Transcarotid versus transfemoral transcatheter aortic valve replacement: A systematic review and meta-analysis.

BACKGROUND: In the 2021 Transcatheter Valve Therapy (TVT) registry, 8.9 % of patients underwent TAVR via access sites other than the femoral artery. Transthoracic approaches may be contraindicated in some patients and may be associated with poorer outcomes. Therefore other alternative access routes are increasingly being performed. We conducted a systematic review of the literature on transcarotid transcatheter aortic valve replacement (TC-TAVR) and meta-analysis comparing outcomes of TC-TAVR and other access routes. METHODS: We comprehensively searched for controlled randomized and non-randomized studies from 4 online databases. We presented data using risk ratios (95 % confidence intervals) and measured heterogeneity using Higgins' I2. RESULTS: Sixteen observational studies on transcarotid TAVR were included in the analysis; 4 studies compared TC-TAVR vs TF-TAVR. The mean age and STS score for patients undergoing TC-TAVR were 80 years and 7.6 respectively. For TF-TAVR patients, mean age and STS score were 81.2 years and 6.5 respectively. There was no difference between patients undergoing TC-TAVR and TF-TAVR in the following 30-day outcomes: MACE [8.4 % vs 6.7 %; OR 1.32 (95 % CI 0.71-2.46 p = 0.38) I2 = 0 %], mortality [5.6 % vs 4.0 %; OR 0.42 (95 % CI 0.60-3.37, P = 0.42) I2 = 0 %] and stroke [0.7 % vs 2.3 %; OR 0.49 (95 % CI 0.09-2.56, P = 0.40) I2 = 0 %]. There was no difference in 30-day major vascular complications [0.7 % vs 3 %; OR 0.55 (95 % CI 0.06-5.29, P = 0.61) I2 = 39 %], major bleeding [0.7 % vs 3.8 %; OR 0.39 (95 % CI 0.09-1.67, P = 0.21) I2 = 0 %], and moderate or severe aortic valve regurgitation [8.6 % vs 9.9 %; OR 0.89 (95 % CI 0.48-1.65, P = 0.72) I2 = 0 %]. CONCLUSION: There are no significant differences in mortality, stroke MACE and major or life-threatening bleeding or vascular complications when TC-TAVR is compared to TF-TAVR approaches.

Transcarotid versus transthoracic transcatheter aortic valve replacement: A systematic review and meta-analysis.

BACKGROUND: Transthoracic approaches may be contraindicated in some patients and may be associated with poorer outcomes. Therefore other alternative access routes are increasingly being performed. We conducted a systematic review of the literature on Transcarotid transcatheter aortic valve replacement (TC-TAVR) and meta-analysis comparing outcomes of TC-TAVR and other access routes. METHODS: We comprehensively searched for controlled randomized and non-randomized studies from 4 online databases. We presented data using risk ratios (95 % confidence intervals) and measured heterogeneity using Higgins' I2. RESULTS: Sixteen observational studies on Transcarotid TAVR were included in the analysis; 4 studies compared 180 TC-TAVR patients vs 524 TT-TAVR patients. The mean age and STS score for patients undergoing TC-TAVR were 80 years and 7.6 respectively. For TT-TAVR patients, the mean age and STS score were 79.7 years and 8.7 respectively. TC-TAVR patients had lower 30-day MACE [7.8 % vs 13.7 %; OR 0.54 (95 % CI 0.29-0.99, P = 0.05)] and major or life-threatening bleeding [4.0 % vs 14.2 %; OR 0.25 (95 % CI 0.09-0.67, P = 0.006)]. There was no significant difference in 30-day: mortality [5.0 % vs 8.6 %; OR 0.61 (95 % CI 0.29-1.30, P = 0.20)], stroke or transient ischemic attack [2.8 % vs 4.0 %; OR 0.65 (95 % CI 0.25-1.73, P = 0.39)] and moderate or severe aortic valve regurgitation [5.0 % vs 4.6 %; OR 1.14. (95 % CI 0.52-2.52, P = 0.75)]. There was a trend towards fewer major vascular complications in TC-TAVR [3.0 % vs 7.8 %; OR 0.42 (95 % CI 0.16-1.12, P = 0.08)]. CONCLUSION: Compared with transthoracic TAVR, TC-TAVR patients had lower odds of 30-day MACE and life-threatening bleeding and no differences in 30-day mortality, stroke or TIA, aortic valve regurgitation.

Prognostic Value of Hospital Frailty Risk Score and Clinical Outcomes in Patients Undergoing Revascularization for Critical Limb-Threatening Ischemia.

Background The impact of medical record-based frailty assessment on clinical outcomes in patients undergoing revascularization for critical limb-threatening ischemia (CLTI) is unknown. Methods and Results This study included patients with CLTI aged ≥18 years from the nationwide readmissions database 2016 to 2018 who underwent endovascular revascularization (ER) or surgical revascularization (SR). The hospital frailty risk score, a previously validated International Classification of Diseases, Tenth Edition, Clinical Modification (ICD-10-CM) claims-based score, was used to categorize patients into low- (<5), intermediate- (5-15), and high-risk (>15) frailty categories. Primary outcomes were in-hospital mortality and major amputation at 6 months. A total of 64 338 patients were identified who underwent ER (82.3%) or SR (17.7%) for CLTI. The mean (SD) age of the cohort was 69.3 (11.8) years, and 63% of patients were male. This study found a nonlinear association between hospital frailty risk score and in-hospital mortality and 6-month major amputation. In both ER and SR cohorts, the intermediate- and high-risk groups were associated with a significantly higher risk of in-hospital mortality (high-risk group: ER: odds ratio [OR], 7.2 [95% CI, 4.4-11.6], P<0.001; SR: OR, 28.6 [95% CI, 3.4-237.6], P=0.002) and major amputation at 6 months (high-risk group: ER: hazard ratio [HR], 1.6 [95% CI, 1.5-1.7], P<0.001; SR: HR, 1.7 [95% CI, 1.4-2.2], P<0.001) compared with the low-risk group. Conclusions The hospital frailty risk score, generated from the medical record, can identify frailty and predict in-hospital mortality and 6-month major amputation in patients undergoing ER or SR for CLTI. Further studies are needed to assess if this score can be incorporated into clinical decision-making in patients undergoing revascularization for CLTI.

Burden of Hypertensive Crisis in Patients With End-Stage Kidney Disease on Maintenance Dialysis: Insights From United States Renal Data System Database.

BACKGROUND: There is paucity of information on the incidence, clinical characteristics, admission trends, and outcomes of hypertensive crisis (HTN-C) in patients with end-stage kidney disease (ESKD) who are on maintenance dialysis. METHODS: We conducted a retrospective observational study of HTN-C admissions in patients with end-stage kidney disease using the United States Renal Data System. We identified patients with end-stage kidney disease aged ≥18 years on dialysis and were hospitalized for HTN-C from January 2006 to August 2015. RESULTS: A total of 54 483 patients with end-stage kidney disease were hospitalized for HTN-C during the study period. After study exclusions, 37 214 patients were included in the analysis. A majority of patients were Black, there were more women than men and the South region of the country accounted for a great majority of patients. During the study period, hospitalization rates increased from 1060 per 100 000 beneficiary years to 1821 (Ptrend<0.0001). Overall, in-hospital mortality, 30-day, and 1-year mortality were 0.6%, 2.3%, and 21.8%, respectively, and 30-day readmission rate was 31.1%. During the study period, most study outcomes showed a significant decreasing trend (in-hospital mortality 0.6%-0.5%, 30-day mortality 2.4%-1.9%, 1-year mortality 23.9%-19.7%, Ptrend<0.0001 for all). CONCLUSIONS: Hospitalizations for HTN-C have increased consistently during the decade studied. Although temporal trends showed improving mortality and readmission rates, the absolute rates were still high with 1 in 3 patients readmitted within 30 days and 1 in 5 patients dying within 1 year of index hospitalization.

In-hospital Outcomes of Patients with Septic Shock and Underlying Chronic Atrial Fibrillation: A Propensity Matched Analysis from A National Dataset.

INTRODUCTION: Atrial fibrillation (AF) is one of the most common arrhythmias among hospitalized patients. Among patients admitted with septic shock (SS), the new occurrence of atrial fibrillation has been associated with an increase in intensive care unit (ICU) length of stay and in-hospital mortality. This is partially related to further reduction in cardiac output and thus worsening organ perfusion due to atrial fibrillation. However, there is a paucity of research on the outcomes of patients who have underlying chronic AF (UCAF) and then develop SS. This study aimed to identify the clinical characteristics and outcomes of patients with UCAF admitted with SS compared to patients with SS without UCAF. METHODS: This study was a retrospective analysis of the 2016 and 2017 Nationwide Readmission Database. ICD-10 codes were used to identify patients with SS, and these patients were stratified into those with and without UCAF. Propensity matching analyses were performed to compare clinical outcomes and in-hospital mortality between the two groups. RESULTS: A total of 353,422 patients with hospitalization for SS were identified, 5.8% (n = 20,772) of whom had UCAF. After 2:1 propensity matching, 20,719 patients were identified as having SS with UCAF, and 41,438 patients were identified as having SS without UCAF. Patients with SS and UCAF had a higher incidence of ischemic stroke [2.5% versus 2.2%, p = 0.012], length of stay [11.5 days versus 10.9 days, p < 0.001], mean total charges [$154,094 versus $144,037, p < 0.001] compared to those with SS without UCAF. In-hospital mortality was high in both groups, but was slightly higher among those with SS and UCAF than those with SS and no UCAF [34.4% versus 34.1%, p = 0.049]. CONCLUSIONS: This study identified UCAF as an adverse prognosticator for clinical outcomes. Patients with SS and UCAF need to be identified as a higher risk category of SS who will require more intensive management.

Hypertension and Cardiovascular Diseases among Electronic and Combustible Cigarette Users.

Introduction: Combustible cigarette use is associated with an increased risk of several cardiovascular diseases; however, less is known about associations between these cardiovascular conditions and electronic cigarette use. Methods: This study investigated relationships between electronic and/or combustible cigarette use and diagnoses of cardiovascular diseases using the National Health Interview Survey from 2014, 2016, 2017, and 2018. Results: Compared to non-users, dual users of electronic and combustible cigarettes had increased likelihood of having prior diagnoses of hypertension (OR 1.660, 95% CI = 1.519-1.814), stroke (OR 2.396, 95% CI = 2.011-2.855), diabetes mellitus (OR 1.219, 95% CI = 1.108-1.341), coronary artery disease (OR 2.211, 95% CI = 1.837-2.660), and myocardial infarction (OR 3.839, 95% CI = 3.232-4.560). Exclusive use of electronic cigarettes was associated with an increased likelihood of having hypertension compared to non-users (OR 1.244, 95% CI = 1.048-1.477). Conclusions: There were no differences in diagnoses of stroke, diabetes mellitus, coronary artery disease, or myocardial infarction among exclusive electronic cigarette users compared to non-users; however, these associations could change as young electronic cigarette users with hypertension age, indicating the need for continued research.

Sepsis, Septic Shock, and Differences in Cardiovascular Event Occurrence.

Introduction: Mortality estimates from sepsis and septic shock ranged from 18% to 35% and 40% to 60%, respectively, prior to 2014. Sepsis patients who experience subsequent cardiovascular events have increased mortality; however, data are limited among septic shock patients. This study reports in-hospital mortality, incident cardiovascular events, and cardiovascular procedures among sepsis patients with and without subsequent septic shock. Methods: Patients with a primary diagnosis of sepsis with and without a secondary diagnosis of septic shock were identified from the 2016 and 2017 National Readmissions Database. These patients were then evaluated for the occurrence of cardiovascular events and procedures. Results: A total of 2,127,137 patients were included in the study, with a mean age of 66 years. Twenty percent of patients (n = 420,135) developed subsequent septic shock. In-hospital mortality among patients with a primary diagnosis of sepsis was 5.3%, and it was 31.2% for those with subsequent septic shock. Notable cardiovascular events occurring among sepsis patients with and without subsequent septic shock, respectively, included: acute kidney injury (65.1% vs. 32.8%, P < .0001), acute systolic heart failure (9.8% vs. 5.1%, P < .0001), NSTEMI (8.8% vs. 3.2%, P < .0001), and ischemic stroke (2.3% vs. 0.9%, P < .0001). Similarly, the most common cardiovascular procedures between the two groups were: percutaneous coronary intervention (0.37% vs. 0.20%, P < .0001), intra-aortic balloon pump (0.19% vs. 0.02%, P < .0001), and extracorporeal membrane oxygenation (0.18% vs. 0.01%, P < .0001). Conclusions: Sepsis with subsequent septic shock is associated with an increased frequency of in-hospital cardiovascular events and procedures.

Impact of Underlying Congestive Heart Failure on In-Hospital Outcomes in Patients with Septic Shock.

Purpose: Septic shock (SS) manifests with profound circulatory and cellular metabolism abnormalities and has a high in-hospital mortality (25%-50%). Congestive heart failure (CHF) patients have underlying circulatory dysfunction and compromised cardiac reserve that may place them at increased risk if they develop sepsis. Outcomes in patients with CHF who are admitted with SS have not been well studied. Materials and Method: Retrospective cross sectional secondary analysis of the Nationwide Readmission Database (NRD) for 2016 and 2017. ICD-10 codes were used to identify patients with SS during hospitalization, and then the cohort was dichotomized into those with and without an underlying diagnosis of CHF. Results: Propensity match analyses were performed to evaluate in-hospital mortality and clinical cardiovascular outcomes in the 2 groups. Cardiogenic shock patients were excluded from the study. A total of 578,629 patients with hospitalization for SS were identified, of whom 19.1% had a coexisting diagnosis of CHF. After propensity matching, 81,699 individuals were included in the comparative groups of SS with CHF and SS with no CHF. In-hospital mortality (35.28% vs 32.50%, P < .001), incidence of ischemic stroke (2.71% vs 2.53%, P = .0032), and acute kidney injury (69.9% vs 63.9%, P = .001) were significantly higher in patients with SS and CHF when compared to those with SS and no CHF. Conclusions: This study identified CHF as a strong adverse prognosticator for inpatient mortality and several major adverse clinical outcomes. Study findings suggest the need for further investigation into these findings' mechanisms to improve outcomes in patients with SS and underlying CHF.

Cardiovascular Outcomes Associated With Adult Electronic Cigarette Use.

Electronic cigarettes (E-Cigs) have been advertised as a safer alternative to smoking. However, E-Cigs use, like smoking, delivers ultra-small aerosol particles, which may be associated with cardiovascular disease. This study aimed to look into the association between E-Cigs use and cardiovascular disease outcomes. The study involved self-reported data from 16,855 participants from the National Health Interview Survey data from years 2014, 2016, 2017, and 2018. Results from the logistic regression analysis report E-Cigs users had higher odds of having myocardial infarction (OR 4.09, 95% CI [1.29, 12.98], P<0.05) when compared to non-users. Dual users had higher odds of myocardial infarction (OR 5.44, 95% CI [2.90, 10.22], P<0.05), stroke (OR 2.32, 95% CI [1.44, 3.74], P<0.05), and coronary artery disease (OR 2.27, 95% CI [1.37, 2.44], P<0.05) when compared to non-users.

Clinical Outcomes of the Dual-Therapy CD34 Antibody-Covered Sirolimus-Eluting Stent Versus Standard Drug-Eluting Coronary Stents: A Meta-Analysis.

BACKGROUND: Coronary stent neoatherosclerosis, thrombosis, and restenosis remain significant concerns with new-generation drug-eluting stents (DES). The Dual-Therapy CD34 antibody-covered sirolimus-eluting stent [dual therapy stent (DTS)] is a sirolimus-eluting stent with CD34 antibodies immobilized on its luminal surface to capture circulating endothelial progenitor cells and promote early endothelialization. We conducted a meta-analysis to determine whether the DTS was superior to standard DES. METHODS: We conducted a comprehensive search for controlled randomized and non-randomized studies. We presented data using risk ratios (95% confidence intervals) and measured heterogeneity using Higgins' I2. RESULTS: Five studies with a low risk of bias met the inclusion criteria, with a total of 1884 patients in the DTS and 1819 in standard DES arms. There was no difference between the 2 arms in the following 1-year outcomes: cardiac death [1% vs 0.9% RR 1.13 (95% CI 0.49-2.62) I2 = 0%], target lesion failure [6.2% vs 5.3% RR 1.12 (0.80-1.58) I2 = 0%], target lesion revascularization (TLR) [4.9% vs 3.4% RR 1.40 (0.93-2.10) I2 = 15%], target vessel failure [8.2% vs 6.1% RR 1.24 (0.75-2.04) I2 = 0%], target vessel myocardial infarction [1.1% vs 1.8% RR 0.73 (0.19-2.90) I2 = 62%] and stent thrombosis [0.4% vs 0.6% HR 0.85 (0.27-2.62) I2 = 0%]. However, compared with second-generation DES (EES and ZES), the DTS had significantly higher one-year TLR [5% vs. 3.1% RR 1.58 (1.02-2.46) P = 0.04 I2 = 0%]. CONCLUSION: One-year TLR was significantly higher in the DTS arm compared with second-generation DES. There was no difference in the other 1-year clinical outcomes compared with standard DES.

Clinical Outcomes of Sentinel Cerebral Protection System Use During Transcatheter Aortic Valve Replacement: A Systematic Review and Meta-Analysis.

OBJECTIVE: To compare the clinical outcomes following transcatheter aortic valve replacement (TAVR) with and without the use of the Sentinel Cerebral Protection System (Sentinel CPS). BACKGROUND: Stroke occurs in 2-5% of patients at 30 days after TAVR and increases mortality >3 fold. The Sentinel CPS is the only FDA (Food and Drug Administration) approved cerebral embolic protection device. METHODS: The Cochrane Library, PubMed and Web of Science were searched for relevant studies for inclusion in the meta-analysis. Two authors independently screened and included studies comparing the clinical outcomes after TAVR with and without the Sentinel CPS. Risk of bias was assessed using the Cochrane tools (RoB2.0 and ROBINS-I). RESULTS: Four studies comparing 606 patients undergoing TAVR with Sentinel CPS to 724 without any embolic protection device were included. Sentinel CPS use was associated with lower rates of 30-day mortality [0.8% vs 2.7%; RR 0.34 (95% CI 0.12, 0.92) I2 = 0%], 30-day symptomatic stroke [3.5% vs 6.1%; RR 0.51 (95% CI 0.29, 0.90) I2 = 0] and major or life-threatening bleeding [3.3% vs 6.6%; RR 0.50 (0.26, 0.98) I2 = 16%]. There was no significant difference between the two arms in the incidence of acute kidney injury [0.8% vs 1%; RR 0.85 (95% CI 0.22, 3.24) I2 = 0%] and major vascular complications [5.1% vs 6%; RR 0.74 (0.33, 1.67) I2 = 45%]. CONCLUSION: The results suggest that Sentinel CPS use in TAVR is associated with a lower risk of stroke, mortality and major or life-threatening bleeding at 30 days.

Ventricular Tachycardia Storm Induced by Loperamide Abuse.

A recent increase in the incidence of ventricular arrhythmias has been observed with the consumption of large dosages of the anti-diarrheal agent, loperamide. Our case is unique in that our patient not only displayed ventricular tachycardia (VT) but sustained VT (known as a VT storm). In this era of the opioid crisis, clinicians should be aware of all of the over-the-counter medications that have opioid-like side effects.

Trans-Catheter Aortic Valve Replacement and Surgical Aortic Valve Replacement Outcomes in Patients with Dialysis: Systematic Review and Meta-Analysis.

BACKGROUND: Dialysis is associated with higher rate of aortic valve calcification and higher cardiovascular mortality. Transcatheter aortic valve replacement (TAVR) is an established alternative for surgical aortic valve replacement (SAVR) in patients with higher and intermediate co-morbidities including dialysis. METHODS: Two independent investigators systematically searched Medline, Cochrane, and Web of Science. The ROBINS-I tool was used to analyze and assess the bias from the selected studies. RESULTS: The search resulted in 4 observational studies with a total of 966 patients. TAVR in dialysis patients was associated with no significant difference in in-hospital mortality [8.1% vs 10.3%; OR (95% CI) 0.74 (0.35, 1.60), I2 = 50%, P = 0.45], risk-of-strokes at 30 days [2% vs 4.4%; OR (95% CI) 0.49 (0.22, 1.09), I2 = 0%, P = 0.08], vascular complications [12.7% vs 13.2%; OR (95% CI) 0.96 (0.55, 1.67), I2 = 0%, P = 0.89], need of blood transfusion [43.1% vs 66.4%; OR (95% CI) 0.27 (0.05, 1.39), I2 = 89%, P = 0.12], or bleeding risk [5.6% vs 6.8%; OR (95% CI) 0.91 (0.18, 4.64), I2 = 5%, P = 0.91] when compared to SAVR. TAVR was associated with significantly shorter length of stay [8.5 days vs 14.2 days; mean difference (95% CI) -5.89 (-9.13, -2.64), I2 = 76%, P < 0.0001] and higher pacemaker implantation [11.4% vs 6.8%; OR (95% CI) 1.74 (1.07, 2.81), I2 = 5%, P = 0.02]. CONCLUSION: TAVR outcomes were comparable to SAVR but had a significantly shorter length of stay and a higher pacemaker implantation rate in dialysis patients.

Decreased Renal Function is Associated with Heart Failure Readmissions.

Introduction Heart failure (HF) is one of the most common causes of hospitalization and readmissions. Approximately six million Americans are living with HF. Among patients with HF, hospitalization rate in the United States is higher for those over age 65, making it one of the leading causes of hospitalization in this age group. Furthermore, about 15% of those who were hospitalized with HF were readmitted within 30 days and 30% within 60 days. HF and chronic kidney disease (CKD) share many risk factors; therefore, it is expected that CKD is more prevalent in HF. About 50% of patients with HF also have concomitant CKD. Those patients have been found to have an increased risk of mortality and morbidity. This risk increases as glomerular filtration rate (GFR) decreases. Strategies to reduce the hospitalization rate in patients with HF include optimizing evidence-based drug and device therapies, addressing the causes of HF, treating comorbidities, and improving management of care. In our study, we aim to find an association between HF and the patient's renal function as well as the GFR level. This study investigates the effect of renal function on HF morbidity and readmission rate. Methods We performed a retrospective study looking at 132 patients who were admitted to the hospital with HF and compared their measured GFR at three key time periods: admissions, discharges, and readmissions at 30 days. A Pearson product-moment correlation coefficient was calculated to determine the association between the GFR and readmission in HF admission cases. Results There is a statistically significant difference in the readmission rate based on the change in GFR between admission and discharge (Admit GFR - Discharge GFR; t = 2.28; p < 0.05). We found that patients who were readmitted in 30 days had an average decrease in GFR by 2.46 ml/min/1.73 m2, whereas patients with a lower readmission rate had an average increase in GFR by 1.92 ml/min/1.73 m2. Conclusion A decline in renal function due to hospitalization in patients with renal failure is associated with an increase in readmission for HF. Providers should be cognizant of the need to optimize renal function as well as cardiac function during hospitalization.

Heart Failure Secondary to Left Ventricular Non-compaction Cardiomyopathy in a 26-Year-Old Male.

Left ventricular non-compaction (LVNC) is a genetic anomaly where the ventricular wall is replaced by thick ventricular trabeculations with deep intertrabecular recesses held together by a thin compacted layer. We present a case of a 26-year-old male who presented with dyspnea on exertion and edema in his legs for the last one week.

Cardiac Mass: A Case of Cardiac Papillary Fibroelastoma.

Cardiac papillary fibroelastoma (CPF) is one of the most common neoplasms of the cardiac valvular structures that are associated with complications such as systemic stroke, embolism, and arrhythmias. We present a case of an incidentally discovered left ventricular mass in a 75-year-old Caucasian woman.