Postoperative outcomes, predictors and trends of mortality and morbidity in patients undergoing hip fracture surgery with underlying aortic stenosis: a nationwide inpatient sample analysis.

BACKGROUND: Hip fractures frequently necessitate hospitalization, especially among patients aged 75 and above who might concurrently suffer from aortic stenosis (AS). This study focuses on postoperative outcomes, potential determinants of morbidity and mortality, as well as evolving trends in patients with AS undergoing surgical repair of hip fractures. METHODS: A retrospective analysis of the Nationwide Inpatient Sample from 2008 to 2019 was conducted. Hip fracture cases were identified, and a subgroup with AS was isolated using the ICD-9 and ICD-10 diagnostic codes. We compared baseline characteristics, postoperative in-hospital outcomes and trends in mortality and morbidity between patients with and without AS. RESULTS: From the dataset, 2,834,919 patients with hip fracture were identified on weighted analysis. Of these, 94,270 (3.3%) were found to have concurrent AS. The AS cohort was characterized by higher mean age and elevated burden of cardiovascular comorbidities, such as coronary artery disease, peripheral vascular disease, pulmonary hypertension, congestive heart failure and cardiac arrhythmias. Postoperative mortality following hip fracture surgery was greater in the AS groups compared to non-AS group (3.3% vs 1.57%, p < 0.001). Risk factors such as congestive heart failure (OR, 2.3[CI, 2.1-2.6]), age above 85 years (OR, 3.2[CI, 2.2-4.7]), cardiac arrhythmias (OR, 2.4[CI, 2.2-2.6]), end-stage renal disease (OR, 3.4[CI, 2.7-4.1]), malnutrition (OR, 2.3[CI, 2.1-2.7]) and AS (OR, 1.2[CI, 1.08-1.5] were associated with increased adjusted odds of postoperative mortality. AS was linked to higher adjusted odds of postoperative mortality (OR, 1.2 [CI, 1.1-1.5]) and complications such as acute myocardial infarction (OR, 1.2 [CI, 1.01-1.4]), cardiogenic shock (OR, 2.0[CI, 1.4-2.9]) and acute renal failure (OR, 1.1[CI, 1.02-1.2]). While hospital stay duration was comparable in both groups (average 5 days), the AS group incurred higher costs (mean $50,673 vs $44,607). The presence of acute heart failure in patients with AS and hip fracture significantly increased mortality, hospital stay, and cost. A notable decline in postoperative in-hospital mortality was observed in both groups from 2008-2019 though the rate of major in-hospital complications rose. CONCLUSION: AS significantly influences postoperative in-hospital mortality and complication rates in hip fracture patients. While a reduction in postoperative mortality was observed in both AS and non-AS cohorts, the incidence of major in-hospital complications increased across both groups.

Pulmonary tumor thrombotic microangiopathy associated with right ventricular rupture and hemopericardium: A case report.

Pulmonary tumor thrombotic microangiopathy is a rare form of pulmonary tumor embolism clinically indistinguishable from pulmonary thromboembolic disease. It is characterized by fibrocellular intimal proliferation of small pulmonary arteries and arterioles in patients with intraluminal tumor embolization. We report the case of a 67-year-old Caucasian woman who had been treated for breast cancer 5 years prior to presentation and had been free of recurrence on routine clinical surveillance. She was admitted for evaluation of three witnessed syncopal events accompanied by tachypnea and hypotension. Transthoracic echocardiography revealed severe right ventricular dilatation and severely reduced right ventricular function. Shortly after admission, the patient became acutely unresponsive and expired despite aggressive resuscitation measures. The proximate cause of death was a rupture of the right ventricular free wall and a large hemopericardium. Histopathology revealed extensive microscopic occlusions of small pulmonary arteries and arterioles by metastatic breast carcinoma with superimposed acute thrombi. Pulmonary tumor thrombotic microangiopathy should be included in the differential diagnosis of patients presenting with symptoms of pulmonary thromboembolism and a history of malignancy. .

Successful treatment of early thrombosis of HeartWare left ventricular assist device with intraventricular thrombolytics.

In the last few years, left ventricular assist devices (LVADs) have moved to the forefront in the management of patients with advanced heart failure. Pumps have gradually become smaller and more efficient and have clearly demonstrated survival benefits and improvement in functional status and quality of life in patients with advanced heart failure. Despite impressive advances in device technology, risk of severe complications remains, such as device thrombosis. A 62-year-old man who underwent HeartWare LVAD implantation as a bridge to cardiac transplant was admitted 18 days after device implantation with severe shortness of breath, fatigue and lethargy; he was found to have increased pump flows with high power demands and evidence of cardiogenic shock. An echocardiogram showed an echo density at the inflow cannula that was suggestive of thrombosis. Laboratory data showed evidence of hemolysis. He was treated successfully with intraventricular tissue plasminogen activator with rapid resolution of his symptoms and return of LVAD flow and power consumption to baseline. The patient was discharged with no complications or recurrence of thrombosis and received a successful transplant 1 month later.

Contemporary management and research directions in advanced heart failure: where are we going?

Advanced heart failure (AHF) is not a uniform disorder, but is rather a heterogeneous group of patients with varying clinical presentations and definitions. It is growing in magnitude and represents a major public health problem. Herein we describe contemporary care of the patient with AHF, novel medical therapies, and mechanical circulatory assist devices. We speculate where progress has been made and where the major gaps in knowledge remain. Clearly, there is ample opportunity for research and discovery to further advance the care of these very sick patients.

Erosion of an Amplatzer septal occluder device into the aortic root.

Atrial septal defects can be closed surgically or percutaneously. We report a patient who underwent percutaneous closure of an atrial septal defect with an Amplatzer septal occluder device (AGA Medical Corp, Golden Valley, MN). The patient presented 4 months later with congestive heart failure secondary to an erosion of the Amplatzer septal occluder into the aortic root. The device was removed surgically, and the fistula was repaired. Amplatzer septal occluder indications, selection criteria, and complications are discussed.