Systolic Heart Failure is Associated with Higher Mortality Among Patients Undergoing Transcatheter Aortic Valve Replacement: A Nationwide Analysis.

Heart failure (HF) is prevalent among patients with aortic stenosis and presents a poor prognosis. In order to better portray outcomes for HF patients undergoing transcatheter aortic valve replacement (TAVR), we evaluated clinical outcomes in patients with systolic vs diastolic heart failure who underwent TAVR in a large nationwide database. We searched the National Inpatient Sample (NIS) for hospitalized adult patients who underwent TAVR with coexisting history of systolic (SHF) or diastolic heart failure (DHF) as a secondary diagnosis using the ICD-10 codes. The primary outcome was in-hospital mortality, with secondary outcomes of cardiac arrest (CA), cardiogenic shock (CS), respiratory failure (RF), Non-ST elevation myocardial infarction (NSTEMI), acute kidney injury (AKI), use of cardiac and respiratory assist device, and health care utilization defined as length of stay, average hospital cost (AHC) and patient charge (APC). Both univariate and multivariate logistic, generalized linear, and Poisson regression analyses were used to evaluate and test the outcomes. A P-value of <0.05 was significant. A total of 106,815 patients were admitted to acute care hospitals for TAVR, and 73% had a secondary diagnosis of heart failure (41% had SHF and 59% DHF). SHF group were older (mean age of 78.9 years [SD ± 8.9] vs 79.9 years [SD ± 8.3]) with more males (61.8% vs 48.2%) and white predominant (whites [85.9% vs 87.9%]). Compared to DHF, SHF had higher inpatient mortality (1.75% vs 1.14%, P = 0.003), CA (1.31% vs 0.81%, P = 0.01), NSTEMI (2.52% vs 1.0%, P = 0.001), RF (10.87% vs 8.01%, P = 0.001), and CS (3.94% vs 1.14%, P = 0.001). In addition, SHF had greater LOS (5.1 days vs. .3.9, P = 0.0001) & AHC ($52,901 vs $48,070, P = 0.0001). HF is common among patients admitted for TAVR. SHF had worse CV outcomes, greater use of hospital resources, and higher acute care hospital mortality compared to those with DHF.

Thirty-Day Readmission Rate and Healthcare Economic Effects of Patients With Transcatheter Aortic Valve Replacement and Coexisting Chronic Congestive Heart Failure.

Transcatheter aortic valve replacement (TAVR) procedures have increased since adoption in 2010. Readmission for TAVR patients with underlying chronic congestive heart failure (cCHF) remains challenging. Therefore, we sought to determine the 30-day readmission rate (30-DRr) of patients who undergo TAVR & co-existing cCHF and its impact on mortality & healthcare utilization in the United States. We performed a retrospective study using the national readmission database year 2017 and 2018. The patients studied were discharged with TAVR as a principal diagnosis and underlying cCHF as a secondary diagnosis according to ICD-10 codes. The primary outcome was a 30-day readmission rate and mortality, while secondary outcomes were the most common diagnoses for readmission, and resource utilization. A total of 76,892 index hospitalization for TAVR with coexisting cCHF: mean age was 79.7 years [SD: ± 2], and 54.5% of patients were males. In-hospital mortality rate for index admission was 1.63%. The 30-DRr was 9.5%. Among the group of readmitted patients, in-hospital mortality rate was 3.13%. Readmission mortality showed a statistically significant increase compared to index mortality (3.13% vs 1.63%, adjusted P ≤ 0.001, aOR: 2.1, 95% CI: 1.6-2.9). The total healthcare in-hospital economic spending was $94.4 million, and total patient charge of $412 million. Approximately 1 in 10 patients who underwent TAVR with underlying cCHF had 30-DRr, with subsequent readmissions associated with increased healthcare spending. Readmission mortality showed a statistically significant increase when compared to index mortality. TAVR patients with cCHF are a vulnerable subset requiring additional outpatient care.

Comparing Accuracy of Thermoplastic Mask versus Commercial Bra for the Immobilization of Pendulous Breast During Radiation Therapy Treatment: A Retrospective Cohort Study.

PURPOSE: This study aimed to compare thermoplastic mask with bra in terms of setup reproducibility and immobilization of pendulous breasts during radiation therapy (RT). METHODS AND MATERIALS: Forty-two female patients with breast cancer treated with either intensity modulated RT or 3-dimensional conformal RT were retrospectively reviewed. Of these, 21 benefited from thermoplastic mask immobilization and 21 used a bra. Setup accuracy was evaluated using consecutive cone beam computed tomography/electronic portal imaging device sessions over the first 3 days before treatment (systematic setting), followed by weekly cone beam computed tomography/electronic portal imaging device (random settings), and compared with the reference image to calculate the corresponding translational shift (setup error) in the 3 planes. Average absolute shift values in both systematic and random settings were compared between the 2 groups. Accuracy was analyzed by comparing the percentage of pooled settings within ±0.05 and ±0.1 cm of the reference image. RESULTS: Compared with a bra, use of the mask was associated with a smaller longitudinal shift in systematic settings (difference in mean: 0.27 cm; P = .027; Mann-Whitney U test) and a lesser lateral shift in random setting (difference in mean: 0.19 cm; P = .005; Mann-Whitney U test). In the pooled systematic settings, the mask performed relatively better than the bra in the lateral and longitudinal planes, with no statistical significance. In pooled random settings, mask showed greater accuracy than bra in the lateral plane with 86.0% versus 58.9% accuracy at ±0.5 cm (P < .001) and 48.8% versus 21.7% accuracy at ±0.1 cm (P < .001), respectively. There was no significant difference in the incidence of radiodermatitis between the 2 groups. However, a hypofractionation regimen was associated with a lower incidence of radiodermatitis, and the severity of skin reactions was positively correlated with treatment dose (unstandardized regression coefficient: B = .001; correlation coefficient: r = .571; P < .001). CONCLUSIONS: Masks provide superior reproducibility compared with commercially available bras.

The impact of regimented aminophylline use on extracardiac radioisotope activity in patients undergoing regadenoson stress SPECT myocardial perfusion imaging: a substudy of the ASSUAGE trial.

BACKGROUND: In patients undergoing regadenoson stress SPECT myocardial perfusion imaging (MPI), the impact of the regimented administration of aminophylline on the cardiac-to-extracardiac photon activity ratio is unknown. METHODS: This is a substudy of the ASSUAGE trial (NCT01250496); a double-blinded, randomized, placebo-controlled clinical trial which investigated the attenuation of regadenoson-related adverse effects using 75 mg of intravenous aminophylline vs placebo, administered 90 seconds following (99m)Tc-tetrofosmin injection in patients undergoing regadenoson stress SPECT-MPI. In subjects with normal MPI enrolled in the trial, we sampled from the antero-posterior planar projection of the post-stress scintigraphic data the mean photon activity in the myocardium, liver, bowel, and lungs. The mean cardiac-to-extracardiac activity ratios were compared between patients randomized to aminophylline vs placebo. RESULTS: We studied 158 eligible subjects, randomized to receive aminophylline (n = 86) or placebo (n = 72). The means of photon activity ratios of the heart-to-liver, heart-to-bowel, heart-to-lungs, inferior wall of the heart-to-liver, and inferior wall of the heart-to-bowel were not statistically different between those who received aminophylline vs placebo (P values > .30). Only the time lapse between stress (99m)Tc-tetrofosmin injection and stress SPECT acquisition independently correlated with higher heart-to-liver and heart-to-bowel activity ratios (P values ≤ .01). Patients' body mass index independently correlated with lower heart-to-lung ratio (P = .009). CONCLUSION: The regimented intravenous aminophylline use following regadenoson stress does not significantly improve the cardiac-to-extracardiac photon activity ratio in patients undergoing regadenoson stress (99m)Tc-tetrofosmin SPECT-MPI.

Regadenoson pharmacologic stress for myocardial perfusion imaging: a three-way comparison between regadenoson administered at peak exercise, during walk recovery, or no-exercise.

BACKGROUND: Regadenoson (Reg) is being administered with increasing frequency either at peak exercise (ExPeak-Reg) or during a slow-down/walking recovery state (ExRec-Reg) rather than at rest (Rest-Reg). The aim of this study was to compare the clinical response of ExPeak-Reg, ExRec-Reg, and Rest-Reg. METHODS: We compared 531 patients divided equally between Rest-Reg, ExPeak-Reg, and ExRec-Reg matched for age, sex, and BMI. RESULTS: The average systolic blood pressure (SBP) rise following Reg was modest, but there was considerable heterogeneity and the ExPeak-Reg group had a higher percentage of patients who had a SBP rise of 40 mm Hg or a fall of 20 mm Hg than either the ExRec-Reg or the Rest-Reg groups (≥40 mm Hg rise 6.8%, 1.7%, and 1.7%, respectively) (P < .02) (≥20 mm Hg fall 15.8%, 13.0%, and 7.3%, respectively) (P < .05). Chest discomfort, nausea, dizziness, and interfering abdominal radiotracer activity were less common in both exercise Reg groups compared to Rest-Reg (P < .05). CONCLUSION: Regadenoson injected at peak of symptom-limited exercise was generally well tolerated, but some patients had a significant rise or drop in SBP. There is no apparent advantage of administering regadenoson at peak exercise rather than during walk recovery, and the latter approach may have a greater safety margin.