The association of pre-transplant atrial fibrillation with in-hospital outcomes in patients undergoing orthotopic liver transplantation: A propensity score matching analysis.

INTRODUCTION: In this study, we sought to evaluate the prevalence and association of pre-transplant atrial fibrillation (AF) on 30-day postoperative outcomes in patients undergoing orthotopic liver transplant (OLT). METHOD: The National Inpatient Sample Database was queried from 2011 to 2017 for relevant ICD-9 and ICD-10 procedural and diagnostic codes. Baseline characteristics and in-hospital outcomes were compared in patients who underwent OLT with AF and those without. RESULTS: Among 45,357 patients who underwent OLT, women made up 35.8% of the overall population. The prevalence of AF before transplant was 2932 (6.5%) with a trend toward increasing prevalence, with an average annual change rate of 4.19%. Applying propensity score matching to control for potential confounding factors, there was no association between pre-transplant AF and in-hospital mortality in patients undergoing OLT, however there was a higher incidence of perioperative complications including: acute kidney injury, ventricular tachycardia, major bleeding, blood product transfusion, and septic shock. CONCLUSION: In patients undergoing OLT, pre-transplant AF is increasing in prevalence and appears to be associated with similar in-hospital mortality but worse perioperative outcomes. Greater emphasis should be placed on AF in the preoperative cardiovascular risk stratification of patients undergoing OLT.

Evaluating the impact of chronic obstructive pulmonary disease on in-hospital outcomes following left ventricular assist device implantation.

BACKGROUND: Chronic obstructive pulmonary disease (COPD) is a cause of ventricular dysfunction. However, in the setting of patients with heart failure undergoing left ventricular assist device (LVAD) implantation, there is a paucity of data on the association between COPD and in-hospital outcomes. METHODS AND RESULTS: Retrospective cohort study based on the NIS including patients ≥18 years who underwent LVAD implantation from 2011 to 2017. Multivariate regression was used to evaluate the impact of COPD on in-hospital outcomes. A total of 25,503 patients underwent LVAD implantation, of which 13.8% also had COPD. COPD group was older (median 62 vs. 58 years), and more males (82% vs. 76.4%, p < .001 for both). COPD group had more hypertension, diabetes, atrial tachyarrhythmias, dyslipidemia, prior stroke, coronary artery diseases, pulmonary hypertension, and chronic kidney disease (p < .001 for all). No differences in strokes, infections, mechanical circulatory support, and LVAD thrombosis. There was a higher incident of inpatient acute kidney injury, major bleeding, cardiac complications, thromboembolism, and cardiac arrest in patients without COPD (p < .05 for all). Compared with no-COPD group, COPD group had a lower mortality (6.2% vs. 12.4%; odds ratio, 0.59; confidence interval, 0.512-0.685; p < .05). CONCLUSION: Patients with COPD undergoing LVAD implantation have more comorbidities, without an associated increase mortality.

National trends and outcomes for extra-corporeal membrane oxygenation use in high-risk pulmonary embolism.

Little is known about the temporal trends and outcomes for extra-corporeal membrane oxygenation (ECMO) in patients with high-risk pulmonary embolism (PE) in the United States. We queried the National Inpatient Sample (NIS) database from 2005 to 2013 to identify patients admitted with high-risk PE. Our objective was to determine trends for ECMO use in patients with high-risk PE. We also assessed in-hospital outcomes among patients with high-risk PE receiving ECMO. We evaluated 77,809 hospitalizations for high-risk PE. There was an upward trend in the utilization of ECMO from 0.07% in 2005 to 1.1% in 2013 ( p = 0.015). ECMO was utilized more in urban teaching hospitals and large hospitals. ECMO use was associated with lower mortality in patients with massive PE ( p < 0.001). In-hospital mortality for patients receiving ECMO was 61.6%, with no change over the observational period ( p = 0.68). Our investigation revealed several independent predictors of increased mortality in patients with high-risk PE using ECMO as hemodynamic support, including: age, female sex, obesity, congestive heart failure, and chronic pulmonary disease. ECMO, therefore, as a rescue strategy or bridge to definitive treatment, may be effective in the management of high-risk PE when selecting patients with favorable clinical characteristics.

Outcomes of Heart Block in Myocarditis: A Review of 31,760 Patients.

BACKGROUND: Various electrocardiographic abnormalities, including atrioventricular conduction block, have been reported in patients with myocarditis. We performed an observation study to describe the characteristics and outcomes of inpatients diagnosed with myocarditis complicated by heart block (HB) in a large national cohort. METHODS: We identified patients with primary ICD-9 codes for myocarditis HB from the Nationwide Inpatient Sample (NIS) Database from 1998 to 2013. We compared the baseline characteristics and compared clinical outcomes between patients with and without HB, and in patients with/without high degree atrioventricular block (HDAVB). RESULTS: From the NIS database, 31,760 patients had a principal diagnosis of myocarditis and HB was reported in 1.7% of these patients (n=540). Female gender and Asian race were independently associated with HB. Out of 540 patients, 363 patients had HDAVB (67.2%) and 177 patients had not advanced HB (32.8%). Not advanced HB was not associated with an increased mortality rate compared to patients without HB (0% vs. 2.7%, p=0.315). On the other hand, the incidence of cardiogenic shock, respiratory failure and renal failure were higher in patients with HDAVB (26.2% vs. 5.0%, 33.9% vs. 5.9% and 29.2% vs. 5.5%, p<0.001 respectively). Patients with HDAVB required more procedural support (incidence of intra-aortic balloon pump 17.8% vs. 3.3%). They also had significantly longer lengths of hospital stay (9.4±9.4 vs. 4.3±8.4, p<0.001) and higher mortality (15.5% vs. 2.7%, p<0.001). Compared to myocarditis patients without HB, the odds for mortality in myocarditis patients with HDAVB 1.58 (95% CI=1.03-2.49, p=0.039). CONCLUSIONS: The incidence of HB and HDAVB among patients with acute myocarditis was 1.7% and 1.1% respectively. Female gender and Asian race were both independently associated with significant odds for the occurrence of HB and HDAVB. High degree atrioventricular block was independently associated with increased morbidity and mortality.

National Trends and Outcomes of Endomyocardial Biopsy for Patients With Myocarditis: From the National Inpatient Sample Database.

BACKGROUND: The utility of endomyocardial biopsy (EMB) in the management of myocarditis in the era of advanced cardiac imaging has been challenged. METHODS AND RESULTS: The Nationwide Inpatient Sample Database (years 1998-2013) was queried to identify hospitalization records with a primary diagnosis of myocarditis, and underwent EMB procedure. We identified 22,299 hospitalization records with a diagnosis of myocarditis during the study period. Of those, 798 (3.6%) underwent EMB procedures. There was an average decrease in the incidence of EMB for myocarditis by 0.15% (P < .01) over the study period. Younger patients, women, and those with chronic kidney disease were more likely to undergo EMB. On multivariate analysis, patients with myocarditis who underwent EMB had higher in-hospital mortality (hazard ratio [HR] 1.97, 95% confidence interval [CI] 1.41-2.74) and longer median hospital stay (9 days vs 3 days; P < .001). EMB was associated with a higher incidence of cardiac tamponade (odds ratio [OR] 5.21, 95% CI 2.76-9.82), cardiogenic shock (OR 4.66, 95% CI 3.75-5.78), need for intra-aortic balloon pump (OR 3.52, 95% CI 2.49-4.97), and need for extracorporeal membrane oxygenation (OR 4.26, 95% CI 2.78-6.53). CONCLUSIONS: The use of EMB in hospitalizations with myocarditis has decreased over time. The use of EMB was associated with a higher likelihood of in-hospital mortality and morbidity. Whether these findings represent a causative association from the procedure or a consequence of more severe disease in this group could not be confirmed in this study.

Open and Endovascular Abdominal Aortic Injury Repair Outcomes in Polytrauma Patients.

INTRODUCTION: The management of patients with abdominal aortic injury (AAI) remains challenging. Open repair of AAI is still the standard of care although it is associated with high mortality. In past few years, endovascular surgery has evolved as a less invasive alternative to open surgery in emergency settings. The objective of this study was to compare outcomes after open repair versus endovascular repair of AAI in polytrauma patients. METHODS: The National Trauma Data Bank, from 2008 to 2012, was queried to identify trauma patients undergoing open and endovascular repair of AAI using International Classification of Diseases, ninth Edition, and Clinical Modification codes. Data reviewed included demographics, type of associated injury, type of operative management, and complications. Factors independently associated with mortality were evaluated using multivariate logistic regression model. RESULTS: Of 325 injured patients with AAI, 91 patients underwent endovascular repair and 234 patients underwent open repair. Of these, 80.6% were male, with a mean age of 35.70 years, and a mean injury severity score (ISS) was 30.59 for patients undergoing open repair and 31.56 for endovascular repair. Associated traumatic injuries included bowel injuries 57.5%, liver-pancreas injuries 36.6%, splenic injuries 14.8%, renal injuries 15.7%, and retroperitoneal injuries 19.1%. In-patient mortality for patients undergoing the open repair cohort was 63.7% and 20.9% for patients in the endovascular cohort (P < 0.001). The endovascular repair cohort patients had a higher incidence of pneumonia 17.6% as compared to open repair cohort 5.1% (P < 0.001). Similarly, patients in the endovascular repair cohort also had a higher abdominal compartment syndrome (4.4% vs. 0.4% in the open repair cohort, P = 0.009), postoperative acute kidney injury (9.9% endovascular repair cohort vs. 6.4% in the open repair cohort, P = 0.281), and acute mesenteric ischemia (1.1%). After controlling for associated injuries, acidosis, blood pressure at presentation, age, and ISS, patients in the open repair cohort had 6.58 times higher odds (confidence interval: 3.25-13.33; P < 0.001) of mortality as compared to the endovascular repair cohort. CONCLUSIONS: Endovascular repair of abdominal aorta in polytrauma patients seems to be feasible and may improve survivorship in appropriately selected patients. More research is needed to understand to identify indications for endovascular repair versus open repair.

Comparison of In-Hospital Outcomes and Readmission Rates of Transcatheter Aortic Valve Implantation in Mixed Aortic Valve Disease Versus Pure Aortic Stenosis.

Recently, transcatheter aortic valve implantation (TAVI) has been performed in patients with combined aortic stenosis (AS) and aortic regurgitation. We sought to evaluate in-hospital outcomes and readmission rates after TAVI in patients with mixed aortic valve disease (MAVD). A total of 100,573 TAVI procedures were identified between 2011 and 2017 using International Classification of Diseases, Ninth Revision and International Classification of Diseases, Tenth Revision procedure codes the from Nationwide Readmissions Database. We separated patients into 2 cohorts, those with MAVD and those with pure AS. The primary outcome was all-cause inpatient mortality after TAVI, and secondary outcomes included rates of 30- and 90-day readmissions and postprocedural complications. A total of 3,260 patients had MAVD (median age 83 years, 43.5% women). In-hospital mortality (2.5% vs 2.6%, p = 0.531) and rates of paravalvular leak (1.0% vs 1.3%, p = 0.056) were similar between the MAVD and pure AS groups. Major bleeding (7.4% vs 9.6%, p <0.001), 30-day readmission (0.5% vs 8.8%, p <0.001) and 90-day readmission rates (0.8% vs 16.0%, p <0.001), acute kidney injury (12.9% vs 15.1%, p <0.001), postoperative ischemic stroke (2.0% vs 5.7%, p <0.001), and mechanic circulatory support use (1.9% vs 4.5%, p <0.001) were less prevalent in the MAVD cohort. Using a multivariate logistic regression model to adjust for confounding factors, MAVD was not predictive of mortality in patients who underwent TAVI (adjusted odds ratio [adjOR] 1.25, 95% confidence interval [CI] 0.99 to 1.57, p = 0.056); however, MAVD was associated with: decreased odds of 30-day readmission (adjOR 0.05, 95% CI 0.03 to 0.08, p <0.001), 90-day readmission rates (adjOR 0.04, 95% CI 0.03 to 0.06, p <0.001), and higher odds of pacemaker implantation (adjOR 1.46, 95% CI 1.29 to 1.65, p <0.001). In conclusion, despite differences in the aortic valve and left ventricular anatomy (pressure vs volume-related adaptive changes) in patients with MAVD and pure AS, TAVI appears safe and feasible. However, patients with MAVD were more likely to have permanent pacemakers implanted. The results of our study warrant further randomized controlled studies to confirm these findings.

Early trends in leadless pacemaker implantation: Evaluating nationwide in-hospital outcomes.

BACKGROUND: Single-chamber leadless intracardiac pacemaker (LICP) implantation was approved in 2016 in the United States. However, little is known regarding trends in real-world utilization and complication rates. OBJECTIVE: The purpose of this study was to assess nationwide demographics, trends, and outcomes among hospitalizations with LICP implantation in the United States. METHODS: Using the National Inpatient Sample, we identified all hospitalizations with LICP or transvenous pacemaker implantation as a comparator between 2017 and 2019. We evaluated baseline patient characteristics, admitting diagnoses, procedural complications, lengths of stay, discharge dispositions, and all-cause mortality. RESULTS: The majority of LICP recipients were elderly (75.4 ± 12.8 years), male (55.2%), and White (76.8%) compared to Black (9.8%), or Hispanic (7.3%). Between 2017 and 2019, the average age increased along with the prevalence of heart failure, atrial fibrillation, and malignancy among recipients. Most hospitalizations were emergent (84.5%). Between 2017 and 2019, pooled procedural complications decreased significantly (10.8% vs 7.9%; P <.001), primarily due to declining infection and device retrieval rates. In-hospital mortality also decreased significantly (8.2% vs 4.2%; P <.001). History of cardiogenic shock or cardiac device infection was associated with the greatest mortality or complication risk. Compared to transvenous pacemaker, LICP implantation was associated with lower complication rates (8.6% vs 11.2%) but greater mortality (5.2% vs 1.3%; P <.001). CONCLUSION: Nationwide LICP implantations were performed in patients of increasing age, comorbidities, and acuity of illness. In-hospital mortality and procedure-related complications declined in the first 3 years after approval of LICP implantation and may reflect improving operator experience. Increased mortality compared with transvenous pacemaker implant remains a concern.

Comparison of in-hospital outcomes of patients undergoing catheter ablation for typical versus atypical atrial flutter.

BACKGROUND: Catheter ablation (CA) is indicated as definitive therapy for patients with either typical or atypical atrial flutter (TAFlutter and AAFlutter, respectively) which is unresponsive to medical therapy. There is a paucity of data regarding in-hospital outcomes of patients undergoing CA. METHODS: Retrospective study using the NIS to identify patients ≥18 years who underwent CA between 2015 and 2017. Individuals were identified using ICD-10-CM/PCS for TAFlutter, AAFlutter, and CA. RESULTS: A total of 17,390 patients underwent CA for Aflutter (33% AAFlutter and 67% TAFlutter). The TAFlutter group was younger (mean 65.9 years vs. 67.2 years), with less females (30% vs. 43%, p ≤ 0.001 for both) compared to the AAFlutter group. The TAFlutter group had a higher rate of diabetes, tobacco use, obesity, and chronic obstructive pulmonary disease (p ≤ 0.001 for all). The AAFlutter cohort had increased prior strokes and atrial fibrillation (p ≤ 0.001 for both). The mean CHA2DS2-VASc score was found to be 2.3 in AAFlutter compared to 2.1 in TAFlutter (p ≤ 0.001). There were significantly higher proportions of thromboembolic events, transfusions, and longer length of stay in the TAFlutter group (p ≤ 0.001 for all) with the AAFlutter group having significantly higher rates of cardioversion, implantation of cardiac devices, and increased hospital charges (p ≤ 0.001 for all); no significant difference was found in mortality after controlling for comorbidities. CONCLUSIONS: We found higher complication rates in CA for patients with TAFlutter, but no difference in in-hospital all-cause mortality. Variation in CA depending upon the mechanism of AFlutter may underlie these differences, and warrant further study.

Effect of Gender on Prognosis in Patients With Takotsubo Syndrome (from a Nationwide Perspective).

Takotsubo syndrome (TTS) largely affects postmenopausal women but has been shown to carry increased mortality risk in men. We sought to evaluate nationwide in-hospital outcomes between men and women admitted with TTS to better characterize these disparities. Using the National Inpatient Sample database from 2011 to 2018, we identified a total of 48,300 hospitalizations with the primary diagnosis of TTS. The primary end point was in-hospital all-cause mortality. Secondary end points included in-hospital complications, length of stay, and discharge disposition. Men with TTS accounted for 8.9% of hospitalizations, were younger in age (62.0 ± 15.1 vs 66.8 ± 12.1 years, p <0.001), and were more frequently Black (9.7% vs 5.8%, p <0.001). Nationwide TTS mortality rates were 1.1% overall and may be improving, but remained higher in men than in women (2.2% vs 1.0%, p <0.001). Male gender was associated with increased all-cause mortality (adjusted odds ratios 2.41, 95% confidence interval 1.88 to 3.10, p <0.001), greater length of stay, and discharge complexity. Men carried increased co-morbidity burden associated with increased cardiogenic shock or mortality, including atrial fibrillation, thrombocytopenia, chronic kidney disease, and chronic obstructive pulmonary disease. Men more frequently developed acute kidney injury, ventricular arrhythmias, cardiac arrest, and respiratory failure. Male gender remains associated with nearly 2.5-fold increase in in-hospital mortality risk. In conclusion, early identification of patients with high-risk co-morbidities and close monitoring for arrhythmias, renal injury, or cardiogenic shock may reduce morbidity and mortality.

Comparison of household income in in-hospital outcomes after implantation of left ventricular assist device.

INTRODUCTION: Due to the inability to keep up with the demand for heart transplantation, there is an increased utilization of left ventricular assist devices (LVAD). However, paucity of data exists regarding the association of household income with in-hospital outcomes after LVAD implantation. METHODS: Retrospective cohort study using the NIS to identify all patients ⩾18 years who underwent LVAD implantation from 2011 to 2017. Statistical analysis was performed comparing low household income (⩽50th percentile) and high income (>50th percentile). RESULTS: A total of 25,503 patients underwent LVAD implantation. The low-income group represented 53% and the high-income group corresponded to 47% of the entire cohort. The low-income group was found to be younger (mean age 55 ± 14 vs 58 ± 14 years), higher proportion of females (24% vs 22%), and higher proportion of blacks (32% vs 16%, p < 0.001 for all). The low-income group was found to have higher prevalence of hypertension, chronic pulmonary disease, smoking, dyslipidemia, obesity, and pulmonary hypertension (p < 0.001 for all). However, the high-income cohort had higher rate of atrial tachyarrhythmias and end-stage renal disease (p < 0.001). During hospitalization, patients in the high-income group had increased rates of ischemic stroke, acute kidney injury, acute coronary syndrome, bleeding, and need of extracorporeal membrane oxygenation (p < 0.001 for all). We found that the unadjusted mortality had an OR 1.30 (CI 1.21-1.41, p < 0.001) and adjusted mortality of OR 1.14 (CI 1.05-1.23, p = 0.002). CONCLUSION: In patients undergoing LVAD implantation nationwide, low-income was associated with increased comorbidity burden, younger age, and fewer in-hospital complications and all-cause mortality.

In-Hospital Utilization and Outcomes of Palliative Care Consultation in Patients With Advanced Heart Failure Complicated by Cardiogenic Shock Requiring Mechanical Circulatory Support.

Prior studies have shown that the early inclusion of palliative care (PC) specialist is associated with better end-of-life experiences. The National Inpatient Sample Database was queried from 2012 to 2017 for relevant of ICD)-9 and -10 procedural and diagnostic codes to identify patients above 18 years with advanced heart failure (HF) admitted with cardiogenic shock (CS) requiring mechanical circulatory support (MCS). Baseline characteristics, utilization trends and invasive procedures and complications were compared among patients evaluated by PC and those who were not. There were 65,230 patients hospitalized for advanced HF complicated by CS requiring MCS, of these a PC consult was placed in in 9,200 patients (14.1%) and trended upward from 9.4 to 16.8%, between 2012 to 2017. The majority of patients, (37.3%) from the total population died in hospital. In reference to patients who were discharged alive, PC consultation was associated with a lower incidence of invasive procedures such as mechanical ventilation, pacemaker implantation, defibrillator implantation, insertion of percutaneous feeding tubes and tracheostomies performed (p <0.05 for all) whereas complications such as major bleeding, septic shock, transfusion of any blood product were comparable between both cohorts (nonsignificant p value for all). On the other hand, in those patients who died in hospital PC was associated with a lower incidence of pacemaker implantation, defibrillator implantation and insertion of percutaneous feeding tubes (p <0.05 for all). Despite the high morbidity and mortality associated with advanced HF patients with CS requiring MCS, the overall prevalence of PC consultation is exceedingly low. When utilized, the incidence of invasive procedures was lower. This study highlights the underutilization of PC services in this patient population, precluding any perceived benefit in end-of-life experiences.

Trends, Predictors and In-Hospital Outcomes of the Next Day Discharge Approach After Transcatheter Mitral Valve Repair.

Early discharge strategies are associated with lower cost and resource utilization during hospitalization, as such we sought to evaluate trends, predictors and outcomes of the next day discharge (NDD) approach after transcatheter mitral valve repair (TMVR) procedures with the MitraClip device. The National Inpatient Sample (NIS) was queried between 2013 and 2018 for patients undergoing TMVR using the International Classification of Diseases (ICD) 9 procedure code '3597' and ICD-10 procedure code '02UG3JZ'. Patients undergoing TMVR were stratified into two groups, determined by hospital length of stay (LOS) [≤1 day, NDD versus >1-day, non-NDD]. Overall, 22,035 patients underwent TMVR with 35.7% (n  = 7,870) belonging to the NDD group (mean age 78.1 ± 9.7 years, women 45%). From 2013 to 2018, the proportion of patients being discharged using the NDD approach trended upward from 18.3% to 46.0%. Amongst demographic and social factors, female sex, black race, and low median household income were predictive of non-NDD (p <0.05 for all). Amongst clinical factors, anemia, iron deficiency anemia, major depressive disorder, thrombocytopenia, obesity and end stage renal disease were some predictors of non-NDD (p <0.05 for all). In the non-NDD group there was a downward trend of pooled post-procedure complications, post procedure cardiogenic shock, vascular complications, acute kidney injury, mechanical circulatory support use, acute respiratory distress and postoperative ischemic stroke and (p for trend <0.001 for all). Despite the overall downward trend, complications began increasing in 2017-18. In conclusion, these trends may reflect improving operator experience, advancement in vascular access device closures and techniques, and prioritization of decreasing length of stay. Ideally, the feasibility and safety of this approach should be confirmed in larger-sized multicenter, randomized trials.

Assessing in-hospital cardiovascular, thrombotic and bleeding outcomes in patients with chronic liver disease undergoing left ventricular assist device implantation.

INTRODUCTION: Chronic liver disease (CLD) and advanced heart failure (HF) often co-exist with coagulopathy and hematologic abnormalities being major concerns in this cohort. Perioperative outcomes of patients undergoing LVAD implantation can be affected by coagulopathy, associated with a higher International Normalized Ratio (INR) and cytopenias, as well as pre-operative use of antiplatelet therapy and systemic anticoagulation. Our study is aimed at evaluating the in-hospital mortality and clinical outcomes of patients with CLD who underwent LVAD implantation compared to patients who underwent LVAD implantation without CLD. METHODS: The National Inpatient Sample Database was queried from 2012 to 2017 for relevant International Classification of Diseases (ICD)-9 and ICD-10 procedural and diagnostic codes. Baseline characteristics and in-hospital outcomes were compared in patients with chronic liver disease and those without, who underwent LVAD implantation. RESULTS: A total of 22,955 patients underwent LVAD implantation, 2200 of which had CLD. There was no difference in mean age between those with and without CLD (52.8 ± 14.2 vs. 55.7 ± 15.4 years old, p < 0.001), and 23.7% of patients were female. The proportion of patients with CLD undergoing LVAD implantation trended downward between 2012 and 2017 (average annual growth rate: "-14.8%"). In-hospital post-LVAD outcomes revealed: all-cause inpatient mortality (14.8% vs. 11.1%), major bleeding (34.3% vs. 30.2%), transfusion of platelets (18.0% vs. 14.0%), subarachnoid hemorrhage (1.6% vs. 0.7%) and hospital length of stay were greater in patients with CLD (p < 0.001 for all values). LVAD thrombosis (6.6% vs. 9.4%) and postoperative ischemic stroke (3.4% vs. 6.1%) occurred less in patients with CLD (p < 0.001 for both). There were no statistically significant differences in occurrence of post-LVAD gastrointestinal bleeding and transfusion of fresh frozen plasma or packed red blood cells (p > 0.05 for all). Using a multivariate logistic regression model to adjust for confounding factors, CLD was predictive of increased in-hospital all-cause mortality in patients undergoing LVAD implantation (adjusted odds ratio: 1.29, 95% confidence interval [CI]; 1.06 to 1.56, p = 0.010). CONCLUSION: LVAD implantation in patients with chronic liver disease was associated with increased mortality and post-LVAD major bleeding with increased utilization of platelet products yet comparable thrombotic complications. Further studies are needed to evaluate the balance and pathophysiology of bleeding risks when compared to thrombosis, as well as predictors in patients with chronic liver disease.

Racial disparities in the utilization and in-hospital outcomes of percutaneous left atrial appendage closure among patients with atrial fibrillation.

BACKGROUND: Select patients with atrial fibrillation and contraindication to anticoagulation may benefit from percutaneous left atrial appendage closure (pLAAC). OBJECTIVE: The purpose of this study was to evaluate racial disparities in the nationwide utilization and outcomes of pLAAC. METHODS: We identified 16,830 hospitalizations for pLAAC between 2015 and 2017 using the National Inpatient Sample. Baseline characteristics, in-hospital mortality, complications, length of stay, and discharge disposition were assessed between White and Black/African American (AA) populations. RESULTS: Black/AA patients represented 4.1% of nationwide pLAAC recipients and were younger, more likely to be female, and had greater prevalence of hypertension, heart failure, hyperlipidemia, obesity, chronic kidney disease, and prior stroke history (P <.001 for all). Black/AA patients had significantly increased length of stay and nonroutine discharge (P <.001 for both) but comparable in-hospital mortality to White patients. Black/AA patients suffered from greater postoperative stroke (0.7% vs 0.2%), acute kidney injury (4.5% vs 2.1%), bleeding requiring transfusion (4.5% vs 1.4%), and venous thromboembolism (0.7% vs 0.1%; P <.01 for all). After controlling for possible confounding factors, Black/AA race was independently associated with significantly increased odds of bleeding requiring blood transfusion, stroke, venous thromboembolism, and nonroutine discharge. CONCLUSION: Among pLAAC recipients nationwide, Black/AA populations were underrepresented and had greater complication rates, length of stay, and discharge complexity. This study highlights the importance of addressing ongoing racial disparities in both utilization and outcomes of pLAAC.

In-Hospital Outcomes in Patients With a History of Malignancy Undergoing Transcatheter Aortic Valve Implantation.

A history of malignancy is incorporated in the Society of Thoracic Surgeons score to assess presurgical risk in patients undergoing surgical aortic valve replacement, however data on the prognostic importance in those undergoing transcatheter aortic valve implantation (TAVI) remains limited. We sought to investigate the utilization and in-hospital outcomes of TAVI in patients with a history of malignancy. The National Inpatient Sample Database was queried from 2012 to 2017 to identify patients who underwent TAVI using International Classification of Diseases (ICD) 9 and ICD-10 procedure codes. Between 2012 and 2017, there were 123,070 patients who underwent TAVI, of these 23,670 patients (19.2%) had a previous history of malignancy. The proportion of patients undergoing TAVI with a history of malignancy trended upward between 2012 and 2017. Patients with a history of malignancy were similar in age to those without (81.1 ± 7.9 vs 80.1 ± 6.7 years old, p <0.001), with a higher prevalence of tobacco use and major depressive disorder (p <0.001 for both). Patients with a history of malignancy had higher rates of post-TAVI pacemaker implantation (p <0.001), otherwise periprocedural complication rates were similar to those without. Using a multivariate logistic regression model to adjust for confounding factors, a history of malignancy was predictive of decreased odds of death in patients underwent TAVI (OR: 0.67, 95% CI, 0.60 to 0.76, p <0.001) and higher odds of pacemaker implantation (OR: 1.14, 95% CI, 1.09 to 1.19, p <0.001). In conclusion, with time the proportion of TAVI patients with a history of malignancy trended upward. Despite a greater prevalence of previous tobacco use and major depressive disorder, patients with a history of malignancy had TAVI safely with a low in-hospital all-cause mortality, yet greater cost of hospitalization and more frequent implantation of pacemaker devices.

National Trends and Outcomes of Percutaneous Coronary Intervention in Patients ≥70 Years of Age With Acute Coronary Syndrome (from the National Inpatient Sample Database).

Several randomized trials have demonstrated the benefits of an invasive strategy for older patients with acute coronary syndromes (ACS); however, there are limited real-world data of the temporal trends in the use of percutaneous coronary intervention (PCI) in this population. This was a retrospective observational analysis. We queried the National Inpatient Sample database from 1998 to 2013 for patients aged ≥70 years who had non-ST-elevation acute coronary syndrome (NSTE-ACS) or ST-elevation myocardial infarction (STEMI). We reported the temporal trends of PCI and in-hospital mortality. A total of 6,720,281 hospitalizations with ACS were identified in advanced age patients, 18.3% of whom also underwent PCI. There was an upward trend in the rate of PCI in older adults ≥70 years with any ACS from 9.4% in 1998 to 28.3% in 2013 (p <0.001), as well as in cases of PCI for NSTE-ACS (7.3% in 1998 vs 24.9% in 2013, p <0.001) and PCI for STEMI (11% in 1998 vs 35.7% in 2013, p = 0.002). This upward trend was consistent in all age categories (70 to 79), (80 to 89) and ≥90 years. Despite an increase in the prevalence of comorbidities for ACS hospitalizations aged ≥70 years who received PCI, the in-hospital mortality rate showed a downward trend (p <0.001). Multivariate analysis adjusting for various comorbidities showed that PCI was associated with lower in-hospital mortality and length of hospital stay among elderly with NSTE-ACS and STEMI. In conclusion, in this 16-year analysis there was an increase in the rate of PCI procedures among older adults with ACS. PCI was independently associated with lower mortality in elderly patients with ACS.

Trends in the Incidence and In-Hospital Outcomes of Patients With Atrial Fibrillation Complicated by Non-ST-Segment Elevation Myocardial Infarction.

Atrial fibrillation (AF) can present with non-ST-segment elevation myocardial infarction (NSTEMI). The incidence, characteristics, outcomes, and treatment of this subgroup of patients with AF remains poorly studied. Using data from the National Inpatient Sample database, we (1) compared baseline characteristics of patients with AF with/without NSTEMI, (2) evaluated their outcomes and associated trends over the study period (2004-2013), and (3) evaluated revascularization (by percutaneous coronary intervention or coronary artery bypass graft [CABG]) and the impact on patient outcomes. Of the 3 923 436 patients admitted with a primary diagnosis of AF, 47 785 (1.2%) had a secondary diagnosis of NSTEMI. In this subgroup with AF and NSTEMI, there was a significant trend toward a decrease in mortality ( P = .002), stroke ( P < .001), and gastrointestinal bleeding ( P < .001) during the study period. Compared to unrevascularized patients, revascularized patients were more likely to be younger (72.2 ± 10.2 vs 77.0 ± 11.8 years old, P < .001), male (57.8 vs 42.7%, P < .001), and had a much higher incidence of coronary risk factors. Revascularization was associated with increased survival in multivariable analysis (odds ratio: 0.562, 95% confidence interval: 0.334-0.946, P = .03). In conclusion, among patients admitted with AF, 1.2% were diagnosed with NSTEMI. A minority of patients with AF and NSTEMI underwent revascularization and had better in-hospital outcomes.

Higher Risk of Bleeding in Asians Presenting With ST-Segment Elevation Myocardial Infarction: Analysis of the National Inpatient Sample Database.

Bleeding is a major complication in patients presenting with ST-segment elevation myocardial infarction (STEMI). Several studies suggested that Asians are more susceptible to bleeding when treated with antiplatelets, anticoagulants, and thrombolytic agents. In our study, we aimed to investigate the association between Asian ethnicity and bleeding events in patients who presented with STEMI. We analyzed the Nationwide Inpatient Sample database from 2002 to 2013 and identified patients hospitalized with a primary diagnosis of STEMI. We compared clinical outcomes between patients of Asian and white ethnicity. Primary outcome was inhospital major bleeding defined as a composite of intracranial hemorrhage and blood transfusions for bleeding events. After exclusions, an estimated 1 695 680 white and 46 563 Asian patients with STEMI were included in the analysis. Asian patients had a higher incidence of inhospital major bleeding (3.6% vs 2.2%, P < .001) without a significant difference in inhospital mortality (9.3% vs 8.7%, P = .06). Asian ethnicity was an independent predictor for major bleeding (estimated odds ratio: 1.32; 95% confidence interval: 1.16-1.51; P < .001). This increased risk of bleeding would warrant further investigation of optimal treatment strategies tailored for patients with STEMI of Asian ethnicity.

In-Hospital Cerebrovascular Outcomes of Patients With Atrial Fibrillation and Cancer (from the National Inpatient Sample Database).

Limited data are available regarding the impact of cancer on cerebrovascular accidents in patients with atrial fibrillation (AF). We queried the Nationwide Inpatient Survey Database to identify patients who have diagnostic code for AF. We performed a 1:1 propensity matching based on the CHA2DS2VASc score and other risk factors between patients with AF who had lung, breast, colon, and esophageal cancer, and those who did not (control). The final cohort included a total of 31,604 patients. The primary outcome of in-hospital cerebrovascular accidents (CVA) was lower in the cancer group than in the control group (4% vs 7%, p < 0.001), but with only a weak association (ф = -0.067). In-hospital mortality was higher in the cancer group than in the control group (18% vs 11%, p < 0.001; ф = -0.099). A subgroup analysis according to cancer type showed similar results with a weak association with lower CVA in breast cancer (4% vs 7%; ф = -0.066, p < 0.001), lung cancer (4% vs 6%; ф = -0.062, p < 0.001), colon cancer (4% vs 6%; ф = -0.062, p < 0.001), and esophageal cancer (3% vs 7%; ф = -0.095, p < 0.001) compared with the control groups. A weak association with higher in-hospital mortality was demonstrated in lung cancer (20% vs 11%; ф = -0.127, p < 0.001), colon cancer (16% vs 11%; ф = -0.076, p < 0.001), and esophageal cancer (20% vs 12%; ф = -0.111, p < 0.001) compared with the control groups, but no significant difference between breast cancer and control groups in mortality (11% vs 11%; ф = -0.002, p = 0.888). In conclusion, in patients with AF, cancer diagnosis may not add a predictive role for in-hospital CVA beyond the CHADS2VASc score.