Left atrial appendage closure device outcomes among cirrhosis patients with atrial fibrillation: a United States National Cohort Study.

AIMS: Literature regarding outcomes associated with atrial fibrillation among cirrhosis patients who had left atrial appendage occlusion (LAAO) device procedure is limited. We aim to evaluate the in-hospital clinical outcomes and 30-day readmissions among LAAO with and without cirrhosis. METHODS AND RESULTS: We performed a retrospective study of all hospitalizations associated with the LAAO procedure, using the Nationwide Readmissions Database for the years 2016-19. Primary outcomes were in-hospital clinical outcomes and 30-day readmissions. A total of 54 897 index hospitalizations for LAAO (female 41.8%) were reported. Of these, 905(1.65%) had cirrhosis. Gastrointestinal (GI) bleeding was reported in 44 (4.9%) vs. 1606 (2.97%) and coagulopathy in 21 (2.3%) vs. 521 (0.96%) in cirrhosis and without-cirrhosis groups, respectively. A total of 872 (1.59%) patients needed blood transfusion, 24 (2.7%) vs. 848(1.57%) in cirrhosis vs. without-cirrhosis groups (P = 0.047). Fresh frozen plasma (FFP) transfusion was reported among 888 (1.62%), with cirrhosis 26 (3%) vs. without cirrhosis 862 (1.6%) (P = 0.05). On adjusted multivariate logistic regression analysis, acute kidney injury, coagulopathy, FFP transfusion, and blood transfusion were strongly associated with cirrhosis, and GI bleeding, ischaemic stroke, and intracranial haemorrhage were not associated with cirrhosis. Readmissions in 30 days were 5028 (9.18%), 167 (18.5%) in the cirrhosis group and 4861 (9%) without-cirrhosis group (P = 0.01). On multivariate Cox regression, CHA2DS2-Vasc score of six was significantly associated with 30-day readmission compared with other scores [hazard ratio 2.24; 95% confidence interval (1.58-3.16); P < 0.001]. CONCLUSION: Left atrial appendage occlusion procedure in patients with cirrhosis had relatively similar GI bleeding and stroke rates, however, had higher rates of 30-day readmission. A higher CHA2DS2-Vasc score was more likely to be associated with 30-day readmissions and hence would help in discharge planning. The long-term safety and efficacy of LAAO in the cirrhosis population need to be demonstrated.

Endovascular Transcatheter Aortic Valve Replacement Outcomes in Hypertrophic Cardiomyopathy: Insights from the National Inpatient Sample (2014-2018).

BACKGROUND: Outcomes of patients with hypertrophic cardiomyopathy (HCM) following transcatheter aortic valve replacement (TAVR) remain largely unknown. OBJECTIVES: This study sought to assess the clinical characteristics and outcomes of HCM patients following TAVR. METHODS: We queried the National Inpatient Sample from 2014 to 2018 for TAVR hospitalizations with and without HCM, creating a propensity-matched cohort to compare outcomes. RESULTS: 207,880 patients that underwent TAVR during the study period, 810 (0.38%) had coexisting HCM. In the unmatched population, TAVR patients with HCM compared to those without HCM, were more likely to be female, had a higher prevalence of heart failure, obesity, cancer, and history of pacemaker/implantable cardioverter defibrillation, and were more likely to have nonelective and weekend admissions (p for all <0.05). TAVR patients without HCM had higher prevalence of coronary artery disease, prior percutaneous coronary intervention, prior coronary artery bypass grafting, and peripheral arterial disease compared to their counterparts (p for all <0.05). In the propensity-matched cohort, TAVR patients with HCM had significantly higher incidence of in-hospital mortality, acute kidney injury/hemodialysis, bleeding complications, vascular complications, permanent pacemaker requirement, aortic dissection, cardiogenic shock, and mechanical ventilation requirement. CONCLUSION: Endovascular TAVR in HCM patients is associated with an increased incidence of in-hospital mortality and procedural complications.

ST-elevation myocardial infarction among cardiac amyloidosis patients; a national readmission database study.

Literature regarding recent trends, mortality outcomes of ST-elevation myocardial infarction (STEMI) in cardiac amyloidosis (CA) patients is limited.To study coronary interventions, and trends in prevalence and mortality outcomes among CA patients with STEMI.Data from the national readmissions database (NRD) sample that constitutes 49.1% of the stratified sample of all hospitals in the USA, representing more than 95% of the national population, were analyzed for hospitalizations associated with CA with STEMI. A linear p-trend was used to assess the trends.Out of the total 4252 adult patients (mean age 73.3 ± 11.7 years, 40.2% females) with diagnosis of CA, 439 (10.3%) had STEMI while 3813 (89.7%) had no STEMI. STEMI-CA patients had higher rates of multi-organ manifestations including VT/VF (12% vs 8.5%; p-value < 0.001), cardiogenic shock (12.7% vs 7.3%; p < 0.001), AKI requiring dialysis (5.3% vs 4%; p < 0.001), and ICU admissions (25.2% vs 15.3%; p < 0.001) compared to CA without STEMI. CA-STEMI had increased mortality rates (23.7% vs 16.1%, p < 0.001) compared to CA without STEMI. On multivariate logistic regression analysis, coronary interventions including PCI (OR 0.6, CI 0.4-1.1; p = 0.3) and CABG (OR 0.7, CI 0.3-1.8; p = 0.2) had no association with mortality among CA patients. The absolute yearly trends for prevalence and mortality associated with STEMI in CA patients remained steady over the study years (linear p-trends 0.2 and 0.6, respectively).CA-STEMI is associated with significant complications and mortality. Coronary interventions may not have significant mortality benefits. Thus, more research will be needed to improve mortality rates among these patients.

ST-Elevation Myocardial Infarction Among Septic Shock and Coronary Interventions: A National Emergency Database Study.

OBJECTIVE: To study coronary interventions and mortality among patients with ST-elevated myocardial infarction (STEMI) who were admitted with septic shock. METHODS: Data from the national emergency department sample (NEDS) that constitutes 20% sample of hospital-owned emergency departments in the United States was analyzed for the septic shock related visits from 2016 to 2018. Septic shock was defined by the ICD codes. RESULTS: Out of 1 375 507 adult septic shock patients, 521 300 had a primary diagnosis of septic shock (mean age 67.41±15.67 years, 51.1% females) in the national emergency database for the years 2016 to 2018. Of these patients, 2768 (0.53%) had STEMI recorded during the hospitalization. Mortality rates for STEMI patients were higher than patients without STEMI (52.3% vs 23.5%). Mortality rates improved with PCI among STEMI patients (43.8% vs 56.2%). Coronary angiography was performed among 16% of patients of which percutaneous coronary intervention (PCI) rates were 7.7% among patients with STEMI septic shock. PCI numerically improved mortality, however, had no significant difference than patients without PCI on multivariate logistic regression and univariate logistic regression post coarsened exact matching of baseline characteristics among STEMI patients. Among the predictors, STEMI was a significant predictor of mortality in septic shock patients (OR 2.87, 95% CI 2.37-3.49; P<.001). Age, peripheral vascular disease, were predominant predictors of mortality in STEMI with septic shock subgroup (P <.001). Pneumonia was the predominant underlying infection among STEMI (36.4%) and without STEMI group (29.5%). CONCLUSION: STEMI complicating septic shock worsens mortality. PCI and coronary angiography numerically improved mortality, however, had no significant difference from patients without PCI. More research will be needed to improve mortality in such a critically ill subgroup of patients.

Thrombotic superior vena cava syndrome: a national emergency department database study.

Literature regarding etiology and trends of incidence of major thoracic vein thrombosis in the United States is limited. To study the causes, complications, in-hospital mortality rate, and trend in the incidence of major thoracic vein thrombosis which could have led to superior vena cava syndrome (SVCS) between 2010 and 2018. Data from the nationwide emergency department sample (NEDS) that constitutes 20% sample of hospital-owned emergency departments (ED) and in-patient sample in the United States were analyzed using diagnostic codes. A linear p-trend was used to assess the trends. Of the total 1082 million ED visits, 37,807 (3.5/100,000) (mean age 53.81 ± 18.07 years, 55% females) patients were recorded with major thoracic vein thrombosis in the ED encounters. Among these patients, 4070 (10.6%) patients had one or more cancers associated with thrombosis. Pacemaker/defibrillator-related thrombosis was recorded in 2820 (7.5%) patients, while intravascular catheter-induced thrombosis was recorded in 1755 (4.55%) patients. Half of the patients had associated complication of pulmonary embolism. A total of 59 (0.15%) patients died during these hospital encounters. The yearly trend for the thrombosis for every 100,000 ED encounters in the United States increased from 2.17/100,000 in 2010 to 5.98/100,000 in 2018 (liner p-trend < 0.001). Yearly trend for catheter/lead associated thrombosis was also up-trending (p-trend 0.015). SVCS is an uncommon medical emergency related to malignancy and indwelling venous devices. The increasing trend in SVCS incidence, predominantly catheter/lead induced, and the high rate of associated pulmonary embolism should prompt physicians to remain vigilant for appropriate evaluation.

Scleroderma hypertensive renal crisis among systemic sclerosis patients: A national emergency department database study.

BACKGROUND: Literature regarding trends for incidence and mortality of scleroderma renal crisis (SRC) in systemic sclerosis (SSc) within the United States (US) emergency departments (EDs) is limited. OBJECTIVE: To study the mortality of SRC among SSc patient encounters within the US EDs. METHODS: Data from the National Emergency Department Sample (NEDS) constitutes 20% sample of hospital-owned EDs and inpatient sample in the US were analyzed for SSc with and without SRC using ICD-9 codes. A linear p-trend was used to assess the trends. RESULTS: Of the total 180,435 encounters with the diagnosis of SSc in NEDS for the years 2009 2014, 771 or 4.27/1000 patients (mean age 59.6 ± 15.5 years, 75.4% females) were recorded with SRC. The numerical differences in mortality among SRC (32 or 4.1%) and non-SRC subgroups (5487 or 3.1%) did not reach statistical significance (p = 0.3). Major complications among SRC in comparison to non-SRC subgroup include ischemic stroke (5.6% vs 0.98%, p = 0.001), new-onset AF (8% vs 6.9%, p = 0.001), new-onset congestive heart failure (24.1% vs 8.8%, p = 0.001), pulmonary arterial hypertension (15.8% vs 10.9%, p = 0.001), respiratory failure (27.5% vs 10.5%, p = 0.001), and deep vein thrombosis (4.7% vs 4.6%, p = 0.001). Congestive heart failure (CHF) was strongly associated with SRC among SSc (OR 4.3 95%CI 2.7-6.7; p < 0.001). The absolute yearly rate of SRC had increased over the study years from 2.11/1000 to 5.79/1000 (linear p-trend 0.002) while the mortality trend remained steady. CONCLUSION: SRC is a relatively rare medical emergency. Although there has been a significant rise in the rate of SRC among SSc patients over the study years, mortality rates had remained steady. SSc patients with CHF should be considered to have low threshold for admission to inpatient services from EDs.

ST-Elevation Myocardial Infarction Outcomes: A United States Nationwide Emergency Departments Cohort Study.

BACKGROUND: Literature regarding trends in incidence and mortality of ST-elevation myocardial infarction (STEMI) in emergency departments (EDs) is limited. OBJECTIVE: To study the trends of incidence and mortality of STEMI. METHODS: Using the National Emergency Department Sample database in the United States, we identified all ED encounters for patients presenting with STEMI using International Classification of Diseases codes. A linear p-trend was used to assess the trends. RESULTS: Out of the 973 million ED encounters represented, 641,762 (65/100,000; mean age 69 [59-81] years, 35.8% female) adult patients were recorded with STEMI. Among the major complications associated with STEMI, a total of 49,401 (7.7%) had cardiac complications, which included acute heart failure (n = 9361, 1.6%), ventricular tachycardia or fibrillation (n = 12,267, 1.91%), conduction block (n = 20,165, 3.1%), and cardiogenic shock (n = 7608, 1.2%). There were 5675 (0.9%) patients recorded with cerebrovascular events, which included acute ischemic stroke among 5205 (0.8%) patients and 470 (0.1%) with transient ischemic attack. Acute kidney injury was recorded for 10,082 (1.6%) patients. The trend for incidence of STEMI in the ED had decreased from 7.76/10,000 in 2011 to 4.07/10,000 in 2018 (linear p-trend 0.0006). However, the yearly mortality of STEMI related to ED encounters had remained relatively steady: 7.56% in 2011 to 7.50% in 2018 (linear p-trend 0.2364). CONCLUSION: Despite the fact that the number of patients presenting to the ED with STEMI has been decreasing, the mortality trends have remained steady. Further research of in-hospital STEMI may yield opportunities to reduce the risk of complications, improve patient outcomes and decrease health care burden.

Myocardial injury in hospitalized COVID-19 patients: a retrospective study, systematic review, and meta-analysis.

INTRODUCTION: The majority of studies evaluating the effect of myocardial injury on the survival of COVID-19 patients have been performed outside of the United States (U.S.). These studies have often utilized definitions of myocardial injury that are not guideline-based and thus, not applicable to the U.S. METHODS: The current study is a two-part investigation of the effect of myocardial injury on the clinical outcome of patients hospitalized with COVID-19. The first part is a retrospective analysis of 268 patients admitted to our healthcare system in Toledo, Ohio, U.S.; the second part is a systematic review and meta-analysis of all similar studies performed within the U.S. RESULTS: In our retrospective analysis, patients with myocardial injury were older (mean age 73 vs. 59 years, P 0.001), more likely to have hypertension (86% vs. 67%, P 0.005), underlying cardiovascular disease (57% vs. 24%, P 0.001), and chronic kidney disease (26% vs. 10%, P 0.004). Myocardial injury was also associated with a lower likelihood of discharge to home (35% vs. 69%, P 0.001), and a higher likelihood of death (33% vs. 10%, P 0.001), acute kidney injury (74% vs. 30%, P 0.001), and circulatory shock (33% vs. 12%, P 0.001). Our meta-analysis included 12,577 patients from 8 U.S. states and 55 hospitals who were hospitalized with COVID-19, with the finding that myocardial injury was significantly associated with increased mortality (HR 2.43, CI 2.28-3.6, P 0.0005). The prevalence of myocardial injury ranged from 9.2 to 51%, with a mean prevalence of 27.2%. CONCLUSION: Hospitalized COVID-19 patients in the U.S. have a high prevalence of myocardial injury, which was associated with poorer survival and outcomes.

Coronavirus disease 2019 (COVID-19) and QTc prolongation.

INTRODUCTION: The cause-and-effect relationship of QTc prolongation in Coronavirus disease 2019 (COVID-19) patients has not been studied well. OBJECTIVE: We attempt to better understand the relationship of QTc prolongation in COVID-19 patients in this study. METHODS: This is a retrospective, hospital-based, observational study. All patients with normal baseline QTc interval who were hospitalized with the diagnosis of COVID-19 infection at two hospitals in Ohio, USA were included in this study. RESULTS: Sixty-nine patients had QTc prolongation, and 210 patients continued to have normal QTc during hospitalization. The baseline QTc intervals were comparable in the two groups. Patients with QTc prolongation were older (mean age 67 vs. 60, P 0.003), more likely to have underlying cardiovascular disease (48% versus 26%, P 0.001), ischemic heart disease (29% versus 17%, P 0.026), congestive heart failure with preserved ejection fraction (16% versus 8%, P 0.042), chronic kidney disease (23% versus 10%, P 0.005), and end-stage renal disease (12% versus 1%, P < 0.001). Patients with QTc prolongation were more likely to have received hydroxychloroquine (75% versus 59%, P 0.018), azithromycin (18% vs. 14%, P 0.034), a combination of hydroxychloroquine and azithromycin (29% vs 7%, P < 0.001), more than 1 QT prolonging agents (59% vs. 32%, P < 0.001). Patients who were on angiotensin-converting enzyme inhibitors (ACEi) were less likely to develop QTc prolongation (11% versus 26%, P 0.014). QTc prolongation was not associated with increased ventricular arrhythmias or mortality. CONCLUSION: Older age, ESRD, underlying cardiovascular disease, potential virus mediated cardiac injury, and drugs like hydroxychloroquine/azithromycin, contribute to QTc prolongation in COVID-19 patients. The role of ACEi in preventing QTc prolongation in COVID-19 patients needs to be studied further.

Incidence, outcomes, and predictors of in-hospital acute coronary syndrome following endovascular transcatheter aortic valve replacement in the United States.

BACKGROUND: Incidence and outcomes of acute coronary syndrome (ACS) immediately following transcatheter aortic valve replacement (TAVR) remain largely unknown. OBJECTIVES: This study sought to assess the incidence, clinical characteristics, and outcomes of ACS following TAVR. METHODS: We queried the National Readmission Database from January 2012 to September 2015 for TAVR admissions with and without ACS, creating a propensity-matched cohort to compare outcomes. RESULTS: A total of 48,454 patients underwent TAVR, with 1,332 (2.75%) developing ACS. TAVR patients with ACS compared to those without ACS had a significantly higher incidence of acute kidney injury (24.7 vs. 19.2%; p = .001), ischemic stroke (3.7 vs. 2.3%; p = .04), vascular complications (8.6 vs. 5.8%; p = .008), cardiogenic shock (9.8 vs. 1.9%; p < .001), cardiac arrest (5.1 vs. 2.8%; p = .002), mechanical circulatory support (8.1 vs. 1.5%; p < .001), and in-hospital mortality (9.6 vs. 3.4%; p < .001). Additionally, TAVR with ACS had longer lengths of stay (median 10 days vs. 6 days; p < .001) and hospital charges (median $23,200 vs. $19,000; p < .001). Positive predictors of ACS were history of PCI (odds ratio, 1.43; 95% CI: 1.25-1.63), hyperlipidemia (odds ratio, 1.20; 95% CI: 1.07-1.34), chronic blood loss anemia (odds ratio, 2.16; 95% CI: 1.54-3.03), chronic kidney disease (odds ratio, 1.17; 95% CI: 1.04-1.31), fluid and electrolyte disorders (odds ratio, 1.65; 95% CI: 1.47-1.85), and weight loss (odds ratio, 1.53; 95% CI: 1.22-1.91). Heart failure (34%) was the most common reason for readmission in the ACS cohort. CONCLUSION: ACS after TAVR is uncommon but is associated with worse clinical outcomes and increased healthcare resource utilization.

Systematic Review and Proportional Meta-Analysis of Endarterectomy and Endovascular Therapy with Routine or Selective Stenting for Common Femoral Artery Atherosclerotic Disease.

INTRODUCTION: Common femoral endarterectomy (CFE) has been the therapy of choice for common femoral artery atherosclerotic disease (CFA-ASD). In the past, there was inhibition to treat CFA-ASD endovascularly with stents due to fear of stent fracture and compromise of future vascular access site. However, recent advances and new evidence suggest that CFA may no longer be a 'stent-forbidden zone'. In the light of new evidence, we conducted a meta-analysis to determine the use of endovascular treatment for CFA-ASD and compare it with common femoral endarterectomy in the present era. METHODS: Using certain MeSH terms we searched multiple databases for studies done on endovascular and surgical treatment of CFA-ASD in the last two decades. Inclusion criteria were randomized control trials, observational, prospective, or retrospective studies evaluating an endovascular treatment or CFE for CFA-ASD. For comparison, studies were grouped based on the treatment strategy used for CFA-ASD: endovascular treatment with selective stenting (EVT-SS), endovascular treatment with routine stenting (EVT-RS), or common femoral endarterectomy (CFE). Primary patency (PP), target lesion revascularization (TLR), and complications were the outcomes studied. We did proportional meta-analysis using a random-effect model due to heterogeneity among the included studies. If confidence intervals of two results do not overlap, then statistical significance is determined. RESULTS: Twenty-eight studies met inclusion criteria (7 for EVT-RS, 8 for EVT-SS, and 13 for CFE). Total limbs involved were 2914 (306 in EVT-RS, 678 in EVT-SS, and 1930 in CFE). The pooled PP at 1 year was 84% (95% CI 75-92%) for EVT-RS, 78% (95% CI 69-85%) for EVT-SS, and 93% (95% CI 90-96%) for CFE. PP at maximum follow-up in EVT-RS was 83.7% (95% CI 74-91%) and in CFE group was 88.3% (95% CI 81-94%). The pooled target lesion revascularization (TLR) rate at one year was 8% (95% CI 4-13%) for EVT-RS, 19% (95% CI 14-23%) for EVT-SS, and 4.5% (95% CI 1-9%) for CFE. The pooled rate of local complications for EVT-RS was 5% (95% CI 2-10%), for EVT-SS was 7% (95% CI 3 to 12%), and CFE was 22% (95% CI 14-32%). Mortality at maximum follow-up in CFE group was 23.1% (95% CI 14-33%) and EVT-RS was 5.3% (95% CI 1-11%). CONCLUSION: EVT-RS has comparable one-year PP and TLR as CFE. CFE showed an advantage over EVT-SS for one-year PP. The complication rate is lower in EVT RS and EVT SS compared to CFE. At maximum follow-up, CFE and EVT-RS have similar PP but CFE has a higher mortality. These findings support EVT-RS as a management alternative for CFA-ASD.

Carbohydrate-restricted diet and acute coronary syndrome: a case report and review of this conflicting and yet unknown association.

We describe a case of a young patient, motivated to follow a carbohydrate-restricted diet intake for 6 years, who presented with an acute myocardial infarction.

Case of paradoxical embolic transient ischemic attack from an unusual extra cardiac shunt detected on a contrast-enhanced echocardiogram.

Paradoxical embolism due to extracardiac right to left shunts (RLSs) manifesting as stroke remains anecdotal. We describe a case of 63-year-old female who presented with a transient ischemic attack and at agitated saline contrast echocardiogram was found to have an unusual type of an extracardiac RLS. Further evaluation leads to diagnosis of superior vena cava (SVC) thrombosis from a prior indwelling central venous catheter. The SVC thrombosis induced systemic-pulmonary venous collaterals were responsible for this unusual extracardiac RLS and paradoxical transient ischemic attack. We discuss the diagnosis and management of this rare clinical case.

Transcatheter Versus Surgical Aortic Valve Replacement in Hypertrophic Cardiomyopathy Patients with Aortic Stenosis.

Surgical aortic valve replacement (SAVR) and transcatheter aortic valve replacement (TAVR) are well established treatment options for severe aortic stenosis (AS). However, patients with hypertrophic cardiomyopathy (HCM) were excluded from pivotal randomized controlled trials of TAVR vs SAVR. We queried the 2016 to 2019 National Inpatient Sample to identify adult hospitalizations with HCM who underwent SAVR or TAVR for severe AS. The primary outcome was in-hospital mortality. Secondary outcomes included cardiac arrest, new permanent pacemaker (PPM), cardiac tamponade, bleeding requiring transfusion, stroke/transient ischemic attack, acute kidney injury (AKI), and resource utilization (length of stay [LOS], hospital costs, and discharge to facility). Of 1245 HCM hospitalizations with severe AS, 595(47.8%) underwent TAVR and 650 (52.2%) underwent SAVR. In-hospital mortality rate was lower in the TAVR group. Cardiac arrest, cardiogenic shock, pressor use, new PPM, and cardiac tamponade were not significantly different between the 2 groups. When compared to SAVR, TAVR was associated with lower rates of bleeding requiring transfusion, vascular complications, AKI, and invasive mechanical ventilation. Furthermore, TAVR was associated with a shorter hospital stay, fewer facility discharges, but comparable hospital costs. Our findings indicate that TAVR is associated with lower risk of in-hospital mortality, certain peri-procedural complications, shorter hospital stay, and fewer facility discharges in HCM patients with isolated AS compared to SAVR. Further studies are needed to assess the mid- and long-term outcomes of TAVR vs SAVR in HCM patients with AS.

Outcomes of Cardiac Arrest with Valve Surgery Among Infective Endocarditis Patients: A United States National Cohort Study.

OBJECTIVE: Cardiac arrest can complicate infective endocarditis (IE) and is associated with significant in-hospital complications and mortality rates. We report the characteristics, outcomes, and readmission rates for IE patients with cardiac arrest in the United States. METHODS: We surveyed the Nationwide Readmission Database (NRD), a database designed to support national level readmission analyses, for patients admitted with IE and who had cardiac arrest during index admission between 2016 and 2019. Baseline demographics, comorbidities, surgical procedures, and outcomes were identified using their respective International Classification of Diseases (ICD) codes. RESULTS: There were 663 index admissions (mean age 55.87 ± 17.21 years;34.2 % females) for IE with cardiac arrest in the study period, with an overall mortality rate of 55.3 %. Of these, 270 (40.7 %) had surgical procedures performed during the hospitalization encounter. In patients who had a surgical procedure, 72 (26.8 %) patients had in-hospital mortality while 293 (74.9 %) patients without surgical procedures had in-hospital mortality (p < 0.001). After coarsened matching for baseline characteristics, surgical valve procedures were less likely to be associated with mortality (OR = 0.09, 95%CI 0.04-0.24; p < 0.001). Among the 295 alive discharges associated with cardiac arrest, 76 (38.57 %) were readmitted within 30-days, with a mortality rate of 22 % noted for readmissions. CONCLUSION: Among IE patients who had cardiac arrest, surgical procedures subgroup had low mortality despite having higher complication rates. However, due to chances of bias more randomized trials are needed evaluate the hypothesis.

Erythropoietin in the treatment of postural orthostatic tachycardia syndrome.

Erythropoietin has been reported to improve symptoms of orthostatic intolerance in patients suffering from orthostatic hypotension. Previous reports on the use of erythropoietin in patients with postural orthostatic tachycardia (POTS) have included only a very small number of patients. In the current study, we report on the use of erythropoietin in patients with refractory POTS. The study was approved by the institutional review board. A retrospective nonrandomized analysis was performed on 39 patients evaluated at our autonomic center for POTS from 2003 to 2010. The diagnosis of POTS was based on patient history, physical examination, and response to head-up tilt-table testing. The mean follow-up period was 6 months. The patients were included in the current study if they had a diagnosis of POTS with severe symptoms of orthostatic intolerance and were refractory to the commonly used medications. All these patients were started on erythropoietin, and the response to therapy was considered successful if it provided symptomatic relief. We screened 200 patients with POTS and found 39 patients (age 33 ± 12, 37 females) to be eligible for inclusion in the current study. The response to the treatment was assessed subjectively in each patient and was obtained in a retrospective fashion from patient charts and physician communications. Eight (21%) patients demonstrated no improvement in symptoms after administration of erythropoietin. Three (8%) patients showed an improvement in symptoms of orthostatic intolerance of <3 months. Twenty-seven (71%) patients demonstrated sustained improvement in their symptoms of orthostatic intolerance at the mean follow-up of 6 months. Erythropoietin significantly improved sitting diastolic blood pressure but had no effect on other hemodynamic parameters. In a select group of POTS patients who are refractory to commonly used medications, erythropoietin may help improve symptoms of orthostatic intolerance.

Transmyocardial voyage of a temporary epicardial lead: an unusual long-term complication.

Although the majority of temporary epicardial leads used during cardiac surgery are removed in the perioperative period, occasionally, the wires are cut and allowed to retract into the subcutaneous tissue. Complications arising from such retained epicardial wires are rare. We present a case of transmyocardial migration of a retained epicardial wire through the right ventricular myocardium into the pulmonary artery in a patient who had undergone coronary artery bypass graft surgery 13 years ago. We describe the presentation and successful management of this case.

Syncope as an initial manifestation of atypical lipomatous hypertrophy of the interatrial septum.

Lipomatous hypertrophy of the interatrial septum (LHIS) is an incidental echocardiographic abnormality characterized by dumb-bell configuration of the interatrial septum from excess fat deposition. We report a case of syncope in a patient with LHIS obstructing the superior vena cava at the right atrial junction.

Non-ST elevation myocardial infarction and cardiac arrest: The United States Nationwide Emergency Department Sample.

BACKGROUND: Literature regarding outcomes of cardiac arrest with associated NSTEMI is limited. We aim to study the predictors and survival outcomes of cardiac arrest patients presenting to the emergency department who were diagnosed with non-ST elevated myocardial infarction (NSTEMI). METHODS: Data from the nationwide emergency department sample (NEDS) that constitutes 20% sample of hospital-owned emergency departments in the United States was analyzed for the cardiac arrest related visits from 2009-2018. Cardiac arrest was defined by the ICD codes. RESULTS: Out of 3,235,555 cardiac arrests (mean age 64.0 ± 19.5 years, 40.7% females) there were 163,970 (5.1%) patients diagnosed with NSTEMI during the years 2009-2018. Among cardiac arrest patients, the survival for NSTEMI patients was higher than patients without NSTEMI (46.7% vs. 22.7%). These patients were more likely to be males and elderly. Among the predictors for NSTEMI cardiac arrests, hypertension (OR 1.12, p < 0.001), peripheral vascular disease (OR 1.16, p < 0.001), prior-coronary artery bypass graft (OR 1.20, p < 0.001) were the predominant ones. Cardiovascular interventions were more common in NSTEMI cardiac arrests and were associated with lower mortality rates (p < 0.001). However, trend for coronary interventions remained steady over study years. We observed an increase in prevalence of NSTEMI cardiac arrests with a worsening trend in survival from 2009-2018. CONCLUSIONS: NSTEMI was not uncommon in patients with cardiac arrest. NSTEMI cardiac arrest had a better prognosis than patients without NSTEMI. Cardiovascular interventions might have survival benefits. More research is required to identify NSTEMI in cardiac arrest patients and further evaluate the effect of cardiovascular interventions on survival.

ST elevation myocardial infarction and kidney transplant: A large cohort study: STEMI and renal transplant.

BACKGROUND: The literature on outcomes of ST-elevation myocardial infarction (STEMI) amongst kidney transplant recipients (KTR) is limited. OBJECTIVE: To study the outcomes of STEMI among KTR. METHODS: Data from the national readmissions database (NRD) sample that constitutes 49.1% of the stratified sample of all hospitals in the USA were analyzed for hospitalizations with STEMI among KTR for the years 2012-2018. Complications associated with STEMI were extracted using International Classification of Diseases codes. RESULTS: A total of 588,668 index KTR hospitalizations (mean age 57.67±14.22 years; female 44.5%) of which 3,496 (0.59%) had STEMI were recorded in the NRD for the years 2012-2018. A total of 11,676 (1.98%) patients died during the hospitalization. In-hospital mortality among STEMI was higher, 465 (13.3%), than without-STEMI 11,211 (1.92%). Among the complications, mechanical complications occurred among 1.0% vs 0.02%, cardiogenic shock 10.6 vs 0.3%, ventricular arrythmias 8.3% vs 0.8%, conduction block 6.9% vs 2%, stroke 4.1% vs 1.9%, and acute kidney injury 31.6% vs 28.3% among STEMI and without-STEMI respectively. Among coronary procedures, coronary angiography was performed among 1,999 (57.2%) of which 1,777 (50.8%) had percutaneous coronary intervention (PCI). On coarsened exact matching of baseline characteristics, PCI was less likely associated with mortality, odds ratio 0.39 (95% confidence interval 0.24-0.64; p=0.0002). The trends of mortality among STEMI were steady (p-trend 0.11). PCI trend increased (p-trend 0.008) and incidence of STEMI decreased over the study years 2012 (0.66%)-2018(0.474%). A total of 84,810 (14.4%) patients were readmitted in 30 days of which 696 (20%) patients were among the STEMI subgroup. CONCLUSION: STEMI is not an uncommon complication among KTR and is associated with significant mechanical complications. Improvement in cardiovascular risk factors might improve the STEMI rates among KTR.