVID-19 Omicron variant, may be hospitalized for reasons other than COVID-19 pneumonia. We describe the clinical presentations of hospitalized adult patients with COVID-19 Omicron variant in a large healthcare system in South Florida. Methods Laboratory-confirmed COVID-19 adult patients hospitalized during January 1-14, 2022 were retrospectively reviewed. Clinical presentations were divided into one of three admission groups: COVID-19 pneumonia or respiratory infection (Group 1), severe extrapulmonary manifestations of COVID-19 (Group 2), and completely incidental diagnosis of COVID-19 (Group 3). Risks of in-hospital mortality and intensive care admission were estimated using logistic regression models. Results Among 500 consecutively hospitalized COVID-19 Omicron patients, the median age was 69 (IQR, 53-80) years, and 271 (54.2%) were women. The most common comorbidities were hypertension (326; 65.5%), diabetes (160; 32%), and chronic kidney disease (120; 24%). 260 (52%) patients were fully vaccinated (defined as a patient who received 2-dose vaccines), and 32 (6.4%) were previously infected with COVID-19. 257(51.4%) patients were classified as Group 1, 82 (16.4%) in Group 2, and 161 (32.2%) in Group 3 (Figure 1). Compared to Group 3, patients in Group 1 and Group 2 had a higher risk for ICU admission, with odds ratios (ORs) of 7.45 (95% CI, 2.62-21.23; p&amp;lt; 0.001) and 4.84 (95% CI, 1.44-16.23; p=0.011), and for in-hospital mortality, with ORs of 27.76 (95% CI, 3.78-204.3; p=0.001) and 12.63 (95% CI, 1.49-106.78; p=0.020), respectively (Figure 2). In multivariable-adjusted models, patients in Group 1 remained at higher risk for ICU admission and in-hospital mortality compared to Group 3, while patients in Group 2 remained at a higher risk for ICU admission, but with no difference in in-hospital mortality compared to Group 3 (Figure 2). Figure 1.Clinical characteristics of consecutively hospitalized patients stratified by clinical presentations at admission.Figure 2.Crude (Upper panel) and multivariable-adjusted (Lower panel) odds ratios for ICU admission and in-hospital mortality from logistic regression models. Group 3 represents patients with a completely incidental diagnosis of COVID-19. The variables included in the final multivariable models were age, gender, history of hypertension, diabetes, chronic obstructive pulmonary disease, chronic kidney disease, coronary artery disease, malignancy, transplantation, HIV, vaccination status, and previous SARS-CoV-2 infection. Conclusion This case series illustrates the clinical presentations of hospitalized adult patients infected with the COVID-19 Omicron variant. Significant differences in in-hospital mortality and ICU admission exist when comparing patients admitted for a COVID-19 related respiratory infection to those admitted with a completely incidental COVID-19 diagnosis. Disclosures All Authors: No reported disclosures.

1116: THE IMPACT OF ADJUNCTIVE KETAMINE ON SEDATION REQUIREMENTS IN VENTILATED PATIENTS WITH COVID-19

Introduction: Patients infected with the SARS-CoV-2 virus (COVID-19) may develop acute respiratory distress syndrome, requiring mechanical ventilation. Reports suggest that these patients may have increased sedation requirements due to intensive mechanical ventilation needs, necessitating the evaluation of additional sedation, with limited guidance available. Due to multiple drug shortages, ketamine became an attractive adjunctive option to meet sedation goals. The primary objective of this study was to compare sedation and analgesic requirements in mechanically ventilated patients with COVID-19 who received continuous ketamine infusions with those who did not. Methods: A multi-center, retrospective cohort study was performed in adult patients with COVID-19 who were mechanically ventilated for at least 24 hours. Groups were allocated based on whether or not adjunctive continuous infusion ketamine was used. The primary outcome was a comparison of the sedation and analgesic agents and the median morphine equivalents (ME) required. Secondary outcomes included intensive care unit (ICU) and hospital length of stay (LOS), duration of mechanical ventilation, and in-hospital mortality. Results: A total of 1,757 patients were screened for inclusion. After exclusions, 40 patients in each group were included for analysis. More patients in the ketamine group received intravenous opiates (100% vs 80%, p < 0.01) and also had higher ME than the non-ketamine group (357 [276–440] vs 222 [141–294] mg ME daily, p < 0.01). There was also a greater LOS in the ketamine group in both the hospital (24 vs 16.5 days, p=0.01) and ICU (18.8 [12.6–27.9] vs 14.9 [7.1–18.7] days, p=0.04). The ketamine group also experienced longer intubation durations (14.5 [9.0–23.5] vs 8.0 [4.0–13.5] days, p=0.01). There were no significant differences in in-hospital mortality or average doses of propofol, midazolam, dexmedetomidine, or vasopressors between groups. Conclusions: Ketamine use was not associated with a decrease in opioid or sedation use in patients with COVID-19 who were mechanically ventilated. Additional studies are needed to assess the role of ketamine and its impact on sedation and analgesia requirements in COVID-19 positive patients.

Transcatheter versus surgical aortic valve replacement for stenotic bicuspid aortic valve: Systematic review and meta-analysis

ObjectivesBicuspid aortic valves have been excluded from randomized trials comparing transcatheter aortic valve replacement with surgical aortic valve replacement. We aimed to evaluate the outcomes of transcatheter aortic valve replacement versus surgical aortic valve replacement in patients with severe bicuspid aortic valve stenosis using a meta-analysis. MethodsMEDLINE and EMBASE were searched through March 2022 to identify observational studies comparing transcatheter aortic valve replacement and surgical aortic valve replacement for severe bicuspid aortic valve stenosis. Outcomes of interest were in-hospital outcomes, including all-cause mortality, stroke, vascular complication, permanent pacemaker implantation, acute kidney injury, blood transfusion, paravalvular leak, and all-cause mortality during follow-up. ResultsFour propensity score–matched studies and 54,047 patients (transcatheter aortic valve replacement, n = 3841; surgical aortic valve replacement, n = 50,206) yielding 3142 pairs using propensity score were included. Median follow-up periods were 21 to 24 months. There were no significant differences in in-hospital mortality (risk ratio, 0.69; 95% confidence interval, 0.40-1.20; P = .19) or stroke (risk ratio, 0.86; 95% confidence interval, 0.64-1.14; P = .29). Although transcatheter aortic valve replacement was associated with higher risks of permanent pacemaker implantation rate (risk ratio, 1.87; 95% confidence interval, 1.23-2.84; P = .0003), transcatheter aortic valve replacement was associated with lower risks of acute kidney injury (risk ratio, 0.58; 95% confidence interval, 0.38-0.88; P = .01) and transfusion (risk ratio, 0.25; 95% confidence interval, 0.21-0.29; P = .0001). There were no significant differences in in-hospital vascular complication, paravalvular leak, and all-cause mortality during follow-up. ConclusionsIn selected patients with severe bicuspid aortic valve stenosis, no significant differences in in-hospital mortality or stroke were observed between transcatheter aortic valve replacement and surgical aortic valve replacement. Further investigations with long-term follow-up and morphological features are warranted.

POST – CARDIOTOMY EXTRACORPOREAL LIFE SUPPORT IN OCTOGENARIANS: SINGLE CENTER EXPERIENCE

<h3>Background</h3> Recently extracorporeal membrane oxygenation (ECMO) is becoming the first line treatment option for post-cardiotomy cardiac failure. The age limit for the use of support is yet to be defined. The aim of our study was to evaluate outcomes of octogenarians supported with ECMO following cardiac surgery in our institution. <h3>Methods</h3> Retrospective review of consecutive elderly patients (age ≥ 70 years) supported with ECMO following surgery during 13 years period in a tertiary care center. Patient's demographic variables, comorbidities, pre-existing medical conditions, perioperative data and outcomes were collected from patient medical records. Data of octogenarian patients were compared with the septuagenarian patient group. The primary endpoint of the study was in-hospital mortality. <h3>Results</h3> Sixty patients in our study were ≥ 70 years old and were included in the final analysis as "elderly group". Eleven patients (18,3 %) in the elderly group were octogenarians (aged 80 years or above) and forty nine (81,7 %) were septuagenarians (aged 70 – 79 years). There was no difference except age in all demographic and preoperative variables between groups. In the majority of cases VA ECMO was initiated in the intensive care unit after surgery (n=37, 61,7 %) and 23 cases (38,3 %) were initiated in the operating room. Central cannulation was more common in septuagenarian group than octogenarian group (83,7 % vs 54,5 %, p = 0,034 respectively). The median duration of ECMO support was 148 (71 – 288) hours and was longer in septuagenarian group (178 (92 – 300) hours vs 70 (46 – 93) hours in octogenarian group, p = 0,007). Pre ECMO Save, SOFA, SAPS – II and inotropic scores were significantly higher in septuagenarians than octogenarians. Pre ECMO data are shown in Table 1. Thirty one patient (52 %) were successfully weaned form ECMO and 13 (22 %) patients survived to hospital discharge. There was no statistically significant difference in hospital mortality between groups (7 (64%) octogenarian group vs. 40 (82%) septuagenarian group, p = 0,19). <h3>Conclusion</h3> ECMO could be successfully used in selected octogenarian patients undergoing cardiac surgery to support failing heart function with acceptable survival rate. Further studies needed to evaluate long term outcomes.

Mechanical and oral antibiotics bowel preparation for elective rectal cancer surgery: A propensity score matching analysis using a nationwide inpatient database in Japan.

The best bowel preparation method for rectal surgery remains controversial. In this study we compared the efficacy and safety of mechanical bowel preparation (MBP) alone and MOABP (MBP combined with oral antibiotic bowel preparation [OABP]) for rectal cancer surgery. In this retrospective study we analyzed data from the Japanese Diagnosis Procedure Combination (DPC) database on 37 291 patients who had undergone low anterior resection for rectal cancer from 2014 to 2017. Propensity score matching analysis was used to compare postoperative outcomes between MBP alone and MOABP. A total of 37 291 patients were divided into four groups: MBP alone: 77.7%, no bowel preparation (NBP): 16.9%, MOABP: 4.7%, and OABP alone: 0.7%. In propensity score matching analysis with 1756 pairs, anastomotic leakage (4.84% vs 7.86%, P < 0.001), small bowel obstruction (1.54% vs 3.08%, P=0.002) and reoperation (3.76% vs 5.98%, P=0.002) were less in the MOABP group than in the MBP group. The mean duration of postoperative antibiotics medication was shorter in the MOABP group (5.2d vs 7.5d, P < 0.001) than in the MBP group. There was no significant difference between the two groups in the incidence of Clostridium difficile (CD) colitis (0.40% vs 0.68%, P=0.250) and methicillin-resistant Staphylococcus aureus (MRSA) colitis (0.11% vs 0.17%, P=0.654). There was no significant difference in in-hospital mortality between the two groups (0.00% vs 0.11% respectively, P=0.157). MOABP for rectal surgery is associated with a decreased incidence of postoperative complications without increasing the incidence of CD colitis and MRSA colitis.

Risk factors and outcomes associated with persistent vancomycin resistant Enterococcal Bacteremia

BackgroundPrior studies have identified that vancomycin resistant enterococcus (VRE) bacteremia that persists for four days or more is an independent predictor of mortality. Despite this, there is no published data to identify those patients at highest risk of developing persistent VRE bacteremia.MethodsThis was a single center, retrospective, case-control study of adult patients with a VRE bloodstream infection (BSI). Case patients were those with persistent bacteremia (≥ 4 days despite VRE-directed therapy) and control patients were those with non-persistent bacteremia. Logistic regression was used to assess risk factors associated with persistent VRE BSIs. Secondary outcomes included in-hospital mortality, recurrent bacteremia, and breakthrough bacteremia.ResultsDuring the study period, 24/108 (22%) patients had persistently positive blood cultures. Risk factors for persistent bacteremia included severe neutropenia (OR 2.13), 4 out of 4 positive index blood cultures (OR 11.29) and lack of source control (OR 11.88). In an unadjusted analysis, no statistically significant differences in in-hospital mortality (58% versus 40%; p = 0.121), recurrent bacteremia (17% versus 6%; p = 0.090), or breakthrough bacteremia (13% versus 7%; p = 0.402) were observed between groups.ConclusionPatients with severe neutropenia, 4 out of 4 positive index blood culture bottles, and lack of source control were more likely to develop persistent VRE bacteremia despite directed antibiotic treatment.

Abstract 11111: In-Hospital Outcomes of Coronary Atherectomy in Teaching vs Non-Teaching Hospitals

INTRODUCTION: Studies have analyzed contemporary data on outcomes at teaching vs non-teaching hospitals with the results found to be dissimilar in certain procedures in the United States. Coronary Atherectomy (CA) is a minimally invasive procedure that involves the opening of obstruction from heavily calcified blocked coronaries to improve blood flow to the heart. This study is set out to examine the differences in health care outcomes between teaching and non-teaching hospitals in patients who underwent CA using a nationally representative sample. METHODS: We reviewed data from the National Inpatient Sample (NIS) of patients admitted between 2016-2019. Using ICD-10 procedural codes, we identified patients who underwent CA (Rotational or Orbital) within the study period. We further categorized our study population into 2 groups based on teaching vs non-teaching status. Multivariate analysis was done to investigate the in-hospital outcomes between both groups and adjust for confounders. RESULTS: A total of 171,740 CA procedures were performed within the study period. 75% (129,585) vs 25% (42,155) of these procedures were performed in teaching vs non-teaching hospitals respectively. The mean age of patients who underwent the procedure was 65 years, with a higher preponderance in males (71.4%). There was no significant difference in in-hospital mortality in both groups (AOR 1.06, 95% CI 0.93 -1.21, p=0.372). There was also no observed difference in the odds of coronary perforation or cardiac tamponade (AOR 1.26, 95% CI 0.89-1.28 p=0.19) and (AOR 1.23, 95% CI 0.82-1.87, p=0.31) respectively. However, the teaching hospital groups had an increased odds of Coronary dissection (AOR 1.34, 95% CI 1.05 - 1.71, p=0.017) and heart Block (AOR 1.22, 95% CI 1.11-1.34, p&lt; 0.001). We also noticed an increased odds of septic shock (AOR 1.24, 95% CI 1.05-1.80, p= 0.018), AKI (AOR 1.12, 95% CI 1.07-1.22, p=0.005) and a higher hospitalization duration (Adjusted coefficient 0.43, 95% CI 0.30-0.56, p&lt; 0.001) in the teaching hospital group . CONCLUSION: CA performed at teaching hospitals is found to be associated with an increased risk of cardiac (coronary dissection and heart block) and non-cardiac (septic shock and AKI) outcomes.

Abstract 12740: Racial and Ethnic Disparities in Mortality in Patients Presenting With STEMI With COVID-19: NACMI Registry

Introduction: COVID-19 infection disproportionally impacts non-Whites with higher morbidity and mortality. However, differences by race and ethnicity in COVID-19 patients with concomitant STEMI have not been previously described. Methods: The North American COVID-19 STEMI (NACMI) registry is a prospective, observational registry enrolling COVID-19 patients with concomitant STEMI from 64 centers in Canada and the United States from March 2020 to December 2021. We compared clinical characteristics, treatment strategies, and in-hospital mortality risks by race/ethnicity. Results: Among 679 STEMI patients with concomitant COVID-19, 54.5% were White, 14.3% Black, 19.4% Hispanic/Latinx, and 11.8% Asian/Indigenous/Other. Blacks had the highest prevalence of current smokers, and Whites had the lowest prevalence of diabetes. The rate of high-risk features including cardiac arrest, cardiogenic shock, and inotropic support was comparable between the groups. Presence of infiltrates and cardiomegaly was higher in Blacks and Hispanic/Latinx; whereas, COVID-19 severity was similar in the groups. Blacks and Hispanic/Latinx and Blacks were more likely to not have coronary angiography performed. Among patients that underwent angiography, Whites and Hispanic/Latinx were more likely to be treated with primary PCI. In-hospital mortality was highest in Hispanic/Latinx (38%) and the Asian/Indigenous/Other group (Table). Conclusions: Despite no difference in high-risk features in patients with COVID-19 and STEMI, there was a significant difference in in-hospital mortality between Whites and non-Whites with highest risk in Hispanic/Latinx and Asian/Indigenous/Other. Further research in needed to explore discrepant outcomes in racial/ethnic minorities in this patient population and the role of discrepant management.

Dopamine versus norepinephrine as the first-line vasopressor in the treatment of cardiogenic shock.

Only a few observational studies using small patient samples and one subgroup analysis have compared norepinephrine and dopamine for the treatment of cardiogenic shock (CS). The objective of the present study was to investigate whether the use of norepinephrine was associated with improvements in clinical outcomes in CS patients compared to dopamine. We retrospectively reviewed hospital medical records of patients who were admitted to cardiac intensive care unit from 2012 to 2018. We included 520 patients with CS in this analysis. The primary outcome was in-hospital mortality, and serial hemodynamic data were also assessed. As a first-line vasopressor, dopamine was used in 156 patients (30%) and norepinephrine in 364 patients (70%). Overall, the norepinephrine group had significantly higher severity of shock, arrest at presentation, vital signs, and lactic acid than did the dopamine group at the time of vasopressor initiation. Nevertheless, in the norepinephrine group, additional vasopressor was required in 123 patients (33.8%), which was a significantly smaller percentage than the 92 patients (56.4%) in the dopamine group who required additional vasopressor (p < 0.001). There was no significant difference in in-hospital mortality between the two groups (26.9% and 31.9%, respectively, p = 0.26). In addition, the incidence of arrhythmia was not different between the two groups (atrial fibrillation, 12.2% vs. 15.7%, p = 0.30; ventricular tachyarrhythmia, 19.9% vs. 25.3%, p = 0.18). The use of norepinephrine as a first-line vasopressor was not associated with reductions of in-hospital mortality or arrythmia but could reduce use of additional vasopressors in CS patients.