Efficacy and safety of TAVR versus SAVR in patients with small aortic annuli: A systematic review and meta-analysis.

INTRODUCTION: Patients with a small aortic annulus (SAA) undergoing aortic valve replacement are at increased risk of patient-prosthesis mismatch (PPM), which adversely affects outcomes. Transcatheter aortic valve replacement (TAVR) has shown promise in mitigating PPM compared to surgical aortic valve replacement (SAVR). METHODS: We conducted a systematic review and meta-analysis following PRISMA guidelines to compare clinical outcomes, mortality, and PPM between SAA patients undergoing TAVR and SAVR. Eligible studies were identified through comprehensive literature searches and assessed for quality and relevance. RESULTS: Nine studies with a total of 2476 patients were included. TAVR demonstrated similar 30-day and 2-year mortality, myocardial infarction, and stroke rates compared to SAVR. However, TAVR showed significant advantages in reducing moderate survival post SAVR, the observed hemodynamic outcomes may potentially contribute to substantial survival variations between TAVR and SAVR during extended follow-up periods.22 Furthermore, previous studies found comparable 30-day and 2-year mortality rates between TAVR and SAVR, with no significant differences across annulus sizes.22, 23 Stroke and myocardial infarction incidences and severe PPM and lowering rates of major bleeding at both 30 days and 2 years. Conversely, SAVR had better outcomes in 30-day permanent pacemaker implantation. Echocardiographic outcomes were comparable between the two interventions. CONCLUSION: Our findings suggest that both TAVR and SAVR are viable options for treating AS in patients with a small aortic annulus. TAVR offers advantages in reducing PPM and major bleeding, while SAVR performs better in terms of pacemaker implantation. Future studies should focus on comparing newer generation TAVR techniques and devices with SAVR. Consideration of patient characteristics is crucial in selecting the optimal treatment approach for AS.

Hypertrophic cardiomyopathy in pregnancy: Nationwide analysis of patients characteristics and outcomes.

INTRODUCTION: Hypertrophic cardiomyopathy (HCM) poses unique challenges in the management of pregnant patients due to the complex interplay of physiological changes of pregnancy. Despite its relatively low prevalence among pregnant women, HCM can significantly impact maternal and fetal outcomes. This study aims to enhance understanding of pregnant patients with HCM and the associated outcomes through a nationwide analysis of patient characteristics and outcomes. METHODS: A retrospective analysis was conducted using data obtained from the Agency for Healthcare Research in Quality (AHRQ) Nationwide Inpatient Sample (NIS) database from January 2016 to December 2020. 3,599,855 pregnant patients without HCM and 187 pregnant patients with HCM were identified using International Classification of Disease (ICD) codes, and baseline characteristics, medical comorbidities, and outcomes were compared between the two groups. RESULTS: Significant differences were observed in baseline characteristics, including age distribution, racial composition, and prevalence of systemic organ disease, between pregnant women with and without HCM. Women with HCM had higher odds of experiencing maternal complications, such as acute heart failure and peripartum cardiomyopathy, as well as higher rates of fetal distress and obstetric interventions, including preterm delivery and caesarean section. CONCLUSION: Comprehensive cardiovascular assessment and risk stratification are essential in pregnant women with HCM to optimize maternal and fetal outcomes. Moreover, disparities in baseline characteristics and outcomes among black pregnant women with HCM highlight the need for a multifactorial approach to addressing pregnancy-related complications.

The various perioperative issues of structural heart diseases and cardiogenic shock.

Up to 20 % of patients presenting with acute heart failure and cardiogenic shock have a structural etiology. Despite efforts in timely management, mortality rates remain alarmingly high, ranging from 50 % to 80 %. Surgical intervention is often the definitive treatment for structural heart disease; however, many patients are considered high risk or unsuitable candidates for such procedures. Consequently, there has been a paradigm shift towards the development of novel percutaneous management strategies and temporizing interventions. This article aims to provide a comprehensive review of the pathophysiology of valvular and structural heart conditions presenting in cardiogenic shock, focusing on the evolving landscape of mechanical circulatory support devices and other management modalities.

Cerebral embolic protection device utilization and outcomes in transcatheter aortic valve replacement: A nationally representative propensity matched analysis.

INTRODUCTION: In patients undergoing transcatheter aortic valve replacement (TAVR), cerebral embolic protection devices (CEPD) are used to possibly diminish the risk of periprocedural stroke. Trends and outcomes of CEPD usage in TAVR are not well characterized. METHODS: National readmission databases (NRD) 2017-2019 was used to identify hospital admissions for TAVR using ICD-10 codes, with versus without Sentinel CEPD. Primary outcomes of the study were in-hospital and 30-day stroke. Secondary outcomes include in-hospital mortality, 30-day mortality, 30-day readmission rate, and other procedural complications. We matched both cohorts using propensity score matching (PSM) and performed logistic regression to compute the odds ratios (ORs) and corresponding 95 % confidence intervals (CI). RESULTS: Out of 190,837 TAVR admissions in the United States, 10,643 (5.6 %) patients had TAVR with Sentinel CEPD. After propensity score matching, our cohort included 10,503 patients with CEPD and 10,541 without CEPD. Trends in CEPD utilization are noted in Fig. 1. In the PSM cohort, Sentinel CEPD was not associated with decreased risk of in-hospital stroke (1.9 % vs. 1.8 %, OR: 0.98, 95 % CI: 0.76-1.26, p = 0.88), 30-day stroke (2.1 % vs. 2.1 %, OR: 1.01, 95 % CI: 0.78-1.30, p = 0.96), or 30-day mortality (1.3 % vs. 1.0 %, OR: 0.74, 95 % CI: 0.51-1.07, p = 0.11) when compared to TAVR without CEPD. Other in-hospital and short-term outcomes post-TAVR were not impacted by Sentinel CEPD usage, including acute kidney injury, vascular complications, paravalvular leak, cardiogenic shock, circulatory support, or permanent pacemaker (Table 1). CONCLUSION: In this nationally representative cohort, Sentinel CEPD utilization during transfemoral TAVR for stroke prevention was not associated with reduced odds of in-hospital stroke, 30-day stroke, or 30-day mortality. Future studies should focus on optimizing patient selection for CEPD and establishing predictive models to identify the subset of TAVR patients with higher risk for periprocedural stroke who might benefit from CEPD.

Early pandemic in-hospital outcomes and mortality risk factors in COVID-19 solid organ transplant patients.

Background: Solid organ transplant (SOT) recipients with COVID-19 have a higher risk of mortality than those without COVID-19. However, it is unclear how SOT patient outcomes compare to the general population without SOT who contract COVID-19. Methods: We used the National Inpatient Sample from January to December 2020 to investigate inpatient outcomes seen in SOT recipients after contracting COVID-19 compared to nontransplant patients. We identified our study sample using ICD-10 CM and excluded those <18 years of age and those with dual organ transplants. Inpatient outcomes were compared in SOT and non-SOT COVID cohorts, and we further evaluated predictors of mortality in the SOT with COVID population. Results: Out of the 1,416,445 COVID-19 admissions included in the study, 8315 (0.59%) were single SOT recipients. Our analysis that adjusted for multiple baseline characteristics and comorbidities demonstrated that COVID-19 in SOT patients was associated with higher rates of acute kidney injury (adjusted odds ratio [aOR] 2.34, 95% confidence interval [CI] 1.81-3.02, P < 0.01), lower rates of acute respiratory distress syndrome (aOR 0.68, 95% CI 0.54-0.85, P < 0.01), and similar rates of cardiac arrest, pulmonary embolism, circulatory shock, cerebrovascular events, and in-hospital mortality. Age >65 was associated with mortality in SOT patients. Conclusion: In this nationally representative sample, SOT patients presenting with COVID-19 experienced similar rates of mortality compared to those without SOT. SOT patients were more likely to develop acute kidney injury. Further research is needed to understand the complex relationship between transplant patient outcomes and COVID-19.

Burden of cardiovascular disease in Sub-Saharan Africa, 1990-2019: An analysis of the Global Burden of Disease Study.

INTRODUCTION: The rise in cardiovascular disease (CVD) in Sub-Saharan Africa (SSA) reflects a major shift from communicable to noncommunicable diseases as primary health challenges. Consequently, this study aims to explore the burden of CVD and associated risk factors in SSA using data from the Global Burden of Disease (GBD) database. METHODS: This study utilized data from the GBD 1990 to 2019 to examine CVD prevalence in 46 SSA countries. We employed Bayesian regression models, demographic techniques, and mortality-to-incidence ratios to analyze both prevalence and mortality rates. Additionally, disability-adjusted life years (DALYs) were computed, and various risk factors were examined using the GBD's comparative risk assessment framework. RESULTS: Between 1990 and 2019, CVD raw counts in SSA rose by 131.7 %, with a 2.1 % increase in age-standardized prevalence rates. The most prevalent conditions were ischemic heart disease, stroke, and rheumatic heart disease. During the same period, the age-standardized CVD deaths per 100,000 individuals decreased from 314 (1990) to 269 (2019), reflecting a -14.4 % decline. Age-standardized CVD DALY rates also showed a decrease from 6,755 in 1990 to 5,476 in 2019, with translates to 18.9 % reduction. By 2019, the Central African Republic, Madagascar, and Lesotho were the countries with the highest age-standardized DALY rates for all CVDs. CONCLUSIONS: The study highlights a contrasting trend in SSA's CVD landscape: a decrease in age-standardized mortality and DALYs contrasts with increasing CVD prevalence, emphasizing the need for targeted public health strategies that balance treatment advancements with intensified prevention and control measures.

Inpatient outcomes of inflammatory bowel disease in hospitalized patients with COVID-19: analysis of a nationally representative sample.

Purpose: To compare the risks of adverse outcomes, including mortality, gastrointestinal bleeding, and venous thromboembolism, between COVID-19 patients with inflammatory bowel disease (IBD) and those without IBD. Methods: We analyzed data from the National Inpatient Sample between January and December 2020. The study included adult patients with Crohn's disease (CD) and ulcerative colitis (UC) who contracted COVID-19. Inpatient outcomes were compared between the IBD and non-IBD COVID-19 cohorts. Results: Out of 1,050,045 COVID-19 hospitalizations, 0.28% had CD (2954 patients) and 0.26% had UC (2794 patients). After adjusting for confounding factors, UC patients had a significantly higher risk of deep vein thrombosis compared to non-IBD patients, with an adjusted odds ratio (aOR) of 2.55 (P < 0.001). However, CD patients did not show a significant association with deep vein thrombosis (aOR 1.29, P = 0.329). There were no significant associations between IBD patients (both UC and CD) and pulmonary embolism, nonvariceal gastrointestinal bleeding, or in-hospital mortality. UC patients had a longer average hospital stay (8.25 days) compared to non-IBD patients (adjusted mean difference 0.89, P = 0.007). Healthcare resource utilization was similar among the three groups. Conclusion: Our national study on COVID-19 hospitalizations indicates that patients with IBD have comparable rates of gastrointestinal bleeding, pulmonary embolism, and mortality as those without IBD. However, patients with UC hospitalized with COVID-19 have a higher risk of deep vein thrombosis than COVID-19 patients hospitalized without UC. Further research is needed to better understand the relationship between COVID-19 and IBD.

Bivalirudin versus unfractionated heparin in patients with myocardial infarction undergoing percutaneous coronary intervention: A systematic review and meta-analysis of randomized controlled trials.

BACKGROUND: Bivalirudin is an alternative accepted therapy to unfractionated heparin for patients with myocardial infarction (MI) undergoing percutaneous coronary intervention (PCI). We aimed in this meta-analysis to compare bivalirudin versus unfractionated heparin in patients with MI undergoing PCI. METHODS: We have screened PubMed/MEDLINE, Cochrane Library, and ClinicalTrials.gov (inception through January 8th, 2023) for randomized controlled trials (RCTs) evaluating bivalirudin versus unfractionated heparin in patients with MI undergoing PCI. The DerSimonian and Laird method was used for estimation of tau2 to calculate the risk ratio (RR) and 95 % confidence interval (CI). RESULTS: Ten RCTs with a total of 40,069 participants were included in our analysis. Bivalirudin as compared with unfractionated heparin was associated with significant decrease in major bleeding (RR 0.64 [0.52 to 0.79]; p < 0.01; I2 = 69 %) and cardiovascular mortality (RR 0.79 [0.67 to 0.92]; p < 0.01; I2 = 0 %). There was no significant difference between bivalirudin and unfractionated heparin groups in terms of major adverse cardiovascular events (RR 1.02 [0.91 to 1.14]; p = 0.73; I2 = 52 %), all-cause mortality (RR 0.89 [0.77 to 1.04]; p = 0.15; I2 = 23 %), MI (RR 1.02 [0.87 to 1.19]; p = 0.80; I2 = 36 %), stent thrombosis (RR 1.12 [0.52 to 2.40]; p = 0.77; I2 = 82 %), or stroke (RR 0.97 [0.73 to 1.29]; p = 0.85; I2 = 0 %). CONCLUSION: Our meta-analysis suggests that bivalirudin compared with unfractionated heparin in patients with MI undergoing PCI was associated with lower rates of major bleeding and cardiovascular mortality without a significant difference in major adverse cardiovascular events, all-cause mortality, MI, stroke, or stent thrombosis.

Liberal versus conservative transfusion strategy for patients with acute myocardial infarction and anemia: A systematic review and meta-analysis.

BACKGROUND: A hemoglobin (Hb) level goal of 7-8 g/dL is a standard care threshold, prompting blood transfusion. The debate over whether acute myocardial infarction (MI) patients benefit from a more liberal transfusion strategy prompted a meta-analysis of relevant trials. METHODS: We performed a meta-analysis of randomized controlled trials (RCTs) comparing liberal and restrictive transfusion strategies in anemic MI patients. Primary outcomes were recurrent MI and death/MI, while secondary outcomes included stroke, revascularization, heart failure, and all-cause mortality. Due to the limited trials, we utilized the Paul-Mendele method with Hartung Knapp adjustment. RESULTS: Involving 2155 patients with liberal transfusion and 2170 with conservative transfusion across four RCTs, liberal transfusion did not significantly reduce MI (relative risk [RR] 0.85; 95 % CI 0.72 - 1.02, p = 0.07) or death/MI (RR 0.88; 95 % CI 0.45 - 1.71, p = 0.57). No significant differences were observed in all-cause mortality (RR 0.82; 95 % CI 0.25 - 2.68, p = 0.63), stroke (RR 0.89; 95 % CI 0.48 - 1.64, p = 0.50), revascularization (RR 0.93; 95 % CI 0.48 - 1.80, p = 0.68), or heart failure (RR 1.14; 95 % CI 0.04 - 28.84, p = 0.88). CONCLUSION: Our meta-analysis supports current medical guidelines, reinforcing the practice of limiting transfusions in acute MI patients to those with an Hb level of 7 or 8 g/dL. Liberal transfusion strategies did not show improved clinical outcomes.

Cardiovascular disease burden in the Middle East and North Africa region.

INTRODUCTION: Cardiovascular disease (CVD) remains the leading cause of death globally, including the Middle East and North Africa (MENA) region. However, limited research has been conducted on the burden of CVD in this region. Our study aims to investigate the burden of CVD and related risk factors in the MENA. METHODS: We used data from the Global Burden of Disease (GBD) 2019 to examine CVD prevalence in 21 MENA countries. Prevalence and mortality were analyzed using Bayesian regression tools, demographic methods, and mortality-to-incidence ratios. Disability-adjusted life years (DALYs) were calculated, and risk factors were evaluated under the GBD's comparative risk assessment framework. RESULTS: Between 1990 and 2019, CVD raw accounts in the MENA increased by 140.9%, while age standardized prevalence slightly decreased (-1.3%). CVD raw mortality counts rose by 78.3%, but age standardized death rates fell by 28%. Ischemic heart disease remained the most prevalent condition, with higher rates in men, while women had higher rates of CVA. Age standardized DALYs decreased by 32.54%. DALY rates varied across countries and were consistently higher in males. Leading risk factors included hypertension, high LDL-C, dietary risks, and elevated BMI.  The countries with the three highest DALYs in 2019 were Afghanistan, Egypt, and Yemen. CONCLUSIONS: While strides have been made in lessening the CVD burden in the MENA region, the toll on mortality and morbidity, particularly from ischemic heart disease, remains significant. Country-specific variations call for tailored interventions addressing socio-economic factors, healthcare infrastructure, and political stability.

Inpatient Outcomes of Gastric Antral Vascular Ectasia in Those With Aortic Stenosis: A Retrospective Study of 85,000 Hospitalizations.

GOALS: To investigate the outcomes of hospitalized patients with gastric antral vascular ectasia (GAVE) in the setting of aortic stenosis (AS). BACKGROUND: Although AS is associated with gastrointestinal arteriovenous malformations, its association with GAVE, a rare cause of upper gastrointestinal bleeding, remains unknown. STUDY: The National Inpatient Sample database from the years 2016 to 2019 was searched for patients admitted with a diagnosis of GAVE, with and without a history of AS. Univariate and multivariate logistic regression analysis was performed to determine the risk of mortality and in-hospital complications in the GAVE/AS group compared with the GAVE-only group. RESULTS: Patients with AS had a 2-fold increase in the risk of GAVE [odds ratio (OR): 2.08, P < 0.001], with no statistically significant difference in inpatient mortality between the study groups (OR: 1.36, P = 0.268). Patients with GAVE-AS had a higher risk of hypovolemic shock (OR: 2.00, P = 0.001) and acute coronary syndromes (OR: 2.25, P < 0.001) with no difference in risk of cardiogenic shock (P = 0.695), acute kidney injury (P = 0.550), blood transfusion (P = 0.270), sepsis (P = 0.598), respiratory failure (P = 0.200), or in-hospital cardiac arrest (P = 0.638). The cost of care in patients with GAVE-AS was increased by a mean of $4729 (P = 0.022), with no increase in length of stay (P = 0.320) when compared with patients with GAVE-only. CONCLUSIONS: Patients with AS have a 2-fold increase in the risk of development of GAVE. Patients with AS admitted for GAVE-related bleeding are at higher rates of hypovolemic shock, acute coronary syndrome, and higher resource utilization when compared with admitted patients with GAVE without AS.

Determinants and outcomes of acute pancreatitis in patients hospitalized for COVID-19: Early pandemic experience.

OBJECTIVES: To examine the predictors and outcomes associated with the development of acute pancreatitis (AP) in patients hospitalized with Coronavirus Disease 2019 (COVID-19). METHODS: This is an observational analysis of the 2020 National Inpatient Sample Database. The study includes adult patients who were admitted with a confirmed diagnosis of COVID-19 and stratifies them based on the presence or absence of AP during their hospitalization. Predictors of AP development between the two groups and differences in outcomes are examined. Multivariate logistic regression analysis using Stata/BE 17.0 is conducted, with adjustments made for age, sex, race, and Charlson Comorbidity Index (CCI). Statistical significance is determined at a p-value of <0.05. RESULTS: Significant factors associated with an increased risk of AP in COVID-19 patients include Hispanic ethnicity, higher Charlson Comorbidity Index (CCI) score, residence in states located in the southern region, history of chronic kidney disease, chronic liver disease, malnutrition, portal hypertension, and alcohol use. COVID-19 patients who developed AP were also found to be at higher risk of adverse outcomes, including mortality, acute coronary syndrome, acute kidney injury, sepsis, septic shock, in-hospital cardiac arrest, invasive mechanical ventilation, upper gastrointestinal bleeding, prolonged length of stay, and increased healthcare cost. CONCLUSIONS: In hospitalized patients with COVID-19, the presence of AP is associated with increased mortality and morbidity. Risk factors for developing AP in this population include Hispanic ethnicity, residence in the southern region, higher Charlson Comorbidity Index (CCI) score, history of chronic kidney disease, chronic liver disease, malnutrition, portal hypertension, and alcohol use.

Racial and Ethnic Disparities in Peripheral Vascular Disease Admissions Using a Nationally Representative Sample.

Our study aimed to identify clinical outcomes and resource utilization associated with race and ethnicity in patients admitted with peripheral vascular disease (PVD) across the United States. We queried the National Inpatient Sample database from 2015 to 2019 and identified 622,820 patients admitted with PVD. Patients across 3 major race and ethnic categories were compared in terms of baseline characteristics, inpatient outcomes, and resource utilization. Black and Hispanic patients were more likely to be younger and of the lowest median income but incur higher total hospital costs. Black race predicted higher rates of acute kidney injury, need for blood transfusion, and need for vasopressor but lower rates of circulatory shock, and mortality. Black and Hispanic patients were less likely to undergo limb-salvaging procedures and more likely to undergo amputation than White patients. In conclusion, our findings indicate that Black and Hispanic patients experience health disparities in resource utilization and inpatient outcomes for PVD admissions.

A Comprehensive Guide to Sodium Glucose Cotransport Inhibitors.

Sodium-glucose cotransport 2 inhibitors (SGLT2i) are a class of drugs initially approved by the Food and Drug Association (FDA) as antihyperglycemic agents for patients with type 2 diabetes mellitus (DM). However, lately, these agents (Canagliflozin, Empagliflozin, Ertugliflozin, Sotagliflozin, and Dapagliflozin) have become better known for their cardiovascular (CV) and reno-protective effects. In this comprehensive review and analysis, we display the advancement of Sodium Glucose Cotransport Inhibitors have shown in cardiology, specifically heart failure in a concise, yet thorough manner.

Pregnancy and Fetal Outcomes in Patients With Ehlers-Danlos Syndrome: A Nationally Representative Analysis.

Cardiovascular complications occur frequently in Ehlers-Danlos syndrome (EDS). Pregnancy outcomes, however, are not well established in patients with EDS. We conducted a population-based, retrospective, cohort study using the national inpatient sample to compare pregnancy and fetal outcomes in patients with and without EDS, delivering between 2016 and 2019. Regression analysis was performed and adjusted for maternal age and race to compare both groups. Of the total 5,887,050 births in our cohort, 1016 were to patients with EDS. The EDS cohort was more likely to be older, white and have multiple comorbidities, such as smoking, mitral valve prolapse, and chronic hypertension. When we adjusted for age and race, patients with EDS were more likely than those without EDS to require Cesarean-section, develop postpartum hemorrhage, experience intrauterine growth restriction, and deliver preterm. In this study, patients with EDS experienced higher rates of maternal complications, however, aortic aneurysmal rupture was not among them.

Outcomes with use of extra-corporeal membrane oxygenation in high-risk pulmonary embolism: a national database perspective.

High-risk pulmonary embolism (PE) patients can be managed with systemic lysis, catheter-based therapies, or surgical embolectomy. Despite the advent of newer therapies, patients with high-risk PE remain with a 50-60% short-term mortality risk. In such patients, extracorporeal membrane oxygenation (ECMO) is increasingly utilized for hemodynamic support. To evaluate the outcomes of the use of ECMO in patients with high-risk PE. Using the National Inpatient Sample (NIS) database, we identified patients with high-risk PE using ICD 10 codes and compared in-hospital outcomes of patients with and without ECMO support. We identified 38,035 patients with high-risk PE, of whom 820 had undergone ECMO placement. Most patients who underwent ECMO were male (54%), white (65%), and with a mean age of 53.7 years. ECMO use was not associated with a meaningful difference in patient mortality when comparing treatment groups (OR, 1.32 ± 0.39; 0.74-2.35; p = 0.35). Rather, ECMO use was associated with a higher frequency of inpatient complications. ECMO use was not associated with a significant difference in patient mortality in patients with high-risk PE.

Rechallenging nivolumab following immune checkpoint inhibitor-induced pericarditis.

We report a case of recurrent pericarditis as an immune-related adverse event in a 47-year-old man with de novo metastatic renal cell carcinoma. After first-line treatment with sunitinib failed, he received three cycles of nivolumab and developed pericarditis following each cycle. The third cycle was accompanied by colchicine as a secondary prophylaxis. Pericarditis is an uncommon and potentially life-threatening immune-related adverse event, if not managed promptly.