Rates and Predictors of Structural Valve Degeneration and Failure of Trifecta Bioprosthetic Valve Over a 5-year Follow-up Period: A Single-center Experience.

Introduction: The Trifecta bioprosthetic valve has been commonly used for surgical aortic valve replacement (SAVR). Multiple studies have been done to define the rate of structural valve degeneration (SVD) and failure (SVF), but the outcomes are still debatable. Therefore, we aim to conduct this single-center study to estimate the rate and predictors of SVD/SVF. Methodology: This retrospective observational cohort single-center study was conducted between 2014 and 2019 among Trifecta SAVR patients. Data were patient's characteristics collected from electronic medical records at baseline and follow-up (3-5 years). Statistical analysis was performed with a significance level of P ≤ 0.05. Results: A total of 271 eligible patients were identified. Most of our sample were males (57.9%), with a mean age of 71.1 ± 10.6 years. The mean baseline preoperative ejection fraction (EF) was 53.0%, with no change (P = 0.88) in the immediate postoperative EF (53.6%). A most recent follow-up EF revealed a significant increase of EF (55.2%), P = 0.01. Furthermore, there was a significant increase from peak velocity to PVMRE (mean difference [MD] ± standard error of mean (SEM) [0.15 ± 0.04], P < 0.01), an increase in pressure gradient (PGIPE) to PGMRE (MD ± SEM [1.70 ± 0.49], P < 0.01), and a decrease in Doppler velocity index (DVIIPE) to DVIMRE (MD ± SEM [-0.037 ± 0.01], P = 0.01). Regarding the SVF rate, 13 (4.8%) patients had failed valves requiring replacement throughout the study period. Conclusions: Over a 5-year follow-up period, 4.8% had SVF with an SVD of 23.2%, with the majority of SVD not being clinically significant except in six patients. These results corroborate with a previously published study suggesting a bad clinical outcome of Trifecta valve placement.

Impact of COVID-19 pandemic on the volume, cost, and outcomes of cardiac electrophysiology procedures in the United States.

BACKGROUND: During the COVID-19 pandemic, professional societies recommended deferral of elective procedures for optimal resource utilization. OBJECTIVE: We sought to assess changes in procedural trends and outcomes of electrophysiology (EP) procedures during the pandemic. METHODS: National Inpatient Sample databases were used to identify all EP procedures performed in the United States (2016-2020) by International Classification of Diseases, Tenth Revision codes. We evaluated trends in utilization, cost/revenue, and outcomes from EP procedures performed. RESULTS: An estimated 1.35 million EP procedures (82% devices and 18% catheter ablations) were performed (2016-2020) with significant yearly uptrend. During the pandemic, there was a substantial decline in EP procedure utilization from a 5-year peak of 298 cases/million population in the second quarter of 2019 to a nadir of 220 cases in the second quarter of 2020. In 2020, the pandemic was associated with the loss of 50,233 projected EP procedures (39,337 devices and 10,896 ablations) with subsequent revenue loss of $7.06 billion. This deficit was driven by revenue deficit from dual-chamber permanent pacemaker (PPM) utilization ($2.88 billion, 49.3% of lost cases), ablation procedures ($1.84 billion, 21.7% of lost cases), and implantable cardioverter-defibrillator implantation ($1.36 billion, 12.0% of lost cases). To the contrary, there was a 9.4% increase in the utilization of leadless PPM. EP device implantation during the pandemic was associated with higher adverse in-hospital events (9.4% vs 8.0%; P < .001). CONCLUSION: In the United States, the significant decline in EP procedures during the pandemic was primarily driven by the reduction in dual-chamber PPM utilization, followed by arrhythmia ablation and implantable cardioverter-defibrillator implantation. There was a substantial increase in leadless PPM utilization during the pandemic.

Should primary care physicians consult on their admitted patients? A single-center survey study.

Background: With the rise of hospital medicine, care has become fragmented between inpatient and outpatient settings. Having primary care physicians (PCPs) consult on their admitted patients through televisits could improve patient and hospital outcomes, but perspectives on this model are unknown in adult hospital medicine. Methods: A single-center cross-sectional survey was conducted to compare PCP and hospitalist attitudes regarding PCP telemedicine consultation for admitted patients in a large US academic hospital. Results: A total of 120 participants (52 hospitalists and 68 PCPs) responded to the survey. Most hospitalists believed that their patients would benefit from PCP consultation, with 45.8% believing it was slightly important, 18.8% moderately important, and 22.9% quite important. The level of importance did not seem to influence the effort required, as most hospitalists would put in only a little effort (35.4%) to obtain a PCP consultation. PCPs were more inclined to consult on their admitted patients; 18.6% considered it slightly important to obtain their consultation, 35.6% believed it was moderately important, and 23.7% believed it was quite important. PCPs were willing to put more effort into setting up a PCP consultation (some effort, 45.8%) vs hospitalists (little effort, 35.4%). The most common challenge perceived by both groups was time commitment (hospitalists, 78.8%; PCPs, 75.0%). Conclusions: Both hospitalists and PCPs agree that a PCP consultation would benefit the patient's medical care in specific situations. However, views on the importance and frequency of PCP consultations vary between the two groups.

Higher body mass index is strongly linked to poor outcomes in adult COVID-19 hospitalizations: A National Inpatient Sample Study.

Aims: The coronavirus disease 2019 (COVID-19) pandemic has resulted in more than 6 million deaths worldwide. Studies on the impact of obesity on patients hospitalized with COVID-19 pneumonia have been conflicting, with some studies describing worse outcomes in patients with obesity, while other studies reporting no difference in outcomes. Previous studies on obesity and critical illness have described improved outcomes in patients with obesity, termed the "obesity paradox." The study assessed the impact of obesity on the outcomes of COVID-19 hospitalizations, using a nationally representative database. Materials and Methods: ICD-10 code U071 was used to identify all hospitalizations with the principal diagnosis of COVID-19 infection in the National Inpatient Database 2020. ICD-10 codes were used to identify outcomes and comorbidities. Hospitalizations were grouped based on body mass index (BMI). Multivariable logistic regression was used to adjust for demographic characteristics and comorbidities. Results: A total of 56,033 hospitalizations were identified. 48% were male, 49% were white and 22% were black. Patients hospitalized with COVID-19 pneumonia in the setting of obesity and clinically severe obesity were often younger. Adjusted for differences in comorbidities, there was a significant increase in mortality, incidence of mechanical ventilation, shock, and sepsis with increased BMI. The mortality was highest among hospitalizations with BMI ≥60, with an adjusted odds ratio of 2.66 (95% Confidence interval 2.18-3.24) compared to hospitalizations with normal BMI. There were increased odds of mechanical ventilation across all BMI groups above normal, with the odds of mechanical ventilation increasing with increasing BMI. Conclusion: The results show that obesity is independently associated with worse patient outcomes in COVID-19 hospitalizations and is associated with higher in-patient mortality and higher rates of mechanical ventilation. The underlying mechanism of this is unclear, and further studies are needed to investigate the cause of this.

Feasibility and Safety of Intracardiac Echocardiography Guidance in Mitral Transcatheter Edge-to-Edge Repair: Analysis of the National Inpatient Sample Data From 2015 to 2020.

Data on the use of intracardiac echocardiography (ICE) guidance in mitral transcatheter edge-to-edge repair (mTEER) procedure is limited to case reports and small case series. Our study aims to assess the feasibility, safety, utilization patterns, and clinical outcomes of mTEER procedure with ICE guidance using a nationally representative real-world cohort of patients. This study used the National Inpatient Sample database from quarter 4 of 2015 to 2020. We used a propensity-matched analysis and adjusted odds ratios for in-hospital outcomes/complications. A P value of < 0.05 was considered significant. A total of 38,770 weighted cases of mTEER were identified. Of the included patients 665 patients underwent ICE-guided mTEER while 38,105 had TEE-guided mTEER. There were no differences in the in-hospital mortality between both groups (2.5% vs 3.0%, P = 0.58). Adjusted odds of in-hospital mortality (aOR 0.83, 95%CI [0.42-1.64]) were not significantly different. There were no differences in periprocedural complications including cardiac (aOR 0.85, 95%CI [0.54-1.35]), bleeding (aOR 1.45, 95%CI [0.93-2.33]), respiratory (aOR 0.88, 95%CI [0.61-1.25]), and renal (aOR 0.89, 95%CI [0.66-1.20]) complications between patients undergoing ICE-guided vs TEE-guided mTEER. There was no difference in GI complications between both groups (aOR 1.11, 95%CI [0.46-2.70]). The adjusted length of stay was less among ICE-guided mTEER (median: 1 vs 2, P < 0.01) with lower inflation-adjusted costs of hospitalization ($35,513 vs $47,067, P < 0.01). ICE-guided mTEER is safe when compared with TEE guided mTEER with no significant differences in in-hospital mortality, cardiac, bleeding, respiratory, and renal complications.

Utility of rapid atrial pacing before and after TAVR with balloon-expandable valve in predicting permanent pacemaker implantation.

BACKGROUND: High-grade or complete atrioventricular block (AVB) requiring permanent pacemaker (PPM) implantation is a known complication of transcatheter aortic valve replacement (TAVR). Wenckebach AVB induced by rapid atrial pacing (RAP) after TAVR was previously demonstrated in an observational analysis to be an independent predictor for PPM. We sought to investigate the utility of both pre- and post-TAVR RAP in predicting PPM implantation. METHODS: In a single-center, prospective study, 421 patients underwent TAVR with balloon-expandable valves (BEV) between April 2020 and August 2021. Intraprocedural RAP was performed in patients without a pre-existing pacemaker, atrial fibrillation/flutter, or intraprocedural complete AVB to assess for RAP-induced Wenckebach AVB. The primary outcome was PPM within 30 days after TAVR. RESULTS: RAP was performed in 253 patients, of whom 91.3% underwent post-TAVR RAP and 61.2% underwent pre-TAVR RAP. The overall PPM implantation rate at 30 days was 9.9%. Although there was a numerically higher rate of PPM at 30 days in patients with RAP-induced Wenckebach AVB, it did not reach statistical significance (13.3% vs. 8.4%, p = 0.23). In a multivariable analysis, RAP-induced Wenckebach was not an independent predictor for PPM implantation at 30 days after TAVR. PPM rates at 30 days were comparable in patients with or without pre-TAVR pacing-induced Wenckebach AVB (11.8% vs. 8.2%, p = 0.51) and post-TAVR pacing-induced Wenckebach AVB (10.2% vs. 5.8%, p = 0.25). CONCLUSION: In patients who underwent TAVR with BEV, there were no statistically significant differences in PPM implantation rates at 30 days regardless of the presence or absence of RAP-induced Wenckebach AVB. Due to conflicting results between the present study and the prior observational analysis, future studies with larger sample sizes are warranted to determine the role of RAP during TAVR as a risk-stratification tool for significant AVB requiring PPM after TAVR.

Epidemiology, characteristics, and outcomes of adult haemophagocytic lymphohistiocytosis in the USA, 2006-19: a national, retrospective cohort study.

Background: Haemophagocytic lymphohistiocytosis (HLH) is a rare and life-threatening syndrome characterized by an excessive inflammatory response. Limited data exist on adult HLH. Methods: In this national, retrospective cohort study, we analysed data from the US National Inpatient Sample database collected between October 1, 2006 and December 31, 2019. Using the International Classification of Diseases (ICD) codes, we identified all adult patients who were admitted non-electively with the diagnosis of HLH. We described demographic characteristics, triggers, and associated conditions. Trends of diagnosis, treatment, and in-hospital mortality were analysed using joinpoint models. In-hospital mortality rates were compared using multivariable logistic regression models that adjusted for demographic characteristics and associated conditions. Finally, we described resource utilization outcomes including cost of hospitalization and length of stay. Findings: We identified 16,136 non-elective adult HLH admissions. The population pyramid showed a bimodal distribution, with peaks in young adults (16-30 years) and older adults (56-70 years). Joinpoint regression analysis revealed a significant increase in HLH incidence per 100,000 admissions over the study period (Average Annual Percent Change [APC] = 25.3%, p < 0.0001), and no significant change in rates of in-hospital mortality (slope = -0.01; p = 0.95) or administration of in-hospital HLH treatment (slope = 0.46, p = 0.20). The most common associated conditions were malignancy (4953 admissions [30.7%]), infections (3913 admissions [24.3%]), autoimmune conditions (3362 admissions [20.8%]), organ transplant status (639 admissions [4%]), and congenital immunodeficiency syndromes (399 admissions [2.5%]). In-hospital mortality was higher in older adults and males. Furthermore, Congenital immunodeficiency syndromes had the worst in-hospital mortality rate (mortality rate 31.1%, adjusted OR 2.36 [1.56-3.59]), followed by malignancies (mortality rate 28.4%, adjusted OR 1.80 [1.46-2.22]), infections (mortality rate 21.4%, adjusted OR 1.33 [1.10-1.62]), other/no trigger (mortality rate 13.6%, adjusted OR 0.73 [0.58-0.92]), autoimmune (mortality rate 13%, adjusted OR 0.72 [0.57-0.92]), and post-organ transplant status (mortality rate 14.1%, adjusted OR 0.64 [0.43-0.97]). The overall mean length of stay was 14.3 ± 13.9 days, and the mean cost of hospitalization was $54,900 ± 59,800. Interpretation: We provide insight into the burden of adult HLH in the USA. The incidence has been increasing and the outcomes remain dismal. This signifies the growing need for the development of updated diagnosis and treatment protocols that are specific to adult HLH. Funding: None.

Outcomes of Percutaneous Atrial Septal Defect Closure With Mitral Transcatheter Edge-to-Edge Repair and Transseptal Mitral Valve Replacement (2015 to 2020).

Patients who underwent transcatheter edge-to-edge repair (TEER) or transcatheter mitral valve replacement (TMVR) have a transeptal access created by an iatrogenic atrial septal defect (ASD) which leads to significant complications requiring closure. Given limited data, we used the National Inpatient Sample between 2015 and 2020 to evaluate the clinical outcomes of percutaneous closure of ASD (PC-ASD) in TEER/TMVR hospitalizations. A total of 44,065 eligible weighted hospitalizations with either TEER (n = 39,625, 89.9%) or TMVR (n = 4,440, 10.1%) with a higher rate of PC-ASD in the TMVR group (10.7% vs 2.0%, p <0.01). The TEER with PC-ASD group were more likely to experience acute heart failure and right ventricular failure and had longer hospital stays but there was no difference in in-hospital mortality compared with the no PC-ASD group. In the TMVR group, there was no difference in the odds of acute heart failure, right ventricular failure, cardiogenic shock, or acute hypoxic respiratory failure, but the odds of mechanical circulatory support, in-hospital mortality, and length of stay were significantly higher in patients with PC-ASD in the TMVR group. In conclusion, rates of percutaneous closure of ASD after TEER were lower than after TMVR and associated with worse in-hospital mortality in TMVR but not in TEER. Further prospective clinical trials are needed to identify patients who would benefit from the closure of iatrogenic ASD.

Delayed vs early cardioversion in patients with paroxysmal atrial fibrillation: a population-based study (2015-2020).

Aim: There is limited data on clinical outcomes of delayed cardioversion (DCV) compared with early cardioversion (ECV) in paroxysmal atrial fibrillation (AF) patients. Methods: We utilized data from National Inpatient Sample (2015-2020) and propensity-score matched analysis to determine adjusted odds ratio (aOR) of major clinical outcomes, including 17,879 AF cases: 9725 and 8154 underwent ECV and DCV, respectively. Results: Compared with ECV, DCV was associated with higher odds of acute heart failure (AHF; aOR 1.79 [1.67-1.92]; p < 0.01), median length of stay (4 vs 2 days; p < 0.01) and cost of hospitalization ($33,410 vs $21,738; p < 0.01) with no significant difference in inpatient mortality and other cardiovascular and neurological outcomes. Conclusion: Compared with ECV, DCV was associated with more AHF and resource utilization.

Bullous herpes zoster masquerading as a bullous pemphigoid flare: A case report.

Herpes zoster (HZ) results from the reactivation of dormant varicella zoster virus (VZV) in the posterior dorsal root ganglia manifesting as painful vesicles along the dermatomal distribution as shingles. The risk of reactivation is higher in immunocompromised patients. Herpes zoster lesions can have varied presentations including bullous forms, may induce BP flare, may co-exist in the same lesions, and should be included in the list of differentials for BP flares not responding to the standard of care. Here, we describe a case of a 74-year-old female with a history of recurrent bullous pemphigoid (BP) flares, who was on mycophenolate mofetil, and presented with skin lesions on her right thigh which were typical for her BP flares. Unlike prior flares, the lesions did not respond to prednisone therapy. Her hospitalization course was complicated by encephalopathy. Intravenous acyclovir was started empirically. Viral cultures and polymerase chain reaction from the lesions came back positive for VZV, but the patient succumbed to her illness shortly afterward.

Shocked to death: a case report of cardiogenic shock and death following electrocardioversion for atrial fibrillation.

BACKGROUND: Atrial fibrillation (AF) is prevalent, especially in patients with heart failure. Their prevalence increases with age and both conditions are interrelated. Electrocardioversion (ECV) is considered a safe and effective procedure and is among one of the recommended therapies to terminate AF back to normal sinus rhythm. Our study highlights one of the rare complications following ECV. A 71-year-old female with a history of atrial fibrillation underwent electrocardioversion and developed sudden onset of ventricular stunning resulting in refractory cardiogenic shock. She was treated with mechanical cardiac support including IABP and Impella. Both provided minimal support then rapid clinical deterioration happened leading to imminent death. CONCLUSION: Patients with atrial fibrillation and heart failure treated with electrocardioversion might develop refractory cardiogenic shock and death as a complication of this procedure.

Outcomes of therapeutic plasma exchange in severe autoimmune hemolytic anemia hospitalizations: An analysis of the National Inpatient Sample.

BACKGROUND: Autoimmune hemolytic anemia (AIHA) is characterized by humoral and/or cellular immune-mediated hemolysis of red blood cells. The role of therapeutic plasma exchange (TPE) in AIHA is unclear. STUDY DESIGN AND METHODS: We queried the National Inpatient Sample (NIS) for 2002-2019 to identify hospitalizations with the primary diagnosis of AIHA. We included hospitalizations with the highest severity subclass identified by All Patient Refined Disease Related Group (APR-DRG). We used multivariate regression analysis to compare in-hospital mortality and other relevant in-hospital outcomes between hospitalizations that received TPE and those that did not. RESULTS: We identified 255 weighted hospitalizations in the TPE group and 4973 in the control group. Those in the control group were older (median age 67 vs. 48 years, p < .001) and had a higher prevalence of most comorbidities. The TPE group had higher odds of all-cause in-hospital mortality (odds ratio [OR], 1.59; 95% confidence interval [CI], 1.19-2.11). They also had higher rates of many secondary outcomes, including requiring mechanical ventilation, developing circulatory shock, acute stroke, urinary tract infections, intracranial hemorrhage, acute kidney injury, and requiring new hemodialysis. No significant differences were noted in the rates of acute myocardial infarctions, bacterial pneumonia, sepsis/septicemia, thromboembolic events, and other bleeding events. Furthermore, the TPE group had a higher median length of hospital stay (19 vs. 9 days, p < .001). CONCLUSION: Hospitalizations with severe AIHA that received TPE had higher rates of adverse in-hospital outcomes.

COVID-19 Infection Is Associated With Increased In-Hospital Mortality and Complications in Patients With Acute Heart Failure: Insight From National Inpatient Sample (2020).

Introduction: Patients with acute heart failure (AHF) exacerbation are susceptible to complications in the setting of COVID-19 infection. Data regarding the clinical outcomes of COVID-19 in patients admitted with AHF is limited. Methods: We used the national inpatient sample database by utilizing ICD-10 codes to identify all hospitalizations with a diagnosis of AHF in 2020. We classified the sample into AHF with COVID-19 infection versus those without COVID-19. Primary outcome was in-hospital mortality. Secondary outcomes were acute myocardial infarction, need for pressors, mechanical cardiac support, cardiogenic shock, and cardiac arrest. Also, we evaluated for acute pulmonary embolism (PE), bacterial pneumonia, need for a ventilator, and acute kidney injury (AKI). Results: We identified a total of 694,920 of AHF hospitalizations, 660,463 (95.04%) patients without COVID-19 and 34,457 (4.96%) with COVID-19 infection. For baseline comorbidities, diabetes mellitus, chronic heart failure, ESRD, and coagulopathy were significantly higher among AHF patients with COVID-19 (P < .01). While CAD, prior MI, percutaneous coronary intervention, and coronary artery bypass graft, atrial fibrillation, chronic obstructive pulmonary disease, and peripheral vascular disease were higher among those without COVID-19. After adjustment for baseline comorbidities, in-hospital mortality (aOR 5.08 [4.81 to 5.36]), septic shock (aOR 2.54 [2.40 to 2.70]), PE (aOR 1.75 [1.57 to 1.94]), and AKI (aOR 1.33 [1.30 to 1.37]) were significantly higher among AHF with COVID-19 patients. The mean length of stay (5 vs 7 days, P < .01) and costs of hospitalization ($42,143 vs $60,251, P < .01) were higher among AHF patients with COVID-19 infection. Conclusion: COVID-19 infection in patients with AHF is associated with significantly higher in-hospital mortality, need for mechanical ventilation, septic shock, and AKI along with higher resource utilization. Predictors for mortality in AHF patients during the COVID-19 pandemic, COVID-19 infection, patients with end-stage heart failure, and atrial fibrillation. Studies on the impact of vaccination against COVID-19 in AHF patients are needed.

Gastrointestinal Bleeding in Patients Supported with Left Ventricular Assist Devices: The Journey from Bridging to Destination.

End-stage heart failure is a prevalent and fatal cardiovascular disease. Almost 1 in 4 cases of mortality in the United States is attributed to heart failure. Left ventricular assist devices (LVADs) have emerged as a safe destination therapy or bridge to transplant. Despite remarkable results, LVAD is associated with significant adverse events, such as gastrointestinal bleeding (GIB). In this review, we aimed to understand the incidence and prevalence, pathophysiologic mechanisms, predictors, diagnostic mechanisms, management, and preventative measures of GIB in patients with an LVAD. GIB is a common adverse event in patients with an LVAD with an incidence of 15% to 25%. The exact pathogenesis of GIB is poorly understood. However, different mechanisms of bleeding have been described, such as arteriovenous malformations, acquired von Willebrand syndrome, coagulopathy, and treatment with antithrombotic therapy. Upper GIB is the most common site of GIB in patients with an LVAD. The management of GIB in patients with LVAD includes ensuring hemodynamic stability, holding or reversing antithrombotic therapy, and investigating and controlling the source of GIB through diagnostic and interventional endoscopic and radiologic means. Prophylactic medication use (e.g., danazol, octreotide, and bevacizumab) can decrease the risk of GIB in patients with an LVAD by decreasing arteriovenous malformations. Despite that the overall risk of GIB has decreased with new advancements in LVAD technology, further studies are needed regarding predictors, risk stratification, and optimal antithrombotic therapy to minimize the morbidity and mortality in patients with an LVAD. In conclusion, prompt diagnosis and management in a multidisciplinary team approach are crucial and lifesaving in such a life-threatening condition.

Atypical Peutz-Jeghers Syndrome Presenting With a Huge Jejunojejunal Intussusception in a Young Male: A Case Report.

Intussusception is considered one of the rare causes of intestinal obstruction in adults compared to pediatric patients. It usually presents with non-specific clinical manifestations ranging from mild recurrent abdominal pain to severe acute abdominal pain. The non-specificity of its symptoms makes it difficult to diagnose preoperatively. As 90% of adult intussusceptions are due to a pathological lead point, this prompts the underlying medical condition to be identified. We herein report a rare case of a 21-year-old male with atypical clinical features of Peutz-Jegher syndrome (PJS), presenting with jejunojejunal intussusception as a result of a hamartomatous intestinal polyp. A preliminary diagnosis of intussusception was made after an abdominal computed tomography (CT) scan and was confirmed intraoperatively. Postoperatively, the patient's condition improved steadily, and he was discharged with a referral to the gastroenterologist for further assessment.

Cardiac Arrest Secondary to Inferior ST-Segment-Elevation Myocardial Infarction in Patient with Paroxysmal Nocturnal Hemoglobinuria and COVID-19 Infection.

Patients with paroxysmal nocturnal hemoglobinuria (PNH) have transient attacks of complement-mediated hemolysis and thrombosis that can be spontaneous or secondary to precipitating factors such as infections. We present a case of a 63-year-old male patient with a medical history of PNH who presented with typical chest pain, fever, cough, jaundice, and dark-colored urine. On examination, he was hemodynamically stable but had conjunctival icterus. A few minutes after presentation, the patient suffered a ventricular fibrillation cardiac arrest and then achieved a return of spontaneous circulation after receiving two defibrillator shocks. EKG showed inferior wall ST-segment elevation myocardial infarction. Labs showed hemoglobin of 6.4 g/dl, elevated cardiac markers, serum lactate dehydrogenase, and indirect bilirubin. Serum haptoglobin was < 1 mg/dl. His COVID-19 polymerase chain reaction test was positive. Immediately, the patient received 2 units of packed RBCs and underwent a coronary angiogram (CA), which revealed total proximal occlusion of the right coronary artery. He underwent successful percutaneous coronary intervention (PCI), and two drug-eluting stents were placed. His peripheral blood immunophenotyping and flow cytometry showed loss of glycosylphosphatidylinositol-linked antigens and decreased expression of CD 59/14/24. He was started on ravulizumab, a humanized monoclonal antibody complement five inhibitor. Both PNH and COVID-19 increase the risk of thrombosis. Endothelial injury and cytokine storm increase the risk of thrombosis in COVID-19 patients, whereas the activation of the coagulation system and the impairment of the fibrinolytic system by complement cascade leads to thrombosis in PNH patients. Regardless of which pathway leads to coronary artery thrombosis, CA and PCI can be life-saving.

Trends and Outcomes of Transcatheter Tricuspid Valve Repair and Surgical Tricuspid Valve Repair in Patients With Tricuspid Valve Regurgitation; A Population Based Study.

Data on clinical outcomes of transcatheter tricuspid valve repair (TTVR) compared with surgical tricuspid valve repair (STVR) in patients with tricuspid valve regurgitation (TVR) remains limited. Data from the national inpatient sample (2016-2020) and propensity-score matched (PSM) analysis was utilized to determine adjusted odds ratio (aOR) of inpatient mortality and major clinical outcomes of TTVR compated with STVR in patients with TVR. A total of 37,115 patients with TVR were included: 1830 (4.9%) and 35,285 (95.1%) underwent TTVR and STVR, respectively. After PSM, there was no statistically significant difference in baseline characteristics and medical comorbidities between both groups. Compared with STVR, TTVR was associated with lower inpatient mortality (aOR 0.43 [0.31-0.59], P < 0.01), cardiovascular complications (aOR 0.47 [0.3-0.45], P < 0.01), hemodynamic complications (aOR 0.47 [0.4-0.55], P < 0.01), infectious complications (aOR 0.44 [0.34-0.57], P < 0.01), renal complications (aOR 0.56 [0.45-0.64], P < 0.01), and need for blood transfusion. There was no statistically significant difference in odds of major bleeding events (aOR 0.92 [0.64-1.45], P 0.84). Also, TTVR was associated with less mean length of stay (7 days vs 15 days, P < 0.01) and less cost of hospitalization ($59,921 vs $89,618) compared with STVR. There was an increase in the utility of TTVR associated with a decrease in the utility of STVR from 2016 to 2020 (P < 0.01). Our study showed that compared with STVR, TTVR was associated with lower inpatient mortality and clinical events. Nevertheless, further studies are needed to investigate the difference in outcomes between both procedures.

Predictors of Mortality in Patients With Refractory Cardiac Arrest Supported With VA-ECMO: A Systematic Review and a Meta-Analysis.

Cardiac arrest (CA) is associated with high mortality rate, ranging between 75% and 93%. Given its significance, venoarterial extracorporeal membrane oxygenation (VA-ECMO) has been used for end-organs perfusion and to maintain adequate oxygenation as a life-saving option in refractory CA. The predictors for the success of VA-ECMO in this setting have not been established yet. In this meta-analysis, we aim to identify the variables associated with increased mortality in patients with CA supported with VA-ECMO. We conducted a systematic review and meta-analysis to evaluate mortality-predicting factors in patients with CA supported with VA-ECMO that were published between January 2000 and July 2022. To identify relevant articles, the MEDLINE (Pubmed, Ovid) and Cochrane Databases were queried with various combinations of our prespecified keywords, including VA-ECMO, CA, and mortality predictors. We performed a meta-analysis using a random-effects model to calculate the odds ratio (OR). We retrieved a total of 4476 records, out of which we included 10 observational studies in our study. A total of 931 patients were included in our study with the age range of 47-68 years, predominantly males (63.9%). The overall mortality was 69.4%. The predictors for mortality were age >65 (OR 4.61, 95% CI 1.63-13.03, P < 0.01), history of chronic kidney disease (OR 2.42, 95% CI 1.37-4.28, P < 0.01), cardiopulmonary resuscitation duration prior to ECMO > 40 minutes (OR 6.62 [95% CI 1.39, 9.02], P < 0.01), having an initial nonshockable rhythm (OR 2.62 [95% CI 1.85, 3.70], P < 0.01) and sequential organ failure assessment score >14 (OR 12.29, 95% CI 2.71-55.74, P <0.01). Regarding blood work, an increase in lactate by 5 mmol/L increased the odds of mortality by 121% (2 studies; OR 2.21 [95% CI 1.26, 3.86], P < 0.01; I2 = 0%) while the increase in lactate by 1 mmol/L increases odd of mortality by 15% (2 studies, OR 1.15 [95% CI 1.02, 1.31], P = 0.03, I = 0%), and an increase in creatinine by 1 mg/dL increased the odds of mortality by 225% (1 study; OR 3.25 [95% CI 1.22, 8.7], P = 0.02). Albumin was protective as for each 1 g/dL increase, the odds of mortality decreased by 68% (1 study; OR 0.32 [95% CI 0.14, 0.74], P < 0.01). Refractory CA requiring VA-ECMO has a high mortality. Predictors of mortality include age >65, history of chronic kidney disease, cardiopulmonary resuscitation duration prior to ECMO > 40 minutes, initial rhythm being non-shockable and Sequential Organ Failure Assessment score >14.