Analysis of Trends and Outcomes of 90 and 180 Day Readmissions After Left Ventricular Assist Device Implantation.

Despite decreasing morbidity and mortality in left ventricular assist device (LVAD) recipients, readmission after implantation remains a major problem. Our aim was to investigate the trends and outcomes of 90 and 180 day readmission in this population. The National Readmission Database from 2012 to 2017 was queried to identify LVAD recipients. A total of 5,907 adults (90 day readmissions) and 3,653 adults (180 day readmissions) who survived LVAD implantation during the index admission were included in our analysis. Readmissions occurred in 45.6% and 65.1% by 90 and 180 days, respectively, with most readmissions occurring within the first 20 days. During the study period, mortality at index admission and readmission rate after discharge from index admission remained stable, whereas mortality during the readmission declined overtime both at 90 and 180 days. Heart failure was the most common cause for readmission (both 90 and 180 days), while its incidence also increased over the years. Among the reasons for readmission, intracranial bleeding, ischemic stroke, and device thrombosis were associated with highest mortality and gastrointestinal bleeding with the lowest. Intracranial bleeding, device thrombosis, and device infection were associated with longer length of stay. Multivariate logistic regression models identified gastrointestinal bleeding, length of stay during index admission, and end-stage renal disease requiring hemodialysis as risk factors of readmissions. Our study has unveiled several important factors associated with readmission and mortality. Approaches to identify and prevent readmissions early after LVAD implantation by addressing these factors may lead to lower morbidity, healthcare cost related to readmission, and improved quality of life.

Racial disparities in in-hospital outcomes after left ventricular assist device implantation.

BACKGROUND: Previous studies of patients undergoing various cardiac surgeries demonstrated worse outcomes among African-American (AA) patients. It remains unclear if the race is a predictor of outcomes among left ventricular assist device (LVAD) recipients. METHODS: Patients who underwent LVAD implantation between 2010 and 2017 were identified using the National Inpatient Sample. The race was classified as Caucasians vs AA vs Hispanics, and endpoints were in-hospital outcomes, length of stay, and cost. Procedure-related complications were identified via the International Classification of Diseases-9 (ICD-9) and ICD-10 coding and analysis performed via mixed-effect models. RESULTS: A total of 27 132 adults (5114 unweighted) underwent LVAD implantation in the U.S. between 2010 and 2017, including Caucasians (63.8%), AA (23.8%), and Hispanics (6%). The number of LVAD implantations increased in both Caucasians and AA during the study period. AA LVAD recipients were younger, with higher rates of females and mostly comorbidities, but lower rates of coronary artery disease and bypass grafting compared to Caucasians and Hispanics. Medicaid and median income at the lowest quartile were more frequent among AA LVAD recipients. We did not identify differences in stroke, bleeding complications, tamponade, infectious complications, acute kidney injury requiring hemodialysis, and in-hospital mortality among racial groups. AA LVAD recipients had lower rates of routine discharge than Caucasians and Hispanics, longer length of stay than Caucasians, but similar cost of hospitalization. After adjustment for clinical comorbidities, race was not a predictor of in-hospital mortality. CONCLUSION: We identified differences in clinical characteristics but not in in-hospital complications among LVAD recipients of a different races.

Meta-Analysis Evaluating the Effects of Renin-Angiotensin-Aldosterone System Blockade on Outcomes of Heart Failure With Preserved Ejection Fraction.

Clinical trials of renin-angiotensin-aldosterone system (RAAS) antagonists in heart failure with preserved ejection fraction (HFpEF) have suggested neutral results and treatment is focused on associated symptoms and comorbidities. MEDLINE and EMBASE were searched through October 2019 for randomized controlled studies investigating the effects of different RAAS antagonists in patients with HFpEF. The main outcomes were all-cause mortality, trial defined cardiovascular mortality, and heart failure (HF) hospitalizations. To compare different RAAS antagonists, a random-effects restricted-maximum-likelihood network meta-analysis based on a frequentist framework for indirect and mixed comparisons was used. We used p scores to rank best treatments per outcome. Our search identified 5 eligible clinical trials (PEP-CHF, perindopril; CHARM-preserved, candesartan; I-PRESERVE, irbesartan; TOPCAT, spironolactone; PARAGON-HF, sacubitril-valsartan and valsartan) enrolling a total 10,523 on RAAS antagonists and 6,259 controls. We did not identify any statistical difference in all-cause and cardiovascular mortality among RAAS antagonists and placebo. The combination of sacubitril-valsartan was associated with significantly decreased HF hospitalization risk compared with controls (odds ratio 0.73, 95% confidence interval 0.61 to 0.87) and angiotensin II receptor blockers (odds ratio 0.80, 95% confidence interval 0.71 to 0.91), without heterogeneity among studies (I2 = 0). Angiotensin receptor neprilysin inhibitor (ARNI) ranked better than other RAAS antagonists for HF hospitalizations (p value 0.9). In conclusion, RAAS antagonists do not affect mortality but the combination of sacubitril-valsartan is associated with lower HF hospitalizations in HFpEF patients.

Trends in utilization, mortality, major complications, and cost after total artificial heart implantation in the United States (2009-2015).

OBJECTIVE: Total artificial heart (TAH) is a viable bridge to transplant (BTT) strategy for patients with severe biventricular failure or complex congenital heart disease. These patients have higher mortality and morbidity than patients undergoing left ventricular assist device (LVAD) implantation. To assess national trends in in-hospital mortality, major complications, cost, length of stay, and disposition of patients undergoing TAH implantation. METHODS: Data from the National Inpatient Sample, the largest all-payer inpatient data set in the United States, and the US Census Bureau, for the years 2009 to 2015 were analyzed. Participants included all adult patients who received TAH from 2009 to 2015. Endpoints included in-hospital mortality, in-hospital complications, heart transplantation (HT) in the same admission, length of stay, cost, and disposition at the time of discharge. RESULTS: We identified a total of 143 (weighted = 703) TAH implantations. The number of TAH implants increased during the study period (average annual change +5.8%, p = 0.03). Rates of in-hospital mortality and major complications including ischemic stroke, major bleeding, postoperative infections, acute kidney injury requiring dialysis, and HT did not change significantly over the study period. Although the length of stay and disposition patterns did not change over time, we found a significant increase in cost of hospitalization (average annual change +44,362, p = 0.01). The number of HT during the same hospital stay decreased significantly (average annual change -8.1%, p = 0.02). CONCLUSION: In-hospital mortality and complication rates associated with TAH implantation remain increased and did not change in the era of continuous flow LVADs.

Trends in In-Hospital Mortality, Length of Stay, Nonroutine Discharge, and Cost Among End-Stage Renal Disease Patients on Dialysis Hospitalized With Heart Failure (2001-2014).

BACKGROUND: Heart failure (HF) is a common cause of morbidity and mortality among end-stage renal disease (ESRD) patients on dialysis. We aimed to assess the trends and outcomes in primary and secondary HF hospitalizations among ESRD patients with the use of a nationally representative database. METHODS AND RESULTS: We analyzed data from the National Inpatient Sample and the US Census Bureau to calculate annual national rates of in-hospital mortality, length of stay, disposition with a focus on nonroutine discharge (discharge to a health care facility rather than to home), and adjusted median cost among patients with ESRD on dialysis with primary or secondary HF admissions from 2001 to 2014. An estimated 812,090 primary and 2,887,432 secondary HF admissions occurred from 2001 to 2014. The prevalence of comorbidities increased during the study period. Primary HF admission rates increased from 2001 to 2006 and decreased from 2007 to 2014, whereas secondary HF admissions increased significantly during the study period (P < .001). We found statistically significant declines of primary and secondary admission in-hospital mortality, with annual percentage changes of -3.1% and -2.6% respectively (P < .001 for both). In addition, the lengths of stay decreased significantly for primary and secondary HF admissions (P < .001 for both). However, nonroutine discharges increased significantly for both. Subgroup analysis showed higher in-hospital mortality for men, patients >65 years of age, whites, and those on peritoneal dialysis. The cost of hospitalization did not change significantly for primary and secondary HF admissions. CONCLUSION: Among ESRD patients on dialysis with primary or secondary HF admission diagnosis, comorbidity prevalence increased but in-hospital mortality and length of stay decreased significantly from 2001 to 2014.

3-Hydroxy-3-methylglutaryl-CoA reductase enzyme inhibitors for prevention of contrast-induced nephropathy: a meta-analysis of prospective randomized controlled studies.

Contrast-induced nephropathy (CIN) is a possible complication of interventional procedures that require administration of an iodinated contrast. Previous observational and small prospective randomized trials suggested that 3-hydroxy-3-methylglutaryl-CoA reductase enzyme inhibitors may reduce the incidence of CIN. We performed a meta-analysis of the effect of statins on CIN including prospective randomized, controlled trials of statin therapy. We conducted an EMBASE and MEDLINE search for studies in which patients were randomized to treatment with a statin plus standard treatment (or placebo) versus standard treatment (or placebo). We included studies that provided data on creatinine clearance, and incidence of CIN before the initiation of the treatment and at the end of the follow-up period. We identified 9 prospective randomized studies of high-dose statin treatment compared with placebo treatment for CIN prevention with 2504 controls and 2480 patients that received statins. A significant reduction in CIN was observed when pharmacologic intervention with statins was used (odds ratio, 0.45; 95% confidence interval, 0.34-0.58; P < 0.0001). In this meta-analysis of prospective controlled studies, we found a statistically significant reduction of CIN incidence in patients pretreated with high-dose statins before the procedure.