Incidence, Current Guidelines and Management of Gastrointestinal Bleeding after Transcatheter Aortic Valve Replacement: A Systematic Review.

BACKGROUND: There is a significant increase in morbidity and mortality in patients complicated by major bleeding following transcatheter aortic valve replacement (TAVR). It has become more challenging to manage such complications when the patient needs to be on anticoagulation or antiplatelet agent post-procedure to prevent thrombotic/embolic complications. METHODS: We systematically reviewed all available randomized controlled trials and observational studies to identify incidence rates of gastrointestinal bleeding post-procedure. After performing a systematic search, a total of 8731 patients from 15 studies (5 RCTs and 10 non-RCTs) were included in this review. RESULTS: The average rate of gastrointestinal bleeding during follow-up was 3.0% in randomized controlled trials and 1.9% among observational studies. CONCLUSION: Gastrointestinal bleeding has been noted to be higher in the RCTs as compared to observational studies. This review expands knowledge of current guidelines and possible management of patients undergoing TAVR.

Sociodemographic Characteristics as Predictors of Outcomes in Hepatocellular Carcinoma: A Retrospective Cohort Study.

BACKGROUND: Race, gender, insurance status, and income play important roles in predicting health care outcomes. However, the impact of these factors has yet to be fully elucidated in the setting of hepatocellular carcinoma (HCC). METHODS: We designed a retrospective cohort study utilizing data from the Surveillance, Epidemiology, and End Results (SEER) program to identify patients diagnosed with resectable HCC (N = 28,518). Demographic factors of interest included race (Asian/Pacific Islander [API], African American [AA], Native American/Alaska Native [NA], or White [WH]) and gender (male [M] or female [F]). Insurance classifications included those having Medicare/Private Insurance [ME/PI], Medicaid [MAID], or No Insurance [NI]. Median household income was estimated for all diagnosed with HCC. Endpoints included: (1) overall survival; (2) likelihood of receiving a recommendation for surgery; and (3) specific surgical intervention performed. Multivariate multinomial logistic regression for relative risk ratio (RRR) and Cox regression models were used to identify pertinent associations. RESULTS: Race, gender, insurance status, and income had statistically significant effects on the likelihood of surgical recommendation and overall survival. API were more likely to receive a recommendation for hepatic resection (RRR = 1.45; 95% CI: 1.31-1.61; Reference Race: AA) and exhibited prolonged overall survival (HR = 0.77; 95% CI: 0.73-0.82; Reference Race: AA) as compared to members of any other ethnic group; there was no difference in these endpoints between AA, NA, or WH individuals. Gender also had a significant effect on survival: Females exhibited superior overall survival (HR = 0.89; 95% CI: 0.85-0.93; Reference Gender: M) as compared to males. Patients who had ME/PI were more likely than those with MAID or NI to receive a surgical recommendation. ME/PI was also associated with superior overall survival. Conclusions: Race, gender, insurance status, and income have measurable effects on HCC management and outcomes. The underlying causes of these disparities warrant further investigation.

Patient outcomes in myeloproliferative neoplasm-related thrombosis: Insights from the National Inpatient Sample.

BACKGROUND: Philadelphia-negative myeloproliferative neoplasms (MPNs) - polycythemia vera (PV), essential thrombocythemia (ET), and primary myelofibrosis (PMF) - often present with thrombosis. We aimed to determine the inpatient mortality, cost of care, and length-of-stay among individuals with Philadelphia-negative MPNs who had arterial or venous thrombosis associated with admission versus those who were admitted for non-thrombosis-related events. METHODS: Using ICD-10M coding, we identified 7,128,770 patients from the National Inpatient Sample (NIS) database who were hospitalized in 2016. 31,302 patients had a diagnosis of a Philadelphia-negative MPN. Mortality, length-of-stay, and cost of care were compared between patients who had thrombosis included among the top three diagnoses and those who were admitted for other reasons. Chi-squared test for categorical variables and t-test for continuous variables were used to compare baseline characteristics. Final multivariable models were constructed to determine predictors of outcomes. RESULTS: Inpatient mortality was significantly higher among individuals with Philadelphia-negative MPN who had thrombosis associated with admission as compared to those who were hospitalized for other reasons (5.7% versus 3.1%, P < 0.001). Unadjusted cost of care was also significantly higher for patients with thrombosis as compared to those without thrombosis ($25,539.06 versus $19,002.72 USD, respectively, P < 0.001). Length-of-stay was longer among the former group as compared to the latter (8.26 versus 7.95 days, P = 0.0963). However, this finding did not reach statistical significance. CONCLUSIONS: Hospitalization for MPN-related thrombotic events is associated with excess inpatient mortality and higher cost of care. However, thrombosis has no statistically significant effect on length-of-stay among this population. The underlying causes of mortality and cost disparities among patients with MPN-associated thrombosis warrant further investigation.

Disappearing "Myxoma": Left Atrial Thrombus Masquerading as a Myxoma.

Intracardiac masses can be challenging to differentiate by echocardiography. We present a case of several intracardiac masses with echocardiographic features of both thrombi and myxoma in a patient with heart failure symptoms. The masses were confirmed to be thrombi after complete resolution on repeat echocardiography following anticoagulation. Echocardiography complements the history and physical exams in diagnosing intracardiac masses but may present a diagnostic challenge when features are not pathognomonic. Follow up imaging after anticoagulation should be standard of care to avoid unnecessary surgeries when the diagnosis of a cardiac mass is uncertain.