Elucidating left atrial electrical potential with microelectrode catheter: A case of coronary sinus ostial atresia with small persistent left superior vena cava.

A 51-year-old woman presented with recurring palpitations. Electrocardiography revealed narrow QRS tachycardia with short RP configuration. Computed tomography showed coronary sinus (CS) ostial atresia along with a small persistent left superior vena cava (PLSVC). Electrophysiological study identified the retrograde earliest atrial activation site (EAAS) at the CS ostium without decremental properties, and para-Hisian pacing suggested retrograde atrioventricular nodal conduction. Using a 1.6-Fr microelectrode catheter distally placed in the CS via the PLSVC, EAAS was confirmed within the left atrium, not the CS ostium. Transseptal approach revealed a left lateral accessory pathway, which was successfully eliminated.

Purkinje-Related Ventricular Tachycardia and Ventricular Fibrillation: Solved and Unsolved Questions.

Of the monomorphic ventricular tachycardias, there are 4 specific tachycardias related to the Purkinje system: 1) idiopathic verapamil-sensitive fascicular ventricular tachycardia (FVT); 2) non-re-entrant FVT; 3) bundle branch re-entry and interfascicular re-entry; and 4) Purkinje-mediated VT in structural heart disease. Verapamil-sensitive FVT is classified into 4 types according to the location of the circuit: 1) left posterior type; 2) left anterior type; 3) left upper septal type;and 4) reverse type. And, in the left anterior and posterior types, there are septal and papillary muscle subtypes. Although macro-re-entry has been reported to be the mechanism underlying verapamil-sensitive FVT, recording the entire circuit is challenging. One possible reason is that the Purkinje-muscle junction may penetrate the myocardial layer as a part of the circuit. The Purkinje network may thus play an important role in the initiation and maintenance of ventricular fibrillation. Further, it has been reported that the development and the abnormalities of the Purkinje system are associated with the arrhythmogenesis of ventricular fibrillation. Furthermore, it has been reported that catheter ablation of trigger ventricular premature complexes, and/or "de-networking" of the Purkinje system, can be used as electrical bailout therapy. There is a hypothesis that the intramural Purkinje system is involved in the generation of J waves. Nevertheless, as there are still unresolved issues that must be debated and accurately analyzed, this review aims to discuss the solved and unsolved questions related to Purkinje-related arrhythmias.

Catheter Ablation for Ventricular Tachycardia Involving the His-Purkinje System: Fascicular and Bundle Branch Reentrant Ventricular Tachycardia.

The Purkinje system has been found to mediate several monomorphic ventricular tachycardias (VTs). These include fascicular VTs and bundle branch reentrant (BBR) VTs. Previous studies have revealed that VTs involving the His-Purkinje system are composed of multiple discrete subtypes that are best differentiated by their mechanism, drug effect, VT morphology, and successful ablation site. Recognition of the heterogeneity of these VTs and their unique characteristics should facilitate the appropriate diagnosis and therapy and help guide catheter ablation therapy. In this article, we focus on the latest updates of the mechanisms underlying left ventricle fascicular VTs and BBR-VTs as well as the latest catheter ablation techniques.

Association between induction of the self-management system for preventing readmission and disease severity and length of readmission in patients with heart failure.

OBJECTIVE: We recently developed the self-management system using the HF points and instructions to visit hospitals or clinics when the points exceed the pre-specified levels. We found that the self-management system decreased the hospitalization for HF with an increase in unplanned visits and early intervention in the outpatient department. However, it is unclear whether we managed severe HF outpatients who should have been hospitalized. In this study, we aimed to compare HF severity in rehospitalized patients with regard to self-management system use. RESULTS: We retrospectively enrolled 306 patients (153 patients each in the system user and non-user groups) using propensity scores (PS). We compared HF severity and length of readmission in rehospitalized patients in both groups. During the 1-year follow-up period, 24 system users and 43 non-system users in the PS-matched cohort were hospitalized. There were no significant differences between the groups in terms of brain natriuretic peptide levels at readmission, maximum daily intravenous furosemide dose, percentage of patients requiring intravenous inotropes, duration of hospital stay and in-hospital mortality. These results suggest that the HF severity in rehospitalized patients was not different between the two groups.

Discrepancy between left ventricular hypertrophy by echocardiography and electrocardiographic hypertrophy: clinical characteristics and outcomes.

BACKGROUND: The clinical significance of the discrepancy between left ventricular hypertrophy (LVH) by echocardiography and ECG remains to be elucidated. METHODS: After excluding patients who presented with pacemaker placement, QRS duration ≥120 ms and cardiomyopathy and moderate to severe valvular disease, we retrospectively analysed 3212 patients who had undergone both scheduled transthoracic echocardiography (echo) and ECG in a hospital-based population. Cornell product >2440 mm · ms was defined as ECG-based LVH; left ventricular mass index >115 g/m2 for men and >95 g/m2 for women was defined as echo-based LVH. The study population was categorised into four groups: patients with both ECG-based and echo-based LVH (N=131, 4.1%), those with only echo-based LVH (N=156, 4.9%), those with only ECG-based LVH (N=409, 12.7%) and those with no LVH (N=2516, 78.3%). RESULTS: The cumulative 3-year incidences of a composite of all-cause death and major adverse cardiovascular events were 32.0%, 33.8%, 19.2% and 15.7%, respectively. After adjusting for confounders, the HRs relative to that in no LVH were 1.63 (95% CI 1.16 to 2.28), 1.68 (95% CI 1.23 to 2.30) and 1.09 (95% CI 0.85 to 1.41) in patients with both ECG-based and echo-based LVH, those with only echo-based LVH, and those with only ECG-based LVH, respectively. CONCLUSIONS: Echo-based LVH without ECG-based LVH was associated with a significant risk of adverse clinical events, and the risk was comparable to that in patients with both echo-based and ECG-based LVH.

The association between late-phase early recurrence within the blanking period after atrial fibrillation catheter ablation and long-term recurrence: Insights from a large-scale multicenter study.

BACKGROUND: The relationship between the timing of the first early recurrence and late recurrence after a single catheter ablation procedure for atrial fibrillation is controversial. METHODS: The Efficacy of Short-Term Use of Antiarrhythmic Drugs After Catheter Ablation for Atrial Fibrillation trial followed 2038 patients who underwent radiofrequency catheter ablation for atrial fibrillation. RESULTS: Of the patients, 907 (45%) had early recurrences within 90 days after the initial ablation. We divided these patients into two groups according to the timing of the first early recurrence episode, namely the ER1 group (early recurrence during the early phase; 0-30 days, n = 814) and ER2 group (early recurrence during the late phase; 31-90 days, n = 93). Three years after ablation, patients with early recurrences had a significantly lower event-free rate from late recurrences after a 90-day blanking period than patients without early recurrences (36.2% and 74.2%, respectively; log-rank, P < 0.0001). Three years after ablation, the event-free rate was significantly higher in the ER1 than the ER2 group (38.3% and 17.1%, respectively; log-rank, P < 0.0001). Moreover, the event-free rate at 3 years in the ER2 group was extremely low (5.6%) in patient with non-paroxysmal atrial fibrillation. CONCLUSION: Early recurrences were strongly associated with late recurrences, especially in patients with the first recurrence episode at >1 month within the blanking period after a single ablation procedure. Therefore, these patients should undergo close observation during follow-up, when they had especially with non-paroxysmal atrial fibrillation.

Clinical impact of left and right axis deviations with narrow QRS complex on 3-year outcomes in a hospital-based population in Japan.

While the prognostic impact of QRS axis deviation has been assessed, it has never been investigated in patients without conduction block. Thus, we evaluated the prognostic impact of QRS-axis deviation in patients without conduction block. We retrospectively analyzed 3353 patients who had undergone both scheduled transthoracic echocardiography and electrocardiography in 2013 in a hospital-based population, after excluding patients with a QRS duration of ≥ 110 ms, pacemaker placement, and an QRS-axis - 90° to - 180° (northwest axis). The study population was categorized into three groups depending on the mean frontal plane QRS axis as follows: patients with left axis deviation (N = 171), those with right axis deviation (N = 94), and those with normal axis (N = 3088). The primary outcome was a composite of all-cause death and major adverse cardiovascular events. The cumulative 3-year incidence of the primary outcome measure was significantly higher in the left axis deviation group (26.4% in the left axis deviation, 22.7% in the right axis deviation, and 18.4% in the normal axis groups, log-rank P = 0.004). After adjusting for confounders, the excess risk of primary outcome measure remained significant in the left axis deviation group (hazard ratio [HR] 1.44; 95% confidence interval [CI] 1.07-1.95; P = 0.02), while the excess risk of primary outcome measure was not significant in the right axis deviation group (HR 1.22; 95% CI 0.76-1.96; P = 0.41). Left axis deviation was associated with a higher risk of a composite of all-cause death and major adverse cardiovascular events in hospital-based patients without conduction block in Japan.

Reverse-Type Left Posterior Fascicular Ventricular Tachycardia: A New Electrocardiographic Entity.

OBJECTIVES: This study sought to demonstrate a new type of verapamil-sensitive fascicular ventricular tachycardia (VT) with a reverse circuit. BACKGROUND: Left posterior fascicular ventricular tachycardia (LPFVT) is the most common form of verapamil-sensitive fascicular VT. Reverse-type LPFVT has not been reported. METHODS: We searched for a reverse-type LPFVT among 242 patients with verapamil-sensitive VT from February 2006 to September 2019. RESULTS: Three patients had a reverse-type LPFVT (cycle lengths: 340, 360, and 340 ms). QRS configuration during VT was narrow (140, 150, and 140 ms) and exhibited rSr' morphology in V1 with an early precordial transition and inferior axis. Two of 3 patients had common-type LPFVT. During reverse-type LPFVT, the earliest ventricular activation was the left superior middle septum. Fragmented Purkinje potentials (P1) buried within the local ventricular electrogram were recorded with an activation sequence from the apex to the base and were linked to the subsequent left ventricular septal activation. After radiofrequency catheter ablation at P1 during LPFVT, the reverse-type LPFVT also became noninducible. In 1 patient with only the reverse-type LPFVT, radiofrequency catheter ablation at the earliest LV activation site suppressed VT. These findings suggest that this new type of verapamil-sensitive fascicular VT shares a re-entrant circuit with a reverse direction of common LPFVT with an intramural exit site at the superior middle septum. CONCLUSIONS: Reverse-type LPFVT can occur. If common LPFVT exists, diastolic P1 during LPFVT can be a common target of ablation. If only reverse-LPFVT is inducible, the earliest ventricular activation site can be a target.

Association of the induction of a self-care management system with 1-year outcomes in patients hospitalized for heart failure.

BACKGROUND: To perform self-care in patients with heart failure (HF), we developed and implemented a new HF point self-care system, which was characterized by 1) the way weight and HF symptoms were scored ("Heart Failure Points") and 2) the timing of consultations defined for both patients and health care providers. We examined the association between the induction of the new system and 1-year outcomes in patients hospitalized for HF. METHODS: We retrospectively enrolled 569 consecutive patients into our study who were admitted for HF treatment at our hospital: 275 patients between November 2011 and October 2013 (before the induction of the self-management system) and 294 patients between November 2015 and October 2017 (after the induction). We sought to compare the clinical outcomes between patients using the self-management system and those not using the system after propensity-score (PS) matching. The primary outcome measure was a composite of all-cause death or HF rehospitalization. RESULTS: The cumulative 1-year incidence of the primary outcome measure in the use group (n = 153) was significantly lower than that in the non-use group (n = 153) (24.5% vs. 34.9%, respectively; p = 0.031; hazard ratio: 0.62; 95% confidence interval: 0.40-0.96), mainly due to a reduction in HF hospitalization. CONCLUSIONS: The induction of the new self-care system was associated with better 1-year outcomes in patients hospitalized for HF. This system may help patients with HF to achieve more efficient self-care.

Prognostic significance of moderate primary mitral regurgitation and concomitant paroxysmal atrial fibrillation.

BACKGROUND: Severe primary mitral regurgitation [degenerative MR (DMR)] is associated with poor outcomes, including cardiac death and hospitalization due to worsening heart failure. However, little information is available regarding the characteristics of moderate DMR and their impacts on prognostic outcome. The aim of the present study was to investigate the prognosis and its determinants in patients with moderate DMR. METHODS: We retroactively reviewed 13,700 consecutive patients who underwent transthoracic echocardiography and selected those with moderate DMR but without other underlying cardiac diseases. We assessed the characteristics and event-free rate of patients with moderate DMR compared with those of age- and gender-matched patients with mild or no MR. RESULTS: The cohort included 182 (1%) patients with moderate DMR, and these were compared with 182 age- and gender-matched patients with mild or no MR. During the follow-up period of 1376 ± 652 days, 30 patients (8%) met the composite endpoint defined as cardiac death or hospitalization due to worsening heart failure. Kaplan-Meier analysis showed that patients with moderate DMR were significantly associated with a poor outcome compared to patients with mild or no MR (log-rank test p < 0.0001). Cox proportional hazard ratio revealed that moderate DMR and paroxysmal atrial fibrillation (PAF) were the independent predictors of the composite endpoint. CONCLUSIONS: Patients with moderate DMR and concomitant PAF had a significantly worse outcome compared to those with mild or no MR. Active surveillance and some intervention for patients with PAF and moderate DMR may be required.

Association with left atrial volume index and long-term prognosis in patients without systolic dysfunction nor atrial fibrillation: an observational study.

The prognostic impact of left atrial size in patients without systolic dysfunction nor atrial fibrillation (AF) has not been fully elucidated in Japan. We retrospectively analyzed data obtained from 4444 consecutive patients who had undergone both scheduled transthoracic echocardiography and electrocardiography in 2013 in our hospital. Those who presented with a history of myocardial infarctions, severe and moderate valvular diseases, low ejection fraction (< 50%), and documented AF, and without data on LA volume index (LAVI) or tissue Doppler early diastolic mitral annular velocity were excluded. We defined high LAVI as a value > 34 ml/m2. The primary outcome measure was a composite of all-cause death and major adverse cardiac events. A total of 2792 patients were categorized into two groups: 2627 with normal LAVI (94.1%), 165 with high LAVI (5.9%). The median age of patients in the normal and high LAVI groups were 67, and 77 years, respectively (p < 0.001). Prevalence of diabetes mellitus, hypertension, and chronic kidney disease, and left ventricular mass index was higher in the high-LAVI group than normal-LAVI group. After adjusting for confounders, the excess 3-year risk of primary outcome of high-LAVI related to normal-LAVI was significant (hazard ratio 1.44; 95% confidence interval 1.03-1.97, p = 0.032). High-LAVI should be considered a marker of a worse long-term follow-up in patients without systolic dysfunction nor AF.

Temporal trends in prevalence and outcomes of atrial fibrillation in patients undergoing percutaneous coronary intervention.

BACKGROUND: Atrial fibrillation (AF) is the most common arrhythmia in patients undergoing percutaneous coronary intervention (PCI). HYPOTHESIS: Large administrative data may provide further insight into temporal trends in the prevalence and burden of AF in patients who underwent PCI. METHODS: Using the National Inpatient Sample database in the U.S., AF patients ≥18 years who underwent PCI between 2005 and 2014 and were identified by the International Classification of Diseases, ninth revision, Clinical Modification, were examined. In-hospital mortality, morbidity, resource use, and medical costs were evaluated in crude and propensity-matched analyses. RESULTS: Among an estimated 6 272 232 hospitalizations, of patients undergoing PCI, AF prevalence was 9.9% and steadily increased from 8.6% to 12.0% between 2005 and 2014 (P < .001); there was also a greater proportion of comorbidities. There was a marked increase in AF prevalence among those aged ≥65 years and those undergoing elective PCIs. AF was independently associated with higher in-hospital mortality and higher rates of transient ischaemic attack/stroke, bleeding complications, and non-home discharge. Excessive in-hospital mortality, stroke rate, gastrointestinal bleeding, blood transfusion, length of stay, and costs among AF hospitalizations were consistently observed throughout the study period. CONCLUSION: AF becomes more prevalent in patients undergoing PCI, possibly due to a higher comorbidity, particularly in elderly patients with non-acute indications. Less favorable trends in mortality, bleeding, and stroke among AF patients who underwent PCI were consistent over time. Continuous efforts are needed to improve outcomes and manage strategies for AF patients undergoing PCI.

Staging Cardiac Damage in Patients With Hypertension.

Ventricular and extraventricular response to pressure overload may be a common process in aortic stenosis and hypertension. We aimed to evaluate the association of a newly defined staging classification characterizing the extent of cardiac damage, originally developed for aortic stenosis, with long-term outcomes in patients with hypertension. We retrospectively analyzed 1639 patients with hypertension who had undergone both scheduled transthoracic echocardiography and electrocardiography in 2013 in a Japanese hospital, after excluding severe and moderate aortic stenosis, aortic regurgitation, mitral stenosis, previous myocardial infarction, or cardiomyopathy. We classified patients according to the presence or absence of cardiac damage as detected on echocardiography as follows: stage 0, no cardiac damage (n=858; 52.3%); stage 1, left ventricular damage (n=358; 21.8%); stage 2, left atrial or mitral valve damage (n=360; 22.0%); or stage 3 and 4, pulmonary vasculature, tricuspid valve, or right ventricular damage (n=63; 3.8%). The primary outcome was a composite of all-cause death and major adverse cardiac events. Cumulative 3-year incidence of the primary outcome was 15.5% in stage 0, 20.7% in stage 1, 31.8% in stage 2, and 60.6% in stage 3. After adjusting for confounders, the stage was incrementally associated with higher risk of the primary outcome (per 1-stage increase: hazard ratio, 1.46 [95% CI, 1.31-1.61]; P<0.001). The staging classification characterizing the extent of cardiac damage, originally developed for aortic stenosis, was associated with long-term outcomes in patients with hypertension in a stepwise manner.

Association of the low e' and high E/e' with long-term outcomes in patients with normal ejection fraction: a hospital population-based observational cohort study.

OBJECTIVE: We aimed to evaluate the association of the severity of left ventricular (LV) diastolic dysfunction with long-term outcomes in patients with normal ejection fraction. DESIGN: Retrospective study. SETTING: A single centre in Japan. PARTICIPANTS: We included 3576 patients who underwent both scheduled transthoracic echocardiography and ECG between 1 January and 31 December 2013, in a hospital-based population after excluding valvular diseases or low ejection fraction (<50%) or atrial fibrillation and categorised them into three groups: septal tissue Doppler early diastolic mitral annular velocity (e')≥7 (without relaxation disorder, n=1593), e'<7 and early mitral inflow velocity (E)/e'≤14 (with relaxation disorder and normal LV end-diastolic pressure, n=1337) and e'<7 and E/e'>14 (with relaxation disorder and high LV end-diastolic pressure, n=646). PRIMARY AND SECONDARY OUTCOME MEASURES: The primary outcome measure was a composite of all-cause death and major adverse cardiac events (MACE). The secondary outcome measure were all-cause death and MACE, separately. RESULTS: The cumulative 3-year incidences of the primary outcome measures were significantly higher in the e'<7 and E/e'≤14 (19.0%) and e'<7 and E/e'>14 group (23.4%) than those for the e'≥7 group (13.0%; p<0.001). After adjusting for confounders, the excess 3-year risk of primary outcome for the groups with e'<7 and E/e'≤14 related to e'≥7 (HR: 1.24; 95% CI 1.02 to 1.52) and e'<7 and E/e'>14 related to e'<7 (HR: 1.57; 95% CI 1.28 to 1.94) were significant. The severity of diastolic dysfunction was associated with incrementally higher risk for primary outcomes (p<0.001). CONCLUSION: The severity of LV diastolic dysfunction using e'<7 and E/e'>14 was associated with the long-term prognosis in patients with normal ejection fraction in an incremental fashion.

Thirty-Day Readmission After Infective Endocarditis: Analysis From a Nationwide Readmission Database.

Background The contemporary incidence of and reasons for early readmission after infective endocarditis ( IE ) are not well known. Therefore, we analyzed 30-day readmission demographics after IE from the US Nationwide Readmission Database. Methods and Results We examined the 2010 to 2014 Nationwide Readmission Database to identify index admissions for a primary diagnosis of IE with survival at discharge. Incidence, reasons, and independent predictors of 30-day unplanned readmissions were analyzed. In total, 11 217 patients (24.8%) were nonelectively readmitted within 30 days among the 45 214 index admissions discharged after IE . The most common causes of readmission were IE (20.5%), sepsis (8.7%), complications of device/graft (8.1%), and congestive heart failure (7.6%). In-hospital mortality and the valvular surgery rates during the readmissions were 8.1% and 9.1%, respectively. Discharge to home or self-care, undergoing valvular surgery, aged ≥60 years, and having private insurance were independently associated with lower rates of 30-day readmission. Length of stay of ≥10 days, congestive heart failure, diabetes mellitus, renal failure, chronic pulmonary disease, peripheral artery disease, and depression were associated with higher risk. The total hospital costs of readmission were $48.7 million per year (median, $11 267; interquartile range, $6021-$25 073), which accounted for 38.6% of the total episodes of care (index+readmission). Conclusions Almost 1 in 4 patients was readmitted within 30 days of admission for IE . The most common reasons were IE , other infectious causes, and cardiac causes. A multidisciplinary approach to determine the surgical indications and close monitoring are necessary to improve outcomes and reduce complications in in-hospital and postdischarge settings.

Age- and Body Size-Adjusted Left Ventricular End-Diastolic Dimension in a Japanese Hospital-Based Population.

BACKGROUND: Using the normal values for the East Asian population, we evaluated age- and body size-adjusted left ventricular end-diastolic dimension (LVEDD) and its prognostic impact in a hospital-based population in Japan. Methods and Results: We retrospectively analyzed data obtained from 4,444 consecutive patients who had undergone both transthoracic echocardiography and electrocardiography at Kitano Hospital in 2013. Those who presented with a history of previous episodes of myocardial infarction and severe or moderate valvular disease or with low ejection fraction (<50%) were excluded from the analysis. We calculated LVEDD adjusted by age and body surface area. A total of 3,474 patients were categorized into 3 groups: 401 with large adjusted LVEDD, 2,829 with normal adjusted LVEDD, and 244 with small adjusted LVEDD. Mean patient age in the large, normal, and small adjusted LVEDD groups was 66.6±18.4, 65.6±15.7, and 62.1±15.5 years, respectively (P<0.001). After adjusting for confounding factors, the excess adjusted 3-year risk of primary outcome of large adjusted LVEDD relative to normal LVEDD was significant (HR, 1.40; 95% CI: 1.08-1.78). The risk for primary outcomes of small adjusted LVEDD relative to normal adjusted LVEDD was significantly lower (HR, 0.55; 95% CI: 0.34-0.85). CONCLUSIONS: Adjusted large LVEDD has a deleterious impact on long-term mortality, whereas small LVEDD carried a significantly lower risk.

Impact of stroke volume on prognostic outcome in patients with atrial fibrillation and concomitant heart failure with preserved ejection fraction.

BACKGROUND: Atrial fibrillation (AF) can lead to a decrease in stroke volume (SV) despite a preserved left ventricular ejection fraction (LVEF). However, no previous studies have evaluated the prognostic importance of the decreased SV in patients with AF and concomitant heart failure with preserved ejection fraction (HFpEF). METHODS: We retrospectively studied the cases of 1520 consecutive patients who had undergone right heart catheterization. HFpEF (New York Heart Association functional class ≥II and LVEF ≥50%) was observed in 574 patients. We selected 47 patients with persistent AF with a heart rate of 40-110bpm and HFpEF without other underlying heart diseases. RESULTS: Among a total of 47 patients, 16 (34%) had normal SV [SV index (SVI) >35ml/m2 and 31 (66%) patients had low SV (SVI≤35ml/m2)]. During the follow-up period of 1115±305 days, 14 patients (30%) met the composite endpoint defined as cardiac death and admission due to worsening heart failure. Cox proportional hazard ratio analysis showed that SVI was a predictor of the endpoint, independently of the cardiac index and other parameters. Kaplan-Meyer analysis showed that low SVI was significantly associated with a poor prognosis, with an event-free rate of 58% at the mean follow-up period of 991 days (log-rank p=0.02). In the multiple regression analysis, a high systemic vascular resistance index and a high heart rate were independent determinants of low SVI. CONCLUSIONS: Our findings suggest that low SV had a significant impact on prognosis in patients with AF despite the preserved LVEF. The SVI depended on the heart rate and SVRI.

Incidence, predictors, causes, and costs of 30-day readmission after in-hospital cardiopulmonary resuscitation in the United States.

BACKGROUND: Readmissions after in-hospital cardiopulmonary resuscitation (ICPR) are common and contribute to increased health care utilization and costs. This study aimed to estimate the burden and patterns of 30-day readmission after ICPR from the US Nationwide Readmission Database (NRD). METHODS: Using International Classification of Diseases-Ninth Revision-Clinical Modification codes, patients who underwent ICPR in the 2014 NRD were included. The incidence, predictors, causes, and costs of 30-day readmission were analyzed with discharge weights to obtain national estimates. RESULTS: Among the 27,278 index admissions that survived to hospital discharge after ICPR, 5439 (20.0%) were readmitted within 30 days. Length of stay (LOS) ≥11 days during index hospitalization, chronic pulmonary disease, congestive heart failure, renal failure, discharge from the teaching metropolitan hospital, Medicare insurance, depression, and diabetes were independent predictors of 30-day readmission. The most common causes of readmission among the 5439 cases were sepsis (13.7%), heart failure (10.9%), and respiratory failure (6.4%). The estimated median costs of readmission were $10,498 (interquartile range, $5797-21,364), which accounted for 25.7% of the total episodes of care (index + readmission). The median LOS of readmission was 5 (3-9) days. CONCLUSIONS: Thirty-day readmissions after ICPR were associated with patient comorbidities and significant cost burden. Recognition of these predictors and individualization of care would allow for the provision of appropriate interventions, and reduce readmissions and healthcare costs.

Risk of myocardial infarction in patients with psoriasis: A cross-sectional patient-population study in a Japanese hospital.

BACKGROUND: Some epidemiological studies have demonstrated the association between psoriasis vulgaris and coronary artery disease (CAD). However, there is a lack of specific data regarding the association between psoriasis vulgaris and myocardial infarction (MI), the more severe and critical presentation of CAD, in the Japanese population. METHODS AND RESULTS: We retrospectively analyzed 113,065 patients of all ages at our hospital from January 1, 2011 to January 1, 2013. We extracted the data of patients with psoriasis vulgaris, diabetes mellitus, dyslipidemia, or MI (acute, sub-acute, or old), including sex and age from the electronic medical record database. The prevalence of MI in patients with hypertension, dyslipidemia, diabetes mellitus, and psoriasis vulgaris were 4.8% (794/16,476), 5.0% (459/9236), 4.6% (531/11,555), and 2.7% (32/1197), respectively. Multivariate analysis showed that psoriasis vulgaris was significantly associated with MI [adjusted odds ratio (OR): 1.87; 95% confidence interval (CI): 1.26-2.68; p=0.0022]. In a subgroup analysis of 24,069 patients who had one or more comorbidities including diabetes mellitus, dyslipidemia, and hypertension, psoriasis vulgaris was still independently associated with MI after adjusting for sex and age (adjusted OR, 1.49; 95% CI: 1.02-2.18; p=0.0358) in adults. CONCLUSION: Psoriasis vulgaris was significantly associated with MI in a Japanese hospital-based population.

Isolated Tricuspid Regurgitation and Long-Term Outcome in Patients With Preserved Ejection Fraction.

Background: The aim of this study was to evaluate the association of isolated tricuspid regurgitation (TR) with long-term outcome in patients with preserved left ventricular ejection fraction (LVEF). Methods and Results: We retrospectively analyzed 3,714 patients who had undergone both scheduled transthoracic echocardiography and electrocardiography in 2013 in a hospital-based population, after excluding severe and moderate left-side valvular disease and LVEF <50%. We classified patients into 2 groups: moderate to severe TR (n=53) and no moderate to severe TR (n=3,661). Next, we generated a propensity score (PS)-matched cohort: the moderate to severe TR group and the no moderate to severe TR group (n=41 in each group). The primary outcome was a composite of all-cause death and major adverse cardiac events. In the moderate to severe TR group, patients were older, and more likely to have higher left atrial volume index and E/e' than those in the no moderate to severe TR group. In the PS-matched cohort, cumulative 3-year incidence of the primary outcome was 61.5% in the moderate to severe TR group and 24.3% in the no moderate to severe TR group (log-rank P=0.043; hazard ratio, 2.86; 95% CI: 1.37-6.37). Conclusions: Isolated moderate to severe TR is associated with poor clinical outcome in patients with preserved LVEF.