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Background Atrial arrhythmias are commonly noted in patients with alcohol withdrawal syndrome (AWS), requiring inpatient admission. Objective The burden of arrhythmias and the association with in-hospital outcomes are incompletely defined in patients hospitalized with AWS. Methods The nationwide inpatient sample database was accessed from September 2015 to December 2018 to identify hospitalizations for AWS. We studied a cohort of patients with arrhythmias noted during hospitalization using the appropriate International Classification of Diseases, Tenth Revision billing codes. We compared patient characteristics, outcomes, and hospitalization costs between alcohol withdrawal hospitalizations with and without documented arrhythmias. Propensity score matching (PSM) and multivariate regression were performed to control confounders and develop odds ratios (OR), respectively. Results Among 1,511,155 hospitalization with AWS, 146,825 (9.72%) had concurrent arrhythmias. After PSM, we identified 135,540 cases in each group. Hospitalizations with AWS and concurrent arrhythmias had higher in-hospital mortality (4.19% vs 1.95%, OR 1.76, confidence interval [CI] 1.67–1.85, P < .0001). The most common arrhythmia was atrial fibrillation (66.7%). Arrhythmias in AWS were also associated with poorer in-hospital outcomes, including a higher risk of acute heart failure (8.40% vs 4.58%, OR 1.97, CI 1.90–2.05, P < .0001), acute kidney injury (21.32% vs 15.27%, OR 1.39, CI 1.36–1.43, P < .0001), and acute respiratory failure (9.19% vs 5.49%, OR 1.70, CI 1.64–1.76, P < .0001) requiring intubation. The length of hospital stay (6 days vs 4 days P < .0001) and cost of hospital care ($12,615 [$6683–$27,330] vs $7860 [$4482–$15,868], P < .0001) were higher in AWS with arrhythmias. Conclusion Arrhythmia in AWS is associated with higher in-hospital mortality and poorer in-hospital outcomes.

Objectives The aim of this study was to evaluate the interaction between hospital endovascular lower extremity revascularization (eLER) volume and outcomes after eLER for critical limb ischemia (CLI). Background There is a paucity of data on the relationship between hospital procedural volume and outcomes of eLER for CLI. Methods The authors queried the Nationwide Readmission Database (2013-2015) for hospitalized patients who underwent eLER for CLI. Hospitals were divided into tertiles according to annual eLER volume: low volume ( 550 eLER procedures). Stepwise multivariable regression models were used. The main outcomes were in-hospital mortality and 30-day readmission with major adverse limb events, defined as the composite of amputation, acute limb ischemia, or repeat revascularization. Results Among 145,785 hospitalizations for eLER for CLI, 5,199 (3.6%) were at low-volume eLER hospitals, 27,857 (19.1%) at moderate-volume eLER hospitals, and 112,728 (77.3%) at high-volume eLER hospitals. On multivariable analysis, there was no difference with regard to in-hospital mortality among moderate-volume hospitals (adjusted odds ratio [OR]: 0.78; 95% CI: 0.60-1.01) and high-volume hospitals (adjusted OR: 0.84; 95% CI: 0.64-1.05) compared with low-volume hospitals. There was lower risk of in-hospital major amputation (adjusted OR: 0.82; 95% CI: 0.70-0.96) and minor amputation at high- versus low-volume hospitals. The length of hospital stay was shorter and discharges to nursing facilities were fewer among moderate- and high-volume hospitals compared with low-volume hospitals. Compared with low-volume hospitals, eLER for CLI at high-volume hospitals had a lower risk for 30-day readmission with major adverse limb events (adjusted OR: 0.83; 95% CI: 0.70-0.99), while there was no difference among moderate-volume hospitals (adjusted OR: 0.92; 95% CI: 0.77-1.10). Conclusions This nationwide observational analysis suggests that annual eLER volume does not influence in-hospital mortality after eLER for CLI. However, high eLER volume (>550 eLER procedures) was associated with better rates of limb preservation after eLER for CLI.

To evaluate the in-hospital mortality and acute STEMI-related complications in a SMuRF-less STEMI population compared with a SMuRF STEMI population in the United States. The National Inpatient Sample (NIS) Database (2005-2014) was analyzed to identify patients with STEMI using ICD-9. Patients were grouped into SMuRF and SMuRF-less based on the presence of ≥1 SMuRF risk factor. The primary outcomes were the prevalence and in-hospital mortality of SMuRF-less patients. Secondary outcomes were rates of in-hospital complications in STEMI patients. A total of 434,111 STEMI patients were identified with 318,281 (73.4%) and 115,830 (26.6%) patients in the SMuRF and SMuRF-less categories, respectively. In multivariable logistic regression analysis, SMuRF-less patients had a higher in-hospital mortality rate (odds ratio [OR]: 1.670; 95% confidence interval [CI]: 1.620-1.722) and acute renal failure (OR: 1.724; 95% CI: 1.662-1.787). SMuRF-less STEMI patients have higher odds of in-hospital mortality and in-hospital STEMI-related complications compared with SMuRF STEMI patients.

Contemporary data on stroke predictors and outcomes in patients undergoing transcatheter aortic valve implantation (TAVI) remains limited. We analyzed National Inpatient Sample data from the year 2011 to 2018. A total of 215,938 patients underwent TAVI. Of the patients who underwent TAVI, 4579 (2.2%) suffered from stroke and 211359 (97.8%) did not have a stroke. Adjusted mortality was higher in patients who had a stroke (10.9%) as compared to patients who did not have a stroke (3.1%). Lower percentage of patients were discharged home who developed a stroke compared to patients without a stroke (10.2% vs 52.3%). Multivariate logistic regression analysis showed that at baseline, age, female sex, atrial fibrillation, chronic kidney disease and peripheral vascular disease were significant predictors of stroke. Median Cost of care ($63367 vs $48070) and length of stay (8 vs 4 days) were considerably higher for patients with stroke when compared to the comparison group (P0.01 for all). In conclusion we report that stroke is associated with increased mortality, morbidity, and resource utilization in patients undergoing TAVI. Baseline characteristics like age, gender, atrial fibrillation, chronic kidney disease and peripheral vascular disease are significant predictors of this adverse event.

Introduction Veno-venous extracorporeal membrane oxygenation (VV-ECMO) as bridge to recovery in critically ill COVID-19 continues to be commonly utilized strategy in cases with persistent respiratory failure refractory to traditional ventilation support Case Report We report 5 cases of severe acute respiratory syndrome coronavirus-2 infection (SARS-CoV-2) who were treated with ECMO (Table 1). All 5 cases presented with fever, cough and shortness of breath and a positive nasopharyngeal swab for SARS-CoV-2 on admission. Case 1, 2, 3 and 5 patients were hypoxemic with saturation less than 90% on admission and decompensated rapidly, whereas Case 4 decompensated after day 14. Mechanical ventilation failed to provide adequate oxygenation in all 5 cases; case 2,3 and 5 were started on recruitment measures with proning while it was not possible for case 1 owing to morbid obesity. Proning was not possible in the case 4 as patient became severely hypoxemic while patient was undergoing mechanical thrombectomy. The case 1-4 remained on ECMO for 19, 17, 17 and 2 days respectively. All except case 2 had improvement in APACHEII and SOFA score after ECMO initiation. All 5 patients had elevated inflammatory markers of serum ferritin, D-dimer, Lactate dehydrogenase (LDH), C-reactive protein (CRP) which trended down after a few days of ECMO initiation All 5 patients received high dose steroids during their stay in the ICU. Case 4 and 5 passed away after compassionate extubation. Case 1-3 had prolonged hospital course with complication of hospital acquired pneumonia requiring multiple courses of broad-spectrum antibiotics. Summary Our observational report of 5 patients reports the use of ECMO in critically ill SARS-CoV-2 with ARDS and difficult to maintain saturation despite mechanical ventilation and proning with recovery for 3 patients. However, given the lack of ECMO centers; this is not a readily available option. Further studies are warranted to investigate the role of ECMO in SARRS-CoV-2 and careful identification of appropriate candidates.

With an aging population and significant overlap of risk factors, the cohort of patients with acute coronary syndrome (ACS) and concomitant atrial fibrillation (AF) is a sizable and growing one, with implications on cardiac reserve, anticoagulation and antiplatelet therapies, and related complications. The present study uses a large national database to analyze the impact of AF on patients admitted with an ACS. We queried the 2012 to 2014 National Readmissions Database to identify patients admitted with an ACS using International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9 CM) codes. These patients were then subcategorized based on the presence or absence of AF. Analysis of their initial hospitalization, 30-day readmissions and healthcare utilization and the economic burden was performed. Among 1,558,205 patients with ACS, 270,966 (17.4%) were noted to have concomitant AF. At baseline, these patients were older and more likely female, with a significantly higher burden of comorbidities. Patients with AF had longer and more complicated index hospitalizations with significantly higher mortality rates (8.6% vs 4.6%). Coronary artery bypass graft was the preferred method of revascularization in patients with AF as compared to percutaneous coronary intervention. The 30-day readmissions were higher in the AF group (15.6 vs 10.8%), largely driven by noncardiac causes. This was associated with higher healthcare utilization with longer hospitalizations during index admission. Patients admitted with ACS and concomitant AF is a high-risk population with increased in-hospital complications and mortality, as well as short term readmissions. Coronary artery bypass graft appears favored over percutaneous coronary intervention for revascularization in patients with AF.

Traditionally ST-elevation myocardial infarction (STEMI) with multivessel coronary artery disease is treated with percutaneous coronary intervention (PCI) to culprit lesion only. The benefit of multivessel (MV) PCI among STEMI patients without cardiogenic shock is unclear.PubMed, EMBASE, and Cochrane Database were searched from 1996 to 2019, for studies of patients with STEMI without cardiogenic shock, who underwent PCI. Only randomized controlled trials comparing culprit PCI to MV PCI vs culprit vessel PCI were included for pairwise meta-analysis. All-cause mortality, cardiac mortality, reinfarction, revascularization and major adverse cardiovascular events (MACE) were compared. Trial sequential analysis (TSA) was performed for outcome variables.Nine randomized controlled trials contributed 6930 patients meeting inclusion criteria. Three thousand three hundred seventy-six underwent MV PCI, and 3554 underwent culprit PCI. Our analysis demonstrated no significant difference in all-cause mortality. MV PCI had a lower risk of cardiac mortality, reinfarction, MACE and repeat revascularization compared to culprit PCI (P values0.05). TSA showed futility for further trials to detect all-cause mortality benefit and lack of firm evidence of benefit in cardiac mortality and re-infarction, but firm evidence of benefit in revascularization and MACE.In conclusion, MV PCI strategy was beneficial in reducing cardiac mortality, reinfarction, repeat revascularization, and MACE but there was no all-cause mortality benefit when compared to culprit only PCI strategy. Evidence for benefit in cardiac mortality and re-infarction is not robust per TSA.

Background Cardiac dysrhythmias are a common cause of hospitalization in patients with left ventricular assist device (LVAD). There is limited data on the incidence of VT over time and associated mortality in patients with LVAD. We aimed to identify the incidence of VT post LVAD implant and associated in hospital mortality. Methods Subjects with history of LVAD who had cardiac dysrhythmias as a primary diagnosis were identified from the National Inpatient Sample (NIS) dataset of the Healthcare Cost and Utilization Project (HCUP) for the years 2005-2017 using ICD-9 and10 codes. We also identified the in-hospital outcomes of VT. We excluded patients with history of orthotropic heart transplant and history of biventricular assist device (BiVAD). Associated morbidities and in-hospital outcomes were evaluated. Results A total of 15131 LAVD hospitalizations were identified and 703 patients hospitalized with a primary diagnosis of cardiac dysrhythmias. The median age of patients was 60 years (IQR 51-67), and 57.8% were White. VT was the primary cause of hospitalization in 542 patients (77.5%), followed by atrial fibrillation and flutter, 126(17.9%), then paroxysmal supraventricular tachycardia, 24(3.4%) . Among patients who had VT, 62 patients (11.4%) had cardiac arrest, 2 (0.4%) needed CPR, 17(3.1%) had cardiogenic shock, 4(0.7%) had acute myocardial infarction, 4(0.7%) had acute stroke, 2(0.4%) had brain death, 13 (2.4%) needed mechanical ventilation, 42 (7.7%) had ICD implanted. There was no significant increase in incidence of hospitalization for VT in LVAD patients over the study period.(Std. J-T Statistic 1.371, p = 0.170). Figure 1. The overall in hospital death in these patients was 13(1.8%). Conclusion In LVAD patient VT was found to be most common arrhythmia causing hospitalization but overall mortality was low.

Background Extracorporeal membrane oxygenation (ECMO) utilization in children is recommended in refractory septic shock. However in adults there are no official recommendation to guide this treatment. Most of the existing evidence consists of small observational and single center experiences. We aimed to investigate the trend of use and outcomes of ECMO in patients with combined septic and cardiogenic shock. Methods We queried the unweighted national inpatient sample (NIS) for patients older than 18 years old, who carried both diagnoses of septic shock and cardiogenic shock during index hospitalization and received ECMO treatment for the years 2004-2017 using ICD-9&10 codes. Results We identified 29,178 patients with combined septic and cardiogenic shock in between 2004 and 2017. Of those, 424 (0.1%) patients underwent ECMO. There was a statistically significant increasing trend of ECMO use over the years of study (Std. J-T Statistic 4.338, p Conclusion ECMO is being increasingly used in patients with combined septic and cardiogenic shock, more data is needed to further guide this treatment modality in this patient population.

Background Atrioventricular block (AVB) is known complication of acute myocarditis. Data is limited on the role of trans-venous pacing in acute myocarditis with atrioventricular block. Aim We aimed to evaluate the clinical characteristics and outcomes of patients requiring temporary trans-venous pacing for AVB in acute myocarditis. Methods We queried the national inpatient sample (NIS) from 2002 through 2015, unweighted, for patients older than 18 years old who carried a diagnosis of acute myocarditis using ICD-9 codes. Outcomes in patient who had trans-venous pacing were evaluated. Results We identified 10,106 patients with acute myocarditis from 2002-2015. Of them, 5573 (55.1%) were idiopathic, 283 (2.8%) were septic, 103 (1.0%) were toxic, 89 (0.9%) were acute rheumatic, and 4058 (40.2%) were unspecified myocarditis. AVB occurred in 393 patients (3.9%) of which 134 (34.1%) patients needed trans-venous pacing (table 1 show distribution of trans-venous pacing according to the types of acute myocarditis). In patient who required trans-venous pacing; median age was 42 years (IQR 29-54), median length of stay was 6 days (IQR 4-9), median cost of hospital charge was $47,520 (IQR $28,265-$103,530), 64.9% were male, and 72.8% were White. In hospital death occurred in 5 patient (3.7%), 12 (9.0%) had septicemia, 2 (1.5%) had cardiac tamponade, 10 (7.5%) had ventricular arrhythmias, 18 (13.4%) needed permanent pacemaker, and 13 (9.7%) had cardiogenic shock. Conclusion Heart block is not uncommon in acute myocarditis and one third of patients require temporary pacing, however AVB is transient in most patient with less than a fifth of patients requiring permanent pacemaker.

Streptobacillus moniliformis is a pleomorphic bacillus found in the oral cavity of rodents. Rat bite can transmit these bacteria to humans and can lead to bacteremia as well as infective endocarditis. We present an unusual case rat-bite endocarditis and septic emboli. 24 year-old-female presented

Primary cardiac malignancy is uncommon. Angiosarcoma (AS) accounts for the most aggressive subset. Manifestations can be crude and the diagnosis may be delayed. Rapid progression results in a dismal prognosis. A 49-year-old male presented with syncope. He was found to have hemopericardium on echo

Leukostasis is an emergency caused by compromise of tissue perfusion due to hyperleukocytosis in acute myeloid leukemia (AML). Typically it affects lungs and brain, with cardiac involvement being exceedingly rare. We present a case of AML presenting as acute coronary syndrome secondary to

Transcatheter aortic valve replacement (TAVR) is an evolving treatment for symptomatic aortic stenosis (AS). We present a case of aorta to right ventricle (RV) fistula as a rare complication of TAVR. 90-year-old male with history of systolic heart failure and severe AS presented to hospital with

Amlodipine toxicity is commonly reported medication involved in overdose. Its management involves early action with aggressive measures. We describe such a case managed successfully. 64-year-old female was admitted to hospital with severe hypotension and junctional rhythm 36 hours following

Hydralazine-induced lupus syndrome (HILS) is an uncommon drug reaction that typically manifests as fever, myalgia, serositis, and arthralgia. This is a rare presentation of HILS with pericardial effusion. A 57-year-old male with hypertension and chronic kidney disease presented with a four-week