Association of Radial Artery Access with Reduced Incidence of Acute Kidney Injury.

Objectives: To determine if radial artery (RA) access compared with femoral artery (FA) access for percutaneous coronary intervention (PCI) is associated with a lower incidence of acute kidney injury (AKI). Background: AKI results in substantial morbidity and cost following PCI. Prior studies comparing the occurrence of AKI associated with radial artery (RA) versus femoral artery (FA) access have mixed results. Methods: Using a large state-wide database, 14,077 patients (8,539 with RA and 5,538 patents with FA access) were retrospectively compared to assess the occurrence of AKI following PCI. To reduce selection bias and balance clinical data across the two groups, a novel machine learning method called a Generalized Boosted Model was conducted on the arterial access site generating a weighted propensity score for each variable. A logistic regression analysis was then performed on the occurrence of AKI following PCI using the weighted propensity scores from the Generalized Boosted Model. Results: As shown in other studies, multiple variables were associated with an increase in AKI after PCI. Only RA access (OR 0.82; 95% CI 0.74-0.91) and male gender (OR 0.80; 95% CI 0.72-0.89) were associated with a lower occurrence of AKI. Based on the calculated Mehran scores, patients were stratified into groups with an increasing risk of AKI. RA access was consistently found to have a lower risk of AKI compared with FA access across these groups of increasing risk. Conclusions: Compared with FA access, RA access is associated with an 18% lower rate of AKI following PCI. This effect was observed among different levels of risk for developing AKI. Although developed from a retrospective analysis, this study supports the use of RA access when technically possible in a diverse group of patients.

Incidence, Characteristics, and Outcomes of Acute Myocardial Infarction among Patients Admitted with Acute Exacerbation of Chronic Obstructive Lung Disease.

The frequency, characteristics and outcomes of acute myocardial infarction (AMI) during exacerbation of chronic obstructive pulmonary disease (COPD) are unknown. Adult patients hospitalized with a principle diagnosis of acute COPD exacerbation were identified using retrospective analysis of the Nationwide Inpatient Sample (NIS) from 2003 to 2016. Patients were stratified into 2-groups with and without a secondary diagnosis of AMI. The study's endpoints were in-hospital morbidity, mortality, and resource utilization. We also assessed the impact of invasive management strategy on the same end-points. We included 6 894 712 hospitalizations, of which 56 515 (0.82%) were complicated with AMIs. Patients with AMI were older, and had higher prevalence of known coronary disease (48.9% vs. 27.4%), atrial fibrillation (23.3% vs. 15.2%), heart failure (47.8% vs. 26.2%), and anemia (20.7% vs. 14.8%) (p < 0.001). Rates of oxygen dependence were similar (16.3% vs. 16.1%, p = 0.24). In 56 486 propensity-matched pairs of patients with and without AMI, mortality was higher in the AMI group (12.1% vs. 2.1%, p < 0.001). Rates of major morbidities, non-home discharge, and cost were all higher in the AMI group. A minority (18.1%) of patients with AMI underwent invasive assessment, and those had lower in-hospital mortality before (4.9% vs. 13.8%) and after (5.0% vs. 10.0%) propensity-score matching (p < 0.001). This lower mortality persisted in a sensitivity analysis accounting for immortal time bias. AMI complicates ∼1% of patients admitted with acute COPD exacerbation, and those have worse outcomes than those without AMI. Invasive management for secondary AMI during acute COPD exacerbation may be associated with improved outcomes but is utilized in <20% of patients.

Mechanical Circulatory Support in Patients with Cardiogenic Shock.

PURPOSE OF REVIEW: To provide a contemporary concise overview of the currently available mechanical circulatory support (MCS) devices and the emerging concepts in the management of cardiogenic shock (CS). RECENT FINDINGS: New classification of CS has emerged and is hoped to allow a unified approach to research and clinical management of CS. A number of MCS devices have also become available for clinical use in the last 2 decades. Those devices have different hemodynamic targets, provide various levels of support, and are associated with specific requirements and potential complications. Data on the utility of MCS in CS remains conflicting with randomized trials showing no benefit of MCS, and observational data suggesting an incremental value for MCS over medical therapy. However, the early use and escalation of MCS in a standardized approach do appear to provide a remarkable improvement in short-term outcomes of patients with CS. MCS devices afforded lifesaving treatment for many patients with CS. However, optimal utilization of such devices requires familiarity with their clinical data, and technical characteristics, and mandates their integration in an algorithmic team-based approach to CS.

Clinical and Economic Burden of Hospitalizations for Infective Endocarditis in the United States.

OBJECTIVE: To assess contemporary trends in the incidence, characteristics, and outcomes of hospital admissions for infective endocarditis (IE) in the United States. PATIENTS AND METHODS: Patients ≥18 years admitted with IE between January 1, 2003, and December 31, 2016, were identified in the National Inpatient Sample. We assessed the annual incidence, clinical characteristics, morbidity, mortality, and cost of IE-related hospitalizations. RESULTS: The incidence of IE-related hospitalizations increased from 34,488 (15.9; 95% confidence interval [CI], 15.73, 16.06) per 100,000 adults) in 2003 to 54,405 (21.8; 95% CI, 21.60-21.97) per 100,000 adults) in 2016 (P<.001). The prevalence of patients below 30 years of age, and those who inject drugs, increased from 7.3% to 14.5% and from 4.8% to 15.1%, respectively (P<.001). The annual volume of valve surgery for IE increased from 4049 in 2003 to 6460 in 2016 (P<.001), but the ratio of valve surgery to IE-hospitalizations did not decrease (11.7% in 2003; 11.8% in 2016). There was also a temporal increase in risk-adjusted rates of stroke (8.0% to 13.2%), septic shock (5.4% to 16.3%), and mechanical ventilation (7.7% to 16.5%; P<.001). However, risk-adjusted mortality decreased from 14.4% to 9.8% (P<.001). Median length-of-stay and mean inflation-adjusted cost decreased from 11 to 10 days and from $45,810±$61,787 to $43,020±$55,244, respectively, (P<.001). Nonetheless, the expenditure on IE hospitalizations increased ($1.58 billion in 2003 to $2.34 billion in 2016; P<.001). CONCLUSIONS: There is a substantial recent rise in endocarditis hospitalizations in the United States. Although the adjusted in-hospital mortality of endocarditis and the cost of admission decreased over time, the overall expenditure on in-hospital care for endocarditis increased.

Racial Disparities in the Utilization and Outcomes of Structural Heart Disease Interventions in the United States.

Background Data on race- and ethnicity-based disparities in the utilization and outcomes of structural heart disease interventions in the United States are scarce. Methods and Results We used the National Inpatient Sample (2011-2016) to examine racial and ethnic differences in the utilization, in-hospital outcomes, and cost of structural heart disease interventions among patients ≥65 years of age. A total of 106 119 weighted hospitalizations for transcatheter aortic valve replacement, transcatheter mitral valve repair, and left atrial appendage occlusion were included. The utilization rates (defined as the number of procedures performed per 100 000 US people >65 years of age) were higher in whites compared with blacks and Hispanics for transcatheter aortic valve replacement (43.1 versus 18.0 versus 21.1), transcatheter mitral valve repair (5.0 versus 3.2 versus 3.2), and left atrial appendage occlusion (6.6 versus 2.1 versus 3.5), respectively (P<0.001). Black and Hispanic patients had distinctive socioeconomic and clinical risk profiles compared with white patients. There were no significant differences in the adjusted in-hospital mortality or key complications between patients of white race, black race, and Hispanic ethnicity following transcatheter aortic valve replacement, transcatheter mitral valve repair, or left atrial appendage occlusion. No difference in cost was observed between white and black patients following any of the 3 procedures. However, Hispanic patients incurred modestly higher cost with transcatheter mitral valve repair and left atrial appendage occlusion compared with white patients. Conclusions Racial and ethnic disparities exist in the utilization of structural heart disease interventions in the United States. Nonetheless, adjusted in-hospital outcomes were comparable among white, black, and Hispanic patients. Further studies are needed to understand the reasons for these utilization disparities.

Contemporary trends and outcomes of mitral valve surgery for infective endocarditis.

BACKGROUND: Contemporary data on mitral valve (MV) surgery in patients with infective endocarditis (IE) are limited. METHODS: The National Inpatient Sample was queried to identify patients with IE who underwent MV surgery between 2003 and 2016. We assessed (a) temporal trends in the incidence of MV surgery for IE, (b) morbidity, mortality, and cost of MV repair vs replacement, and (c) predictors of in-hospital mortality. RESULTS: The proportion of MV operations involving patients with IE increased from 5.4% in 2003 to 7.3%, and the proportion of MV repair among those undergoing surgery for IE increased from 15.2% to 25.0% (Ptrend < .001). In-hospital mortality was higher in the replacement group (11.3% vs 8.1%; P < .001), and this excess mortality persisted after propensity score matching (11.2% vs 8.1%; P < .001), and in sensitivity analyses excluding concomitant surgery (unadjusted 11.3% vs 4.8%; adjusted 8.5% vs 4.5%; P < .001), and stratifying patients by the time of operation (within 7 days, 11.3% vs 6.8%; P < .001 and >7 days, 11.9% vs 9.1%; P = .012). In the propensity-matched cohorts, shock and need for tracheostomy were more frequent in the replacement group, but rates of stroke, pacemaker implantation, new dialysis, and blood transfusion were similar. Mitral valve repair was, however, associated with shorter hospitalizations, more home discharges, and less cost. In a multivariate regression analysis, age above 70 and chronic dialysis were the strongest predictors of in-hospital mortality. CONCLUSION: Mitral valve repair in IE patients is associated with lower in-hospital mortality, resource utilization, and cost compared with MV replacement.

Cardiac prostheses-related hemolytic anemia.

Hemolysis is an unintended sequel of temporary or permanent intracardiac devices. However, limited data exist on the characteristics and treatment of hemolysis in patients with cardiac prostheses. This entity, albeit uncommon, often poses significant diagnostic and management challenges to the clinical cardiologist. In this article, we aim to provide a contemporary overview of the incidence, mechanisms, diagnosis, and management of cardiac prosthesis-related hemolysis.

Mobile Jet-Related Atrial Lesions in Patients with Mitral Paravalvular Leak.

Regurgitant jet lesions are often encountered in patients with paravalvular leak (PVL) and may pose significant challenge to percutaneous PVL closure. This report describes the case of a 78-year-old female with severe mitral PVL with an associated jet lesion in the left atrium and illustrates its successful percutaneous management. (Level of Difficulty: Intermediate.).

Intracardiac Echocardiography-Guided Biopsy of a Left Ventricular Mass.

Intracardiac echocardiography (ICE) has been used to guide percutaneous biopsies of atrial masses. However, the use of ICE to direct left ventricular mass sampling has not been described. This clinical vignette illustrates the role of ICE-guided left ventricular biopsy in establishing a definitive diagnosis after a failed computed tomography-guided lung mass biopsy. (Level of Difficulty: Intermediate.).

Safety and efficacy of switching from unfractionated heparin to bivalirudin during primary percutaneous coronary intervention.

OBJECTIVES: To evaluate the safety and efficacy of switching to bivalirudin during primary percutaneous coronary intervention (PCI) for patients who received preprocedure unfractionated heparin (UFH). BACKGROUND: Current guidelines favor bivalirudin for primary PCI in patients at high risk of bleeding, particularly when femoral access is used. However, patients with ST-segment elevation myocardial infarction frequently receive UFH before arrival in the catheterization laboratory. METHODS: Scientific databases and websites were searched for randomized controlled trials. Patients were divided into those who received heparin with or without glycoprotein IIb/IIIa inhibitors (heparin group); those switched to bivalirudin during primary PCI from preprocedure UFH (switch group); and those who received bivalirudin without preprocedure UFH (Biv-alone group). Both traditional pairwise meta-analyses using moderator analyses and network meta-analyses using mixed-treatment comparison models were performed. RESULTS: Data from five trials including13,547 patients were analyzed. In mixed-comparison models, switching to bivalirudin during primary PCI was associated with lower rates for all-cause mortality and major adverse cardiovascular events (MACEs) compared to the other strategies. Rates for all-cause mortality, MACEs, and net adverse clinical events (NACEs) were similar for the heparin and Biv-alone groups. Switching strategies was also associated with lower major bleeding rates compared to heparin alone. Similarly, in a standard pairwise model, both the switch and Biv-alone groups were associated with decreased bleeding risk compared to the heparin group. However, only the switch strategy was associated with decreased all-cause mortality (RR, 0.47; 95% CI, 0.30-0.75; P = 0.001), MACE (RR, 0.67; 95% CI, 0.49-0.91; P = 0.012), and NACE (RR, 0.61; 95% CI, 0.41-0.92; P = 0.019) compared with heparin alone. CONCLUSIONS: During primary PCI, use of bivalirudin for those receiving preprocedure UFH was associated decreased rates for major bleeding, NACEs, MACEs, and all-cause mortality compared to heparin +/- GPI. This strategy was also associated with decreased rates for MACEs and all-cause mortality compared to bivalirudin alone without preprocedure UFH.

Comparative early outcomes of tricuspid Valve repair versus replacement for secondary tricuspid regurgitation.

Background: Comparative outcome data on tricuspid valve repair (TVr) versus tricuspid valve replacement (TVR) for severe secondary tricuspid regurgitation (TR) are limited. Methods: We used a national inpatient sample to assess in-hospital morbidity and mortality, length of stay and cost in patients with severe secondary TR undergoing isolated TVr versus TVR. Results: A total of 1364 patients (national estimate=6757) underwent isolated tricuspid valve surgery during the study period, of whom 569 (41.7%) had TVr and 795 (58.3%) had TVR. There was no difference in the prevalence of major morbidities between the two groups, except for liver disease and hepatic cirrhosis, which were more common in the TVR group. Before propensity matching, in-hospital mortality was similar between patients who underwent isolated TVr and TVR (8.1% vs 10.8%, p=0.093), but the incidence of postoperative morbidities differed: TVR was associated with higher rates of permanent pacemaker implantation and blood transfusion, while TVr was associated with more acute kidney injury. After rigorous propensity score matching, TVR was associated with significantly higher rates of in-hospital death (12% vs 6.9%, p=0.009) and permanent pacemaker implantation (33.7% vs 11.2%, p<0.001). Postoperative morbidities and length of stay, however, were not different between the two groups. Nonetheless, cost of hospitalisation was 16% higher in the TVr group. Conclusions: In patients undergoing isolated surgery for secondary TR, TVR is associated with higher in-hospital mortality and need for permanent pacemaker compared with TVr. Further studies are needed to understand the impact of the type of surgery on the short-term and long-term mortality in this complex undertreated population.

Contemporary outcomes of isolated bioprothestic mitral valve replacement for mitral regurgitation.

Background: Early experience with transcatheter mitral valve replacement (TMVR) highlighted several investigational challenges related to this novel therapy. Conclusive randomised clinical trials in the field may, therefore, be years ahead. In the interim, contemporary outcomes of isolated surgical bioprosthetic mitral valve replacement (MVR) can be used as a benchmark for the emerging TMVR therapies. Methods: We used the nationwide inpatient sample to examine recent trends and outcomes of surgical bioprosthetic MVR for mitral regurgitation (isolated and combined). Results: 21 007 patients who had bioprosthetic MVR between 2003 and 2014 were included. Of those, 30% had isolated MVR and 70% had concomitant cardiac surgical procedure(s). In patients who underwent isolated bioprothestic MVR, mean age was 68±13, and females were the majority (58.4%). Most of these procedures were performed at teaching institutions (71.3%) and during an elective admission (64%). In-hospital mortality improved during the study period (7.8% in 2003 to 4.7% in 2014, p trend=0.016). Postoperative morbidities were common; permanent pacemaker 11.7%, stroke 2.4%, new dialysis 4.9% and blood transfusion 41.6%. Mean length of stay was 13±12 days, and 27.2% of patients were discharged to an intermediate care of rehabilitation facility. Cost of hospitalisation was $62 443±50 997. Conclusions: Isolated bioprosthetic MVR for mitral regurgitation is performed infrequently but is associated with significant in-hospital morbidity and mortality and cost in contemporary practice. These data are useful as benchmarks for the evolving TMVR therapies.

Incidence and Outcomes of Non-ST Elevation Myocardial Infarction in Patients Hospitalized with Decompensated Diabetes.

Single center studies suggested that non-ST elevation myocardial infarction (NSTEMI) in patients admitted with acute decompensated diabetes is associated with poor long-term prognosis. We hypothesize that acute decompensated diabetes is also associated with worse early morbidity and mortality in patients admitted with NSTEMI. Adult patients with a primary discharge diagnosis of diabetic ketoacidosis (DKA) or hyperosmolar hyperglycemic state (HHS) were identified in the national inpatient sample. We then assessed contemporary trends in the incidence and management patents of NSTEMI in patients admitted with DKA/HHS and compared in-hospital morbidity and mortality, resource utilization, and cost between DKA/HHS patients with and without NSTEMI. In 431,037 patients admitted with decompensated diabetes from 2003 to 2014, 13,069 (3.03%) suffered a NSTEMI during their hospitalization. Patients with NSTEMI were older and had higher prevalence of atherosclerotic and nonatherosclerotic comorbidities. After propensity score matching, NSTEMI was associated with a 60% increase in in-hospitalmortality (9.1% vs 5.5%; p < 0.001), higher incidences of stroke, acute kidney injury, blood transfusion, longer hospitalizations, and higher costs. A minority (35%) ofNSTEMI patients underwent invasive coronary assessment, and those had lower in-hospitalmortality compared with NSTEMI patients who did not undergo invasive assessment(3.3% vs 12.2%, adjusted OR 0.30, 95%CI 0.24 to 0.36, p < 0.001). About 3% of patients admitted with decompensated diabetes suffer a NSTEMI and those experience higher in-hospital morbidity and mortality, longer hospitalization, and higher cost.

Impact of acute diabetes decompensation on outcomes of diabetic patients admitted with ST-elevation myocardial infarction.

BACKGROUND: Acute hyperglycemia is associated with worse outcomes in diabetic patients admitted with ST-elevation myocardial infarction (STEMI). However, the impact of full-scale decompensated diabetes on STEMI outcomes has not been investigated. METHODS: We utilized the national inpatient sample (2003-2014) to identify adult diabetic patients admitted with STEMI. We defined decompensated diabetes as the presence of diabetic ketoacidosis (DKA) or hyperglycemic hyperosmolar state (HHS). We compared in-hospital morbidity and mortality and cost between patients with and without diabetes decompensation before and after propensity-score matching. RESULTS: A total of 73,722 diabetic patients admitted with STEMI were included in the study. Of those, 1131 (1.5%) suffered DKA or HSS during the hospitalization. After propensity-score matching, DKA/HHS remained associated with a significant 32% increase in in-hospital mortality (25.6% vs. 19.4%, p = 0.001). The DKA/HHS group also had higher incidences of acute kidney injury (39.4% vs. 18.9%, p < 0.001), sepsis (7.3% vs. 4.9%, p = 0.022), blood transfusion (11.3% vs. 8.2%) and a non-significant trend towards higher incidence of stroke (3.8% vs. 2.4%, p = 0.087). Also, DKA/HHS diagnosis was associated with lower rates of referral to coronary angiography (51.5% vs. 55.5%, p = 0.023), coronary stenting (26.1% vs. 34.8%, p < 0.001), or bypass grafting (6.2% vs. 8.7%, p = 0.033). Referral for invasive angiography was associated with lower odds of death during the hospitalization (adjusted OR 0.66, 95%CI 0.44-0.98, p = 0.039). CONCLUSIONS: Decompensated diabetes complicates ~ 1.5% of STEMI admissions in diabetic patients. It is associated with lower rates of referral for angiography and revascularization, and a negative differential impact on in-hospital morbidity and mortality and cost.

Temporal Trends in the Outcomes of Dialysis Patients Admitted With Acute Ischemic Stroke.

BACKGROUND: There is a paucity of contemporary data on the characteristics and outcomes of acute ischemic stroke (AIS) in patients on maintenance dialysis. METHODS AND RESULTS: We used the nationwide inpatient sample to examine contemporary trends in the incidence, management patterns, and outcomes of AIS in dialysis patients. A total of 930 010 patients were admitted with AIS between 2003 and 2014, of whom 13 642 (1.5%) were on dialysis. Overall, the incidence of AIS among dialysis patients decreased significantly (Ptrend<0.001), while it remained stable in non-dialysis patients (Ptrend=0.78). Compared with non-dialysis patients, those on dialysis were younger (67±13 years versus 71±15 years, P<0.001), and had higher prevalence of major comorbidities. Black patients constituted 35.2% of dialysis patients admitted with AIS compared with 16.7% of patients in the non-dialysis group (P<0.001). After propensity score matching, in-hospital mortality was higher in the dialysis group (7.6% versus 5.2%, P<0.001), but this mortality gap narrowed overtime (Ptrend<0.001). Hemorrhagic conversion and gastrointestinal bleeding rates were similar, but blood transfusion was more common in the dialysis group. Rates of severe disability surrogates (tracheostomy, gastrostomy, mechanical ventilation and non-home discharge) were also similar in both groups. However, dialysis patients had longer hospitalizations, and accrued a 25% higher total cost of acute care. CONCLUSIONS: Dialysis patients have 8-folds higher incidence of AIS compared withnon-dialysis patients. They also have higher risk-adjusted in-hospital mortality, sepsis and blood transfusion, longer hospitalizations, and higher cost. There is a need to identify preventative strategies to reduce the risk of AIS in the dialysis population.

Percutaneous axillary access for large-bore arteriotomy: A step-by-step guide.

The last decade has witnessed a tremendous growth in the type and complexity of transcatheter cardiovascular interventions that require large-bore access. While the common femoral artery has become the main route for these interventions, sizable cohorts of patients are unsuitable for transfemoral access due to vascular disease or small vessel caliber. Percutaneous axillary access has emerged as a feasible alternative in these patients. We provide a step-by-step guide for transaxillary large-bore access and closure for patients requiring transcatheter interventions.