Nationwide Trends and Outcomes for Coronary Artery Bypass Grafting in End-Stage Kidney Disease and Stable Coronary Artery Disease.

Patients with end-stage kidney disease (ESKD) on dialysis have an increased burden of coronary artery disease (CAD). This study assessed the trend and outcomes for coronary artery bypass surgery (CABG) in patients with ESKD and stable CAD. We conducted a longitudinal study using the United States Renal Data System of patients with ESKD and stable CAD who underwent CABG from the years 2009 to 2017. The outcomes included in-hospital, long-term mortality, and repeat revascularization. The follow-up was until death, end of Medicare AB coverage, or December 31, 2018. A total of 11,952 patients were identified. The mean age was 62.8 years, 68% were male, and 67% were white. The common co-morbidities included hypertension (97%), diabetes mellitus (75%), and congestive heart failure (53%). A significant decrease in CABG procedures from 2.9 to 1.3 procedures per 1,000 patients with ESKD (p <0.001) was noted during the years studied. The overall in-hospital mortality rate was 5.9%, and there was a significant decrease over the study period (p = 0.01). Although the 30-day mortality rate was 6.9% and remained steady (p = 0.14), the 1-year mortality rate was 22.8% and decreased significantly (p <0.001). At 5 years, the overall survival rate was 35%, and patients with internal mammary artery grafts showed better survival than those without (36% vs 25%). In conclusion, there has been a decrease in CABG procedures performed in patients with ESKD with stable CAD with decreasing in-hospital and 1-year mortality. Those with an internal mammary artery graft do better, but the overall long-term survival remains dismal in this population. There remains need for caution and individualization of revascularization decisions in this high-risk population.

Transcatheter versus surgical mitral valve repair in patients with mitral regurgitation.

OBJECTIVES: The aim of this study was to compare clinical outcomes of transcatheter and surgical mitral valve repair (SMVr) in primary mitral regurgitation (MR) and MR with heart failure with reduced ejection fraction (HFrEF). METHODS: In this retrospective cohort study, we used the Nationwide Readmission Database to identify primary MR and MR with HFrEF patients who underwent transcatheter or SMVr from 2016 to 2019. A propensity score with 1:1 matching was applied. The primary outcome was a cumulative event rate of major adverse cardiovascular events (MACE), which was a composite of all-cause mortality, myocardial infarction, stroke, heart failure, cardiac arrest and mitral valve replacement. Other important secondary outcome was in-hospital mortality. RESULTS: After propensity score matching, 2187 matched pairs were found in the primary MR cohort and 2178 matched pairs were found in the MR-HFrEF cohort. Transcatheter mitral valve repair (TMVr) had significantly higher medium-term MACE compared with SMVr in both cohorts (primary MR: hazard ratio: 1.73, 95% confidence interval: 1.33-2.26, P ≤ 0.001; MR-HFrEF: hazard ratio: 2.00, 95% confidence interval: 1.58-2.54, P ≤ 0.001). TMVr showed similar in-hospital mortality in both cohorts. CONCLUSIONS: Although TMVr showed better short-term outcomes, it had significantly higher medium-term MACE than SMVr in both cohorts. Thus, shared decision-making should be performed for TMVr after discussing the benefits and risks in patients who can undergo SMVr.

Impact of Biopsy Proven Liver Fibrosis on Patients Undergoing Evaluation and Treatment for Advanced Heart Failure Surgical Therapies.

There is a paucity of data regarding the impact of liver fibrosis on patients with stage D heart failure (HF). We conducted a retrospective study (January 1, 2017 to December 12, 2020) in patients with stage D HF who underwent liver biopsy as part of their advanced HF therapy evaluation. Baseline characteristics and 1-year outcomes were compared between no- or mild-to-moderate-fibrosis (grade 0 to 2) and advanced-fibrosis (grade 3 to 4) groups. Of 519 patients with stage D HF, 136 who underwent liver biopsy (113 [83%] no or mild-to-moderate fibrosis and 23 [17%] advanced fibrosis) were included. A total of 71 patients (52%) received advanced HF therapies (23 heart transplantation, 48 left ventricular assist devices). One-year mortality was higher among patients with advanced fibrosis (52% vs 18%, p <0.001). Further subgroup analysis suggested a trend toward increased 1-year mortality among patients with advanced fibrosis who underwent advanced therapies (37% vs 13%, p = 0.09). There was a trend of lower likelihood of receiving advanced HF therapies in the advanced-fibrosis group, only 1 heart transplantation and 7 left ventricular assist devices, but it did not reach statistical significance (35% vs 56%, p = 0.06). After adjustment for confounders, degree of liver fibrosis was an independent predictor of mortality (odds ratio 6.2; 95% 1.27 to 30.29, p = 0.02). We conclude that advanced liver fibrosis is common among patients with stage D HF who undergo evaluation for advanced HF surgical therapies and significantly increases 1-year mortality. Further larger studies are needed to support our findings.

Outcomes and Readmission in Patients With Retinal Artery Occlusion (from the Nationwide Readmission Database).

Retinal artery occlusion (RAO) is an ophthalmologic emergency, leading to sudden vision loss. Understanding its risk factors and garnering information on the incidence of adverse events can provide helpful information on the cost-effective evaluation of patients and secondary prevention. In this retrospective cohort study, we used the Nationwide Readmission Database from 2016 to 2018 and queried the database to identify patients with RAO. The clinical outcomes were cumulative incidence of myocardial infarction (MI), stroke, death (in-hospital and 6 months after discharge), resource utilization, all-cause readmission at 6 months, and reasons for all-cause readmission. We identified a total of 14,527 patients with RAO. The mean age of patients with RAO was 69 ± 13 years. Hypertension (11,839, 82%), hyperlipidemia (8,868, 61%), ischemic cardiomyopathy (4,826, 33%), smoking (4,772, 33%), and diabetes (4,588, 32%) were common co-morbidities in patients with RAO. Of 14,527 patients with RAO, 308 patients (2.1%) died, 1,577 (10.9%) developed stroke, and 615 (4.2%) developed MI within 6 months. A total of 2,841 patients (24.9%) were readmitted within 6 months of discharge. Carotid artery stenosis (386, 10.8%) was the most common cause of readmission. History of stroke or transient ischemic attack and Elixhauser co-morbidity index ≥3 were predictors of stroke. Female gender, ischemic cardiomyopathy, carotid artery disease, heart failure, chronic kidney disease, and cancer were predictors of MI. Cancer, chronic kidney disease, Elixhauser co-morbidity index ≥3, Medicare/Medicaid payer status, nonelective index admission, atrial fibrillation, and carotid artery disease were predictors of 6-month all-cause readmission. In conclusion, patients with RAO have a significant burden of co-morbidities, death, stroke, MI, and readmission. RAO may be used as a clinical marker of future stroke and MI, and should trigger screening for acute vascular ischemic events.

Partial vena cava occlusion (VCO) to counteract refractory heart failure: A new era in interventional heart failure strategy.

BACKGROUND: Patients with acute decompensated heart failure are prone to recurrent exacerbation leading to poor quality of life when they do not respond to an optimal medical regimen. Due to the lack of linear positive inotropy response to increasing preload in heart failure patients, increasing preload is associated with poor outcomes. Partial occlusion of either IVC or SVC is a proposed novel treatment that can improve cardiac function or quality of life by altering preload/pressure in heart failure (HF) patients unresponsive to diuretics. METHODS: PubMed, Ovid (MEDLINE), and Cochrane database we searched using the MeSH terms including "Superior vena cava occlusion," "Inferior vena cava occlusion," "Heart failure exacerbation." The inclusion criteria included studies that enrolled patients > 18 years with diagnosed NYHA II-IV HF with reduced ejection fraction (HFrEF) on optimal medical treatment (OMT). RESULTS: The analysis involved two studies with 14 patients; the mean age was 64.4 ± 10 and 100% males. The difference in the mean pulmonary pressures between pre-and-post VCO devices were 1.56 (95% CI 0.66-2.46, p-value = 0.006). There was no heterogeneity among the study of mean pulmonary pressures. With the use of VC occlusion devices, the mean difference in pulmonary artery systolic pressure decreased by 1.70 (95% CI 0.68-2.71, p-value = 0.001) (Fig. 1B). The heterogeneity of mean pressure was minimal 14%. CONCLUSION: In conclusion, VCO can help decrease pulmonary pressure that can indirectly prevent heart failure exacerbations and possibly hospitalization in this cohort of patients.

Meta-Analysis of Transcatheter Aortic Valve Implantation in Patients With Stenotic Bicuspid Versus Tricuspid Aortic Valve.

Most of the trials investigating the role of transcatheter aortic valve implantation (TAVI) across various strata of risk categories have excluded patients with bicuspid aortic stenosis (BAS) due to its anatomical complexities. The aim of this study was to perform a meta-analysis with meta-regression of studies comparing clinical, procedural, and after-procedural echocardiographic outcomes in BAS versus tricuspid aortic stenosis (TAS) patients who underwent TAVI. We searched the PubMed and Cochrane databases for relevant articles from the inception of the database to October 2019. Continuous and categorical variables were pooled using inverse variance and Mantel-Haenszel method, respectively, using the random-effect model. To rate the certainty of evidence for each outcome, we used the GRADE (Grading of Recommendations, Assessment, Development, and Evaluations) approach. Nineteen articles were included in the final analysis. There was no difference in the risk of 30-day mortality, 1-year mortality, 30-day cardiovascular mortality, major and/or life-threatening bleeding, major vascular complications, acute kidney injury, permanent pacemaker implantation, device success, annular rupture, after-procedural aortic valve area, and mean pressure gradient between the 2 groups. BAS patients who underwent TAVI had a higher risk of 30-day stroke, conversion to surgery, need for second valve implantation, and moderate to severe paravalvular leak. In conclusion, the present meta-analysis supports the feasibility of TAVI in surgically ineligible patients with BAS. However, the incidence of certain procedural complications such as stroke, conversion to surgery, second valve implantation, and paravalvular leak is higher among BAS patients compared with TAS patients, which must be discussed with the patient during the decision-making process.

Exendin-4-based imaging in insulinoma localization: Systematic review and meta-analysis.

BACKGROUND AND CONTEXT: Glucagon-like peptide-1 receptor (GLP-1 R) based imaging has shown higher sensitivity for insulinoma localization as compared to other anatomic/functional imaging. METHODOLOGY: We reviewed the published English literature for GLP-1 R targeted imaging in insulinoma in PubMed until August 2020 in accordance with PRISMA guidelines using the MeSH terms "((Exendin-4 PET/CT) OR (Exendin-4 SPECT/CT) OR (GLP-1 R imaging)) AND (Insulinoma)". An individual patient data-metanalysis (IPD-MA) was performed, and performance parameters were calculated for the histopathological diagnosis of insulinoma. MAIN OUTCOME MEASURES: True-positive (TP), false-positive (FP), false-negative (FN), true-negative (TN), sensitivity (Sn), specificity (Sp), positive predictive value (PPV) and negative predictive value (NPV) for insulinoma localization. RESULTS: A total of 179 cases (316 lesions) from 16 publications were included for IPD-MA. For insulinoma localization, exendin-4-PET/CT (Sn & PPV: 94%) performed better than exendin-4-SPECT/CT (Sn: 63%, PPV: 94%). The Sn was lower in malignant insulinoma cases whereas the Sp was higher in cases with MEN-1 syndrome. With exendin-4-based imaging, FP uptakes in Brunner's gland, normal pancreas, and other ß-cell pathologies and FN results in pancreatic tail lesions and malignancy were seen in a few patients. TN results suggested the correct diagnosis of other endogenous hyperinsulinemic hypoglycaemia (EHH) subtypes. CONCLUSION: For insulinoma localization, exendin-4 PET/CT should be preferred over exendin-4 SPECT/CT because of higher sensitivity and specificity. FP uptakes in Brunner's gland, normal pancreas, and other ß-cell pathologies and FN results in tail lesions, and malignant insulinomas are limitations. Higher specificity for insulinoma localization is particularly useful in patients with MEN-1 syndrome.

National rates and trends of tobacco and substance use disorders among atrial fibrillation hospitalizations.

BACKGROUND: Atrial Fibrillation (AF) has been associated with various behavioral risk factors such as tobacco, alcohol, and/or substances abuse. OBJECTIVE: The main objective is to describe the national trends and burden of tobacco and substance abuse in AF hospitalizations. Also, this study identifies potential population who are more vulnerable to these substance abuse among AF hospitalizations. METHODS: The National Inpatient Sample database from 2007 to 2015 was utilized and the hospitalizations with AF were identified using the international classification of disease, Ninth Revision, Clinical Modification code. They were stratified into without abuse, tobacco use disorder (TUD), substance use disorder (SUD), alcohol use disorder (AUD) and drug use disorder (DUD). RESULTS: Of 3,631,507 AF hospitalizations, 852,110 (23.46%) had TUD, 1,851,170 (5.1%) had SUD, 155,681 (4.29%) had AUD and 42,667 (1.17%) had DUD. The prevalence of TUD, SUD, AUD, and DUD was substantially increased across all age groups, races, and gender during the study period. Female sex was associated with lower odds TUD, SUD, AUD, and DUD. Among AF hospitalizations, the black race was associated with higher odds of SUD, and DUD. The younger age group (18-35 years), male, Medicare/Medicaid as primary insurance, and lower socioeconomic status were associated with increased risk of both TUD and SUDs. CONCLUSION: TUD and SUD among AF hospitalizations in the United States mainly affects males, younger individuals, white more than black, and those of lower socioeconomic status which demands for the development of preventive strategies to address multilevel influences.

Meta-Analysis of the Role of Cangrelor for Patients Undergoing Percutaneous Coronary Intervention.

Inhibition of the P2Y12 receptor by an oral P2Y12 inhibitor with loading doses along with Cyclooxygenase-1 inhibition by aspirin is considered a first-line treatment strategy in patients with the acute coronary syndrome and patients undergoing percutaneous coronary intervention (PCI). Limitations associated with oral P2Y12 receptor inhibitors include a requirement for in vivo conversion (thienopyridines), delayed onset of action, suboptimal inhibition, irreversible inhibition (thienopyridines), and delayed offset. In the acute setting, therapy with potent platelet inhibitors that have a fast onset and offset is desirable to attenuate thrombotic complications. Cangrelor, an intravenous agent, is an adenosine triphosphate analog, selectively and explicitly blocking P2Y12 receptor-mediated platelet activation. Cangrelor has been studied in a series of CHAMPION trials. A patient-level, meta-analysis of all 3 phase III trials (24,910 patients), demonstrated that cangrelor significantly reduced the rate of the composite outcome of death, myocardial infarction, ischemia-driven revascularization, or stent thrombosis at 48 hours and 30 days compared with clopidogrel, with no significant increase in major bleeding. It is approved for clinical use in patients undergoing PCI to reduce the risk of myocardial infarction, repeat revascularization, and stent thrombosis in patients who have not been treated with a P2Y12 platelet inhibitor and are not being given a GPIIbIIIa inhibitor. In conclusion, patients unable to take oral medications undergoing emergent/urgent PCI and those who had recent PCI with drug eluting stent in need for urgent cardiac or noncardiac surgery are potential candidates for cangrelor.