Financial Implications and Impact of Pre-existing Atrial Fibrillation on In-Hospital Outcomes in Patients Who Underwent Transcatheter Aortic Valve Implantation (from the National Inpatient Database).

The objective of this study was to evaluate the financial implications and the impact of pre-existing atrial fibrillation (AF) on in-hospital outcomes in patients who underwent transcatheter aortic valve implantation (TAVI) using the Nationwide Inpatient Sample (NIS) database. We identified patients who underwent TAVI from 2011 to 2014. The primary end point was the effect of pre-existing AF on in-hospital mortality. Secondary end points included periprocedural cardiac complications, stroke, and hemorrhage requiring transfusion. We also assessed length of stay (LOS) and cost of hospitalization. A mixed-effect logistic model was used for clinical end points, and a linear mixed model was used for cost and LOS. In 6,778 patients who underwent TAVI (46.1% women and 81.4 ± 8.5 years old), the incidence of AF was 43.3%. After adjusting for patient- and hospital-level characteristics, pre-existing AF was not found to influence in-hospital mortality (odds ratio 1.05, 95% confidence interval 0.80 to 1.36). AF was associated with an increased risk of periprocedural cardiac complications (odds ratio 1.46, 95% confidence interval 1.22 to 1.75), longer LOS (p <0.001) and an increased cost of hospitalization (US$51,852 vs US$49,599). In conclusion, pre-existing AF did not impact in-hospital mortality in TAVI patients but was associated with increased cardiac complications, a longer hospital LOS, and a higher cost of hospitalization.

Low referral pattern for implantable defibrillator therapy in a tertiary hospital: referral physician survey and Monte Carlo simulation.

Although implantable cardioverter defibrillator (ICD) therapy is the standard of care for prevention of sudden cardiac death (SCD), its underutilization is a clinical concern. We performed a retrospective study on patients who underwent cardiac catheterization at a tertiary medical center to identify those who were eligible for ICD therapy as per the guidelines and those who actually received it as a part of treatment. Surprisingly, only 4.4% of eligible patients received ICD for SCD prevention. Assuming that the major cause of this underutilization of ICD therapy was low referral, we performed a structured survey among the referring physicians to assess specialists' availability, primary care physicians' role in ICD referral, patient management concerns, familiarity with ICD guidelines, and economics of ICD implantation. Physician response rate of the survey was 51% (35/68). Survey results showed that the common reasons for underreferral included nonavailability of electrophysiologists (34%), poor quality of life of patients (25.7%), patients not being on optimal therapy (25.7%), and low awareness (22.85%). Subsequently, a Monte Carlo simulation was used to assess a hypothetical survival of the study cohort, which showed that in an "ideal scenario" of ICD implantation, the mortality in the study cohort was decreased by 6.9% and 12.3% at 2- and 5-year follow-up, respectively. This study highlights the underutilization of ICDs and the referring physicians' approach to this therapy.