Krunalkumar Patel

Trends in the Utilisation and In-hospital Mortality Associated with Pulmonary Artery Catheters Use for Cardiogenic Shock Hospitalisations

Pulmonary artery catheter (PAC) (i.e. SwaneGanz catheter) is a diagnostic tool for quantitative hemodynamic measurements. The Evaluation Study of Congestive Heart Failure and Pulmonary Artery Catheterization Effectiveness (ESCAPE) trial in 2005 discouraged the use of PAC. This is because PAC use demonstrates an unanticipated increase in the adverse events and resource utilizations in the ESCAPE trial.1 In addition, recent studies have demonstrated PAC to increase short-term mortality and resource utilization associated with critically ill patients.2,3 However, recent studies have demonstrated an increase in the utilization of PAC for heart failure (HF) admissions.4 Currently, the American College of Cardiology/American Heart Association guidelines recommend using PAC for HF with cardiogenic shock (CS) or those on a mechanical circulatory support (class I, level of evidence, C).5 However, PAC use is discouraged for routine management of HF.5 The role of PAC for hospitalizations with CS is not well described and remains somewhat enigmatic in its use. We sought to investigate the use of PAC for the management of CS hospitalizations and in-hospital mortality associated with it. This study retrospectively analyzed the National Inpatient Sample (NIS) from 2005 to 2014.6 The NIS is a subset of the Healthcare Cost and Utilisation Project sponsored by the Agency for Healthcare Research and Quality. The details about the NIS database have been described earlier.7 This study used the International Classification of Disease, Ninth Revision, Clinical Modification (ICD-9-CM) diagnostic code 785.51 to identify hospitalizations with CS (N 1⁄4 855,252).8 Hospitalizations of patients younger than 18 years of age were excluded from this study (N 1⁄4 12,884). Utilization of PAC was identified using ICD-9-CM procedures codes 89.63, 89.64, 89.66, 89.67, 89.68 which have been validated previously (N 1⁄4 71,452).9 To represent national estimates, discharge weights were utilized. The primary end point of this study was to observe the utilization of PAC for CS hospitalizations. Trends in the hospitalizations were calculated using the JonckheereeTerpstra test. This study further stratifies PAC use into clinically important subgroups by the presence of acute coronary syndrome (ACS). Rates of PAC use was calculated using the number of PAC procedures per 1000 hospitalizationwith CS. Continuous variables were analyzed using Students t-test and were represented as the mean ± standard deviation. Categorical variables were analyzed using the chisquared test or Fishers exact test and were represented as frequencies and percentages. All p-values were two sided, and a value of less than 0.05 was considered statistically significant. A hierarchical, mixed-effect, multivariate logistic regressionwas performed to calculate adjusted in-hospital mortality, and data on age, gender,

Association of chronic kidney disease with in-hospital outcomes of transcatheter mitral valve repair

Percutaneous edge-to-edge transcatheter mitral valve repair (TMVr) using MitraClip1 has been approved for the treatment of degenerative mitral valve regurgitation (MR). Chronic kidney disease (CKD) is shown to be an independent predictor for worse outcomes for transcatheter aortic valve replacement. The presence of chronic MR may further deteriorate renal function. However, an association of CKD and/or end-stage renal disease (ESRD) and mortality in patients undergoing TMVr has not been well described. In the EVEREST II trial, the prevalence of CKD was 23%. Most major randomized clinical trials have excluded such CKD patients from the cohorts. Therefore, this study aims to find an association between CKD/ESRD and in-hospital outcomes of TMVr in “real-world” hospitalizations. This study used National Inpatient Sample (NIS) data from the year 2012 to 2014. The NIS database has been described earlier which is sponsored by HealthCare Cost and Utilization Project. Briefly, the NIS includes more than 4000 hospitals across the United States which represents 95% of the US population. This study identifies adult hospitalizations (age 18 years) with TMVr using International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) procedure code 35.97 which is specific for mitral valve repair (N = 2570). Hospitalizations with CKD were identified using ICD-9-CM diagnosis codes 585.1–585.5 and 585.9. Hospitalizations with ESRD were identified using ICD9-CM diagnosis code 585.6 or procedures code of hemodialysis (39.95) or peritoneal dialysis (54.98). Calculation of cost was performed by merging cost-to-charge ratio (CCR) with the total cost. These CCR files are provided by the sponsor. The severity of co-morbid conditions was defined using Deyo modification of Charlson co-morbidity Index (CCI). Mann-Whitney U test was used for comparison of continuous variables, while Fischer’s Exact test was utilized for comparison of categorical variables. Finally, multivariate logistic regression analysis was performed to analyze adjusted outcomes and age, gender, race and Elixhauser comorbidities were included in the model. This study was exempted from the intuitional review board committee review. Additionally, all the principles outlined in the Helsinki Declaration of 1975, as revised in 2000, have been followed in all the experiments involving human subjects during the current study. A total of 500 (19.5%) hospitalizations were identified having CKD and 130 (5%) hospitalizations with having ESRD. Baseline differences existed between the groups (Table 1). Mean age was higher in the CKD group (79.1 vs. 72.2 years, P = <0.001) while lower in the ESRD group (64.7 vs. 72.2 years, P = <0.001) as compared to those without CKD or ESRD. Patients in the CKD (93%)

Gender disparities with the use of percutaneous left ventricular assist device in patients undergoing percutaneous coronary intervention complicated by cardiogenic shock: From pVAD Working Group

Background Hemodynamic support with Impella (Abiomed Inc., Danvers, MA) devices is becoming a more prevalent treatment option for patients with cardiogenic shock (CS) undergoing percutaneous coronary intervention (PCI). There exists only limited published data regarding outcome differences between male and female patients. Therefore, the objective of this paper is to analyze these gender differences between short-term survival and in-hospital outcomes in those undergoing PCI with CS. Methods Between January 2011 and July 2016, patients undergoing PCI with simultaneous use of Impella were identified. Only patients presenting with CS were included in the analysis. All-cause in-hospital mortality was the primary outcome. Using SAS 9.4 for propensity score matching, additional secondary outcomes were also compared. Results The primary outcome was comparable between males and females (39.5% vs. 26.3%, p = 0.33) in CS patients. Secondary outcomes were also comparable and included: myocardial infarction, stroke, CS, heart failure, dialysis requirement, bleeding within 72 h, blood transfusion, dysrhythmia, composite of all complications, major adverse cardiac events. Survival at 30 days was equal in both groups. A reduced mortality in males was noted for pre-PCI initiation of Impella. Additionally, both genders who received pre-PCI Impella support, experienced a significant reduction in inotrope use. Conclusions Despite the small number of cohorts, this study did not reveal any significant differences among gender with the use of percutaneous left ventricular assist devices for PCI in patients with acute myocardial infarction complicated by CS. However, initiation of Impella prior to PCI may be associated with improved mortality and morbidity in both genders.

Trends in the Utilisation and In-Hospital Mortality Associated With Short-Term Mechanical Circulatory Support for Heart Failure With Reduced Ejection Fraction

Heart failure with reduced ejection fraction (HFrEF) is a systolic dysfunction with an ejection fraction below 40% and the prevalence of it is substantially increasing in the United States. Mechanical circulatory support (MCS) devices have increasingly been used for the management of HFrEF and are associated with improved outcomes. The National Inpatient Sample database was used to identify hospitalisations with mechanical circulatory support for HFrEF from 2005 to 2014. This study observed a reduction in the utilisation of intra-aortic balloon pump (IABP), which is partially replaced by percutaneous left ventricular assist device (pLVAD) and extracorporeal membrane oxygenation (ECMO) for the management of HFrEF. In-hospital mortality in IABP and ECMO recipients decreased during the study period while mortality with pLVAD did not change. Finally, technology for the short-term MCS in HFrEF hospitalisations continues to improve, however, there is still some space for updated technology in future.

Comparison of Outcomes and Cost of Endovascular Management Versus Surgical Bypass for the Management of Lower Extremities PeripheralArterial Disease

The management of lower extremities peripheral arterial disease (LE-PAD) has always been debatable. We sought to explore in-hospital outcomes in hospitalizations that underwent endovascular or bypass surgery for LE-PAD from nations largest, publicly available database. The National Inpatient Sample from 2012 to 2014 was queried to identify adult hospitalizations underwent endovascular management and bypass surgery for LE-PAD. Appropriate International Classification of Diseases, Ninth Revision, Clinical Modification diagnostic and procedural codes were utilized to identify hospitalizations. A total of 89,256 hospitalizations were identified having endovascular management or bypass surgery for LE-PAD. More hospitalizations underwent endovascular intervention as compared with bypass surgery. Overall, hospitalizations for endovascular management had higher baseline co-morbidities and older age. A propensity score matched analysis was performed to compare in-hospital outcomes. After matching, 28,791 hospitalizations were included in each group. In-hospital mortality was significantly lower with endovascular intervention procedure as compared with surgical bypass group (1.5% vs 2.5%, p ≤0.001). All other secondary outcomes were noted lower with endovascular management except stroke and postprocedural infection. Taken together, these may account for higher discharges to home, lower length of stay, and less cost of hospitalizations associated with endovascular management. In conclusion, endovascular management is associated with lower in-hospital morbidity, mortality, length of stay, and cost when compared with bypass surgery in this study.