Left Ventricular Hypertrophy Regression Following Transcatheter Aortic Replacement: A Comparison of Self-Expanding Versus Balloon-Expandable Prostheses.

There are limited reports on the impact of prosthesis-patient mismatch (PPM) on the regression of left ventricular hypertrophy (LVH) after transcatheter aortic valve replacement (TAVR). We compared the relative effects of supra-annular, self-expanding (SE) versus intra-annular, balloon-expandable (BE) prostheses on TAVR LVH regression. Regression of left ventricular mass index (LVMi) was evaluated in 168 consecutive TAVR patients, including 60 treated with SE valves (Evolut series) and 108 treated with BE valves (Sapien 3). All patients had LVH determined at baseline by echocardiography and had repeat LVMi measurements at a mean follow-up time of 707 ± 528 days. SE patients were more likely female (68.3% vs 46.3%, p = 0.007), but otherwise, the 2 cohorts did not differ with respect to baseline demographics and Society of Thoracic Surgeons risk score. SE patients had a higher effective orifice area indexed to body surface area after TAVR (0.98 ± 0.29 vs 0.86 ± 0.25 cm²/m², p = 0.006), with lower mean aortic valve gradients (9.9 ± 6.5 vs 12.8 ± 5.8 mm Hg, p = 0.003) and a lower prevalence of moderate/severe PPM (33.3% vs 49.1%, p = 0.049). On follow-up, changes in LVMi were similar between the SE and BE groups, with similar absolute changes in LVMi (19.2 ± 26.8 vs 21.9 ± 31.7 g/m2, p = 0.578) and relative LVMi decrease (14.0 ± 19.5 vs 16.2% ± 24.2%, p = 0.547). No difference in LVMi regression was also noted comparing combined SE/BE patients with moderate/severe PPM versus those without PPM. In conclusion, despite differences in effective orifice area indexed to body surface area, mean aortic valve gradient, and PPM after TAVR, the degree of LVH regression during intermediate follow-up did not differ between patients receiving supra-annular SE and intra-annular BE prostheses.

Spontaneous coronary artery dissection: a case series illustrating current challenges in diagnosis and treatment.

Spontaneous coronary artery dissection (SCAD) has been increasingly recognized in recent years as an important cause of acute coronary syndrome, myocardial infarction, and sudden death, especially among young women. However, due to the lack of clinical trials on SCAD, evidence-based guidance on management is currently lacking. Presented are four case studies that illustrate the recent insights and challenges in SCAD diagnosis and treatment.

Spontaneous coronary artery dissection (SCAD) is a condition where the layers of a coronary artery tear without any apparent cause. In recent years, it has become more recognized as an important cause of chest pain, heart attacks, and sudden death, especially in younger women. However, because of the lack of clinical trials focused on SCAD, there is insufficient evidence-based guidance on managing the condition. This article shares four cases to show the current knowledge and challenges in diagnosing and treating SCAD.

Community-level bystander treatment and outcomes for witnessed out-of-hospital cardiac arrest in the state of Connecticut.

Background: Prior reports have demonstrated underutilization of bystander cardiopulmonary resuscitation (CPR) and automated external defibrillator (AED) use in patients with witnessed out-of-hospital cardiac arrest (OHCA) in Connecticut. This study aimed to identify community-level risk factors that contribute to low rates of bystander intervention to improve statewide OHCA outcomes. Methods: We analyzed 2,789 adult patients with witnessed, non-traumatic OHCA submitted to the Connecticut Cardiac Arrest Registry to Enhance Survival (CARES) between 2013-2022. Patients were grouped by zip code, and associated municipal characteristics were acquired from 2022 United States Census Bureau data. Use of bystander CPR, attempted bystander AED defibrillation, and patient survival with favorable neurological function were determined for 19 of the 20 most populous cities and towns. Pearson correlation tests and linear regression were used to determine associations between OHCA treatment and outcomes with population size, racial/ethnic demographics, language use, income, and educational level. Results: Bystander CPR was lower in municipalities with population size > 100,000 and in communities where > 40% of residents are non-English-speaking. AED use was also lower in these municipalities, as well as those with per capita incomes < $40,000 or > 1/3 Hispanic residents. Communities with populations > 100,000, > 40% non-English-speaking, per capita income < $40,000, and > 1/3 Hispanic residents were all associated with lower survival rates. Conclusions: OHCA pre-hospital treatment and outcomes vary significantly by municipality in Connecticut. Community outcomes might be improved by specifically targeting urban population centers and Hispanic communities with culturally sensitive, low, or no-cost CPR and AED educational programs, using instructional languages other than English.

Impact of Small Aortic Annuli on the Performance of Transcatheter Aortic Valve Replacement Bioprostheses: An Updated Meta-Analysis of Recent Studies.

A metanalysis of available randomized controlled trials and observational studies comparing self-expanding (SE) and balloon-expandable (BE) bioprostheses in patients with small aortic annulus and aortic stenosis for short- and midterm hemodynamic and clinical outcomes was performed. A total of 21 studies with a total 8,647 patients (SE: n = 4,336 patients vs BE: n = 4,311 patients) were included. SE bioprostheses had a lower postoperative mean gradient at 30 days (Mean Difference [MD] -5.16, 95% confidence interval [CI] 4.7 to 5.5, p <0.001) and at 1 year (MD -6.6, 95%CI 6.1 to 7.03, p <0.001), with a larger indexed effective orifice area (0.17, 95% CI 0.13 to 0.22, p <0.001 and 0.17, 95% CI 0.08 to 0.27, p <0.001) at both time intervals. BE bioprostheses had a higher risk of 30-day and 1-year severe prosthesis-patient mismatch (risk ratio [RR] 1.07, 95% CI 1.04 to 1.09, p <0.001; RR 1.07, 95% CI 1.04 to 1.11, p <0.001). The 30-day and 1 year paravalvular leaks (RR 0.99, 95% CI 0.98 to 0.99, p <0.001; RR 0.89, 95% CI 0.82 to 0.95, p <0.001) and permanent pacemaker implantation (RR 0.97, 95% CI 0.94 to 0.99, p 0.01, I2 = 40%,) were lower in the BE group. BE bioprostheses were associated with a lower risk of in-hospital stroke (RR 0.99, 95% CI 0.98 to 1, p = 0.01). In conclusion, in patients with small aortic annulus and aortic stenosis, SE bioprostheses have superior hemodynamic performance but higher rates of paravalvular leak, permanent pacemaker implantation, and in-hospital stroke. BE bioprostheses were associated with a higher risk of severe prosthesis-patient mismatch.

Impact of Persistent Versus Paroxysmal Preoperative Atrial Fibrillation on In-Hospital, One-Year, and Late Clinical Outcomes Following Transcatheter Aortic Valve Implantation.

Previous reports on the impact of preexisting atrial fibrillation (AF) on clinical outcomes after transcatheter aortic valve implantation (TAVI) have presented limited data on the relative impact of paroxysmal versus persistent AF subtypes. We compared in-hospital, 1-year, and late clinical outcomes in 1,098 patients who underwent TAVI with preoperative AF (556 paroxysmal, 542 persistent) versus 1,787 patients without AF. The propensity-matched cohorts with AF (n = 643) and without AF (n = 686) did not differ with respect to baseline clinical characteristics, operative technique, or in-hospital TAVI complications. At 1-year, patients with AF had higher all-cause mortality (9.0% vs 6.1%, p = 0.046) and readmission rates (13.1 vs 8.8%, p = 0.014), with lower Kansas City cardiomyopathy questionnaire scores (77.8 ± 21.8 vs 84.3 ± 17.1, p <0.001). Echocardiographic follow-up (mean time 455 ± 285 days) demonstrated no significant intergroup differences in hemodynamic findings other than a progressive increase in left atrial volume index in patient subgroups (without AF: 37.4 ± 14.7 ml/m2 vs paroxysmal AF: 46.4 ± 21.4 ml/m2 vs persistent AF: 60.5 ± 26.3 ml/m2, p <0.001). On late follow-up (mean time 49.0 [45.1 to 52.9] months), patients with persistent AF had worse all-cause mortality than patients without AF (hazard ratio 1.55, 95% confidence interval 1.17 to 2.06, p = 0.003), with no significant survival differences between the paroxysmal AF and without AF subgroups. In conclusion, patients with preexisting AF and patients without AF who underwent TAVI had similar in-hospital outcomes but worse 1-year mortality, hospital readmission, and quality of life outcomes. Compared with patients without AF, patients with persistent but not paroxysmal preexisting AF have higher late all-cause mortality at a mean follow-up of 49 months. Patients with persistent AF have higher levels of left atrial volume index than patients with paroxysmal AF and patients without AF on intermediate echocardiographic follow-up.

Half-dose direct oral anticoagulation versus warfarin for atrial fibrillation following cardiac surgery.

BACKGROUND: Optimal anticoagulation strategies have not been defined for patients with atrial fibrillation following cardiac surgery. METHODS: From a total cohort of 228 patients with pre-existing or new onset atrial fibrillation following coronary artery bypass grafting and/or valve surgery, we compared in-hospital and 30-day outcomes in 119 patients treated with low-dose aspirin and a half-dose direct oral anticoagulant (DOAC) versus 109 treated with low-dose aspirin and warfarin. RESULTS: DOAC patients were older (73.1±7.0 vs. 68.7±11.4 years, P<0.001) and had a lower incidence of preoperative atrial fibrillation (37 [31.1%] vs. 69 [63.3%], P<0.001). Otherwise, the two cohorts were well matched for baseline demographics, cardiovascular risk factors, comorbidities, prior cardiac history and STS Risk Score. In comparison to Warfarin patients, DOAC patients had a shorter length of post-surgical stay (6 [5-8] vs. 7 [5-10] days, P=0.037). The two cohorts, however, had a similar incidence of stroke, transient ischemic attack, reoperation for bleeding and postoperative blood bank product usage. Follow-up 30-day outcomes did not differ between the two groups with respect to mortality (0 [0.0%] vs. 0 [0.0%], P=1.000) and hospital readmission (16 [13.4%] vs. 14 [12.8%], P=0.893), although two DOAC patients required drainage of sanguineous pericardial effusions. CONCLUSIONS: In comparison to warfarin, half-dose DOAC anticoagulation in patients with atrial fibrillation following cardiac surgery is associated with a shorter postoperative length of stay, without a significant increase in stroke/transient ischemic attack, reoperation for bleeding or postoperative blood product transfusion. Follow-up echocardiography in anticoagulated patients is recommended to rule out significant sanguineous pericardial effusions in the early postoperative period following hospital discharge.

The Benefit of Percutaneous Coronary Intervention Before Transcatheter Aortic Valve Replacement: A Multicenter Retrospective Outcome-Based Study.

There is inadequate evidence regarding the role of percutaneous coronary intervention (PCI) in patients who underwent transcatheter aortic valve replacement (TAVR). The current American Heart Association/American College of Cardiology guidelines are limited to class 2A recommendations for pre-TAVR revascularization in the setting of hemodynamically significant left main (LM), proximal left anterior descending (pLAD), or extensive bifurcation disease regardless of angina status. We performed a multicenter, retrospective, observational study assessing the benefit of PCI in patients with coronary artery disease who underwent transfemoral TAVR for severe symptomatic aortic stenosis. Patients were divided into 2 cohorts: (1) patients who did not undergo pre-TAVR PCI within the preceding 12 months (no-PCI group) and (2) patients who received pre-TAVR PCI within the preceding 12 months (PCI group). The primary outcome was defined as the composite end point of in-hospital and 30-day adverse events, including all-cause mortality, cardiac arrest, and myocardial infarction. Subgroup analyses were performed on patients with LM and/or pLAD disease and other high-risk features, including angina and heart failure. Comparisons were made between 1,809 consecutive patients (1,364 in the no-PCI group and 445 in the PCI group). There were no differences between the 2 cohorts regarding the primary composite outcome (2.0% vs 2.8%, p = 0.918) or individual secondary outcomes. Although LM/pLAD disease, New York Heart Association classes III to IV, and Society of Thoracic Surgeons risk score ≥8 were all independent predictors of the primary outcome, none of the subgroups demonstrated a benefit favoring PCI. In conclusion, there is no observed benefit from PCI within 12 months pre-TAVR in patients with severe aortic stenosis and concomitant coronary artery disease, including patients with LM/pLAD disease.

In-Hospital and One-Year Outcomes of Transcatheter Aortic Valve Replacement in Patients Requiring Supplemental Home Oxygen Use.

Background: There have been limited reports with inconsistent results on the impact of long-term use of oxygen therapry (LTOT) in patients treated with transcatheter aortic valve replacement (TAVR). Methods: We compared in-hospital and intermediate TAVR outcomes in 150 patients requiring LTOT (home O2 cohort) with 2,313 non-home O2 patients. Results: Home O2 patients were younger, and had more comorbidities including chronic obstructive pulmonary disease (COPD), diabetes, carotid artery disease, lower forced expiratory volume (FEV1) (50.3±21.1% vs. 75.0±24.7%, P < 0.001), and lower diffusion capacity (DLCO, 48.6±19.2% vs. 74.6±22.4%, P < 0.001). These differences represented higher baseline Society of Thoracic Surgeons (STS) risk score (15.5±10.2% vs. 9.3±7.0%, P < 0.001) and lower pre-procedure Kansas City Cardiomyopathy Questionnaire (KCCQ-12) scores (32.5 ± 22.2 vs. 49.1 ± 25.4, P < 0.001). The home O2 cohort required higher use of alternative TAVR vascular access (24.0% vs. 12.8%, P = 0.002) and general anesthesia (51.3% vs. 36.0%, P < 0.001). Compared to non-home O2 patients, home O2 patients showed increased in-hospital mortality (5.3% vs. 1.6%, P = 0.001), procedural cardiac arrest (4.7% vs. 1.0%, P < 0.001), and postoperative atrial fibrillation (4.0% vs. 1.5%, P = 0.013). At 1-year follow-up, the home O2 cohort had a higher all-cause mortality (17.3% vs. 7.5%, P < 0.001) and lower KCCQ-12 scores (69.5 ± 23.8 vs. 82.1 ± 19.4, P < 0.001). Kaplan-Meir analysis revealed a lower survival rate in the home O2 cohort with an overall mean (95% confidence interval (CI)) survival time of 6.2 (5.9 - 6.5) years (P < 0.001). Conclusion: Home O2 patients represent a high-risk TAVR cohort with increased in-hospital morbidity and mortality, less improvement in 1-year KCCQ-12, and increased mortality at intermediate follow-up.

Racial and ethnic disparities in the treatment and outcomes for witnessed out-of-hospital cardiac arrest in Connecticut.

BACKGROUND: Racial and ethnic disparities in the treatment and outcomes for witnessed out-of-hospital cardiac arrest (OHCA) in the United States have been previously described. We sought to characterize disparities in pre-hospital care, overall survival, and survival with favorable neurological outcomes following witnessed OHCA in the state of Connecticut. METHODS: We performed a cross-sectional study to compare pre-hospital treatment and outcomes for White versus Black and Hispanic (Minority) OHCA patients submitted from Connecticut to the Cardiac Arrest Registry to Enhance Survival (CARES) between 2013 and 2021. Primary outcomes included bystander CPR use, bystander automated external defibrillator (AED) use with attempted defibrillation, overall survival, and survival with favorable cerebral function. RESULTS: 2,809 patients with witnessed OHCA were analyzed (924 Black or Hispanic; 1885 White). Minorities had lower rates of bystander CPR (31.4% vs 39.1%, P = 0.002) and bystander AED placement with attempted defibrillation (10.5% vs 14.4%, P = 0.004), with lower rates of survival to hospital discharge (10.3% vs 14.8%, P = 0.001) and survival with favorable cerebral function (65.3% vs 80.2%, P = 0.003). Minorities were less likely to receive bystander CPR in communities with median annual household income >$80, 000 (OR, 0.56; 95% CI, 0.33-0.95; P = 0.030) and in integrated neighborhoods (OR, 0.70; 95% CI, 0.52-0.95; P = 0.020). CONCLUSIONS: Black and Hispanic Connecticut patients with witnessed OHCA have lower rates of bystander CPR, attempted AED defibrillation, overall survival, and survival with favorable neurological outcomes compared to White patients. Minorities were less likely to receive bystander CPR in affluent and integrated communities.

Recovery From the Impact of COVID-19 on Treatment Times and Clinical Outcomes of Patients With ST-Segment Elevation Myocardial Infarction: An Interim Analysis.

BACKGROUND: Previous studies have documented a negative impact of the COVID-19 pandemic on emergent percutaneous treatment of patients with ST-segment elevation myocardial infarction (STEMI), but few have examined recovery of healthcare systems in restoring prepandemic STEMI care. METHODS: Retrospective analysis was performed of data from 789 patients with STEMI from a large tertiary medical center treated with percutaneous coronary intervention between January 1, 2019, and December 31, 2021. RESULTS: For patients with STEMI presenting to the emergency department, median time from door to balloon was 37 minutes in 2019, 53 minutes in 2020, and 48 minutes in 2021 (P < .001), whereas median time from first medical contact to device changed from 70 to 82 to 75 minutes, respectively (P = .002). Treatment time changes in 2020 and 2021 correlated with median emergency department evaluation time (30 to 41 to 22 minutes, respectively; P = .001) but not median catheterization laboratory revascularization time. For transfer patients, median time from first medical contact to device changed from 110 to 133 to 118 minutes, respectively (P = .005). In 2020 and 2021, patients with STEMI had greater late presentation (P = .028) and late mechanical complications (P = .021), with nonsignificant increases in yearly in-hospital mortality (3.6% to 5.2% to 6.4%; P = .352). CONCLUSION: COVID-19 was associated with worsening STEMI treatment times and outcomes in 2020. Despite improving treatment times in 2021, in-hospital mortality had not decreased in the setting of a persistent increase in late patient presentation and associated STEMI complications.

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

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

Enhanced Recovery After Surgery Is Associated With Reduced Hospital Length of Stay after Urgent or Emergency Isolated Coronary Artery Bypass Surgery at an Urban, Tertiary Care Teaching Hospital: An Interrupted Time Series Analysis With Propensity Score Matching.

OBJECTIVE: To evaluate whether enhanced recovery after surgery (ERAS) was associated with reduced length of stay (LOS) after urgent or emergency coronary artery bypass graft surgery (CABG). DESIGN: A retrospective analysis of an institutional database for urgent or emergency isolated CABG before versus after ERAS. Propensity matching identified comparable subpopulations pre- versus post-ERAS. Interrupted time series analysis was used to evaluate LOS. SETTING: At a tertiary care teaching hospital. PARTICIPANTS: A total of 1,012 patients undergoing urgent or emergent CABG-346 from 2016 to 2017 (pre-ERAS), and 666 from 2018 to 2020 (post-ERAS). Emergent CABG was performed within 24 hours, and urgent CABG was performed during the same hospitalization to reduce clinical risk. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Propensity-matched post-ERAS (n = 565) versus pre-ERAS patients (n = 330) demonstrated reduced LOS (9 [8-13] v (10 [8-14] days p = 0.015), increased likelihood of extubation within 6 hours (46.0% v 35.8%, p = 0.003), shorter ventilation time (6.3 [5.1-10.2] v (7.2 [5.4-12.2] hours, p = 0.003), reduced morphine milligram equivalent use on postoperative days 1 and 2 (69.6 ± 62.2 v 99.0 ± 61.6, p < 0.001), and increased intraoperative ketamine use (58.8% v 35.2%, p < 0.001). There were no differences regarding reintubation, intensive care unit readmission, or 30-day morbidity. Adjusted segmental regression (n = 1,012) for LOS demonstrated reduced mean LOS of approximately 2 days after ERAS (ß2 coefficient -1.943 [-3.766 to -0.121], p = 0.037), with stable trends for mean LOS and no change in slope throughout the pre-ERAS and post-ERAS time periods. CONCLUSIONS: Enhanced recovery after surgery was associated with reduced LOS after urgent or emergency CABG without adverse effects on prolonged ventilation, reintubation, intensive care unit readmission, or 30-day outcomes.

Impact of Ticagrelor Versus Clopidogrel on Bleeding Outcomes of Isolated Coronary Artery Bypass Grafting.

BACKGROUND: Increased bleeding risks have been documented in patients exposed to P2Y12 inhibitors within 5 days of coronary artery bypass surgery (CABG). This study aimed to determine the relative CABG bleeding risks of clopidogrel versus ticagrelor exposure and the proper time course of ticagrelor discontinuation prior to surgery. METHODS: Clinical outcomes were assessed in 2075 isolated CABG patients, including 375 who had received P2Y12 inhibitors within 5 days of surgery (155 clopidogrel, 213 ticagrelor, 7 prasugrel). BARC-4 CABG bleeding complications and perioperative blood product usage were assessed in propensity-matched P2Y12-inhibited and non-P2Y12-inhibited cohorts. RESULTS: P2Y12-inhibited patients (n = 375) in comparison to matched non-P2Y12-inhibited patients (n = 1138) had higher rates of re-operation for bleeding (3.8 % vs 1.3 %, p = 0.003), postoperative red blood cell transfusion ≥5 units (5.7 % vs 2.7 %, p = 0.007), and intraoperative and postoperative blood product utilization (42.3 % vs 27.1 %, p < 0.001; 41.8 % vs 32.2 %, p < 0.001, respectively). Univariate predictors of BARC-4 bleeding included clopidogrel (OR: 2.145, 95 % CI: 1.131-4.067, p = 0.019) and ticagrelor discontinued within 3 days of surgery (OR: 2.153, 95 % CI: 1.003-4.169, p = 0.049). Multivariate logistic regression demonstrated that only clopidogrel exposure was an independent BARC-4 bleeding predictor (OR: 1.850, 95 % CI: 1.007-3.398, p = 0.048). Unadjusted ticagrelor patients with drug discontinuation 4-5 days prior to CABG only demonstrated higher rates of perioperative platelet transfusion, without additional signs of excessive bleeding. CONCLUSIONS: Clopidogrel exposure within 5 days of CABG is an independent predictor of BARC-4 bleeding, whereas major ticagrelor bleeding effects are confined to drug exposure within 3 days of surgery.

Transcarotid Versus Transfemoral Transcatheter Aortic Valve Replacement (from a Propensity-Matched Comparison).

Previous reports comparing transcarotid (TC) versus transfemoral (TF) approaches for patients undergoing transcatheter aortic valve replacement have had inconsistent conclusions. We compared in-hospital and 1-year clinical outcomes, changes in quality of life, and direct hospital costs for 138 TC versus 1,926 TF procedures. Propensity matching based on the Society of Thoracic Surgery Predicted Risk of Mortality was used to compare 130 patients who underwent TC with 813 patients who underwent TF. Matched TC versus TF cohorts did not differ with respect to in-hospital mortality (0.0% vs 1.4%, p = 0.380), stroke (2.3% vs 2.5%, p = 0.917), major vascular complications (0.8% vs 2.2%, p = 0.268), composite bleeding complications (4.6% vs 6.4%, p = 0.647), requirement for permanent pacemaker (14.6% vs 12.9%, p = 0.426), postoperative hospital length of stay (3.3 ± 3.4 vs 3.1 ± 3.3 days, p = 0.467), or direct hospital costs ($52,899 ± 9,560 vs $50,464 ± 10,997, p = 0.230). Similarly, at 1-year, patients who underwent TC versus patients who underwent TF did not differ with respect to all-cause mortality (7.6% vs 6.4%, p = 0.659), hospital readmission (20.0% vs 23.9%, p = 0.635), or quality of life as measured by the Kansas City Cardiomyopathy Questionnaire score (84.0 ± 17.1 vs 88.4 ± 13.9, p = 0.062). Patients who underwent TC and TF did not differ with respect to in-hospital complications, length of hospital stay, and direct hospital costs, as well as 1-year mortality, readmission, and quality of life. These data add to ongoing support for the TC approach as the optimal alternative access for patients with transcatheter aortic valve replacement deferred from a transfemoral approach.

Propensity-matched comparison of right mini-thoracotomy versus median sternotomy for isolated mitral valve repair.

BACKGROUND: A right mini-thoracotomy (RT) versus median sternotomy (MS) approach for isolated mitral valve (MV) repair has been associated with less postoperative morbidity, shorter hospital stay, and faster functional recovery, but with consistently longer cross-clamp time and higher operative costs. METHODS: We assessed the impact of a modified operative technique on outcomes in 158 RT versus 129 MS patients treated with myxomatous MV repair from 2016 through 2021. Propensity matching based upon the Society of Thoracic Surgeons Risk Score was used to compare 108 patients in each cohort. RESULTS: Propensity-matched RT patients had reductions in total ventilation time (P=0.025), postoperative atrial fibrillation (P=0.019), and hospital length of stay (P<0.001). RT and MS patients had similar cross-clamp times (66.4±13.7 vs 64.8±16.0 minutes, P=0.414), with less overall leaflet resection (32.4% vs 57.4%, P<0.001) and fewer Gore-Tex NeoChords implanted per patient (1.7±0.7 vs 2.1±1.0, P=0.028) in the RT group. The two cohorts did not differ with respect to 30-day major surgical complications. No patient died and there was no difference between the two groups with respect to freedom from re-operation (98.2% vs 98.2%, P=0.800) at a mean follow-up of 21.4±18.5 months. Direct total hospital costs were lower for the RT group (P=0.018), with reductions in postoperative charges offsetting increased operating room costs. CONCLUSIONS: In this single-center study, the RT compared to the MS approach for myxomatous MV repair resulted in less postoperative morbidity and shorter hospital length of stay, with similar cross-clamp time, reduced total hospital costs, and comparable intermediate outcomes.

Enhanced Recovery After Surgery Is Associated With Improved Outcomes and Reduced Racial and Ethnic Disparities After Isolated Coronary Artery Bypass Surgery: A Retrospective Analysis With Propensity-Score Matching.

OBJECTIVES: To evaluate whether enhanced recovery after surgery (ERAS) protocol implementation was associated with improved outcomes and decreased racial and ethnic outcome disparities after isolated coronary artery bypass graft (CABG) surgery. DESIGN: A retrospective analysis of an institutional CABG database with propensity-score matching. SETTING: At a single tertiary care teaching hospital. PARTICIPANTS: One thousand seven hundred thirty-five patients undergoing isolated CABG: 656 patients from 2016 to 2017 (pre-ERAS) and 1,079 patients from 2018 to 2020 (post-ERAS). Each patient cohort was divided into a White subgroup and a racial and ethnic minorities (Minorities) subgroup. INTERVENTIONS: None MEASUREMENTS AND MAIN RESULTS: Propensity-matched post-ERAS patients (n = 584) compared to pre-ERAS patients (n = 584) demonstrated reductions in total length of stay (LOS) (median [interquartile range]): (7 [5-10] v 8 [6-11.5] days, p = .006), postoperative LOS (5 [4-7] v 5 [4-7] days, p = .001), total ventilation time (6.1 [4.8-9.5] v 6.6 [5.2-10.9] hours, p = .004), postoperative morphine milligram equivalents (mean ± standard deviation: 68.6 ± 57.5 v 100.0 ± 59.4, p < .001), and increased likelihood of early extubation (48.8% v 42.3%, p = .026); the Minorities subgroup demonstrated reductions in likelihood of intensive care unit (ICU) readmission (1.3% v 8.1%, p = .012) and postoperative morphine milligram equivalents (73.6 ± 64.0 v 107.8 ± 71.9, p < .001). Logistic regression models demonstrated that disparities in ICU readmission and postoperative LOS between White and Minorities patients were eliminated post-ERAS. CONCLUSIONS: ERAS for isolated CABG surgery was associated with reduced total and postoperative LOS, reduced total ventilation time, and increased early extubation for all patients, as well as reduced ICU readmission for the Minorities subgroup. ERAS implementation was associated with reduced disparities between White and racial and ethnic minority patients for ICU readmission and postoperative LOS.

Outcomes of Transcatheter Aortic Valve Replacement in Patients Treated With Systemic Steroids.

BACKGROUND: Chronic steroid therapy is associated with higher vascular complication rates in patients undergoing transcatheter aortic valve replacement (TAVR). The effect of corticosteroids on aortic annular complications has not been directly assessed in this population. METHODS: A retrospective analysis of 1095 patients undergoing transfemoral TAVR was performed. Patients treated with chronic steroids at the time of the procedure (n = 99) were compared with those who received no steroids (n = 992). The primary outcome included a composite of aortic annular complications, defined as a combination of aortic annular rupture, aortic dissection/perforation, and left ventricular perforation. RESULTS: The primary outcome was significantly higher in the steroid group (4.0% vs 0.5%; P<.01). This finding was primarily driven by higher rates of acute annular rupture in the steroid group (2.0% vs 0.2%; P=.04). Steroid use was associated with higher rates of intraoperative cardiac arrest (5.1% vs 1.5%; P=.03), device capture/retrieval (4.0% vs 0.8%; P=.01), and emergent conversion to open heart surgery (4.0% vs 0.6%; P<.01). There were no differences with respect to in-hospital mortality, stroke, myocardial infarction, need for permanent pacemaker, bleeding complications, minor vascular complications, hospital length of stay, hospital 30-day readmission, or 30-day echocardiographic findings. Additionally, within the steroid group, there were no significant differences between balloon-expandable vs self-expanding TAVR prostheses with respect to composite aortic annular complications. CONCLUSION: Chronic steroid therapy increases the risk of aortic annular complications in patients undergoing TAVR, with detrimental consequences including intraoperative cardiac arrest and conversion to open heart surgery. Steroid use should be considered in patient selection and determination of procedural technique for TAVR.

The impact of asthma on in-hospital outcomes of COVID-19 patients.

OBJECTIVE: The impact of asthma as a possible risk factor for adverse clinical outcomes in patients diagnosed with COVID-19 remains controversial. The purpose of this study was to examine the impact of asthma on adverse clinical outcomes in a COVID-19 hospitalized cohort. METHODS: Retrospective, propensity-matched observational study of consecutive COVID-19-positive patients between February 24, 2020, and November 3, 2020 at a single health care system. RESULTS: In the initial population of 1925 patients, 4.4% presented with asthma. Propensity score matching reduced the total sample to n = 1045: 88 (8.4%) with asthma and n = 957 without asthma. A total of 164 (15.7%) patients died during the hospitalization, including 7 (8.0%) in the asthma group and 157 (16.4%), p = .037, in the non-asthmatic cohort. There was no difference between these groups in need for mechanical ventilation, length of stay on a ventilator, or hospital length of stay.Logistic regression analysis demonstrated that asthma was an independent predictor of lower mortality, while older age, BMI > 30 kg/m2, heart failure, chronic kidney disease, and admission National Early Warning Score (NEWS) were significantly associated with an increased risk of in-hospital death. There were no significant differences between asthmatic and non-asthmatic cohorts with respect to need for mechanical ventilation, length of mechanical ventilation, serum markers of severe COVID-19 disease, or overall length of hospital stay. CONCLUSION: We conclude that asthma in hospitalized COVID-19 patients is associated with a lower risk of mortality and no increase in disease severity in hospitalized COVID-19 patients.

Racial and Ethnic Disparities in the Use of Transcatheter Aortic Valve Replacement in the State of Connecticut.

BACKGROUND: Although prior national reports have identified trends in the underutilization of transcatheter aortic valve replacement (TAVR) in Afro-American and Latino populations, racial and ethnic healthcare disparities in TAVR use in the State of Connecticut have not been previously reported. METHODS: We conducted a retrospective analysis of 1461 patients undergoing TAVR at our institute between from 2012 to 2020. Baseline demographics, procedural characteristics, clinical outcomes, median incomes and insurance coverage were compared between 1417 Caucasian and 44 minority patients, including 23 patients designated as Afro-American and 10 designated as Latino. Demographics of TAVR utilization at our institution were further compared to 6 additional Connecticut TAVR centers using Connecticut Hospital Association (CHA) ChimeData detailing hospital discharges for DRG 266 and 267. RESULTS: In comparison to Caucasian patients, minority cohorts were younger (75.7 ± 9.0 vs 81.5 ± 5.1 years, p < 0.001) and had more co-morbidities including diabetes (64% vs 34%, p < 001), coronary artery disease (95% vs 78%, p = 0.039), end stage renal disease requiring dialysis (9% vs 3%, p = 0.009) and atrial fibrillation (77% vs 62%, p = 0.041). The two groups did not differ with respect to other risk factors or co-morbidities, baseline echocardiographic or CTA findings, STS risk score, or procedural technique. Minority patients had a longer length of hospital stay (9.5 ± 9.0 vs 6.4 ± 6.9 days, p = 0.003), but did not differ with respect to procedural complications. Socioeconomic differences between the two groups included lower median incomes and higher rates of Medicaid or no insurance coverage for minority versus Caucasian patients. CHA ChimeData revealed a similar underutilization of TAVR in minority subgroups in the remaining 6 Connecticut TAVR centers. CONCLUSIONS: Despite statewide demographics describing 10.7% and 15.7% of the total population as Afro-American and Latino, respectively, only 3.0% of the total TAVR procedures performed at a large Connecticut health care facility were performed in minority subgroups. Despite having a higher burden of co-morbidities, minority patients had similar outcomes compared to Caucasian patients. Similar racial and ethnic disparities in TAVR utilization were confirmed statewide using CHA ChimeData.