Ross procedure after prosthetic valve thrombosis in a patient with antiphospholipid syndrome and recurrent bleeding.

The Ross procedure allows replacement of a diseased aortic valve with pulmonary root autograft, possibly avoiding the highly thrombotic mechanical valves and immunologic deterioration of tissue valves in antiphospholipid syndrome (APS). Here, we present the use of the Ross procedure in a 42-year-old woman with mild intellectual disability, APS, and a complex anticoagulation history after she presented with thrombosis of her mechanical On-X aortic valve previously implanted for non-bacterial thrombotic endocarditis.

Analysis of Cardiovascular Complications During Delivery Admissions Among Patients With Systemic Lupus Erythematosus, 2004-2019.

Importance: Individuals with systemic lupus erythematosus (SLE) have an increased risk of pregnancy-related complications. However, data on acute cardiovascular complications during delivery admissions remain limited. Objective: To investigate whether SLE is associated with an increased risk of acute peripartum cardiovascular complications during delivery hospitalization among individuals giving birth. Design, Setting, and Participants: This population-based cross-sectional study was conducted with data from the National Inpatient Sample (2004-2019) by using International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) or International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, Clinical Modification (ICD-10-CM) codes to identify delivery hospitalizations among birthing individuals with a diagnosis of SLE. A multivariable logistic regression model was developed to report an adjusted odds ratio (OR) for the association between SLE and acute peripartum cardiovascular complications. Data were analyzed from May 1 through September 1, 2022. Exposure: Diagnosed SLE. Main Outcomes and Measures: Primary study end points were preeclampsia, peripartum cardiomyopathy, and heart failure. Secondary end points included ischemic and hemorrhagic stroke, pulmonary edema, cardiac arrhythmias, acute kidney injury (AKI), venous thromboembolism (VTE), length of stay, and cost of hospitalization. Results: A total of 63 115 002 weighted delivery hospitalizations (median [IQR] age, 28 [24-32] years; all were female patients) were identified, of which 77 560 hospitalizations (0.1%) were among individuals with SLE and 63 037 442 hospitalizations (99.9%) were among those without SLE. After adjustment for age, race and ethnicity, comorbidities, insurance, and income level, SLE remained an independent risk factor associated with peripartum cardiovascular complications, including preeclampsia (adjusted OR [aOR], 2.12; 95% CI, 2.07-2.17), peripartum cardiomyopathy (aOR, 4.42; 95% CI, 3.79-5.13), heart failure (aOR, 4.06; 95% CI, 3.61-4.57), cardiac arrhythmias (aOR, 2.06; 95% CI, 1.94-2.21), AKI (aOR, 7.66; 95% CI, 7.06-8.32), stroke (aOR, 4.83; 95% CI, 4.18-5.57), and VTE (aOR, 6.90; 95% CI, 6.11-7.80). For resource use, median (IQR) length of stay (3 [2-4] days vs 2 [2-3] days; P < .001) and cost of hospitalization ($4953 [$3305-$7517] vs $3722 [$2606-$5400]; P < .001) were higher for deliveries among individuals with SLE. Conclusions and Relevance: This study found that SLE was associated with increased risk of complications, including preeclampsia, peripartum cardiomyopathy, heart failure, arrhythmias, AKI, stroke, and VTE during delivery hospitalization and an increased length and cost of hospitalization.

Autoimmune Pericarditis: Multimodality Imaging.

PURPOSE OF THE REVIEW: The purpose of this review is to understand the underlying mechanism that leads to pericarditis in systemic autoimmune and autoinflammatory diseases. The underlying mechanism plays a vital role in the appropriate management of patients. In addition, we will review the current landscape of available cardiac imaging modalities with emphasis on pericardial conditions as well as proposed treatment and management tailored toward pericardial autoimmune and autoinflammatory processes. RECENT FINDINGS: Approximately 22% of all cases of pericarditis with a known etiology are caused by systemic autoimmune diseases such as systemic lupus erythematosus, rheumatoid arthritis, systemic sclerosis, and vasculitis. In recent years, there have been advancements of imaging modalities including cardiac MRI, cardiac CT scan, and PET scan and their respective nuances in regard to contrast use, technique, and views which clinicians may utilize to better understand the extent of a patient's pericardial pathology and the trajectory of his or her disease process. In this review, we will discuss systemic autoimmune and autoinflammatory diseases that involve the pericardium. We will also review different imaging modalities that are currently used to further characterize such conditions. Having a deeper understanding of such techniques will improve patient outcomes by helping clinicians tailor treatment plans according to the unique underlying condition.

Outcomes Following Acute Coronary Syndrome in Patients With and Without Rheumatic Immune-Mediated Inflammatory Diseases.

Background Rheumatic immune mediated inflammatory diseases (IMIDs) are associated with high risk of acute coronary syndrome. The long-term prognosis of acute coronary syndrome in patients with rheumatic IMIDs is not well studied. Methods and Results We identified Medicare beneficiaries admitted with a primary diagnosis of myocardial infarction (MI) from 2014 to 2019. Outcomes of patients with MI and concomitant rheumatic IMIDs including systemic lupus erythematosus, rheumatoid arthritis, systemic sclerosis, dermatomyositis, or psoriasis were compared with propensity matched control patients without rheumatic IMIDs. One-to-three propensity-score matching was done for exact age, sex, race, ST-segment-elevation MI, and non-ST-segment-elevation MI variables and greedy approach on other comorbidities. The study primary outcome was all-cause mortality. The study cohort included 1 654 862 patients with 3.6% prevalence of rheumatic IMIDs, the most common of which was rheumatoid arthritis, followed by systemic lupus erythematosus. Patients with rheumatic IMIDs were younger, more likely to be women, and more likely to present with non-ST-segment-elevation MI. Patients with rheumatic IMIDs were less likely to undergo coronary angiography, percutaneous coronary intervention or coronary artery bypass grafting. After propensity-score matching, at median follow up of 24 months (interquartile range 9-45), the risk of mortality (adjusted hazard ratio [HR], 1.15 [95% CI, 1.14-1.17]), heart failure (HR, 1.12 [95% CI 1.09-1.14]), recurrent MI (HR, 1.08 [95% CI 1.06-1.11]), and coronary reintervention (HR, 1.06 [95% CI, 1.01-1.13]) (P<0.05 for all) was higher in patients with versus without rheumatic IMIDs. Conclusions Patients with MI and rheumatic IMIDs have higher risk of mortality, heart failure, recurrent MI, and need for coronary reintervention during follow-up compared with patients without rheumatic IMIDs.

Autoimmune connective tissue diseases and aortic valve replacement outcomes: a population-based study.

Aims: Patients with autoimmune connective tissue diseases (CTDs) have a high burden of valvular heart disease and are often thought of as high surgical risk patients. Methods and results: Patients undergoing aortic valve replacement (AVR) were identified in the Nationwide Readmissions Database between January 2012 and December 2018. Patients with a history of systemic lupus erythematosus, rheumatoid arthritis, systemic sclerosis, mixed C, Sjögren syndrome, polymyositis, and dermatomyositis were included in the CTD cohort. Patients undergoing coronary artery bypass grafting concomitantly with AVR were excluded. A total of 569 600 hospitalizations were included, of which16 531 (2.9%) had CTD. CTD patients were more likely to be females, with higher rates of heart failure, pulmonary hypertension, and more likely to be insured by Medicare. CTD patients had lower mortality than non-CTD patients [odds ratio (OR) 0.66; 95% confidence interval (CI): 0.59-0.74] and stroke [OR 0.87; 95% (CI): 0.79-0.97]. CTD patients undergoing SAVR had lower mortality [OR 0.69; 95% (CI): 0.60-0.80] and stroke [OR 0.86; 95% (CI): 0.75-0.98). CTD patients undergoing TAVR had lower mortality outcomes [OR 0.67; 95% (CI): 0.56-0.80]; however, they had comparable stroke outcomes [OR 0.97; 95% (CI): 0.83-1.13, P = 0.69]. Conclusions: Outcomes for patients with CTD requiring AVR are not inferior to their non-CTD counterparts. A comprehensive heart team selection of patients undergoing AVR approaches should place CTD history under consideration; however, pre-existing CTD should not be prohibitive of AVR interventions.

COVID-19 telehealth preparedness: a cross-sectional assessment of cardiology practices in the USA.

Aim: The COVID-19 pandemic forced medical practices to augment healthcare delivery to remote and virtual services. We describe the results of a nationwide survey of cardiovascular professionals regarding telehealth perspectives. Materials & methods: A 31-question survey was sent early in the pandemic to assess the impact of COVID-19 on telehealth adoption & reimbursement. Results: A total of 342 clinicians across 42 states participated. 77% were using telehealth, with the majority initiating usage 2 months after the COVID-19 shutdown. A variety of video-based systems were used. Telehealth integration requirements differed, with electronic medical record integration being mandated in more urban than rural practices (70 vs 59%; p < 0.005). Many implementation barriers surfaced, with over 75% of respondents emphasizing reimbursement uncertainty and concerns for telehealth generalizability given the complexity of cardiovascular diseases. Conclusion: Substantial variation exists in telehealth practices. Further studies and legislation are needed to improve access, reimbursement and the quality of telehealth-based cardiovascular care.

As the COVID-19 pandemic was just beginning, the American College of Cardiology administered a survey to cardiology professionals across the USA regarding their preparedness for telehealth and video-visits. The results demonstrated rapid adoption of video based telehealth services, however revealed uncertainty for how to best use these services in different practice settings. Many providers expressed concerns about how these visits will be compensated, but fortunately federal agencies have dramatically changed the way telehealth is reimbursed as the pandemic has progressed. Further studies are needed to explore the impact of telehealth on healthcare inequality, however we hope that rather it serves to increase healthcare access to all.

Impact of hospital volume of valve operations on the utilization and outcomes of surgery for patients with infective endocarditis.

AIMS: Valve surgery is indicated and can be life-saving in patients with infective endocarditis (IE). We evaluated the impact of hospital valvular surgery volume on utilization and outcomes of surgery for IE. METHODS AND RESULTS: National Inpatient Sample (NIS) database was used for IE hospitalizations from 2008 to 2015. Hospitals were divided into quartiles based on valve surgery volume with quartile 1 (Q1) indicating lowest volume and quartile 4 (Q4) highest volume. Primary outcome was utilization of valve surgery in patients hospitalized with IE and secondary outcomes were in-hospital mortality and length of stay for IE patients undergoing valve surgery. Volume-outcome relationship was analysed both as categorical (quartiles) and continuous variable (restricted cubic splines). A total of 36 471 hospitalizations for IE were identified using the NIS database from 2008 to 2015 of which 17.33% underwent any valve surgery. Utilization rates of valve surgery for IE were significantly higher in Q4 hospitals (Q1: 6.73%; Q2: 10.39%; Q3: 14.91%; Q4: 2321%). Amongst the admissions for IE endocarditis undergoing valve surgery, there was no significant difference in in-hospital mortality when analysed as a categorical variable (as quartiles). However, when analysed as a continuous variable we note significant variation in outcomes across the Q4 hospitals, with highest volume centres having reduced mortality rates and length of stay. CONCLUSION: Hospital valvular surgery volume has direct impact on utilization and outcomes of surgery for IE. Given rising rates of IE and ongoing intravenous drug pandemic, there is need for regionalization of care for IE patients and development of 'endocarditis centres of excellence' for improved patient outcomes.

Telephone titration of heart failure medications.

BACKGROUND: In clinical practice, heart failure (HF) medications are underused and prescribed at lower than recommended doses. Telephone care is an option that could help to titrate HF medication in a timely manner. We describe our experience of a nurse-run, cardiologist- or nurse practitioner-supervised clinic to up-titrate HF medications via telephone. METHODS: Patients with the diagnosis of HF, New York Heart Association classes I to III, were referred to a registered nurse-run, cardiologist-/nurse practitioner-supervised HF medication titration clinic. Clinical and medication data collected at enrollment to the clinic and at 3 to 6 months after optimization of HF medications in patients who did or did not reach the target doses were compared. Effect on left ventricular (LV) function was also evaluated. RESULTS: There were 79 patients in the evaluation: 64 with HF and LV systolic dysfunction (LVSD) and the remaining 15 with HF and preserved ejection fraction (EF). Seventy-two percent of patients with LVSD were on an angiotensin-converting enzyme inhibitor (ACEI) or angiotensin receptor blocker (ARB), and 61% were on a ß-blocker at baseline, and this increased to 98% and 97%, respectively, after optimization. Target doses was achieved in 50% of patients for ACEI or ARB, and in 41% for ß-blockers. The median time to optimization was 54 days (interquartile range, 20-97 days). The average number of phone calls at the time of optimization were 5.4 (SD, 3.7), and the average number of clinic visits was 1.9 (SD, 1.3). Reasons for not reaching the target doses included hypotension, hyperkalemia, and renal dysfunction for ACEI and bradycardia for ß-blockers. Overall, the EF increased by 10% (SD, 10%) after 6 months, and 35% or greater in 42% of patients whose baseline EF was less than 35%. There were no adverse events related to the dose up-titration. CONCLUSION: Telephonic titration of HF medications was feasible and safe and was achieved in 97% patients on ACEI/ARB and ß-blockers. Medication titration was associated with significant improvement in LV function, avoiding the need for device therapy in many patients.

Preoperative pulmonary function and mortality after cardiac surgery.

BACKGROUND: The aim of the study was to examine the relationship between preoperative pulmonary function and outcomes after cardiac surgery. METHODS: We performed preoperative pulmonary function tests (PFTs) in 1,169 patients undergoing cardiac surgery at the Minneapolis Veterans Affairs Medical Center. Airway obstruction was defined as forced expiratory volume in 1 minute (FEV(1)) to forced vital capacity ratio <0.7. RESULTS: Of the 1,169 patients, 483 (41%) had a prior history of chronic obstructive pulmonary disease (COPD). However, 178 patients with a history of COPD had no airway obstruction on PFT. Conversely, 186 patients without a COPD history had airway obstruction on PFT. Thus, PFT results helped reclassify the COPD status of 364 patients (31%). Operative mortality was 2% in patients with no or mild airway obstruction versus 6.7% in those with moderate or severe obstruction (ie, FEV(1) to forced vital capacity ratio <0.7 and FEV(1) <80% predicted). Postoperative mortality was higher (odds ratio 3.2, 95% CI 1.6-6.2, P = .001) in patients with moderate or severe airway obstruction and in patients with diffusing capacity of the lung for carbon monoxide <50% of predicted (odds ratio 4.9, 95% CI 2.3-10.8, P = .0001). Notably, mortality risk was 10x higher (95% CI 3.4-27.2, P = .0001) in patients with moderate or severe airway obstruction and diffusing capacity of the lung for carbon monoxide <50% of predicted. CONCLUSIONS: These data show that PFT before cardiac surgery reclassifies the COPD status of a substantial number of patients and provides important prognostic information that the current risk estimate models do not capture.