In-hospital mortality and length of stay among patients with infective endocarditis and solid organ transplant: A study from National Inpatient Sample 2016-2019.

Infective endocarditis (IE) is a rare but serious complication following a Solid Organ Transplant (SOT). Due to the lack of sufficient studies, we aimed to compare in-hospital mortality and length of stay (LOS) of patients primarily admitted for IE (index or principal hospitalization) with history of SOT, including the subgroup of heart or lung transplant (HLT), to those without a history of SOT (non-SOT) or HLT (non-HLT). We used the 2016-2019 National Inpatient Sample, the largest all-payer inpatient hospital data from Healthcare Cost and Utilization Project (HCUP), including patients 18 years or older with IE, as a principal diagnosis for hospitalization. From 2016 to 2019, there were 56,330 principal or index hospitalizations for IE. Among them, 0.6 % (n = 327) were SOT recipients, 0.1% (n = 68) were HLT recipients, and 41.4% were females. The mean age was 51.9 ± 19.2 years. Compared to non-SOT controls, SOT recipients were older (mean age 59.3 vs. 51.8 years; P = 0.002) and had higher Charlson-comorbidity-index (CCI) of 3 or more (87.7% vs. 33.2%; p < 0.001). SOT status was not statistically significant for a higher or lower odds of in-hospital mortality (adjusted odds ratio (aOR) 0.7; 95% confidence interval (CI): 0.2, 2.4; p = 0.60) or increased or decreased LOS (coefficient: -0.1, 95% CI: -0.4, 0.1; p = 0.23) among index IE hospitalizations after controlling for age, sex, race, hospital-region, hospital-teaching status, income, insurance status, and CCI. HLT status was also not associated with higher or lower odds of in-hospital mortality (aOR 1.4; 95% CI: 0.2, 13.1; p = 0.77) or increased or decreased LOS (coefficient: -0.1, 95% CI: -0.3, 0.5; p = 0.59). From 2016 to 2019, the rate of index IE hospitalization trends from 37.8 to 41.4 per 100,000 overall hospitalizations (p = 0.001). We found the rate of index IE hospitalizations increasing with time. Among index IE hospitalizations, SOT, including a subgroup of HLT recipients, have similar in-hospital mortality and LOS compared to non-SOT or non-HLT groups. We need a larger sample size to comment on outcomes of IE hospitalizations with the HLT subgroup.

A Case Report of Thromboembolic Stroke in a Patient with Holt-Oram Syndrome.

Ischemic stroke associated with rare clinical syndromes represents less than 5% of etiologic factors. From those syndromes are Holt-Oram syndrome and Left ventricular non-compaction syndrome. We report a case of a 66 years old male with genetically confirmed Holt-Oram syndrome due to TBX5 mutation who presented with cryptogenic stroke most likely due to cardioembolic etiology. The patient has a history of moderate nonischemic cardiomyopathy due to an atypical pattern of left ventricular non-compaction confirmed by Cardiac Magnetic Resonance Imaging. The patient was treated appropriately with thrombolytic therapy and catheter-directed mechanical thrombectomy with minimal residual stroke symptoms. Holt-Oram syndrome is a genetic condition with variable clinical phenotypes, including cardiac manifestations. Left ventricular non-compaction syndrome is rare congenital cardiomyopathy defined as prominent left ventricular trabeculae, deep intertrabecular recesses, and a thin compacted layer. And only a few cases were reported with both conditions. Therefore, patients with the Holt-Oram Syndrome should get a comprehensive cardiac evaluation to exclude non-compaction cardiomyopathy, which may have significant prognostic implications.

Novel Modification of Impella Sheath to Prevent Limb Ischemia.

Limb ischemia is a dreaded complication of large-bore access during prolonged Impella support. We report a novel technique to modify 14F Impella sheath by creating two perfusion holes in the dorsal sheath surface to enable distal limb perfusion via dead space surrounding 9F Impella catheter in flow-occlusive iliofemoral arteries.

Systematic Review and Meta-Analysis: Can We Compare Direct Oral Anticoagulants to Warfarin in Patients With Atrial Fibrillation and Bio-Prosthetic Valves?

Background There are no clear consensus guidelines on the indications and types of anticoagulation therapies in patients with bio-prosthetic valves either with concomitant atrial fibrillation (AF) or sinus rhythm. In our meta-analysis, we assessed the safety and efficacy of DOACs as compared to the standard treatment with warfarin in patients with AF and bioprosthetic valves. Methods We included randomized controlled trials (RCTs), cohort studies in the English language, and studies reporting patients with valvular heart disease that included bioprosthetic valvular disease. A systematic literature review using Embase, PubMed, and Web of Science was performed using the terms "Direct Acting Oral Anticoagulant," "Oral Anticoagulants," "Non-Vitamin K Antagonist Oral Anticoagulant," "Atrial Fibrillation," "Bioprosthetic Valve" for literature published prior to January 2021. Extraction of data from included studies was carried out independently by three reviewers from Covidence. We assessed the methodical rigor of the included studies using the modified Downs and Black checklist. Results Four RCTs and one observational study (n=1776) were included in our study. A random-effect model using RevMan (version 5.4; The Nordic Cochrane Centre, The Cochrane Collaboration, Copenhagen) was used for data analysis. The pooled data showed that there was a non-significant reduction in the incidence of stroke and systemic embolism in the patients taking DOACs as compared to warfarin (HR 0.69; 95% CI, 0.29, 1.67; I2 = 50%). The incidence of major bleeding was lower in the DOACs group; the difference was statistically significant (HR 0.42; 95% CI, 0.26, 0.67; I2 = 7%). The difference was not statistically significant for all-cause mortality in both groups (HR 1.24; 95% CI, 0.91, 1.67; I2 = 0%). Conclusion Our results showed that there was no difference in the outcomes of stroke and systemic embolism between DOACs and warfarin but there were statistically significantly lower major bleeding events. We conclude that larger clinical trials are needed to assess the true safety and efficacy of DOACs in patients with AF and bioprosthetic valves.

Coronary Artery Bypass Grafting Versus Percutaneous Coronary Intervention in Patients with Left Ventricular Systolic Dysfunction.

PURPOSE: There is a paucity of comparative data examining the optimal revascularization strategy in patients with left ventricular systolic dysfunction (LVD). METHODS: We performed an aggregate data meta-analysis of clinical outcomes comparing percutaneous coronary intervention (PCI) versus coronary artery bypass (CABG) in patients with LVD (left ventricle ejection fraction (LVEF) of ≤ 40%), using the random effects model. Effects size is reported as odds ratio (OR) and a 95% confidence interval. Outcomes included all-cause mortality, myocardial infarction, stroke, repeat revascularization, and a composite of major adverse cardiac and cerebrovascular events (MACCE) at 30-day, 3-year, and long-term (6.3 ± 0.9 years) follow-ups. Seventeen studies (16 observational, 1 randomized) and 18,599 patients (CABG 9651; PCI 8948) were included. RESULTS: PCI and CABG had comparable all-cause mortality at 30 days (OR 0.78, 95% CI 0.49-1.23) and 3 years (OR 1.05, 95% CI 0.91-1.21); however, PCI was associated with increased long-term morality after a mean follow-up of 6.3 ± 0.9 years (31.6% vs. 24.3%, OR 1.41, 95% CI 1.21-1.64). A similar mortality trend was observed in the subgroup of patients with EF ≤ 35%. PCI had a higher rate of repeat revascularization at 3-year and long-term follow-ups. The long-term rates of stroke and MI were comparable. PCI, on the other hand, had lower rates of stroke at 30-day and 3-year follow-ups. CONCLUSION: CABG was associated with lower rates of long-term mortality and revascularization but higher rate of upfront stroke in patients with LVD. However, the data included consisted predominantly of observational studies, highlighting the paucity and need for randomized trials.

A case report of absolute thrombocytopenia with ticagrelor.

BACKGROUND: We report a rare case of absolute thrombocytopenia with ticagrelor after 6 h of single loading dose of ticagrelor. CASE SUMMARY: A 68-year-old male with ischaemic cardiomyopathy, hypertension, and dyslipidaemia presented with chest pain. He was found to be in new-onset atrial flutter and ruled in for a non-ST-segment elevation myocardial infarction. An echocardiogram showed decreased left ventricular ejection fraction, estimated at 15-20% and serum troponin peaked at 0.2 ng/dL, baseline platelet count was 203 × 103/µL. He underwent a drug-eluting stent placement to the right coronary artery with excellent angiographic results. He received 3000 units of unfractionated heparin and 180 mg of ticagrelor during the procedure. About 6 h after the procedure, he had coffee ground emesis. A complete blood count revealed a platelet count of 2 × 103 and 0 × 103/µL on repeat testing. Peripheral smear did not show any evidence of platelet clumping and schistocytes, serum haptoglobin and lactate dehydrogenase were normal. Ticagrelor and heparin were discontinued, while the aspirin was continued. Five units of platelet were transfused. The platelet count improved to 200 × 103/µL. Since his CHADS2VASC score was 3, he was discharged on apixaban and clopidogrel in addition to other medication. No thrombocytopenia was seen on outpatient follow-up. DISCUSSION: The common side effects of ticagrelor include bleeding, dyspnoea, gynaecomastia, and rarely thrombotic thrombocytopenic purpura. Although extremely rare, absolute or profound thrombocytopenia can occur with ticagrelor, hours after administration and should be considered when other potential causes of thrombocytopenia have been ruled out.

Coronary artery occlusion following low-power catheter ablation.

Myocardial infarction (MI) is an unusual but potentially serious complication of catheter ablation procedures. This case describes the occurrence of acute myocardial infarction following low-power ablation in a young patient and highlights the importance of maintaining high index of suspicion following catheter ablation irrespective of the ablation power used. A 22-year-old patient had low-power ablation of the right posteroseptal accessory pathway in the ostium of the coronary sinus on account of persistently symptomatic WPW syndrome with orthodromic re-entrant tachycardia. Two hours after the procedure, she developed moderately severe chest pain. Electrocardiogram showed ST elevation in the inferior leads. Coronary angiography showed 100% stenosis of the right coronary artery just beyond the posterior descending artery. She failed balloon angioplasty and a drug eluting stent was placed in the posterolateral branch of the right coronary artery. The symptoms resolved and follow up echocardiogram showed normal left ventricular systolic and diastolic functions with no regional wall motion abnormality. This case demonstrates the occurrence of MI following low-power catheter ablation. Patients should be monitored for this complication irrespective of the ablation power used.

Challenges and Controversies in the Management of ACS in Elderly Patients.

PURPOSE OF REVIEW: Elderly patients presenting with acute coronary syndrome (ACS) represent a challenging patient population. A high index of suspicion is needed for their diagnosis, as they are less likely to present with typical anginal symptoms compared to their younger counterparts. RECENT FINDINGS: Disrupted coronary plaques with superimposed thrombosis are the predominant pathophysiology of ACS; however, an increased proportion of calcified nodules is encountered in elderly patients. Emergent reperfusion and revascularization remain the mainstay treatment for ST-elevation myocardial infarction or cardiogenic shock. In elderly patients with NSTE-ACS, a routine invasive strategy is generally superior to an ischemia-guided strategy, and the safety of an early invasive strategy has also been recently demonstrated. When treating elderly ACS patients with antiplatelet and antithrombotic therapies, close attention to co-morbidities, frailty and the balance of ischemia-bleeding risk should be undertaken, and medication doses should be carefully adjusted. Overall, elderly patients with ACS remain undertreated with evidence-based therapies, experience worse outcomes, and represent an opportunity for enhancing and mitigating healthcare disparities.

Comparison of surgical versus transcatheter aortic valve replacement for patients with aortic stenosis at low-intermediate risk.

BACKGROUND: To compare safety and efficacy of transcatheter aortic valve replacement (TAVR) with surgical aortic valve replacement (SAVR) in patients at low-intermediate risk, given the paucity of robust data. METHODS: We performed an aggregate data meta-analysis of 7 randomized controlled trials (RCTs) and 6,778 patients comparing TAVR with SAVR for aortic stenosis (AS) in low-intermediate risk patients (Society of Thoracic Surgeons risk-score ≤8%) using the random-effects model. Primary outcome was all-cause mortality at 30-day, 1-year and 2-year of follow-up. Secondary outcomes included cardiac-mortality, stroke, acute kidney injury (AKI), atrial fibrillation (AF), permanent pacemaker (PPM) implantation, major-bleeding, moderate-severe paravalvular regurgitation (PVR) and rehospitalization. RESULTS: All-cause mortality, cardiac-mortality and stroke were comparable between the two groups. AF was higher with SAVR at 30-day [odds ratio (OR) 0.17, 95% confidence intervals (CI): 0.12-0.24] thorough to 2-year (OR 0.34, 95% CI: 0.21-0.55), while PPM implantation was higher with TAVR (30-day: OR 3.31, 95% CI: 1.64-6.66, 2-year: OR 3.17, 95% CI: 1.02-9.86). Moderate-severe PVR was more prevalent with TAVR at all follow-ups. On inter-group comparison, patients in the low-risk group had an even lower risk of AF, but a higher risk of PPM implantation as compared to the patients in the intermediate-risk group undergoing TAVR. CONCLUSIONS: Compared to SAVR, TAVR had comparable all-cause mortality and stroke, lower-risk of AF, but was associated with a higher risk of PPM implantation and moderate-severe PVR in low-intermediate-risk patients. Thus, highlighting the need for longer-term follow-up before robust inferences are drawn.

Inspiratory Muscle Training in Patients With Heart Failure With Preserved Ejection Fraction: A Meta-Analysis.

Objectives To explore the role of inspiratory muscle training (IMT) in improving cardiorespiratory fitness of stable heart failure with preserved ejection fraction (HFpEF) patients. Background There is a paucity of data on the role of IMT in patients with HFpEF. HFpEF is a growing problem in the developed world, especially in the aging population. Methods We conducted a systematic literature search for English studies in PubMed, EMBASE, and Cochrane Central Register of Controlled Trials. We searched databases using terms relating to or describing breathing exercise, IMT, and HFpEF. RevMan 5.4 (The Cochrane Collaboration, 2020) was used for data analysis, and two independent investigators performed literature retrieval and data extraction. Results We identified three randomized controlled trials (RCTs) and one prospective study on the role of IMT in HFpEF. We calculated the pooled mean difference of peak oxygen consumption (Peak VO2) and six-min walk distance (6MWD) between the IMT and standard care (SC) groups. Our meta-analysis showed that compared with SC, IMT could significantly improve peak VO2 with a mean difference (MD) of 2.82 ml/kg/min, 95% CI [1.90, 3.74] P < 0.00001 and improve 6MWD with MD of 83.97 meters, 95% CI [59.18, 108.76] P< 0.00001 to improve cardiorespiratory fitness at 12 weeks of IMT and improve peak VO2 with MD of 2.18 ml/kg/min, 95% CI [0.38, 3.99] P < 0.00001 at 24 weeks of therapy. Conclusion IMT should be further studied as a possible treatment option to improve cardiorespiratory fitness for patients with stable HFpEF.

Effect of increasing age on percutaneous coronary intervention vs coronary artery bypass grafting in older adults with unprotected left main coronary artery disease: A meta-analysis and meta-regression.

BACKGROUND: Older adults (≥70-year-old) are under-represented in the published data pertaining to unprotected left main coronary artery disease (ULMCAD). HYPOTHESIS: Percutaneous coronary intervention (PCI) might be comparable to coronary artery bypass grafting (CABG) for revascularization of ULMCAD. METHODS: We compared PCI versus CABG in older adults with ULMCAD with an aggregate data meta-analyses (4880 patients) of clinical outcomes [all-cause mortality, myocardial infarction (MI), repeat revascularization, stroke and major adverse cardiac and cerebrovascular events(MACCE)] at 30 days, 12-24 months & ≥36 months in patients with mean age ≥70 years and ULMCAD. A meta-regression analysis evaluated the effect of age on mortality after PCI. Odds ratios (OR) and 95% confidence intervals (CI) were estimated using random-effects model. RESULTS: All-cause mortality between PCI and CABG was comparable at 30-days (OR0.77, 95% CI 0.42- 1.41) and 12-24-months (OR 1.22, 95% CI 0.78-1.93). PCI was associated with a markedly lower rate of stroke at 30-day follow-up in octogenarians (OR 0.14, 95% CI 0.02-0.76) but an overall higher rate of repeat revascularization. At ≥36-months, MACCE (OR 1.26,95% CI 0.99-1.60) and all-cause mortality (OR 1.39, 95% CI 1.00-1.93) showed a trend favoring CABG but did not reach statistical significance. On meta-regression, PCI was associated with a higher mortality with advancing age (coefficient=0.1033, p=0.042). CONCLUSIONS: PCI was associated with a markedly lower rate of early stroke in octogenarians as compared to CABG. All-cause mortality was comparable between the two arms with a trend favoring CABG at ≥36-months.PCI was however associated with increasing mortality with advancing age as compared to CABG.

Effect of glycemic control on mortality and infections in patients undergoing coronary artery bypass grafting: a Genesee County experience.

Background: We report post-coronary artery bypass outcomes and factors affecting the outcomes from the Genesee County, MI, where the population is distinctly characterized by a higher prevalence of renal failure (RF), diabetes, obesity and smoking than the national average. Methods: We performed a retrospective cohort study on 1133 patients undergoing isolated CABG at our hospital from June 2012 to July 2017. Primary outcome was the association between preoperative hemoglobin A1c (HbA1c) and all-cause postoperative mortality after CABG, secondary outcomes included the association between HbA1c and a composite of postoperative infections including sternal-wound infections, leg harvest-site infections, pneumonia or sepsis. Logistic Regression analyses were also performed. Results: There was no difference in the mortality rate (OR 1.0, 95% CI 0.4-2.3) and composite of all infections (OR 1.0, 95% CI 0.7-1.6) between the controlled (HbA1c ≤7%) and uncontrolled (HbA1c >7%) groups. However, RF (OR 5.9, 95% CI 1.5-22.9), smoking (OR 3.7, 95% CI 1.3-11.2) and ejection fraction <35% (OR 3.4, 95% CI 1.4-8.3) were independently associated with increased mortality after CABG. Additionally, low EF (OR 2.4, 95% CI 1.4-4.1) and smoking (OR 2.3, 95% CI 1.2-4.1) were associated with an increased rate of composite of all infections after CABG. Conclusion: Although not different in controlled and uncontrolled diabetic groups, mortality, in our population was associated with comorbidities like RF, smoking and congestive heart failure that are highly prevalent, emphasizing the need for interventions at primary care level to improve the postoperative outcomes after CABG.

Meta-Analysis of Comparison of 5-Year Outcomes of Percutaneous Coronary Intervention Versus Coronary Artery Bypass Grafting in Patients With Unprotected Left Main Coronary Artery in the Era of Drug-eluting Stents.

Patients with unprotected left main coronary artery (ULMCA) disease are increasingly being treated with percutaneous coronary intervention (PCI) using drug-eluting stents (DES), but long-term outcomes comparing PCI with coronary artery bypass grafting (CABG) remain limited. We performed aggregate data meta-analyses of clinical outcomes (all-cause death, nonfatal myocardial infarction, stroke, repeat revascularization, cardiac death, and major adverse cardiac and cerebrovascular events) in studies comparing 5-year outcomes of PCI with DES versus CABG in patients with ULMCA disease. A comprehensive literature search (January 1, 2003 to December 10, 2016) identified 9 studies (6,637 patients). Effect size for individual clinical outcomes was estimated using odds ratio (OR) with 95% confidence intervals (CI) using a random effects model. At 5 years, PCI with DES was associated with equivalent cardiac (OR 0.95, 95% CI 0.62 to 1.46) and all-cause mortality (OR 0.98, 95% CI 0.72 to 1.33), lower rates of stroke (OR 0.50, 95% CI 0.30 to 0.84), and higher rates of repeat revascularization (OR 2.52, 95% CI 1.63 to 3.91); compared with CABG, major adverse cardiac and cerebrovascular events showed a trend favoring CABG but did not reach statistical significance (OR 1.19, 95% CI 0.93 to 1.54). In conclusion, for ULMCA disease, PCI can be considered as a comparably effective and yet less invasive alternative to CABG given the comparable long-term mortality and lower incidences of stroke.