Early readmissions after transcatheter and surgical aortic valve replacement.

OBJECTIVES: We aimed to determine and compare the prevalence, and predictors of readmissions after the transcatheter aortic valve replacement (TAVR) and surgical aortic valve replacement (SAVR). BACKGROUND: There are limited data on the readmission rates after TAVR in comparison with SAVR. METHODS: We analyzed the data from 2013 National Readmission Database. Propensity-matched pairs were used to analyze differences in readmission rates between TAVR and SAVR for patients aged ≥65. RESULTS: A total of 24,020 (TAVR-transfemoral 3,469, TAVR-transapical 1,433, SAVR 19,118) patients were included. The readmission rates were not statistically different for all propensity-matched TAVR and SAVR patients (17.2% vs. 20.6%, P = 0.28). However, in subgroup analysis, transapical TAVR had the highest readmission rate (22.8% vs. 16.5% vs. 16.0%, P < 0.001, respectively) and readmission leading to death (7.1% vs. 5.3% vs. 3.9%, P = 0.022, respectively) when compared with transfemoral TAVR and SAVR. In all the groups, two-thirds of readmissions were due to noncardiac causes. Congestive heart failure (CHF) and arrhythmia were the most frequent cardiac etiologies. The independent predictors of readmission were female sex, CHF, and chronic obstructive pulmonary disease. Patients who received care in teaching hospitals had lower probability of readmission. CONCLUSIONS: One of six patients were readmitted within 30 days after the aortic valve replacement. On propensity score analysis, there were no significant differences between the early readmission rates between TAVR and SAVR groups. However, the patients undergoing transapical TAVR were at higher risk for readmission, and subsequent deaths when compared with transfemoral TAVR and SAVR. © 2017 Wiley Periodicals, Inc.

Comparison of 30-day mortality and myocardial scar indices for patients treated with prehospital reduced dose fibrinolytic followed by percutaneous coronary intervention versus percutaneous coronary intervention alone for treatment of ST-elevation myocardial infarction.

OBJECTIVES: We investigated whether prehospital, reduced dose fibrinolysis coupled with urgent percutaneous coronary intervention (FAST-PCI) reduces mortality and cardiac magnetic resonance (CMR) measures of infarct size, compared with primary percutaneous coronary intervention (PPCI), in patients with ST-elevation myocardial infarction (STEMI). BACKGROUND: Current standard therapy for STEMI is PPCI. However, FAST-PCI may shorten ischemic time (IT) and improve outcomes. METHODS: Eligible STEMI patients received prehospital, reduced dose fibrinolysis along with standard therapy, and were transported for urgent percutaneous coronary intervention, or else they received usual treatment without prehospital fibrinolysis. Patients were divided retrospectively into four groups based on IT (<120, 120-179, 180-239 min, ≥240) for a mortality analysis cohort, and into three groups (<120, 120-179, ≥180 min) for a CMR analysis cohort. Within each IT group, patients were compared by FAST-PCI vs. PPCI strategy. RESULTS: Between 1/2007 and 2/2014, 1,112 STEMI patients were treated. FAST-PCI was employed in 551 and PPCI in 561. Of these, 357 (32.1%) underwent CMR. The treatment groups were well matched. In STEMI patients with short IT (<120 and 120-179 min groups), those treated by FAST-PCI had lower 30-day mortality and myocardial scar sizes compared with PPCI treatment. For IT ≥180 min, the mortalities and myocardial scar sizes were equivalent for both groups. CONCLUSIONS: In STEMI patients with IT <180 min, FAST-PCI may reduce 30-day mortality and myocardial scar size compared with PPCI. This suggests that infarct interventions must be instituted within 3 hr of symptom onset in order to detect an optimal beneficial effect both clinically and by CMR measurement. © 2016 Wiley Periodicals, Inc.

Ischemic time is a better predictor than door-to-balloon time for mortality and infarct size in ST-elevation myocardial infarction.

BACKGROUND: Current guidelines for ST-elevation myocardial infarction (STEMI) recommend early revascularization with optimal ischemic time (IT) < 120 min and door-to-balloon (D2B) time < 90 min. The focus of most studies has been D2B time, while IT is not frequently reported. We tested the hypothesis that total IT is a better predictor than D2B time for mortality and infarct size. METHODS AND RESULTS: Between December 2008 and April 2013, 786 patients with STEMI were treated in our STEMI center, and 262 of these had cardiac magnetic resonance imaging 3-5 days after the index event. Total IT was defined as time from symptom onset to device activation, while D2B time was defined as hospital arrival to device activation. Patients were divided into three groups according to IT (<120, 120-239, ≥240 min) and into four groups according to D2B time (<30, 30-59, 60-89, ≥90 min). Baseline demographics including age, cardiac risk factors, and LAD infarct location were similar between groups. The 30-day mortality rate significantly increased across IT groups but did not correlate with D2B time groups. Similarly, infarct size significantly increased across IT groups but did not correlate with D2B time groups. CONCLUSIONS: In STEMI patients, IT was a better predictor than D2B time for 30-day mortality and infarct size. Our findings suggest that the focus of STEMI care should be directed at early initiation of therapy and minimizing IT rather than on D2B time alone. The potential impact of IT reporting in current STEMI registries merits further consideration. © 2015 Wiley Periodicals, Inc.