Hospital variation of 30-day readmission rate following transcatheter aortic valve implantation.

OBJECTIVES: Thirty-day readmission rate is one of the hospital quality metrics. Outcomes of transcatheter aortic valve implantation (TAVI) have improved significantly, but it remains unclear whether hospital-level variance in 30-day readmission rate exists in the contemporary TAVI era. METHODS: From the 2017 US Nationwide Readmission Database, endovascular TAVI were identified. The unadjusted 30-day readmission rate and 30-day risk-standardised readmission rate (RSRR) were calculated and we then conducted model testing to determine the relative contribution of hospital characteristics, patient-level covariates and economic status to the variation in readmission rates observed between the hospitals. RESULTS: A total of 44 899 TAVI from 338 hospitals were identified. The range of unadjusted 30-day readmission rate and 30-day RSRR was 2.0%-33.3% and 9.4%-15.3%, respectively. Median 30-day RSRR was 11.8% and there was a significant hospital-level variation (median OR 1.22, 95% CI 1.16 to 1.32, p<0.01) and this was similar in both readmissions caused due to major cardiac and non-cardiac conditions. Patient, hospital and economic factors accounted for 9.6%, 1.9% and 3.8% of the variability in hospital readmission rate, respectively. CONCLUSIONS: There was significant hospital-level variation in 30-day RSRR following TAVI. Further measures are required to mitigate this variance in the readmission rate.

Risk of Ischemic Stroke in Transcatheter Aortic Valve Implantation Versus Surgical Aortic Valve Replacement in Patients With Prior Stroke.

It has not been well studied whether transcatheter aortic valve implantation (TAVI) or surgical aortic valve replacement (SAVR) have lower risk of ischemic stroke (IS) in those with prior history of IS. From the Nationwide Readmission Database from October 2015 to November 2017, TAVI and SAVR above age 50 were identified with the International Classification of Diseases, Tenth Revision, Clinical Modification/Procedure Coding System codes. Transapical TAVI and SAVR with concomitant bypass, mitral, or tricuspid surgery were excluded. The primary outcome was in-hospital IS. A total of 92,435 TAVI (13,292 with prior stroke) and 68,651 SAVR (5,365 with prior stroke) were identified. In-hospital IS was significantly lower in TAVI compared with SAVR (3.7% vs 8.0%, adjusted odds ratio 0.65, 95% confidence interval 0.47 to 0.89, p <0.01) with prior stroke whereas it was similar between TAVI and SAVR (1.7% vs 2.1%, adjusted odds ratio 0.97, 95% confidence interval 0.78 to 1.19, p = 0.75) in those without prior stroke (P interaction < 0.001). In-hospital mortality, acute kidney injury, and bleeding were lower in TAVI compared with SAVR in patients with and without prior stroke (P interaction > 0.05 for all). This analysis of a national claims database showed that TAVI was associated with a lower risk of in-hospital IS compared with SAVR among patients with prior stroke.

Large mural thrombus in the distal arch of the aorta without atherosclerotic disease.

Aortic mural thrombus (AMT) is an uncommon cause of arterial thromboembolism. It is very rare in patients without significant cardiovascular risk factors. Many aetiologies can cause AMT, but there are no clear guidelines for the evaluation and treatment. We present the case of a 43-year-old woman without arteriosclerotic disease who was admitted to the hospital with peripheral embolisation from the mural thrombus in the distal arch of the aorta. Therapy with systemic anticoagulation resulted in complete resolution without necessitating any surgical or endovascular interventions. There were no reported recurrence or complications of the intra-aortic thrombus within 1-year surveillance imaging study.

How the COVID-19 Pandemic Has Affected Cardiology Fellow Training.

With the advent of the COVID-19 pandemic in the United States, resources have been reallocated and elective cases have been deferred to minimize the spread of the disease, altering the workflow of cardiac catheterization laboratories across the country. This has in turn affected the training experience of cardiology fellows, including diminished procedure numbers and a narrow breadth of cases as they approach the end of their training before joining independent practice. It has also taken a toll on the emotional well-being of fellows as they see their colleagues, loved ones, patients or even themselves struggling with COVID-19, with some succumbing to it. The aim of this opinion piece is to focus attention on the impact of the COVID-19 pandemic on fellows and their training, challenges faced as they transition to practicing in the real world in the near future and share the lessons learned thus far. We believe that this is an important contribution and would be of interest not only to cardiology fellows-in-training and cardiologists but also trainees in other procedural specialties.

In-Hospital Outcomes and Trends of Endovascular Intervention vs Surgical Revascularization in Octogenarians With Peripheral Artery Disease.

It is unknown whether endovascular intervention (EVI) is associated with superior outcomes when compared with surgical revascularization in octogenarian. National Inpatient Sample (NIS) database was used to compare the outcomes of limb revascularization in octogenarians who had surgical revascularization versus EVI. The NIS database's information on PAD patients ≥80-year-old who underwent limb revascularization between 2002 and 2014 included 394,504 octogenarian patients, of which 184,926 underwent surgical revascularization (46.9%) and 209,578 underwent EVI (53.1%). Multivariate analysis was performed to examine in-hospital outcomes. Trend over time in limb revascularization utilization was examined using Cochrane-Armitage test. EVI group had lower odds of in-hospital mortality (adjusted odds ratio [aOR]: 0.61 [95% CI: 0.58 to 0.63], myocardial infarction (aOR: 0.84 [95% CI: 0.81 to 0.87]), stroke (aOR: 0.93 [95% CI: 0.89 to 0.96]), acute kidney injury (aOR: 0.79 [95% CI: 0.77 to 0.81]), and limb amputation (aOR: 0.77 [95% CI: 0.74 to 0.79]) compared with surgical group (p < 0.001 for all). EVI group had higher risk of bleeding (aOR: 1.20 [95% CI: 1.18 to 1.23]) and vascular complications (3.2% vs 2.7%, aOR: 1.25 [95% CI: 1.19 to 1.30]) compared with surgical group (p < 0.001 for all). Within study period, EVI utilization increased in octogenarian patients from 2.6% to 8.9% (ptrend < 0.001); whereas use of surgical revascularization decreased from 11.6% to 5.2% (ptrend < 0.001). In conclusion, the utilization of EVI in octogenarians is increasing, and associated with lower risk of in-hospital mortality and adverse cardiovascular and limb outcomes as compared with surgical revascularization.

Palliative Care in Ruptured Aortic Aneurysm in the United States: A Retrospective Analysis of Nationwide Inpatient Sample Database.

We assessed the trend of palliative care (PC) referrals and its effect on hospitalization cost and length of stay (LOS) in ruptured aortic aneurysm (rAA). The Nationwide Inpatient Sample from 2005 to 2014 was used to identify admissions with age ≥50 and rAA. A total of 54 134 rAA admissions were identified and 5019 (9.3%) had PC referrals. During the study period, PC referral rate increased from 0.97% to 15.3% (P trend < .0001). Length of stay (1.7 vs 2.8 days, adjusted mean ratio [aMR] = 0.62, 95% confidence interval [CI]: 0.58-0.66), and cost (US$7778 vs US$13 575, aMR = 0.57, 95% CI: 0.52-0.63) were significantly lower in rAA admissions that did not undergo interventions. In the percutaneous repair group, LOS was similar but the cost was higher (US$61 759 vs US$52 260, aMR = 1.18, 95% CI: 1.05-1.30), whereas in surgical repair group, LOS was shorter (4.6 vs 5.9 days, aMR = 0.77, 95% CI: 0.73-0.82) but the cost was higher (US$59 755 vs US$52 523, aMR = 1.14, 95% CI: 1.02-1.28). Palliative care could shorten LOS and save hospitalization cost in rAA admissions not a candidate for repair. Further studies are required to investigate the variable effects of PC on rAA.

MitraClip to Treat Severe Ischemic Mitral Regurgitation During Impella CP Support in a 70-Year-Old Woman.

Acute mitral regurgitation is a life-threatening complication of acute myocardial infarction. We present the case of a 70-year-old woman who had acute myocardial infarction complicated by severe mitral regurgitation and cardiogenic shock. Although current guidelines recommend mitral valve surgery for such patients, surgery often carries prohibitive risk of morbidity and mortality. Thus, in certain patients, percutaneous repair may be the only viable treatment option. In this case, we used a 3-step percutaneous approach involving coronary artery revascularization with a drug-eluting stent in the left circumflex coronary artery, mechanical circulatory support with an Impella CP pump for cardiogenic shock, and mitral valve repair with the MitraClip system for severe mitral regurgitation. After successful intervention, our patient regained hemodynamic stability and showed clinical improvement at one-month follow-up.

Keeping up to date: a current review of wearable cardioverter defibrillator use.

The introduction of wearable cardioverter defibrillators (WCD) provides a novel means of protection in select patients at high risk for sudden cardiac death. The WCD can safely record and terminate life-threatening arrhythmias. In this review, we explore the data behind indications for WCD use and discuss its limitations. We searched PubMed, Google Scholar and Cochrane Central Register of controlled trials for relevant studies. The VEST trial, the first randomised controlled trial on WCD use, did not show statistical significance in utility of the WCD in post-myocardial infarction patients with low ejection fraction. While the use of WCD in this select patient population showed no benefit, the findings of the trial merit closer inspection. Various other indications of WCD use still exist and others require exploration. Select subsets of patients who stand to benefit for other indications include severely decreased left ventricular function post-revascularization with high arrhythmic burden, severe non-ischaemic cardiomyopathy, patients awaiting heart transplant and patients who have had their implantable cardioverter device temporarily removed. The role of the WCD is also being explored in children, peripartum cardiomyopathy, haemodialysis patients, and in syncope secondary to high-risk arrhythmias.

Palliative care referral in ST-segment elevation myocardial infarction complicated with cardiogenic shock in the United States.

BACKGROUND: ST-segment elevation myocardial infarction complicated with cardiogenic shock (STEMI-CS) is associated with high mortality but the trends of utilization and predictors of palliative care (PC) referral in this population have not been well described. OBJECTIVES: To investigate the utilization trends and predictors of PC referral in STEMI-CS. METHODS: Nationwide inpatient sample from 2005-2014 was queried to identify patients with STEMI-CS of age ≥18. PC referral was identified International Classification of Diseases, Ninth Edition Clinical Modification, V66.7. RESULTS: A total of 33,294 admissions were identified and 1,878 (5.6%) had PC encounter. PC referral group were older and had higher comorbidities. PC consultation increased approximately 10 times over the study period in those who died (from 2.3% to 27.4%) and in those who survived (from 0.21% to 2.83%). In multivariable analysis, age, higher Exlixhauser score, no revascularization, teaching hospital, large bed hospital, mechanical circulatory support use, and lower income status were associated with increased PC referral whereas coronary artery bypass graft was associated with lower PC referral rates. Patients under PC group were more often discharged to an extended care facility and less likely discharged home. CONCLUSION: PC utilization increased substantially during the 10-years study period in the United States in STEMI-CS. Several baseline, procedural, hospital, and socioeconomic factors were associated with PC referral in the setting STEMI-CS.

Large Right Coronary Artery Aneurysm.

Complications of aneurysm include thrombosis and distal embolization, rupture, and vasospasm. The natural history and prognosis remain obscure. Controversies persist regarding the use of surgical or medical management.

Impact of Chronic Thrombocytopenia on Outcomes After Transcatheter Valvular Intervention and Cardiac Devices Implantation (From a National Inpatient Sample).

To evaluate the impact of chronic thrombocytopenia (cTCP) on outcomes of transcatheter valvular procedures such as aortic valve implantation (TAVI), MitraClip, permanent pacemaker (PPM), implantable-cardioverter defibrillator (ICD), cardiac resynchronization therapy (CRT), left atrial appendage closure, and pericardiocentesis. Impact of cTCP on clinical outcomes following TAVI, Mitraclip, PPM, ICD, CRT, left atrial appendage closure, and pericardiocentesis procedures is not well described. Utilizing the National Inpatient Sample and (ICD-9-CM) procedural codes, we evaluated patients (age ≥18 years) who underwent these procedures, from January 1, 2009 to December 31, 2014, with or without cTCP as a chronic condition variable indicator. Propensity score matching model implemented to derive 2 matched groups. Propensity score matching created 47,292 and 47,351 hospitalizations matched pairs with and without cTCP, respectively. Patients with cTCP were older (mean age, 74.27 vs 72.26 years; absolute standardized differences [ASD] = 15.6) and less likely to be female (36.76% vs 43.74%, ASD = -14.31). They experienced higher in-hospital mortality (3.0% vs 2.0%; odds ratio [OR], 1.53; 95% confidence interval [CI], 1.27 to 1.83) and higher odds of vascular injury requiring surgery (2.63% vs 1.10%; OR, 2.43; 95% CI, 1.93 to 3.05). Postoperative hematoma and bleeding were 2-fold higher (4.57% vs 2.24%; OR, 2.08; 95% CI, 1.77 to 2.45) and 3-fold higher (6.34% vs 2.45%; OR, 2.69; 95% CI, 2.31 to 3.13) respectively among cTCP patients. They had greater health-care cost ($47,163 vs $35,763, p <0.0001) and longer hospital stay (mean 9.26 days vs 6.84 days, p <0.0001). In conclusion, cTCP patients had higher risk of complications after TAVI, MitraClip, PPM, ICD, CRT, left atrial appendage closure, and pericardiocentesis, including a 1.5-fold increased risk of in-hospital mortality.

In-Hospital Outcomes of ST-Segment Elevation Myocardial Infarction Complicated With Cardiogenic Shock at Safety-Net Hospitals in the United States (from the Nationwide Inpatient Sample).

Safety-net hospitals (SNHs) are hospitals that serve a higher proportion of patients insured by Medicaid or uninsured and have been reported to have poor outcomes compared with non-SNHs. Procedural and clinical outcomes of ST-segment elevation myocardial infarction complicated by cardiogenic shock (STEMI-CS) at SNHs have not been well described. Nationwide Inpatient Sample from 2005 to 2011 was queried to identify STEMI-CS and age ≥18. SNHs were defined as hospitals with the highest number of inpatient stays that were paid by Medicaid or were uninsured (the top quartile). A total of 23,229 STEMI-CS of which 3,639 (15.7%) were treated at SNHs. Admissions to SNHs were younger (mean age 66.0 vs 67.2, p < 0.001), more likely men (64.0% vs 62.2%, p = 0.04), more frequently ethnic minorities (Black; 11.0% vs 6.0%, Hispanic 20.4% vs 5.8%, p < 0.001), and had higher Elixhauser ≥4 (25.8% vs 21.9%, respectively, p < 0.001). Percutaneous coronary interventions were less performed (60.4% vs 65.8%, p < 0.001) whereas administrations of thrombolysis (2.9% vs 2.1%, p = 0.001) were more frequent at SNHs. Coronary artery bypass and the use of mechanical circulatory support was similar. In-hospital mortality was significantly elevated at SNHs (36.6% vs 32.7%, adjusted odds ratio 1.24, 95% confidence interval 1.10 to 1.39) whereas new dialysis, stroke, and fatal arrhythmias were similar. The median length of stay was similar (6 vs 7 days, p = 0.58) but the median cost was higher (40,175 vs 38,012 US dollars, p = 0.01) at SNHs. SNHs had lower utilization of percutaneous coronary intervention and higher in-hospital mortality compared with non-SNHs in STEMI-CS. Further cause analysis is warranted to improve outcomes of STEMI-CS admitted at SNHs.

Meta-Analysis of Effectiveness and Safety of Transcatheter Aortic Valve Implantation Versus Surgical Aortic Valve Replacement in Low-to-Intermediate Surgical Risk Cohort.

Transcatheter aortic valve implantation (TAVI) has been used to treat high surgical risk cohorts but has been expanded to treat low-to-intermediate risk cohort as well. We performed a systematic review and meta-analysis to compare the outcomes between TAVI and surgical aortic valve replacement (SAVR) in low-to-intermediate risk cohort. We queried PUBMED, EMBASE, and ClinicalTrial.gov for relevant articles. Randomized controlled trials that compared at least one of the outcomes of interest between TAVI and SAVR were included. Risk ratio (RR) and 95% confidence interval (CI) were pooled with a random-effects model to compare the risk of the primary outcome between the 2 procedures. The primary outcome was a composite of all-cause mortality or disabling/major stroke at 1 year. Seven studies with a total of 7,143 patients (3,665 TAVI) were included. All-cause mortality or disabling/major stroke at 30 days (6 studies, RR 0.71, 95% CI 0.49 to 1.03) was similar between TAVI and SAVR but was significantly lower in TAVI at 1 year (5 studies, RR 0.81, 95% CI 0.67 to 0.98). All-cause mortality was similar at both 30 days (7 studies, RR 0.90, 95% CI 0.67 to 1.21) and 1 year (6 studies, RR 0.89, 95% CI 0.76 to 1.04). Disabling/major stroke was similar between the 2 procedures (6 studies, RR 0.69, 95% CI 0.42 to 1.12) at 30 days but was significantly lower in TAVI at 1 year (5 studies RR 0.71, 95% CI 0.51 to 0.98). Age, gender, diabetes, and surgical risk score did not modulate the primary outcome. TAVI had a significantly lower composite of all-cause mortality or disabling/major stroke at 1 year compared with SAVR in low-to-intermediate surgical risk cohort.

Apical Ballooning of Takotsubo Cardiomyopathy in a Patient with Non-ST Elevation Myocardial Infarction Due to Right Coronary Artery Stenosis: The Trapped Octopus Got a Heart Attack.

Takotsubo cardiomyopathy (TCM) is characterized by apical ballooning with basal preservation in the absence of obstructive coronary artery disease (CAD) that can otherwise explain wall motion abnormalities. However, there is increasing evidence that acute coronary syndromes (ACSs) may coexist with TCM. This report describes a 61-year-old man with a previous medical history of hypertension, diabetes mellitus, and hyperlipidemia, who presented with acute chest pain and associated shortness of breath. He was diagnosed with a non-ST segment myocardial infarction. Echocardiography revealed impaired systolic function with evidence of apical and periapical ballooning of the left ventricle, characteristic of TCM. Coronary angiography revealed evidence of significant luminal stenosis of the right coronary artery (RCA), necessitating intervention with a drug-eluting stent. This patient demonstrated wall motion abnormalities characteristic of TCM beyond the territory of the affected coronary artery suggesting that CAD and TCM can coexist.

Incidence and predictors of readmissions to non-index hospitals after transcatheter aortic valve replacement and the impact on in-hospital outcomes: From the nationwide readmission database.

INTRODUCTION: Whether readmission to non-index hospitals (where the initial procedure was not performed) could result in adverse outcomes and increased utilization of healthcare resources compared with readmission to index hospitals after transcatheter aortic valve replacement (TAVR) remains unclear. METHODS: From January 2012 to September 2015, a nationwide readmission database was queried to identify those who were older than 50 years and had endovascular TAVR, using the International Classification of Disease, 9th Revision, Clinical Modification code 35.05. Elective readmissions were excluded. In-hospital outcomes were compared between the index and non-index hospital readmissions. A multivariable logistic regression analysis was performed to identify predictors of non-index hospital readmissions. RESULTS: A total of 6808 readmissions were identified of which 2564 (37.7%) were readmitted to non-index hospitals. Residents at smaller counties, metropolitan non-teaching hospitals, or hospitals at large metropolitan areas were predictors of non-index readmissions. In-hospital mortality (adjusted odds ratio [aOR] 1.27, p = 0.20), acute myocardial infarction (aOR 0.83, p = 0.53), pacemaker placement (aOR 0.97, p = 0.90), acute kidney injury (aOR 0.98, p = 0.84), and stroke (aOR 1.03, p = 0.90) were similar between index and non-index readmissions but bleeding events requiring transfusions were more frequently observed in readmissions at non-index hospitals (aOR 1.32, p = 0.025). Hospital cost (15,410 dollars vs. 16,390 dollars, p = 0.25) and length of stay (5.70 days vs. 5.65 days, p = 0.85) were comparable between groups. CONCLUSIONS: Non-index readmissions post-TAVR was relatively common but did not result in increased hospital mortality or healthcare utilization. Our results are reassuring for TAVR recipients with limited access to index hospitals.

Predictors of Hospital Cost After Transcatheter Aortic Valve Implantation in the United States: From the Nationwide Inpatient Sample Database.

We aimed to identify risk factors of high hospitalization cost after transcatheter aortic valve implantation (TAVI). TAVI expenditure is generally higher compared with surgical aortic valve replacement. We queried the Nationwide Inpatient Sample database from January 2011 to September 2015 to identify those who underwent endovascular TAVI. Estimated cost of hospitalization was calculated by merging the Nationwide Inpatient Sample database with cost-to-charge ratios available from the Healthcare Cost and Utilization Project. Patients were divided into quartiles (lowest, medium, high, and highest) according to the hospitalization cost, and multivariable regression analysis was performed to identify patient characteristics and periprocedural complications associated with the highest cost group. A total of 9,601 TAVI hospitalizations were identified. Median in-hospital costs of the highest and lowest groups were $82,068 and $33,966, respectively. Patients in the highest cost group were older and more likely women compared with the lowest cost group. Complication rates (68.4% vs 22.5%) and length of stay (median 10 days vs 3 days) were both approximately 3 times higher and longer, respectively, in the highest cost group. Co-morbidities such as heart failure, peripheral vascular disease, atrial fibrillation, anemia, and chronic dialysis as well as almost all complications were associated with the highest cost group. The complications with the highest incremental cost were acute respiratory failure requiring intubation ($28,209), cardiogenic shock ($22,401), and acute kidney injury ($16,974). Higher co-morbidity burden and major complications post-TAVI were associated with higher hospitalization costs. Prevention of these complications may reduce TAVI-related costs.

Transradial versus transfemoral percutaneous coronary intervention of left main disease: A systematic review and meta-analysis of observational studies.

OBJECTIVES: To assess the efficacy and safety of transradial (TR) versus transfemoral (TF) percutaneous coronary intervention (PCI) in left main (LM) lesion. BACKGROUND: TR-PCI is the preferred approach compared with TF approach because of less bleeding risk. LM-PCI is often challenging because of the anatomical complexity and uniqueness of supplying a large myocardium territory. We performed a systematic review and meta-analysis to assess the safety and efficacy of TR-PCI compared with TF-PCI of the LM lesions. METHODS: A comprehensive literature search of PUBMED, EMBASE, and Cochrane database was conducted to identify studies that reported the comparable outcomes between both approaches. Odds ratio (OR) and 95% confidence interval (CI) was calculated using the Mantel-Haenszel method. RESULTS: A total of eight studies were included in the quantitative meta-analysis. TR-PCI resulted in lower bleeding risk (OR 0.31, 95%CI 0.18-0.52, P < 0.01, I2 = 0%) while maintaining similar procedural success rate, target lesion revascularization, myocardial infarction, stent thrombosis, and all-cause mortality during the study follow-up period. CONCLUSIONS: TR-PCI may achieve similar efficacy with decreased bleeding risk compared to TF-PCI in LM lesions. When operator experience and anatomical complexity are favorable, TR approach is an attractive alternative access over TF approach in LM-PCI.

Acute Myocardial Infarction Outcomes in Systemic Lupus Erythematosus (from the Nationwide Inpatient Sample).

One of the major causes of mortality in systemic lupus erythematosus (SLE) is acute myocardial infarction. Whether in-hospital outcomes and management of ST-segment elevation myocardial infarction (STEMI) and non-STEMI (NSTEMI) are different in SLE patients compared with those without SLE from large, recent dataset is unclear. We queried the Nationwide Inpatient Database from 2005 to 2014 and identified STEMI and NSTEMI admissions with and without SLE. The primary outcome was in-hospital mortality. Secondary outcomes were revascularization strategy (percutaneous coronary intervention, coronary artery bypass surgery, or thrombolytics), medical therapy rates (no reperfusion), and major adverse clinical events. A propensity-matched cohort was created to compare these outcomes. Odds ratio (OR) was calculated from the propensity-matched cohort. A total of 321,048 STEMI admissions, of which 1,001 (0.31%) and 572,971 NSTEMI admissions, of which 2,134 (0.37%) were SLE, were identified. In those with STEMI, 882 SLE and non-SLE admissions were propensity-matched. In-hospital mortality (9.1% vs 11.8%, OR 0.75, p = 0.07), revascularization strategy, medical therapy rates, and major adverse events were similar. Similarly, in those with NSTEMI, 1,770 SLE and 1,775 non-SLE were matched. In-hospital mortality (4.1% vs 4.50%, OR 0.90, p = 0.51), coronary artery bypass surgery, medical therapy rates, and major adverse events were mostly similar but the rate of percutaneous coronary intervention was higher in SLE (32.9% vs 29.6%, OR 1.16, p = 0.04). For both STEMI and NSTEMI, hospital cost and length of stay were similar between SLE and non-SLE cohorts. From a large administrative database in the United States, revascularization strategies and in-hospital outcomes of acute coronary syndrome were mostly similar between SLE and non-SLE.