Fahad Alqahtani

Sex Differences in the Utilization and Outcomes of Surgical Aortic Valve Replacement for Severe Aortic Stenosis

Background Studies assessing the differential impact of sex on outcomes of aortic valve replacement (AVR) yielded conflicting results. We sought to investigate sex‐related differences in AVR utilization, patient risk profile, and in‐hospital outcomes using the Nationwide Inpatient Sample. Methods and Results In total, 166 809 patients (63% male and 37% female) who underwent AVR between 2003 and 2014 were identified, and 48.5% had a concomitant cardiac surgery procedure. Compared with men, women were older and had more nonatherosclerotic comorbid conditions including hypertension, diabetes mellitus, obstructive pulmonary disease, atrial fibrillation/flutter, and anemia but fewer incidences of coronary and peripheral arterial disease and prior sternotomies. In‐hospital mortality was significantly higher in women (5.6% versus 4%, P<0.001). Propensity matching was performed to assess the impact of sex on the outcomes of isolated AVR and yielded 28 237 matched pairs of male and female participants. In the propensity‐matched groups, in‐hospital mortality was higher in women (3.3% versus 2.9%, P<0.001). Along with vascular complications and blood transfusion (6% versus 5.6%, P=0.027 and 40.4% versus 33.9%, P<0.001, respectively). Rates of stroke, permanent pacemaker implantation, and acute kidney injury requiring dialysis were similar (2.4% versus 2.4%, P=0.99; 6% versus 6.3%, P=0.15; and 1.4% versus 1.3%, P=0.14, respectively). Length of stay median and interquartile range were both similar between groups (7±6 days). Rates of nonhome discharge were higher among women (27.9% versus 19.6%, P<0.001). Conclusions Women have worse in‐hospital mortality following AVR compared with men. Coupled with the accumulating evidence suggesting higher magnitude of benefit of transcatheter AVR over AVR in women, women should perhaps be offered transcatheter AVR over AVR at a lower threshold than men.

Mechanical circulatory support in patients with severe aortic stenosis and left ventricular dysfunction undergoing percutaneous coronary intervention

Management of obstructive coronary artery disease in patients with aortic stenosis and severe left ventricular dysfunction is challenging. Mechanical circulatory support at the time of percutaneous coronary interventions may be necessary in these extreme‐risk patients. We present a case in which the TandemHeart was used to support a patient with severe aortic stenosis, severe protected left main and circumflex disease, and severe cardiomyopathy and review the literature on this subject.

Contemporary Trends in the Use and Outcomes of Surgical Treatment of Tricuspid Regurgitation

Background Tricuspid regurgitation (TR), if untreated, is associated with an adverse impact on long‐term outcomes. In recent years, there has been an increasing enthusiasm about surgical and transcatheter treatment of patients with severe TR. We aim to evaluate the contemporary trends in the use and outcomes of tricuspid valve (TV) surgery for TR using the National Inpatient Sample. Methods and Results Between January 1, 2003 and December 31, 2014, an estimated 45 477 patients underwent TV surgery for TR in the United States, of whom 15% had isolated TV surgery and 85% had TV surgery concomitant with other cardiac surgery. There was a temporal upward trend to treat sicker patients during the study period. Patients who underwent isolated TV repair or replacement had a distinctly different clinical risk profile than those patients who underwent TV surgery simultaneous with other surgery. Isolated TV replacement was associated with high in‐hospital mortality (10.9%) and high rates of permanent pacemaker implantation (34.1%) and acute kidney injury requiring dialysis (5.5%). Similarly, isolated TV repair was also associated with high in‐hospital mortality (8.1%) and significant rates of permanent pacemaker implantation (10.9%) and new dialysis (4.4%). Isolated TV repair and TV replacement were both associated with protracted hospitalizations and substantial cost. Conclusions In contemporary practice, surgical treatment of TR remains underused and is associated with high operative morbidity and mortality, prolonged hospitalizations, and considerable cost.

Transcatheter mitral valve replacement: an evolution of a revolution

Mitral regurgitation (MR) is the most prevalent valve disease in the United States, affecting 6% of people over 75 years of age (1).

Transcatheter closure of a residual aortopulmonary window defect

A 35-year-old male who underwent surgical closure of an aortopulmonary window (APW) defect at 6 weeks of age, presented with increasing dyspnea on exertion, and recurrent episodes of symptomatic atrial arrhythmias. Echocardiography suggested left to right shunting at the level of the pulmonary artery (PA) (Video S1). Cardiac computed tomography confirmed the presence of an aortopulmonary fistula (Figure 1). A cardiac catheterization revealed a PA pressure of 48mmHg, amean pulmonarywedge pressure of 14mmHg, pulmonary vascular resistance of 2.3 wood units, and a shunt fraction (QP/QS) of 2.3. Intracardiac echocardiography (ICE) confirmed the presence of a

Incidence and Outcomes of Myocardial Infarction in Patients Admitted With Acute Ischemic Stroke

Background and Purpose— Data on the incidence and outcomes of acute myocardial infarction (AMI) complicating acute ischemic stroke (AIS) are limited. We aim to evaluate the incidence, treatment patterns, and outcomes of AMI in patients with AIS using a nationwide database. Methods— The National Inpatient Sample was used to identify patient with AIS between 2003 and 2014. Trends of incidence of AMI and its associated in-hospital mortality were evaluated. Univariate and multivariate logistic regressions were used to evaluate predictors of AMI. The impact of AMI on in-hospital outcomes was assessed in a comparative analysis of propensity-matched groups of patients with and without AMI. Results— Patients with AIS (n=864 043) were identified in the national inpatient sample, of whom 13 573 patients (1.6%) had an AMI (79.5% non–ST-segment–elevation myocardial infarction and 20.5% ST-segment–elevation myocardial infarction). In-hospital mortality was 21.4% and 7.1% in propensity-matched cohorts of patients with and without AMI, P<0.001. In-hospital length of stay and cost of care were 50% higher in the AMI group. In a multivariate logistical regression analysis, the strongest predictors of having AMI after AIS were older age, history of coronary artery disease, chronic renal insufficiency, undergoing mechanical thrombectomy, and rhythm and conduction abnormalities. In the AMI group, undergoing coronary angiography and undergoing percutaneous coronary intervention both strongly correlated with lower in-hospital mortality (odds ratio, 0.34 [confidence interval, 0.23–0.51] and 0.26 [confidence interval, 0.20–0.34], respectively, P<0.001). However, these were only performed in 7.5% and 2% of patients, respectively. Conclusions— AMI complicating stroke carries a substantial in-hospital mortality and cost of care. Patients who underwent coronary angiography with or without intervention may have improved survival although it was only utilized in a minority of patients. Further studies needed to discern the ideal approach in AMI in patients with AIS.

Percutaneous closure of left ventricular pseudoaneurysm caused by a central venting cannula

Minimally invasive transcatheter closure using Amplatzer occluders have been used to treat myocardial and aortic fistulas following surgical procedures. We present images demonstrating the use of an Amplatzer plug to treat a left ventricular (LV) pseudoaneurysm following a surgical procedure in which an LV vent was inserted. A 72-year old female with severe tricuspid regurgitation, history of patent foramen ovale closure, and pacemaker implantation was evaluated for recurrent heart failure and constrictive pericarditis and underwent a pericardiectomy, tricuspid valve ring repair, and bypass grafting of the right coronary artery. During cardiopulmonary bypass, a 15-French DLP vent cannula (Medtronic, Minneapolis, MN) was advanced into the LV via the right superior pulmonary vein. After a

Morbidity and Mortality of Transcatheter Aortic Valve Replacement Performed During Non-Elective Hospitalizations

Calcific aortic stenosis (AS) is a progressive disease with an insidious onset. While asymptomatic patients can be monitored closely, those who are symptomatic or have reduced left ventricular function should be referred for aortic valve replacement. Unfortunately, the onset of symptoms in patients with severe AS is not always gradual, and some patients present acutely with myocardial infarction or decompensated heart failure. Balloon valvuloplasty has been utilized in acute presentations to avoid the morbidity of urgent surgery, but the introduction of TAVR offered a more definitive minimally invasive treatment option. Non-elective TAVR has been associated with higher in-hospital mortality in a single center European study, but the incidence and outcomes of non-elective TAVR in contemporary US practice has not been thoroughly assessed. We utilized a national representative database to investigate the rate and in-hospital outcomes of non-elective TAVR Patients who underwent TAVR were identified in the national inpatient sample (NIS) using ICD-9-CM codes 35.05 and 35.06. The NIS is the largest publicly available all-payer administrative database and contains information about patient discharges from 1000 hospitals in 45 states representing 20% of all US inpatient hospitalizations (random sample). National estimates (NE) of the entire US hospitalized population were calculated using the Agency for Healthcare Research and Quality sampling and weighting method. The procedure was classified as elective if the admission was assigned an “elective status” in the NIS and TAVR occurred on day 0,1 of the admission. The primary outcome was in-hospital death. Secondary outcomes were post-operative complications, length of stay, hospital charges, and rates of non-home discharges. A propensity score-matching model was developed using logistic regression to derive two-matched cohorts (elective vs. non-elective TAVR) for comparative analyses. Variables included in the propensity matching included demographics, clinical variables, TAVR access, and hospital characteristics (Supplemental data). Key baseline characteristics, and the main admission diagnoses were entered into a univariate and multivariate logistic regression model to assess the impact of admission diagnosis on in-hospital mortality. Descriptive statistics were presented as frequencies with percentages for categorical variables and as means with standard deviations for continuous variables. Baseline characteristics were compared using chi-square test for categorical variables and independent samples t-test for continuous variables. Statistical analyses were performed using SPSSversion-24 (IBM Corporation, Armonk, NY, USA). Between November 2, 2011 and December 31, 2014 a total of 7,759 patients who underwent TAVR were identified in the NIS (National Estimate 38,715). Of those, 10.5% were performed during a non-elective admission. Most common admission diagnoses for patients undergoing non-elective TAVR were acute heart failure, acute respiratory failure, and myocardial infarction. The frequency of TAVR performance during non-elective admissions remained steady during the study period (11.6% in 2011–2012, 11% in 2013 and 11.6% in 2014) (Supplemental data). Median operative day in the non-elective group was 7.5 (range 2–44) (Supplemental data). Patients undergoing non-elective TAVR had a higher prevalence of coronary artery disease and chronic renal insufficiency, andweremore likely to be treated at a teaching hospital (Table 1). After propensity matching, in-hospital mortality following TAVR was two-folds higher in the non-elective admission group (5.4% vs. 2.8%, p = 0.012). Rates of vascular complications, pacemaker implantation, and stroke were similar between the two groups, but blood transfusionwasmore common in the non-elective group (30.7% vs. 22.6%, p < 0.001) (Table 1). Patients who underwent TAVR during a non-elective admission also had rates of non-home discharges (51.8% vs. 30.3%, p < 0.001), total charges (

Trends and predictors of implantable cardioverter defibrillator implantation after sudden cardiac arrest: Insight from the national inpatient sample

314,311 ± 229,676 vs.

Management of Coronary Artery Aneurysms

221,467 ± 153,817, p < 0.001), and longer hospitalizations (mean ± standard deviation [SD] = 16 ± 11 vs. 7 ± 7 days, median interquartile range [IQR] = 14 (11) vs. 5 (4), p < 0.001 for all). However, the longer hospitalization was mostly driven by more pre-procedural days in the non-elective group. Mean±SD and median (IQR) post-procedural length of stay was 8.3 ± 3, and 8 (1) vs. 6.4 ± 0.5 and 6 (1) days in the non-elective vs. elective groups, respectively, p < 0.001. In the non-elective TAVR group, acute respiratory failure and chronic renal insufficiency were the only significant predictors of in-hospital mortality in the multivariate regression analysis (OR 4.9, 95% CI 2.6–9.4, and OR 2.2, 95% CI 1.14– 4.24, respectively, p < 0.001) (Supplemental data). Themain findings of our investigation are: (1) ~10%of patients referred for TAVR in the US between 2011 and 2014 underwent