Procedural and cardiovascular outcomes of geriatric vs non-geriatric patients undergoing permanent pacemaker implantation - a nationwide cohort analysis.

BACKGROUND: Permanent pacemaker implantation is increasing exponentially to treat atrio-ventricular block and symptomatic bradyarrhythmia. Despite being a minor surgery, immediate complications such as pocket infection, pocket hematoma, pneumothorax, hemopericardium, and lead displacement do occur. METHODS: The Nationwide Inpatient Sample was queried from 2016 to 2018 to identify patients with pacemakers using ICD-10 procedure code. The Chi-square test was used for statistical analysis. RESULTS: The sample size consisted of 443,460 patients with a pacemaker, 26% were <70 years (male 57%, mean age of (60.6±9.7) yr, Caucasian 70%) and 74% were ≥70 years (male 50%, mean age of (81.4±5.9) yr, Caucasian 79%). Upon comparison of rates in the young vs elderly: mortality (1.6% vs 1.5%; P<0.01), obesity (26% vs 13%; P<0.001), coronary artery disease (40% vs 49%; P<0.001), HTN (74% vs 87%; P<0.01), anemia (4% vs 5%; P<0.01), atrial fibrillation (34% vs 49%; P<0.01), peripheral artery disease (1.7% vs 3%; P<0.01), CHF (31% vs 39%; P<0.001), diabetes (31% vs 27.4%; P<0.01), vascular complications (1.1% vs 1.2%; P<0.01), pocket hematoma (0.5% vs 0.8%; P<0.01), AKI (16% vs 21%; P<0.01), hemopericardium (0.1% vs 0.1%; P = 0.1), hemothorax (0.3% vs 0.2%; P<0.01), cardiac tamponade (0.4% vs 0.5%; P<0.01), pericardiocentesis (0.4% vs 0.4%; P<0.01), cardiogenic shock (4% vs 2.3%; P<0.01), respiratory complications (1.9% vs 0.9%; P<0.01), mechanical ventilation (5.1% vs 2.9%; P<0.01); post-op bleed (0.5% vs 0.3%; P<0.01), need for transfusion (4.8% vs 3.8%; P<0.01), severe sepsis (0.6% vs 0.5%; P<0.01 ), septic shock (2% vs 1%; P<0.01), bacteraemia (0.8% vs 0.4%; P<0.01), lead dislodgement (1.4% vs 1.1%; P<0.01). CONCLUSIONS: Our study revealed that the overall complication rates were lower in the elderly despite higher co-morbidities. This aligns with previous studies which showed lower rates in the elderly. Hence providers should not hesitate to provide guideline driven pacemaker placement in the elderly especially in patients with good life expectancy.

Impact of Social Vulnerability on Cardiac Arrest Mortality in the United States, 2016 to 2020.

BACKGROUND: Cardiac arrest is 1 of the leading causes of morbidity and mortality, with an estimated 340 000 out-of-hospital and 292 000 in-hospital cardiac arrest events per year in the United States. Survival rates are lower in certain racial and socioeconomic groups. METHODS AND RESULTS: We performed a county-level cross-sectional longitudinal study using the Centers for Disease Control and Prevention's Wide-Ranging Online Data for Epidemiologic Research multiple causes of death data set between 2016 and 2020 among individuals of all ages whose death was attributed to cardiac arrest. The Social Vulnerability Index is a composite measure that includes socioeconomic vulnerability, household composition, disability, individuals from racial and ethnic minority groups status and language, and housing and transportation domains. We examined the impact of social determinants on cardiac arrest mortality stratified by age, race, ethnicity, and sex in the United States. All age-adjusted mortality rate (cardiac arrest AAMRs) are reported as per 100 000. Overall cardiac arrest AAMR during the study period was 95.6. The cardiac arrest AAMR was higher for men compared with women (119.6 versus 89.9) and for the Black population compared with the White population (150.4 versus 92.3). The cardiac arrest AAMR increased from 64.8 in counties in quintile 1 of Social Vulnerability Index to 141 in quintile 5, with an average increase of 13% (95% CI, 9.8%-16.9%) in AAMR per quintile increase. CONCLUSIONS: Mortality from cardiac arrest varies widely, with a >2-fold difference between the counties with the highest and lowest social vulnerability, highlighting the differential burden of cardiac arrest deaths throughout the United States based on social determinants of health.

Contemporary National Trends of Mechanical Circulatory Support Among Myocarditis Hospitalizations Before the Pandemic: A National In-patient Database (2005-2019) Study.

According to the Global Burden of Disease Project, the morbidity and mortality of myocarditis continue to be a significant worldwide burden. On October 1, 2015, hospital administrative data started using the International Classification of Diseases (ICD)-10 codes instead of the ICD-9. To our knowledge, nationwide trends of myocarditis have not been studied after this update. The NIS database from 2005-2019 was analyzed using ICD-9 and 10 codes. Our search yielded 141,369 hospitalizations due to myocarditis, with 40.9% females. There were 6627 (4.68%) patients who required mechanical circulatory support (MCS) using left ventricular assisted devices (LVAD), intra-aortic balloon pump (IABP), or extracorporeal membrane oxygenation (ECMO). The use of LVAD and ECMO increased significantly during the study period (p-trend 0.003 and <0.001, respectively), whereas the use of IABP decreased during the same period (p-trend 0.025). Our study demonstrated an overall increase in the use of MCS overall in myocarditis, with increasing utilization of more advanced MCS in the forms of LVAD and ECMO.

Trends in Premature Mortality from Acute Myocardial Infarction in American Indians/Alaska Natives in the United States from 1999 to 2020.

Cardiovascular disease is the leading cause of mortality in American Indian and Alaska Native (AI/AN) groups. They are disproportionately found to have a higher rate of premature myocardial infarction (MI). The Centers for Disease Control and Prevention's Wide-ranging Online Data for Epidemiologic Research were queried to identify premature MI deaths (female <65 years and male <55 years) occurring within the United States between 1999 and 2020. We investigated proportionate mortality trends related to premature MI in AI/ANs stratified by gender. Deaths attributed to acute MI (AMI) were identified using the International Classification of Diseases, Tenth Revision, Clinical Modification codes I21 to I22. We compared the proportional mortality rate because of premature MI with that of a non-AI/AN racial group, which comprised all other races (Blacks, Whites, and Asian/Pacific Islander populations). In AI/ANs, we analyzed a total of 14,055 AMI deaths, of which 3,211 were premature MI deaths corresponding to a proportionate mortality rate of 22.8% (male 20.8%, female 26.2%). The non-AI/AN population had a lower proportionate mortality of 14.8% (male 13.7%, female 16%), p <0.01). On trend analysis, there was no significant improvement over time in the proportionate mortality of AI/ANs (19.8% in 1999 to 21.7% in 2020, p = 0.09). Upon comparison of gender, proportionate mortality of premature MI in women showed a statistically nonsignificant increase from 21.6% in 1999 to 27.3% in 2020 [average annual percent change of 0.7, p = 0.06)]. However, men had a statistically significant decrease in proportionate mortality of premature MI from 18.5% in 1999 to 18.2% in 2020 [average annual percent change of -0.8, p = 0.01)]. AI/ANs have an alarmingly higher rate of proportionate mortality of premature MI than that of other races, with no improvement in the proportionate mortality rates over 20 years, despite an overall downtrend in AMI mortality. Further research to address the reasons for the lack of improvement in premature MI is needed to improve outcomes in this patient population.

Advancements in the Clinical Outcomes of Functional Neurosurgery With Deep Brain Stimulation for Movement Disorders: A Literature Review.

This literature review explores recent advancements in deep brain stimulation (DBS) surgery for movement disorders. It highlights notable improvements, including closed-loop stimulation techniques, optogenetics, and improved surgical targeting. Positive clinical outcomes with low complication rates and improved motor symptoms are consistently reported. The review emphasizes the importance of minimizing risks through meticulous surgical practices and discusses potential complications associated with DBS surgery. Future prospects focus on enhancing technology, refining surgical techniques, and conducting further research. Closed-loop stimulation optimizes DBS efficacy by tailoring stimulation parameters to individual patient needs. Optogenetics offers precise modulation of neural activity with light-sensitive proteins, enabling more targeted treatments. Cybersecurity measures are essential due to the integration of wireless and digital technologies in DBS systems. DBS surgery has significantly improved the management of movement disorders with its safety and effectiveness. Ongoing research in closed-loop stimulation, optogenetics, and cybersecurity is expected to further enhance DBS technology and outcomes, benefiting patients with treatment-resistant movement disorders.

Lead Cap Use in Interventional Cardiology: Time to Protect Our Head in the Cardiac Catheterisation Laboratory?

Background: Radiation exposure is an occupational hazard for interventional cardiologists and cardiac catheterisation laboratory staff that can manifest with serious long-term health consequences. Personal protective equipment, including lead jackets and glasses, is common, but the use of radiation protective lead caps is inconsistent. Methods: A systematic review qualitative assessment of five observational studies using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines protocol was performed. Results: It was concluded that lead caps significantly reduce radiation exposure to the head, even when a ceiling-mounted lead shield was present. Conclusion: Although newer protective systems are being studied and introduced, tools, such as lead caps, need to be strongly considered and employed in the catheterisation laboratory as mainstay personal protective equipment.

Meta-Analysis of Efficacy and Safety of Intravenous Iron in Patients With Iron Deficiency and Heart Failure With Reduced Ejection Fraction.

Iron deficiency is an independent risk factor for heart failure (HF) exacerbation. We aim to study the safety and efficacy of intravenous (IV) iron therapy in patients with HF with reduced ejection fraction (HFrEF). A literature search was conducted on MEDLINE (Embase and PubMed) using a systematic search strategy by PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) until October 2022. CRAN-R software (The R Foundation for Statistical Computing, Vienna, Austria) was used for statistical analysis. The quality assessment was performed using the Cochrane Risk of Bias and Newcastle-Ottawa Scale. We included 12 studies with a total of 4,376 patients (IV iron n = 1,985 [45.3%]; standard of care [SOC] n = 2,391 [54.6%]). The mean age was 70.37 ± 8.14 years and 71.75 ± 7.01 years in the IV iron and SOC groups, respectively. There was no significant difference in all-cause mortality and cardiovascular mortality (risk ratio [RR] 0.88, 95% confidence interval [CI] 0.74 to 1.04, p <0.15). However, HF readmissions were significantly lower in the IV iron group (RR 0.73, 95% CI 0.56 to 0.96, p = 0.026). Non-HF cardiac readmissions were not significantly different between the IV iron and SOC groups (RR 0.92, 95% CI 0.82 to 1.02, p = 0.12). In terms of safety, there was a similar rate of infection-related adverse events in both arms (RR 0.86, 95% CI 0.74 to 1, p = 0.05). IV iron therapy in patients with HFrEF is safe and shows a significant reduction in HF hospitalizations compared with SOC. There was no difference in the rate of infection-related adverse events. The changing landscape of HFrEF pharmacotherapy in the last decade may warrant a re-demonstration of the benefit of IV iron with current SOC. The cost-effectiveness of IV iron use also needs further study.

Cardiovascular Outcomes of Transulnar Versus Transradial Percutaneous Coronary Angiography and Intervention: A Regression Matched Meta-Analysis.

Transradial access (TRA) and transulnar access (TUA) are in close vicinity, but TRA is the preferred intervention route. The cardiovascular outcomes and access site complications of TUA and TRA are understudied. Databases, including MEDLINE and Cochrane Central registry, were queried to find studies comparing safety outcomes of both procedures. The outcome of interest was in-hospital mortality and access site bleeding. Secondary outcomes were all-cause major adverse cardiovascular events, crossover rate, artery spasm, access site large hematoma, and access site complications between TUA and TRA. A random-effect model was used with regression to report unadjusted odds ratios (ORs) by limiting confounders and effect modifiers, using software STATA V.17. A total of 4,796 patients in 8 studies were included in our analysis (TUA = 2,420 [50.4%] and TRA = 2,376 [49.6%]). The average age was 61.3 and 60.1 years and the patients predominantly male (69.2% vs 68.4%) for TUA and TRA, respectively. TUA had lower rates of local access site bleeding (OR 0.58, 95% confidence interval 0.34 to 0.97, I2 = 1.89%, p = 0.04) but higher crossover rate (OR 1.80, 95% confidence interval 1.04 to 3.11, I2 = 75.37%, p = 0.04) than did TRA. There was no difference in in-hospital mortality, all-cause major adverse cardiovascular events, arterial spasm, and large hematoma between both cohorts. Furthermore, there was no difference in procedural time, fluoroscopy time, and contrast volume used between TUA and TRA. TUA is a safer approach, associated with lower access site bleeding but higher crossover rates, than TRA. Further prospective studies are needed to evaluate the safety and long-term outcomes of both procedures.

Meta-Analysis on the Impact of Coronary Bypass Graft Markers on Angiographic Procedural Outcomes.

Utilization of radio-opaque coronary artery bypass graft markers is known to decrease the amount of contrast dye required to complete the procedure. The practice of marking bypass grafts varies significantly among surgeons. Limited data exist comparing the outcomes of percutaneous coronary intervention with and without coronary artery bypass graft (CABG) markers. We sought to explore the impact of proximal radio-opaque markers placed during CABG in subsequent percutaneous coronary intervention procedural risks. In our understanding of the current literature, this is the first meta-analysis conducted to evaluate the association between procedural angiographic metrics and CABG radio-opaque markers. We performed a query of MEDLINE and Scopus databases through August 2022 to identify relevant studies evaluating procedural metrics among patients with previous CABG with and without radio-opaque markers who underwent angiography. The primary outcomes of interest were fluoroscopy time, amount of contrast, and duration of angiography. We identified a total of 4 studies with 2,046 patients with CABG (CABG with markers n = 688, CABG without markers n = 1,518).2-5 Total fluoroscopy time was significantly reduced among patients with CABG markers compared with those with no markers (odds ratio [OR] -3.63, p <0.0001). The duration of angiography (OR -36.39, p >0.10) was reduced, although the result was not statistically significant. However, the amount of contrast utilization was significantly reduced (OR -33.41, p <0.0001). In patients who underwent CABG with radio-opaque markers, angiographic procedural metrics were improved, including reduced fluoroscopic time and the amount of contrast agent required compared with no markers.

Cardiac Metastasis of Neuroendocrine Tumor Without Cardiovascular Symptoms.

A 72-year-old man with a stage IV small intestinal neuroendocrine tumor presented to our cardiology clinic as a referral for an abnormal positron emission tomography-computed tomography scan with an intense gallium uptake in the heart. Follow-up cardiac magnetic resonance was suggestive of myocardium infiltration by the neuroendocrine tumor with late gadolinium enhancement and T1 time elevation. (Level of Difficulty: Intermediate.).

A case report of congenital absence of the pericardium that was diagnosed by cardiac computed tomography angiogram (CCTA).

This case report describes a 40-year-old male who presented to the emergency department (ED) with chest pain. Initial diagnostic workup was concerning for a congenital cardiac anomaly, further imaging revealed complete congenital absence of the pericardium (CAP) which is a rare condition. Multimodality cardiac imaging including cardiac computed tomography angiogram (CCTA) was used to confirm the diagnosis of CAP. We briefly discuss various clinical presentations of CAP along with potential complications and other anomalies that could be associated with pericardial agenesis.

A Rare Case of Acute Pericarditis as a Primary Presentation of Differentiation Syndrome.

A 47-year-old male with a history of acute promyelocytic leukemia was admitted for his induction chemotherapy session with all-trans retinoic acid and arsenic trioxide. On day 25, his medical course became complicated with differentiation syndrome and he developed isolated acute pericarditis.

Baseline characteristics and outcomes of end-stage renal disease patients after in-hospital sudden cardiac arrest: a national perspective.

PURPOSE: End-stage renal disease (ESRD) is a well-recognized risk factor for the development of sudden cardiac arrest (SCA). There is limited data on baseline characteristics and outcomes after an in-hospital SCA event in ESRD patients. METHODS: For the purpose of this study, data were obtained from the National Inpatient Sample from January 2007 to December 2017. In-hospital SCA was identified using the International Classification of Disease, 9th Revision, Clinical Modification and International Classification of Disease, 10th Revision, Clinical Modification codes of 99.60, 99.63, and 5A12012. ESRD patients were subsequently identified using codes of 585.6 and N18.6. Baseline characteristics and outcomes were compared among ESRD and non-ESRD patients in crude and propensity score (PS)-matched cohorts. Predictors of mortality in ESRD patients after an in-hospital SCA event were analyzed using a multivariate logistic regression model. RESULTS: A total of 1,412,985 patients sustained in-hospital SCA during our study period. ESRD patients with in-hospital SCA were younger and had a higher burden of key co-morbidities. Mortality was similar in ESRD and non-ESRD patients in PS-matched cohort (70.4% vs. 70.7%, p = 0.45) with an overall downward trend over our study years. Advanced age, Black race, and key co-morbidities independently predicted increased mortality while prior implantable defibrillator was associated with decreased mortality in ESRD patients after an in-hospital SCA event. CONCLUSIONS: In the context of in-hospital SCA, mortality is similar in ESRD and non-ESRD patients in adjusted analysis. Adequate risk factor modification could further mitigate the risk of in-hospital SCA among ESRD patients.

Transcatheter Aortic Valve Replacement vs Surgical Replacement in Patients With Pure Aortic Insufficiency.

OBJECTIVE: To compare the outcomes of transcatheter aortic valve replacement (TAVR) with surgical aortic valve replacement (SAVR) in patients with pure aortic insufficiency (PAI). BACKGROUND: The treatment of choice for patients with severe symptomatic PAI is SAVR. However, not all patients are candidates for surgery because of comorbidities or are deemed high risk for surgery. As a result, TAVR is being used as an off-label procedure in some patients with PAI. PATIENTS AND METHODS: We analyzed the National Inpatient Sample database from January 1, 2016, to December 31, 2017, using the International Classification of Diseases, 10th Revision. Inclusion criteria were patients with aortic valve insufficiency undergoing either TAVR or SAVR. Patients with concomitant aortic stenosis, or history of infective endocarditis, and those below the age of 18 years were excluded. RESULTS: A total of 14,720 patients with PAI underwent valve replacement. Of those, 6.2% underwent TAVR. The TAVR group was significantly older (median age 78 years vs 64 years; P <.001). There was no evidence of a difference in in-hospital mortality between the 2 groups. However, after adjustment, patients in the TAVR group were associated with favorable outcomes in terms of acute kidney injury, cardiogenic shock, postoperative respiratory complications, and length of stay. On the other hand, those in the SAVR group were less likely to need permanent pacemakers. CONCLUSION: There was no evidence of a significant statistical difference in in-hospital mortality between patients with PAI treated by either SAVR or TAVR, both in unmatched and propensity-matched cohorts. TAVR could be considered for patients with PAI who are not candidates for surgery.

Comparison of Outcomes in Patients With Takotsubo Syndrome With-vs-Without Cardiogenic Shock.

There is limited data on the in-hospital outcomes of cardiogenic shock (CS) secondary to takotsubo syndrome (TS). We aimed to assess the incidence, predictors, and outcomes of CS in hospitalized patients with TS. All patients with TS were identified from the National Inpatient Sample database from September 2006 to December 2017. The cohort was divided into those with versus without CS and logistic regression analysis was used to identify predictors of CS and mortality in patients admitted with TS. A total of 260,144 patients with TS were included in our study, of whom 14,703 (6%) were diagnosed with CS. In-hospital mortality in patients with CS was approximately six-fold higher compared with those without CS (23% vs 4%, p <0.01). TS patients with CS had a higher incidence of malignant arrhythmias like ventricular tachycardia or ventricular fibrillation (15.0% vs 4%, p <0.01) and non-shockable cardiac arrests (12% vs 2%, p <0.01). Independent predictors of CS were male gender, Asian and Hispanic ethnicity, increased burden of co-morbidities including congestive heart failure, chronic pulmonary disease, and chronic diabetes. Independent predictors of mortality were male gender, advanced age, history of congestive heart failure, chronic renal failure, and chronic liver disease. In conclusion, CS occurs in approximately 6% of patients admitted with TS, in-hospital mortality in TS patients with CS was approximately six-fold higher compared with those without CS (23% vs 4%, p <0.01), male gender and increased burden of co-morbidities at baseline were independent predictors of CS and mortality.

Contemporary Trends and Outcomes in Patients With ST-Segment Elevation Myocardial Infarction and End-Stage Renal Disease on Dialysis: Insight from the National Inpatient Sample.

BACKGROUND: Cardiovascular disease is the major cause of mortality in end stage renal disease (ESRD) patients on dialysis and myocardial infarction constitutes almost 20% of such deaths. We assessed the trends, characteristics and in-hospital outcomes in patients with ESRD. METHODS: We used national inpatient sample (NIS) to identify patients with ESRD presenting with ST-segment elevation myocardial infarction (STEMI) for calendar years 2012-2016. Multiple logistic regression analysis and propensity matched data was used to compare outcomes for the purpose of our study. RESULTS: Patients on dialysis who presented with STEMI were less likely to be treated with emergent reperfusion therapies including percutaneous coronary intervention, bypass graft surgery and thrombolytics with in first 24 h. In propensity-matched cohort, the mortality was nearly double in patients who have ESRD compared to patients without ESRD (29.7% vs. 15.9%, p < 0.01). In-patient morbidity such as utilization of tracheostomy, mechanical ventilation and feeding tubes was also more prevalent in propensity matched ESRD cohort. In multivariate regression analysis, ESRD remains a strong predictor of increased mortality in STEMI patients (OR 2.65, 95% CI, 2.57-2.75, p < 0.01). CONCLUSION: Our study showed low utilization of evidence-based prompt reperfusion therapies in ESRD patients with STEMI along with concomitant increased poor outcomes and resource utilization. Future research specifically targeting this extremely high-risk patient population is needed to identify the role of prompt reperfusion therapies in improving outcomes in these patients.

Axillary Artery Pseudoaneurysm Following Percutaneous Transaxillary Access for Impella Device Placement During Percutaneous Coronary Intervention.

Percutaneous transaxillary access is currently considered an acceptable alternative to transfemoral approach for large-bore access, especially in the setting of hostile iliofemoral arteries. Few published reports exist concerning complications of upper extremity access. We describe development of an axillary artery pseudoaneurysm and its management following transaxillary access. (Level of Difficulty: Advanced.).

Trends, Outcomes, and Predictors of Revascularization in Cardiogenic Shock.

Cardiogenic shock (CS) carries high mortality and morbidity. Early revascularization is an important strategy in management of these patients. We sought to determine the outcomes and predictors of revascularization among patients with CS. Patients with CS and acute myocardial infarction were identified using the National Inpatient Sample (NIS) data from January 2002 to December 2014 using the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) codes. Subsequently, patients who underwent revascularization were then selected. A total of 118,618 patients with CS were identified. Out of these, about 55,735 (47%) patients underwent revascularization. Mean age of patients who underwent revascularization was lower when compared with patients not who underwent revascularization (66.40 vs 72.24 years, p < 0.01). Patients who underwent revascularization had lower mortality when compared with patients not who underwent revascularization (25.1% vs 52.2%, p < 0.01). Extracorporeal membrane oxygenation and mechanical circulatory support devices were often utilized more in patients who underwent revascularization. Overall, we found modest increased trend of revascularization over our study years with decline in mortality. Female gender, weekend admission, drug abuse, pulmonary hypertension, anemia, renal failure, neurological disorders, malignancy were associated with lower odds of revascularization. In conclusion, in this large nationally represented US population sample of CS patients, we found revascularization rate of about 47% with improvement in overall mortality over our study years.