Dementia is associated with worse procedural outcomes after mitral valve transcatheter edge-to-edge repair.

BACKGROUND: Patients with dementia are at increased risk for adverse events following valvular surgery. Outcomes after mitral transcatheter edge-to-edge repair (TEER) for mitral regurgitation in this vulnerable population are not well understood. METHODS: We queried the National Inpatient Sample database for all hospitalizations for mitral TEER between 2016 and 2019. Patients with a validated diagnosis code for dementia were identified by ICD-10 codes and compared to a matched cohort of non-dementia patients using multivariable regression analysis. The primary outcome was in-hospital mortality. Secondary outcomes were hospital length of stay, discharge to nursing facility, total hospital charges, and in-hospital adverse events. RESULTS: 24,550 hospitalizations for mitral TEER were identified, including 880 patients (3.6 %) with dementia. Dementia was associated with higher in-hospital mortality (OR 4.31, 95 % CI 2.65 to 6.99, p < 0.001), prolonged length of hospital stay (OR 1.33, 95 % CI 1.12 to 1.57, p 0.001), higher discharge rate to nursing facility (OR 2.71, 95 % CI 2.13-3.44, p < 0.001), and higher rate of in-hospital adverse events including delirium (OR 5.88, 95 % CI 4.06 to 8.52, p < 0.001) and acute stroke (OR 8.87, 95 % CI 5.01 to 15.70, p < 0.001). CONCLUSIONS: Dementia is associated with worse post-procedural outcomes after mitral TEER. Further investigation is needed to elucidate mechanisms of poor clinical outcomes and guide shared decision-making in this vulnerable population.

Chronic Limb-Threatening Ischemia Is Associated With Higher Mortality and Limb Revascularization After Transcatheter Aortic Valve Replacement.

Peripheral arterial disease (PAD) is common in patients with symptomatic aortic stenosis. PAD exists as a spectrum, and patients with chronic limb-threatening ischemia (CLTI), the most severe form of PAD, are at high risk for limb loss and death. We seek to determine patient characteristics and clinical outcomes among patients who underwent TAVR with or without CLTI. We identified all hospitalizations for TAVR from October 2015 to December 2018 using the National Inpatient Sample database. Patients with any diagnosis of CLTI were identified using the International Classification of Diseases 10th Revision codes. The primary outcome was in-hospital mortality, and secondary outcomes were major complications, open revascularization, and endovascular revascularization after TAVR. During the study period, a total of 31,335 hospitalizations for TAVR procedures were included, including 7,048 (22.5%) in patients with CLTI. CLTI was associated with higher in-hospital mortality (odds ratio [OR] 1.4, 95% confidence interval [CI] 1.13 to 1.74, p = 0.002) and major complications (OR 1.2, 95% CI 1.09 to 1.25, p <0.001). CLTI was also associated with a significantly higher rate of open limb revascularization (OR 5.1, 95% CI 3.94 to 6.48, p <0.001) and endovascular revascularization (OR 4.0, 95% CI 3.54 to 4.59, p <0.001). CLTI among patients who underwent TAVR is associated with higher in-hospital mortality, major complications, and longer lengths of stay compared with patients without CLTI. However, the overall rates of adverse events remain low. Further studies are needed to optimize the multidisciplinary care of these patients before TAVR with a focus on shared decision-making.

Outcomes of Percutaneous Coronary Intervention for In-Stent Restenosis Versus De Novo Lesions: A Meta-Analysis.

Background In-stent restenosis (ISR) is commonly encountered even in the era of contemporary percutaneous coronary intervention (PCI). There is a paucity of data on the comparative outcomes of PCI for ISR lesions versus de novo lesions. Methods and Results An electronic search was conducted for MEDLINE, Cochrane, and Embase through August 2022 for studies comparing the clinical outcomes after PCI for ISR versus de novo lesions. The primary outcome was major adverse cardiac events. Data were pooled using a random-effects model. The final analysis included 12 studies, with a total of 708 391 patients, of whom 71 353 (10.3%) underwent PCI for ISR. The weighted follow-up duration was 29.1 months. Compared with de novo lesions, PCI for ISR was associated with a higher incidence of major adverse cardiac events (odds ratio [OR], 1.31 [95% CI, 1.18-1.46]). There was no difference on a subgroup analysis of chronic total occlusion lesions versus none (Pinteraction=0.69). PCI for ISR was associated with a higher incidence of all-cause mortality (OR, 1.03 [95% CI, 1.02-1.04]), myocardial infarction (OR, 1.20 [95% CI, 1.11-1.29]), target vessel revascularization (OR, 1.42 [95% CI, 1.29-1.55]), and stent thrombosis (OR, 1.44 [95% CI, 1.11-1.87]), but no difference in cardiovascular mortality (OR, 1.04 [95% CI, 0.90-1.20]). Conclusions PCI for ISR is associated with higher incidence of adverse cardiac events compared with PCI for de novo lesions. Future efforts should be directed toward prevention of ISR and exploring novel treatment strategies for ISR lesions.

Caregiver Stress Is Improved and Sustained Following Transcatheter Aortic Valve Replacement.

Background: Little is known about the impact of symptomatic aortic stenosis and subsequent transcatheter aortic valve replacement (TAVR) on stress and health for the caregiver. In this prospective cohort study, we measured caregiver stress before and after TAVR. Methods: We interviewed 34 primary caregivers for patients undergoing outpatient TAVR at an academic institution. Caregiver stress was measured using the Kingston Caregiver Stress Scale (KCSS) and the Caregiver Self-Assessment Questionnaire (CSAQ) before TAVR and at one and six months after. Mean scores were compared pre- and post-TAVR using the Wilcoxon signed-rank test. Results: There was significant improvement in KCSS caregiver stress at one month that was sustained at six months post-TAVR (mean change -1.91 ± 2.50 for six months, p-value 0.01). This was primarily driven by improvement in caregiving issues rather than family or financial issues. There was also significant improvement in CSAQ self-assessed health/illness at one and six months (mean change -2.78 ± 4.01 for six months, p-value 0.016). Conclusions: Our findings support further investigation of caregiver outcomes in shared decision making before TAVR.

Outcomes of Mitral Transcatheter Edge-to-Edge Repair in Patients With Rheumatic Heart Disease.

Mitral transcatheter edge-to-edge repair (TEER) in patients with rheumatic heart disease (RHD) is challenging owing to leaflet thickening and calcification but is performed in select cases. Limited data exist on its outcomes. The aim of this analysis was to investigate the safety and efficacy of mitral TEER in patients with severe symptomatic rheumatic mitral regurgitation. We queried the Nationwide Readmissions Database for hospitalizations for mitral TEER between 2016 and 2018. Propensity score-weighted regression analysis was conducted to evaluate the association of RHD with in-hospital outcomes and 90-day readmissions after mitral TEER. A total of 18,240 procedures were included in the analysis, including 1,779 in patients with RHD. Mitral TEER in patients with RHD was associated with similar in-hospital mortality to that in patients without RHD (odds ratio [OR] 1.47, 95% confidence interval [CI] 0.94 to 2.30, p = 0.089). However, RHD was associated with higher acute myocardial infarction (OR 1.65, 95% CI 1.07 to 2.56), acute kidney injury (OR 1.58, 95% CI 1.30 to 1.94), ventricular arrhythmia (OR 1.50, 95% CI 1.12 to 2.01), high-degree heart block (OR 1.67, 95% CI 1.25 to 2.23), and conversion to open surgical repair/replacement (OR 2.53, 95% CI 1.02 to 6.30). Mitral TEER in RHD was also associated with higher 90-day all-cause readmission (hazard ratio [HR] 1.19, 95% CI 1.04 to 1.47, p = 0.012). In conclusion, mitral TEER in patients with RHD is associated with higher rates of hospital complications, crossover to surgery, and readmissions but could be performed selectively in patients at high surgical risk who have favorable anatomy.

Coronary artery bypass grafting after acute ST-elevation myocardial infarction.

OBJECTIVES: The study objectives were to describe the trends and outcomes of isolated coronary artery bypass grafting after ST-elevation myocardial infarction using a nationwide database. METHODS: We queried the 2002-2016 National Inpatient Sample database for hospitalized patients with ST-elevation myocardial infarction who underwent isolated coronary artery bypass grafting. We report temporal trends, predictors, and outcomes of coronary artery bypass grafting in the early (2002-2010) and recent (2011-2016) cohorts. RESULTS: Of 3,347,470 patients hospitalized for ST-elevation myocardial infarction, 7.7% underwent isolated coronary artery bypass grafting. The incidence of isolated coronary artery bypass grafting after ST-elevation myocardial infarction decreased over time (9.2% in 2002 vs 5.5% in 2016, Ptrend < .001), whereas perioperative crude in-hospital mortality did not change (5.1% in 2002 vs 4.2% in 2016, Ptrend = .66), coinciding with an increase in the burden of comorbidities. There was an increase in performing isolated coronary artery bypass grafting on hospitalization day 3 or more, as well as an increase in the use of mechanical support devices and precoronary artery bypass grafting percutaneous coronary intervention. In the early cohort, isolated coronary artery bypass grafting on days 1 and 2 was associated with higher in-hospital mortality. In the recent cohort, coronary artery bypass grafting on day 2 had similar in-hospital mortality compared with day 3 or more and lower rates of acute kidney injury, ischemic stroke, ventricular arrhythmia, and length of hospital stay. CONCLUSIONS: In this nationwide analysis, there has been a decline in the use of isolated coronary artery bypass grafting after ST-elevation myocardial infarction. Isolated coronary artery bypass grafting on day 1 was performed in sicker patients and was associated with higher in-hospital mortality than coronary artery bypass grafting performed on day 3 or more. In the recent cohort, isolated coronary artery bypass grafting on day 2 had similar in-hospital mortality compared with day 3 or more.

Utilization Rate and Outcomes of Intravascular Imaging in Elderly Patients Presenting With ST-Elevation Myocardial Infarction.

BACKGROUND: Elderly patients presenting with ST-elevation myocardial infarction (STEMI) represent a vulnerable population with comorbid conditions and complex coronary anatomy. We aimed to describe the utilization rate and outcomes of intravascular imaging to guide percutaneous coronary intervention (PCI) in this population. METHODS: The Nationwide Readmissions Database was queried for all hospitalizations for STEMI involving PCI from 2018 to 2019. Hospitalizations were stratified by patient age into a younger cohort <75 years (mean age 58.7 ± 9.5 years) and an older cohort ≥75 years. Propensity score-weighed regression analysis was used to identify the association of intravascular imaging with in-hospital mortality, 90-day all-cause readmission, and readmission for myocardial infarction (MI). RESULTS: A total of 299,619 STEMI PCI hospitalizations were included. Intravascular imaging was utilized less frequently in the older cohort (6.8 % vs 7.8 %, odds ratio [OR] 0.87, 95 % CI 0.82-0.92, p < 0.001). In both cohorts, intravascular imaging was more likely to be used with anterior STEMI, complex PCI, mechanical support, and thrombectomy. Propensity score analysis showed the use of intravascular imaging was associated with lower in-hospital mortality in both cohorts (OR 0.60, 95 % CI 0.52-0.68, p < 0.001 in the younger cohort and OR 0.61, 95 % CI 0.51-0.72, p < 0.001 in the older cohort). There was no difference in 90-day all-cause readmission or readmission for MI with intravascular imaging. CONCLUSIONS: Intravascular imaging during STEMI PCI is associated with lower in-hospital mortality regardless of age. Further studies are needed to understand the low utilization rates especially among elderly patients.

Circulating Biomarkers in Hypertrophic Cardiomyopathy.

Hypertrophic cardiomyopathy is the most common genetic heart disease. Biomarkers, molecules measurable in the blood, could inform the clinician by aiding in diagnosis, directing treatment, and predicting outcomes. We present an updated review of circulating biomarkers in hypertrophic cardiomyopathy representing key pathologic processes including wall stretch, myocardial necrosis, fibrosis, inflammation, hypertrophy, and endothelial dysfunction, in addition to their clinical significance.

Meta-Analysis of Efficacy of Vasopressin During Cardiopulmonary Resuscitation.

Randomized controlled trials evaluating the efficacy of vasopressin versus standard of care during cardiopulmonary resuscitation (CPR) have yielded conflicting results. An electronic search of MEDLINE, Cochrane, and Embase databases was conducted through February 2022 for randomized controlled trials that evaluated the outcomes of vasopressin versus standard of care during CPR among patients with cardiac arrest. The primary outcome was the likelihood of spontaneous circulation (ROSC) return. Data were pooled using the random-effects model. The final analysis included 11 trials with 6,609 patients. The weighted mean age was 65.5 years, and 68.2% were men. There was no significant difference between the vasopressin and control groups in the likelihood of ROSC (33.1% vs 31.9%, odds ratio [OR] 1.23, 95% confidence interval [CI] 0.98 to 1.55). Subgroup analyses suggested that the use of vasopressin versus control increased the likelihood of ROSC when used in combination with steroids (pinteraction = 0.01) and in cases of in-hospital cardiac arrest (pinteraction = 0.01). There was no significant difference between the vasopressin and control groups in the likelihood of favorable neurological outcome (OR 1.14, 95% CI 0.75 to 1.71), in-hospital mortality (OR 0.89, 95% CI 0.60 to 1.31), or ventricular arrhythmias (OR 0.93, 95% CI 0.44 to 1.97). In conclusion, compared with the standard of care, the use of vasopressin during CPR did not increase the likelihood of ROSC among patients with cardiac arrest. There was no difference between the vasopressin and control groups in the likelihood of the favorable neurological outcome, in-hospital mortality, or ventricular arrhythmias.

Fixed-dose aspirin monotherapy compared with thromboelastography directed antiplatelet therapy in long-term management of left ventricular assist devices.

BACKGROUND AND AIM: The role of thromboelastography (TEG) in managing antiplatelet therapy (APT) in left ventricular assist devices (LVADs) is controversial. Our aim was to determine whether removal of TEG from an LVAD-specific APT protocol reduced late-onset bleeding without increasing thromboembolic complications. METHODS: We performed a single-center, retrospective cohort study including all recipients of a continuous-flow LVAD between April 2005 and November 2019 (n = 293). LVAD recipients before June 1, 2017 (n = 221) whose APT was monitored and adjusted using TEG were compared with LVAD recipients after June 1, 2017 (n = 72) where TEG was not utilized. Occurrence of late-onset bleeding events after postoperative Day 7 and thromboembolic events were collected. APT doses, warfarin use and International normalized ratio (INR) values were collected at discharge and at 1, 3, 6, and 12-months postimplantation. RESULTS: Over a median 12-month follow-up, INTERMACS major bleeding events occurred in 35% of patients where TEG was utilized compared with 29% where TEG was not utilized (p = 0.375), and procedural intervention was required in 29% compared with 18%, respectively (p = 0.058). Use of TEG was associated with higher doses of aspirin (>325 mg) (41% compared with none) and use of a second antiplatelet (dipyridamole) (43% compared to 1%). Despite this, there was no significant difference in thromboembolic events (15% in each). CONCLUSIONS: Our study suggests the use of TEG led to increased doses of aspirin as well as adding a second antiplatelet agent, without improving outcomes in LVAD recipients. Furthermore, the removal of TEG from an LVAD-specific APT protocol did not worsen thromboembolic outcomes.

Estimation of Right Atrial Pressure Using a Portable Handheld Ultrasound Device.

BACKGROUND: Handheld ultrasound devices are increasingly used by clinicians for their ease of use and portability. Their utility for estimating right atrial pressure (RAP) is poorly described. METHODS: This prospective study enrolled 50 consecutive patients presenting for outpatient right heart catheterization (RHC). A handheld ultrasound device was used to measure inferior vena cava size and collapsibility and estimate RAP to be 3, 8, or 15 mmHg according to American Society of Echocardiography recommendations for cardiac chamber quantification. Invasive pressure measurements were then performed using RHC. Spearman's correlation and linear regression analysis were used to evaluate the association between estimated RAP using ultrasound and invasive RAP. RESULTS: Fifty patients were enrolled (mean age 68 ± 8 years). Estimated RAP by ultrasound was significantly associated with invasive RAP (r 0.80; R2 0.63; 95% confidence interval, 0.61-0.96; P < .001). The correlation was stronger when RHC was indicated for evaluation of heart failure (r 0.88; P < .001) compared with other indications (r 0.69; P < .001). An estimated RAP of 3, 8, and 15 mmHg by ultrasound had a sensitivity and specificity of predicting an invasive RAP of 0-5, 6-10, and > 10 mmHg of 88% and 76%, 56% and 88%, and 81% and 97%, respectively, with overall accuracy of 80%, 76%, and 92%, respectively. Estimated RAP also correlated with invasive pulmonary capillary wedge pressure (r 0.64; R2 0.41; 95% confidence interval, 0.26-0.54; P < .001). CONCLUSIONS: Handheld ultrasonography is a useful tool that can accurately estimate RAP at the bedside.

A Multi-Center Retrospective Analysis Examining the Effect of Dipeptidyl Peptidase-4 Inhibitors on Progression-Free Survival in Patients With Prostate Cancer.

Background Cluster of differentiation 26/dipeptidyl peptidase-4 (DPP4) is a cell surface glycoprotein with multifaceted roles, including immune regulation, glucose metabolism, and tumorigenesis. Recent literature has identified DPP4 inhibitors to improve survival in diabetic patients with prostate cancer. DPP4 inhibitors have been proposed to play a role in prostate cancer, as DPP4 is found at higher levels in malignant prostate tissue compared to benign and correlates with PSA levels and cancer stage. In this multi-center retrospective study, we aim to define the effects of DPP4 inhibitors on progression-free survival (PFS) in diabetic patients with advanced-stage prostate cancer. Methodology We performed a retrospective analysis of 161 patients with diabetes and advanced-stage (III or IV) prostate cancer at the University of Florida Health Cancer Center and Moffitt Cancer Center. Our cohort included 120 patients on metformin (control group) and 41 on a DPP4 inhibitor (study group). Results No significant difference in progression of prostate cancer was identified between those on DPP4 inhibitors versus metformin (hazard ratio [HR]: 1.01; 95% confidence interval [CI]: 0.64-1.61; p = 0.955). Median time to progression was 3.5 years (range: 2.4-4.6 years). Conclusions Despite prior literature indicating survival benefit of DPP4 inhibitors in prostate cancer, our study did not identify a statistically significant improvement of PFS in diabetic patients with advanced prostate cancer. Additional analysis with larger sample sizes and prospective investigation with study of tumor microenvironment are needed to evaluate clinical impact and potential survival benefit of DPP4 inhibitors in prostate cancer.

Contemporary Revascularization Strategies and Outcomes Among Patients With Diabetes With Critical Limb Ischemia: Insights From the National Inpatient Sample.

OBJECTIVES: The purpose of this study was to evaluate temporal trends in the frequency of revascularization and associated outcomes in patients with diabetes mellitus and critical limb ischemia (CLI). BACKGROUND: Little is known about outcomes following revascularization for CLI in patients with diabetes mellitus. METHODS: Temporal trends in hospitalization for CLI among patients with diabetes were determined using the 2002-2015 National Inpatient Sample database. Propensity score matching was used to compare patients who underwent revascularization with those who did not and, separately, to compare those who underwent endovascular versus surgical revascularization. The main study outcome was in-hospital mortality. RESULTS: The analysis included 1,222,324 hospitalizations. The number of hospitalizations for CLI among patients with diabetes increased over time (ptrend < 0.001). There was an increase in the use of lower extremity revascularization, paralleled by a decline in in-hospital mortality during the study period. In the matched cohort, patients who were revascularized had lower in-hospital mortality (odds ratio [OR]: 0.68; 95% confidence interval [CI]: 0.63 to 0.72) and major amputation (OR: 0.25; 95% CI: 0.24 to 0.27) compared with those who were treated medically. Compared with endovascular revascularization, those who underwent surgical revascularization had higher rates of in-hospital mortality (OR: 1.18; 95% CI: 1.04 to 1.35) but lower rates of major amputation (OR: 0.75; 95% CI: 0.70 to 0.81). Major bleeding, blood transfusion, post-operative infection, respiratory complications, discharges to nursing facility, and longer length of hospital stay were also more common among those who underwent surgery. CONCLUSIONS: In this national analysis of patients with DM and CLI, we demonstrated an increase in hospitalization for CLI among patients with diabetes in the United States. Although in-hospital mortality decreased over time regardless of the treatment strategy used, this outcome occurred less frequently among those who underwent revascularization than not. Compared with surgical revascularization, endovascular revascularization was associated with lower in-hospital mortality but higher rates of major amputation.

Outcomes of transcatheter versus surgical aortic valve replacement among solid organ transplant recipients.

BACKGROUND: There is a paucity of data regarding the outcomes of transcatheter aortic valve replacement (TAVR) versus surgical aortic valve replacement (SAVR) among solid-organ transplant recipients. METHODS: Temporal trends in hospitalizations for aortic valve replacement among solid-organ transplant recipients were determined using the National Inpatient Sample database years 2012-2017. Propensity matching was conducted to compare admissions who underwent TAVR versus SAVR. The primary outcome was in-hospital mortality. RESULTS: The analysis included 1,730 hospitalizations for isolated AVR; 920 (53.2%) underwent TAVR and 810 (46.7%) underwent SAVR. TAVR was increasingly utilized for solid-organ transplant recipients (Ptrend = 0.01), while there was no change in the number of SAVR procedures (Ptrend = 0.20). The predictors of undergoing TAVR for solid-organ transplant recipients included older age, diabetes, and prior coronary artery bypass surgery, while TAVR was less likely utilized in small-sized hospitals. TAVR was associated with lower in-hospital mortality after matching (0.9 vs. 4.7%, odds ratio [OR] 0.19; 95% confidence interval [CI] 0.11-0.35, p < .001) and after multivariable adjustment (OR 0.07; 95% CI 0.03-0.21, p < .001). TAVR was associated with lower rate of acute kidney injury, acute stroke, postoperative bleeding, blood transfusion, vascular complications, discharge to nursing facilities, and shorter median length of hospital stay. There was no difference between both groups in the use of mechanical circulatory support, hemodialysis, arrhythmias, or pacemaker insertion. CONCLUSION: This contemporary observational nationwide analysis showed that TAVR is increasingly performed among solid-organ transplant recipients. Compared with SAVR, TAVR was associated with lower in-hospital mortality, complications, and shorter length of stay.

Circulating fibrocyte levels correlate with infarct size in patients with ST elevation myocardial infarction treated with primary percutaneous coronary intervention.

STUDY OBJECTIVE: Infarct size is a strong predictor of outcomes after ST elevation myocardial infarction (STEMI). Circulating fibrocytes are bone marrow-derived progenitor cells associated with fibrotic processes. We tested whether fibrocytes correlate with infarct size in STEMI patients treated with primary percutaneous coronary intervention (PCI). DESIGN: Prospective observational study. SETTING: Academic medical center. PARTICIPANTS: Subjects with STEMI treated with primary PCI. INTERVENTIONS: Peripheral blood draw and cardiac magnetic resonance imaging (CMR). MAIN OUTCOME MEASURE: Correlation of fibrocyte levels with infarct size. METHODS: Peripheral blood fibrocytes were quantified at discharge from STEMI hospitalization and at 6 months follow-up using flow cytometry. Infarct size was determined within 2 weeks of discharge and at 6 months follow-up using late gadolinium enhancement on CMR. RESULTS: Among 14 patients (median age 54 years, 79% men) with STEMI, there was a statistically significant positive correlation between fibrocyte levels at 6 months and 6-month infarct size on CMR (r = 0.58, p = 0.031). In addition, there was positive correlation between peak troponin I level (r = 0.85, p < 0.001), and white blood cell count (r = 0.55, p = 0.042) during the hospital stay and 6-month infarct size on CMR. CONCLUSIONS: Circulating fibrocytes measured 6 months after STEMI positively correlate with 6-month infarct size assessed by CMR.

Hemodynamic effects of ivabradine use in combination with intravenous inotropic therapy in advanced heart failure.

Intravenous inotropic therapy can be used in patients with advanced heart failure, as palliative therapy or as a bridge to cardiac transplantation or mechanical circulatory support, as well as in cardiogenic shock. Their use is limited to increasing cardiac output in low cardiac output states and reducing ventricular filling pressures to alleviate patient symptoms and improve functional class. Many advanced heart failure patients have sinus tachycardia as a compensatory mechanism to maintain cardiac output. However, excessive sinus tachycardia caused by intravenous inotropes can increase myocardial oxygen consumption, decrease coronary perfusion, and at extreme heart rates decrease ventricular filling and stroke volume. The limited available hemodynamic studies support the hypothesis that adding ivabradine, a rate control agent without negative inotropic effect, may blunt inotrope-induced tachycardia and its associated deleterious effects, while optimizing cardiac output by increasing stroke volume. This review analyzes the intriguing pathophysiology of combined intravenous inotropes and ivabradine to optimize the hemodynamic profile of patients in advanced heart failure. Graphical abstract Illustration of the beneficial and deleterious hemodynamic effects of intravenous inotropes in advanced heart failure, and the positive effects of adding ivabradine.

Temporal trends and outcomes of critical limb ischemia among patients with chronic kidney disease.

There is a paucity of data on the outcomes and revascularization strategies for critical limb ischemia (CLI) among patients with chronic kidney disease (CKD). Hence, we conducted a nationwide analysis to evaluate the trends and outcomes of hospitalizations for CLI with CKD. The National Inpatient Sample database (2002-2015) was queried for hospitalizations for CLI. The trends of hospitalizations for CLI with CKD were reported, and endovascular versus surgical revascularization strategies for CLI with CKD were compared. The main study outcome was in-hospital mortality. The analysis included 2,139,640 hospitalizations for CLI, of which 484,224 (22.6%) had CKD. There was an increase in hospitalizations for CLI with CKD (Ptrend = 0.01), but a reduction in hospitalizations for CLI without CKD (Ptrend = 0.01). Patients with CLI and CKD were less likely to undergo revascularization compared with patients without CKD. CLI with CKD had higher rates of in-hospital mortality (4.8% vs 2.5%, adjusted odds ratio (OR) 2.01; 95% CI 1.93-2.11) and major amputation compared with no CKD. Revascularization for CLI with CKD was associated with lower rates of mortality (3.7% vs 5.3%, adjusted-OR 0.78; 95% CI 0.72-0.84) and major amputation compared with no revascularization. Compared with endovascular revascularization, surgical revascularization for CLI with CKD was associated with higher rates of in-hospital mortality (4.7% vs 2.7%, adjusted-OR 1.67; 95% CI 1.43-1.94). In conclusion, this contemporary observational analysis showed an increase in hospitalizations for CLI among patients with CKD. CLI with CKD was associated with higher in-hospital mortality compared with no CKD. Compared with endovascular therapy, surgical revascularization for CLI with CKD was associated with higher in-hospital mortality.