Single Nucleotide Polymorphisms in Coronary Microvascular Dysfunction.

Coronary microvascular dysfunction is an underdiagnosed pathologic process that is associated with adverse clinical outcomes. There are data to suggest that coronary microvascular dysfunction, in some cases, may be genetically determined. We present an updated review of single nucleotide polymorphisms in coronary microvascular dysfunction.

Outcome and Cost Comparisons Between Surgical and Transcatheter Aortic Valve Replacements.

OBJECTIVE: Surgical aortic valve replacement (SAVR) has been the standard of care for severe aortic stenosis. In 2019, annual transcatheter aortic valve replacement (TAVR) implantations surpassed SAVR. We compared in-hospital costs and outcomes between these two procedures. METHODS: A single-center retrospective review was performed of patients who underwent isolated SAVR or TAVR from October 2013 to December 2019. Baseline patient characteristics, operating room (OR) time, intensive care unit (ICU) length of stay (LOS), total LOS, cumulative cost, and complication rates were collected. Propensity matching was performed to identify differences in costs and outcomes between comparable groups. RESULTS: There were 515 patients who met inclusion criteria. TAVR was performed in 402 patients, while SAVR was performed in 113. Propensity matching resulted in 82 matched pairs. The SAVR cohort more frequently spent >1 day in the ICU, had longer total hospital LOS, longer OR time, and higher hospitalization cost. However, TAVR was associated with higher mean OR cost and higher valve cost. The cumulative index admission costs were not significantly different between groups. TAVR patients had less postoperative atrial fibrillation but more frequent pacemaker placement. One-year mortality was similar between SAVR (2.4%) and TAVR (3.8%), but 3-year (5.8% vs 19.2%) and 5-year (5.8% vs 37.2%) mortality favored SAVR. CONCLUSIONS: In propensity-matched groups, TAVR was associated with shorter ICU and hospital LOS and OR times but increased permanent pacemaker rates. In addition, while 1-year survival was similar between groups, SAVR had significantly improved 3-year and 5-year survival.

Monitored Anesthesia Care Versus General Anesthesia for Transcatheter Aortic Valve Replacement.

OBJECTIVE: Monitored anesthesia care (MAC) has been increasingly used in lieu of general anesthesia (GA) for transcatheter aortic valve replacement (TAVR). We sought to compare outcomes and in-hospital costs between MAC and GA for TAVR at a Veterans Affairs Medical Center. METHODS: A single-center retrospective review was performed of 349 patients who underwent transfemoral TAVR (MAC, n = 244 vs GA, n = 105) from January 2014 to December 2019. Baseline patient characteristics, operating room (OR) time, intensive care unit (ICU) length of stay (LOS), and cost, total LOS, hospital cost, total cost, and complication rates were collected. Propensity matching was performed and resulted in 83 matched pairs. RESULTS: In the unmatched TAVR cohort, MAC TAVR was associated with reduced OR time (146 vs 198 min, P < 0.001), ICU LOS (1.4 vs 1.8 days, P < 0.001), total hospital LOS (3.4 vs 5.4 days, P < 0.001), and lower index total cost ($81,300 vs $85,400, P = 0.010). After propensity matching, MAC TAVR patients had reduced OR time (146 vs 196 min, P < 0.05), ICU LOS (1.2 vs 1.7 days, P = 0.006), total LOS (3.5 vs 5.1 days, P = 0.001), and 180-day mortality (2.4% vs 12%, P < 0.03). There was no difference in total hospitalization cost or total cost. CONCLUSIONS: In propensity-matched groups, TAVR utilizing MAC is associated with improved OR time efficiency, decreased LOS, and a reduction in 180-day mortality but no significant difference in cost.

Misdiagnosis of Thoracic Aortic Disease Occurs Commonly in Emergency Transfers.

BACKGROUND: Acute aortic syndromes (AASs) are prone to misdiagnosis by facilities with limited diagnostic experience. We assessed long-term trends in misdiagnosis among patients transferred to a tertiary care facility with presumed AASs. METHODS: Our institutional transfer center database was queried for emergency transfers in patients with a diagnosis of AASs or thoracic aortic aneurysm between January 2008 and May 2018. There were 784 patients classified as emergency transfer for presumed AAS. Transferring diagnosis and actual diagnosis were compared through a review of physician notes and radiology reports from referring facilities and our center. RESULTS: Mean age was 62 years, with 478 (61%) men. Differences in transferring diagnosis and actual diagnosis were identified in 89 patients (11.4%). Among misdiagnosed patients, the wrong classification of Stanford type A or type B dissections was identified among 24 patients (27%). No dissection was found in 23 patients (26%) with a referring diagnosis of aortic dissection. No signs of rupture were found in 18 patients (20%) transferred for contained/impending rupture. All misdiagnoses were secondary to misinterpretation of radiographic imaging, with motion artifacts in 14 (16%) and postsurgical changes in 22 (25%) being common sources of diagnostic error. Repeat scans were performed in 64 patients (72%) at our facility due to limited access to or suboptimal quality of outside imaging. CONCLUSIONS: Although AASs misdiagnosis rates appear to be improving from the prior decade, there are opportunities for improved physician awareness through campaigns such as "Think Aorta." Centralized web-based imaging may prevent the costly hazards of unnecessary emergency transfer.