Achieving Equity in Hospital Performance Assessments Using Composite Race-Specific Measures of Risk-Standardized Readmission and Mortality Rates for Heart Failure.

BACKGROUND: The contemporary measures of hospital performance for heart failure hospitalization and 30-day risk-standardized readmission rate (RSRR) and risk-standardized mortality rate (RSMR) are estimated using the same risk adjustment model and overall event rate for all patients. Thus, these measures are mainly driven by the care quality and outcomes for the majority racial and ethnic group, and may not adequately represent the hospital performance for patients of Black and other races. METHODS: Fee-for-service Medicare beneficiaries from January 2014 to December 2019 hospitalized with heart failure were identified. Hospital-level 30-day RSRR and RSMR were estimated using the traditional race-agnostic models and the race-specific approach. The composite race-specific performance metric was calculated as the average of the RSRR/RMSR measures derived separately for each race and ethnicity group. Correlation and concordance in hospital performance for all patients and patients of Black and other races were assessed using the composite race-specific and race-agnostic metrics. RESULTS: The study included 1 903 232 patients (75.7% White [n=1 439 958]; 14.5% Black [n=276 684]; and 9.8% other races [n=186 590]) with heart failure from 1860 hospitals. There was a modest correlation between hospital-level 30-day performance metrics for patients of White versus Black race (Pearson correlation coefficient: RSRR=0.42; RSMR=0.26). Compared with the race-agnostic RSRR and RSMR, composite race-specific metrics for all patients demonstrated stronger correlation with RSRR (correlation coefficient: 0.60 versus 0.74) and RSMR (correlation coefficient: 0.44 versus 0.51) for Black patients. Concordance in hospital performance for all patients and patients of Black race was also higher with race-specific (versus race-agnostic) metrics (RSRR=64% versus 53% concordantly high-performing; 61% versus 51% concordantly low-performing). Race-specific RSRR and RSMR metrics (versus race-agnostic) led to reclassification in performance ranking of 35.8% and 39.2% of hospitals, respectively, with better 30-day and 1-year outcomes for patients of all race groups at hospitals reclassified as high-performing. CONCLUSIONS: Among patients hospitalized with heart failure, race-specific 30-day RSMR and RSRR are more equitable in representing hospital performance for patients of Black and other races.

Impact of age over 70 years in the new allocation system on the outcomes of heart transplantation in the US.

BACKGROUND: United Network for Organ Sharing (UNOS) allocation criteria changed in 2018 to accommodate the increased prevalence of patients on a ventricular assist device as a bridge to heart transplant and prioritize sicker people in anticipation of a heart graft. We aimed to assess the impact of patient age in the new allocation policy on mortality following heart transplantation. Secondary outcomes included the effect of age ≥70 on post-transplant events, including stroke, dialysis, pacemaker, and rejection requiring treatment. METHODS: The UNOS Registry was queried to identify patients who underwent heart transplants alone in the US between 2000 and 2021. Patients were divided into groups according to their age (over 70 and under 70 years old). RESULTS: Patients aged over 70 were more likely to require dialysis during follow-up, but less likely to experience rejection requiring treatment, compared with patients aged <70. Age ≥70 in the new allocation system was a significant predictor of 1-year mortality (adjusted HR: 1.41; 95% CI: 1.05-1.91; p = .024), but its effect on 5-year mortality was not significant after adjusting for potential confounders (adjusted HR: 1.27; 95% CI:.97-1.66; p = .077). Undergoing transplantation under the new allocation policy vs the old allocation policy was not a significant predictor of mortality in patients over 70 years old. CONCLUSIONS: Age ≥70 is a significant predictor of 1-year mortality following heart transplantation, but not at 5 and 10 years; however, the new allocation does not seem to have changed the outcomes for this group of patients.

Prognostic implications of inactive status in highest urgency categories among heart transplantation recipients in the new donor heart allocation system.

BACKGROUND: Patients on the waiting list for heart transplantation (HT) can become inactive or made status seven because of medical reasons, such adverse events, complications, or psychosocial circumstances. If the condition that caused the inactivation is resolved, patients are re- activated. Information about the prognostic implications of Status 7 in the new donor heart allocation system has not been described. To bridge this knowledge gap, we performed an analysis of the United Network of Organ Sharing (UNOS) registry. METHODS: Data on adult patients who underwent HT between October 18th, 2018 and October 2021, were queried from the UNOS registry. The main outcomes were post- transplant all-cause mortality, 1-year all-cause mortality and treated acute rejection. Since re-transplantation is a competing event for all-cause mortality, we performed competing risk survival analysis and reported sub distribution hazard ratios (SHR) from the Fine and Gray model to examine the relationship between inactive status and all-cause mortality. RESULTS: A total of 5267 adult patients underwent HT and were previously listed as Status 1 or Status 2 in the new allocation system. We identified 946 HT recipients temporarily inactivated while on HT list (18%). The number of temporarily inactive patients remained stable since the implementation of the new donor allocation system (p = .37). Approximately, two-thirds of temporarily inactive patients (65.9%) were inactivated for being too sick, whereas other frequent justifications for inactivity included left ventricular assist device implantation (7.8%) and insurance related issues (4.8%). Temporarily inactive HT recipients were more likely to be African Americans, males, have a higher body mass index (BMI) and significantly longer waiting time (391.6 ± 600 vs. 72.3 ± 223 days, p < .001) compared with never inactivated patients. In the unadjusted analyses 30-day mortality did not differ between groups, but both 1-year and overall all-cause mortality was significantly higher in temporarily inactive patients (1-year: SHR: 1.3; 95% confidence intervals [CI]: 1.03, 1.64; p = .028, overall mortality SHR: 1.31; 95% CI: 1.06, 1.64; p = .014). After adjustment for donor and recipient characteristics, a trend towards higher 1-year and overall mortality remained (1-year: SHR 1.32; 95% CI .99, 1.76, p = .006, overall mortality SHR: 1.29; 95% CI: .98-1.68, p = .065). No differences in treated acute allograft rejection at 1 year were found between groups. CONCLUSIONS: Temporary inactive status while waiting for HT occurs in approximately one in five HT recipients listed in higher urgency categories after the implementation of the new allocation system. A signal of adverse long-term outcomes was found, and this could be explained by differences in recipient characteristics. Further research is required to elucidate pathways involved and possible implications for clinical practice.

Impact of new allocation system on length of stay following heart transplantation in the United States.

BACKGROUND: United Network for Organ Sharing (UNOS) allocation criteria changed in 2018 to accommodate the increased prevalence of ventricular assist device use as a bridge to heart transplant, which consequently prioritized sicker patients. We aimed to assess the impact of this new allocation policy on the length of stay following heart transplantation. Secondary outcomes include other risk factors for prolonged hospitalization and its effect on mortality and postoperative complications. METHODS: The UNOS Registry was queried to identify patients who underwent isolated heart transplants in the United States between 2001 and 2023. Patients were divided into quartiles according to their respective length of stay. RESULTS: A total of 57 020 patients were included, 15 357 of which were allocated with the new system. The median hospital length of stay was 15 days (mean 22.7 days). Length of stay was longer in the new allocation era (25 ± 30 vs. 22 ± 27 days, p < .001). The longer length of stay was associated with increased 5-year mortality in the new allocation system (aHR: 1.18; 95% CI: 1.15, 1.20; p-value: < .001). CONCLUSION: Longer hospital stays and associated observed increased risk for mortality in the era after the allocation criteria change reflect the rationale of this shift which was to prioritize heart transplants for sicker patients. Further studies are needed to track the progress of surgical and perioperative management of these studies over time.

Machine learning-based prediction of mortality after heart transplantation in adults with congenital heart disease: A UNOS database analysis.

BACKGROUND: Machine learning (ML) is increasingly being applied in Cardiology to predict outcomes and assist in clinical decision-making. We sought to develop and validate an ML model for the prediction of mortality after heart transplantation (HT) in adults with congenital heart disease (ACHD). METHODS: The United Network for Organ Sharing (UNOS) database was queried from 2000 to 2020 for ACHD patients who underwent isolated HT. The study cohort was randomly split into derivation (70%) and validation (30%) datasets that were used to train and test a CatBoost ML model. Feature selection was performed using SHapley Additive exPlanations (SHAP). Recipient, donor, procedural, and post-transplant characteristics were tested for their ability to predict mortality. We additionally used SHAP for explainability analysis, as well as individualized mortality risk assessment. RESULTS: The study cohort included 1033 recipients (median age 34 years, 61% male). At 1 year after HT, there were 205 deaths (19.9%). Out of a total of 49 variables, 10 were selected as highly predictive of 1-year mortality and were used to train the ML model. Area under the curve (AUC) and predictive accuracy for the 1-year ML model were .80 and 75.2%, respectively, and .69 and 74.2% for the 3-year model, respectively. Based on SHAP analysis, hemodialysis of the recipient post-HT had overall the strongest relative impact on 1-year mortality after HΤ, followed by recipient-estimated glomerular filtration rate, age and ischemic time. CONCLUSIONS: ML models showed satisfactory predictive accuracy of mortality after HT in ACHD and allowed for individualized mortality risk assessment.

Prominent para-cardiac fat mimicking left atrial appendage thrombus on echocardiography: Utility of cardiac computed tomography.

Transesophageal echocardiography is the most frequently used imaging modality for exclusion of left atrial appendage thrombus prior to cardioversion. Echocardiographers should be aware of rare conditions that may mimic left atrial appendage thrombus. Here, we describe a rare case of prominent para-cardiac fat mimicking left atrial appendage thrombus on transesophageal echocardiographic imaging. Multimodality imaging with cardiac computed tomography was instrumental in providing further anatomical delineation and characterization of the echodensity as prominent para-cardiac fat in this case.

Maintenance immunosuppression in heart transplantation: insights from network meta-analysis of various immunosuppression regimens.

Previous studies have reported superiority of mechanistic target-of-rapamycin (mTOR) antagonists (mTA) over calcineurin inhibitors (CNI) as part of maintenance immunosuppression (IS) in mitigating cardiac allograft vasculopathy (CAV) after heart transplantation (HT). MEDLINE and EMBASE were searched through October 2019 for studies comparing maintenance IS with mTA + antimetabolites (AM), CNI + mTA or CNI + AM post HT. The main outcomes were all-cause mortality, CAV, acute rejection, CMV infections, and change in eGFR. To compare different IS antagonists, a random-effects network meta-analysis was performed. We used p-scores to rank best treatments per outcome. Our search identified fifteen eligible studies (5 studies comparing mTA + AM vs. CNI + AM, 9 comparing CNI + mTA vs. CNI + AM, 1 comparing mTA + AM vs. CNI + mTA, 8 using everolimus and 7 sirolimus as mTA) reporting the selected outcomes. We did not identify any statistical difference in all-cause mortality among the three IS regimens without heterogeneity among studies. CAV rates were significantly lower with CNI + mTA (odds ratio [OR] 0.53, 95% confidence interval [CI] 0.3-0.92). Acute rejection rates were significantly lower with CNI + AM (OR 0.26, 95% CI 0.12-0.56) and with CNI + mTA (OR 0.16, 95% CI 0.07-0.33) compared with mTA + AM without significant heterogeneity (I2 = 43%, p = 0.9). CMV infections were significantly lower with mTA + AM (OR 0.13, 95% CI 0.03-0.46) and with CNI + mTA (OR 0.27, 95% CI 0.2-0.38) compared with CNI + AM without heterogeneity. mTA + AM led to higher eGFR compared with CNI + AM (9.06 ml/min/1.73 m2, 95% CI 3.15-14.97) and CNI + Mta (9.64 ml/min/1.73 m2, 95% CI 0.91-18.36), but the heterogeneity among studies was significant. CNI + mTA ranked better for CAV (p = 0.78), and acute rejection (p = 0.99) while mTA + AM for CMV infection (p = 0.94) and improvement in renal function (p = 0.93) than other regimens. Different IS regimens have similar effects on survival post HT, but CNI + mTA was associated with lower CAV rates, and acute rejection, while mTA + AM with less CMV infection post HT.

Management of heart failure with reduced ejection fraction: challenges in patients with atrial fibrillation, renal disease and in the elderly.

Heart failure with reduced ejection fraction (HFrEF) is an increasing global pandemic affecting more than 30 million individuals worldwide. Importantly, HFrEF is frequently accompanied by the presence of cardiac and non-cardiac comorbidities that may greatly influence the management and prognosis of the disease. In this review article, we will focus on three important comorbidities in HFrEF; atrial fibrillation (AF), advanced renal disease, and elderly, which all have a paramount impact on progression of the disease, management strategies, and response to therapy. AF is very common in HFrEF and shares many risk factors. AF aggravates heart failure and contributes to HF-related adverse clinical outcomes; hence it requires special consideration in HFrEF management. The kidney function is largely affected by the reduced cardiac output developed in the setting of HFrEF, and the neurohormonal feedback effects create a complex interplay that pose challenges in the management of HFrEF when renal function is significantly impaired. Cardiorenal syndrome is a challenging sequela with increased morbidity and mortality thereby reflecting the delicate and complex balance between the heart and the kidney in HFrEF and renal failure conditions. Furthermore, patients with advanced renal failure have poor prognosis in the presence of HFrEF with limited treatment options. Finally, aging and frailty are important factors that influence treatment strategies in HFrEF with greater emphasis on tolerability and safety of the various HFrEF therapies in elderly individuals.

Outcomes of diabetic patients with end-stage heart failure listed for heart transplantation: A propensity-matched analysis.

BACKGROUND: We investigated the current trends and outcomes of diabetic patients listed for heart transplants in the U.S. and provided a method for risk-stratification. METHODS: Using data from the United Network for Organ Sharing (UNOS), we identified heart failure patients listed for heart transplants between 2010 and 2019. Diabetic patients were propensity-matched with non-diabetics, and waitlist mortality as well as post-transplant graft survival were compared between the two groups. Further risk-stratification of diabetic patients was done based on the risk factors that independently predict graft failure. RESULTS: 28,928 adult patients (30% diabetic) with end-stage heart failure were added to the waitlist over the study period. In the propensity-matched cohort, waitlist mortality was higher in diabetic patients compared to non-diabetics (HR = 1.13 (95% CI = 1.04-1.22, P = .002). Over the study period, 5739 patients with diabetes were transplanted. In the propensity-matched cohorts of transplant recipients, the rate of graft failure was significantly higher for diabetic patients (23.3%) compared to non-diabetics (20.4%); HR = 1.17, 95% CI = 1.08-1.26, P < .001. We identified 12 risk factors of graft failure among diabetic patients and developed a risk score that further risk-stratify these patients. Diabetic patients at low risk (score≤4) had similar graft survival as patients without diabetes (HR = .91, 95% CI = .82-1.01, P = .06). On the other hand, high-risk diabetic patients had worse graft survival compared to non-diabetics (HR = 1.52, 95% CI = 1.38-1.67, P < .001). CONCLUSION: Among patients with end-stage heart failure, pre-existing diabetes was associated with higher waitlist mortality and worse graft survival. However, with careful patient selection, graft survival is similar to those without diabetes.

Noninvasive measurement of arterial blood pressure in patients with continuous-flow left ventricular assist devices: a systematic review.

Accurate mean blood pressure determination is essential to prevent adverse events in patients with continuous-flow left ventricular assist devices (CFLVAD). We sought to evaluate the accuracy of noninvasive methods of blood pressure measurement compared with invasive intra-arterial recordings in patients with CFLVAD. Systematic electronic search was performed on four online databases (PubMed, Scopus, Embase, and Web of Knowledge) for the terms "Blood Pressure" AND ("Heart-Assist Devices" OR "Left ventricular Assist Devices"). Only studies that compared an intra-arterial and noninvasive blood pressure measurement were included. Electronic search of scientific literature identified 5968 articles. After deduplication, screening of titles and abstracts, full-text review, and excluding incorrect populations and comparator, a total of 12 studies with 502 participants were included, of those 402 participants who had intra-arterial blood pressure measurement. Doppler mean arterial blood pressure showed a very high correlation with mean intra-arterial blood pressure (r = 0.97, r = 0.87) in low pulsatility situations. When the pulsatility was not evaluated, the correlation was high moderate (r = 0.63, r = 0.741). In low pulsatility situations, the correlation was moderate to high moderate (r = 0.42 to r = 0.65). Oscillometer automatic blood pressure cuff showed a moderate to very high correlation with intra-arterial mean arterial blood pressure (r = 0.42, r = 0.86) but also could be low in the context of low pulsatility associated with inconsistent success in noninvasive measurement (r = 0.25). Studies correlating intra-arterial with noninvasive techniques were performed in the context of routine clinical care using fluid-filled catheters. The degree of correlation between both methods is at least moderate.

Chronic disease management in heart failure: focus on telemedicine and remote monitoring.

In the context of the COVID-19 pandemic, many barriers to telemedicine disappeared. Virtual visits and telemonitoring strategies became routine. Evidence is accumulating regarding the safety and efficacy of virtual visits to replace in-person visits. A structured approach to virtual encounters is recommended. Telemonitoring includes patient reported remote vital sign monitoring, information from wearable devices, cardiac implantable electronic devices and invasive remote hemodynamic monitoring. The intensity of the monitoring should match the risk profile of the patient. Attention to cultural and educational barriers is important to prevent disparities in telehealth implementation.

Impact of induction therapy on outcomes after heart transplantation.

BACKGROUND: Approximately 50% of heart transplant (HT) programs utilize induction therapy (IT) with interleukin-2 receptor antagonists (IL2RA) or polyclonal anti-thymocyte antibodies (ATG). METHODS: Adult HT recipients were identified in the UNOS Registry between 2010 and 2020. We compared mortality between IT strategies with competing risk analysis. RESULTS: A total of 28 634 HT recipients were included in the study (50.1% no IT, 21.3% ATG, 27.9% IL2RA, .7% alemtuzumab, .01% OKT3). Adjusted all-cause, 30 day and 1 year mortality were lower among those treated with IT than no IT (sub-hazard ratio [SHR] .87, 95% CI .79-.96, SHR .86, .76-.97, SHR .76, .63-.93, P = .007, respectively). In propensity score matching analysis IT was associated with lower 30-day and 1-year mortality. IL2RA had higher all-cause and 1-year mortality than ATG (SHR 1.41, 95% CI 1.23-1.69 and 1.55, 95% CI 1.29-1.88, respectively). Utilization of IT was associated with significantly lower risk of treated rejection at 1 year after HT compared with no IT (relative risk ratio [RRR] .79) and similarly ATG compared with IL2RA (RRR .51). CONCLUSION: IT was associated with lower mortality and treated rejection episodes than no IT. IL2RA is the most used IT approach but ATG has lower risk of treated rejection and mortality.

Comparative Effectiveness and Safety of Direct Oral Anticoagulants in Obese Patients with Atrial Fibrillation.

BACKGROUND: Unlike warfarin direct oral anticoagulants (DOACs) are administered in fixed doses, which raises concerns of its effectiveness on larger patients. Data from randomized trials are limited on the safety and efficacy of DOACs in morbidly obese individuals with atrial fibrillation (AF). METHODS: We analyzed a cohort of obese (≥ 120 kg) and morbidly obese (BMI > 40 kg/m2) patients from the Veterans Health Administration system with AF who initiated apixaban, rivaroxaban, dabigatran, or warfarin between years 2012 and 2018. We used inverse probability of treatment weighting (IPTW) and Cox proportional hazards regression models to evaluate the relative hazard of death, myocardial infarction (MI), ischemic stroke, heart failure (HF), and bleeding events between oral anticoagulant (OAC) groups while censoring for medication cessation. RESULTS: We identified 6052 obese patients on apixaban, 4233 on dabigatran, 4309 on rivaroxaban, and 13,417 on warfarin (mean age 66.7 years, 91% males, 80.4% whites). At baseline patients on apixaban had the lowest glomerular filtration rate and highest rates of previous stroke and MI compared to other OACs. Among patients with weight ≥ 120 kg and those with BMI > 40 kg/m2, all DOACs were associated with lower risk of any hemorrhage, hemorrhagic stroke, and gastrointestinal (GI) bleeding. Patients with BMI > 40 kg/m2 treated with DOACs had similar ischemic stroke risk with those on warfarin. CONCLUSIONS: In this large cohort of obese Veterans Health Administration system patients, the use of DOACs resulted in lower hemorrhagic complications than warfarin while maintaining efficacy on ischemic stroke prevention.

Temporal trends and outcomes of patients waiting on left ventricular assist devices and inotropes for heart transplantation.

We sought to evaluate the trends and outcomes of patients with left ventricular assist devices (LVADs) and inotropes at the time of listing for heart transplantation. Adults with an LVAD implanted and listed with 1A status were identified in the United Network for Organ Sharing (UNOS) registry between 2010 and 2017. Patients were grouped according to the presence or absence of inotropes at the time of listing and transplantation. A total of 2714 patients were included in the study including 664 patients on inotropes at the time of listing, 235 at the time of transplantation, and 118 on inotropes both at listing and at the time of transplantation. Patients on LVAD and inotropes at the time of listing were more frequently supported with a right ventricular assist device (RVAD) (P < .001), had higher risk of death in the waiting list (sub-hazard ratio [SHR] = 1.48, 95% CI 1.14-1.90, P = .002), and were less likely to be transplanted (SHR = 0.70, 95% CI 0.63-0.78, P < .001) compared with those not on inotropes, after adjusting for described confounders. Approximately 1 in 10 LVAD recipients listed as status 1A are on inotropic therapy at the time of heart transplantation. Patients on LVAD and inotropes have worse outcomes in terms of survival and lower rates of transplantation.

Characteristics and outcomes in patients with atrial fibrillation receiving direct oral anticoagulants in off-label doses.

BACKGROUND: We evaluated adherence to dosing criteria for patients with atrial fibrillation (AF) taking dabigatran or rivaroxaban and the impact of off-label dosing on thromboembolic and bleeding risk. METHODS: We used data for a retrospective cohort from a large U.S. health plan for Medicare beneficiaries age > =65 years with AF who initiated dabigatran or rivaroxaban during 2010-2016. Stroke and major bleeding were quantified in patients who were eligible for low dose but received standard dose, and in patients who were eligible for standard dose but received low dose. RESULTS: We identified 8035 and 19,712 patients who initiated dabigatran or rivaroxaban, respectively. Overall, 1401 (17.4%) and 7820 (39.7%) patients who received dabigatran and rivaroxaban met criteria for low dose, respectively. Of those, 959 (68.5%) and 3904 (49.9%) received standard dose. In contrast, 1013 (15.3%) and 2551 (21.5%) of patients eligible for standard dose dabigatran and rivaroxaban received low dose. Mean follow-up for patients eligible for low and standard dose dabigatran and rivaroxaban were 13.9, 15.1, 10.1, and 12.3 months, respectively. In unadjusted analyses, patients eligible for low or standard dose dabigatran and rivaroxaban but receiving off-label dose, had no differences in the rates of ischemic stroke. Among patients who met criteria for standard dose direct oral anticoagulants (DOAC), use of low dose was associated with significantly higher risk of any major bleeding (Dabigatran: HR = 1.44; 95% CI 1.14-1.8, P = 0.002, Rivaroxaban HR 1.34, 95% CI 1.11-1.6, P = 0.002) and gastrointestinal bleeding (Dabigatran: HR = 1.48; 95% CI 1.08-2, P = 0.016). In patients who met criteria for low dose DOACs, there was lower risk of major bleeding (Dabigatran: HR = 0.59; 95% CI 0.43-0.8, P < 0.001), gastrointestinal (Rivaroxaban: HR 0.79; 95% CI 0.64-0.98, P = 0.03) and intracranial bleeding (Dabigatran: HR = 0.33; 95% CI 0.12-0.9, P = 0.001) with standard dosing. After propensity matching, use of off-label doses was not associated with stroke, major, gastrointestinal or intracranial bleeding for either dabigatran or rivaroxaban. CONCLUSIONS: While a significant number of patients receive higher or lower dose of dabigatran and rivaroxaban than recommended, we found no evidence of significant impact on thromboembolic or hemorrhagic outcomes.

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.

Cardiac resynchronization therapy and outcomes in patients with left ventricular assist devices: a systematic review and meta-analysis.

The impact of cardiac resynchronization therapy (CRT) on clinical outcome in patients with a continuous-flow left ventricular assist device (LVAD) is currently not well understood. We conducted a systematic literature review and meta-analysis with an intention to summarize all published clinical evidence. We searched MEDLINE and EMBASE databases through March 2018 for studies that compared the outcomes in patients with LVAD and CRT. Pooled odds ratios (OR) and 95% confidence intervals (CI) were calculated using a random-effects model, inverse variance method. The between-study heterogeneity was assessed using the Q statistic and I2. A total of seven studies that included 1157 (575 CRT; 582 non-CRT) patients were identified. Our meta-analysis did not demonstrate a significant difference in the risk of mortality (pooled OR = 1.21, 95% CI 0.90-1.63, P = 0.21), ventricular arrhythmia incidence (pooled OR = 1.36, 95% CI 0.99-1.86, P = 0.06), hospitalization (pooled OR = 1.36, 95% CI 0.59-3.14, P = 0.48), or implantable cardioverter defibrillator therapies (pooled OR = 1.08, 95% CI 0.51-2.30, P = 0.84) among the CRT group compared with the non-CRT group. There was high heterogeneity with an I2 of 75% for ICD therapies. Among LVAD patients, CRT combined did not significantly affect mortality, re-hospitalization, ventricular arrhythmia incidence, and ICD therapies.

Procedural Outcomes of Patients With Heart Failure Undergoing Catheter Ablation of Atrial Fibrillation.

BACKGROUND: Catheter ablation is being increasingly performed for rhythm control of atrial fibrillation (AF). Heart failure (HF) frequently coexists with AF because they share common risk factors. STUDY QUESTION: This study aims at identifying the characteristics and procedural outcomes of patients with HF undergoing catheter ablation of AF. STUDY DESIGN: In this retrospective cohort study, we analyzed 264 consecutive patients who underwent catheter ablation for AF. Seventy-three patients (28%) had a known history of stage C HF either with reduced ejection fraction or preserved ejection fraction. MEASURES AND OUTCOMES: We compared procedural outcomes between patients who had known HF with those who did not. RESULTS: Patients with HF were more likely to have higher rates of atrial fibrillation recurrence at both 3 months (odds ratio 2.9, confidence interval = 1.5-5.7, P = 0.0022) and 1 year after the procedure (odds ratio 2.3, confidence interval 1.2-4.3, P = 0.0097) and risk factors for recurrence of AF including left atrial enlargement, persistent AF, and a higher CHA2DS2-VASc score. However, on logistic regression analysis adjusting for left atrial size, atrial fibrillation type (persistent vs. paroxysmal), and CHA2DS2-VASc score as covariates, there was no significant difference in AF recurrence rates at both 3 months and 1 year. Recurrence rates did not differ significantly between patients with HF either with reduced ejection fraction or preserved ejection fraction. Among patients with paroxysmal AF, HF was predictive of AF recurrence at both 3 months and 1 year after ablation. The procedure length was longer in patients with HF, but there were no differences in periprocedural complications. CONCLUSION: Patients with HF undergoing catheter ablation of AF tend to have more risk factors for recurrence, but after adjustment for risk factors, the recurrence rates were similar at 3 months and 1 year. Among patients with paroxysmal atrial fibrillation, HF was predictive of higher recurrence rates.

Burden and consequences of retained cardiovascular implantable electronic device lead fragments after heart transplantation.

We performed a retrospective review of 402 consecutive patients who underwent heart transplantation at our institution between January 2009 and March 2017. A retained cardiovascular implantable electronic device (CIED) fragment was identified after transplantation in 49 of the 301 patients (16.2%) with CIED at baseline. Patients with retained fragments had leads with longer dwell times (median 2596 [1982, 3389] vs 1384 [610, 2202] days, P < .001), higher prevalence of previously abandoned leads (14.3% vs 2.8%, P = .003), and dual-coil defibrillator leads (98% vs 81%, P = .001) compared with patients without retained fragments. Five patients (10%) with retained CIED fragments underwent magnetic resonance imaging without adverse events. There was no difference in overall mortality between patients with and without CIED fragments (12% vs 11%, P = .81) Patients with retained fragments located in the superior vena cava had significantly higher fluoroscopic times (3.3 vs 2.9 minutes, P = .024) during subsequent endomyocardial biopsies. In a competing risk analysis, presence of a retained CIED fragment was associated with upper extremity deep venous thrombosis (sub hazard ratio [HR] 2.19, 95% confidence interval [CI] 1.17-4.10, P = .014) but not bloodstream infection after adjusting for potential confounders. In summary, retained CIED fragments are common after heart transplantation, and are associated with longer radiation exposure during biopsy procedures and upper extremity deep venous thrombosis.