Factor Eight Inhibitor Bypassing Activity as First-line Therapy for Coagulopathy in Cardiac Surgery.

OBJECTIVES: To compare the outcomes of factor eight inhibitor bypassing activity (FEIBA) versus fresh frozen plasma (FFP) as the primary treatment for postoperative coagulopathy in patients undergoing cardiac surgery. DESIGN: A retrospective, propensity-matched study. SETTING: A single, tertiary hospital. PARTICIPANTS: Patients who underwent noncoronary cardiac surgery with cardiopulmonary bypass between 2015 and 2023. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: We stratified patients into 2 groups based on whether they received intraoperative FFP or FEIBA; cases using both were excluded. We analyzed 434 cases, with 197 receiving FFP and 237 receiving FEIBA. After propensity matching, there was no significant difference in the proportion of the patients who required packed red blood cell transfusions (p = 0.08). However, of those who required packed red blood cell transfusions, patients in the FEIBA group required significantly fewer units of packed red blood cells (p < 0.001). Significantly fewer patients in the FEIBA group required platelet (p < 0.001) and cryoprecipitate (p < 0.001) transfusions. The FEIBA group showed decreased prolonged postoperative intubation (p = 0.05), decreased intensive care unit length of stay (p = 0.04), and lower 30-day readmission rates (p = 0.03). There were no differences in the rates of thrombotic complications between the 2 cohorts. CONCLUSIONS: In the initial treatment of postcardiopulmonary bypass coagulopathy, FEIBA may be more effective than FFP in decreasing blood product transfusions and readmission rates. Further studies are needed to explore the potential routine use of FEIBA as first-line agent in this patient population.

Low respiratory quotient correlates with high mortality in patients undergoing mechanical ventilation.

OBJECTIVE: Oxygen consumption (VO2), carbon dioxide generation (VCO2), and respiratory quotient (RQ), which is the ratio of VO2 to VCO2, are critical indicators of human metabolism. To seek a link between the patient's metabolism and pathophysiology of critical illness, we investigated the correlation of these values with mortality in critical care patients. METHODS: This was a prospective, observational study conducted at a suburban, quaternary care teaching hospital. Age 18 years or older healthy volunteers and patients who underwent mechanical ventilation were enrolled. A high-fidelity automation device, which accuracy is equivalent to the gold standard Douglas Bag technique, was used to measure VO2, VCO2, and RQ at a wide range of fraction of inspired oxygen (FIO2). RESULTS: We included a total of 21 subjects including 8 post-cardiothoracic surgery patients, 7 intensive care patients, 3 patients from the emergency room, and 3 healthy volunteers. This study included 10 critical care patients, whose metabolic measurements were performed in the ER and ICU, and 6 died. VO2, VCO2, and RQ of survivors were 282 +/- 95 mL/min, 202 +/- 81 mL/min, and 0.70 +/- 0.10, and those of non-survivors were 240 +/- 87 mL/min, 140 +/- 66 mL/min, and 0.57 +/- 0.08 (p = 0.34, p = 0.10, and p < 0.01), respectively. The difference of RQ was statistically significant (p < 0.01) and it remained significant when the subjects with FIO2 < 0.5 were excluded (p < 0.05). CONCLUSIONS: Low RQ correlated with high mortality, which may potentially indicate a decompensation of the oxygen metabolism in critically ill patients.

Impact of Limited Enhanced Recovery Pathway for Cardiac Surgery: A Single-Institution Experience.

OBJECTIVES: Enhanced recovery pathway (ERP) refers to extensive multidisciplinary, evidence-based pathways used to facilitate recovery after surgery. The authors assessed the impact that limited ERP protocols had on outcomes in patients undergoing cardiac surgery at their institution. DESIGN: A retrospective cohort study. SETTING: This study was a single-institution study conducted at a university hospital. PARTICIPANTS: Patients undergoing open adult cardiac surgery. INTERVENTIONS: Enhanced recovery pathways limited to preoperative, intraoperative, and postoperative management of pain, atrial fibrillation prevention, and nutrition optimization were implemented. MEASUREMENTS AND MAIN RESULTS: A total of 1,058 patients were included in this study. There were 374 patients in each pre- and post-ERP cohort after propensity matching, with no significant baseline differences between the 2 cohorts. Compared to the matched patients in the pre-ERP group, patients in the post-ERP group had decreased total ventilation hours (6.8 v 7.8, p = 0.006), less use of postoperative opioid analgesics as determined by total morphine milligram equivalent (32.5 v 47.5, p < 0.001), and a decreased rate of postoperative atrial fibrillation (23.3% v 30.5%, p = 0.032). Post-ERP patients also experienced less subjective pain and postoperative nausea and drowsiness as compared to their matched pre-ERP cohorts. CONCLUSIONS: Limited ERP implementation resulted in significantly improved perioperative outcomes. Patients additionally experienced less postoperative pain despite decreased opioid use. Implementation of ERP, even in a limited format, is a promising approach to improving outcomes in patients undergoing cardiac surgery.

Continuous and repeat metabolic measurements compared between post-cardiothoracic surgery and critical care patients.

OBJECTIVE: Using a system, which accuracy is equivalent to the gold standard Douglas Bag (DB) technique for measuring oxygen consumption (VO2), carbon dioxide generation (VCO2), and respiratory quotient (RQ), we aimed to continuously measure these metabolic indicators and compare the values between post-cardiothoracic surgery and critical care patients. METHODS: This was a prospective, observational study conducted at a suburban, quaternary care teaching hospital. Age 18 years or older patients who underwent mechanical ventilation were enrolled. RESULTS: We included 4 post-surgery and 6 critical care patients. Of those, 3 critical care patients died. The longest measurement reached to 12 h and 15 min and 50 cycles of repeat measurements were performed. VO2 of the post-surgery patients were 234 ± 14, 262 ± 27, 212 ± 16, and 192 ± 20 mL/min, and those of critical care patients were 122 ± 20, 189 ± 9, 191 ± 7, 191 ± 24, 212 ± 12, and 135 ± 21 mL/min, respectively. The value of VO2 was more variable in the post-surgery patients and the range of each patient was 44, 126, 71, and 67, respectively. SOFA scores were higher in non-survivors and there were negative correlations of RQ with SOFA. CONCLUSIONS: We developed an accurate system that enables continuous and repeat measurements of VO2, VCO2, and RQ. Critical care patients may have less activity in metabolism represented by less variable values of VO2 and VCO2 over time as compared to those of post-cardiothoracic surgery patients. Additionally, an alteration of these values may mean a systemic distinction of the metabolism of critically ill patients.

Simultaneous Heart-Kidney Transplant-Does Hospital Experience With Heart Transplant or Kidney Transplant Have a Greater Impact on Patient Outcomes?

High institutional transplant volume is associated with improved outcomes in isolated heart and kidney transplant. The aim of this study was to assess trends and outcomes of simultaneous heart-kidney transplant (SHKT) nationally, as well as the impact of institutional heart and kidney transplant volume on survival. All adult patients who underwent SHKT between 2005-2019 were identified using the United Network for Organ Sharing (UNOS) database. Annual institutional volumes in single organ transplant were determined. Univariate and multivariable analyses were conducted to assess the impact of demographics, comorbidities, and institutional transplant volumes on 1-year survival. 1564 SHKT were identified, increasing from 54 in 2005 to 221 in 2019. In centers performing SHKT, median annual heart transplant volume was 35.0 (IQR 24.0-56.0) and median annual kidney transplant volume was 166.0 (IQR 89.5-224.0). One-year survival was 88.4%. In multivariable analysis, increasing heart transplant volume, but not kidney transplant volume, was associated with improved 1-year survival. Increasing donor age, dialysis requirement, ischemic times, and bilirubin were also independently associated with reduced 1-year survival. Based on this data, high-volume heart transplant centers may be better equipped with managing SHKT patients than high-volume kidney transplant centers.

Impact of age on outcomes after transcatheter aortic valve implantation.

AIMS: Usage of transcatheter aortic valve implantation (TAVI) for treatment of severe aortic stenosis is increasing across age groups. However, literature on age-specific TAVI outcomes is lacking. The purpose of this study is to assess the risks of procedural complications, mortality, and readmission in patients undergoing TAVI across different age groups. METHODS AND RESULTS: The Nationwide Readmissions Database was used to identify 84 017 patients undergoing TAVI from 2016 to 2018. Patients were stratified into four age groups: younger than 70, 70-79, 80-89, and older than 90. Complications, mortality, and readmission rates were compared between groups in a proportional hazards regression model. Risk of post-procedural stroke, acute kidney injury, and pacemaker or implantable cardioverter defibrillator implantation increased with incremental age grouping. Compared with patients younger than 70, patients aged 70-79 had no significant difference in mortality, whereas patients aged 80-89 and older than 90 had an increased mortality risk [odds ratio (OR) 1.39, confidence interval (CI) 1.14-1.70, P = 0.001 and OR 1.68, CI 1.33-2.12, P < 0.001, respectively]. Patients aged 80-89 and older than 90 had increased overall readmission compared with patients younger than 70 (HR 1.09, CI 1.03-1.14, P = 0.001 and HR 1.33, CI 1.25-1.41, P < 0.001, respectively). Cardiac readmissions followed the same trend. CONCLUSION: Patients aged 80-89 and older than 90 undergoing TAVI have increased risk of readmission, complications, and mortality compared with patients younger than 70.

Patient Satisfaction Scores After Cardiac Surgery: Should They Be Risk-Adjusted?

The Hospital Consumer Assessment of Health Care Providers and Systems (HCAHPS) is a survey tool that quantifies patient satisfaction after hospitalization. We sought to interrogate our HCAHPS results in order to identify any association between preoperative health, type of operation, and postoperative outcomes, with patient satisfaction after cardiac surgery. Of 12,572 patients who underwent cardiac surgery between December 2012 and December 2019, 2587 patients (20.6%) completed the HCAHPS survey. Patient satisfaction was quantified using HCAHPS responses, focused on 'top-box' rating in nursing care, physician care, hospital environment, and overall hospital rating, as primary endpoints. Multivariable logistic regression was used to identify those variables associated with top-box scores. Elevated patient risk, as measured by the Society of Thoracic Surgeons (STS) risk score in 2112 patients, was predictive of lower rates of top-box responses in nursing care (OR 0.963, P = 0.003), physician care (OR 0.96, P = 0.002), and overall hospital rating (OR 0.97, P = 0.007). Major postoperative complications were associated with lower patient satisfaction for nursing care (OR 0.67, P = 0.038), physician care (OR 0.59, P = 0.012), and overall hospital rating (OR 0.64, P = 0.035); length of stay ≥ 6 days was associated with increased patient satisfaction for nursing care (OR 1.45, P < 0.001). Increased preoperative risk and postoperative complications are associated with lower rates of top-box patient satisfaction scores after cardiac surgery. When assessing patient satisfaction after cardiac surgery, we suggest that a preoperative risk profile be considered.

Short- and Mid-Term Outcomes of Complex and High-Risk Versus Standard Percutaneous Coronary Interventions in Patients Undergoing Transcatheter Aortic Valve Replacement.

BACKGROUND: The prevalence of coronary artery disease (CAD) in patients undergoing TAVR varies and is associated with increased morbidity and mortality. We evaluated the outcomes of complex and high-risk percutaneous coronary interventions (CHIP-PCIs) and TAVR compared with standard PCI and TAVR. Between January 2014 and March 2021, a total of 276 consecutive patients with severe aortic stenosis (AS) who underwent TAVR and PCI at 3 centers within Northwell Health were retrospectively reviewed. CHIP-PCI was defined as PCI with one of the following: left ventricular ejection fraction (LVEF) <30%; left main coronary artery (LMCA)/chronic total occlusion (CTO) intervention; atherectomy; or need for left ventricular (LV) support. One hundred twenty- seven patients (46%) had CHIP-PCI prior to TAVR and 149 patients (54%) had standard PCI. Thirteen percent of CHIP-PCI and 22% of standard PCI cases were done concomitantly with TAVR. CHIP-PCI criteria were met for low EF (19%), LMCA (25%), CTO (3%), LV support (20%), and atherectomy (50%). The types of valves used were similarly divided (49% balloon expandable vs 51% self expanding. Major adverse cardiac or cerebrovascular event (MACCE) rate for CHIP-PCI/TAVR was 4.9% at 30 days vs 1.3% for standard PCI/TAVR (P=.09), driven by in-hospital stroke. At 1 year, the rates of MACCE for CHIP-PCI/TAVR remained higher than for standard PCI/TAVR, but was not statistically significant (8.7% vs 4%; P=.06), driven by revascularization. We found no differences between major and/or minor vascular complications. New York Heart Association classification at 1 month was similar (I/II 93% vs 95%; P=.87). Our study suggests that CHIP-PCI can be safely performed in patients with complex CAD and concomitant severe AS.

Factor eight inhibitor bypassing activity for refractory bleeding in coronary artery bypass grafting: A propensity-matched analysis.

Background: Perioperative bleeding and transfusion have been associated with major morbidity and mortality after cardiac surgery. As concerns remain regarding potential graft thrombosis following administration of a prothrombin factor concentrate, the use of factor eight inhibitor bypassing activity (FEIBA) in managing refractory postoperative bleeding has never been evaluated in patients undergoing isolated coronary artery bypass grafting (CABG). Objectives: We aimed to examine the safety of FEIBA in patients undergoing isolated CABG, with respect to 30-day mortality, perioperative outcomes, and thrombotic complications. Methods: A retrospective review was undertaken of all consecutive patients who had undergone isolated on-pump CABG between January 2015 and December 2019 at North Shore University Hospital. Patients requiring intraoperative extracorporeal membrane oxygenator support were excluded. Patients were divided into two groups, dependent upon whether they received FEIBA (n = 63) versus no FEIBA (n = 2493). A 1:5 propensity match analysis was employed, and patients were analyzed with respect to thrombotic complications, reintervention for myocardial ischemia, and short-term clinical outcomes. Results: There was no difference in 30-day mortality between the two cohorts. There was also no significant difference in a composite of thrombotic complications (composed of deep vein thrombosis, pulmonary embolism, and stroke) between the two groups. Similarly, there was no significant difference in the requirement for postoperative reintervention for myocardial ischemia between patients who received FEIBA versus those who did not. Conclusions: Factor eight inhibitor bypassing activity may be safe when used as rescue therapy for refractory bleeding following isolated CABG.

Suction-based catheter retrieval of right ventricular clot-in-transit.

Right ventricular clot-in-transit (CIT) is a rare finding in venous thromboembolic disease and carries a high mortality rate. Its optimal treatments have yet to be established in the literature. Here we describe the usage of a suction-based catheter, the INARI FlowTriever® system (INARI Medical Inc.) to successfully retrieve a CIT from the right ventricle of a patient with coronavirus disease 2019 acute respiratory distress syndrome on veno-veno extracorporeal membrane oxygenation.

Survival and readmission among patients with advanced cardiomyopathy undergoing transcatheter edge-to-edge mitral valve repair: Are we applying COAPT findings too broadly?

OBJECTIVE: Transcathether edge-to-edge mitral valve repair (TEER) has been shown to be an effective treatment for secondary mitral regurgitation (MR). However, the outcomes of TEER in patients with severe cardiomyopathy is less clear. The objective of this study is to determine the outcomes of such patients who underwent TEER at our institution. METHODS: A retrospective review of patients with severe cardiomyopathy, defined as ejection fraction ≤30% or the requirement of inotropic support preoperatively, undergoing TEER for secondary MR at our institution from 11/2016 to 11/2020 was performed. Univariate analysis associating preoperative characteristics with our primary endpoint of 1-year death or orthotopic heart transplant (OHT) was performed. Kaplan-Meier analysis was conducted for the composite outcome of death or OHT, as well as for heart failure-related readmission. Finally, an assessment of changes in MR severity from the preoperative, to immediate postoperative period, to 30-day postoperative period was conducted. RESULTS: There were 48 patients identified. Median age was 74.5 years (IQR 65.5-79.5), median ejection fraction was 21.5% (IQR 16.0-27.5), and 81.4% of patients had severe or torrential mitral regurgitation preoperatively. The composite endpoint of 1-year mortality or OHT occurred in 15 of 48 patients (31.3%, 14 deaths and 1 OHT). One-year heart failure readmission rate was 47.9%. Mortality or OHT at 2 years occurred in 45.8%. CONCLUSION: Patients at extremes of heart failure who underwent TEER had poor outcomes when assessed at 1-year. Our study may suggest that the results of cardiovascular outcomes assessment of the mitraclip percutaneous therapy for heart failure patients with secondary mitral regurgitation may not be applicable to patients with severe cardiomyopathy.

Use of TIMP-2 and IGFBP-7 for prediction of postoperative acute kidney injury after cardiac surgery.

BACKGROUND: The following cell cycle arrest urinary biomarkers, tissue inhibitor of metalloproteinases-2 (TIMP-2) and insulin-like growth factor-binding protein 7 (IGFBP-7), have been used for early detection of acute kidney injury (AKI) in critically ill patients. The purpose of this study is to validate the use of these urinary biomarkers in patients undergoing open heart surgery. MATERIALS AND METHODS: In a single-center prospective observational study, urine samples were collected in 108 consecutive patients who underwent open heart surgery immediately after separation from cardiopulmonary bypass and on postoperative day 1, and were sent for the biomarker [TIMP-2]*[IGFBP7] analysis. Acute kidney injury was defined based on KDIGO criteria, and levels of [TIMP-2]*[IGFBP7] were analyzed for the ability to predict AKI. RESULTS: Of the 108 patients, 19 (17.6%) patients developed postoperative AKI within 48 hours of surgery. At the threshold of > 0.3 (ng/mL)2/1,000, post-cardiopulmonary bypass [TIMP-2]*[IGFBP-7] had a sensitivity of 13% and specificity of 82% for predicting postoperative AKI. Postoperative day-1 [TIMP-2]*[IGFBP-7] had a sensitivity of 47% and a specificity of 59% for predicting postoperative AKI. There were no differences in [TIMP-2]*[IGFBP-7] values at either timepoint between patients who developed postoperative AKI as compared to those who did not. CONCLUSION: Urinary [TIMP-2]*[IGFBP7] was not predictive of the risk of AKI after cardiac surgery in this single-center study population.

An Automation System Equivalent to the Douglas Bag Technique Enables Continuous and Repeat Metabolic Measurements in Patients Undergoing Mechanical Ventilation.

PURPOSE: To develop a system that is equivalent to the gold standard Douglas Bag (DB) technique for measuring oxygen consumption (V̇o2), carbon dioxide generation (V̇co2), and respiratory quotient (RQ) and to validate its use in clinical settings. METHODS: This was a prospective, observational study conducted at a suburban, quaternary care teaching hospital. Healthy volunteers and patients 18 years or older who received mechanical ventilation were enrolled. FINDINGS: Data from 3 healthy volunteers and 7 patients were analyzed in this study. The interrater reliability between the automation device and DB methods were 0.999, 0.993, and 0.993 for V̇o2, V̇co2, and RQ, respectively. In healthy volunteers, mean (SD) V̇o2, V̇co2, and RQ measured by DB were 411 (100) mL/min, 288 (79) mL/min, and 0.70 (0.03) at high fraction of inspired oxygen (Fio2) and 323 (46) mL/min, 280 (45) mL/min, and 0.85 (0.05) at normal Fio2, respectively. V̇o2 was significantly higher (P < 0.05) and RQ was lower (P < 0.01) in the high Fio2 group as compared to those in the normal Fio2 group. Values measured by the automation system were 227 (31) mL/min, 141 (18) mL/min, and 0.62 (0.04) at high Fio2 and 209 (25) mL/min, 147 (18) mL/min, and 0.70 (0.06) at normal Fio2, respectively. RQ was significantly lower (P < 0.05) in the high Fio2 group as compared to the normal Fio2 group. We also successfully performed continuous and repeat measurements by using the device. The longest measurement reached 12 hours 15 minutes, including 50 cycles of repeat measurements that are equivalent to the DB technique as described above. IMPLICATIONS: We developed an automation system that enables repeat measurements of V̇o2, V̇co2, and RQ, and the accuracy was equivalent to the DB technique. High Fio2 may decrease RQ because of an increase in V̇o2.

Age, sex, and contemporary outcomes in surgical repair of type A aortic dissection: Insights from the National Inpatient Sample.

Objective: Acute type A aortic dissection (ATAAD) is a surgical emergency with significant morbidity and mortality, as well as significant center-level variation in outcomes. Our study aims to leverage a nationally representative database to assess contemporary in-hospital outcomes in surgical repair of ATAAD, as well as the association of age and sex with outcomes. Methods: The National Inpatient Sample was queried to identify hospital discharge records of patients aged ≥18 years who underwent urgent surgical repair of ATAAD between 2017 and 2018. Patients with a diagnosis of thoracic aortic dissection, who underwent surgical intervention of the ascending aorta, were identified. Patient demographics were assessed, and predictors of in-hospital mortality were identified. Results: We identified 7805 weighted cases of surgically repaired ATAAD nationally, with an overall mortality of 15.3%. Mean age was 60.0 ± 13.6 years. There was a male predominance, although female subjects made up a larger proportion of older age groups-female subjects up 18.4% of patients younger than 40 years with ATAAD but 53.6% of patients older than 80 years. In multivariable analysis controlling for sex, race, comorbidities, and malperfusion, age was a significant predictor of mortality. Patients aged 71 to 80 years had a 5.3-fold increased risk of mortality compared with patients ≤40 years old (P < .001), and patients aged >80 years had a 6.8-fold increased risk of mortality (P < .001). Sex was not significantly associated with mortality. Conclusions: Surgical repair of ATAAD continues to carry high risk of morbidity and mortality, with outcomes impacted significantly by patient age, regardless of patient comorbidity burden.

Contemporary national utilization of extracorporeal cardiopulmonary resuscitation (ECPR) for out-of-hospital cardiac arrest.

OBJECTIVE: The utilization of extracorporeal membrane oxygenation (ECMO) during cardiopulmonary resuscitation (ECPR) has demonstrated promising evidence for the management of out-of-hospital cardiac arrest (OHCA). We aim to describe contemporary utilization and predictors of survival of patients receiving ECPR for OHCA. METHODS: The National Inpatient Sample (NIS) was queried to identify hospital discharge records of patients aged ≥18 years who underwent ECPR from 2012 to 2017. Patients with an International Classification of Diseases, Tenth Revision, Clinical Modification diagnosis of cardiac arrest, admitted urgently and placed on ECMO on Day 0 of hospitalization, were selected. Patients with a primary diagnosis indicative of veno-venous ECMO were excluded. Predictors of mortality were assessed using multivariable analyses. RESULTS: There were 1675 cases of ECPR, increasing from 185 cases in 2012 to 400 in 2017 (p < .001). Overall mortality was 63.3%, which remained stable over time (p = .441). Common diagnoses included ST-elevation myocardial infarction (39.1%), non-ST-elevation myocardial infarction (9.3%), and pulmonary embolism (13.7%). Percutaneous coronary intervention was performed in 495 patients (29.6%); coronary artery bypass grafting was performed in 125 patients (7.5%). In multivariable analysis, decreased age, female gender, and left ventricular (LV) decompression were associated with reduced mortality. CONCLUSION: Utilization of ECPR is increasing nationally with stable mortality rates. Younger age, female gender, and utilization of LV decompression were associated with increased survival.

Association between multimodality measures of aortic stenosis severity and quality-of-life improvement outcomes after transcatheter aortic valve replacement.

AIMS: Up to 40% of patients with aortic stenosis (AS) present with discordant grading of AS severity based on common transthoracic echocardiography (TTE) measures. Our aim was to evaluate the utility of TTE and multi-detector computed tomography (MDCT) measures in predicting symptomatic improvement in patients with AS undergoing transcatheter aortic valve replacement (TAVR). METHODS AND RESULTS: A retrospective review of 201 TAVR patients from January 2017 to November 2018 was performed. Pre- and post-intervention quality-of-life was measured using the Kansas City Cardiomyopathy Questionnaire (KCCQ-12). Pre-intervention measures including dimensionless index (DI), stroke volume index (SVI), mean transaortic gradient, peak transaortic velocity, indexed aortic valve area (AVA), aortic valve calcium score, and AVA based on hybrid MDCT-Doppler calculations were obtained and correlated with change in KCCQ-12 at 30-day follow-up. Among the 201 patients studied, median KCCQ-12 improved from 54.2 pre-intervention to 85.9 post-intervention. In multivariable analysis, patients with a mean gradient >40 mmHg experienced significantly greater improvement in KCCQ-12 at follow-up than those with mean gradient ≤40 mmHg (28.1 vs. 16.4, P = 0.015). Patients with MDCT-Doppler-calculated AVA of ≤1.2 cm2 had greater improvements in KCCQ-12 scores than those with computed tomography-measured AVA of >1.2 cm2 (23.4 vs. 14.1, P = 0.049) on univariate but not multivariable analysis. No association was detected between DI, SVI, peak velocity, calcium score, or AVA index and change in KCCQ-12. CONCLUSION: Mean transaortic gradient is predictive of improvement in quality-of-life after TAVR. This measure of AS severity may warrant greater relative consideration when selecting the appropriateness of patients for TAVR.

Racial and socioeconomic disparities in urgent transcatheter mitral valve repair: A National Inpatient Sample analysis.

BACKGROUND: Cardiac interventions performed urgently are known to be associated with poor outcomes compared with electively performed procedures. Transcatheter edge-to-edge mitral valve repair (TMVr) has developed as a reasonable alternative to mitral valve surgery in certain patient populations. We aimed to leverage a national database to identify predictors of urgent versus elective TMVr, as well as the association between urgency and outcomes. METHODS: The National Inpatient Sample (NIS) was queried to identify patients who underwent TMVr from 2016 to 2017. Hospitalizations were identified within the database as elective versus nonelective. Univariate and multivariable analyses were performed to identify patient characteristics associated with urgent procedures. In-hospital outcomes were assessed. RESULTS: There were 10,195 cases of TMVr in this cohort, 24.2% of which were performed urgently. In multivariable analysis, Hispanic race, Medicaid insurance, and low income were associated with increased likelihood of urgent hospital admission and TMVr. Additionally, small hospital size and Northeast region were associated with increased likelihood of urgent admission and procedure. Urgent TMVr was associated with increased mortality (4.5% vs. 1.6%, p < .001), prolonged length of stay (6.0 vs. 2.0, p < .001), and increased cost ($71,451.90 vs. $44,981.20, p < .001). CONCLUSIONS: Racial and socioeconomic disparities exist in the utilization of TMVr as an urgent versus elective procedure, suggesting differences in access to surveillance and preventive care. Urgent TMVr is associated with increased morbidity and mortality, prolonged length of stay, and increased hospital costs. Priority should be placed on mitigating such disparities to improve outcomes.