Vikas Singh

Elective or Emergency Use of Mechanical Circulatory Support Devices During Transcatheter Aortic Valve Replacement.

OBJECTIVEnEvaluate the use of mechanical circulatory support (MCS) devices in high-risk patients undergoing transcatheter aortic valve replacement (TAVR).nnnBACKGROUNDnThe use of MCS devices in elderly patients with multiple comorbidities undergoing TAVR is underexplored.nnnMETHODSnAll patients undergoing TAVR at a single tertiary academic center who required MCS during index procedure between 2008 and 2015 were included in a prospective database.nnnRESULTSnMCS was used in 9.4% (54/577) of all TAVRs (nu2009=u200952 Edwards Sapien and nu2009=u20092 CoreValves) of which 68.5% (nu2009=u200937) were used as part of a planned strategy, and 31.5% (nu2009=u200917) were used in emergency bail-out situations. IABP was the most commonly used device (87%) followed by Impella and ECMO (6% each). Among the MCS group, 22% required cardiopulmonary resuscitation during the procedure (nu2009=u20094 elective [11%] vs. nu2009=u20098 emergent [47%]) and 15% upgrade to a second device (Impella or CPB after IABP; nu2009=u20095 elective [14%] vs. nu2009=u20093 emergent [18%]). Median duration of support was 1-day. Device related complications were low (4%). In-hospital mortality in this extremely high-risk population was 24% (13/54) (11% [4/37] for elective cases and 53% [9/17] for emergency cases). Cardiogenic shock (50%) was the most common cause of in-hospital death. Cumulative all-cause 1-year mortality was 35% (19/54) (19% 97/370 for elective and 71% [12/17] for emergency cases).nnnCONCLUSIONnEmergent use of MCS during TAVR in extremely high-risk population is associated with high short and long-term mortality rates. Early identification of patients at risk for hemodynamic compromise may rationalize elective utilization of MCS during TAVR.

Comparison of Outcomes of Transcatheter Aortic Valve Replacement Plus Percutaneous Coronary Intervention Versus Transcatheter Aortic Valve Replacement Alone in the United States

Transcatheter aortic valve replacement (TAVR) with percutaneous coronary intervention (PCI) has emerged as a less-invasive therapeutic option for high surgical risk patients with aortic stenosis and coronary artery disease. The aim of this study was to determine the outcomes of TAVR when performed with PCI during the same hospitalization. We identified patients using the International Classification of Diseases, Ninth Revision, Clinical Modification procedure codes from the Nationwide Inpatient Sample between the years 2011 and 2013. A total of 22,344 TAVRs were performed between 2011 and 2013. Of these, 21,736 (97.3%) were performed without PCI (TAVR group) while 608 (2.7%) along with PCI (TAVRxa0+ PCI group). Among the TAVRxa0+ PCI group, 69.7% of the patients had single-vessel, 22.2% had 2-vessel, and 1.6% had 3-vessel PCI. Drug-eluting stents were more commonly used than bare-metal stents (72% vs 28%). TAVRxa0+ PCI group witnessed significantly higher rates of mortality (10.7% vs 4.6%) and complications: vascular injury requiring surgery (8.2% vs 4.2%), cardiac (25.4% vs 18.6%), respiratory (24.6% vs 16.1%), and infectious (10.7% vs 3.3%), p <0.001% for all, compared with the TAVR group. The mean length of hospital stay and cost of hospitalization were also significantly higher in the TAVRxa0+ PCI group. The propensity score-matched analysis yielded similar results. In conclusion, performing PCI along with TAVR during the same hospital admission is associated with higher mortality, complications, and cost compared with TAVR alone. Patients would perhaps be better served by staged PCI before TAVR.

Comparison of Utilization Trends, Indications, and Complications of Endomyocardial Biopsy in Native Versus Donor Hearts (from the Nationwide Inpatient Sample 2002 to 2014)

Native heart endomyocardial biopsy (NH-EMB) is an infrequently performed procedure. The objective of this study is to describe utilization trends, indications, and complications associated with NH-EMB in the United States and compare them with transplanted heart endomyocardial biopsy (TH-EMB). Using the Healthcare Cost and Utilization Project National Inpatient Sample database, we identified 71,105 adult patients undergoing EMB in the inpatient setting in participating hospitals from 2002 to 2014. A total of 20,770 (29%) were performed on NHs (mean age 52.2u2009±u200915.3, 61% men). Approximately half of patients were white and mean Charlson co-morbidity index was 1.97u2009±u20091.6. Common indications for NH-EMB included a suspected primary cardiomyopathy (disorder confined to the myocardium), heart failure without cardiogenic shock, and acute myocarditis. Less common indications included heart failure with cardiogenic shock, unexplained heart failure with ventricular tachycardia or high-degree atrioventricular block, and cardiac neoplasms. Complications included pericardial effusion (3.8%), third-degree atrioventricular block (2.7%), vascular complications (1.9%), and deep venous thrombosis (3.5%), in others. Predictors of complications included presence of a cardiac malignant neoplasm, use of hemodynamic support, heart failure with ventricular tachyarrhythmias, and female gender. Compared with NH-EMB, TH-EMB was associated with lower rates of pericardial effusion, third-degree atrioventricular block, ventricular tachyarrhythmias requiring cardioversion, and higher rates of deep venous thrombosis, infections, and pneumothorax. NH-EMB utilization is low in the United States and constitutes less than 1/3 of all EMBs performed.

Hospital Admissions for Chest Pain Associated with Cocaine Use in the United States

BACKGROUNDnThe outcomes related to chest pain associated with cocaine use and its burden on the healthcare system are not well studied.nnnMETHODSnData were collected from the Nationwide Inpatient Sample (2001-2012). Subjects were identified by using the International Classification of Diseases, Ninth Revision, Clinical Modification codes. Primary outcome was a composite of mortality, myocardial infarction, stroke, and cardiac arrest.nnnRESULTSnWe identified 363,143 admissions for cocaine-induced chest pain. Mean age was 44.9 (±21.1) years with male predominance. Left heart catheterizations were performed in 6.7%, whereas the frequency ofxa0acute myocardial infarction and percutaneous coronary interventions were 0.69% and 0.22%, respectively. The in-hospital mortality was 0.09%, and the primary outcome occurred in 1.19% of patients. Statistically significant predictors of primary outcome included female sex (odds ratio [OR], 1.16; confidence interval [CI], 1.00-1.35; Pxa0= .046), age >50 years (OR, 1.24, CI, 1.07-1.43; Pxa0= .004), history of heart failure (OR,xa01.63, CI, 1.37-1.93; P <.001), supraventricular tachycardia (OR, 2.94, CI, 1.34-6.42; Pxa0=xa0.007), endocarditis (OR, 3.5, CI, 1.50-8.18, Pxa0= .004), tobacco use (OR, 1.3, CI, 1.13-1.49; P <.001), dyslipidemia (OR, 1.5, CI, 1.29-1.77; P <.001), coronary artery disease (OR, 2.37, CI, 2.03-2.76; Pxa0<.001), and renal failure (OR, 1.27, CI, 1.08-1.50; Pxa0= .005). The total annual projected economic burden ranged from

Outcomes of hemodynamic support with Impella in very high-risk patients undergoing balloon aortic valvuloplasty: Results from the Global cVAD Registry

155xa0toxa0

Transcatheter Mitral Valve Repair With MitraClip for Symptomatic Functional Mitral Valve Regurgitation

226 million with a cumulative accruement of more than

Coronary revascularization for acute myocardial infarction in the HIV population

2 billion over a decade.nnnCONCLUSIONnHospital admissions due to chest pain and concomitant cocaine use are associated with low rates of adverse outcomes. For the low-risk cohort in whom acute coronary syndrome has been ruled out, hospitalization may not be beneficial and may result in unnecessary cardiac procedures.

Outcomes of transcatheter aortic valve replacement for bicuspid aortic stenosis – a systematic review of existing literature

BACKGROUNDnReports on the role of hemodynamic support devices in patients with severe aortic stenosis (AS) and left ventricular (LV) dysfunction undergoing balloon aortic valvuloplasty (BAV) are limited.nnnMETHODSnPatients were identified from the cVAD registry, an ongoing multicenter voluntary registry at selected sites in North America that have used Impella in >10 patients.nnnRESULTSnA total of 116 patients with AS who underwent BAV with Impella support were identified. Mean age was 80.41±9.03years and most patients were male. Mean STS score was 18.77%±18.32, LVEF was 27.14%±16.07, and 42% underwent concomitant PCI. In most cases Impella was placed electively prior to BAV, whereas 26.7% were placed as an emergency. The two groups had similar baseline characteristics except for higher prevalence of CAD and lower LVEF in the elective group, and higher STS score in the emergency group. Elective strategy was associated higher 1-year survival compared to emergency placement (56% vs. 29.2%, p=0.003). One-year survival was higher when BAV was used as a bridge to definitive therapy as opposed to palliative treatment (90% vs. 28%, p<0.001). On multivariate analysis, STS score and aim of BAV (bridge to definitive therapy vs. palliative indication) were independent predictors of mortality.nnnCONCLUSIONnIn this large cohort of patients with AS and severe LV dysfunction undergoing BAV, our results demonstrates feasibility and promising long-term outcomes using elective Impella support with the intention to bridge to a definitive therapy.

Updates on transcatheter aortic valve replacement: Techniques, complications, outcome, and prognosis

Transcatheter edge-to-edge mitral valve repair (TMVr) with MitraClip has proved to be safe and effective for high-risk surgical patients with severe symptomatic degenerative mitral regurgitation. There is paucity of data regarding its use in functional mitral regurgitation (FMR). The objective of this study was to evaluate the use of MitraClip in patients with symptomatic moderate or severe FMR and a high surgical risk. Medical libraries were systematically searched for studies assessing the use of MitraClip for patients with symptomatic moderate or severe FMR and a high surgical risk. Studies reporting safety and efficacy outcomes at 12xa0months were included in the analysis. A total of 12 studies including 1,695 patients (age 73 [interquartile range [IQR] 70.5 to 74], 69.8% men, left ventricular ejection fraction 32.5% [IQR 29.5 to 36], New York Heart Association class II to IV) who underwent TMVr with MitraClip were included in the analysis. Acute procedural success was 89% (IQR 85.5 to 92). Ischemic cardiomyopathy was the most common cause of left ventricular dysfunction. Over 2/3 of patients had known coronary artery disease, 35% a previous myocardial infarction, and 38.5% had a previous cardiac surgery. Survival to hospital discharge was 98% (IQR 97 to 100) and 30-day survival 97% (IQR 96 to 98). Overall survival at 12 months was 82% (IQR 77 to 87). Mitral valve re-intervention at 12xa0months was infrequent (3%; IQR 2 to 6.5). In conclusion, our pooled analysis suggests that TMVr with MitraClip is feasible, safe, and carries a low rate of mitral valve re-intervention at 12xa0months in patients with symptomatic moderate or severe FMR and a high surgical risk.

A Review of Alternative Access for Transcatheter Aortic Valve Replacement

OBJECTIVEnTo analyze trends in management and outcomes of patients infected with the human immunodeficiency virus (HIV) undergoing percutaneous coronary intervention (PCI) for an acute myocardial infarction (AMI) in the United States.nnnBACKGROUNDnInfection with HIV is an independent risk factor for accelerated atherosclerosis associated with higher rates of AMI. Current trends and outcomes of HIV-infected individuals presenting with AMI in the United States remain unknown.nnnMETHODSnUsing the Healthcare Cost and Utilization Project National Inpatient Sample database we identified HIV-infected individuals who underwent PCI for an AMI from 2002 to 2013. Multivariable logistic regression and propensity-score matching were performed to analyze outcomes.nnnRESULTSnWe identified a total of 59u2009194 patients of which 7841 underwent PCI during index hospitalization (13.3%). Most patients were men (71%), ≥50 years of age (82%), and white (74%). ST-elevation myocardial infarction was present in 21% of cases. Charlson comorbidity index (CCI) was 5.67u2009±u20090.4. Predictors of post-procedural complications included female sex, black race, higher CCI, and placement of a bare metal stent, whereas predictors of mortality included occurrence of a complication, ST-elevation myocardial infarction, age ≥70 years, and higher CCI. Conversely, placement of a drug-eluting stent was associated with a reduced risk of complications and mortality. After propensity-score matching, HIV-infected individuals were less likely to undergo PCI and receive a drug-eluting stent, while having longer length of stay, higher hospitalization costs, and higher in-hospital mortality when compared to non-infected individuals.nnnCONCLUSIONnSignificant disparities continue to affect HIV-infected individuals undergoing PCI for AMI in the United States.