Similar In-hospital Mortality Research Articles

The Outcomes of Pulmonary Hypertension Patients With Severe Aortic Stenosis Who Underwent Surgical Aortic Valve Replacement or Transcatheter Aortic Valve Implantation

The outcomes for patients who undergo transcatheter aortic valve implantation (TAVI) and surgical aortic valve replacement (SAVR) with pulmonary hypertension (PH) is not well understood. We sought to evaluate the outcomes of patients with PH who underwent TAVI compared with SAVR. We identified patients who were diagnosed with PH and underwent TAVI SAVR for aortic valve stenosis in the National Inpatient Sample database who were admitted from 2011 to 2014. Propensity score matching was used to generate 2 matched cohorts for TAVI and SAVR and outcomes were compared using logistic regressions. A total of 36,786 patients were diagnosed with PH and had an intervention for aortic valve stenosis. Twenty six percent underwent TAVI (n = 9,560) and 74% underwent SAVR (n = 27,225). Patients in the TAVI group were older (81.0 vs 68.5, p <0.001) had more women (53.2% vs 45.4%) and less African-American patients (4.6% vs 8.3%; p <0.001 for both). Although both groups had comparable co-morbidities, the TAVI group had higher prevalence of congestive heart failure, chronic pulmonary disease, renal failure, peripheral vascular disease, coronary artery disease, and previous stroke compared with the SAVR group (p ≤0.002). After propensity-score-matching, patients with PH had no statistically significant difference in in-hospital mortality between for TAVI or SAVR procedures (5.6% vs 4.6%, odds ratio [OR] 1.23, confidence interval [CI] 0.92 to 1.66, p = 0.165). However, TAVI patients were less likely to have cardiac complications (15.4% vs 19.9%, OR 0.73, CI 0.61 to 0.87, p = 0.001) and respiratory complications (12.4% vs 25.1%, OR 0.42, CI 0.35 to 0.51, p <0.001). In conclusion, whereas patient with PH who underwent TAVI and SAVR had similar in-hospital mortality, TAVI was associated with lower cardiac, respiratory and bleeding complications compared with SAVR.

ICU Utilization for Patients With Acute Exacerbation of Chronic Obstructive Pulmonary Disease Receiving Noninvasive Ventilation

We investigated whether patients with chronic obstructive pulmonary disease could safely receive noninvasive ventilation outside of the ICU. Retrospective cohort study. Twelve states with ICU utilization flag from the State Inpatient Database from 2014. Patients greater than or equal to 18 years old with primary diagnosis of acute exacerbation of chronic obstructive pulmonary disease and secondary diagnosis of respiratory failure who received noninvasive ventilation. None. Multilevel logistic regression models were used to obtain hospital-level ICU utilization rates. We risk-adjusted using both patient/hospital characteristics. The primary outcome was in-hospital mortality; secondary outcomes were invasive monitoring (arterial/central catheters), hospital length of stay, and cost. We examined 5,081 hospitalizations from 424 hospitals with ICU utilization ranging from 0.05 to 0.98. The overall median in-hospital mortality was 2.62% (interquartile range, 1.72-3.88%). ICU utilization was not significantly associated with in-hospital mortality (β = 0.01; p = 0.05) or length of stay (β = 0.18; p = 0.41), which was confirmed by Spearman correlation (ρ = 0.06; p = 0.20 and ρ = 0.02; p = 0.64, respectively). However, lower ICU utilization was associated with lower rates of invasive monitor placement by linear regression (β = 0.05; p < 0.001) and Spearman correlation (ρ = 0.28; p < 0.001). Lower ICU utilization was also associated with significantly lower cost by linear regression (β = 14.91; p = 0.02) but not by Spearman correlation (ρ = 0.09; p = 0.07). There is wide variability in the rate of ICU utilization for noninvasive ventilation across hospitals. Chronic obstructive pulmonary disease patients receiving noninvasive ventilation had similar in-hospital mortality across the ICU utilization spectrum but a lower rate of receiving invasive monitors and probably lower cost when treated in lower ICU-utilizing hospitals. Although the results suggest that noninvasive ventilation can be delivered safely outside of the ICU, we advocate for hospital-specific risk assessment if a hospital were considering changing its noninvasive ventilation delivery policy.

Safe cross-clamp time using Custodiol®-histidine-tryptophan-ketoglutarate cardioplegia in the adult.

Safe cross-clamp time using single-dose Custodiol®-histidine-tryptophan-ketoglutarate cardioplegia has not been established conclusively. Immediate post-operative outcomes of 1,420 non-consecutive, cardiac surgery patients were reviewed retrospectively. Predictors of a combined endpoint made of in-hospital mortality and any major complication post-surgery were found with the multivariable method. Analysis of variance was used to evaluate the impact of cross-clamp time on most relevant complications. Discriminatory power and cut-off value of cross-clamp time were established for in-hospital mortality and each of the major complications (receiver operating characteristic curve analysis). A comparative analysis (with propensity matching) with multidose cold blood cardioplegia on in-hospital mortality post-surgery was performed in non-coronary surgery patients. Coronary, aortic valve and mitral valve surgery and surgery on thoracic aorta were performed in 45.4%, 41.9%, 49.5%, 20.6% of cases, respectively. In-hospital mortality and the rate of any major complication post-surgery were 6.5% and 41.9%, respectively. Cross-clamp time had significant impact on in-hospital mortality and almost all major post-operative complications, except neurological dysfunctions (p = 0.084), myocardial infarction (p = 0.12) and mesenteric ischaemia (p = 0.85). Areas under the receiver operating characteristic curve and the optimal cut-off values for in-hospital mortality and any major complication were of 0.657, 0.594, >140 and >127 minutes, respectively. Comorbidities-adjusted odds ratio for any major complication of cross-clamp time <127 minutes was 1.86 (p < 0.0001). Despite similar in-hospital mortality (p = 0.57), there was an earlier significant increase of mortality in Custodiol-HTK than in multidose cold blood propensity-matched, non-coronary surgery patients. The use of Custodiol-HTK cardioplegia is associated with a low risk of serious post-operative complications provided that cross-clamp time is of 2 hours or less.

Gastrointestinal Hemorrhage among LVAD Recipients. A Nationwide Inpatient Sample Study

Purpose Patients with left ventricular assist device (LVAD) have high incidence of gastrointestinal bleeding (GIB). We sought to investigate in-hospital outcomes of patients with LVAD who were admitted with GIB. Methods We utilized data from the National Inpatient Sample and the US Census Bureau to calculate annual national rates of GI bleeding admissions, in-hospital mortality, length of stay and hospitalization cost among LVAD patients with GIB for years 2011 to 2014. Results We identified 695 (weighted n=3440) LVAD patients admitted with GIB with LVAD and 5047 (weighted n=24,903) admitted without GIB. Patients with GIB were older (GIB: 62.5 years vs. non-GIB 57.99 years, P<0.0001) and higher comorbidity burden as assessed by Elixhauser score (GIB: 4.63 vs. non-GIB 3.96, P<0.0001). We found a small but statistically significant decline of in-hospital mortality among GIB patients (4.96% in 2011 vs. 3.85% in 2014, p=0.03). In-hospital mortality did not differ significantly between patients admitted with and without GIB (5% among GIB patients vs. 4.8 among non-GIB patients, p=0.8). Although length of stay was longer among GIB patients (10.7 days vs. 9.2 days, p=0.006), the total hospital cost did not differ significantly ($31768 for GIB vs $29345 for non-GIB, p=0.3). Conclusion In-hospital mortality from GIB among LVAD recipients decreased during the study period. GIB admissions were associated with similar in-hospital mortality and cost but slightly more prolonged length of stay compared with non-GIB admissions among LVAD recipients. Patients with left ventricular assist device (LVAD) have high incidence of gastrointestinal bleeding (GIB). We sought to investigate in-hospital outcomes of patients with LVAD who were admitted with GIB. We utilized data from the National Inpatient Sample and the US Census Bureau to calculate annual national rates of GI bleeding admissions, in-hospital mortality, length of stay and hospitalization cost among LVAD patients with GIB for years 2011 to 2014. We identified 695 (weighted n=3440) LVAD patients admitted with GIB with LVAD and 5047 (weighted n=24,903) admitted without GIB. Patients with GIB were older (GIB: 62.5 years vs. non-GIB 57.99 years, P<0.0001) and higher comorbidity burden as assessed by Elixhauser score (GIB: 4.63 vs. non-GIB 3.96, P<0.0001). We found a small but statistically significant decline of in-hospital mortality among GIB patients (4.96% in 2011 vs. 3.85% in 2014, p=0.03). In-hospital mortality did not differ significantly between patients admitted with and without GIB (5% among GIB patients vs. 4.8 among non-GIB patients, p=0.8). Although length of stay was longer among GIB patients (10.7 days vs. 9.2 days, p=0.006), the total hospital cost did not differ significantly ($31768 for GIB vs $29345 for non-GIB, p=0.3). In-hospital mortality from GIB among LVAD recipients decreased during the study period. GIB admissions were associated with similar in-hospital mortality and cost but slightly more prolonged length of stay compared with non-GIB admissions among LVAD recipients.

Cardiac Surgical Procedures with Concomitant vs. Staged Orthotopic Liver Transplant

Purpose In patients who require orthotopic liver transplant (OLT), cardiac surgery may be needed to optimize preoperative cardiac status for OLT. The aim of this systematic review was to evaluate patient characteristics and outcomes undergoing staged versus concomitant cardiac procedures with OLT. Methods An electronic search was performed to identify all case reports and series, from which patient-level data was extracted regarding cardiac procedures associated with OLT. After assessment for inclusion and exclusion criteria, 26 articles were pooled for systematic review. Results Overall, 49 patients were included in the analysis, of whom 12 (24%) underwent staged procedures and 37 (76%) underwent concomitant procedures. The median age was lower in the staged group [staged: 51.0 (IQR, 43.8-59.2) years vs. concomitant: 60.0 (IQR, 55.0-64.0) years, p=0.02]. Other baseline characteristics were comparable between the two groups. For staged procedures, the median time between heart procedures and OLT was 2 months. The most commonly reported cardiac procedures were coronary artery bypass graft (CABG) [staged: 4/12 (33.3%) vs. concomitant: 21/37 (56.8%), p=0.28], aortic valve replacement (AVR) [staged: 3/12 (25.0%) vs. concomitant: 19/37 (51.2%), p=0.21], and transcatheter aortic valve replacement (TAVR) [staged: 4/12 (33.3%) vs. concomitant: 0/37 (0%), p=0.002]. There was a significantly shorter post-OLT hospital stay for those who had staged procedures versus those who had concomitant procedures [staged: 8 (IQR, 5-13) days vs. concomitant: 17 (IQR, 14-24) days, p=0.007]. However, both groups had similar in-hospital mortality [staged: 1/12 (8.3%) vs. concomitant: 4/37 (10.8%), p=1.0]. Stratified survival between the two groups is shown in the figure. Conclusion Patients who underwent the staged approach had a shorter post-transplant hospital stay, but survival appeared comparable with respect to those who underwent concomitant cardiac procedures with OLT.

Use of Intra-Aortic Balloon Pump in Heart Failure Admissions Requiring Inotropic Support in the United States between 2004-2014

Purpose The utility of the intra-aortic balloon pump (IABP) in cardiogenic shock is debated in the heart failure (HF) community. We analyzed the nationwide usage and outcomes of IABP in patients admitted for HF exacerbation who required inotropic support, as well as the hospital cost incurred. Methods All hospitalizations of patients with class-IV HF symptoms (ICD-9 diagnosis codes 428.2-4x, 428.9x) and inotrope usage (ICD-9 procedure code 00.17) were identified from the 2004-2014 National Inpatient Sample. Within this cohort, patients with and without IABP (procedure code 37.61) were compared in terms of demographics, comorbidities, in-hospital mortality, length of stay (LOS), and cost of care. Results Use of IABP increased from 2004-2014 (p Conclusion HF patients requiring an IABP, who had more comorbidities and a far greater prevalence of cardiogenic shock than those with no IABP, showed similar in-hospital mortality and LOS. This additional benefit of IABP comes at a mean added cost of $74,230 for the hospitalization.

Elevated Vancomycin Trough Levels in a Tertiary Health System: Frequency, Risk Factors, and Prognosis

ObjectiveTo investigate the frequency of, risk factors for, and outcomes after elevated levels of vancomycin. Patients and MethodsWe identified hospitalizations among 21,285 individuals in which intravenous vancomycin was given between August 29, 2007, and October 10, 2014. We investigated frequency and risk factors for elevated vancomycin levels (trough levels >30 mg/L) as well as associations with subsequent acute kidney injury (AKI), length of stay, and in-hospital mortality. ResultsAmong the 21,285 patients, the mean age was 62.9 years, and 10,478 (49.2%) were female. Trough levels of vancomycin were checked in 7422 patients, and 755 elevated levels were detected. Compared with patients with trough levels checked but no elevated levels found, those with elevated levels had longer duration of vancomycin therapy (median, 6.0 days vs 3.4 days; P<.001) and slightly higher doses (mean, 1.72 g vs 1.58 g; P<.001). Patients with higher body mass index or lower estimated glomerular filtration rate had more elevated levels. In propensity-matched analyses, patients had higher risk of incident AKI after elevated levels compared with patients without elevated levels (hazard ratio, 1.55; 95% CI, 1.09-2.20; P=.02), as well as longer subsequent length of stay (relative risk, 1.14; 95% CI, 1.02-1.28; P=.03) but similar in-hospital mortality. ConclusionIn this study, elevated vancomycin levels were common, particularly in patients with higher body mass index and lower estimated glomerular filtration rate, and were associated with greater subsequent AKI and length of stay.

Electrocardiographic left ventricular hypertrophy is not associated with increased in-hospital adverse events in patients with first Non-ST segment elevation myocardial infarction: A single center study.

Background:There is conflicting data about prognostic implication of electrocardiographic (ECG) left ventricular hypertrophy (LVH) in patients with first non- ST-segment elevation myocardial infarction (NSTEMI). We aimed to examine the association of left ventricular hypertrophy (LVH) on admission electrocardiogram with adverse outcomes in patients with NSTEMI.Methods:In the present study, 460 patients (77.5% males with mean age of 65.44±13.15 years) with first NSTEMI were evaluated. ECG left ventricular hypertrophy (LVH) was diagnosed based on Sokolow-Lyon voltage criteria. Baseline laboratory and clinical results, angiographic data, as well as in- hospital adverse events were compared between the patients with and without LVH.Results:Electrocardiographic LVH was observed in 74 (16.1%) patients. Patients with LVH had higher admission systolic blood pressure (132.91±21.08 vs 125.80±21.78; P=0.01) and higher peak troponin (6.42±1.03 vs 4.41±0.28; P=0.004), but less likely to undergo coronary angiography (54.1% vs 66.8%; P=0.03) .Patients with electrocardiographic LVH had similar in-hospital mortality (5.4% vs 3.6%, P=0.5) and heart failure/ pulmonary edema (2.7% vs 2.07%, P=0.6) compared to patients without LVH.Conclusion:The present study showed that among the patients with first NSTEMI, electrocardiographic LVH was not associated with increased in-hospital adverse events.

Impact of type 2 diabetes mellitus on short- and long-term mortality after coronary artery bypass surgery

BackgroundType 2 diabetes mellitus (DM) is a frequent co-morbidity among patients undergoing coronary artery bypass grafting (CABG) surgery. The aim of this study was to evaluate the impact of DM on the early- and long-term outcomes of patients who underwent isolated CABG.MethodsWe performed an observational cohort study in a large tertiary medical center over a period of 11 years. All data from patients who had undergone isolated CABG surgery between 2004 and 2014 were obtained from our departmental database. The study population included 2766 patients who were divided into two groups: Group I (1553 non-diabetic patients), and Group II (1213 patients suffering from type 2 DM). Group II patients were then divided into two subgroups: subgroup IIA (981 patients treated with oral antihyperglycemic medications) and subgroup IIB (232 insulin-treated patients with or without additional oral antihyperglycemic drugs). In-hospital, 1-, 3-, 5- and 10-year mortality outcome variables were evaluated. Mean follow-up was 97 ± 41 months.ResultsIn-hospital mortality was similar between Group I and Group II patients (1.87% vs. 2.31%, p = 0.422) and between the subgroups IIA and IIB (2.14% vs. 3.02%, p = 0.464). Long-term mortality (1, 3, 5 and 10 years) was higher in Group II (DM type 2) compared with Group I (non-diabetic patients) (5.3% vs. 3.6%, p = 0.038; 9.3% vs. 5.6%, p < 0.001; 15.3% vs. 9.3%, p < 0.001 and 47.3% vs. 29.6% p < 0.001). Kaplan–Meier analysis demonstrated that all-cause mortality was higher in Group II compared with Group I (p < 0.001) and in subgroup IIB compared with subgroup IIA (p = 0.001). Multivariable analysis showed that DM increased the mortality hazard by twofold, and among diabetic patients, insulin treatment increased the mortality hazard by twofold.ConclusionsDiabetic and non-diabetic patients have similar in-hospital mortality rates. Survival rates of diabetic patients start to deteriorate 3 year after surgery. Type 2 DM is an independent predictor for long-term mortality after isolated CABG surgery. Mortality is even higher when the diabetes treatment strategy included insulin.

1257. Assessing Risk Factors for an Outbreak of Burkholderia cenocepacia in Non-cystic Fibrosis (CF) Patients

Background Burkholderia spp. have been associated with outbreaks of healthcare-associated infections in non-CF patients, mostly attributable to point sources of contaminated solutions or medications. Fewer non-point source outbreaks have been described.MethodsWe conducted a matched case:control (1:3) study to assess risk factors for B. cenocepacia during an outbreak that occurred in 2017 in a 738-bed university-affiliated hospital involving patients hospitalized on several ICUs and non-ICUs. Clinical isolates identified as B. cepacia complex were speciated using sequencing of the recA allele and genotyped by pulsed field gel electrophoresis (PFGE). Case subjects were patients with a positive culture for the B. cenocepacia outbreak strain (PFGE pattern 17-A, recA 365) from June 1–December 31, 2017. Control subjects had negative respiratory cultures for Burkholderia spp. within 10 days of respective cases’ culture dates and were hospitalized on the same unit at the same time as respective cases. Potential risk factors including procedures, devices, and medications (previously linked to point source outbreaks) were examined. A 5-day exposure window was studied for procedures and devices as this was the shortest interval noted between a case subject’s negative and first positive culture. Exact conditional logistic regression was used to analyze risk factors; Mann–Whitney U and Fisher’s exact tests were used to compare demographic and clinic characteristics of case and control subjects.ResultsSeventeen cases (all with positive respiratory tract cultures) and 41 unit-matched controls were studied. Case and control subjects had similar demographic characteristics, illness severity, and comorbidities. No point source was identified. Only exposure to invasive mechanical ventilation was associated with case status (OR: 10.5, [CI95 1.9, ∞), P = 0.0083). Cases had longer hospital lengths of stay (52 vs. 33 days, P = 0.02) than controls, but similar in-hospital mortality (24% vs.12%, P = 0.43).ConclusionThese findings suggest that suboptimal infection prevention and control practices related to respiratory interventions, including cleaning and disinfection of ventilators, may have contributed to the outbreak. Reinforcement of best practices helped reduce transmission of the outbreak clone.Disclosures All authors: No reported disclosures.

Heparin-induced thrombocytopaenia diagnostic testing after adult cardiac surgery: a single-centre experience and development.

To assess the incidence and outcome of heparin-induced thrombocytopaenia (HIT) in patients after cardiac surgery on cardiopulmonary bypass (CPB) and to review the time course of platelet counts and the use of different immunological diagnostic tests. All patients ≥18 years of age who underwent CPB from 2006 to 2015 and who were postoperatively admitted to our cardiac intensive care unit (ICU) were included in this retrospective study. Screening for heparin/platelet factor-4 antibodies was performed using an antibody test, which was later replaced with a screening test specific for IgG antibodies without IgA/IgM cross-reactivity. The enzyme immunoassay (EIA) for the detection of antibodies of all immunoglobulin classes against heparin/PF4 complexes was replaced with an IgG-specific EIA. HIT was confirmed by a heparin-induced platelet aggregation test until 2014. Among 4978 patients admitted between 2006 and 2015, 539 (11%) patients were evaluated for HIT. Patients were excluded because of age <18 years (n = 9), non-cardiac surgery without CPB (n = 10) or incomplete data (n = 3). Of the remaining 517 patients, 43 (8.3%) patients were HIT-positive. HIT incidence was 0.86%. The proportion of HIT-positive patients was similar in men and women (8.4% and 8.2%, respectively). Men and women with suspected HIT also had similar in-hospital mortality (odds ratio ≈ 1; P = 0.926). The incidence of HIT was lower in our study than previously reported. Novel immunological tests have improved to specifically detect IgG antibodies. Furthermore, they are able to detect anti-protamine antibodies, which may be present in patients with high clinical probability of testing negative for HIT. Incidence and clinical relevance of heparin/protamine antibodies will be subjects of future investigation.

Post-operative Bleeding Increases the Rate of Right Ventricular Failure and In-Hospital Mortality after LVAD Implantation

Purpose Surgical bleeding in the immediate post-operative period presents a frequent challenge in the management of LVAD recipients. We hypothesized that implementing an aggressive approach to surgical hemostasis would reduce the rate of early mortality. Methods We conducted a single-center retrospective review of 78 patients who underwent LVAD implantation between 9/13/11 and 8/24/17. Logistic regressions were utilized to estimate the odds ratio for RVAD requirement and in-hospital mortality based on risk factors of six-hour chest tube output and return to operating room for bleeding. Chest tube output of greater than 600 cc in the first six hours was considered to be significant. Results When comparing chest tube outputs in the first six hours, there were no significant differences in age, gender, heart failure etiology, or device type in patients with >600 cc and those with lower outputs. Greater than 600 cc chest tube output in the first six hours was an independent predictor for RVAD requirement (15.2% vs. 2.3%, p=0.04) and in-hospital mortality (24.2% vs. 4.7%, p=0.012) than those with lower outputs. Patients who returned to the operating room for bleeding complications experienced a similar in-hospital mortality rate (17.6% vs. 9.3%, p=0.28) but had a higher RVAD requirement (14.7% vs. 2.3%, p=0.04). Multivariate analysis showed a statistical significance for in-patient mortality in patients with chest tube output >600 cc in the first 6 hours (p = 0.013). There was a close correlation between the amount of chest tube output during the first six hours and the risk of in-hospital mortality ( Figure 2 ). Conclusion Minimizing the degree of post-operative bleeding after LVAD surgery may result in a reduced rate of right ventricular failure and in-hospital mortality. These findings suggest that efforts should be undertaken to identify surgical strategies for achieving improved hemostasis at the time of implantation.

Highlights From the Circulation Family of Journals.

Highlights From the Circulation Family of Journals.

Clinical End Points of Transcatheter Aortic Valve Implantation Compared With Surgical Aortic Valve Replacement in Patients

It is unknown if transcatheter aortic valve implantation (TAVI) is a safe alternative to surgical aortic valve replacement (SAVR) in patients <65 years old. Data from the National Inpatient Sample database were utilized. Patients from 2011 to 2015, ages 18 to 64 years old (inclusive) who underwent TAVI and SAVR were included. Patients who underwent SAVR and who also received a concomitant nonaortic valve surgery were excluded. A propensity score analysis was used. A total of 18,970 (528 TAVI and 18,442 SAVR) patients were identified. Patients who underwent TAVI were older (57 ± 7 vs 54 ± 10 years old, p <0.001) with more frequent co-morbidities. Overall in-hospital mortality was similar between TAVI and SAVR (odds ratio [OR] = 0.52, p = 0.12). Postprocedure stroke (OR = 0.50, p = 0.24), acute kidney injury (OR = 0.98, p = 0.89), acute myocardial infarction (OR = 0.48, p = 0.08), and vascular complication requiring surgery (OR = 0.20, p = 0.11) were similar between patients who underwent TAVI and SAVR. Bleeding requiring transfusion (OR = 0.32, p <0.01) was less frequent in patients who underwent TAVI, but new pacemakers (OR = 1.7, p = 0.02) were more frequent in these patients. Patients who underwent TAVI had shorter hospital stays (7.9 vs 10.0 days, p <0.001) and were more likely to be discharged to home. Cost between TAVI and SAVR was similar ($49,014 vs $42,907, respectively, p = 0.82). In the <65 years old patient population, TAVI also conferred similar overall in-hospital mortality compared with patients who underwent SAVR. TAVI resulted in fewer major complications, shorter hospital stay, and more frequent discharge to home, but higher rates of pacemaker implantation compared with SAVR. Therefore, TAVI appears to be a safe alternative to SAVR in patients <65 years old.

Transcatheter Versus Surgical Aortic Valve Replacement in Patients With Prior Coronary Artery Bypass Grafting: Trends in Utilization and Propensity-Matched Analysis of In-Hospital Outcomes.

A significant proportion of patients requiring aortic valve replacement (AVR) have undergone prior coronary artery bypass grafting (CABG). Reoperative heart surgery is associated with increased risk. Data on relative utilization and comparative outcomes of transcatheter (TAVR) versus surgical AVR (SAVR) in patients with prior CABG are limited. We queried the 2012 to 2014 National Inpatient Sample databases to identify isolated AVR hospitalizations in adults with prior CABG. In-hospital outcomes of TAVR versus SAVR were compared using propensity-matched analysis. Of 147 395 AVRs, 15 055 (10.2%) were in patients with prior CABG. The number of TAVRs in patients with prior CABG increased from 1615 in 2012 to 4400 in 2014, whereas the number of SAVRs decreased from 2285 to 1895 (Ptrend<0.001). There were 3880 records in each group in the matched cohort. Compared with SAVR, TAVR was associated with similar in-hospital mortality (2.3% versus 2.4%; P=0.71) but lower incidence of myocardial infarction (1.5% versus 3.4%; P<0.001), stroke (1.4% versus 2.7%; P<0.001), bleeding complications (10.6% versus 24.6%; P<0.001), and acute kidney injury (16.2% versus 19.3%; P<0.001). Requirement for prior permanent pacemaker was higher in the TAVR cohort, whereas the incidence of vascular complications and acute kidney injury requiring dialysis was similar in the 2 groups. Average length of stay was shorter in patients undergoing TAVR. TAVR is being increasingly used as the preferred modality of AVR in patients with prior CABG. Compared with SAVR, TAVR is associated with similar in-hospital mortality but lower rates of in-hospital complications in this important subset of patients.

Myocardial revascularization among patients with severe left ventricular dysfunction: a comparison between on-pump beating-heart and off-pump coronary artery bypass grafting

Objective: To evaluate the impacts of an on-pump beating-heart versus an off-pump coronary artery bypass grafting (CABG) technique for surgical revascularization on the early clinical outcomes in patients with a left ventricular ejection fraction (EF) of 35% or less. Methods: A total of 216 consecutive patients with an echocardiographic estimated EF of 35% or less who underwent non-emergency, primary, isolated CABG from January 2010 to December 2014 at Department of Cardiovascular Surgery, Zhongshan Hospital, Fudan University were included in this study and were divided into either an OBCAB group (patients who received on-pump beating-heart CABG surgery, n=88) or an OPCAB group (patients who received off-pump CABG surgery, n=128). The early clinical outcomes were investigated and compared. The outcomes were compared between groups by t-test, χ2 test or Fisher's exact test, when appropriate. Results: No significant differences emerged between the two groups in baseline characteristics of the entire cohort except for more patients with diabetes and a larger left ventricular endo-diastolic diameter in the OBCAB group. Patients in the OBCAB group compared to the OPCAB group had a similar in-hospital mortality (3.4% vs. 4.7%, P= 0.741). Mean EF, as measured preoperatively and early postoperatively (before discharge), significantly improved from (31.0±2.8)% to (35.6±2.9)% (t=10.61, P=0.000) in the OBCAB group and from (31.0±2.9)% to (34.8±3.3)% (t=9.68, P=0.000) in the OPCAB group, respectively. The improvement of mean LVEF in the OBCAB group was significantly higher than that in the OPCAB group ((4.7±0.2)% vs. (3.6±0.3)%, t=29.53, P=0.000). Patients in the OBCAB group compared to the OPCAB group had a significant higher early postoperative EF ((35.6±2.9)% vs.(34.8±3.3)%, t=1.892, P=0.034) but shared a similar baseline EF ((31.0±2.8)% vs. (31.0±2.9)%, t=0.012, P=0.930). Patients in the OBCAB group compared to the OPCAB group received a greater number of grafts and an increased amount of drainage during the first 24 h (3.7±0.8 vs. 2.8±0.6, t=9.442, P=0.000; (715±187) ml vs. (520±148) ml, t=8.544, P=0.000, respectively), without evidence of worse in-hospital mortality or major postoperative morbidity. Conclusion: The on-pump beating-heart technique may be an acceptable alternative to the off-pump technique for surgical revascularization in patients with an estimated EF of 35% or less.

Effect of Race on the Incidence of Aortic Stenosis and Outcomes of Aortic Valve Replacement in the United States

ObjectiveTo assess the effect of race on the incidence of aortic stenosis (AS) and utilization and outcomes of aortic valve replacement (AVR). Patients and MethodsPatients older than 60 years hospitalized with a primary diagnosis of AS and those who underwent AVR between 2003 and 2014 were included. Adjusted and unadjusted incidence of AS-related hospitalizations, utilization rates of AVR, in-hospital morbidity and mortality, and resource utilization was compared between whites and African Americans (AAs). ResultsBetween January 1, 2003, and December 31, 2014, the incidence of AS-related admissions increased from 13 (95% CI, 12.8-13.2) to 26 (95% CI, 25.7-26.4) cases per 100,000 patient-years in whites and from 3 (95% CI, 3.5-3.8) to 9.5 (95% CI, 9.4-9.8) cases per 100,000 patient-years in AAs (P<.001). The incidence density ratio decreased from 4.3 (95% CI, 2.27-6.6) in 2003 to 2.7 (95% CI, 1.1-3.8) in 2014. The ratio of AVR to AS-related admissions was 11.3% in whites and 6.7% in AAs (P<.001). Crude in-hospital mortality after AVR was higher in AAs (6.4% vs 4.7%; P<.001). However, after propensity score matching, in-hospital morality after isolated AVR was not significantly different between AAs and whites (4.7% vs 3.7%; P=.12). African Americans also had longer hospitalizations (12±12 days vs 10±9 days; P<.001), higher rates of nonhome discharge (32.1% vs 27.2%; P=.004), and higher cost of hospitalization ($55,631±$37,773 vs $52,521±$38,040; P<.001). ConclusionsAfrican Americans undergo AVR less than whites. The underlying etiology of this disparity is multifactorial, but may be related to a lower incidence of AS in AAs. Aortic valve replacement is associated with similar risk-adjusted in-hospital mortality but higher cost and longer hospitalizations in AAs than in whites.

La insuficiencia tricúspide, y no la insuficiencia mitral, determina la mortalidad en pacientes que presentan insuficiencia mitral no grave previa a TAVI

Introduction and objectivesMany patients undergoing transcatheter aortic valve implantation (TAVI) have concomitant mitral regurgitation (MR) of moderate grade or less. The impact of coexistent tricuspid regurgitation (TR) remains to be determined. We sought to analyze the impact of moderate vs none-to-mild MR and its trend after TAVI, as well as the impact of concomitant TR and its interaction with MR. MethodsMulticenter retrospective study of 813 TAVI patients treated through the transfemoral approach with MR ≤ 2 between 2007 and 2015. ResultsThe mean age was 81 ± 7 years and the mean Society of Thoracic Surgeons score was 6.9% ± 5.1%. Moderate MR was present in 37.3% of the patients, with similar in-hospital outcomes and 6-month follow-up mortality to those with MR < 2 (11.9% vs 9.4%; P = .257). However, they experienced more rehospitalizations and worse New York Heart Association class (P = .008 and .001, respectively). Few patients (3.8%) showed an increase in the MR grade to > 2 post-TAVI. The presence of concomitant moderate/severe TR was associated with in-hospital and follow-up mortality rates of 13% and 34.1%, respectively, regardless of MR grade. Moderate-severe TR was independently associated with mortality (HR, 18.4; 95%CI, 10.2-33.3; P < .001). ConclusionsThe presence of moderate MR seemed not to impact short- and mid-term mortality post-TAVI, but was associated with more rehospitalizations. The presence of moderate or severe TR was associated with higher mortality. This suggests that a thorough evaluation of the mechanisms underlying concomitant mitral and tricuspid valve regurgitation should be performed to determine the best strategy for avoiding TAVI-related futility.Full English text available from:www.revespcardiol.org/en

ST Depression, No ST Change, or ST Elevation in Inferior Derivations: Which Has the Worst Outcomes in Acute Anterior Myocardial Infarction?

Objective: The combination of electrical phenomena and remote myocardial ischemia is the pathophysiological mechanism of ST segment changes in inferior leads in acute anterior myocardial infarction (MI). We investigated the prognostic value of ST segment changes in inferior derivations in patients with first acute anterior MI treated with primary percutaneous coronary intervention (PCI). Methods: In this prospective single-center analysis, we evaluated the prognostic impact of ST segment changes in inferior derivations on 354 patients with acute anterior MI. Patients were divided into the following 3 groups according to admission ST segment changes in inferior derivations: ST depression (group 1), no ST change (group 2), and ST elevation (group 3). Results: In-hospital multivariate analysis revealed notably high rates of in-hospital death for patients in group 3 compared to patients in group 2 (OR 2.5; 95% CI 1.6-7.6, p < 0.001). Group 1 and group 2 had similar in-hospital and long-term mortality rates. After adjusting for confounding baseline variables, group 3 had higher rates of 18-month mortality (HR 3.3; 95% CI 1.5-8.2, p < 0.001). Conclusion: In patients with a first acute anterior MI treated with primary PCI, ST elevation in inferior leads had significantly worse short-term and long-term outcomes compared to no ST change or ST segment depression.

Gender Differences in Presentation, Treatment, and In-Hospital Outcome of Patients Admitted With Heart Failure Complicated by Atrial Fibrillation (from the Get With the Guidelines—Heart Failure [GWTG-HF] Registry)

Almost 25% of patients with heart failure (HF) have coexisting atrial fibrillation (AF), the latter of which may increase morbidity and mortality. Despite the high prevalence of HF with concomitant AF, this subgroup of patients remains understudied. This study examines gender differences in presentation, treatment and in-hospital outcome of patients with HF and AF. The Get With the Guidelines-Heart Failure (GWTG-HF) database enrolled 6,496 patients with HF who presented to Cooper University Hospital from 2005 to 2012. Twenty-four percent (1,561 patients) had concomitant AF. Pearson chi-square tests and the Student T-tests were used to compare patient characteristics by gender. Multivariate logistic regression was used to predict in-hospital mortality. Six hundred sixty-nine (42.8%) patients with HF and AF were women. Women were older (p <0.001), had a higher ejection fraction (p <0.001), had systolic hypertension (p <0.001), and were more likely to have health insurance (p <0.001). Despite a higher CHADS2 score in women (p = 0.007), there was no gender difference in percent of anticoagulation medications prescribed before admission. Women were less likely to present with dizziness, lightheadedness, or syncope, and were more likely to be compliant with medications and diet recommendations before admission. Despite differences in presentation, co-morbidities, and therapy, in-hospital mortality was similar between men and women. Decreased appetite or early satiety predicted in-hospital mortality in women, whereas age, chest pain on admission, and decreased appetite or early satiety predicted in-hospital mortality in men. In conclusion, women presenting with HF complicated by AF clinically differ from men, but despite these differences, both groups shared similar symptom presentation and in-hospital mortality rates.