Poonam Velagapudi

Association Between Hospital Volume and 30-Day Readmissions Following Transcatheter Aortic Valve Replacement

Importance With the approval of transcatheter aortic valve replacement (TAVR) for patients with severe symptomatic aortic stenosis at intermediate surgical risk, TAVR volume is projected to increase exponentially in the United States. The 30-day readmission rate for TAVR was recently reported at 17.9%. The association between institutional TAVR volume and the 30-day readmission metric has not been examined. Objective To assess the association between hospital TAVR volume and 30-day readmission. Design, Setting, and Participants In this observational study, we used the 2014 Nationwide Readmissions Database to identify hospitals with established TAVR programs (performing at least 5 TAVRs in the first quarter of 2014). Based on annual TAVR volume, hospitals were classified as low (<50), medium (≥50 to <100), and high (≥100) volume. Rates, causes, and costs of 30-day readmissions were compared between low-, medium-, and high-volume hospitals. Data were analyzed from November to December 2016. Exposure Transcatheter aortic valve replacement. Main Outcomes and Measures Thirty-day readmissions. Results Of 129 hospitals included in this study, 20 (15.5%) were categorized as low volume, 47 (36.4%) as medium volume, and 62 (48.1%) as high volume. Of 16 252 index TAVR procedures, 663 (4.1%), 3067 (18.9%), and 12 522 (77.0%) were performed at low-, medium-, and high-volume hospitals, respectively. Thirty-day readmission rates were significantly lower in high-volume compared with medium-volume (adjusted odds ratio, 0.76; 95% CI, 0.68-0.85; Pu2009<u2009.001) and low-volume (adjusted odds ratio, 0.75; 95% CI, 0.60-0.92; Pu2009=u2009.007) hospitals. Noncardiac readmissions were more common in low-volume hospitals (65.6% vs 60.6% in high-volume hospitals), whereas cardiac readmissions were more common in high-volume hospitals (39.4% vs 34.4% in low-volume hospitals). There were no significant differences in length of stay and costs per readmission among the 3 groups (mean [SD], 5.5 [5.0] days vs 5.9 [7.5] days vs 6.0 [5.8] days; Pu2009=u2009.74, and

Valvular Heart Disease in Patients ≥80 Years of Age

13 886 [18 333] vs

A New Educational Framework to Improve Lifelong Learning for Cardiologists

14 135 [17 939] vs

Less than two versus greater than two hour invasive strategy in non-ST elevation myocardial infarction: a meta-analysis of randomized controlled trials

13 432 [15 725]; P = .63, respectively). Conclusions and Relevance We report for the first time, to our knowledge, an inverse association between hospital TAVR volume and 30-day readmissions. Lower readmission at higher-volume hospitals was associated with significantly lower cost to the health care system.

Intramyocardial autologous CD34+ cell therapy for refractory angina: A meta-analysis of randomized controlled trials

In the United States, the octogenarian population is projected to triple by 2050. With this aging population, the prevalence of valvular heart disease (VHD) is on the rise. The etiology, approach to treatment, and expected outcomes of VHD are different in the elderly compared with younger patients. Both stenotic and regurgitant lesions are associated with unfavorable outcomes if left untreated. Surgical mortality remains high due to multiple co-morbidities, and long-term survival benefit is dependent on many variables including valvular pathology. Quality of life is an important consideration in treatment decisions in this age group. Increasingly, octogenarian patients are receiving transcatheter therapies, with transcatheter aortic valve replacement having the greatest momentum. Numerous transcatheter devices for management of other valve lesions are currently in early clinical trials. This review will describe the epidemiology, etiology, diagnosis,xa0and therapeutic options for VHD in the oldest old, with a focus on transcatheter technologies.

Temporal Trends and Factors Associated With Prolonged Length of Stay in Patients With ST-Elevation Myocardial Infarction Undergoing Primary Percutaneous Coronary Intervention

Lifelong learning is essential for the practicing cardiologist. Present lifelong learning mechanisms are stagnant and at risk for not meeting the needs of currently practicing cardiologists. With the increasing burden of cardiovascular disease, growing complexity of patient care, and ongoing pressures of nonclinical responsibilities, educational programming must evolve to meet the demands of the contemporary cardiovascular professional. A paradigm shift, replete with modern and practical educational tools, is needed in the lifelong learning armamentarium. Emerging evidence of novel educational strategies in graduate medical education supports the promise of broader application of these tools to different stages of professional life. In this commentary from the Fellows-in-Training Section Leadership Council, the authors propose 3 novel educational tools-personalized learning, adaptive learning, and the flipped classroom-to improve lifelong learning to meet the educational needs of fellows-in-training to practicing cardiologists alike.

INTRAMYOCARDIAL AUTOLOGOUS CD34+ CELL THERAPY FOR REFRACTORY ANGINA: A META-ANALYSIS

ABSTRACT Background: Optimal timing for an invasive strategy in non-ST elevation myocardial infarction (NSTEMI) is unclear. Whether clinical outcomes are improved with a less than two (LT2) compared with greater than two hour (GT2) invasive strategy remains to be determined. We performed a meta-analysis of randomized controlled trials (RCTs) comparing LT2 vs GT2 for NSTEMI. Methods: A comprehensive literature search for RCTs comparing LT2 vs. GT2 in NSTEMI patients was performed. Three eligible studies consisting of 1,075 patients (LT2: 537, GT2: 538) with NSTEMI were identified. Follow-up ranged from 1 to 12 months. Results: Time from randomization to sheath insertion ranged from 0.5–2.2 and 14.0–85.0 hours in the LT2 and GT2 groups. More percutaneous coronary interventions and fewer coronary artery bypass grafting were performed in the LT2 vs. GT2 group. There was no significant difference in all-cause mortality, myocardial infarction (MI), and major bleeding between the two groups. LT2 was numerically, but not statistically superior to GT2 at preventing recurrent ischemia/urgent revascularization/refractory ischemia. Conclusion: Our meta-analysis found no significant difference in outcomes between less than two versus greater than two hours invasive strategy for NSTEMI. The differences observed in the mode of revascularization according to timing of catheterization deserve further study.

TCT-248 Pacemaker Implantation in Transcatheter Aortic Valve Replacement vs. Sutureless Surgical Aortic Valve Replacement: A Meta-analysis

BACKGROUNDnPrevious studies have demonstrated that intramyocardial human CD34+ cells may relieve symptoms and improve clinical outcomes in chronic refractory angina unresponsive to optimal medical therapy or not amenable to revascularization.nnnMETHODSnWe performed a meta-analysis of randomized controlled trials (RCTs) to evaluate the impact of human CD34+ cells compared with placebo in chronic refractory angina. Primary efficacy outcomes in our analysis were angina frequency and exercise time. Primary safety outcomes included major adverse cardiovascular events such as myocardial infarction (MI), stroke and death.nnnRESULTSnThree eligible randomized trials including 269 patients (placebou202f=u202f90, CD34+u202f=u202f179) were included. Dose of auto-CD34+ cells ranged from 5u202f×u202f104 to 5u202f×u202f105u202fcells/kg. Follow-up ranged from 6 to 24u202fmonths. In a pooled analysis, administration of CD34+ cells decreased the risk of all-cause mortality [OR 0.24, 95% CI (0.08-0.73), pu202f=u202f0.01], reduced angina frequency [mean difference -2.91, 95% CI (-4.57 to -1.25), pu202f=u202f0.0006] and improved exercise time [mean difference 58.62u202fs, 95% CI (21.19 to 96.06), pu202f=u202f0.02] compared with control group. However, there was no significant difference in the risk of myocardial infarction (MI) and stroke between groups.nnnCONCLUSIONnIn a meta-analysis, intra-myocardial CD34+ cell therapy was superior to placebo in improving risk of all - cause mortality, angina frequency with an increase in exercise time, without a significant increase in adverse events. This analysis supports further trials of CD34+ cell therapy for ischemic heart disease.

TCT-154 Multivessel Revascularization versus Culprit Vessel Only Revascularization in Patients with ST-Elevation Myocardial Infarction and multivessel disease: An Updated Meta-analaysis

Improved procedural techniques and process of care initiatives have decreased length of stay (LOS) after primary percutaneous coronary intervention (PPCI) for ST-elevation myocardial infarction (STEMI). However, there remains a subset of patients who continue to require longer LOS. We used the 2005 to 2014 National Inpatient Sample databases to identify all hospitalizations for PPCI for STEMI in patients ≥18 years of age. Hospitalizations in which patients were discharged home alive were included. Multivariable linear and logistic regression models were used to examine temporal trends in LOS and to identify independent predictors of longer LOS (LOS >3 days). In 678,545 hospitalizations for PPCI for STEMI, mean ± standard error of mean LOS decreased significantly from 3.3 (±0.04) days to 2.7 (±0.02) days (ptrend<0.001). There was a marked decrease in the proportion of STEMI hospitalizations with LOS >3 days from 31.9% in 2005 to 16.9% in 2014 (p<0.001). Patient demographics, co-morbidities, hospital region, use of mechanical circulatory support, and periprocedural complications were independently associated with longer LOS. In conclusion, LOS for hospitalizations for PPCI for STEMI has decreased significantly over time. Targeting strategies to reduce procedure-related risk may translate into shorter LOS.

Long-Term Outcomes of Drug-Eluting Stents versus Bare-Metal Stents in End Stage Renal Disease Patients on Dialysis: A Systematic Review and Meta-Analysis.

Background: Intramyocardial injection of human CD34+ cells may improve outcomes in patients with chronic refractory angina not amenable to revascularization or standard medical therapy. We performed a meta-analysis to evaluate the effect of this therapy in patients with refractory angina.nnMethods: