Surgical Outcomes of Septal Myectomy With and Without Mitral Valve Surgeries in Hypertrophic Cardiomyopathy: a National Propensity-Matched Analysis (2005 to 2020).

The management of concomitant mitral valve (MV) disease in patients with hypertrophic cardiomyopathy (HCM) remains controversial. The 2020 American Heart Association/American College of Cardiology HCM guidelines recommend that MV replacement (MVR) at the time of myectomy should not be performed for the sole purpose of relieving outflow obstruction. At the national level, limited data exist on the surgical outcomes of MV repair/replacement in patients with HCM who underwent septal myectomy (SM). Hospitalizations of patients with HCM who underwent SM between 2005 and 2020 were identified using International Classification of Diseases, Ninth and Tenth Revision codes (International Classification of Diseases, Ninth and Tenth Revision Clinical Modification/Procedure Coding System). The 3 comparison cohorts were SM alone, MV repair, and MVR with concomitant SM. After propensity matching, 2 cohorts, SM + MVR versus SM + MV repair, were studied for surgical outcomes. Demographic characteristics, baseline co-morbidities, procedural complications, inpatient mortality, length of stay, and cost of hospitalization were compared between the propensity-matched cohorts. A total of 16,797 SM procedures were identified from 2005 to 2020. Among them, 11,470 hospitalizations had SM alone (68.2%), SM + MVR was seen in 3,101 (18.4%), and SM + MV repair comprised 2,226 (13.2%). After propensity matching, the MVR and MV repair formed the matched cohorts of 1,857. There were no significant differences in the odds of cardiogenic shock (adjusted odds ratio [aOR] 0.88, 95% confidence interval [CI] 0.63 to 1.24, p = 0.49), mechanical circulatory support requirement (aOR 0.58, 95% CI 0.37 to 0.90, p = 0.015), stroke (aOR 1.27, 95% CI 0.81 to 1.99, p = 0.29), and major bleeding (aOR 0.52, 95% CI 0.34 to 0.79, p = 0.0026) between the comparison groups. MVR, compared with MV repair, was associated with a higher risk of procedural mortality (8.02% vs 3.18%, aOR 2.98, 95% CI 2.05 to 4.33, p <0.0001), complete heart block (16.36% vs 12.15%, aOR 1.76, 95% CI 1.44 to 2.12, p <0.0001), and the need for permanent pacemaker (16.39% vs 10.62%, aOR 1.83, 95% CI 1.41 to 2.38, p <0.0001). The total length of hospital stay and median hospitalization cost was higher in the MVR group. SM in HCM concomitant with MVR is associated with higher procedural mortality and in-hospital complication risk. These real-world data support the 2020 American Heart Association/American College of Cardiology guidelines that in patients who are candidates for surgical myectomy, MVR should not be performed as part of the operative strategy for relieving outflow obstruction in HCM.

Sex-Based Differences in Clinical Outcomes of Acute Coronary Syndrome Among Patients With Mediastinal Radiation Exposure: Insights From The National Inpatient Sample (2009-2020).

There is a paucity of data about the sex differences in acute coronary syndrome (ACS) outcomes in patients with prior mediastinal radiation. The National Inpatient Sample database from years 2009 to 2020 were queried for ACS hospitalizations of patients with prior mediastinal radiation. The primary outcome was MACCE (major cardiovascular events), and secondary outcomes included other clinical outcomes. A total of 23,385 hospitalizations for ACS with prior mediastinal radiation exposure ([15,904 (68.01%) females, and 7481 (31.99%) males]) were included in analysis. Males were slightly younger than females (median, age (70 [62-78] vs 72 [64-80]). Female patients with ACS had a higher burden of hypertension (80.82% vs 73.55%), diabetes mellitus (33% vs 28.35%), hyperlipidemia (66.09% vs 62.2%), obesity (17.02% vs 8.6%) however, males had a higher burden of peripheral vascular disease (18.29% vs 12.51%), congestive heart failure (41.8% vs 39.35%) and smoking (70.33% vs 46.92%). After propensity matching, primary outcome MACCE was higher in males (20.85% vs 13.29%, aOR: 1.80 95% CI (1.65-1.96), P < 0.0001) along with cardiogenic shock (8.74% vs 2.42%, aOR: 1.77 95% CI (1.55-2.02), P < 0.0001) and mechanical circulatory support use (aOR: 1.48 95% CI [1.29 -1.71], P < 0.0001). We observed no differences in the length of hospital stay, however total hospitalization cost was higher in males. This nationwide analysis showed significant disparities in outcomes among male and female ACS patients with prior mediastinal radiation history, with increasing trend in hospitalization for ACS among males and females but decreasing mortality among females.

Meta-Analysis on the Impact of Coronary Bypass Graft Markers on Angiographic Procedural Outcomes.

Utilization of radio-opaque coronary artery bypass graft markers is known to decrease the amount of contrast dye required to complete the procedure. The practice of marking bypass grafts varies significantly among surgeons. Limited data exist comparing the outcomes of percutaneous coronary intervention with and without coronary artery bypass graft (CABG) markers. We sought to explore the impact of proximal radio-opaque markers placed during CABG in subsequent percutaneous coronary intervention procedural risks. In our understanding of the current literature, this is the first meta-analysis conducted to evaluate the association between procedural angiographic metrics and CABG radio-opaque markers. We performed a query of MEDLINE and Scopus databases through August 2022 to identify relevant studies evaluating procedural metrics among patients with previous CABG with and without radio-opaque markers who underwent angiography. The primary outcomes of interest were fluoroscopy time, amount of contrast, and duration of angiography. We identified a total of 4 studies with 2,046 patients with CABG (CABG with markers n = 688, CABG without markers n = 1,518).2-5 Total fluoroscopy time was significantly reduced among patients with CABG markers compared with those with no markers (odds ratio [OR] -3.63, p <0.0001). The duration of angiography (OR -36.39, p >0.10) was reduced, although the result was not statistically significant. However, the amount of contrast utilization was significantly reduced (OR -33.41, p <0.0001). In patients who underwent CABG with radio-opaque markers, angiographic procedural metrics were improved, including reduced fluoroscopic time and the amount of contrast agent required compared with no markers.

Cardiovascular Outcomes of Redo-coronary Artery Bypass Graft Versus Percutaneous Coronary Intervention of Index Bypass Grafts Among Acute Coronary Syndrome: Regression Matched National Cohort Study.

Procedural and hospital outcomes of Percutaneous coronary intervention (PCI) versus Coronary artery bypass grafting (CABG) among ACS patients with prior history of CABG remains understudied. PCI and CABG formed the 2 comparison cohorts. Nationwide Inpatient Sample (NIS) from 2015 to 2020 were analyzed using the ICD-10 coding system. Demographic characteristics, baseline comorbidities, and outcomes such as inpatient mortality, cardiogenic shock, mechanical circulatory support, length of stay (LOS), and cost of hospitalization were compared between the two cohorts. A total of 503,900 ACS hospitalizations with prior history of CABG were identified who underwent PCI and CABG (141650 vs 7715, respectively). Median age was 71 vs 67, with male predominance (74.6% vs 75.4%), Caucasian had the most hospitalizations (79.3% vs 75.1%) in the PCI group compared to patients who underwent CABG. A higher burden of smoking (57.1% vs 52.6%, P < 0.0001) was noted in the CABG group. On adjusted analysis, ACS patients undergoing Redo- CABG had a higher risk of in-hospital mortality (aOR 1.69, CI 1.53-1.87, P < 0.0001) compared to those undergoing PCI. In addition, Redo-CABG group were more likely to have CS (aOR 1.37, CI 1.26-1.48, P < 0.0001), MCS devices use (aOR 2.61, CI 2.43-2.80, P < 0.0001), AKI (aOR 1.42, CI 1.34-1.50, P < 0.0001) and respiratory failure (aOR 1.39, CI 1.29-1.47, P < 0.0001) as compared to PCI group. CABG in acute myocardial infarction with prior history of CABG is associated with higher cardiovascular complications compared to PCI. Further exploration and individual-patient level risk assessment is crucial.

Coronavirus disease 2019 (COVID-19): Multisystem review of pathophysiology.

Coronavirus disease-19 (COVID-19) pandemic is associated with high morbidity and mortality. COVID-19, which is caused by the Severe Acute Respiratory Syndrome Coronavirus-2 (SARS CoV-2), affects multiple organ systems through a myriad of mechanisms. Afflicted patients present with a vast constellation of symptoms, from asymptomatic disease to life-threatening complications. The most common manifestations pertain to mild pulmonary symptoms, which can progress to respiratory distress syndrome and venous thromboembolism. However, in patients with renal failure, life-threatening cardiac abnormalities can ensue. Various mechanisms such as viral entry through Angiotensin receptor (ACE) affecting multiple organs and thus releasing pro-inflammatory markers have been postulated. Nevertheless, the predictors of various presentations in the affected population remain elusive. An ameliorated understanding of the pathology and pathogenesis of the viral infection has led to the development of variable treatment options, with many more that are presently under trial. This review article discusses the pathogenesis of multiple organ involvement secondary to COVID-19 infection in infected patients.

Arrhythmia in tumor lysis syndrome and associated in-hospital mortality: A nationwide inpatient analysis.

BACKGROUND: Tumor lysis syndrome (TLS) is a life-threatening oncologic emergency associated with fatal complications including arrhythmia. The epidemiology and mortality outcomes of arrhythmia in TLS are scarcely studied in the literature. METHODS: We used the National Inpatient Sample (NIS) to study the prevalence and outcome of arrhythmia in patients hospitalized with TLS (ICD-9 code 277.88) from 2009 to 2014. Baseline characteristics, burden of arrhythmia, and pertinent outcomes were analyzed. Multivariable regression analysis was performed to identify the impact of underlying malignancy in predicting TLS-related mortality. RESULTS: A total of 9034 cases of arrhythmia among 37 861 TLS patients were identified. More than half of the arrhythmia cases (67%) were found among white old (>65) males admitted to large bed size and urban teaching hospitals. Arrhythmic cohort showed higher frequency of comorbidities such as fluid-electrolyte disturbances, hypertension, congestive heart failure, renal failure, dyslipidemia, diabetes, pulmonary circulatory disorders, chronic pulmonary disease, coagulopathy, and deficiency anemia. The most common malignancies were leukemia, lymphoma, metastatic tumor, and solid tumor without metastasis. We found significantly higher odds of in-hospital mortality among patients with TLS compared to general inpatient population on unadjusted (OR 9.69, 95% CI: 9.27-10.13, P < .001) and adjusted (OR 4.62, 95% CI: 4.39-4.85) multivariable analyses. Overall in-hospital mortality (32% vs 21.3%), median length of stay (11 days vs 9 days), and hospital charges were higher among arrhythmic than nonarrhythmic patients. CONCLUSION: With the availability of more advanced cancer therapy in the US, nearly one in four inpatient encounters of TLS had arrhythmia. Arrhythmia in TLS patients was associated with higher odds of mortality and increased resource utilization. Therefore, strategies to improve the supportive care of TLS patients plus timely diagnosis and treatment of arrhythmia are of utmost importance in reducing mortality and health-care cost.

Metastatic Spread of Neuroblastoma to the Left Atrium Mimicking Atrial Myxoma: A Rare Occurrence in an Adolescent.

Neuroblastoma is the most common childhood malignancy arising from the sympathetic neuroblast cells. The most common sites of origin are the adrenal glands and paravertebral regions. However, the involvement of the heart is a rare occurrence in adolescents. Here, we report a case of a 12-year-old male child who was misdiagnosed as a case of cardiac myxoma on initial presentation. Following surgical resection and histological examination, neuroblastoma was revealed. This case report highlights the differential diagnosis for the cardiac mass in an adolescent with an unknown primary origin and also the importance of tissue histopathology for the diagnosis and management of neuroblastoma.

Epidemiology of Cholangiocarcinoma; United States Incidence and Mortality Trends.

BACKGROUND: Cholangiocarcinoma is an aggressive malignancy with few available studies assessing incidence and mortality. In this study, we aim to investigate trends of incidence and mortality in a large nation-wide epidemiologic study. METHODS: We used SEER 18 database to study cholangiocarcinoma cases in the US during 2000-2015. Incidence and mortality rates of cholangiocarcinoma were calculated by race and were expressed by 1,000,000 person-years. Annual percent change (APC) was calculated using joinpoint regression software. RESULTS: We reviewed 16,189 patients with cholangiocarcinoma, of which 64.4% were intrahepatic. Most patients were whites (78.4%), males (51.3%), and older than 65 years (63%). A total of 13,121 patients died of cholangiocarcinoma during the study period. Cholangiocarcinoma incidence and mortality were 11.977 and 10.295 and were both higher among Asians, males, and individuals older than 65 years. Incidence rates have significantly increased over the study period (APC=5.063%, P<.001), while mortality increased significantly over the study period (APC=5.964%, P<.001), but decreased after 2013 (APC=-25.029, P<.001). CONCLUSION: The incidence and mortality of cholangiocarcinoma were increasing in the study period with significant observed disparities based on race and gender.

Contemporary Trends and Outcomes in Patients With ST-Segment Elevation Myocardial Infarction and End-Stage Renal Disease on Dialysis: Insight from the National Inpatient Sample.

BACKGROUND: Cardiovascular disease is the major cause of mortality in end stage renal disease (ESRD) patients on dialysis and myocardial infarction constitutes almost 20% of such deaths. We assessed the trends, characteristics and in-hospital outcomes in patients with ESRD. METHODS: We used national inpatient sample (NIS) to identify patients with ESRD presenting with ST-segment elevation myocardial infarction (STEMI) for calendar years 2012-2016. Multiple logistic regression analysis and propensity matched data was used to compare outcomes for the purpose of our study. RESULTS: Patients on dialysis who presented with STEMI were less likely to be treated with emergent reperfusion therapies including percutaneous coronary intervention, bypass graft surgery and thrombolytics with in first 24 h. In propensity-matched cohort, the mortality was nearly double in patients who have ESRD compared to patients without ESRD (29.7% vs. 15.9%, p < 0.01). In-patient morbidity such as utilization of tracheostomy, mechanical ventilation and feeding tubes was also more prevalent in propensity matched ESRD cohort. In multivariate regression analysis, ESRD remains a strong predictor of increased mortality in STEMI patients (OR 2.65, 95% CI, 2.57-2.75, p < 0.01). CONCLUSION: Our study showed low utilization of evidence-based prompt reperfusion therapies in ESRD patients with STEMI along with concomitant increased poor outcomes and resource utilization. Future research specifically targeting this extremely high-risk patient population is needed to identify the role of prompt reperfusion therapies in improving outcomes in these patients.

An Unusual Case of Alveolar Rhabdomyosarcoma of the Neck in an Adult Patient.

Rhabdomyosarcoma is the most common soft tissue malignancy in adolescents. It is extremely rare for sarcomas to occur in patients more than 18 years of age. We present a case of rhabdomyosarcoma originating in skeletal muscles on the right side of the neck. Our case demonstrates the importance of considering an extensive differential diagnosis for a neck mass in adults. Our patient was diagnosed with alveolar variant of rhabdomyosarcoma and underwent chemotherapy and radiation therapy, but eventually due to recurrence opted for palliative therapy.

A Rare Case Report of Biloma After Cholecystectomy.

Biloma is an encapsulated collection of bile outside or inside the biliary system within the abdominal cavity. It is a rare condition with an incidence of 0.3%-2%. The most common cause of spontaneous biloma is choledocholithiasis, and other causes include abdominal trauma and surgery, bile duct tumors, liver infarction, percutaneous catheter drainage, transhepatic cholangiogram and endoscopic retrograde cholangiopancreatography (ERCP) but the exact cause is yet to be discovered. We herein present a case report of biloma as a complication of laparoscopic cholecystectomy. A 58-year-old male presented to our hospital emergency room with complaints of fever, nausea, vomiting, and pain in the right upper quadrant after six weeks of laparoscopic cholecystectomy for cholecystitis. He was diagnosed with computed tomography (CT) scan quickly, and he has treated with pigtail catheter percutaneous drainage. On a follow-up visit, after four weeks, his abdominal pain had improved and white blood count was also reduced to baseline.

Idiopathic Lateral Rectus Myositis Without Signs of Orbital Inflammation.

Idiopathic orbital inflammation (IOI), also known as orbital pseudotumor, is a nonspecific term that represents inflammation of unknown etiology that could affect various orbital structures. We report a case of IOI with an atypical presentation mimicking other clinical conditions. Our patient did not show the typical signs of inflammation that are usually seen in patients with orbital pseudotumor and are paramount in its diagnosis. Hence the diagnosis of IOI should be considered in the differential diagnosis of periorbital pain even when clinical signs of orbital inflammation are absent.

Cardiac Tamponade in the Setting of a Thymoma.

Thymoma is the most common neoplasm originating in the anterior mediastinum and accounts for a quarter of all mediastinal tumors. A pericardial effusion is an uncommon initial manifestation present in approximately 20% of patients. However, our patient had hemorrhagic pericardial effusions causing a cardiac tamponade with bilateral pleural effusions, nodular left pleural based masses, and ascites. In this report, we describe the unique features of our case and its management.

Improving breast cancer screening rates in a primary care setting.

Biannual mammogram has been recommended for all women aged 50-74 years by USPSTF. Our aim was to improve the screening rates of biannual mammogram among women aged 50-74 years in a primary care clinic. Medical records were reviewed. Patients who were not up-to-date with their breast cancer screening, were contacted by telephone or a letter was sent. Our screening rate was found to be 64.7%. After 6 months, 38.5% had undergone mammograms after our intervention. This improved the compliance rate from 64.7% to 76.6%. Hence discussion of breast cancer screening status between a patient and provider can significantly increase compliance.