Trends and outcomes of combined percutaneous (TAVI+PCI) and surgical approach (SAVR+CABG) for patients with aortic valve and coronary artery disease: A National Readmission Database (NRD) analysis.

BACKGROUND: In patients with severe aortic stenosis (AS) and concomitant severe coronary artery disease (CAD), the relative merits of a combined percutaneous (transcatheter aortic valve implantation [TAVI] and percutaneous coronary intervention [PCI]] versus surgical approach (surgical aortic valve replacement [SAVR] and coronary artery bypass graft [CABG]) remain unknown. AIMS: To determine the utility of combined percutaneous versus surgical approaches in patients with severe AS and CAD. METHODS: The National Readmission Database (NRD) (2015-2019) was queried to identify all cases of TAVI+PCI and SAVR+CABG. The adjusted odds ratios (aOR) of mortality, stroke, and its composite (major adverse cardiovascular events [MACE]) were calculated using a propensity-score matched (PSM) analysis. RESULTS: A total of 89,314 (5358 TAVI+PCI, 83,956 SAVR+CABG) patients were included in the crude analysis. There was a gradual increase in the utilization of TAVI+PCI from 2016 to 2019 by 2%-4% per year. Using PSM, a subset of 11,361 (5358 TAVI+PCI, 6003 SAVR+CABG) patients with a balanced set of demographics and baseline comorbidities was selected. During index hospitalization, the adjusted odds of MACE (aOR 0.72, 95% confidence interval [CI] 0.62-0.83), and all-cause mortality (aOR 0.68, 95% CI 0.57-0.81) were significantly lower in patients undergoing TAVI+PCI compared with SAVR+CABG. However, patients undergoing TAVI+PCI had a higher incidence of MACE (aOR 1.40, 95% CI 1.05-1.87), and mortality (aOR 1.75, 95% CI 1.22-2.50) at 30-days. The risk of index-admission (aOR 0.82, 95% CI 0.62-1.09) and 30-day (aOR 0.88, 95% CI 0.51-1.51) stroke was similar between the two groups. CONCLUSION: In selected patients with severe AS and concomitant CAD, a combined percutaneous approach (TAVR+PCI) compared with SAVR+CABG may confer a lower risk of MACE and mortality during index admission but a higher incidence of 30-day complications.

Trends, predictors, and outcomes of transcatheter aortic valve implantation in patients with bicuspid aortic valve related disease: Insights from the Nationwide Inpatient Sample and Nationwide Readmission Database.

BACKGROUND: Transcatheter aortic valve implantation (TAVI) has increasingly been utilized in patients with bicuspid aortic valve (BAV) related aortic stenosis (AS) with insufficient large-scale data on its safety. METHODS: The Nationwide Inpatient Sample and Nationwide Readmission Database (2011-2018) were queried to identify patients undergoing TAVI for BAV versus trileaflet aortic valve (TAV) associated AS. The in-hospital, 30- and 180-day odds of outcomes were assessed using a propensity-matched analysis (PSM) to calculate adjusted odds ratios (aOR) with its 95% confidence interval (CI). RESULTS: A total of 216,723 TAVI (TAV: 214,050 and BAV: 2,673) crude and 5,347 matched population (TAV: 2,674 and BAV: 2,673) was included in the final analysis. At index admission, the adjusted odds of in-hospital mortality (aOR: 1.57, 95% CI: 0.67-3.66), stroke (aOR: 0.77, 95% CI: 0.38-1.57), cardiac tamponade (aOR: 0.75, 95% CI: 0.17-3.36), vascular complications (aOR: 0.33, 95% CI: 0.09-1.22), cardiogenic shock (aOR: 1.77, 95% CI: 0.93-3.38), paravalvular leak (aOR: 0.55, 95% CI: 0.26-1.14), need for mechanical circulatory support device, and permanent pacemaker implantation (PPM) (aOR: 1.02, 95% CI: 0.69-1.52) were not significantly different between TAVI for BAV versus TAV. At 30- and 180-day follow-up duration, the risk of stroke and major postprocedural complications remained similar, except that TAVI in BAV had a higher incidence of PPM implantation compared with TAV. The yearly trend showed an increase in the utilization of TAVI for both TAV and BAV and a steady decline in the overall annual rate of in-hospital complications. CONCLUSION: TAVI utilization in patients with BAV has increased over the recent years. The relative odds of in-hospital mortality, and all other major complications, were similar between patients undergoing TAVI for BAV- and TAV-related AS.

Trends and Outcomes of Transcatheter Aortic Valve Implantation in Aortic Insufficiency: A Nationwide Readmission Database Analysis.

Transcatheter aortic valve implantation (TAVI) has increasingly been utilized in patients with aortic insufficiency (AI) with insufficient data on its safety. The Nationwide Readmissions Database (NRD) was queried to identify patients undergoing TAVI for AI. Net clinical events (composite of in-hospital mortality, stroke, major bleeding) and procedural complications were assessed using a propensity-score matched (PSM) analysis to calculate adjusted odds ratios (OR). A total of 185,703 (AI 3873, aortic stenosis [AS] 181,830) patients were included in the analysis. Due to a significant difference in the baseline characteristics, a matched sample of 7929 patients (AI 3873, AS 4056) was selected. At index admission, the adjusted odds of in-hospital NACE (aOR 2.0, 95% CI 1.59-2.51), mortality (aOR 3.06, 95% CI 2.38-5.47), major bleeding (aOR 1.53, 95% CI 1.13-2.06) and valvular complications (aOR 9.48, 95% CI 6.73-13.38) were significantly higher in patients undergoing TAVI for AI compared with those undergoing TAVI for AS. However, there was no significant difference in the incidence of NACE, mortality, stroke, major bleeding, and need for permanent pacemaker implantation at 30- and 180-days follow-up. TAVI in AI was associated with a higher risk of periprocedural NACE, mortality, and major bleeding. The risk of these complications attenuated at 30- and 180-day readmission.

Polypill Therapy in Cardiovascular Disease: A Meta-Analysis of Randomized Controlled Trials.

The effectiveness of polypill therapy in the prevention and treatment of cardiovascular disorders is still unclear. This meta-analysis aimed to assess the efficacy of polypill therapy in reducing cardiovascular risk factors. We conducted a systematic search of PubMed, Cochrane CENTRAL, SCOPUS, and Google Scholar for randomized controlled trials (RCTs) that evaluated polypill therapy for cardiovascular diseases, hypertension, or dyslipidemia. We included 18 RCTs with a total of 20,463 participants in our analysis. Pooled effect estimates were reported as Odds ratios (ORs) with a 95% confidence interval (CI) using a random-effects model. Polypill therapy was associated with a statistically significant reduction in systolic blood pressure (SBP) (OR: -0.33, 95% CI [-0.64, -0.03]; P-value = 0.03), diastolic blood pressure (DBP) (OR: -0.70, 95% CI [-1.20, -0.21]; P-value = 0.005), and total cholesterol level (OR: -1.25, 95% CI [-1.82, -0.68]; P-value < 0.0001). Polypill therapy also showed improved adherence (OR 2.18, 95% CI [1.47, 3.24]; P-value = 0.0001). However, there was no statistically significant benefit in the reduction of all-cause mortality, major cardiovascular events, and LDL-c levels. The use of polypill therapy is associated with a statistically significant reduction in SBP, DBP, and total cholesterol levels, as well as improved adherence. Further research is needed to determine its impact on hard clinical outcomes such as mortality and major cardiovascular events.

Outcomes After Transcatheter Aortic Valve Implantation in Patients Excluded From Clinical Trials.

Background: The use of transcatheter aortic valve implantation (TAVI) in patients with aortic valve disease excluded from clinical trials has increased with no large-scale data on its safety. Objectives: The purpose of this study was to assess the trend of utilization and adjusted outcomes of TAVI in clinical trials excluded (CTE) vs clinical trials included TAVI (CTI-TAVI) patients. Methods: We used the National Readmission Database (2015-2019) to identify 15 CTE-TAVI conditions. A propensity score-matched analysis was used to calculate the adjusted odds ratio (aOR) of net adverse clinical events (composite of mortality, stroke, and major bleeding) in patients undergoing CTE-TAVI vs CTI-TAVI. Results: Among the 223,238 patients undergoing TAVI, CTE-TAVI was used in 41,408 patients (18.5%). The yearly trend showed a steep increase in CTE-TAVI utilization (P = 0.026). At index admission, the adjusted odds of net adverse clinical events (aOR: 1.83, 95% CI: 1.73-1.95) and its components, including mortality (aOR: 2.94, 95% CI: 2.66-3.24), stroke (aOR: 1.20, 95% CI: 1.07-1.34), and major bleeding (aOR: 1.49, 95% CI: 1.36-1.63) were significantly higher in CTE-TAVI compared with CTI-TAVI. Among the individual contraindications to clinical trial enrollment in the CTE-TAVI, patients with bicuspid aortic valve, leukopenia, and peptic ulcer disease appeared to have similar outcomes compared with CTI-TAVI, while patients with end-stage renal disease, bioprosthetic aortic valves, and coagulopathy had a higher readmission rate at 30 and 180 days. Conclusions: CTE-TAVI utilization has increased significantly over the 4-year study period. Patients undergoing CTE-TAVI have a higher likelihood of mortality, stroke, and bleeding than those undergoing CTI-TAVI.

Trends and Outcomes of TAVI and SAVR in Cancer and Noncancer Patients: A Nationwide Analysis.

Background: Patients with severe aortic stenosis and cancer are often denied surgical aortic valve replacement (SAVR) due to a prohibitive risk of perioperative mortality. Objectives: The purpose of this study was to determine the safety of transcatheter aortic valve implantation (TAVI) in patients with severe aortic stenosis and cancer. Methods: The Nationwide Inpatient Sample database (2002-2018) was used to study the outcomes of TAVI vs SAVR in patients with active or prior history of prostate, lung, colorectal, breast, and renal cancer. A propensity score-matched analysis to calculate adjusted odds ratios (aORs) for major adverse cardiovascular events (MACEs) and its components. Results: A total of 1,505,995 crude population and a subset of 345,413 noncancer and 33,565 cancer patients were selected on propensity score-matched analysis. The yearly trend showed a steep increase in the utilization of TAVI. Compared with SAVR, TAVI had a lower risk of in-hospital mortality in prostate cancer, while there was no difference among other cancer types. Patients with lung (aOR: 0.65; 95% CI: 0.43-0.97) and prostate cancer (aOR: 0.79; 95% CI: 0.66-0.96) had lower, while colorectal cancer (aOR: 1.43; 95% CI: 1.08-1.90) had higher odds of MACE with TAVI. The incidence of major bleeding was lower with TAVI (except for lung cancer), while the risk of stroke was similar (except for colorectal cancer) between TAVI and SAVR. Conclusions: TAVI in patients with prostate, breast, lung, and renal cancer appears to be a reasonable alternative to SAVR with lower or similar risks of mortality and MACE.

Evaluation of patients with coronary artery disease for major modifiable risk factors for ischemic heart disease.

BACKGROUND: Incidence of cardiovascular diseases is on the rise in developing countries. Deaths due to ischemic heart disease can be reduced by modifying the risk factors. The present study was conducted to evaluate the patients scheduled for Coronary Artery Bypass Surgery for the presence of major modifiable risk factors for ischemic heart disease (IHD). METHODS: It was a descriptive study. All patients who underwent elective Coronary Artery Bypass cardiac surgery between November 1, 2008 and February 28, 2009 at Rehman Medical Institute, Peshawar, were included in the study. Presence of Diabetes, Hypertension, Smoking, Dyslipidemia, Sedentary life style, and Obesity was looked for in these patients. RESULTS: A total of 104 patients were studied during this period. Majority (97.11%) of patients had at least one major modifiable risk factor for IHD. Sedentary life style (53.84%) was the most common risk factor present in these patients followed by hypertension and dyslipidemia (47.11% each), smoking (43.27%), diabetes (35.57%), and obesity (9.61%). Multiple risk factors (two or more) were found in 78 (75.0%) of patients. CONCLUSION: Most of the patients with coronary artery disease, severe enough to warrant coronary artery bypass grafting, have at least one of the major modifiable risk factors for IHD. Modification of these factors may well reduce the disease burden of CAD and reduce the cardiovascular mortality.

Left ventricular outflow tract thrombus in a patient with COVID-19-a ticking time bomb: a case report.

Background: Coronavirus disease 2019 (COVID-19) is a manifestation of severe acute respiratory syndrome coronavirus 2, which results in many different complications including left ventricular (LV) thrombi. Case summary: We present a 30-year-old female presenting with chest pain and shortness of breath. Patient had an extensive history including heart failure with an ejection fraction 15-20% and COVID-19 2 months ago. Echocardiogram revealed a 3.3 cm × 1.7 cm LV thrombus which was not present 4 months ago before her diagnosis of COVID-19. The LV thrombus embolized resulting in an embolus extending from the distal infrarenal abdominal aorta to the common iliac arteries bilaterally. Repeat COVID pre-procedure was positive. She underwent bilateral femoral artery cutdown, bilateral iliac artery embolectomy, superficial femoral artery embolectomy, and bilateral lower extremity fasciotomy. An extensive workup for the aetiology of the LV thrombus turned out to be negative and COVID-19 was deemed to be the aetiology of the thrombus. The patient was bridged from apixaban to warfarin and was successfully discharged within a few weeks. Discussion: Hypercoagulability is a known complication of COVID-19 causing thrombi in various parts of the body including the LV. Early recognition with echocardiography, especially in patients with heart failure, and prompt treatment is key to avoid further complications such as embolization.

Antemortem diagnosis of nonbacterial thrombotic endocarditis in a patient with previously resected pancreatic adenocarcinoma: a case report.

BACKGROUND: Nonbacterial thrombotic endocarditis (NBTE) is a rare manifestation of a number of systemic diseases, which include advanced malignancy and hypercoagulable states. CASE SUMMARY: We present a 67-year-old woman who had presented with chest pain and heart failure. Eight years ago, she had a successful Whipple resection for pancreatic adenocarcinoma. Echocardiography revealed mitral valve vegetations with negative blood cultures. She had multiple infarcts in the kidney, spleen, and brain. She was found to have a mass in the left 8th rib, consistent with metastatic pancreatic adenocarcinoma on biopsy. Ultimately, a diagnosis of NBTE was made after excluding other causes for her presentation. Because of her general poor condition, she expressed the wish for palliative care and later died 28 days after presentation. DISCUSSION: This case illustrates the possibility of NBTE in patients successfully treated for pancreatic adenocarcinoma and highlights the consideration of this relatively rare differential in patients with a previously treated malignancy presenting with heart failure.