Impact of Center Procedural Volume on Mortality and Readmission Rates Following Pericardiectomy in the United States.

Our study aimed to explore the national trends in the rates of perioperative complications, in-hospital mortality, and readmissions after pericardiectomy and the impact of center volume on these outcomes. Using the Nationwide Readmission Database, we identified patients who underwent isolated pericardiectomy from 2010 to 2019. In-hospital mortality and readmission rates were assessed using orthogonal polynomial contrasts, with the linear and nonlinear trends evaluated as needed. Multivariable logistic regression models were constructed to identify the independent predictors of mortality and readmission. All analyses accounted for the Nationwide Readmission Database sampling design and were performed using SAS version 9.4 (SAS Institute Inc. Cary, NC.) with p <0.05 used to indicate statistical significance. A total of 26,169 hospitalizations for pericardiectomy were identified during the study period. The median age was 59 years and 44% were female. In-hospital mortality was 5.2%, and the median length of stay was 7 days. Advanced age, higher co-morbidity index, and lower annual facility pericardiectomy volume were independent predictors of in-hospital mortality. The 30- and 90-day readmission rates after pericardiectomy were 18% and 28%, respectively. Previous cardiac surgery, diagnosis of constrictive pericarditis, and greater co-morbidity score were independent predictors of readmission. In conclusion, isolated pericardiectomy rates have remained mostly constant, with relatively small changes in in-hospital mortality and 30- and 90-day readmission rates over the last decade. Advanced age, lower facility pericardiectomy volume, and higher Elixhauser co-morbidity index are independent predictors of surgical mortality.

Association Between Stable Coronary Artery Disease and Hospital Readmissions Following Catheter Ablation for Atrial Fibrillation.

OBJECTIVE: To evaluate the association of stable coronary artery disease (CAD) with readmission following hospitalization for catheter ablation (CA) for atrial fibrillation (AF). PATIENTS AND METHODS: Using the Nationwide Readmissions Database, we identified all hospitalizations from the last quarter of 2015 through 2019 with a Medicare Severity-Diagnosis Related Group designation for a percutaneous intracardiac procedure, a procedure code for CA, and a primary discharge diagnosis of AF. Cases of acute coronary syndrome (ACS) at index hospitalization were excluded to define stable CAD. The primary outcome was all-cause 90-day hospital readmission; secondary end points included readmissions for AF, repeated CA, ACS, and heart failure (HF). RESULTS: Among 28,466 hospitalizations for CA for AF identified, 3171 (11.1%) involved patients with stable CAD. No hospitalizations included patients with HF diagnosis codes. The incidence of 90-day all-cause readmission was higher in patients with stable CAD (18.4% [400 of 2172] vs 14.4% [2549 of 17,667]; P=.006), as was the incidence of subsequent hospitalization with ACS (5.3% [21] vs 1.1% [28]; P<.001) or HF (17.0% [68] vs 10.2% [260]; P=.007). The incidence of readmission within 90 days with recurrent AF did not differ for those with or without stable CAD (21.9% [88] vs 26.5% [675]; P=.217). Pooled analysis of 90-day HF readmissions revealed a higher incidence among older patients, those with chronic kidney or pulmonary disease, and those with persistent and chronic AF subtypes. CONCLUSION: Results of this large-scale analysis suggest that among patients hospitalized for CA for AF, stable CAD is associated with hospital readmissions within 90 days, including admissions for ACS and decompensated HF.

Impact of delirium on mortality in patients hospitalized for heart failure.

OBJECTIVE: Heart Failure (HF) is one of the leading causes of hospitalization in the United States accounting for ≈800,000 hospital discharges and $11 billion in annual costs. Delirium occurs in approximately 30% of elderly hospitalized patients and its incidence is significantly higher among those admitted to the critical care units. Despite this, there has been limited exploration of the clinical and economic impact of delirium in patients hospitalized with acute HF. We hypothesized that delirium in HF is associated with excess mortality and hospital costs. METHODS: We queried the 2001-2014 Nationwide Inpatient Sample to identify hospitalizations that included a primary discharge diagnosis of HF (ICD-9-CM: 428.xx) and stratified them by presence or absence of delirium (ICD-9-CM: 239.0, 290.41, 293.0, 293.1, 348.31). Differences in in-hospital mortality, length of stay (LOS), and hospital costs were assessed using propensity-score matched cohorts. RESULTS: Major predictors of delirium included advanced age, Caucasian race, underlying dementia or psychiatric diagnoses, higher Elixhauser Comorbidity Index, renal failure, cardiogenic shock, and coronary artery bypass surgery. In the propensity-score matched analysis of 76,411 hospitalization with delirium compared to 76,612 without delirium, in-hospital mortality (odds ratio: 1.67, 95% CI: 1.51-1.77), LOS (rate ratio [RR]: 1.47, 95% CI: 1.45-1.51), and hospital costs (RR: 1.44, 95% CI: 1.41-1.48) were all statistically higher in the presence of delirium (all p < 0.001). CONCLUSION: In patients hospitalized with HF, delirium is an independent predictor of increased in-hospital mortality, longer LOS, and excess hospital costs despite adjustment for baseline characteristics.

Sex disparities in in-hospital outcomes of left ventricular aneurysm complicating acute myocardial infarction: A United States nationwide analysis.

Background: Previous studies have reported sex-specific differences in the presentation, mechanisms, and outcomes of acute myocardial infarction (AMI). We assessed differences between women and men in the incidence and in-hospital outcomes of left ventricular (LV) aneurysm complicating AMI. Methods: Hospitalizations for AMI with LV aneurysm were identified retrospectively in the National Inpatient Sample (NIS) from 2001 to 2017. Incidence and trends in in-hospital mortality, complications, length of stay and costs were analyzed in women and men. Results: A total of 16,334 AMI hospitalizations with concomitant LV aneurysm were identified including 6994 (42.8%) women and 9340 (57.2%) men. Among these hospitalizations, women had a higher incidence of LV aneurysm compared to men (0.16% vs. 0.14%; p < 0.001). Unadjusted in-hospital mortality was higher in women than men (12.7% vs. 7.2%; p < 0.001). After adjusting for demographic and baseline characteristics and excluding inter-hospital transfers, women with AMI complicated by LV aneurysm had 49% greater odds of in-hospital mortality than men (OR 1.49, 95% confidence interval 1.06-2.10, p = 0.02). Women with LV aneurysm were less likely than men to undergo percutaneous coronary intervention (28.5% vs. 35.4%; p < 0.001), bypass surgery (15.8% vs. 25.1%; p < 0.001), coronary atherectomy (0.8% vs. 1.9%; p = 0.009) and LV aneurysm surgery (7.8% vs. 11.1%; p = 0.001). Conclusions: In this large population-based cohort study, women had a slightly higher incidence but dramatically higher in-hospital mortality associated with LV aneurysm complicating AMI compared to men. Further research is necessary to validate strategies to ensure that women receive guideline-directed therapy for AMI and LV aneurysm to address the sex disparity in mortality.

Impact of Renin-Angiotensin System Blockers on Mortality in Veterans Undergoing Cardiac Surgery.

Background Renin-angiotensin system blockers (RASBs) have well-validated benefit in patients with hypertension, coronary artery disease, and left ventricular systolic dysfunction. Their use in the perioperative period, however, has been controversial, including in patients undergoing cardiac surgery, who often have a strong indication for their use. In the current study, we explore the impact of RASB use with 30-day and 1-year mortality after cardiac surgery. Methods and Results The Veterans Affairs Surgical Quality Improvement Program and Corporate Data Warehouse were data sources for this retrospective cohort study. A total of 37 197 veterans undergoing elective coronary artery bypass grafting and or valve repair or replacement over a 10-year period met inclusion criteria and were stratified into 4 groups by preoperative exposure (preoperative exposure versus no preoperative exposure) and postoperative continuing exposure (current exposure versus no current exposure) to RASBs. After adjusting for all baseline covariates, the preoperative exposure/current exposure group had lower 30-day and 1-year mortality than the preoperative exposure/no current exposure (30-day hazard ratio [HR], 0.25; 95% CI, 0.19-0.33 [P<0.001] and 1-year HR, 0.40; 95% CI, 0.33-0.48 [P<0.001] or no preoperative exposure/no current exposure (30-day HR, 0.44; 95% CI, 0.32-0.60 [P<0.001] and 1-year HR, 0.72; 95% CI, 0.62-0.84 [P<0.001] groups. The no preoperative exposure/current exposure group had significantly lower 30-day (HR, 0.31; 95% CI, 0.14-0.71 [P=0.006]) and 1-year (HR, 0.64; 95% CI, 0.53-0.77 [P<0.001]) mortality than the no preoperative exposure/no current exposure group. Conclusions Continuation of preoperative RASBs and initiation before discharge is associated with decreased mortality in veterans undergoing cardiac surgery. Given these findings, continuation of preoperative RASBs or initiation in the early postoperative period should be considered in patients undergoing cardiac surgery.

Valve-in-valve transcatheter aortic valve replacement versus redo surgical valve replacement for degenerated bioprosthetic aortic valve: An updated meta-analysis comparing midterm outcomes.

BACKGROUND: Redo surgical aortic valve replacement (redo SAVR) and valve-in-valve transcatheter aortic valve replacement (ViV TAVR) are the two treatment strategies available for patients with severe symptomatic bioprosthetic aortic valve dysfunction. Herein, we performed a systematic review and meta-analysis comparing both early and mid-term outcomes of ViV TAVR versus redo SAVR in patients with bioprosthetic aortic valve disease. METHODS: PubMed, Cochrane reviews, and Google scholar electronic databases were searched and studies comparing ViV TAVR versus redo SAVR were included. The primary outcome of interest was mid-term (1-5 years) and 1-year all-cause mortality. Secondary outcomes included were 30-day all-cause mortality, myocardial infarction, pacemaker implantation, stroke, acute kidney injury, major or life-threatening bleeding, and postprocedural aortic valve gradients. Pooled risk ratios (RR) with their corresponding 95% confidence intervals (CIs) were calculated for all outcomes using the DerSimonian-Laird random-effects model. RESULTS: Nine observational studies with a total of 2,891 individuals and mean follow-up of 26 months met the inclusion criteria. There is no significant difference in mid-term and 1-year mortality between ViV-TAVR and redo SAVR groups with RR of 1.15 (95% CI 0.99-1.32; p = .06) and 1.06 (95% CI 0.69-1.61; p = .8). 30-day mortality rate was significantly lower in ViV-TAVR group with RR of 0.65 (95% CI 0.45-0.93; p = .02). ViV-TAVR group had lower 30-day bleeding, length of stay, and higher postoperative gradients. CONCLUSION: Our study demonstrates a lower 30-day mortality and similar 1-year and mid-term mortality for ViV TAVR compared to redo SAVR despite a higher baseline risk. Given these findings and the ongoing advances in the transcatheter therapeutics, VIV TAVR should be preferred over redo SAVR particularly in those at intermediate-high surgical risk.

Sex Differences in Clinical Outcomes Following Percutaneous Coronary Intervention of Unprotected Left Main Coronary Artery: A Systematic Review and Meta-Analysis.

INTRODUCTION: Percutaneous coronary intervention (PCI) has emerged as a reasonable alternative to coronary artery bypass graft (CABG) surgery in well-selected patients with unprotected left main coronary disease (LMCD). We conducted a systematic review and meta-analysis with the aim of assessing the impact of sex on outcomes of PCI in patients with unprotected LMCD. METHODS: A systematic search of PUBMED, EMBASE, Cochrane, and Google Scholar databases was performed to identify studies comparing the outcomes of men vs. women among patients undergoing PCI for unprotected LMCD. The primary outcome of interest was study defined major adverse cardiac events (MACE) and secondary outcomes were all-cause mortality, cardiac mortality, myocardial infarction (MI), target lesion revascularization (TLR), stent thrombosis and stroke. For all outcomes, pooled odds ratios (OR) with their corresponding 95% confidence intervals (CIs) were calculated using the DerSimonian-Laird random-effects model. RESULTS: Six studies with a total of 6515 individuals (4954 men, 1561women) with a mean follow up of 36 months were included in the analysis. MACE and MI were significantly higher in women with OR of 1.17 (95% CI 1.01-1.36; p = 0.03) and 1.42 (95% CI 1.07-1.87; p = 0.01) respectively. All-cause mortality, cardiac mortality, and TLR were similar among men and women. CONCLUSION: Our meta-analysis suggests that women undergoing PCI for unprotected LMCD have higher rates of MACE and MI compared to men.

Surgical Repair of Moderate Ischemic Mitral Regurgitation-A Systematic Review and Meta-analysis.

Introduction Moderate mitral regurgitation (MR) of ischemic etiology has been associated with worse outcomes after coronary artery bypass grafting (CABG). Studies comparing concomitant mitral valve replacement/repair (MVR/Re) with CABG and standalone CABG have reported conflicting results. We performed a systematic review and meta-analysis of the published literature. Patients and Methods We searched using PubMed, Cochrane, EMBASE, CINAHL, and Google scholar databases from January 1960 to June 2016 for clinical trials comparing CABG to CABG + MVR/Re for moderate MR. Pooled risk ratio or mean difference (MD) with 95% confidence intervals (CI) for individual outcomes were calculated using random effects model and heterogeneity was assessed using Cochrane's Q-statistic. Results A total of 11 studies were included. Mean follow-up was 35.3 months. All-cause mortality (Mantel-Haenszel [MH] risk ratio [RR]: 0.96, 95% CI: 0.75-1.24, p = 0.775), early mortality (MH RR: 0.65, 95% CI: 0.39-1.07, p = 0.092), and stroke rates (MH RR 0.65, 95% CI: 0.21-2.03, p = 0.464) were similar between CABG and CABG + MVR/Re groups. Adverse event at follow-up was lower with CABG (MH RR: 0.90, 95% CI: 0.61-1.32, p = 0.584). MD of change from baseline in left ventricular (LV) end-systolic dimension (MD: - 2.50, 95% CI: - 5.21 to - 0.21, p = 0.071) and LV ejection fraction (MD: 0.48, 95% CI: - 2.48 to 3.44, p = 0.750) were not significantly different between the groups. Incidence of moderate MR (MH RR: 3.24, 95% CI: 1.79-5.89, p < 0.001) was higher in the CABG only group. Conclusion Addition of MVR/Re to CABG in patients with moderate ischemic MR did not result in improvement in early or overall mortality, stroke risk, or intermediate markers of LV function when compared with CABG alone.

A 50-year-old man with incidental cardiac mass.

CLINICAL INTRODUCTION: A 50-year-old white male with a history of paroxysmal atrial fibrillation presented for transoesophageal echocardiogram prior to atrial fibrillation ablation. However, an echo lucent mass was noted (figure 1A). Colour Doppler and contrast administration showed no flow across the mass or the interatrial septum (see online supplementary videos 1 and 2). CT of the chest demonstrated a thin-walled, well-demarcated mass in the inferior border of the fossa ovalis protruding into the left atrium (figure 1B). QUESTION: Which of the following is the most likely diagnosis? Atrial myxomaBronchogenic cystCardiac angiosarcomaHydatid cyst.

Coronary artery ectasia: current concepts and interventions.

Coronary artery ectasia (CAE) is a well-recognized angiographic finding, characterized by abnormal dilatation of the coronary arteries. We reviewed the current concepts of the condition including etiology, pathogenesis, flow alterations, clinical implications, prognosis and treatment. CAE is often viewed as a variant of obstructive coronary atherosclerosis. Exaggerated positive vascular remodeling due to inflammation, and chronic overstimulation of the endothelium by nitric oxide are potential causative mechanisms. The condition is associated with cardiovascular risk factors such as smoking and hypertension, while it appears to be inversely associated with age and diabetes mellitus. Patients with CAE typically present with angina, and are at risk for myocardial infarctions and sudden cardiac death due to slow flow, coronary vasospasm, dissection, and/or intracoronary thrombosis. CAE may be a diffuse disease associated with dilatation in other parts of the vasculature. As the incidence of this not so benign condition is expected to rise, the optimal treatment options remain undefined. Medical therapy with anticoagulants, nitrates and calcium channel blockers has been proposed and seems rational; however prospective studies with proof of efficacy are needed.

Revisiting the past: intra-arterial vasopressin for severe gastrointestinal bleeding in Crohn's disease.

Technological advances in the last couple of decades have led to a tremendous improvement in the safety and efficacy of embolization making it the therapeutic intervention of choice in angiogram positive lower gastrointestinal bleeding. Vasopressin has thus been forgotten and it is hardly ever used by the current generation of interventionists. However, coil embolization is technically challenging and requires greater expertise. Difficulty in super-selective catheterization and lack of adequate collateralization can also prevent successful delivery of coils. In this article we present the successful use of intra-arterial vasopressin in a patient with Crohn's disease with severe lower gastrointestinal bleeding. Despite not being the first choice, vasopressin can be safely and effectively used in selected patients who are not candidates for embolotherapy. The purpose of this article is to discuss the relative merits and demerits of vasopressin vis-à-vis embolization and to identify the role of vasopressin in the current era of super-selective embolization. Successful control of massive lower gastrointestinal bleeding by intra-arterial vasopressin infusion has previously been reported only once before in Crohn's disease. We suggest that this technique may be used in an attempt to avoid surgery in these patients.

Thoracic aortic pseudoaneurysm following noncardiovascular surgery: a rare complication that can mimic common chest emergencies.

Pseudoaneurysm of the thoracic aorta is an extremely rare and potentially fatal condition that can mimic acute coronary syndrome, aortic dissection, or pulmonary embolism. Chest trauma and aortic surgery are the usual predisposing factors. Rarely, noncardiovascular thoracic surgeries can result in aortic pseudoaneurysm secondary to unrecognized perioperative injury. Clinical presentation is very variable, and a high index of suspicion is necessary for diagnosis. Computed tomography or magnetic resonance angiography is the preferred diagnostic test. In this paper, we report the case of a 58-year-old woman who presented with atypical chest pain due to a thoracic aortic pseudoaneurysm, most likely a result of previous nonvascular surgery.