Venous thromboembolic outcomes in patients with lymphedema and lipedema: An analysis from the National Inpatient Sample.

BACKGROUND: Patients with lymphedema and lipedema share physical exam findings that may lead to misdiagnosis. Poor mobility is common in patients with obesity and patients with lymphedema and lipedema. This may constitute a risk factor for venous thromboembolism (VTE). Our objective was to evaluate the association of VTE in obese patients with lymphedema and lipedema. METHODS: The National Inpatient Sample (NIS) was searched from 2016 to 2020 to identify hospital admissions of obese female patients with lymphedema and lipedema. Patients were analyzed in the context of presence or absence of VTE while adjusting for complex cluster sampling techniques. Predictors of VTE were accessed by multivariable regression. RESULTS: Lymphedema was identified in 189,985 patients and lipedema in 50,645 patients. VTE was observed in 3.12% (n = 374,210) of patients with obesity. In patients with obesity, VTE was more common in patients with lymphedema than without (2.6% vs 1.6%; p < 0.01). Similarly, VTE was more common in patients with lipedema than without (0.6% vs 0.4%; p < 0.01). After multivariable logistic regression, VTE events in obese patients with lymphedema were higher versus without (OR 1.6; CI 1.08-2.43; p = 0.02). Similarly, VTE events were more common in obese patients with lipedema versus obese patients without lipedema (OR 1.20; CI 1.03-1.41; p = 0.02). CONCLUSIONS: In this hypothesis-generating study, lymphedema and lipedema show a positive association with VTE after adjusting for baseline patient characteristics such as obesity, which is a known independent risk factor for VTE. Mechanisms whereby lymphedema and lipedema are associated with VTE should be investigated.

Outcomes with plug-based versus suture-based vascular closure device after transfemoral transcatheter aortic valve replacement: A systematic review and meta-analysis.

BACKGROUND: Studies comparing plug-based (i.e., MANTA) with suture-based (i.e., ProStar XL and ProGlide) vascular closure devices (VCDs) for large-bore access closure after transcatheter aortic valve replacement (TAVR) have yielded mixed results. AIMS: To examine the comparative safety and efficacy of both types of VCDs among TAVR recipients. METHODS: An electronic database search was performed through March 2022 for studies comparing access-site related vascular complications with plug-based versus suture-based VCDs for large-bore access site closure after transfemoral (TF) TAVR. RESULTS: Ten studies (2 randomized controlled trials [RCTs] and 8 observational studies) with 3113 patients (MANTA = 1358, ProGlide/ProStar XL = 1755) were included. There was no difference between plug-based and suture-based VCD in the incidence of access-site major vascular complications (3.1% vs. 3.3%, odds ratio [OR]: 0.89; 95% confidence interval [CI]: 0.52-1.53). The incidence of VCD failure was lower in plug-based VCD (5.2% vs. 7.1%, OR: 0.64; 95% CI: 0.44-0.91). There was a trend toward a higher incidence of unplanned vascular intervention in plug-based VCD (8.2% vs. 5.9%, OR: 1.35; 95% CI: 0.97-1.89). Length of stay was shorter with MANTA. Subgroup analyses suggested significant interaction based on study designs such that there was higher incidence of access-site vascular complications and bleeding events with plug-based versus suture-based VCD among RCTs. CONCLUSION: In patients undergoing TF-TAVR, large-bore access site closure with plug-based VCD was associated with a similar safety profile as suture-based VCD. However, subgroup analysis showed that plug-based VCD was associated with higher incidence of vascular and bleeding complications in RCTs.

Transcatheter edge-to-edge repair for mitral regurgitation using PASCAL or MitraClip.

BACKGROUND: There is a paucity of data regarding the comparative efficacy and safety of Mitral valve transcatheter edge-to-edge repair (MTEER) using the PASCAL or MitraClip systems for patients with mitral regurgitation (MR). METHODS: An electronic search was conducted for MEDLINE, COCHRANE, and EMBASE, through February 2023, for studies comparing the clinical outcomes of MTEER using PASCAL versus MitraClip systems among patients with severe MR. The primary study outcome was residual MR ≤ 2 at discharge. Data were pooled using a random-effects model. RESULTS: The final analysis included six studies with a total of 1581 patients, with a weighted follow-up period of 3.5 months. Two studies only included patients with degenerative MR, while the remaining studies included both degenerative and functional MR. There was no significant difference in procedure duration between MTEER with the PASCAL or MitraClip systems. There was no difference in residual MR ≤ 2 at discharge (94.7% vs. 91.9%; odds ratio [OR]: 1.44; 95% confidence interval [CI]: 0.92-2.27) or residual MR ≤ 2 at the mid-term follow-up (94.6% vs. 91.0%, p = 0.05) among the PASCAL versus MitraClip systems. There was no difference between both groups in residual MR ≤ 1 at discharge (73.1% vs. 63.8%, p = 0.12), while there was greater incidence of residual MR ≤ 1 at midterm follow-up with the PASCAL system (71.3% vs. 56.2%, p < 0.001). There was no difference between the PASCAL and MitraClip MTEER systems in technical success (97.0% vs. 97.9%, p = 0.15), procedural success (89.1% vs. 87.1%, p = 0.78), single leaflet detachment (1.8% vs. 1.4%, p = 0.55), or all-cause mortality (3.6% vs. 4.6%, p = 0.71). CONCLUSION: In this meta-analysis, we demonstrated comparable efficacy and safety between the PASCAL and MitraClip MTEER systems at short- and mid-term assessments. Randomized trials are warranted to evaluate the comparative long-term outcomes between both MTEER systems.

Role of oesophageal cooling in the prevention of oesophageal injury in atrial fibrillation catheter ablation: a systematic review and meta-analysis of randomized controlled trials.

AIMS: To evaluate the efficacy of oesophageal cooling in the prevention of oesophageal injury in patients undergoing atrial fibrillation (AF) catheter ablation. METHODS AND RESULTS: Comprehensive search of MEDLINE, EMBASE, and Cochrane databases through April 2022 for randomized controlled trials (RCTs) evaluating the role of oesophageal cooling compared with control in the prevention of oesophageal injury during AF catheter ablation. The study primary outcome was the incidence of any oesophageal injury. The meta-analysis included 4 RCTs with a total of 294 patients. There was no difference in the incidence of any oesophageal injury between oesophageal cooling and control [15% vs. 19%; relative risk (RR) 0.86; 95% confidence interval (CI) 0.31-2.41]. Compared with control, oesophageal cooling showed lower risk of severe oesophageal injury (1.5% vs. 9%; RR 0.21; 95% CI 0.05-0.80). There were no significant differences among the two groups in mild to moderate oesophageal injury (13.6% vs. 12.1%; RR 1.09; 95% CI 0.28-4.23), procedure duration [standardized mean difference (SMD) -0.03; 95% CI -0.36-0.30], posterior wall radiofrequency (RF) time (SMD 0.27; 95% CI -0.04-0.58), total RF time (SMD -0.50; 95% CI -1.15-0.16), acute reconnection incidence (RR 0.93; 95% CI 0.02-36.34), and ablation index (SMD 0.16; 95% CI -0.33-0.66). CONCLUSION: Among patients undergoing AF catheter ablation, oesophageal cooling did not reduce the overall risk of any oesophageal injury compared with control. Oesophageal cooling might shift the severity of oesophageal injuries to less severe injuries. Further studies should evaluate the long-term effects after oesophageal cooling during AF catheter ablation.

Sex-related differences in the trends and outcomes of trans-septal transcatheter mitral valve replacement: Insights from the National Readmissions Database.

BACKGROUND: There is a paucity of data regarding the sex-related differences in the trends and outcomes of trans-septal transcatheter mitral valve replacement (TS-TMVR). METHODS: The Nationwide Readmissions Database (2015-2018) was queried for admissions for TS-TMVR. Propensity matched analysis was conducted to compare outcomes with hospitalizations for TS-TMVR among women versus men. The main study outcome was in-hospital mortality. RESULTS: Our final analysis included 2063 hospitalizations for TS-TMVR; of whom, 58.1% were women. The proportion of women among those undergoing TS-TMVR increased from 50% in 2015 to 60.2% in 2018 (Ptrend = 0.04). Compared with men, women undergoing TS-TMVR were slightly younger, and had a distinct profile of comorbidities. After matching, there was no significant difference in in-hospital mortality among women versus men undergoing TS-TMVR (7.8% vs. 6.1%, OR = 1.30; 95% CI: 0.79-2.13). Subgroup analyzes showed an interaction toward higher mortality with women versus men among patients with CKD (Pinteraction = 0.07). There were no significant differences between women and men in in-hospital complications or length of stay after TS-TMVR. Compared with men, women undergoing TS-TMVR were more likely to be discharged to a nursing facility (17.7% vs. 11.5%, p = 0.01) and had higher rates of 30-day readmissions (22.4% vs. 13.6%, p = 0.01). CONCLUSION: This nationwide analysis showed an increase in the proportion of women among patients undergoing TS-TMVR during the study years. There were no differences in in-hospital mortality, in-hospital complications, or length of stay between both sexes following TS-TMVR. Women were more likely to be discharged to nursing facilities and had higher rates of readmission at 30 days even after propensity matching.

Transcatheter edge-to-edge repair of the tricuspid valve: The US experience.

OBJECTIVES: To examine the trends in utilization and outcomes of tricuspid valve (TV) transcatheter edge-to-edge repair (TEER). BACKGROUND: Surgery for isolated tricuspid regurgitation is associated with high morbidity and mortality and is rarely performed. TV TEER is an attractive alternative. METHODS: The Nationwide Readmissions Database was queried using the International Classification of Diseases, 10th Revision, procedure code for TV TEER for years 2016-2019. The main outcomes were trends in utilization and in-hospital all-cause mortality. RESULTS: We identified 918 hospitalizations for TV TEER. There was an uptrend in its utilization from 13 cases in the first quarter of 2016 to 122 cases in the last quarter of 2019 (p trend < 0.001). Concomitant mitral valve (MV) TEER was performed in 42.1% of admissions. The overall in-hospital mortality was 2.1%. Surgical TV replacement was needed in 1.1% of admissions; none of them died during the index hospitalization. Unplanned rehospitalizations were common at 30 days (15.7%); 38.2% of those were due to heart failure. There was no difference in in-hospital mortality between isolated TV TEER and combined MV and TV TEER (1.7% vs. 2.6%, p = 0.359). However, admissions receiving combined procedure had lower length of stay and urgent readmission rate. CONCLUSION: The current study showed that there was an increase in the utilization of TV TEER over 2016-2019 in the United States. TV TEER was associated with low rates of in-hospital mortality; however, the rate of urgent readmission remains high, mainly due to heart failure.

Early versus late discharge after transcatheter aortic valve replacement and readmissions for permanent pacemaker implantation.

OBJECTIVE: To examine the rate of readmission for permanent pacemaker (PPM) implantation with early versus late discharge after transcatheter aortic valve replacement (TAVR). BACKGROUND: There is a current trend toward early discharge after TAVR. However, paucity of data exists on the impact of such practice on readmissions for PPM implantation. METHODS: The Nationwide Readmission Database 2016-2018 was queried for all hospitalizations where patients underwent TAVR. Hospitalizations were stratified into early (Days 0 and 1) versus late (≥Day 2) discharge groups. Observations in which PPM was required in the index admission were excluded. Multivariable regression analyses involving patient- and hospital-related variables were utilized. The primary outcome was 90-day readmission for PPM implantation. RESULTS: The final analysis included 68,482 TAVR hospitalizations, 20,261 (29.6%) with early versus 48,221 (70.4%) with late discharge. Early discharge after TAVR increased over the study period (16.2% in 2016 vs. 37.9% in 2018, Ptrend < 0.01). Nevertheless, 90-day readmission for PPM implantation remained stable (1.8% in 2016 vs. 2.0% in 2018, Ptrend = 0.32). The 90-day readmission rate for PPM implantation (2.0% vs. 1.8%; adjusted odds ratio: 1.15; 95% confidence interval: 0.95-1.39; p = 0.15) and median time-to-readmission (5 days [interquartile range, IQR 3-9] vs. 5 days [IQR 3-14], p = 0.92) were similar with early versus late discharge. Similar rates were observed regardless of whether readmission was elective versus not. Early discharge was associated with lower hospitalization cost ($39,990 ± $13,681 vs. $46,750 ± $18,218, p < 0.01) compared with late discharge. CONCLUSION: In patients who did not require PPM during the index TAVR hospitalization, the rate of readmission for PPM implantation was similar with early versus late discharge.

In-hospital outcomes of transesophageal versus intracardiac echocardiography guided left atrial appendage closure.

BACKGROUND: Transesophageal echocardiogram (TEE) is the preferred imaging modality to guide transcatheter left atrial appendage closure (LAAC). Intracardiac echocardiography (ICE) has evolved as a less invasive alternative to TEE. Several observational studies have shown similar success rates and perioperative complications between TEE and ICE for LAAC. OBJECTIVES: We sought to examine the temporal trends and patient characteristics of TEE versus ICE use in LAAC using a national database. We also evaluated hospital outcomes including periprocedural complications, mortality, and length of hospital stay. METHODS: This is a retrospective analysis of data from the National Readmission Database, collected from 2016 to 2018. The primary outcome was major adverse events (MAE) defined as in-hospital mortality, cardiac arrest, pericardial effusion with or without tamponade, pericardiocentesis or window pericardiocentesis and pericardial window, pericardial effusion and tamponade, and hemorrhage requiring transfusion. RESULTS: Trend analysis showed that TEE-guided LAAC increased from 96.6% in 2016 to 98.4% in 2018 (relative increase, 1.9%), while ICE-guided LAAC decreased from 3.4% to 1.6% during the same period (relative decrease, 53%, p for trend = 0.08). In the unmatched cohorts, the MAE was significantly lower in TEE-guided LAAC compared to ICE-guided LAAC (6.5% vs. 9.3%, p = 0.022). In the propensity score matching analysis, MAE remained significant (5.6% vs. 9.4%, p < 0.001). The incidence of pericardial effusion with or without tamponade remained significantly lower in the TEE group (2.3% vs. 5.8%, p < 0.001). Length of stay (3.4 vs. 1.9 days, p < 0.001) and hospitalization cost ($34,826 vs. $20,563, p < 0.001) remained significantly lower for TEE-guided LAAC. CONCLUSIONS: Compared to ICE, the incidence of MAE was significantly lower for TEE-guided LAAC, driven mainly by less pericardial effusion events. Large-scale randomized trials are needed to confirm the findings of the current and previous studies.

Trends in utilization, outcomes, and readmissions after transcatheter mitral valve replacement.

BACKGROUND: There is a paucity of real-world data regarding the temporal trends and outcomes of trans-septal transcatheter mitral valve replacement (TS-TMVR) in the United States (US). METHODS: We queried the Nationwide Readmissions Database (October 2015 to December 2018) for patients undergoing TS-TMVR procedures. We reported the temporal trends in the utilization, in-hospital outcomes and 30-day readmissions after TS-TMVR. The main study outcome was in-hospital mortality. RESULTS: There was an increase in the number of TS-TMVR procedures over time (48 in 2015 vs. 978 in 2018, Ptrend < 0.001), with a notable increase in the proportion of women (Ptrend  = 0.04) and the prevalence of diabetes (Ptrend  = 0.03). There was an increase in the number of centers performing TS-TMVR (21 in 2015 vs. 164 in 2018, Ptrend < 0.001). The overall in-hospital mortality was 7.2% with no change over time (6.3% in 2015 vs. to 5.2% in 2018, Ptrend  = 0.67). There was no change in the frequency of in-hospital complications after TS-TMVR; however, the median length of stay has decreased over time. The overall 30-day readmission rate was 17.8%, with no change during the study years. The most frequent cause for 30-day readmission after TS-TMVR was acute heart failure followed by bleeding and infection-related complications. Prior coagulopathy and small-sized hospitals were independently associated with higher in-hospital mortality and 30-day readmissions. CONCLUSION: This nationwide observational analysis of real-world data showed an increase in the number of TS-TMVR procedures over time, which is now performed at a greater number of centers. There was no change in the rate of in-hospital mortality, complications or 30-day readmissions; but a significant reduction in the length of hospital stay over time was noted. As the number of TS-TMVR continue to expand, these data provide a perspective on the early experience with this procedure.

Outcomes of Cardiac Arrest and Cardiopulmonary Resuscitation in Patients With Left Ventricular Assist Device; an Insight From a National Inpatient Sample.

BACKGROUND: Outcomes of patients with implanted left ventricular assist device (LVAD) implantation experiencing a cardiac arrest (CA) are not well reported. We aimed at defining the in-hospital outcomes of patients with implanted LVAD experiencing a CA. METHODS: The national inpatient sample (NIS) was queried using ICD9/ICD10 codes for patients older than 18 years with implanted LVAD and CA between 2010-2018. We excluded patients with orthotropic heart transplantation, biventricular assist device (BiVAD) implantation and do not resuscitate (DNR) status. RESULTS: A total of 93,153 hospitalisations between 2010 and 2018 with implanted LVAD were identified. Only 578 of these hospitalisations had experienced CA and of those, 173 (33%) hospitalisations underwent cardiopulmonary resuscitation (CPR). The mean age of hospitalisations that experienced a CA was 60.61±14.85 for non-survivors and 56.23±17.33 for survivors (p=0.14). The in-hospital mortality was 60.8% in hospitalisations with CA and 74.33% in hospitalisations in whom CPR was performed. In an analysis comparing survivors with non-survivors, non-survivors had more diabetes mellitus (DM) (p=0.01), and ischaemic heart disease (IHD) (p=0.04). Age, female sex, peripheral vascular disease and history of coronary artery bypass graft (CABG) were independently associated with increased mortality in our cohort. Also, ventricular tachycardia (VT) and CPR were independently associated with in-hospital mortality. During the study period, there was a significantly decreasing trend in performing CPR in LVAD hospitalisations with CA. CONCLUSION: In conclusion, age, female sex, peripheral vascular disease, history of CABG, VT and CPR were independently associated with in-hospital mortality in LVAD hospitalisations who experienced CA.

Outcomes of transcatheter versus surgical aortic valve replacement among solid organ transplant recipients.

BACKGROUND: There is a paucity of data regarding the outcomes of transcatheter aortic valve replacement (TAVR) versus surgical aortic valve replacement (SAVR) among solid-organ transplant recipients. METHODS: Temporal trends in hospitalizations for aortic valve replacement among solid-organ transplant recipients were determined using the National Inpatient Sample database years 2012-2017. Propensity matching was conducted to compare admissions who underwent TAVR versus SAVR. The primary outcome was in-hospital mortality. RESULTS: The analysis included 1,730 hospitalizations for isolated AVR; 920 (53.2%) underwent TAVR and 810 (46.7%) underwent SAVR. TAVR was increasingly utilized for solid-organ transplant recipients (Ptrend = 0.01), while there was no change in the number of SAVR procedures (Ptrend = 0.20). The predictors of undergoing TAVR for solid-organ transplant recipients included older age, diabetes, and prior coronary artery bypass surgery, while TAVR was less likely utilized in small-sized hospitals. TAVR was associated with lower in-hospital mortality after matching (0.9 vs. 4.7%, odds ratio [OR] 0.19; 95% confidence interval [CI] 0.11-0.35, p < .001) and after multivariable adjustment (OR 0.07; 95% CI 0.03-0.21, p < .001). TAVR was associated with lower rate of acute kidney injury, acute stroke, postoperative bleeding, blood transfusion, vascular complications, discharge to nursing facilities, and shorter median length of hospital stay. There was no difference between both groups in the use of mechanical circulatory support, hemodialysis, arrhythmias, or pacemaker insertion. CONCLUSION: This contemporary observational nationwide analysis showed that TAVR is increasingly performed among solid-organ transplant recipients. Compared with SAVR, TAVR was associated with lower in-hospital mortality, complications, and shorter length of stay.

Outcomes with catheter-directed thrombolysis compared with anticoagulation alone in patients with acute deep venous thrombosis.

OBJECTIVE: The authors aimed to investigate the benefits and risks of catheter-directed thrombolysis (CDT) in acute deep venous thrombosis (DVT). BACKGROUND: The role of CDT in the management of DVT is evolving. Data on CDT versus anticoagulation alone in acute DVT is sparse. METHODS: We performed a systematic review and meta-analysis of published studies that compared CDT to anticoagulation alone in patients with acute DVT. RESULTS: We included 11 studies (four randomized control trials [RCTs] and seven observational studies) with a total of 8,737 patients. During hospital stay, patients who received CDT had higher odds of major bleeding (2.5% vs. 1.6%; OR 1.46, 95% CI [1.07, 1.98], p = .02), blood transfusion (10.8% vs. 6.2%; OR 1.8, 95% CI [1.52, 2.13], p < .001), and thromboembolism (15.5% vs. 10%; OR 1.67, 95% CI [1.47, 1.91], p < .001) compared with anticoagulation alone. At 6-month follow-up, patients who received CDT had higher venous patency (71.1% vs. 37.7%; OR 5.49, 95% CI [2.63, 11.5], p < .001) and lower postthrombotic syndrome (PTS; 27% vs. 40.7%; OR 0.44, 95% CI [0.22, 0.86], p = .02). During a mean follow-up duration of 30.5 ± 28 months, CDT group continued to have higher venous patency (79.6% vs. 71.8%; OR 3.79, 95% CI [1.54, 9.32], p = .004) and lower PTS (44.7% vs. 50.5%; OR 0.43, 95% CI [0.23, 0.78], p = .006), but no difference in thromboembolism. CONCLUSION: Compared with anticoagulation alone, CDT for patients with acute DVT was associated with a higher risk of complications, but a higher rate of venous patency and lower risk of postthrombotic syndrome at 2.5 years follow-up.

Temporal trends and outcomes of critical limb ischemia among patients with chronic kidney disease.

There is a paucity of data on the outcomes and revascularization strategies for critical limb ischemia (CLI) among patients with chronic kidney disease (CKD). Hence, we conducted a nationwide analysis to evaluate the trends and outcomes of hospitalizations for CLI with CKD. The National Inpatient Sample database (2002-2015) was queried for hospitalizations for CLI. The trends of hospitalizations for CLI with CKD were reported, and endovascular versus surgical revascularization strategies for CLI with CKD were compared. The main study outcome was in-hospital mortality. The analysis included 2,139,640 hospitalizations for CLI, of which 484,224 (22.6%) had CKD. There was an increase in hospitalizations for CLI with CKD (Ptrend = 0.01), but a reduction in hospitalizations for CLI without CKD (Ptrend = 0.01). Patients with CLI and CKD were less likely to undergo revascularization compared with patients without CKD. CLI with CKD had higher rates of in-hospital mortality (4.8% vs 2.5%, adjusted odds ratio (OR) 2.01; 95% CI 1.93-2.11) and major amputation compared with no CKD. Revascularization for CLI with CKD was associated with lower rates of mortality (3.7% vs 5.3%, adjusted-OR 0.78; 95% CI 0.72-0.84) and major amputation compared with no revascularization. Compared with endovascular revascularization, surgical revascularization for CLI with CKD was associated with higher rates of in-hospital mortality (4.7% vs 2.7%, adjusted-OR 1.67; 95% CI 1.43-1.94). In conclusion, this contemporary observational analysis showed an increase in hospitalizations for CLI among patients with CKD. CLI with CKD was associated with higher in-hospital mortality compared with no CKD. Compared with endovascular therapy, surgical revascularization for CLI with CKD was associated with higher in-hospital mortality.

Effect of aspirin on short-term outcomes in hospitalized patients with COVID-19.

Coronavirus disease 2019 (COVID-19) caused by SARS-CoV-2 is an ongoing viral pandemic marked by increased risk of thrombotic events. However, the role of platelets in the elevated observed thrombotic risk in COVID-19 and utility of antiplatelet agents in attenuating thrombosis is unknown. We aimed to determine if the antiplatelet effect of aspirin may mitigate risk of myocardial infarction, cerebrovascular accident, and venous thromboembolism in COVID-19. We evaluated 22,072 symptomatic patients tested for COVID-19. Propensity-matched analyses were performed to determine if treatment with aspirin or nonsteroidal anti-inflammatory drugs (NSAIDs) affected thrombotic outcomes in COVID-19. Neither aspirin nor NSAIDs affected mortality in COVID-19. Thus, aspirin does not appear to prevent thrombosis and death in COVID-19. The mechanisms of thrombosis in COVID-19, therefore, appear distinct and the role of platelets as direct mediators of SARS-CoV-2-mediated thrombosis warrants further investigation.

Effect of platelet inhibitors on thrombus burden in patients with acute pulmonary embolism.

Venous thromboembolism (VTE) whether provoked or not can be life-threatening due to an acute increase in load on the right ventricle (RV) from obstruction of the pulmonary artery (PA). Treatment for and prevention of VTE involves anti-thrombotic agents; more specifically, medications targeting the anticoagulation cascade. In spite of the widespread acceptance of anticoagulants in the treatment of VTE, there appears to be an ongoing belief that platelet reactivity contributes to thrombus burden in patients with acute pulmonary embolism (PE). This investigation of 398 patients presenting with acute PE evaluated whether anti-platelet medication use, which consisted mostly of aspirin therapy, at the time of presentation, affects PA thrombus burden, RV load, or short-term patient outcomes. We conclude that platelets may have been erroneously incriminated as direct thrombotic mediators in patients with acute PE since aspirin neither decreased PA thrombus burden, nor did aspirin improve short-term mortality following acute PE.

Critical Review and Meta-Analysis of Postoperative Sedation after Adult Cardiac Surgery: Dexmedetomidine Versus Propofol.

OBJECTIVE: To evaluate reports from the published literature of all randomized clinical trials (RCT) comparing postoperative sedation with dexmedetomidine versus propofol in adult patients, after open cardiac surgery. DESIGN: A computerized search on Medline, EMBASE, Web of Science, and Agency for Healthcare Research and Quality databases was completed through June 2020. Meta-analysis of all published RCT comparing dexmedetomidine versus propofol utilization in the postoperative phase, using the standard Preferred Reporting Items for Systematic Reviews and Meta-Analyses checklist. SETTING: Assemblage and critical discussion of 11 RCTs comparing postoperative sedation from standard published reports from 2003 to 2019. PARTICIPANTS: The study comprised 1,184 patients and analyzed critical discussion of time-based parameters (time to extubation, intensive care unit length of stay, and hospital length of stay) and nontime-dependent factors (delirium, bradycardia, and hypotension). MEASUREMENTS AND MAIN RESULTS: Time to extubation was significantly reduced in the dexmedetomidine group (standardized mean difference [SMD] = -0.70, 95% confidence interval [CI] -0.98 to -0.42, p < 0.001); however, no difference in mechanical ventilation time was observed (SMD = -0.72, 95% CI -1.60 to 0.15, N.S.). Dexmedetomidine significantly reduced the intensive care unit length of stay (SMD = 0.23, 95% CI -1.06 to -0.16, p = 0.008), but this did not translate into a reduced hospital length of stay (SMD = -1.13, 95% CI -2.43 to 0.16, N.S). For nontime-dependent factors, incidence of delirium was unaffected between groups (odds ratio [OR]: 0.68, 95% CI 0.43-1.06, N.S), and higher rates of bradycardia (OR: 3.39, 95% CI: 1.20-9.55, p = 0.020) and hypotension (OR: 1.68, 95% CI 1.09-2.58, p = 0.017) were reported with propofol. CONCLUSIONS: Despite the ICU time advantages afforded by dexmedetomidine over propofol, the former did not seem to contribute to an overall reduction in hospital length of stay or improvement in postoperative outcomes of heart valve surgery and CABG patients.

Treatment Bias in Management of HIV Patients Admitted for Acute Myocardial Infarction: Does It Still Exist?

INTRODUCTION: Previous studies have reported lower rates of coronary angiography and revascularization, and significantly higher mortality among patients infected with human immunodeficiency virus (HIV) presenting with acute myocardial infarction (AMI). This observational study was designed to evaluate characteristics and inpatient outcomes of patients with seropositive HIV infection presenting with AMI. METHODS: Using the National Inpatient Sample (NIS) database, we identified patients (admissions) with a primary diagnosis of myocardial infarction and a co-occurring HIV. We described baseline characteristics and outcomes. Our primary outcomes of interest were prevalence of coronary angiography, revascularization (percutaneous coronary intervention (PCI) or CABG), and mortality. RESULTS: From 2010 to 2014, of about 2,977,387 patients with a primary diagnosis of AMI, 10,907 (0.4%) were HIV seropositive. Patients with HIV were younger and more likely to be African American or Hispanic. Coronary angiography and revascularization were performed more frequently in the HIV population. The higher prevalence of revascularization was driven by a higher incidence of PCI. In a multivariable model, patients with HIV were no more likely to undergo revascularization than the general population. This was also the case for PCI. Unadjusted all-cause mortality was lower among patients with HIV. After controlling for confounders, this finding was not significant (OR 0.97, 95% CI 0.75-1.25, p = 0.79). The length of stay between both groups was comparable. CONCLUSION: In this current analysis, we did not note any treatment bias or difference in the rate of in-hospital total mortality for HIV-seropositive patients presenting with AMI compared with the general population.

Outcomes of urgent versus nonurgent transcatheter aortic valve replacement.

BACKGROUND: There is a paucity of data regarding the outcomes of transcatheter valve replacement (TAVR) performed in an urgent clinical setting. METHODS: The Nationwide Inpatient Sample (NIS) database years 2011-2014 was used to identify hospitalizations for TAVR in the urgent setting. Using propensity score matching, we compared patients who underwent TAVR in nonurgent versus urgent settings. RESULTS: Among 42,154 hospitalizations in which TAVR was performed, 10,114 (24%) underwent urgent TAVR. There was an uptrend in the rate of urgent TAVR procedures (p = .001). The rates of in-hospital mortality among this group did not change during the study period (p = .713). Nonurgent TAVR was associated with lower mortality (odds ratio [OR] = 0.78; 95% confidence interval [CI]: 0.69-0.89, p < .001) compared with urgent TAVR. Nonurgent TAVR was associated with lower incidence of cardiogenic shock (OR = 0.46; 95%CI: 0.40-0.53 p < .001), use of mechanical circulatory support devices (OR = 0.69; 95%CI: 0.59-0.82, p < .001), AKI (OR = 0.60; 95%CI: 0.56-0.64 p < .001), hemodialysis (OR = 0.67; 95%CI: 0.56-0.80 p < .001), major bleeding (OR = 0.94; 95%CI: 0.89-0.99 p = .045) and shorter length of stay (7.08 ± 6.317 vs. 12.39 ± 9.737 days, p < .001). There was no difference in acute stroke (OR = 0.96; 95%CI: 0.81-1.14, p = .636), vascular complications (OR = 1.07; 95%CI: 0.89-1.29, p = .492), and pacemaker insertions (OR = 0.92; 95%CI: 0.84-1.01, p = .067) between both groups. Among those undergoing urgent TAVR, subgroup analysis showed higher mortality in patients ≤80 years (p = .033), women (p < .001), chronic kidney disease (p = .001), heart failure (p < .001), and liver disease (p = .003). CONCLUSION: In this large nationwide analysis, almost a quarter of TAVR procedures were performed in the urgent settings. Although urgent TAVR was associated with higher mortality and increased complications compared with nonurgent TAVR, the absolute difference in in-hospital mortality was not remarkably higher. Thus, urgent TAVR can be considered as a reasonable approach when indicated.

Temporal trends, outcomes, and predictors of mortality after pericardiocentesis in the United States.

BACKGROUND: Data regarding the temporal trends, outcomes, and predictors of in-hospital mortality after pericardiocentesis are limited. METHODS: The National Inpatient Sample database was used to extract hospitalizations of patients who underwent pericardiocentesis from January 2007 to September 2015. We examined the rates of in-hospital mortality, its predictors, and the temporal trends of pericardiocentesis utilization in the United States during the study period. We also examined trends and outcomes of pericardiocentesis associated with different cardiovascular procedures. RESULTS: A total of 96,377 hospitalizations with pericardiocentesis were examined. The number of pericardiocentesis procedures performed trended up significantly between 2007 and 2015 (p trend <.001), and this increase was observed predominantly in patients with unstable conditions. In-hospital mortality after pericardiocentesis decreased over time (14.6% in 2007 vs. 12.0% in 2015, p trend <.001), but remained higher than that after surgical pericardial intervention (13.1 vs. 8.9%, p value <.0001), predominantly attributable to a higher patient risk profile. Rates of in-hospital mortality were not statistically different between the procedural cohort and the nonprocedural cohort, 13.5 versus 13.0%, p value = .051. After multivariable adjustment, structural heart interventions (odds ratio [OR] 2.86; 95% confidence interval [CI] 2.35-3.49), bacterial and/or infective endocarditis (OR 2.09; 95% CI 1.72-2.54) and active neoplasms (OR 1.72; 95% CI 1.6-1.85) were independently associated with increased in-hospital mortality in pericardiocentesis patients. CONCLUSION: In this nationwide analysis, the number of pericardiocentesis procedures increased significantly over time. Structural interventions, endocarditis, and active neoplasms were associated with increased in-hospital mortality after pericardiocentesis.

Right ventricular dysfunction is superior and sufficient for risk stratification by a pulmonary embolism response team.

Several risk stratification tools are available to predict short-term mortality in patients with acute pulmonary embolism (PE). The presence of right ventricular (RV) dysfunction is an independent predictor of mortality and may be a more efficient way to stratify risk for patients assessed by a Pulmonary Embolism Response Team (PERT). We evaluated 571 patients presenting with acute PE, then stratified them by the pulmonary embolism severity index (PESI), by the BOVA score, or categorically as low risk (no RV dysfunction by imaging), intermediate risk/submassive (RV dysfunction by imaging), or high risk/massive PE (RV dysfunction with sustained hypotension). Using imaging data to firstly define the presence of RV strain, and plasma cardiac biomarkers as additional evidence for myocardial dysfunction, we evaluated whether PESI, BOVA, or RV strain by imaging were more appropriate for determining patient risk by a PERT where rapid decision making is important. Cardiac biomarkers poorly distinguished between PESI classes and BOVA stages in patients with acute PE. Cardiac TnT and NT-proBNP easily distinguished low risk from submassive PE with an area under the curve (AUC) of 0.84 (95% CI 0.73-0.95, p < 0.0001), and 0.88 (95% CI 0.79-0.97, p < 0.0001), respectively. Cardiac TnT and NT-proBNP easily distinguished low risk from massive PE with an area under the curve (AUC) of 0.89 (95% CI 0.78-1.00, p < 0.0001), and 0.89 (95% CI 0.82-0.95, p < 0.0001), respectively. In patients with RV dysfunction, the predicted short-term mortality by PESI score or BOVA stage was lower than the observed mortality by a two-fold order of magnitude. The presence of RV dysfunction alone in the context of acute PE is sufficient for the purposes of risk stratification. More complicated risk stratification tools which require the consideration of multiple clinical variables may under-estimate short-term mortality risk.