In-hospital and Readmission Outcomes With Percutaneous Balloon Mitral Valvuloplasty.

Percutaneous balloon mitral valvuloplasty (PBMV) is primarily performed for rheumatic mitral stenosis (MS). Therefore, limited data exist on PBMV in countries with a low incidence of rheumatic disease. Using the Nationwide Readmission Database, we examined trends in in-hospital mortality and 30-day readmission among patients who received PBMV for rheumatic and non-rheumatic MS. We also examined the change in 90-day hospitalization rate before vs after PBMV. Between 2016 and 2019, there were 1109 hospitalizations in which patients received PBMV for rheumatic (n = 955, 86.1%) vs non-rheumatic MS (n = 154, 13.9%). The all-cause in-hospital mortality for rheumatic and non-rheumatic MS did not change over time (0.9% → 2.0%, P = 0.94, and 5.9% → 9.5%, P = 0.09 respectively). Similarly, the 30-day readmission for patients with rheumatic and non-rheumatic MS did not change over time (12.4% → 9.9%, P = 0.26, and 4.4% → 10.5%, P = 0.30, respectively). The 90-day all-cause hospitalization rate remained the same before vs after PBMV for rheumatic and non-rheumatic MS (25.5% → 21.8%; P = 0.14, and 24.0% → 33.7%; P = 0.19, respectively). Although no statistically significant change was noted over time for trends in in-hospital mortality, 30-day readmission, or even in the change in 90-day all-cause hospitalizations before and after PBMV for both types of MS, among those with non-rheumatic MS, there was a signal of an increase in the in-hospital mortality, and 30-day readmission, even more, there was 29% relative increase in 90-day hospitalizations after PBMV. Future studies are needed to examine the role of PBMV in patients with non-rheumatic MS.

Mechanical Complications in ST-Elevation Myocardial Infarction (STEMI) Based on Different Reperfusion Strategies.

Contemporary trends of mechanical complications like papillary muscle rupture (PMR), ventricular septal defect/rupture (VSR), and free wall rupture (FWR) in ST-elevation m'yocardial infarction (STEMI), especially in the era of primary percutaneous coronary interventions (PPCI) has not been definitively investigated. We utilized the National Inpatient Sample (NIS) database from years 2003 to 2017 using International Classification of Disease 9th and 10th revision (ICD-9 and ICD-10) codes to identify STEMI patients undergoing PPCI, fibrinolysis alone, and fibrinolysis with subsequent PCI. We identified those developing in-hospital PMR /VSD / FWR. We identified a total of 2,034,153 STEMI patients where 93.5% had PPCI, 3.2% had fibrinolysis alone, and 3.3% had fibrinolysis with subsequent PCI. Rates of all mechanical complications was low for all three different reperfusion strategies evaluated, with downward trends (p <0.05) over time. No statistically significant difference in the rates of mechanical complication was noted among patients treated with different reperfusion strategies on multivariable logistic regression models. In conclusion, in a contemporary cohort of US patients-majority of whom were managed with PPCI, the rates of overall mechanical complications after STEMI were low even with initial use of fibrinolytics and exhibited a downward temporal trend.

Contemporary Trends in Hospital Admissions and Outcomes in Patients With Critical Limb Ischemia: An Analysis From the National Inpatient Sample Database.

BACKGROUND: Critical limb ischemia (CLI) morbidity and mortality rates have historically been disproportionately higher than for other atherosclerotic diseases, however, recent trends have not been reported. In patients admitted with CLI, we aimed to examine trends in in-hospital mortality, major amputations, length of stay, and cost of hospitalizations overall and stratified by type of revascularization procedures. METHODS: Using 2011 to 2017 National Inpatient Sample data, we identified CLI-related admissions based on International Classification of Diseases, Ninth and Tenth Edition, Clinical Modification codes. Primary outcomes of interest were in-hospital mortality and major amputations. Secondary outcomes were the length of stay and cost of hospitalization. We stratified outcomes based on endovascular or open surgical interventions. We also performed hierarchical multivariable regression analyses of outcomes based on age, sex, race, hospital size, type, and location. RESULTS: We identified 2 643 087 CLI-related admissions between 2011 and 2017. CLI admissions increased from 0.9% to 1.4% Ptrend<0.0001 as well as overall peripheral artery disease admissions (4.5%-8.9%, Ptrend<0.0001). In-hospital mortality for the entire CLI cohort decreased from 3.3% to 2.7%, Ptrend<0.0001, and major amputations decreased from 10.9% to 7%, Ptrend<0.0001. A decline was also noted for the length of stay from 5.7 (3.1-10.1) to 5.4 (3.0-9.2) days (Ptrend<0.0001), whereas admission costs increased from USD $11 791 ($6676-$21 712) to $12 597 ($7248-$22 748; Ptrend<0.0001). Endovascular interventions increased (Ptrend<0.0001) against a decline in surgical interventions (Ptrend<0.0001). Black race, female sex, and age ≥60 years were associated with higher in-hospital mortality, whereas Black race, male sex, and age<60 years were associated with higher major amputations. CONCLUSIONS: A relatively small decrease in absolute numbers for mortality and major amputations were observed against a backdrop of increasing CLI admissions over recent years. Patients with CLI received more endovascular interventions than surgical interventions over time. However, admissions for endovascular interventions were characterized by higher risk patient profiles and a higher risk of major amputations as compared with surgical interventions.

Sex-Specific Outcomes in Cardiovascular Device Evaluations.

Background: Females have historically been underrepresented in cardiovascular device trials. As a result, differences in outcomes for males and females are not possible to be determined in subanalyses. Materials and Methods: Against a backdrop of troubling trends in cardiovascular outcomes for females, we provide a narrative review on the differences in outcomes observed in females undergoing device evaluations in multiple fields of cardiovascular medicine, including coronary revascularization, structural heart disease, and heart failure. We also review predictors of cardiovascular trial nonparticipation as it may provide avenues by which female enrollment in cardiovascular device trials can be improved. Results: Advances have been made in structural heart therapy, where female representation in transcatheter aortic valve replacement studies was nearly 50%. For other indications, coronary revascularization and heart failure, there was clearly a disparity in female recruitment. On average, female representation was 25% in major clinical trials evaluating drug eluting stents, implantable cardioverter defibrillators, cardiac resynchronization defibrillators, and ventricular assist devices. As a result, the best treatment recommendations for females in these fields are currently guided by outcomes evaluated primarily in males. Conclusions: Female enrollment in device clinical trials for coronary revascularization and heart failure has lagged, leaving uncertainty in making benefit/risk assessments of device therapy. The predictors of female nonparticipation in clinical trials can inform a comprehensive strategy to facilitate and enrich the enrollment of females in cardiovascular device trials. This is critical to ensure that sex differences can be considered in treatment selection, so that patients can receive the best available care.

Biodegradable polymer drug-eluting stent vs. contemporary durable polymer drug-eluting stents in patients with diabetes: a meta-analysis of randomized controlled trials.

AIMS: The biodegradable polymer drug-eluting stents (BP-DES) offer controlled drug elution and complete degradation of the polymer over time, eventually lowering the risk for chronic inflammation and neoatherosclerosis, which can be particularly helpful in patients with diabetes. While BP-DES and durable polymer drug-eluting stents (DP-DES) have demonstrated comparable efficacy in all-comers population, their efficacy and safety in patients with diabetes remains uncertain. METHODS AND RESULTS: Electronic databases were systematically searched for randomized controlled trials (RCTs) comparing BP-DES with contemporary DP-DES in patients with diabetes. Study investigators were contacted to obtain additional data. The primary outcome was efficacy in terms of target-vessel revascularization (TVR) and target-lesion revascularization (TLR). We also evaluated the following safety outcomes separately: all-cause mortality, cardiac mortality, myocardial infarction (MI), and definite or probable stent thrombosis. Eleven RCTs including 5190 diabetic patients were included. At the longest available follow-up (mean 2.7 years), there was no significant difference in TLR [relative risk (RR): 1.02, 95% confidence interval (CI): 0.85-1.24; P = 0.80] or TVR (RR: 1.04, 95% CI: 0.81-1.34; P = 0.76). Safety outcomes of all-cause mortality, cardiac mortality, and MI were similar between the two groups. Stent thrombosis rates were also similar between BP-DES and DP-DES groups (1.66% vs. 1.83%; RR: 0.84, 95% CI: 0.54-1.31; P = 0.45). The heterogeneity was low and fixed-effect model yielded similar results. Meta-regression analysis showed no relationship between insulin requiring diabetes and difference in TLR or stent thrombosis between BP-DES and DP-DES. CONCLUSION: Overall, BP-DESs have similar safety and efficacy profiles compared to contemporary DP-DES in patients with diabetes.

Etiologies, trends, and predictors of readmission in ST-elevation myocardial infarction patients undergoing multivessel percutaneous coronary intervention.

BACKGROUND: Recent trials have shown benefits with percutaneous coronary intervention (PCI) on nonculprit coronary vessels in select ST-elevation myocardial infarction (STEMI) patients with multivessel coronary artery disease (CAD). However, readmission rates and causes in this high-risk group are unknown. Objective of this study is to explore pattern, causes and factors associated with 30-day readmission after multivessel PCI in STEMI patients. METHODS AND RESULTS: Nationwide Readmissions Data (NRD) between 2010 and 2014 was utilized to identify multivessel PCI cases in STEMI patients using appropriate ICD-9 codes. We evaluated 30-day readmission rate and factors associated with 30-day readmission. Hierarchical logistic regression model was used to identify factors associated with 30-day readmission. Among 22,257 STEMI patients who survived to discharge after multivessel PCI, 2,302 (10.3%) were readmitted within 30-days. Subsequent unresolved/aggravated cardiac issues most commonly triggered readmission (62.66%). Among cardiac causes, heart failure and ischemic heart disease were most frequent etiologies. Advancing age (OR: 1.073, 95%CI: 1.026 to 1.122, p = .002), female sex (OR: 1.36, 95%CI: 1.23 to 1.50, p < .001), comorbid conditions like chronic kidney disease (CKD; OR: 1.35, 95%CI: 1.17 to 1.57, p = .001), congestive heart failure (CHF; OR: 1.40, 95%CI: 1.24 to 1.57, p = .04), anemia (OR: 1.16, 95%CI: 1.002 to 1.34, p = .04), and utilization of a mechanical circulatory support (MCS) device (OR: 1.45, 95%CI: 1.19 to 1.77, p < .001) during the index procedure were predictive of subsequent readmission within 30 days. CONCLUSION: In this large nationally representative study, nearly one in 10 patients were readmitted within 30 days from discharge after index admission for multivessel PCI in STEMI, most commonly for cardiac causes.

Interventional Therapies for Heart Failure in Older Adults.

Heart failure (HF) remains the leading cause of hospitalization in older adults and is associated with increased morbidity and mortality despite the use of guideline-directed medical therapy. There has been tremendous progress in the development of novel transcatheter and interventional therapies for HF over the past decade. The evolution of structural heart disease interventions and interventional HF has led to a multidisciplinary heart team approach in the management of HF patients. Careful selection of the appropriate patient population and end points in future randomized controlled trials will be crucial to demonstrate the potential efficacy of the novel interventional HF therapies.