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Background. Despite an association between operator volumes and procedural success, there remains an incomplete understanding of the contemporary utilization and procedural volumes for mitral valve transcatheter edge-to-edge repair (MTEER). We aimed to identify annual operator procedural volumes, temporal trends, and geographic variability for MTEER among Medicare patients in the United States (US). Methods. We queried the National Medicare Provider Utilization and Payment Database for a CPT code (33418) specific for MitraClip device from 2015 through 2019. We analyzed annual operator procedural volumes and incidence and identified longitudinal and geographic trends in MTEER utilization. Results. From 2015 through 2019, a total of 27,034 MTEER procedures were performed among Medicare patients in the US. The nationwide incidence increased from 6.2 per 100,000 patients in 2015 to 23.8 per 100,000 patients in 2019, a 283% increase over the study period (Ptrend < 0.001). The incidence of MTEER by state varied by nearly 900% (range 5.5 to 54.9 per 100,000 person-years). In 2019, the mean annual MTEER operator annual volume was 9.1 MTEER procedures and had grown from 6.2 per year in 2015. Conclusions. In this nationwide study of Medicare beneficiaries in the United States, we identified a significant and sustained increase in the utilization of MTEER devices and operators and growth in annual procedural volumes from 2015 through 2019 with considerable variability in utilization by state. Further studies are needed to understand the clinical impact of variability in utilization and the optimal procedural volumes to ensure high efficacy outcomes and maintain critical access to MTEER therapies. [ABSTRACT FROM AUTHOR]

Background: Patients with post‐infarct cardiomyopathy and ventricular arrhythmias (VT) necessitating implantable cardioverter defibrillators (ICD) are at risk of recurrent shocks with increased morbidity. Methods: A comprehensive search of electronic databases for all randomized clinical trials that evaluated the role of catheter ablation as a preventive strategy at the time of secondary prevention ICD implantation was performed. We calculated hazard ratios (HR) and 95% confidence intervals (CI) using random‐effects model. Results: Four trials were identified with a total of 505 patients (average age 66.4 ± 9.0 years; 87.7% were male). Preventive ablation was associated with a significant reduction in appropriate device therapies (shocks and/or anti‐tachycardia therapy) (HR = 0.62; 95% CI = 0.46‐0.82; P <.01), sustained VT (HR = 0.74; 95% CI = 0.55‐0.99; P =.04) compared to control. There were no differences in inappropriate device shocks (HR = 0.80; 95% CI = 0.38‐1.71), all‐cause death (HR = 0.93; 95% CI = 0.53‐1.64), cardiac death (HR = 0.63; 95% CI = 0.29‐1.36), arrhythmic death (HR = 0.26; 95% CI = 0.05‐1.31), or cardiac hospitalization (HR = 0.79; 95% CI = 0.57‐1.11) between strategies. Preventive ablation was associated with improved SF‐36 physical component (mean difference = 2.81; 95% CI‐0.53‐5.10; P =.02), but not the mental component (mean difference = 1.30; 95% CI = ‐2.06‐4.66). Conclusion: Among patients with post‐infarct cardiomyopathy and VT, preventive catheter ablation at the time of ICD implantation is associated with a significant reduction of appropriate ICD therapy and sustained VT, and improvement in the physical component of quality‐of‐life, but no reduction in mortality. [ABSTRACT FROM AUTHOR]

Background: Cryptogenic stroke and embolic stroke of undetermined source (ESUS) are a frequently encountered categories of ischemic stroke with an uncertain cause.Methods: We analyzed all randomized clinical trials (RCTs) that evaluated antithrombotic therapy and patent foramen ovale (PFO) closure in cryptogenic stroke and/or ESUS. We calculated aggregate hazard ratios (HRs) using direct and network meta-analysis. The primary outcome was recurrent ischemic stroke.Results: Ten RCTs with a total of 16,876 patients, randomizing 32,143 patient-years of follow-up (mean age 61.2 ± 13.5 with 39.2% female) were identified. Anticoagulation therapy was associated with significantly reduced recurrent ischemic stroke compared with antiplatelet therapy (HR = 0.66; [95% confidence interval (CI) = 0.47-0.94]). Meta-regression analysis showed significantly reduced recurrent stroke with longer duration of therapy, and significantly increased events with advanced age. Significant interactions were observed based on the presence of PFO, stroke type, and anticoagulant used. There were no significant differences with regard to the composite ischemic outcome, transient ischemic attack, any death, major bleeding, or intracranial bleeding. In the network meta-analysis, compared to antiplatelet therapy, warfarin (HR = 0.31; [95% credible interval (CrI) = 0.12-0.68]) and PFO closure (HR = 0.14; 95% CrI = 0.05-0.31]) were associated with significantly reduced recurrent ischemic stroke. In rank order, PFO closure was associated with the best outcome, followed by warfarin.Conclusions: Among patients with cryptogenic stroke, anticoagulation therapy, as compared with antiplatelet therapy is associated with lower rate of recurrent stroke. The small sample size and high heterogeneity with regards to bleeding outcomes require further large trials. In patients with PFO, closure and warfarin are associated with the lowest rates of recurrent stroke. [ABSTRACT FROM AUTHOR]

Introduction: Although systolic and diastolic dysfunction must coexist, they are most often considered in isolation. Therefore, a simple and reproducible quantitative measurement that integrates systolic and diastolic function is desirable. We hypothesize that the absolute sum of lateral mitral annular systolic and early diastolic peak velocities is predictive of overall cardiac function. Methods: In this study, lateral mitral annular systolic (S′) and early diastolic (E′) peak velocities were measured in healthy subjects and compared against subjects with progressive degrees of systolic and diastolic dysfunction. Results: A total of 149 subjects (56% male, mean age 48 years) were enrolled and stratified according to global left ventricular function: 76 normal, 40 mild‐moderate dysfunction, and 33 moderate‐severe dysfunction. Adjusting for baseline differences including age, univariate analysis showed mean S′ + E′ values were significantly different between subjects with normal, mild‐moderate, and moderate‐severe global left ventricular function (27, 17, 13 cm/s; P < 0.001 for all comparisons). The absolute sum of S′ + E′ ≥ 20 cm/s identified normal global left ventricular function with a sensitivity of 95%, specificity of 85%, and ROC area under the curve of 0.924. Conclusions: In a cohort of subjects with varying levels of combined systolic and diastolic function, the easily obtainable composite score of S′ + E′ ≥ 20 cm/s is strongly predictive of normal global left ventricular function with a high degree of sensitivity and specificity. Additional studies should be considered to expand this concept to additional populations. [ABSTRACT FROM AUTHOR]

Background: Mitral regurgitation is the most common form of valvular heart disease worldwide, however, there is an incomplete understanding of predictors of mortality in this population. This study sought to identify risk factors of mortality in a real-world population with mitral regurgitation.Methods: All patients with moderate or severe mitral regurgitation were identified at a single center from January 1, 2016 to August 31, 2017. Multivariate regression was performed to evaluate variables independently associated with all-cause mortality.Results: A total of 490 patients with moderate (76.3%) or severe (23.7%) mitral regurgitation due to primary (20.8%) or secondary (79.2%) etiology were identified. The mean age was 66.7 years; 50% were male. At a median follow-up of 3.1 years, the incidence of all-cause mortality was 30.1%, heart failure hospitalization 23.1%, and mitral valve intervention 11.6%. Of 117 variables, multivariate analysis demonstrated 5 that were independently predictive of mortality: baseline creatinine (hazard ratio [HR] 1.2; 95% CI, 1.0-1.3; P = .02), right atrial pressure by echocardiogram (HR 1.3; 95% CI, 1.07-1.55; P = .008), hemoglobin (HR 0.65; 95% CI, 0.52-0.83; P = .001), hospitalization for heart failure (HR 1.6; 95% CI, 1.1-2.4; P = .015), and mitral valve intervention (HR 0.40; 95% CI, 0.16-0.83; P = .049).Conclusion: In this retrospective, pragmatic analysis of patients with moderate or severe mitral regurgitation, admission for heart failure exacerbation, elevated right atrial pressure, renal dysfunction, anemia, and lack of mitral valve intervention were independently associated with increased risk of all-cause mortality. Whether these risk factors may better identify select patients who may benefit from more intensive monitoring or earlier intervention should be considered in future studies. [ABSTRACT FROM AUTHOR]

The article deals with the decision of evangelicals in the U.S. to shift their political support from the Republican Party to the Democratic Party. One of many substantial matter of concern for evangelical voters seemed to have been the issue of corruption in government, which was mentioned as significant by four out of ten of them in exit polls. The author suggests that the Democratic majority will have to avoid pitfalls that beset their Republican counterparts.

The article contends that U.S. President George W. Bush has no coherent movement or ideological platform to which American people can turn for a new direction. The social and political problems including the war in Iraq, record budget deficits and rising number of poor facing Bush are considered. An assessment of Bush second term in office is presented. The impact of public pressure on some of Bush's policies is emphasized.

Analyzes a variety of issues associated with the outcome of the November 2, 2004 elections in the U.S. Implications of the election outcome to the Democrats; Religious aspects of the U.S. politics; Comparison between the political theological beliefs of Republicans and Democrats.

We read with great interest the study, "Prophylactic Use of Implantable Cardioverter-Defibrillators in the Prevention of Sudden Cardiac Death in Dialysis Patients" by Jukema et al[1] published recently in I Circulation i . In the prospective POST SCD study (San Francisco Postmortem Systematic Investigation of Sudden Cardiac Death), we demonstrated that the World Health Organization criteria had poor specificity for SAD; nearly half (45%) of all 525 World Health Organization-defined (presumed) SCDs occurring countywide over a 3-year period were found to have a nonarrhythmic cause of death on autopsy.[3] Our cohort included 58 patients with chronic renal disease not yet on dialysis; of those, 33 (56.9%) had SAD, and 25 (43.1%) had nonarrhythmic death. The editorial by Kaplan and Passman[4] cites an autopsy study that demonstrates that this discrepancy could be worse in patients with end-stage renal disease with a higher risk of sudden neurological death. [Extracted from the article]

Of patients presenting to the emergency department (ED) only a minority are admitted to inpatient care, while the vast majority are evaluated, treated, and discharged for ongoing care in the community.[1] A significant proportion of discharged patients will return to the ED within 30 days, with more than three-quarters being discharged a second time.[2] An estimated 25% of ED visits in the USA may be managed in the community at a savings up to $4.4 billion annually[3]; thus, subjects re-presenting to the ED typifies a targeted population- where interventions preventing unnecessary visits may lead to reduced healthcare costs and improved quality of care. Authors successfully identified high-risk subjects as the overall rate of return was high, but found no difference in the primary outcome of repeat ED visits within 30 days between routine care and intervention groups. [Extracted from the article]

Background: Among patients with heart failure and left ventricular (LV) dysfunction despite guideline directed medical therapy, cardiac resynchronization (CRT) is an effective technology to reverse LV remodeling. Given that a large portion of patients are non‐responders, alternatives to traditional LV‐lead placement have been explored. A promising alternative is image targeted placement of an LV‐lead to latest mechanically activated segment without scar. Methods: Electronic database search for randomized controlled trials (RCTs) that evaluated the imaging‐guided LV‐lead placement on clinical, echocardiographic, and functional outcomes. The primary outcome was a composite of mortality and heart failure hospitalization. The secondary outcomes included CRT responders, New York Heart Association (NYHA), 6‐minute walk test, Minnesota Living with Heart Failure Questionnaire (MLHFQ), and ejection fraction (EF) changes. Results: Analysis included 4 RCTs of 691 patients with an average follow‐up of 2 years (age 69.5 ± 10.3 years, 76% males, 54% ischemic cardiomyopathy, 81% with NYHA classes III/IV, and EF of 24.4% ± 8). The most common site for LV‐lead paced segment was the anterolateral segment (45%) and at mid‐LV (49%). Compared with the control, imaging‐guided LV‐lead placement was associated with a significant reduction of the primary outcome (hazard ratio [HR] = 0.60; 95% CI = 0.40–0.88; p =.01), higher CRT responders (odd ratio [OR] = 2.10; p <.01), more NYHA improvements by ≥1 (OR = 1.89; p =.01), increased 6MWT (mean difference [MD] = 25.78 feet; p <.01), and lower MLHFQ (MD = ‐4.04; p =.04), without significant differences in the LVEF (p =.08). Conclusions: In patients undergoing CRT, imaging‐guided LV‐lead placement was associated with improved clinical, echocardiographic, and functional status. [ABSTRACT FROM AUTHOR]

Background: We aimed to conduct this study with the goal of further clarifying the role of sodium-glucose cotransporter-2 inhibitors (SGLT2i) in patients with preexisting heart failure with reduced ejection fraction with or without diabetes and to leverage increased sample size and power to evaluate clinically important secondary safety and efficacy outcomes.Methods: This meta-analysis was completed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The primary outcome was a composite of cardiovascular death or heart failure hospitalization. Secondary outcomes included the individual components of the primary outcome; major adverse cardiovascular events (defined as a composite of cardiovascular death, myocardial infarction, stroke), any death, myocardial infarction, or stroke, along with adverse events such as volume depletion, acute kidney injury, adverse events leading to drug discontinuation, amputation, and severe hypoglycemia. Other outcomes included the Kansas City Cardiomyopathy Questionnaire (KCCQ) total symptom score and changes in N-terminal pro-hormone BNP (NT-proBNP). Pooled hazard ratios (HRs) and 95% confidence intervals (CIs) for dichotomous variables and weighted difference (MD) and 95% CI for continuous variables.Results: Compared with placebo, SGLT2i use was associated with a significant reduction of cardiovascular death or heart failure hospitalization (HR = 0.74; 95% CI = 0.66-0.82; P <0.01), heart failure hospitalization (HR = 0.69; 95% CI = 0.57-0.84; P <0.01), cardiovascular death (HR = 0.79; 95% CI = 0.68-0.92; P <0.01), and any death (HR = 0.80; 95% CI = 0.70-0.92; P <0.01).Conclusions: SGLT2i was associated with a decreased risk of clinically relevant cardiovascular death, heart failure hospitalization, and heart failure symptoms with similar rates of adverse events. [ABSTRACT FROM AUTHOR]