In-Hospital Outcomes and Predictors of Mortality for Redo Surgical Mitral Valve Replacement Versus Transcatheter Mitral Valve-in-Valve Replacement.

Durability is a major limitation with bioprosthetic heart valves. For mitral valve prosthesis dysfunction, redo surgical mitral valve replacement (rSMVR) has been the mainstay of treatment; however, transcatheter mitral valve-in-valve replacement (mViV) has emerged as a viable alternative. Data comparing these procedures remains limited; therefore, we sought to compare the real-world in-hospital mortality, likelihood of adverse peri-operative outcomes, and predictors of mortality between rSMVR versus mViV using the National Inpatient Sample. During the study period, a weighted total of 1,890 patients (78%) underwent rSMVR, and 520 (22%) underwent mViV. After propensity matching, there were 310 patients in each cohort. There was no statistically significant difference in mortality with these procedures (odds ratio 1.53; 95% confidence interval 0.67 to 3.45; p = 0.31). rSMVR was associated with increased length of hospitalization (13 vs 7.5 days; p <0.001), increased medical costs ($324,124 vs $241,147; p <0.001), and increased peri-operative complications compared with mViV. Predictors of mortality unique to rSMVR were age >75 years, cirrhosis, sleep apnea, malnourishment/low body mass index, and obesity, signalizing greater suitability for mViV in these populations.

Mechanical chest compressions improve rate of return of spontaneous circulation and allow for initiation of percutaneous circulatory support during cardiac arrest in the cardiac catheterization laboratory.

BACKGROUND: Performing advanced cardiac life support (ACLS) in the cardiac catheterization laboratory (CCL) is challenging. Mechanical chest compression (MCC) devices deliver compressions in a small space, allowing for simultaneous percutaneous coronary intervention and reduced radiation exposure to rescuers. In refractory cases, MCC devices allow rescuers to initiate percutaneous mechanical circulatory support (MCS) and extracorporeal life support (ECLS) during resuscitation. This study sought to assess the efficacy and safety of MCC when compared to manual compressions in the CCL. METHODS: We performed a retrospective analysis of patients who received ACLS in the CCL at our institution between May 2011 and February 2016. Baseline characteristics, resuscitation details, and outcomes were compared between patients who received manual and mechanical compressions. RESULTS: Forty-three patients (67% male, mean age 58 years) required chest compressions for cardiac arrest while in the CCL (12 manual and 31 MCC). Patients receiving MCC were more likely to achieve return of spontaneous circulation (ROSC) (74% vs. 42%, p=0.05). Of those receiving MCC, twenty-two patients (71%) were treated with MCS. Patients receiving percutaneous ECLS were more likely to achieve ROSC (100% vs. 53%, p=0.003) and suffered no episodes of limb loss or TIMI major bleeding. There were no significant differences in 30-day survival or survival to hospital discharge between groups. CONCLUSIONS: Use of MCC during resuscitation of cardiac arrest in the CCL increases the rate of ROSC. Simultaneous implantation of MCS, including percutaneous ECLS, is feasible and safe during MCC-assisted resuscitation in the CCL.

Sequential Organ Failure Assessment Score at Presentation Predicts Survival in Patients Treated With Percutaneous Veno-Arterial Extracorporeal Membrane Oxygenation.

BACKGROUND AND PURPOSE: This study sought to investigate demographic, clinical, and procedural determinants of outcomes in patients treated with percutaneous veno-arterial (VA) extracorporeal membrane oxygenation (ECMO) initiated in the cardiac catheterization laboratory with a portable system. METHODS: We performed a retrospective review of patients treated with percutaneous VA-ECMO during the study period at our institution. A logistic regression model was applied to investigate the association between sequential organ failure assessment (SOFA) score and survivor status. Fisher's exact test was used to examine the association between survivor status and cannula size (15 Fr vs >15 Fr). RESULTS: Percutaneous VA-ECMO was initiated in 25 patients. At 30 days, 10 patients were alive (40%). Fifteen patients had cardiac arrest (CA) prior to ECMO initiation, of which 5 were alive at 30 days (33%). Survivors had a lower baseline median SOFA score (9 vs 16; P=.02; odds ratio, 0.577). Use of a smaller cannula was associated with survival (P=.01). There was an association between the size of the arterial cannula and increased blood transfusions (P<.01). CONCLUSIONS: Lower presenting SOFA score and smaller cannula size were associated with increased survival in patients with cardiogenic shock (CS) or CA who underwent percutaneous VA-ECMO placed in the cardiac catheterization laboratory using a portable system. Calculation of the SOFA score at presentation may help physicians determine which patients may derive benefit from ECMO. Smaller cannula size, while decreasing the amount of flow, may result in decreased bleeding and increased survival.

Predictors of survival following trans-catheter aortic valve closure for left ventricular assist device associated aortic insufficiency.

OBJECTIVE: This study sought to assess the long-term clinical benefits and predictors of survival of trans-catheter aortic valve closure in left ventricular assist device (LVAD) patients. BACKGROUND: LVADs have been shown to increase survival and quality of life in patients with end-stage heart failure. However, severe aortic insufficiency (AI) can develop in up to 50% of patients at 12 months resulting in significant morbidity and mortality. Trans-catheter treatment of LVAD associated AI has emerged as a potential alternative to surgical treatment. METHODS: We conducted a retrospective analysis of all patients undergoing trans-catheter aortic valve closure using an Amplatzer Multi-Fenestrated Septal Occluder "Cribriform" device to assess potential clinical and procedural factors associated with survival. Student's t-tests were used to compare baseline patient demographics and procedural characteristics, as well as patient outcomes immediately post procedure and at 6 months. A P-value of less than 0.05 was considered statistically significant. RESULTS: A total of 10 patients (70% male, median age 59 years) were included. Technical success was accomplished in 100% of patients with a 6 month survival rate of 30% (3/10). Compared with survivors, non-survivors had a higher rate of pre-procedural clinical co-morbidities, an increased likelihood of right ventricular failure, and received larger occluder devices. CONCLUSIONS: Trans-catheter aortic valve closure successfully treats late severe AI in LVAD patients, however, the presence or development of right heart failure portends a worse prognosis. Further studies are needed to investigate the factors involved in the development of right ventricular failure, and potential treatment, in patients undergoing trans-catheter aortic valve closure.

A Practical Scoring System to Select Optimally Sized Devices for Percutaneous Patent Foramen Ovale Closure.

BACKGROUND: Patent foramen ovale (PFO) has been linked to cryptogenic stroke, and closure has been reported to improve clinical outcomes. However, there are no clear guidelines to direct device sizing. This study sought to use patient characteristics and echocardiographic findings to create a prediction score for device sizing. METHODS: This was a retrospective review of patients undergoing percutaneous PFO closure at our institution between July 2010 and December 2014. Demographic and clinical characteristics were recorded, and all pre- and intraprocedural echocardiography results were evaluated. RESULTS: Thirty-six patients underwent percutaneous PFO closure during the study period. All procedures were performed using an Amplatzer Septal Occluder "Cribriform" (ASOC) device in one of three disc diameters: 25, 30, or 35 mm. Closure was indicated for cryptogenic stroke/transient ischemic attack in 75% of cases. Every case (100%) was successful with durable shunt correction at the 6-month follow-up without complications of erosion or device embolization. The presence of atrial septal aneurysm (ASA) (p = 0.027) and PFO tunnel length >10 mm (p = 0.038) were independently associated with increased device size. A scoring system of 1 point for male sex, 1 point for ASA, and 1 point for PFO tunnel >10 mm long was associated with the size of closure device implanted (p = 0.006). CONCLUSIONS: A simple scoring system may be used to select an optimally sized device for percutaneous PFO closure using the ASOC device.

Clinical and economic effectiveness of percutaneous ventricular assist devices for high-risk patients undergoing percutaneous coronary intervention.

BACKGROUND: Comparative effectiveness research (CER) is taking a more prominent role in formalizing hospital treatment protocols and health-care coverage policies by having health-care providers consider the impact of new devices on costs and outcomes. CER balances the need for innovation with fiscal responsibility and evidence-based care. This study compared the clinical and economic impact of percutaneous ventricular assist devices (pVAD) with intraaortic balloon pumps for high-risk patients undergoing percutaneous coronary intervention (PCI). METHODS: This study conducted a review of all comparative randomized control trials of the pVADS (Impella and TandemHeart) vs IABP for patients undergoing high-risk percutaneous coronary intervention (PCI). A retrospective analysis of the 2010 and 2011 Medicare MEDPAR data files was also performed to compare procedural costs and hospital length of stay (LOS). Readmission rates between the devices were also studied. RESULTS: Based on available trials, there is no significant clinical benefit with pVAD compared to IABP. Use of pVADs is associated with increased length of Intensive Care Unit stay and a total longer LOS. The incremental budget impact for pVADs was $33,957,839 for the United States hospital system (2010-2011). CONCLUSIONS: pVADs are not associated with improved clinical outcomes, reduced hospital length of stay, or reduced readmission rates. Management of high-risk PCI and cardiogenic shock patients with IABP is more cost effective than a routine use of pVADS. Use of IABP as initial therapy in high-risk PCI and cardiogenic shock patients may result in savings of up to $2.5 billion annually of incremental costs to the hospital system.

Successful percutaneous trans-catheter treatment of left ventricular assist device outflow graft stenosis with a covered stent.

Left ventricular assist devices improve survival in patients with advanced heart failure but can be associated with significant complication including infection, pump thrombosis, and de novo severe aortic insufficiency. Outflow graft stenosis is a much more rare complication, but one with significant hemodynamic consequences. Surgical repair is often necessary, but many patients are too high risk for further surgical intervention. We describe the first case of left ventricular assist device outflow graft stenosis treated with percutaneous trans-catheter placement of a covered stent.

Novel transcatheter closure of an iatrogenic perimembranous ventricular septal defect.

Iatrogenic membranous ventricular septal defects (VSD) are rare complications of cardiothoracic surgery, most commonly seen as a complication of aortic valve replacements. An iatrogenic VSD can lead to right sided heart failure, systemic hypoxia, and arrhythmias, and closure is often necessary. Given the increased mortality associated with repeat surgical procedures, percutaneous transcatheter closure of these iatrogenic VSDs has increasingly become the preferred choice of therapy. We describe the first case of iatrogenic membranous VSD in the setting of mitral valve replacement and tricuspid valve repair, using the newly approved Amplatzer Duct Occluder II Device from an entirely retrograde approach. © 2014 Wiley Periodicals, Inc.

One size does not fit all: case report of two percutaneous closures of aortic pseudoaneurysm and review of the literature.

Aortic pseudoaneurysms (PSAs) are common complications following cardiac surgery, and carry significant morbidity and mortality. Surgical management of aortic PSAs is associated with high mortality, however there are emerging reports of transcatheter techniques for closure of aortic PSAs. We present two cases of ascending aorta PSA which developed following cardiac surgery and were treated percutaneously with novel closure devices. We also describe a comprehensive review of the literature of all published cases of ascending aorta PSA which have been closed percutaneously, and report on the success rate and available devices for percutaneous closure.

Supplementing cross-cover communication with the patient acuity rating.

BACKGROUND: Patient hand-offs at physician shift changes have limited ability to convey the primary team's longitudinal insight. The Patient Acuity Rating (PAR) is a previously validated, 7-point scale that quantifies physician judgment of patient stability, where a higher score indicates a greater risk of clinical deterioration. Its impact on cross-covering physician understanding of patients is not known. OBJECTIVE: To determine PAR contribution to sign-outs. DESIGN: Cross-sectional survey. SUBJECTS: Intern physicians at a university teaching hospital. INTERVENTIONS: Subjects were surveyed using randomly chosen, de-identified patient sign-outs, previously assigned PAR scores by their primary teams. For each sign-out, subjects assigned a PAR score, then responded to hypothetical cross-cover scenarios before and after being informed of the primary team's PAR. MAIN MEASURE: Changes in intern assessment of the scenario before and after being informed of the primary team's PAR were measured. In addition, responses between novice and experienced interns were compared. KEY RESULTS: Between May and July 2008, 23 of 39 (59 %) experienced interns and 25 of 42 (60 %) novice interns responded to 480 patient scenarios from ten distinct sign-outs. The mean PAR score assigned by subjects was 4.2 ± 1.6 vs. 3.8 ± 1.8 by the primary teams (p < 0.001). After viewing the primary team's PAR score, interns changed their level of concern in 47.9 % of cases, their assessment of the importance of immediate bedside evaluation in 48.7 % of cases, and confidence in their assessment in 43.2 % of cases. For all three assessments, novice interns changed their responses more frequently than experienced interns (p = 0.03, 0.009, and <0.001, respectively). Overall interns reported the PAR score to be theoretically helpful in 70.8 % of the cases, but this was more pronounced in novice interns (81.2 % vs 59.6 %, p < 0.001). CONCLUSIONS: The PAR adds valuable information to sign-outs that could impact cross-cover decision-making and potentially benefit patients. However, correct training in its use may be required to avoid unintended consequences.

Patient acuity rating: quantifying clinical judgment regarding inpatient stability.

BACKGROUND: New resident work-hour restrictions are expected to result in further increases in the number of handoffs between inpatient care providers, a known risk factor for poor outcomes. Strategies for improving the accuracy and efficiency of provider sign-outs are needed. OBJECTIVE: To develop and test a judgment-based scale for conveying the risk of clinical deterioration. DESIGN: Prospective observational study. SETTING: University teaching hospital. SUBJECTS: Internal medicine clinicians and patients. MEASUREMENTS: The Patient Acuity Rating (PAR), a 7-point Likert score representing the likelihood of a patient experiencing a cardiac arrest or intensive care unit (ICU) transfer within the next 24 hours, was obtained from physicians and midlevel practitioners at the time of sign-out. Cross-covering physicians were blinded to the results, which were subsequently correlated with outcomes. RESULTS: Forty eligible clinicians consented to participate, providing 6034 individual scores on 3419 patient-days. Seventy-four patient-days resulted in cardiac arrest or ICU transfer within 24 hours. The average PAR was 3 ± 1 and yielded an area under the receiver operator characteristics curve (AUROC) of 0.82. Provider-specific AUROC values ranged from 0.69 for residents to 0.85 for attendings (P = 0.01). Interns and midlevels did not differ significantly from the other groups. A PAR of 4 or higher corresponded to a sensitivity of 82% and a specificity of 68% for predicting cardiac arrest or ICU transfer in the next 24 hours. CONCLUSIONS: Clinical judgment regarding patient stability can be reliably quantified in a simple score with the potential for efficiently conveying complex assessments of at-risk patients during handoffs between healthcare members.

Capnography and chest-wall impedance algorithms for ventilation detection during cardiopulmonary resuscitation.

OBJECTIVE: Hyperventilation is both common and detrimental during cardiopulmonary resuscitation (CPR). Chest-wall impedance algorithms have been developed to detect ventilations during CPR. However, impedance signals are challenged by noise artifact from multiple sources, including chest compressions. Capnography has been proposed as an alternate method to measure ventilations. We sought to assess and compare the adequacy of these two approaches. METHODS: Continuous chest-wall impedance and capnography were recorded during consecutive in-hospital cardiac arrests. Algorithms utilizing each of these data sources were compared to a manually determined "gold standard" reference ventilation rate. In addition, a combination algorithm, which utilized the highest of the impedance or capnography values in any given minute, was similarly evaluated. RESULTS: Data were collected from 37 cardiac arrests, yielding 438min of data with continuous chest compressions and concurrent recording of impedance and capnography. The manually calculated mean ventilation rate was 13.3+/-4.3/min. In comparison, the defibrillator's impedance-based algorithm yielded an average rate of 11.3+/-4.4/min (p=0.0001) while the capnography rate was 11.7+/-3.7/min (p=0.0009). There was no significant difference in sensitivity and positive predictive value between the two methods. The combination algorithm rate was 12.4+/-3.5/min (p=0.02), which yielded the highest fraction of minutes with respiratory rates within 2/min of the reference. The impedance signal was uninterpretable 19.5% of the time, compared with 9.7% for capnography. However, the signals were only simultaneously non-interpretable 0.8% of the time. CONCLUSIONS: Both the impedance and capnography-based algorithms underestimated the ventilation rate. Reliable ventilation rate determination may require a novel combination of multiple algorithms during resuscitation.

CPR quality improvement during in-hospital cardiac arrest using a real-time audiovisual feedback system.

BACKGROUND: Cardiopulmonary resuscitation (CPR) quality during actual cardiac arrest has been found to be deficient in several recent investigations. We hypothesized that real-time feedback during CPR would improve the performance of chest compressions and ventilations during in-hospital cardiac arrest. METHODS: An investigational monitor/defibrillator with CPR-sensing and feedback capabilities was used during in-hospital cardiac arrests from December 2004 to December 2005. Chest compression and ventilation characteristics were recorded and quantified for the first 5 min of resuscitation and compared to a baseline cohort of arrest episodes without feedback, from December 2002 to April 2004. RESULTS: Data from 55 resuscitation episodes in the baseline pre-intervention group were compared to 101 resuscitations in the feedback intervention group. There was a trend toward improvement in the mean values of CPR variables in the feedback group with a statistically significant narrowing of CPR variable distributions including chest compression rate (104+/-18 to 100+/-13 min(-1); test of means, p=0.16; test of variance, p=0.003) and ventilation rate (20+/-10 to 18+/-8 min(-1); test of means, p=0.12; test of variance, p=0.04). There were no statistically significant differences between the groups in either return of spontaneous circulation or survival to hospital discharge. CONCLUSIONS: Real-time CPR-sensing and feedback technology modestly improved the quality of CPR during in-hospital cardiac arrest, and may serve as a useful adjunct for rescuers during resuscitation efforts. However, feedback specifics should be optimized for maximal benefit and additional studies will be required to assess whether gains in CPR quality translate to improvements in survival.