Gbolahan Ogunbayo

Incidence, predictors, and outcomes associated with pneumothorax during cardiac electronic device implantation: A 16-year review in over 3.7 million patients

BACKGROUND Pneumothorax (PTX) is a potential complication of vascular access during cardiac implantable electronic device (CIED) procedures and is being scrutinized as a health care-acquired condition. OBJECTIVE The purpose of this study was to determine the trends in PTX incidence in the United Stated over a 16-year period and to determine whether PTX is associated with increased mortality after adjustment for other factors. METHODS Using weighted sampling in the largest inpatient health database in the United States (National Inpatient Sample), we evaluated data from patients with a primary procedure of CIED implantation from 1998 to 2013 who had at least 1 new vascular access (new or upgrade of prior CIED). The unadjusted and adjusted associations of PTX with mortality and other parameters were examined. RESULTS Among 3,764,703 CIED procedures, PTX occurred in 47,839 cases (1.3%). The apparent incidence of PTX peaked at 1.6% in 2012 and 2013, although this result may have been affected by a concomitant decrease of inpatient (vs outpatient) CIED. PTX was significantly associated with pulmonary complications, chest tube insertion, length of stay, and costs. Mortality was statistically higher in patients with PTX (1.2% vs 0.7%; P <.001), a relationship that remained significant in a multivariate logistic regression analysis (odds ratio 1.50, 95% confidence interval 1.36-1.65; P <.001). Age >80 years, female gender, Caucasian race, chronic obstructive pulmonary disease, and dual-chamber (vs single-chamber) device were all associated with higher odds for PTX occurrence. Placement of a chest tube was a major determinant of worse outcomes and higher costs. CONCLUSION PTX remains an important complication of CIED procedures and is associated with increased morbidity, mortality, and costs.

Impact of Left Atrial Appendage Exclusion on Cardiovascular Outcomes in Patients With Atrial Fibrillation Undergoing Coronary Artery Bypass Grafting (From the National Inpatient Sample Database)

Left atrial appendage (LAA) exclusion is performed by some surgeons in patients with atrial fibrillation (AF) who undergo coronary artery bypass grafting (CABG). However, the available evidence regarding the efficacy and safety of this procedure remains mixed. We queried the Nationwide Inpatient Survey Database for the 10-year period from 2004 to 2013. Using International Classification of Diseases, Ninth Edition, Clinical Modification diagnosis codes, we identified patients who had a diagnosis of AF and underwent a primary procedure of CABG with or without LAA exclusion. We then performed a 1:5 matching based on the CHA2DS2VASc score between patients who got LAA exclusion and those who did not (control group). The primary outcome was the incidence of in-hospital cerebrovascular events, whereas the secondary outcomes included in-hospital bleeding events, pericardial effusion, cardiac tamponade, postoperative shock, and mortality. Our analysis included a total of 15,114 patients. Patients who underwent LAA exclusion had significantly less incidence of cerebrovascular events (2.0% vs 3.1%, p = 0.002). However, LAA exclusion group had higher incidences of bleeding events (36.4% vs 21.3%, p <0.001), pericardial effusion (2.7% vs 1.2%, p <0.001), cardiac tamponade (0.6% vs 0.2%, p <0.001), and postoperative shock (1.2% vs 0.4%, p <0.001). LAA exclusion was associated with higher in-hospital mortality (1.6% vs 0.3%, p <0.001). Multivariate regression analysis showed that LAA exclusion was significantly associated with lower cerebrovascular accident events and higher in-hospital mortality. In conclusion, LAA exclusion in patients with AF undergoing CABG might be associated with a lower incidence of in-hospital cerebrovascular events. This benefit is offset by a higher incidence of higher bleeding events, pericardial effusion, cardiac tamponade, postoperative shock, and in-hospital mortality.

Comparison of Outcomes in Patients Having Acute Myocardial Infarction With Versus Without Sickle-Cell Anemia

Sickle-cell disease (SCD) affects millions worldwide. Sickle-cell anemia (SCA), the most severe form of this disease, is the most common inherited blood disorder in the United States. There are limited data on the incidence, clinical characteristics, and outcomes of acute myocardial infarction (AMI) in these patients. Using data from the National Inpatient Sample database, we matched cases (AMI with SCA) with controls (AMI without SCA) in a 1:1 ratio for age, gender, race, and year of admission. We compared both groups in terms of clinical characteristics and inpatient outcomes and performed a logistic regression with mortality as the primary outcome. Using weighted samples, we also described trends of SCA in the general population of patients with AMI. Of the 2,386,657 admissions with AMI, SCA was reported in 501 (0.02%) patients, and 495 were successfully matched to controls. Patients with SCA were less likely to have risk factors for coronary artery disease than those without SCA. Patients with SCA were more likely to develop pneumonia, respiratory failure, and acute renal failure, and require mechanical ventilation, hemodialysis for acute renal failure and blood transfusion. In-hospital mortality was significantly higher in patients with SCA. In a multivariate analysis, SCA was an independent predictor of mortality (odds ratio 3.49; 95% confidence interval 1.99 to 6.12; p = < .001). In conclusion, myocardial infarction occurs in patients with SCA at a relatively early age. These patients do not typically have the traditional risk factors for the acute coronary syndrome. Mortality in these patients is significantly higher in age-, gender-, and race-matched controls.

Higher Risk of Bleeding in Asians Presenting With ST-Segment Elevation Myocardial Infarction: Analysis of the National Inpatient Sample Database

Bleeding is a major complication in patients presenting with ST-segment elevation myocardial infarction (STEMI). Several studies suggested that Asians are more susceptible to bleeding when treated with antiplatelets, anticoagulants, and thrombolytic agents. In our study, we aimed to investigate the association between Asian ethnicity and bleeding events in patients who presented with STEMI. We analyzed the Nationwide Inpatient Sample database from 2002 to 2013 and identified patients hospitalized with a primary diagnosis of STEMI. We compared clinical outcomes between patients of Asian and white ethnicity. Primary outcome was inhospital major bleeding defined as a composite of intracranial hemorrhage and blood transfusions for bleeding events. After exclusions, an estimated 1 695 680 white and 46 563 Asian patients with STEMI were included in the analysis. Asian patients had a higher incidence of inhospital major bleeding (3.6% vs 2.2%, P < .001) without a significant difference in inhospital mortality (9.3% vs 8.7%, P = .06). Asian ethnicity was an independent predictor for major bleeding (estimated odds ratio: 1.32; 95% confidence interval: 1.16-1.51; P < .001). This increased risk of bleeding would warrant further investigation of optimal treatment strategies tailored for patients with STEMI of Asian ethnicity.

Use of adenosine to shorten the post ablation waiting period for cavotricuspid isthmus-dependent atrial flutter

Dormant conduction unmasked by adenosine predicts clinical recurrences of cavotricuspid isthmus (CTI) dependent atrial flutter following catheter ablation. Conventional practice involves a waiting period of 20 to 30 minutes after achievement of a bidirectional line of block (BDB) to monitor for recovery of conduction.

In-Hospital Cerebrovascular Outcomes of Patients With Atrial Fibrillation and Cancer (from the National Inpatient Sample Database)

Limited data are available regarding the impact of cancer on cerebrovascular accidents in patients with atrial fibrillation (AF). We queried the Nationwide Inpatient Survey Database to identify patients who have diagnostic code for AF. We performed a 1:1 propensity matching based on the CHA2DS2VASc score and other risk factors between patients with AF who had lung, breast, colon, and esophageal cancer, and those who did not (control). The final cohort included a total of 31,604 patients. The primary outcome of in-hospital cerebrovascular accidents (CVA) was lower in the cancer group than in the control group (4% vs 7%, p < 0.001), but with only a weak association (ф = -0.067). In-hospital mortality was higher in the cancer group than in the control group (18% vs 11%, p < 0.001; ф = -0.099). A subgroup analysis according to cancer type showed similar results with a weak association with lower CVA in breast cancer (4% vs 7%; ф = -0.066, p < 0.001), lung cancer (4% vs 6%; ф = -0.062, p < 0.001), colon cancer (4% vs 6%; ф = -0.062, p < 0.001), and esophageal cancer (3% vs 7%; ф = -0.095, p < 0.001) compared with the control groups. A weak association with higher in-hospital mortality was demonstrated in lung cancer (20% vs 11%; ф = -0.127, p < 0.001), colon cancer (16% vs 11%; ф = -0.076, p < 0.001), and esophageal cancer (20% vs 12%; ф = -0.111, p < 0.001) compared with the control groups, but no significant difference between breast cancer and control groups in mortality (11% vs 11%; ф = -0.002, p = 0.888). In conclusion, in patients with AF, cancer diagnosis may not add a predictive role for in-hospital CVA beyond the CHADS2VASc score.

Temporal Trends in Inpatient Use of Intravascular Imaging Among Patients Undergoing Percutaneous Coronary Intervention in the United States

Intravascular ultrasound (IVUS) and optical coherence tomography (OCT) have emerged as helpful intravascular imaging tools to guide revascularization decisions during percutaneous coronary intervention (PCI). Studies have demonstrated that intravascular imaging is associated with improved clinical

Higher Risk of Bleeding in Asians Presenting With Non-ST-Segment Elevation Myocardial Infarction

Bleeding events are associated with unfavorable prognosis in patients with acute coronary syndromes. In a recent publication, we reported that Asian patients presenting with ST-segment elevation myocardial infarction are at a higher risk of bleeding than whites. Although similar results were noted in Asian patients with non-ST-segment elevation myocardial infarction (NSTEMI) using registry data from 2003 to 2005, characteristics of contemporary NSTEMI cohort and their bleeding risks may differ following advancements in troponin assays, changes in definition of myocardial infarction, and adoption of newer antiplatelet agents. In this context, we sought to reinvestigate the impact of Asian ethnicity on bleeding in a contemporary NSTEMI cohort. We analyzed the Nationwide Inpatient Sample database, a part of the Healthcare Cost and Utilization Project from the Agency for Healthcare Research and Quality, and identified all patients older than 18 years who were hospitalized with a primary diagnosis of NSTEMI (International Classification of Diseases diagnosis code 410.7x) between 2010 and 2014. The institutional review board of our facility determined that this study was exempted from formal review. The exclusion criteria, codes used to identify comorbidities and outcomes, and covariates included in multivariate models (except for systemic thrombolysis) were identical to our prior study. The primary outcome was in-hospital major bleeding, defined as a composite of intracranial hemorrhage and blood transfusion for bleeding events. All statistical analyses were performed with SPSS version 24.0 (IBM Corp, Armonk, New York). Data on race were missing in 7.9% of the population. After exclusions, 285 076 white and 8608 Asian patients were included. Hypertension, diabetes, renal failure, anemia, and cardiogenic shock were more commonly observed in Asians, while obesity was less prevalent (Table 1). Asian patients had a

Exploring the “Weekend Effect” on the Care of Patients with Left Ventricular Assist Devices

Using data from the National Inpatient Sample (NIS) database, with a weighted estimate of more than 35 million admissions per year. We identified patients 18 years or older with an ICD code signifying presence of a LVAD. Characteristics, comorbidities and clinical outcomes were compared between patients admitted on Citation: Ogunbayo G (2018) “Exploring the “Weekend Effect” on the Care of Patients with Left Ventricular Assist Devices”

Junctional ectopic rhythm after AVNRT ablation: An underrecognized complication

Ablation is an effective treatment for atrioventricular nodal reentrant tachycardia (AVNRT). The occurrence of junctional ectopic rhythm (JER), including junctional ectopic tachycardia, following AVNRT ablation has been described as an extremely rare phenomenon, but may be underestimated. We aimed to determine the incidence of JER following AVNRT ablation within our institution, as well as that reported in the literature via an extensive review.