Outcomes Following Surgical Repair of Sinus Venosus Atrial Septal Defects: A Systematic Review and Meta-Analysis.

BACKGROUND: Sinus venosus atrial septal defect (SVASD) is a rare congenital cardiac anomaly comprising 5% to 10% of all atrial septal defects. Although surgical closure is the standard treatment for SVASD, data on outcomes have been confined to small cohorts. Thus, we conducted a systematic review of the outcomes of SVASD repair. METHODS AND RESULTS: The primary outcome was death. Secondary outcomes encompassed atrial fibrillation, sinus node dysfunction, pacemaker insertion, cerebrovascular accident, reoperation, residual septal defect, superior vena cava obstruction, and reimplanted pulmonary vein obstruction. Pooled incidences of outcomes were calculated using a random-effects model. Forty studies involving 1320 patients who underwent SVASD repair were included. The majority were male patients (55.4%), with 88.0% presenting with associated anomalous pulmonary venous connection. The weighted mean age was 18.6±12.5 years, and the overall weighted mean follow-up period was 8.6±10.4 years. The in-hospital mortality rate was 0.24%, with a 30-day mortality rate of 0.5% reported in 780 patients. Incidences of atrial fibrillation, sinus node dysfunction, pacemaker insertion, and cerebrovascular accident over the long-term follow-up were 3.3% (2.18%-4.93%), 6.5% (5.09%-8.2%), 2.23% (1.34%-3.57%), and 2.03% (0.89%-2.46%) respectively. Reoperation occurred in 1.36% (0.68%-2.42%) of surgeries, residual septal defect in 1.34% (0.69%-2.42%), superior vena cava obstruction in 1.76% (1.02%-2.9%), and reimplanted pulmonary vein obstruction in 1.4% (0.7%-2.49%). CONCLUSIONS: This is the first comprehensive analysis of outcomes following surgical repair of SVASD. The findings affirm the safety and effectiveness of surgery, establishing a reference point for evaluating emerging transcatheter therapies. Safety and efficacy profiles comparable to surgical repair are essential for widespread adoption of transcatheter treatments.

Device-related thrombosis after transcatheter closure of atrial septal defect using the Gore Cardioform ASD occluder.

A previously healthy 60-year-old female was diagnosed with a secundum atrial septal defect measuring 23 x 12 mm on transesophageal echocardiogram.

Complete Revascularization and Angina-Related Health Status in the ISCHEMIA Trial.

BACKGROUND: The impact of complete revascularization (CR) on angina-related health status (symptoms, function, quality of life) in chronic coronary disease (CCD) has not been well studied. OBJECTIVES: Among patients with CCD randomized to invasive (INV) vs conservative (CON) management in ISCHEMIA (International Study of Comparative Health Effectiveness with Medical and Invasive Approaches), we compared the following: 1) the impact of anatomic and functional CR on health status compared with incomplete revascularization (ICR); and 2) the predicted impact of achieving CR in all INV patients compared with CON. METHODS: Multivariable regression adjusting for patient characteristics was used to compare 12-month health status after independent core laboratory-defined CR vs ICR in INV patients who underwent revascularization. Propensity-weighted modeling was then performed to estimate the treatment effect had CR or ICR been achieved in all INV patients, compared with CON. RESULTS: Anatomic and functional CR were achieved in 43.3% and 57.8% of 1,641 INV patients, respectively. Among revascularized patients, CR was associated with improved Seattle Angina Questionnaire Angina Frequency compared with ICR after adjustment for baseline differences. After modeling CR and ICR in all INV patients, patients with CR and ICR each had greater improvements in health status than CON, with better health status with CR than ICR. The projected benefits of CR were most pronounced in patients with baseline daily/weekly angina and not seen in those with no angina. CONCLUSIONS: Among patients with CCD in ISCHEMIA, health status improved more with CR compared with ICR or CON, particularly in those with frequent angina. Anatomic and functional CR provided comparable improvements in quality of life. (International Study of Comparative Health Effectiveness With Medical and Invasive Approaches [ISCHEMIA]; NCT01471522).

Surgical vs transcatheter aortic valve replacement in bicuspid aortic valve stenosis: A systematic review and meta-analysis.

This systematic review and meta-analysis aim to provide a comprehensive analysis of the literature directly comparing the outcomes of surgical aortic valve replacement (SAVR) and TAVR in patients with BAV stenosis. Medline, PubMed, and Scopus were systematically searched for articles published between 2000 and 2023, 1862 studies were screened, and 6 retrospective studies met the inclusion criteria. We included 6550 patients in the final analyses: 3,292 and 3,258 in the SAVR and TAVR groups, respectively. Both groups have similar rates of in-hospital mortality (odds ratio (OR) 1.11; 95% CI 0.59-2.10; p = 0.75) and stroke (OR 1.25; 95% CI 0.85-1.86; p = 0.26. Patients who underwent SAVR experienced lower rates of permanent pacemaker implantation (OR 0.54; 95% CI 0.35-0.83; p = 0.005) and paravalvular leak (OR 0.47; 95% CI 0.26-0.86; p = 0.02). On the other hand, patients who underwent TAVR displayed lower rates of acute kidney injury (OR 1.81; 95% CI 1.15-2.84; p = 0.010), major bleeding (OR 3.76; 95% CI 2.18-6.49; p < 0.00001), and pulmonary complications (OR 7.68; 95% CI 1.21-48.84; p = 0.03). Despite the early mortality data suggesting that TAVR may be a reasonable strategy for patients with bicuspid AS with low to intermediate surgical risk, the increased risk of PPI and PVL is concerning. A prospective, randomized, controlled trial reporting long-term outcomes with pre-defined subgroup analyses based on BAV morphology is paramount. In the interim, caution should be exercised in the widespread adoption of TAVR in lower surgical-risk patients.

Diagnostic Imageology of Goldenhar Syndrome: Report of a Rare Case.

Goldenhar syndrome is a rare disorder that normally affects just one side and is distinguished by a variety of anomalies in internal organs, vertebrae, and craniofacial tissues. Although this sickness varies genetically and has been linked to a variety of factors, its etiology is unknown. We describe a case of hemifacial microsomia linked with Goldenhar syndrome that was clinically and radiographically investigated using cone-beam computed tomography. Several classical indications of the condition were present in the patient along with few uncommon ones. The many facets of this uncommon disease have been covered, with a focus on early detection and a multidisciplinary approach to treatment.

Effect of skin phototype on quantitative nailfold capillaroscopy.

Objectives: To determine the impact of Fitzpatrick scale-based skin phototype on visualization of capillary density using nailfold capillaroscopy in healthy Indian adults. Methods: In this cross-sectional study, healthy adults were examined for nailfold capillaroscopy findings utilizing a portable capillary microscope at 800× magnification. Photographs of two contiguous areas measuring 1 mm2 each of the distal row of capillaries were captured. Images were captured from the central area of all fingers except thumb in both hands. Capillary density and morphology of nailfold capillaroscopies were assessed by two blinded assessors. The nailfold capillaroscopy parameters were compared between the Standard Fitzpatrick scale-based skin phototypes. Results: A total of 118 healthy adults were enrolled in the study. Type III, IV, V, and VI skin phototypes were seen in 27 (22.90%), 32 (27.19%), 29 (24.58%), and 30 (25.42%) participants, respectively. All participants (100%) had normal nailfold capillaroscopy morphology and architecture. Zero capillaries were visible in 11 fingers among 5 patients (4.24%) and all of them had Type VI phototype. The median capillary density per mm was 5.19 (interquartile range = 4.37-6.75) with 90 (76.27%) participants having less than seven capillaries. The median average capillary density was significantly different (p-value < 0.0001) across Type III (8.13, interquartile range = 6.44-8.88), Type IV (5.67, interquartile range = 4.41-6.98), Type V (4.94, interquartile range = 4.19-5.38), and Type VI (4.53, interquartile range = 3.72-4.91) phototypes (p < 0.05). Conclusion: The number of capillaries visualized during nailfold capillaroscopy decreases as the skin pigmentation increases. There is a need to redefine the nailfold capillaroscopy density and avascularity by taking skin phototype as one of the determinants before labeling a nailfold capillaroscopy finding with less visualized capillaries as abnormal.

Cardiovascular and Renal Implications of Myocardial Infarction in the ISCHEMIA-CKD Trial.

BACKGROUND: ISCHEMIA-CKD (International Study of Comparative Health Effectiveness With Medical and Invasive Approaches-Chronic Kidney Disease) reported an initial invasive treatment strategy did not reduce the risk of death or nonfatal myocardial infarction (MI) compared with a conservative treatment strategy in patients with advanced chronic kidney disease, stable coronary disease, and moderate or severe myocardial ischemia. The cumulative frequency of different MI type after randomization and subsequent prognosis have not been reported. METHODS: MI classification was based on the Third Universal Definition for MI. For procedural MI, the primary MI definition used creatine kinase-MB as the preferred biomarker, whereas the secondary MI definition used cTn (cardiac troponin); both definitions included elevated biomarker-only events with higher thresholds than nonprocedural MIs. The cumulative frequency of MI type according to treatment strategy was determined. The association of MI with subsequent all-cause death and new dialysis initiation was assessed by treating MI as a time-dependent covariate. RESULTS: The 3-year incidence of type 1 or 2 MI with the primary MI definition was 11.2% in invasive treatment strategy and 13.6% in conservative treatment strategy (hazard ratio [HR], 0.66 [95% CI, 0.42-1.02]). Procedural MIs were more frequent in invasive treatment strategy and accounted for 9.8% and 28.3% of all MIs with the primary and secondary MI definitions, respectively. Patients had an increased risk of all-cause death after type 1 MI (adjusted HR, 4.35 [95% CI, 2.73-6.93]) and after procedural MI with the primary (adjusted HR, 2.75 [95% CI, 0.99-7.60]) and secondary MI definitions (adjusted HR, 2.91 [95% CI, 1.73-4.88]). Dialysis initiation was increased after a type 1 MI (HR, 6.45 [95% CI, 2.59-16.08]) compared with patients without an MI. CONCLUSIONS: In ISCHEMIA-CKD, the invasive treatment strategy had higher rates of procedural MIs, particularly with the secondary MI definition, and lower rates of type 1 and 2 MIs. Procedural MIs, type 1 MIs, and type 2 MIs were associated with increased risk of subsequent death. Type 1 MI increased the risk of dialysis initiation. REGISTRATION: URL: https://www. CLINICALTRIALS: gov; Unique identifier: NCT01985360.

Transcatheter Aortic Valve Implantation in a Failed Perceval Sutureless Valve, Complicated by Aortic Annular Rupture.

As the use of surgically implanted sutureless aortic valves has increased over the past decade, we expect to encounter their failure increasingly in coming years. We describe a case of Perceval aortic valve failure with stent infolding and severe stenosis. This condition was treated with valve-in-valve transcatheter aortic valve implantation and complicated by aortic annular rupture at the site of infolding. This case is important because it outlines the limited experience with valve-in-valve transcatheter aortic valve implantation to treat failed sutureless valves and identifies sutureless valve infolding as a potential risk for annular rupture.

Puisque l'implantation valvulaire aortique sans suture s'est accrue au cours de la dernière décennie, nous nous attendons à rencontrer de plus en plus de défaillances de valves dans les années à venir. Nous décrivons un cas de défaillance de la valve aortique Perceval avec pliage de l'endoprothèse et sténose grave. Le traitement qui consistait en l'implantation valvulaire aortique de type valve-in-valve par cathéter a été compliqué par la rupture de l'anneau aortique au site du pliage. Il s'agit d'un cas important puisqu'il décrit le peu d'expérience en matière d'implantation valvulaire aortique de type valve-in-valve par cathéter dans le traitement des valves sans suture défectueuses et établit que le pliage d'une valve sans suture expose à un risque de rupture de l'anneau.

Outcomes of pregnancy in women with hypertrophic cardiomyopathy: A systematic review.

INTRODUCTION: Hypertrophic cardiomyopathy (HCM) is a genetic disorder that can be complicated by heart failure and sudden cardiac death. Pregnancy causes hemodynamic changes, which may be deleterious in patients with HCM. Existing cohort studies, analyzing maternal and fetal outcomes of pregnant HCM patients, are limited by small sample sizes. We performed a systematic review of maternal and fetal outcomes of pregnancy in patients with HCM. METHODS: We performed a literature search for studies reporting maternal or fetal outcomes in pregnant women with HCM. Primary outcomes included maternal death, stillbirth, and fetal death. Secondary maternal outcomes included both sustained and non-sustained ventricular tachycardia (VT), atrial fibrillation, heart failure (HF), syncope, cesarean delivery, and preeclampsia/eclampsia. The secondary fetal outcome was preterm birth. We used a random-effects model to determine pooled incidences of outcomes. RESULTS: We identified a total of 18 studies with 1624 pregnancies. The incidence of maternal death was 0.2%. The rates of sustained VT, any VT (including non-sustained), AF, HF, and syncope were 1% (0-1%), 6% (4-8%), 4% (2-6%), 5% (3-8%), and 9% (3-14%), respectively. Postpartum hemorrhage, preeclampsia/eclampsia, and cesarean section complicated 2% (1-4%), 4% (2-6%), and 43% (32-54%) of pregnancies, respectively. Neonatal death occurred in 0.2% of pregnancies. Stillbirth complicated 1% (95% CI, 0-3%) of pregnancies, whereas the incidence of preterm birth was 22% (95% CI, 18-25%). CONCLUSIONS: Women with HCM considering pregnancy can be reassured that the risk of maternal, fetal, or neonatal death is low. However, they are at risk of several non-fatal cardiac and pregnancy-related complications.

Dialysis Initiation in Patients With Chronic Coronary Disease and Advanced Chronic Kidney Disease in ISCHEMIA-CKD.

Background In participants with concomitant chronic coronary disease and advanced chronic kidney disease (CKD), the effect of treatment strategies on the timing of dialysis initiation is not well characterized. Methods and Results In ISCHEMIA-CKD (International Study of Comparative Health Effectiveness With Medical and Invasive Approaches-Chronic Kidney Disease), 777 participants with advanced CKD and moderate or severe ischemia were randomized to either an initial invasive or conservative management strategy. Herein, we compare the proportion of randomized participants with non-dialysis-requiring CKD at baseline (n=362) who initiated dialysis and compare the time to dialysis initiation between invasive versus conservative management arms. Using multivariable Cox regression analysis, we also sought to identify the effect of invasive versus conservative chronic coronary disease management strategies on dialysis initiation. At a median follow-up of 23 months (25th-75th interquartile range, 14-32 months), dialysis was initiated in 18.9% of participants (36/190) in the invasive strategy and 16.9% of participants (29/172) in the conservative strategy (P=0.22). The median time to dialysis initiation was 6.0 months (interquartile range, 3.0-16.0 months) in the invasive group and 18.2 months (interquartile range, 12.2-25.0 months) in the conservative group (P=0.004), with no difference in procedural acute kidney injury rates between the groups (7.8% versus 5.4%; P=0.26). Baseline clinical factors associated with earlier dialysis initiation were lower baseline estimated glomerular filtration rate (hazard ratio [HR] associated with 5-unit decrease, 2.08 [95% CI, 1.72-2.56]; P<0.001), diabetes (HR, 2.30 [95% CI, 1.28-4.13]; P=0.005), hypertension (HR, 7.97 [95% CI, 1.09-58.21]; P=0.041), and Hispanic ethnicity (HR, 2.34 [95% CI, 1.22-4.47]; P=0.010). Conclusions In participants with non-dialysis-requiring CKD in ISCHEMIA-CKD, randomization to an invasive chronic coronary disease management strategy (relative to a conservative chronic coronary disease management strategy) is associated with an accelerated time to initiation of maintenance dialysis for kidney failure. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT01985360.

Sex and Medium-term Outcomes of ST-Segment Elevation Myocardial Infarction in Kerala, India: A Propensity Score-Matched Analysis.

BACKGROUND: Sex-based differences have been found in outcomes following ST-segment myocardial infarction (STEMI). Studies assessing sex-based differences in STEMI among Indian patients have reported conflicting results. METHODS: A prospective multicenter registry of consecutive patients with STEMI who presented to percutaneous coronary intervention (PCI)-capable hospitals in the Indian state of Kerala between June 2013 and March 2017 was used to assess 1-year outcomes. The primary endpoint was a composite of major adverse cardiac events (MACE), including death, stroke, nonfatal myocardial infarction, and rehospitalization for heart failure. Outcomes of 2 sex-based propensity score-matched groups were compared. RESULTS: We included 3194 patients (19.4% women). Women presenting with STEMI were older, had more traditional cardiovascular risk factors, and were more likely to be classified as living in poverty. After propensity-score matching, women experienced greater incidence of MACE (20.9% vs 14.3%, P < 0.01), primarily driven by increased 1-year mortality (14.3% vs 8.6%, P < 0.01). Women were more likely to experience prehospital delays, compared with men. Although reperfusion rates were similar between the groups, men were more likely than women to undergo reperfusion within the first 12 hours of chest pain onset. Among patients undergoing primary PCI, women were more likely to have delayed PCI than were men (80.2% vs 72.9%, P = 0.03). Procedural characteristics were similar between groups. CONCLUSIONS: Women in this cohort experienced higher incidence of MACE at 1 year, compared to men, primarily owing to increased mortality. Timeliness of reperfusion appears to be the primary factor impacting differences in outcomes between the 2 groups and may represent an attractive target for quality-improvement initiatives.

CONTEXTE: Des différences entre les sexes ont été constatées dans les résultats obtenus à la suite d'un infarctus du myocarde avec élévation du segment ST (STEMI). Des études évaluant les différences entre les sexes parmi des patients indiens ayant subi un STEMI ont produit des résultats contradictoires. MÉTHODOLOGIE: Un registre multicentrique et prospectif de patients consécutifs qui ont subi un STEMI et se sont présentés dans des hôpitaux où pouvait être pratiquée une intervention coronarienne percutanée (ICP) dans l'État indien du Kerala entre juin 2013 et mars 2017 a été utilisé pour évaluer les résultats à 1 an. Le paramètre d'évaluation principal regroupait des événements cardiaques indésirables majeurs (ECIM) comprenant le décès, l'accident vasculaire cérébral, l'infarctus du myocarde non fatal et la réhospitalisation pour cause d'insuffisance cardiaque. Les résultats de deux groupes appariés selon les scores de propension en fonction du sexe ont été comparés. RÉSULTATS: Nous avons inclus 3 194 patients (19,4 % de femmes). Les femmes qui avaient subi un STEMI étaient plus âgées, présentaient des facteurs de risque cardiovasculaire plus classiques et étaient plus susceptibles d'appartenir à la catégorie des personnes vivant dans la pauvreté. Après l'appariement selon les scores de propension, l'incidence des ECIM était plus élevée chez les femmes (20,9 % vs 14,3 %, p < 0,01), surtout en raison d'une mortalité accrue à 1 an (14,3 % vs 8,6 %, p < 0,01). Les femmes étaient plus susceptibles de subir des retards avant l'hospitalisation que les hommes. Bien que les taux de reperfusion étaient semblables dans les groupes étudiés, les hommes étaient plus susceptibles que les femmes de subir une reperfusion dans les 12 premières heures suivant l'apparition de la douleur thoracique. Parmi les patients ayant subi une ICP primaire, les femmes étaient plus susceptibles d'être touchées par un retard d'intervention que les hommes (80,2 % vs 72,9 %, p = 0,03). Les caractéristiques de l'intervention étaient similaires dans les groupes étudiés. CONCLUSIONS: L'incidence des ECIM à 1 an au sein de cette cohorte était plus élevée chez les femmes que chez les hommes, surtout en raison d'une mortalité accrue. La rapidité de la reperfusion semble être le principal facteur ayant des répercussions sur les différences de résultats entre les deux groupes et pourrait représenter une cible intéressante dans le cadre d'initiatives d'amélioration de la qualité.

Tele-rheumatology for overcoming socioeconomic barriers to healthcare in resource constrained settings: lessons from COVID-19 pandemic.

OBJECTIVES: To assess acceptability of teleconsultation among the socioeconomically marginalized sections of patients with rheumatic and musculoskeletal diseases (RMDs), to identify the socioeconomic barriers in continuing rheumatology care during the COVID-19 crisis and to identify patients who could benefit by shifting to tele-rheumatology consultations. METHODS: This was a cross sectional analytical study done at a tertiary care teaching hospital in India including patients with RMDs who were not on biological diseases modifying agents. Assessment of disease status, socioeconomic status and economic impact of COVID-19 was done via tele-consultation. RESULTS: Out of the 680 patients satisfying inclusion criteria, 373 completed the study. The format was found easy by 334 (89.6%) of them and 284 (76.1%) considered tele-rheumatology better than in-person consultation. During the pre-COVID months, the median monthly per capita income of the families of our patients and cost of illness was Indian rupees (INR) 2000 (US$ 26) and INR 1685 (US$ 21.91), respectively. Families whose financial needs were met (OR = 0.38, 95% CI: 0.239, 0.598) or those with schooling upto at least secondary school (OR = 0.442, 95% CI: 0.260, 0.752) (P =0.002) were less likely to stop prescription drugs. In a hypothetical model, 289 (77.4%) could be successfully switched to tele-rheumatology follow-up. CONCLUSION: The acceptability of tele-rheumatology among socioeconomically marginalized patients with RMDs is good. During times of crisis, patients from poorer strata of society and lower educational background are likely to abruptly stop medications. Switching to a telemedicine-based hybrid model is likely to improve drug adherence with substantial savings on loss of pay and out of pocket expenditure.

Mid-term outcomes with adult endovascular treatment of coarctation of the aorta.

BACKGROUND: This study examines the contemporary medium- and long-term outcomes of endovascular repair of aortic coarctation in the adult. METHODS: We reviewed the clinical and imaging data of 56 consecutive adult patients with aortic coarctation who underwent endovascular repair at the Mazankowski Alberta Heart Institute, Edmonton, Alberta, Canada, from 2003 to 2018. RESULTS: There were 20 (35.7%) female and 36 (64.3%) male patients (including 9 re-intervention cases) with a mean age of 33.6 ± 13.6 years. Thirty-seven (66.1%) were treated with balloon-expandable covered stent and 12 (21.4%) were treated with balloon-expandable bare-metal stent. Pressure gradients decreased from baseline level of 27.99 ± 12.75 (8-70) mm Hg to 5.33 ± 4.42 (0-17.5) mm Hg following the procedure. There were 2 (3.6%) procedure related complications (aortic dissection [n = 1] and stent malposition [n = 1]). During a median (Q1 - Q3) follow up of 5.36 (2.28-7.58) years, 2 deaths (4.2%) and 9 (19%) re-interventions occurred, and the overall survival was 95.8%. CONCLUSION: Percutaneous coarctoplasty, with either covered or bare metal stents, is a safe and durable option for aortic coarctation repair with excellent long-term survival.

Procedural Volume and Outcomes After Primary Percutaneous Coronary Intervention for ST-Segment-Elevation Myocardial Infarction in Kerala, India: Report of the Cardiological Society of India-Kerala Primary Percutaneous Coronary Intervention Registry.

Background There are limited data to inform policy mandating primary percutaneous coronary intervention (PPCI) volume benchmarks for catheterization laboratories in low- and middle-income countries. Methods and Results This prospective state-wide registry included ST-segment-elevation myocardial infarction patients with symptoms of <12 hours, or with ongoing ischemia at 12 to 24 hours, reperfused with PPCI. From June 2013 to March 2016, we recruited 5560 consecutive patients. We categorized hospitals on the basis of annual PPCI volumes into low, medium, and high volume (<100, 100-199, and ≥200 PPCIs per year, respectively). Kaplan-Meier curves and Cox regression models were used to examine the association between PPCI volume and 1-year mortality. Among 42 recruiting hospitals, there were 24 (57.2%) low-volume, 8 (19%) medium-volume, and 10 (23.8%) high-volume hospitals. The median (25th-75th percentile) TIMI (Thrombolysis in Myocardial Infarction) ST-segment-elevation myocardial infarction risk score was 3 (2-5). Cardiac arrest before admission occurred in 4.2%, 2.1%, and 2.9% of cases at low-, medium-, and high-volume hospitals, respectively (P=0.02). Total ischemic time differed significantly among low-volume (median [25th-75th percentile], 3.5 [2.4-5.5] hours), medium-volume (median, 3.8 [25th-75th percentile, 2.58-6.05] hours), and high-volume hospitals (median, 4.16 [25th-75th percentile 2.8-6.3] hours) (P=0.01). Vascular access was radial in 61.5%, 71.3%, and 63.2% of cases at low-, medium-, and high-volume hospitals, respectively (P=0.01). The observed 1-year mortality rate was 6.5%, 3.4%, and 8.6% at low-, medium- and high-volume hospitals, respectively (P<0.01), and the difference did not attenuate after multivariate adjustment (low versus medium: hazard ratio [95% CI], 1.80 [1.12-2.90]; high versus medium: hazard ratio [95% CI], 2.53 [1.78-3.58]) (P<0.01). Conclusions Low- and middle-income countries, like India, may have a nonlinear relationship between institutional PPCI volume and outcomes, partly driven by procedural variations and inequalities in access to care.

Predictors of mortality, strategies to reduce readmission, and economic impact of acute decompensated heart failure: Results of the Vellore Heart Failure Registry.

AIM: Heart failure is a global problem that is increasing in prevalence. We undertook the initiative to compile the Vellore Heart Failure Registry (VHFR) to assess the clinical profile, mortality, risk factors and economic burden of heart failure by conducting a prospective, observational, hospital-based cohort study in Vellore, Tamil Nadu. METHODS AND RESULTS: This study was a prospective observational cohort study conducted at the Christian Medical College and Hospital, Vellore, between January 2014 and December 2016. A total of 572 patients who satisfied the Boston criteria for "definite heart failure" were included and the primary outcome was all-cause mortality. The median duration of hospital stay was eight days and the in-hospital, one, three and six month mortalities were 13.25%, 27.3%, 32.53% and 38.15%, respectively. The median duration of survival was 921 days. Readmission for heart failure constituted 42%, and the most common cause of decompensation was an infection(31.5%). The presence of cyanosis at admission, history of previous stroke or transient ischemic attack, and American College of Cardiology (ACC)/American Heart Association (AHA) stage D at the time of discharge were independently associated with mortality at six months. The median total direct cost of admission was INR 84,881.00 ($ 1232.34) CONCLUSION: The VHFR cohort had younger, more diabetic, and fewer hypertensive subjects than most cohorts. Admission for heart failure is a catastrophic health expenditure. Attempts should be made to ensure a reduction in readmission rates by targeting goal-directed therapy. As the most common cause of acute decompensation is pneumonia, vaccinating all patients before discharge may also help in this regard.