Infective endocarditis surgery timing.

BACKGROUND: The optimum timing of surgical intervention in complicated left-sided infective endocarditis is not well established. Guidelines from various professional societies are not consistent regarding this. Data concerning this remains limited with conflicting results. METHODS: The national inpatient database (NIS) was used to identify patients hospitalized from the year 2016 to 2020 for infective endocarditis and who underwent surgical intervention for complicated left-sided endocarditis. Primary and secondary outcomes were analyzed in patients who had surgical intervention within 7 days (early surgery group) and after 7 days (late surgery group) of the index hospitalization. RESULTS: Primary outcome [composite of all-cause death, acute cerebrovascular accident (CVA), peripheral septic emboli, intracranial or intraspinal abscess, and cardiac arrest] was better in the early surgery group compared to the late surgery group 32.6 % vs 45.1 % [adjusted Odds ratio (aOR) = 0.59, 95 % Confidence interval (CI) = 0.52-0.67, P value â‰ª 0.001]. This was mainly due to better incidence of acute CVA (15.7 %vs 24 %, aOR = 0.59, CI = 0.50-0.69, P value â‰ª 0.001), peripheral septic emboli (18.5 % vs 27.3 %, aOR = 0.60, CI = 0.52-0.70, P value â‰ª 0.001) and intracranial/intraspinal abscess (1.2 % vs 4.74 %, aOR = 0.24, CI = 0.14-0.38, P value â‰ª 0.001). There is no difference in the incidence of all-cause in-hospital death (7.57 % vs 7.75 % aOR = 0.97, CI = 0.77-1.23, P value = 0.82) or cardiac arrest (3.4 % vs 3.54 %, aOR = 0.96, CI = 0.68-1.35, P value = 0.80). CONCLUSION: Surgical intervention within 7 days of index hospitalization is associated with a better incidence of acute CVA, peripheral septic emboli, and intracranial or intraspinal abscess but not with a better incidence of all-cause in-hospital death.

TAVR vs balloon aortic valvotomy for severe aortic stenosis and cardiogenic shock: An insight from the National Inpatient Sample database.

BACKGROUND: Severe Aortic stenosis (AS) complicated by cardiogenic shock (CS) represents a grave clinical condition with limited treatment options. Evidence from small observation studies favors that Transcatheter Aortic Valve Replacement (TAVR) might be a feasible option in these patients in contrast to emergent Balloon Aortic Valvuloplasty (BAV) which is associated with very high short and long-term mortality. METHODS: 11,405 hospitalizations with severe AS complicated by CS between 2016 and 2020 were identified using the National Inpatient Sample (NIS) Database, and patients were then stratified according to whether they received TAVR or BAV. Propensity-score matching was used to account for differences in the baseline characteristics. Primary and secondary outcomes were then compared between 3485 hospitalizations in direct TAVR group and with 3485 matched hospitalizations in the BAV group. The primary outcome was a composite of all-cause in-hospital death, acute cerebrovascular accident (CVA), and myocardial infarction (MI). Secondary outcomes and safety outcomes were also compared between the two groups. RESULTS: TAVR was associated with fewer primary outcomes events as compared to BAV {36.8 % vs 56.8 %, aOR (95%CI) = 0.38(0.30-0.47)}, due to fewer all-cause in-hospital deaths {17.8 % vs 38.9 %, aOR (95%CI) =0.34 (0.26-0.43)} and MI {12.3 % vs 32.4 %, aOR (95%CI) = 0.29 (0.22-0.39)}. TAVR was associated with higher rates of acute CVA {6.17 % vs 3.44 %, aOR (95%CI) = 1.84 (1.08-3.21)} and pacemaker implantation post procedure {11.9 % vs 6.03 %, aOR (95%CI) = 2.10 (1.41-3.18)}. CONCLUSION: Direct TAVR in shock and severe Aortic stenosis is a better strategy than rescue Balloon aortic valvotomy.

Early Neonatal Death Possibly From a Rare Congenital Coronary Artery Anomaly.

We report a term female newborn who presented with bradycardia and weak respiratory efforts immediately after birth. Mother had an uneventful pregnancy and the infant was delivered by cesarean section secondary to arrest of labor. The infant did not respond to the neonatal resuscitation and was declared dead 32 minutes after birth. Autopsy findings include left coronary artery (LCA) ostium stenosis and moderate-to-severe chorioamnionitis on placental examination. An autopsy did not find any anatomic or histologic abnormalities in other organ systems that could be attributed to the cause of early neonatal death. To the best of our knowledge, ours is the third case reported in the literature on LCA ostium stenosis presenting immediately after delivery. Unfortunately, all the infants had a fatal outcome. Our case report emphasizes the importance of a meticulous autopsy examination, considering coronary artery anomalies, in case of early neonatal deaths.

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.

Can the Pediatric Early Warning Score (PEWS) Predict Hospital Length of Stay?

BACKGROUND: Limited studies have evaluated the utility of scoring systems in the pediatric emergency department (PED) and no studies have evaluated their ability to predict hospital length of stay (LOS) and the usage of Observation units (OUs). OBJECTIVE: To evaluate the utility of the Pediatric Early Warning Score (PEWS) in predicting LOS in pediatric patients and thus anticipate admission to an OU versus the pediatric ward. METHODS: A retrospective study of pediatric inpatients (0 to 18 years) at an inner-city community hospital between January 2014 and December 2014. Patients with psychiatric illness, non-medical reasons for hospital stay, and those not discharged to 'home' were excluded. Demographic data, PEWS in the ED, and LOS for each patient were recorded and analyzed. RESULTS: A total of 719 patients were analyzed. PEWS range was 0 to 8. The mean LOS was 56.8 hours for patients with PEWS 0-1 compared to 62.7 hours for patients with PEWS ≥2 (p=0.02). There was a significant difference in PEWS for LOS ≤24 and ≤36 hours in comparison to those with LOS >24 hours and >36 hours, respectively (p<0.001). Overall, the PEWS correlated with LOS (r=0.11, p=0.002). Age correlated inversely with LOS (r=-0.16, p<0.001), without correlation to PEWS (r=-0.002, p= 0.96). CONCLUSIONS:  PEWS correlated weakly with LOS. A statistically significant lower PEWS was observed for patients who had short stays (both ≤24 and ≤36 hours) in comparison to those requiring longer inpatient care. Therefore, the PEWS is a useful tool to predict LOS and aid ED physicians to determine disposition, although further prospective studies in centers with OUs would better characterize its ability to suggest admission to an OU compared to the wards.