Outcomes and predictors of readmission after implantation of a percutaneous left atrial appendage occlusion device in the United States: A propensity score-matched analysis from The National Readmission Database.

BACKGROUND: Left atrial appendage occlusion (LAAO) devices have become a favorable alternative option among nonvalvular atrial fibrillation (AF) patients with long-term contraindication to anticoagulation. Real-world experience with postprocedural readmission rates and predictors of readmission in LAAO patients is limited. OBJECTIVE: To assess all-cause 30-day readmission rate and predictors of readmission after LAAO procedure in the United States. METHOD: This retrospective observational study included all AF patients undergoing percutaneous LAAO procedures in the United States from January 1, 2016, and December 31, 2017, in the National Readmission Database. The primary outcome measure was all-cause 30-day readmission. A propensity score-matched analysis compared outcomes with a non-LAAO AF cohort. RESULT: Among 14 024 LAAO procedures (age: 76 ± 8 years; 60.5% males), 9.4% were readmitted within 30-days and, 0.2% died during their index hospitalization. The most frequent primary diagnosis during readmission among LAAO was gastrointestinal bleeding (12%). The incidence of LAAO procedures increased by 102%. In the multivariate model, gender and CHA2 DS2 -VASc failed to predict readmission. Age 55-64 years had lower odds (adjusted odds ratios [aOR]: 0.41; 95% confidence interval [CI]: 0.18-0.94), while drug abuse (aOR: 4.1; 95% CI: 1.34-12.54), and deficiency anemia (aOR: 1.88; 95% CI: 1.12-3.18) had higher odds of readmission. In propensity-matched cohort, compared to non-LAAO AF, LAAO patients had lower 30-day readmission (9.4% vs. 10.98%, p = .002) and all-cause in-hospital mortality (0.19% vs. 0.57%, p < .001). CONCLUSION: The readmission rate following the LAAO procedure is substantial (approximately 10%), and largely attributable to gastrointestinal bleeding. Factors such as drug abuse and anemia must be explored further to minimize readmission risk.

Cannabis-induced basal-mid-left ventricular stress cardiomyopathy: A case report.

Cannabis, popularly known as marijuana, is a recreational drug derived from the plant Cannabis Sativa. It has been recognized as the most widely used mood-altering substance in the world and is falsely perceived as a safe substance by the public at large. This is mostly due to lack of awareness of its adverse effects as well as successful attempts for legalization of its use in many states. We present a unique case of a 56-year-old man who presented with neurological deficits concerning for stroke. Soon after presentation, he required endotracheal intubation for airway protection due to worsening mental status changes and pulmonary edema. Echocardiogram revealed severe hypokinesis of the basal and mid-left ventricular (LV) walls with hyperdynamic motion of the apex (reverse takotsubo). Coronary angiography revealed no obstructive disease. Urine toxicology screen was positive for Δ-9-tetrahydrocannabinol. The patient then stated to have used excess marijuana before the symptom onset, while denying any recent emotional stressors. The findings were consistent with stress cardiomyopathy (SC) triggered by marijuana use. Myocardial infarction, stroke, and peripheral arteriopathy have been increasingly reported in younger individuals using marijuana. SC appears to be another unique complication of marijuana use triggered through its effects on the autonomic nervous and endocannabinoid systems.

Cardiac transplantation for hypertrophic cardiomyopathy in the United States 2003-2011.

BACKGROUND: Cardiac transplant (CT) is the sole option in a minority of hypertrophic cardiomyopathy (HC) adults with refractory symptoms or end-stage disease. AIMS/METHODS: We aimed to examine the trends and hospital outcomes of CT in HC using 2003-2011 Nationwide Inpatient Sample database. RESULTS: HC comprised 1.1% of CT (151 of 14,277) performed during this time period (age 45±12 years, 67% male, 79% Caucasians). Number of HC CT increased from 2003 to 2011 (odds ratio=1.174; 95% confidence interval=1.102-1.252; P< 0.001). Comorbidities included congestive heart failure (76%), hypertension (23%), chronic kidney disease (23%), hyperlipidemia (19%), diabetes (13%), and coronary artery disease (10%). Acute in-hospital major adverse events occurred in 1 in 4 (23%) patient and 1 in 25 (3.8%) patients died perioperatively. Other major adverse events included allograft rejection or vasculopathy (23%), postoperative stroke or transient ischemic attack (3.5%), acute renal failure (43%), respiratory failure requiring mechanical ventilation (13%), sepsis (10%) or need for blood transfusion (10%). Compared to 1990-2004 United Network of Organ Sharing registry data (n=303), patients in current cohort had more comorbid conditions [diabetes (13%-vs-0%); chronic obstructive lung disease (9%-vs-1%); P < 0.001 for both), were more likely to be male (66%-vs-48% P< 0.001), were less likely to be Caucasian (79%-vs-86%; P < 0.001) or smokers (3%-vs-17%; P < 0.001) and less often required perioperative circulatory support or hemodialysis (17%-vs-49%, P < 0.001 and 3.2%-vs-8.3%, P = 0.04, respectively). CONCLUSION: HC comprises a small proportion of patients undergoing CT. The annual number of CT in HC has increased in recent years at least in part due to inclusion of patients with more comorbid conditions. Transplant recipients in the current cohort, however, required less postoperative circulatory support or renal replacement therapy.

Influence of comorbidity on survival after out-of-hospital cardiac arrest in the United States.

AIM: Association between survival rate and Elixhauser Comorbidity Index (ECI) among individuals suffering an out-of-hospital cardiac arrest (OHCA) in the United States (US). METHODS: We utilized the US National Emergency Department Sample (NEDS) dataset to retrospectively identify individuals experiencing OHCA between January 1, 2006 to December 31, 2015; using the International Classification of Diseases, Ninth Revision-Clinical Modification (ICD-9-CM) and Tenth Revision-Clinical Modification (ICD-10-CM) codes. Logistic regression analysis with twenty-nine ECIs as predictor variables were performed to compute for odds ratio (OR), after controlling for age and gender. Linear regression analysis performed to assess survival trend after clustering based on ECI. We also assessed the association of ECI with survival rate after stratifying patients based on cardiac rhythm (shockable versus non-shockable). RESULTS: We identified 1,282,520 (16.4%, survived-to-discharge) weighted observations presenting primarily after OHCA in the US during the study period. Annual percentage change (APC) in survival rate among OHCA patients with no ECI and those with >3 ECI was -1.53% (95% CI: -1.98% to -1.09%, Ptrend < 0.001) and 1.2% (95% CI: 0.69%-1.7%, Ptrend = 0.001), respectively. Adjusted OR for ECI was 1.31 (95% CI: 1.3-1.31, P < 0.001). Percentage change in the survival rate among shockable and non-shockable rhythm was 5.6% (95% CI: -3.9% to 15.13%, Ptrend = 0.127) and 1.04% (95% CI: 0.01%-2.07%, Ptrend = 0.05), respectively, with a unit increase in ECI. CONCLUSION: In the US, OHCA patients with higher ECI have greater survival-to-discharge rate, demonstrating "comorbidity paradox".

Dynamic left ventricular changes in patients with gestational diabetes: A speckle tracking echocardiography study.

PURPOSE: The left ventricle (LV) undergoes physiologic remodeling in adaptation to the hemodynamic changes that occur in pregnancy. Speckle tracking echocardiography (STE) is a novel and reliable tool to evaluate subtle myocardial alterations that have been utilized to assess myocardial changes in patients with diabetes mellitus (DM) but not in patients with gestational DM (GDM). We seek to evaluate changes in LV function using STE in patients with GDM compared with women with normal pregnancy. METHODS: This was a single-center retrospective cohort study. A total of 312 pregnant patients that underwent transthoracic echocardiogram (TTE) between 2009 and 2014 were screened. After excluding patients with comorbidities or insufficient data, 90 women were included. TTE from the second and third trimester for each patient were then reviewed, and STE analysis was performed. RESULTS: Of the 90 subjects, 72 had normal pregnancies and 18 developed GDM. There was no difference in LV end-diastolic diameter (4.73 ± 0.40 versus 4.60 ± 0.56, p = 0.25), LV end-systolic diameter (3.12 ± 0.35 versus 2.91 ± 0.61, p = 0.152), or ejection fraction (62.26 ± 4.12 versus 63.50 ± 5.24, p = 0.314) between the two groups. Global longitudinal strain was lower (-19.8 ± 3.34 versus -17.2 ± 2.18, p < 0.001) in patients with GDM, while time-to-peak strain was greater (0.43 ± 0.05 versus 0.50 ± 0.06, p < 0.001). Circumferential and radial strains were preserved in both groups. CONCLUSIONS: Although conventional TTE variables show preserved LV size and function, LV longitudinal strain suggests subclinical myocardial dysfunction in patients with GDM. © 2016 Wiley Periodicals, Inc. J Clin Ultrasound 45:20-27, 2017.

Protective effect of cytomegalovirus reactivation on relapse after allogeneic hematopoietic cell transplantation in acute myeloid leukemia patients is influenced by conditioning regimen.

Cytomegalovirus (CMV) reactivation after allogeneic hematopoietic cell transplant (allo-HCT) has been associated with a reduced risk of relapse in patients with acute myeloid leukemia (AML). However, the influence of the conditioning regimen on this protective effect of CMV reactivation after allo-HCT is relatively unexplored. To address this, we evaluated the risk of relapse in 264 AML patients who received T cell-replete, 6/6 HLA matched sibling or 10/10 HLA matched unrelated donor transplantation at a single institution between 2006 and 2011. Of these 264 patients, 206 received myeloablative (MA) and 58 received reduced-intensity conditioning (RIC) regimens. CMV reactivation was observed in 88 patients with MA conditioning and 37 patients with RIC. At a median follow-up of 299 days, CMV reactivation was associated with significantly lower risk of relapse in patients who received MA conditioning both in univariate (P = .01) and multivariate analyses (hazard ratio, .5246; P = .006); however, CMV reactivation did not significantly affect the risk of relapse in our RIC cohort. These results confirm the protective effect of CMV reactivation on relapse in AML patients after allo-HCT reported by previous studies but suggest this protective effect of CMV reactivation on relapse is influenced by the conditioning regimen used with the transplant.