Coronavirus disease 19 in minority populations of Newark, New Jersey.

BACKGROUND: The purpose of this study is to report the clinical features and outcomes of Black/African American (AA) and Latino Hispanic patients with Coronavirus disease 2019 (COVID-19) hospitalized in an inter-city hospital in the state of New Jersey. METHODS: This is a retrospective cohort study of AA and Latino Hispanic patients with COVID-19 admitted to a 665-bed quaternary care, teaching hospital located in Newark, New Jersey. The study included patients who had completed hospitalization between March 10, 2020, and April 10, 2020. We reviewed demographics, socioeconomic variables and incidence of in-hospital mortality and morbidity. Logistic regression was used to identify predictor of in-hospital death. RESULTS: Out of 416 patients, 251 (60%) had completed hospitalization as of April 10, 2020. The incidence of In-hospital mortality was 38.6% (n = 97). Most common symptoms at initial presentation were dyspnea 39% (n = 162) followed by cough 38%(n = 156) and fever 34% (n = 143). Patients were in the highest quartile for population's density, number of housing units and disproportionately fell into the lowest median income quartile for the state of New Jersey. The incidence of septic shock, acute kidney injury (AKI) requiring hemodialysis and admission to an intensive care unit (ICU) was 24% (n = 59), 21% (n = 52), 33% (n = 82) respectively. Independent predictors of in-hospital mortality were older age, lower serum Hemoglobin < 10 mg/dl, elevated serum Ferritin and Creatinine phosphokinase levels > 1200 U/L and > 1000 U/L. CONCLUSIONS: Findings from an inter-city hospital's experience with COVID-19 among underserved minority populations showed that, more than one of every three patients were at risk for in-hospital death or morbidity. Older age and elevated inflammatory markers at presentation were associated with in-hospital death.

Outcomes After Transcatheter Mitral Valve-in-Valve Replacement in Patients With Degenerated Bioprosthesis: A Single-Center Experience.

BACKGROUND: This study sought to describe a single center's experience with transcatheter mitral valve-in-valve (TM-ViV) implantation. METHODS: Consecutive patients who had TM-ViV due to degenerative biological valve prosthesis at a single center during a 4-year period were identified from a prospectively maintained database. Operative outcomes were assessed both in-hospital and at 30 days. The primary outcome was in-hospital mortality. Secondary outcomes included valve function, functional status, and quality of life at follow-up. RESULTS: Mean (± standard deviation) patient age was 69 ± 12 years and all patients were high risk for redo surgery (STS risk score, 9.6 ± 6.2%). The primary mechanism of bioprosthetic valve failure was stenosis in 7 patients (47%) and regurgitation in 8 patients (53%). Mean duration between mitral valve replacement (MVR) and transcatheter MVR was 89 months (range, 66-72 months). Failed bioprosthetic valves were replaced with Sapien XT (n = 10; 67%), Sapien (n = 4; 26%), or Sapien S3 valves (n = 1; 7%) (all valves manufactured by Edwards Lifesciences). Procedural success was 100%. No intraoperative deaths were recorded. Postimplantation valve hemodynamics was satisfactory, with a significant improvement in mean valvular gradient (Δ = -12 mm Hg; P<.001) and mitral valve area (Δ = 0.9 cm²; P<.01). At 30-day follow-up, no reports of death, disabling stroke, or rehospitalization for cardiac reasons was recorded. Health status scores were available for 11 of the 15 study patients (73%). Except for 1 patient, significant improvements were seen for all components of the health assessment survey. CONCLUSIONS: TM-ViV for failing biological mitral prosthesis can be performed with minimal operative morbidity and acceptable mid-term clinical and hemodynamic outcomes.

Left Ventricular Function Recovery After Transapical TAVR in Patients With Previous Coronary Artery Bypass Graft Surgery.

OBJECTIVE: The transapical (TA) approach is an alternative access technique for transcatheter aortic valve replacement (TAVR) in patients with symptomatic aortic valve stenosis. The impact of prior coronary artery bypass graft (CABG) surgery and how it affects left ventricular function recovery is not well defined. METHODS: Patients who had TAVR at a single center between June 2012 and December 2016 were reviewed. High-risk patients who underwent the procedure via a TA approach were divided into 2 groups based on their history of CABG surgery. Postoperative outcomes were compared between groups. CABG/TA-TAVR patients were subdivided into 2 per baseline left ventricular ejection fraction (LVEF) <50%. The changes in LVEF and valve function at follow-up (1 to 12 months) were analyzed using paired t-tests. RESULTS: Of 923 cases in total, 183 (19.8%) were performed via a TA approach. The mean ± SD Society of Thoracic Surgeons risk score of TA patients was 10.2 ± 4.6. Forty-nine (27%) had a surgical history of CABG. Overall all-cause mortality rates at 30 days, 1 year, and 2 years were similar for both groups (P = 0.59, P = 0.64, P = 0.78). Subgrouping of CABG-TAVR patients (n = 49) identified 24 patients (49%) with LVEF ≥50% vs. 25 (51%) with LVEF <50%. At 1-year follow-up, significant improvements in LVEF (low LVEF group) and valve function for both groups were observed. LVEF ≥50% group (LVEF: ∆: -3%, P = 0.878; aortic valve area [AVA]: ∆: 1.3 cm2, P < 0.001; mean gradient: ∆: -38 mmHg, P < 0.001); LVEF <50% group (LVEF: ∆: 10%, P = 0.01; AVA: ∆: 1.3 cm2, P < 0.001; MG: ∆: -31 mmHg, P < 0.001). CONCLUSIONS: TA-TAVR can be safely performed with acceptable postoperative outcomes in patients with a history of CABG surgery. In those with reduced EF, significant improvements in LV and valve functions are seen at 1-year follow-up.

Racial Disparities and Outcomes After Left Ventricular Assist Device Implantation as Bridge to Transplantation or Destination Therapy.

OBJECTIVE: We sought to investigate outcomes after left ventricular assist device (LVAD) implantation in advanced heart failure patients stratified by race. METHODS: Patients who had LVADs inserted at a single center as a bridge to transplant (BTT) or destination therapy (DT) were divided into 3 groups based on race: Caucasian, African American (AA), and Hispanic. Postoperative outcomes including complications, discharge disposition, and survival at defined time points were compared. Cox proportional hazards were used to identify factors associated with 1-year all-cause survival. RESULTS: A total of 158 patients who had LVADs as BTT (n = 63) and DT (n = 95) were studied. Of these, 56% (n = 89) were Caucasians, 35% (n = 55) were AA, and 9% (n = 14) were Hispanics. AA patients had higher BMI and lower socioeconomic status and educational level, and were more likely to be single or divorced. Operative outcomes were similar among all 3 groups. Unadjusted 30-day, 6-month, 1-year, and 2-year survival rates for Caucasians versus AA versus Hispanics were 82% versus 89% versus 93%, P = 0.339; 74% versus 80% versus 71%, P = 0.596; 67% versus 76% versus 71%, P = 0.511; and 56% versus 62% versus 68%, P = 0.797. On multivariate analysis, device-related infection, malfunction, and abnormal rhythm were factors associated with overall all-cause mortality. CONCLUSION: AA patients who undergo LVAD implantation as BTT or DT have lower socioeconomic status and educational level compared to their Caucasian or Hispanic counterparts. These differences, however, do not translate into postimplant survival outcomes.

Predictors of Extended Postoperative Length of Stay After Uncomplicated Transcatheter Aortic Valve Replacement.

BACKGROUND: The current study aims to identify predictors of extended postoperative length of stay (PLOS) after uncomplicated transcatheter aortic valve replacement (TAVR). METHODS: Patients who underwent TAVR at a single center between June 2012 and June 2016 were analyzed. Patients were stratified by time into an early cohort (EC; 2012-2014) and current cohort (CC; 2015-2016). Those who had complications post procedure were excluded. The CC group was dichotomized based on its median PLOS. Factors associated with a longer PLOS were investigated by using multivariable logistic regression analysis. RESULTS: Mean age of the 686 patients (299 in the EC group and 387 in the CC group) was 82 ± 8 years. PLOS in the CC group was significantly lower than in the EC group (4 days vs 6 days, respectively; P<.001). Median PLOS in the CC group was 2 days. Dichotomizing the CC group by median PLOS resulted in 148 patients (54%) ≤2 days vs 128 patients (46%) >2 days. Of these, PLOS was 1 day in 71 patients (26%) and 2 days in 61 patients (28%). Independent predictors of PLOS >2 days were non-transfemoral approach, non-elective admission, female sex, low mean transaortic gradient, presence of chronic renal failure, and pulmonary hypertension. CONCLUSION: Experience coupled with improvements in TAVR technology over the past few years have led to a significant decrease in PLOS after TAVR. In the current TAVR era, 1 out of every 2 patients stays for a day or two in the absence of perioperative adverse events.

Clinical and Functional Outcomes Associated with Age after Transapical Transcatheter Aortic Valve Replacement.

OBJECTIVE: Transcatheter aortic valve replacement (TAVR) via a transapical (TA) approach has been associated with high morbidity. The aim of this study is to investigate the association of age and clinical and functional outcomes after TA-TAVR. METHODS: Patients who had TA-TAVR at a single center were divided into 3 age groups: <75 years (Group I), 75 to 85 years (Group II), and >85 years (Group III). Pre- and postoperative clinical, functional status, and procedure-related outcomes were compared among patient groups. A multivariable Cox proportional hazards model was used to assess the impact of age on overall all-cause mortality. RESULTS: Out of 183 TA-TAVR cases performed, 117 met the study criteria. These included 15 aged <75 years, 60 aged 75 to 85 years, and 42 aged >85 years. Short-term (30-day) clinical and functional status improved significantly for all age groups. The incidence of acute kidney injury, access site complications, and requirement for permanent pacemaker were similar for all age groups at 30 days. After a median follow-up of 26 months, overall all-cause survival rates were 86% for Group I, 88% for Group II, and 83% for Group III at 1 year. Cox proportional hazards model showed frailty status (HR: 1.84; 95% CI, 1.23 to 2.69; P = 0.003) but not age as an independent predictor of overall all-cause mortality. CONCLUSIONS: Findings from this study suggest that both older and younger patients benefit from TA-TAVR with comparable operative outcomes. Age should not be an exclusion criterion for TA-TAVR.

The Effect of Continuous-Flow Left Ventricular Assist Device Duration on Postoperative Outcomes.

BACKGROUND: This study evaluated the effect of continuous-flow left ventricular assist device (CF-LVAD) duration on postoperative outcomes in heart transplant patients. METHODS: United Network of Organ Sharing heart transplant follow-up data from 2005 to 2015 were obtained. Patients supported by CF-LVADs who subsequently underwent cardiac transplantation were studied. The study population was divided into three groups by CF-LVAD duration of less than 1 year, 1 to 2 years, and more than 2 years. Multivariable Cox regression analysis was used to identify predictors of overall postoperative graft survival. Kaplan-Meier survival functions were used to estimate actuarial survival at 1, 2, and 5 years after transplant. The association between CF-LVAD duration and postoperative acute rejection episodes before and after hospital discharge was assessed. RESULTS: Of 21,336 recipients, 4,382 had CF-LVADs before cardiac transplantation: 2,603 (59.4%) had CF-LVADs for less than 1 year, 1,178 (26.9%) for 1 to 2 years, and 601 (13.7%) for more than 2 years. Donor age, high body mass index, dialysis dependence, and poor functional status at transplant were significant predictors of poor posttransplant graft survival. CF-LVAD duration was associated with increased incidence of acute rejection before hospital discharge (odds ratio, 1.14; 95% confidence interval, 1.02 to 1.28; p = 0.019). Duration was not related to acute rejection episodes after discharge. There was no difference in survival among patients with increasing time durations (hazard ratio, 1.01; 95% CI, 0.89 to 1.15; p = 0.824). Graft survival at 1, 2, and 5 years among patient groups was not significantly different (p = 0.824 by log-rank test) CONCLUSIONS: Duration of CF-LVAD support does not affect posttransplant graft survival. Longer duration of support increases acute rejection episodes; however, this may not translate into diminished survival.

The impact of frailty status on clinical and functional outcomes after transcatheter aortic valve replacement in nonagenarians with severe aortic stenosis.

BACKGROUND: The impact of frailty status on TAVR outcomes in nonagenarians is unknown. The present study aims to investigate the impact of frailty status on procedural outcomes and overall survival in nonagenarians after TAVR. METHODS: A frailty score (FS) was derived by using preoperative grip strength, gait speed, serum albumin, and daily activities. Patients were divided into two groups: Frail (FS ≥ 3/4) and Non-Frail (FS <3/4). Health status was assessed using the 12-item Kansas City Cardiomyopathy Questionnaire (KCCQ). Baseline demographic and clinical characteristics were compared in both groups. The effect of frailty status on outcomes was investigated. Cox regression analyses were performed to determine predictors of overall all-cause mortality. Kaplan-Meier survival curves were used to estimate survival. RESULTS: Seventy-five patients >90 years underwent full assessment for frailty status. There was a significant improvement in overall health status of non-frail patients (mean difference: 11.03, P = 0.032). Unadjusted 30-day and 2-year mortality rates were higher in the frail group than the non-frail group. (14% vs. 2% P = 0.059; 31% vs. 9% P = 0.018). Kaplan-Meier estimated all-cause mortality to be significantly higher in the frail group (log-rank test; P = 0.042). Frailty status was independently associated with increased mortality (hazard ratio: 1.84, 95% C.I: 1.06-3.17; P = 0.028) after TAVR. CONCLUSION: Among nonagenarians selected to undergo TAVR for severe aortic stenosis, a considerable number are frail. Nonfrail patients report a significant improvement in overall health status in the short term. Worse frailty is strongly associated with diminished long-term survival. © 2017 Wiley Periodicals, Inc.

Association of Change in Patient-Reported Health Status after Transcatheter Aortic Valve Replacement, and Postoperative Outcomes.

BACKGROUND: The study aim was to investigate the relationship between postoperative morbidity after transcatheter aortic valve replacement (TAVR) and short-term patient-reported health status, using the Kansas City Cardiomyopathy Questionnaire (KCCQ). METHODS: The association between 30-day post-procedure changes in patient-reported heath status and post-TAVR outcomes was examined. Patients were stratified into three groups based on observed changes in KCCQ-Overall scores (OS): Group A, increase in KCCQ-OS ≥10 points; Group B, KCCQ-OS scores <10 points; and Group C, decline in KCCQ-OS ≥10 points. Variation components of KCCQ scores were determined using paired t-tests. Postoperative morbidity was investigated. Multivariable logistic regression was used to identify pre-procedural factors associated with an increase or decline in KCCQ-OS at 30 days. RESULTS: A total of 223 patients with complete baseline and postoperative 30-day KCCQ responses was studied. At the 30-day follow up there was a significant change in baseline mean KCCQ-OS for all patients (mean difference 14.1; p <0.0001). Improvement in KCCQ-OS ≥10 was observed in 130 patients (58%), 64 patients (29%) had no change, and 29 patients (13%) had a decline in KCCQ-OS ≥10. The incidence of acute kidney injury (AKI), permanent pacemaker (PPM) placement and new-onset arrhythmia (NOA) was higher in group C than in groups A and B: AKI, 11%, 0%, 0%; p <0.001; PPM, 21%, 4%, 6%; p = 0.004; and NOA, 21%, 5%, 8%, p = 0.026. Independent predictors of decline in KCCQ scores after TAVR were PPM requirement (estimate: 0.76 CI 0.22, 1.29; p = 0.005) and NYHA functional class (III/IV) (estimate: -0.41 CI -0.71, 0.10; p = 0.009). CONCLUSIONS: TAVR patients experienced an improvement in health status after the procedure, but for a smaller proportion their health status worsened. Patients who experience perioperative complications may have a decline in their health status after the procedure in the short term.