A novel method to manage a dislodged self-expanding transcatheter aortic valve.

Despite advancements in technology, operator experience, and procedural planning, transcatheter aortic valve replacement (TAVR) procedures are complex, and complications remain inevitable. Valve embolization may prove to be fatal and conventional rescue techniques are dependent on the anatomy of the aorta. We describe a case of postimplant embolization of a self-expanding valve during valve-in-valve application where the valve could not be stabilized due to the anatomy of the aorta and a novel technique was utilized to stabilize the valve in the aortic arch using a wire fixed to the left axillary artery.

Prevalence and Outcomes of Patients With Acute Ischemic Stroke With Concomitant ST-Segment-Elevation Myocardial Infarction (Results From National Inpatient Sample 2016-2019).

BACKGROUND: Acute myocardial infarction may concomitantly occur with acute ischemic stroke. The prevalence, complications, and outcomes of acute ST-segment-elevation myocardial infarction (STEMI) in patients hospitalized with acute ischemic stroke are not well studied. METHODS: We examined hospitalized patients with acute ischemic stroke who were included in the National Inpatient Sample from 2016 to 2019. Acute ischemic stroke and STEMI were defined by using the International Classification of Diseases-Tenth Revision diagnostic codes. Patients with Non-STEMI were excluded. The prevalence of complications and outcomes were expressed as percentages. Multivariable logistic regression analysis was used to examine the association of STEMI with a primary outcome of mortality and secondary outcomes. A subgroup analysis of patients with STEMI who underwent percutaneous coronary intervention was also performed. RESULTS: Of the total (n=2 080 795) patients with acute ischemic stroke, 0.3% (n=6275; mean age, 70.5 years, 50.1% females, 69.5% White) also had STEMI diagnosed during the hospitalization. Of these, 1775 (28.3%) died in the STEMI group and 76 435 (3.7%) died in the group without STEMI. The most frequent complications in the STEMI group were acute kidney injury, intracranial hemorrhage, and ventricular arrhythmias. All secondary outcomes were associated with the diagnosis of STEMI (odds ratio [OR], 3.19 [95% CI, 2.82-3.6]; P≤0.001). STEMI was associated with mortality (OR, 8.37 [95% CI, 7.25-9.66]; P≤0.001) and intracranial hemorrhage (OR, 2.23 [95% CI, 1.84-2.70]; P≤0.001). Percutaneous coronary intervention was performed in 14.3% of STEMI subgroup patients. Percutaneous coronary intervention is not associated with mortality (OR, 0.93 [95% CI, 0.6-1.43]; P=0.7), and intracranial hemorrhage (OR, 1.54 [95% CI, 0.0.93-2.56]; P=0.1). CONCLUSIONS: Patients with acute ischemic stroke with STEMI have a higher percentage of mortality. Percutaneous coronary intervention in the subgroup of patients with acute ischemic stroke with concomitant STEMI was not associated with increased odds of mortality and intracranial hemorrhage.

Procedural success in transaxillary transcatheter aortic valve implantation according to type of transcatheter heart valve: results from the multicenter TAXI registry.

BACKGROUND: Transaxillary (TAx) transcatheter aortic valve implantation (TAVI) is a preferred alternative access in patients ineligible for transfemoral TAVI. AIMS: This study used the Trans-AXillary Intervention (TAXI) registry to compare procedural success according to different types of transcatheter heart valves (THV). METHODS: For the TAXI registry anonymized data of patients treated with TAx-TAVI were collected from 18 centers. Acute procedural, early and 1-month clinical outcomes were adjudicated in accordance with standardized VARC-3 definitions. RESULTS: From 432 patients, 368 patients (85.3%, SE group) received self-expanding (SE) THV and 64 patients (14.8%, BE group) received balloon-expandable (BE) THV. Imaging revealed lower axillary artery diameters in the SE group (max/min diameter in mm: 8.4/6.6 vs 9.4/6.8 mm; p < 0.001/p = 0.04) but a higher proportion of axillary tortuosity in BE group (62/368, 23.6% vs 26/64, 42.6%; p = 0.004) with steeper aorta-left ventricle (LV) inflow (55° vs 51°; p = 0.002) and left ventricular outflow tract (LVOT)-LV inflow angles (40.0° vs 24.5°; 0.002). TAx-TAVI was more often conducted by right sided axillary artery in the BE group (33/368, 9.0% vs 17/64, 26.6%; p < 0.001). Device success was higher in the SE group (317/368, 86.1% vs 44/64, 68.8%, p = 0.0015). In logistic regression analysis, BE THV were a risk factor for vascular complications and axillary stent implantation. CONCLUSIONS: Both, SE and BE THV can be safely used in TAx-TAVI. However, SE THV were more often used and were associated with a higher rate of device success. While SE THV were associated with lower rates of vascular complications, BE THV were more often used in cases with challenging anatomical circumstances.

Clinical Outcomes of Aortic Stenosis in Amyloidosis: A United States National Cohort Study.

BACKGROUND: Literature regarding outcomes associated with surgical aortic valve replacement (SAVR) or transcatheter aortic valve replacement (TAVR) among amyloidosis (AM) with aortic stenosis (AS) is limited. OBJECTIVES: We aim to study the mortality and in-hospital clinical outcomes among AM with AS associated with SAVR or TAVR. METHODS: We performed a retrospective study of all hospitalisation encounters associated with a diagnosis of AM with AS, using the Nationwide Readmissions Database for the years 2012-2019. Primary outcomes were in-hospital mortality, and 30-day readmissions. RESULTS: A total of 4,820 index hospitalisations of AS (mean age 78.35±10.11; female 37.76%) among AM were reported. Total 464 patients had mechanical intervention, 251 patients (54.1%) TAVR and 213 patients (45.9%) SAVR. A total of 317 patients (6.77%) with AS died; TAVR 4.4%, SAVR 11.9% (p=0.01) and 6.66% died among the subgroup who did not have any mechanical intervention. Higher complication rates were observed among patients who had SAVR than those who had TAVR including acute kidney injury (39.8% vs 22.4%; p=0.01), septic shock (12.1% vs 4.4%; p=0.05) and cardiogenic shock (22% vs 4.4%; p<0.001). Acute heart failure was higher among patients who had TAVR (40.2% vs 27.5%; p=0.04) than those who had SAVR. All conduction block and ischaemic stroke were similar between the two groups (p=0.09 and p=0.1). The overall 30-day readmission rate among AM with AS encounters was 16.82%, higher among TAVR compared to SAVR subgroups (21.25% vs 11.17%; p=0.001). CONCLUSIONS: Among AM with AS hospitalisations, TAVR had mortality benefits compared to SAVR and non-mechanical intervention subgroups. Moreover, higher 30-day mortality rate were observed among SAVR subgroup, which may suggest that TAVR should be strongly considered in AM patients complicated by AS.

Insights Into the Standard Echocardiographic Views From Multimodality Imaging: Ventricles, Pericardium, Valves, and Atria.

The widespread use of cardiac computed tomography and cardiac magnetic resonance imaging in patients undergoing echocardiography presents an opportunity to correlate the images side by side. Accordingly, the aim of this report is to review aspects of the standard echocardiographic examination alongside similarly oriented images from the two tomographic imaging modalities. It is hoped that this exercise will enhance understanding of the structures depicted by echocardiography as they relate to other structures in the thorax. In addition to reviewing basic cardiac anatomy, the authors take advantage of these correlations with computed tomography and cardiac magnetic resonance imaging to better understand the issue of foreshortening, a common pitfall in transthoracic echocardiography. The authors also highlight an important role that three-dimensional echocardiography can potentially play in the future, especially as advances in image processing permit higher fidelity multiplanar reconstruction images.

Clinical outcomes and 30-day readmissions associated with high-output heart failure.

BACKGROUND: High-output heart failure (HOHF) is an underdiagnosed type of heart failure (HF) characterized by low systemic vascular resistance and high cardiac output. OBJECTIVE: This study sought to characterize the causes, mortality, and readmissions related to HOHF within the United States. METHODS: Data were collected from the Agency for Healthcare Research and Quality's Healthcare Cost and Utilization Project (HCUP) National Readmissions Database (NRD) from January 1, 2017, to November 30, 2019. We used the International Classification of Diseases, 10th revision (ICD-10), diagnostic codes to identify encounters with HOHF and heart failure with reduced ejection fraction (HFrEF). RESULTS: Of the total 5,080,985 encounters with HF, 3,897 hospitalizations (mean age 62.5 ± 17.9 years, 56.5% females) with HOHF and 5,077,088 hospitalizations with HFrEF were recorded. The most commonly associated putative etiologies of HOHF included pulmonary disease (19.8%), morbid obesity (9.9%), sepsis (9.6%), cirrhosis (8.9%), myelodysplastic syndrome (MDS) (7.9%), hyperthyroidism (5.5%), and sickle cell disease (3.3%). There was no significant difference in mortality rates [4.3% vs. 5.2%; odds ratio (OR) 0.9, 95% confidence interval (CI) 0.7-1.2] between HOHF and HFrEF. However, the 30-day readmission rate for HOHF was significantly lower than that for HFrEF (5.7% vs. 21.2%; OR 0.39, 95% CI 0.30-0.51). Cardiovascular (39.9%) followed by hematological (20.6%) complications accounted for the majority of 30-day readmissions in the HOHF group. CONCLUSIONS: HOHF is an infrequently reported cardiovascular complication associated with noncardiovascular disorders and is encountered in 0.07% of all encounters with HF. Although comparable in-hospital mortality between studied cohorts was observed, raising awareness and timely recognition of this entity are warranted.

Cardiovascular Outcomes of Older versus Newer Generation Transcatheter Aortic Valve Replacement Recipients: A Systematic Review & Meta-analysis.

Newer generation transcatheter heart valves (THV) are presumed to yield better clinical efficacy and postprocedural complication profile as compared to transcatheter aortic valve replacement (TAVR) using older generation THVs. The real impact of newer generation valves on TAVR outcomes is not well known. Studies comparing older and newer generation THVs were identified from online databases including PubMed, EMBASE, Cochrane, and ClinicalTrials.gov from inception until August 2020. The primary outcome of the study was to compare mortality. Secondary outcomes included cerebrovascular events, myocardial infarction, major vascular complications, major bleeding, acute kidney injury, paravalvular leak, and post-procedural pacemaker implantation. Statistical analysis was performed using the Mantel-Haenszel random effect model with an odds ratio (OR), 95% confidence interval (CI), and p-value significance ≤0.05. A total of 14 studies were included with a combined patient population of 5697 patients (older generation n=1996; newer generation n=3701). Newer generation valves showed statistically significant results favoring lower major vascular complications (OR=2.05; 95% CI, 1.33-3.18; P = 0.00), major bleeding (OR=1.99; 95% CI, 1.35-2.93; P = 0.00), acute kidney injury (OR=1.71; 95% CI, 1.13-2.59; P = 0.01), paravalvular leak (OR=2.41; 95% CI, 1.11-5.28; P = 0.03) and mortality (OR=1.50; 95% CI, 1.10-2.06; P = 0.01) as compared to older generation valves. Cerebrovascular events, myocardial infarction, and pacemaker placement rates were found to be similar between older and newer generation valves. TAVR outcomes using newer generation valves are superior to those of older generation valves in terms of major vascular complications, acute kidney injury, paravalvular leak, and mortality.

Sodium-glucose cotransporter-2 inhibitors improve liver enzymes in patients with co-existing non-alcoholic fatty liver disease: a systematic review and meta-analysis.

Introduction: Non-alcoholic fatty liver disease (NAFLD) is characterized by hepatic steatosis, inflammation, and fibrosis. While sodium-glucose cotransporter-2 (SGLT-2) inhibitors have been established to improve glycaemic control in type-2 diabetes mellitus (T2DM), evidence of the beneficial effects in diabetics with coexisting NAFLD has yet to be quantitatively summarized. Material and methods: We searched the PubMed, Medline, CINAHL, and Cochrane databases and ClinicalTrial.gov from database inception to July 2020. We included randomized controlled trials assessing the impact of SGLT2 inhibitors on liver enzymes among patients with NAFLD. Our primary outcome included liver inflammation as measured using liver transaminase. Secondary outcomes included drug efficacy on hepatic steatosis and body mass index. Risk differences were calculated using a random model. Results: A total of 10,555 patients were included in this meta-analysis (SGLT2 inhibitor group: n = 7125; control group: n = 3430). The treatment duration ranged from 8 to 52 weeks. Patients with T2DM, who were treated with SGLT2 inhibitor had decrease in ALT (SMD = -0.22, 95% CI: -0.27 to -0.20) and AST levels (SMD = -0.20, 95% CI: -0.31 to -0.08). The SGLT-2 inhibitor did not cause statistically significant weight loss (SMD = -0.21, 95% CI: -0.47 to 0.06), fibrosis regression utilizing FIB-4 score (SMD = -0.12, 95% CI: -0.41 to 0.18), and hepatic steatosis by using MRI-PDFF (SMD = -0.31, 95% CI: -0.68 to 0.07), as compared to controls. Conclusions: The SGLT2 inhibitor treatment may improve liver function, as demonstrated in the statistically significant reduction in transaminase levels. There were also notable trends in improved liver fibrosis and steatosis across the study periods.

Relation of Exercise Capacity to Incident Heart Failure Among Men and Women With Coronary Heart Disease (from the Henry Ford Exercise Testing [FIT] Project).

Exercise capacity (EC) is inversely related to the risk of cardiovascular disease and incident heart failure (HF) in healthy subjects. However, there are no present studies that exclusively evaluate EC and the risk of incident HF in patients with known coronary heart disease (CHD). We aimed to determine the relation between EC and incident HF in patients with an established clinical diagnosis of CHD. We retrospectively identified 8,387 patients (age 61 ± 12 years; 30% women; 33% non-White) with a history of myocardial infarction (MI) or coronary revascularization procedure and no history of HF at the time of a clinically indicated exercise stress test completed between 1991 and 2009. EC was quantified in metabolic equivalents of task (METs) estimated from treadmill testing. Incident HF was identified through June 2010 from administrative databases based on ≥3 encounters with International Classification of Diseases, Ninth Revision 428.x. Cox regression analysis was used to evaluate the risk of incident HF associated with METs. Covariates included age; gender; race; hypertension, diabetes, hyperlipidemia, smoking, and MI; medications for CHD and lung diseases; and clinical indication for treadmill testing. During a median follow-up of 8.2 years (interquartile range 4.7 to 12.4 years) after the exercise test, 23% of the cohort experienced a new HF diagnosis. Lower EC categories were associated with higher HF incidence compared with METs ≥12, with nearly fourfold greater adjusted risk among patients with METs <6. Per unit increase in METs of EC was associated with a 12% lower adjusted risk for HF. There was no significant interaction based on race (p = 0.06), gender (p = 0.88), age ≤61 years (p = 0.60), history of MI (p = 0.31), or diabetes (p = 0.38). This study reveals that among men and women with CHD and no history of HF, EC is independently and inversely related to the risk of future HF.

Pediatric Cardiac Arrest Outcomes in the United States: A Nationwide Database Cohort Study.

Background Knowledge about the causes and outcomes of pediatric cardiac arrest in the emergency department is limited. The aim of our study was to evaluate the characteristics and outcomes of pediatric cardiac arrest in the emergency department (EDCA) and inpatient (IPCA) settings in the United States using a large database designed to provide nationwide estimates. Methods We performed a retrospective cohort study using the Nationwide Emergency Department Sample (NEDS), a database that includes both ED and inpatient encounters. The NEDS was analyzed for episodes of cardiac arrest between 2016-2018 in patients aged ≤18 years. Patients with cardiac arrest were identified using the International Classification of Diseases, 10th revision codes. Results A total of 15,348 pediatric cardiac arrest events with cardiopulmonary resuscitation were recorded, of which 13,239 had EDCA and 2,109 had IPCA. A lower survival rate of 19% was observed for EDCA compared to 40.4% for IPCA. While more than half of the EDCA events had no associated diagnoses, trauma (15.6%), respiratory failure (5%), asphyxiation (2.7%), acidosis (2.4%), and ventricular arrhythmia (1.4%) were associated with the remaining events. In comparison, the most frequently associated diagnoses for IPCA were respiratory failure (75.8%), acidosis (43.9%), acute kidney injury (27.2%), trauma (27.1%), and sepsis (22.5%).  Conclusions Survival rates for EDCA were less than half of that for IPCA. The low survival rates along with the distinctive characteristics of EDCA events suggest the need for further research in this area to identify remediable factors and improve survival.

Outcome and Post-Surgical Lung Biopsy Change in Management of ARDS: A Proportional Prevalence Meta-Analysis.

BACKGROUND: Limited epidemiological data are available on changes in management, benefits, complications, and outcomes after open lung biopsy in patients with ARDS. METHODS: We performed a literature search of PubMed, Ovid, and Cochrane databases for articles from the inception of each database till November 2020 that provided outcomes of lung biopsy in ARDS patients. The primary outcome was the proportion of patients that had a change in management with alteration of treatment plan, after lung biopsy. Secondary outcomes included pathological diagnoses and complications related to the lung biopsy. Pooled proportions with a 95% confidence interval (CI) were calculated for the prevalence of outcomes. RESULTS: After analysis of 22 articles from 1994 to 2018, a total of 851 ARDS patients (mean age 59.28 ± 7.41, males 56.4%) that were admitted to the ICU who underwent surgical lung biopsy for ARDS were included. Biopsy changed the management in 539 patients (pooled proportion 75%: 95% CI 64-84%). There were 394 deaths (pooled proportion 49%: 95% CI 41-58%). The most common pathologic diagnosis was diffuse alveolar damage that occurred in 30% (95% CI 19-41%), followed by interstitial lung disease in 10% (95% CI 3-19%), and viral infection in 9% (95% CI 4-16%). Complications occurred among 201 patients (pooled proportion 24%, 95% CI 17-31%). The most common type of complication was persistent air-leak among 115 patients (pooled estimate 13%, 95% CI 9-17%). CONCLUSION: Despite the high mortality risk associated with ARDS, lung biopsy changed management in about 3/4 of the patients. However, 1/4 of the patients had a complication due to lung biopsy. The risks from the procedure should be carefully weighed before proceeding with lung biopsy.

Rationale and design of SAVI-AoS: A physiologic study of patients with symptomatic moderate aortic valve stenosis and preserved left ventricular ejection fraction.

Background: Moderate aortic valve stenosis occurs twice as often as severe aortic stenosis (AS) and carries a similarly poor prognosis. Current European and American guidelines offer limited insight into moderate AS (MAS) patients with unexplained symptoms. Measuring valve physiology at rest while most patients experience symptoms during exertion might represent a conceptual limitation in the current grading of AS severity. The stress aortic valve index (SAVI) may delineate hemodynamically significant AS among patients with MAS. Objectives: To investigate the diagnostic value of SAVI in symptomatic MAS patients with normal left ventricular ejection fraction (LVEF ≥ 50%): aortic valve area (AVA) > 1 cm2 plus either mean valve gradient (MG) 15-39 mmHg or maximal aortic valve velocity (AOV max) 2.5-3.9 m/s. Short-term objectives include associations with symptom burden, functional capacity, and cardiac biomarkers. Long-term objectives include clinical outcomes. Methods and results: Multicenter, non-blinded, observational cohort. AS severity will be graded invasively (aortic valve pressure measurements with dobutamine stress testing for SAVI) and non-invasively (echocardiography during dobutamine and exercise stress). Computed tomography (CT) of the aortic valve will be scored for calcium, and hemodynamics simulated using computational fluid dynamics. Cardiac biomarkers and functional parameters will be serially monitored. The primary objective is to see how SAVI and conventional measures (MG, AVA and Vmax) correlate with clinical parameters (quality of life survey, 6-minute walk test [6MWT], and biomarkers). Conclusions: The SAVI-AoS study will extensively evaluate patients with unexplained, symptomatic MAS to determine any added value of SAVI versus traditional, resting valve parameters.

Percutaneous vs. surgical axillary access for transcatheter aortic valve implantation: the TAXI registry.

BACKGROUND: Transcatheter aortic valve implantation (TAVI) is an established management strategy for severe aortic valve stenosis. Percutaneous axillary approach for TAVI holds the promise of improving safety without jeopardizing effectiveness in comparison to surgical access. We aimed at appraising the comparative effectiveness of percutaneous vs. surgical axillary approaches for TAVI. METHODS: We performed an international retrospective observational study using de-identified details on baseline, procedural, and 1-month follow-up features. Valve Academic Research Consortium (VARC)-3 criteria were applied throughout. Outcomes of interest were clinical events up to 1 month of follow-up, compared with unadjusted and propensity score-adjusted analyses. RESULTS: A total of 432 patients were included, 189 (43.8%) receiving surgical access, and 243 (56.2%) undergoing percutaneous access. Primary hemostasis failure was more common in the percutaneous group (13.2% vs. 4.2%, P<0.001), leading to more common use of covered stent implantation (13.2% vs. 3.7%, P<0.001). Irrespectively, percutaneous access was associated with shorter hospital stay (-2.6 days [95% confidence interval: -5.0; -0.1], P=0.038), a lower risk of major adverse events (a composite of death, myocardial infarction, stroke, type 3 bleeding, and major access-site related complication; odds ratio=0.44 [0.21; 0.95], P=0.036), major access-site non-vascular complications (odds ratio=0.21 [0.06; 0.77], P=0.018), and brachial plexus impairment (odds ratio=0.16 [0.03; 0.76], P=0.021), and shorter hospital stay (-2.6 days [-5.0; -0.1], P=0.038). CONCLUSIONS: Percutaneous axillary access provides similar or better results than surgical access in patients undergoing TAVI with absolute or relative contraindications to femoral access.

Mortality outcomes and 30-day readmissions associated with coronary artery aneurysms; a National Database Study.

BACKGROUND: The literature on prevalence and outcomes of coronary artery aneurysm (CAA) in the United States (US) is limited. OBJECTIVE: To study the prevalence, outcomes, and trends of CAA. METHODS: Data from the national readmissions database (NRD) sample that constitutes 49.1% of the stratified sample of all hospitals in the US were analyzed for CAA among coronary angiography (CA) related hospitalizations for the years 2012-2018. RESULTS: A total of 6,843,910 index CA related hospitalizations were recorded for the years 2012-2018 in the NRD (Mean age 64.37 ± 13.30 years' 38.6% females). Of these 9671 (0.141%) were CAA, 5092 (52.7%) without-ACS and 4579 (47.3%) with ACS [NSTEMI occurred in 2907(63.5%) and STEMI in 1672(36.5%)]. In-hospital mortality among CAA was comparable to those without-CAA on angiography (n-209,2.17% vs n = 175,120,2.56%;p = 0.08). CAA patients who presented with ACS vs those without ACS had higher mortality (n = 150,3.28%vsn = 60,1.16%;p < 0.001) cardiogenic shock 6.9%vs2%, ventricular arrythmias 9.2%vs5.2%, coronary dissection 58%vs42.7%, and need for mechanical circulatory support 7%vs2.7% respectively. Percutaneous coronary intervention (PCI) was performed among 45.2% patients; however, on coarsened exact matching of baseline characteristics, PCI had no association with mortality, patients (OR 1.22, 95%CI0.69-2.16, p = 0.49). The prevalence of CAA on CA trend towards increased mortality with ACS increased over the years 2012-2018 (linear p-trend <0.05). The 30-day readmissions rate were 13.8% (non-CAA) vs 4.6% (CAA) p = 0.001 predominantly cardiovascular causes (50.9%vs70.7%) and PCI on readmission (7.06%vs17.5%). CONCLUSION: CAA is an uncommon anomaly noted on coronary angiography. The higher mortality in patients with ACS and increasing trend of CAA-ACS warrants more research.

N-acetylcysteine in non-acetaminophen-induced acute liver failure: a systematic review and meta-analysis of prospective studies.

Introduction: There are discordant reports on N-acetylcysteine (NAC) efficacy in non-acetaminophen acute liver failure (ALF). Aim: To determine whether NAC is beneficial in non-acetaminophen ALF. Material and methods: We performed a systemic review and meta-analysis of published data to address the question. PubMed and MEDLINE were searched using the terms non-acetylcysteine and ALF due to non-acetaminophen, viral infection, drug-induced or autoimmune hepatitis. The primary outcome was overall mortality. Secondary outcomes were transplant-free survival and length of hospital stay. Risk ratios were calculated using a random model for meta-analysis. Results: A total of 672 patients were included in this meta-analysis from 5 prospective studies (NAC group: n = 334; control group: n = 338). Viral hepatitis (45.8% vs. 32.8%) followed by drug-induced liver injury (24.6% vs. 27.5%), indeterminate cause (13.2% vs. 21.6%) and autoimmune hepatitis (6.6% vs. 8.9%) were the most common etiologies of ALF in the treatment group and control group respectively. Treatment with N-acetylcysteine improved the transplant-free survival significantly (55.1% vs. 28.1%; RR = 0.56; 95% CI: 0.33-0.94) whereas the overall survival was not improved with NAC (71% vs. 59.8%; RR = 0.73; 95% CI: 0.48-1.09). The NAC treatment was associated with shorter hospital stay (standard difference in means (SMD) = -1.62; 95% CI: -1.84 to -1.40, p < 0.001). Conclusions: The treatment of patients with acute liver failure with N-acetylcysteine improved transplant-free survival and length of stay.

Acute myocardial infarction and acute heart failure among renal transplant recipients: a national readmissions database study.

BACKGROUND: The literature on the mortality and 30-day readmissions for acute heart failure and for acute myocardial infarction among renal-transplant recipients is limited. OBJECTIVE: To study the in-hospital mortality, cardiovascular complications, and 30-day readmissions among renal transplant recipients (RTRs). METHODS: Data from the national readmissions database sample, which constitutes 49.1% of all hospitals in the United States and represents more than 95% of the stratified national population, was analyzed for the years 2012-2018 using billing codes. RESULTS: A total of 588,668 hospitalizations in renal transplant recipients (mean age 57.7 ± 14.2 years; 44.5% female) were recorded in the study years. A total of 15,788 (2.7%) patients had a diagnosis of acute heart failure; 11,320 (71.7%) had acute heart failure with preserved ejection fraction and 4468 (28.3%) had acute heart failure with reduced ejection fraction; 17,256 (3%) patients had myocardial infarction, 3496 (20%) had ST-Elevation myocardial infarction while 13,969 (80%) had non-ST-elevation myocardial infarction. Overall, 11,675 (2%) renal-transplant patients died, of whom 757 (6.5%) had acute heart failure, 330 (2.8%) had acute reduced and 427 (3.7%) had acute preserved ejection fraction failure. Among 1652 (14.1%) patient deaths with myocardial infarction, 465 (4%) were ST-elevation- and 1187 (10.1%) were non-ST-Elevation-related. The absolute yearly mortality rate due to acute heart failure increased over the years 2012-2018 (p-trend 0.0002, 0.001, 0.002, 0.05, respectively), while the mortality rate due to myocardial infarction with ST-elevation decreased (p-trend 0.002). CONCLUSION: Cardiovascular complications are significantly associated with hospitalizations among RTRs. The absolute yearly mortality, and rate of heart failure (with reduced or preserved ejection fraction) increased over the study years, suggesting that more research is needed to improve the management of these patients.

Non-ST elevation myocardial infarction and cardiac arrest: The United States Nationwide Emergency Department Sample.

BACKGROUND: Literature regarding outcomes of cardiac arrest with associated NSTEMI is limited. We aim to study the predictors and survival outcomes of cardiac arrest patients presenting to the emergency department who were diagnosed with non-ST elevated myocardial infarction (NSTEMI). METHODS: Data from the nationwide emergency department sample (NEDS) that constitutes 20% sample of hospital-owned emergency departments in the United States was analyzed for the cardiac arrest related visits from 2009-2018. Cardiac arrest was defined by the ICD codes. RESULTS: Out of 3,235,555 cardiac arrests (mean age 64.0 ± 19.5 years, 40.7% females) there were 163,970 (5.1%) patients diagnosed with NSTEMI during the years 2009-2018. Among cardiac arrest patients, the survival for NSTEMI patients was higher than patients without NSTEMI (46.7% vs. 22.7%). These patients were more likely to be males and elderly. Among the predictors for NSTEMI cardiac arrests, hypertension (OR 1.12, p < 0.001), peripheral vascular disease (OR 1.16, p < 0.001), prior-coronary artery bypass graft (OR 1.20, p < 0.001) were the predominant ones. Cardiovascular interventions were more common in NSTEMI cardiac arrests and were associated with lower mortality rates (p < 0.001). However, trend for coronary interventions remained steady over study years. We observed an increase in prevalence of NSTEMI cardiac arrests with a worsening trend in survival from 2009-2018. CONCLUSIONS: NSTEMI was not uncommon in patients with cardiac arrest. NSTEMI cardiac arrest had a better prognosis than patients without NSTEMI. Cardiovascular interventions might have survival benefits. More research is required to identify NSTEMI in cardiac arrest patients and further evaluate the effect of cardiovascular interventions on survival.

Trends and complications associated with acute new-onset heart failure: a National Readmissions Database-based cohort study.

Literature regarding recent trends and outcomes of acute new-onset heart failure (AHF) with preserved ejection fraction (AHFpEF) and reduced ejection fraction (AHFrEF) is limited. The objective of this study is to study the outcomes of AHFpEF and AHFrEF in the USA. Data from the National Readmissions Database (NRD) sample that constitutes 49.1% of the stratified sample of all hospitals in the USA, representing more than 95% of the national population, were analyzed for hospitalization visits for acute heart failure. ICD-9 and ICD-10 codes were used to identify AHF. A total of 2,559,102 adult index AHF patients (mean age 70.79 ± 14.58 years, 49.4% females), 1,028,970 (40.2%) AHFpEF and 1,330,999 (52%) AHFrEF, were recorded in the National Readmissions Database for the years 2016-2018. A total of 152,465 (5.96%) acute heart failure, 47,271 (4.6%) AHFpEF and 91,973 (6.91%) AHFrEF, died during hospitalization, and 45,810 (1.9%) were readmitted in 30 days among alive discharges. Higher complication rates which included ventricular arrhythmias, acute coronary, and cerebrovascular events were observed among AHFrEF than AHFpEF. Higher proportion of patients with AHFrEF needed intensive care unit and ventilatory support during the hospitalization. The trend of incidence of AHFrEF, mortality among AHFrEF, and overall mortality worsened while AHFpEF improved over the study years 2012-2018 (p-trend < 0.05). Coronary procedures improved mortality rates among AHFpEF and AHFrEF. AHF is very common and is associated with significant mortality. The incidence of AHFrEF and mortality among AHFrEF had worsened, which calls for urgent intervention. Improved recognition of AHF is needed, and guideline-directed treatment of underlying risk factors including coronary artery disease can improve mortality. Graphic abstract of the analysis presented (created with BioRender.com).

Brain Natriuretic Peptide as a Marker of Adverse Neurological Outcomes Among Survivors of Cardiac Arrest.

BACKGROUND: Neurological prognosis after cardiac arrest remains ill-defined. Plasma brain natriuretic peptide (BNP) may relate to poor neurological prognosis in brain-injury patients, though it has not been well studied in survivors of cardiac arrest. METHODS: We performed a retrospective review and examined the association of BNP with mortality and neurological outcomes at discharge in a cohort of cardiac arrest survivors enrolled from January 2012 to December 2016 at the Wake Forest Baptist Hospital, in North Carolina. Cerebral performance category (CPC) and modified Rankin scales were calculated from the chart based on neurological evaluation performed at the time of discharge. The cohort was subdivided into quartiles based on their BNP levels after which multivariable adjusted logistic regression models were applied to assess for an association between BNP and poor neurological outcomes as defined by a CPC of 3 to 4 and a modified Rankin scale of 4 to 5. RESULTS: Of the 657 patients included in the study, 254 patients survived until discharge. Among these, poor neurological status was observed in 101 (39.8%) patients that had a CPC score of 3 to 4 and 97 patients (38.2%) that had a modified Rankin scale of 4 to 5. Mean BNP levels were higher in patients with poor neurological status compared to those with good neurological status at discharge (P = .03 for CPC 3-4 and P = .02 for modified Rankin score 4-5). BNP levels however, did not vary significantly between patients that survived and those that expired (P = .22). BNP did emerge as a significant discriminator between patients with severe neurological disability at discharge when compared to those without. The area under the curve for BNP predicting a modified Rankin score of 4 to 5 was 0.800 (95% confidence interval [CI] 0.756-0.844, P < .001) and for predicting CPC 3 to 4 was 0.797 (95% CI 0.756-0.838, P < .001). BNP was able to significantly improve the net reclassification index and integrated discriminatory increment (P < .05). BNP was not associated with long-term all-cause mortality (P > .05). CONCLUSIONS: In survivors of either inpatient or out-of-hospital cardiac arrest, increased BNP levels measured at the time of arrest predicted severe neurological disability at discharge. We did not observe an independent association between BNP levels and long-term all-cause mortality. BNP may be a useful biomarker for predicting adverse neurological outcomes in survivors of cardiac arrest.