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Previous research indicates varying stroke rates after mitral valve (MV) interventions. This study aimed to compare postprocedural stroke risks after transcatheter and surgical MV interventions. Electronic databases were searched from inception to February 2024 for studies comparing stroke rates after mitral transcatheter edge-to-edge repair (mTEER), surgical MV repair/replacement, or guideline-directed medical therapy (GDMT). Primary end points were all-time and early (<30 days) stroke. Secondary outcomes included new-onset atrial fibrillation and 1-year all-cause mortality. A frequentist network meta-analysis was employed to compare outcomes. The network meta-analysis included 18 studies (3 randomized controlled trials and 15 observational), with 51,703 patients. mTEER was associated with a decreased risk of all-time (odds ratio [OR] 0.61, 95% confidence interval [CI] 0.41 to 0.89) and early stroke (OR 0.41, 95% CI 0.33 to 0.51) compared with surgery, and a similar risk of all-time (OR 1.54, 95% CI 0.76 to 3.12) and early stroke (OR 2.12, 95% CI 0.53 to 8.47) compared with GDMT. Conversely, surgery was associated with an increased risk of all-time (OR 2.55, 95% CI 1.17 to 5.57) and early stroke (OR 5.15, 95% CI 1.27 to 20.84) compared with GDMT. There were no statistically significant differences in the risk of new-onset atrial fibrillation (OR 0.38, 95% CI 0.11 to 1.31) and 1-year all-cause mortality (OR 1.43, 95% CI 0.91 to 2.24) between mTEER versus surgery. In conclusion, mTEER was associated with a lower risk of stroke and similar risks of new-onset atrial fibrillation and 1-year mortality compared with surgical MV interventions. Further studies are needed to understand the mechanisms of stroke and to determine strategies to reduce stroke risk after MV interventions., Competing Interests: Declaration of competing interest Dr. Khera is a consultant and proctor for Medtronic, consultant and proctor for Abbott Structural Heart, consultant for Terumo and W. L. Gore & Associates, consultant and advisory board member of EastEnd Medical, and serves on the speaker's bureau for Zoll Medical and Edwards Lifesciences. Dr. Kolte has received research funding from the Nation Heart, Lung, and Blood Institute outside of the submitted work. The remaining authors have no competing interests to declare., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Risks among nonagenarian (age ≥90 years) and octogenarian (age 80 to 89 years) patients who underwent transcatheter aortic valve implantation (TAVI) compared with clinically similar septuagenarian (age 70 to 79 years) patients remain unclear. This study aimed to assess the outcomes of TAVI in nonagenarians and octogenarians compared with septuagenarians. We conducted a retrospective cohort study using the National Inpatient Sample database to identify patients aged ≥70 years hospitalized for TAVI from 2016 to 2020 and to compare outcomes in nonagenarians and octogenarians versus septuagenarians. The primary outcome was in-hospital mortality. Secondary outcomes included procedural complications, length of stay (LOS), and total costs. The trends in in-hospital outcomes were evaluated. Results were adjusted for demographic/clinical factors. The total cohort included 263,325 patients hospitalized for TAVI, of whom 11.9% were nonagenarians, 51.1% octogenarians, and 37.0% septuagenarians. After adjustment, nonagenarians and octogenarians had higher odds of in-hospital mortality (adjusted odds ratio 1.80, 95% confidence interval 1.34 to 2.41 for nonagenarians; adjusted odds ratio 1.65, 95% confidence interval 1.35 to 2.01 for octogenarians), heart block, permanent pacemaker insertion, stroke, major bleeding, blood transfusion, and palliative care consultation than septuagenarians (all p <0.01). LOS was longer and the total costs were higher for nonagenarians and octogenarians (both p <0.01). Over the study period, in-hospital mortality decreased in nonagenarians (p trend  = 0.04), and major bleeding, permanent pacemaker insertion, LOS, and costs decreased in all patients aged ≥70 years (p trend <0.01). In conclusion, nonagenarians and octogenarians who underwent TAVI have higher rates of mortality and procedure-related complications than clinically similar septuagenarians. Further research is necessary to optimize outcomes in this frail population., Competing Interests: Declaration of Competing Interest Dr. Goldsweig reports consulting fees from Inari Medical and speaking fees from Philips and Edwards Lifesciences. The remaining authors have no conflicts of interest to declare., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Transcarotid access has emerged as the preferred access site for transcatheter aortic valve implantation (TAVI) in patients with prohibitive iliofemoral anatomy. This study aimed to compare outcomes with transcarotid with those of other accesses in patients who underwent TAVI. Cochrane, EMBASE, and MEDLINE databases were searched for all published studies that compared outcomes with transcarotid with those of other accesses (transfemoral, transaxillary/subclavian, transaortic, and transapical) in patients who underwent TAVI. The primary outcome was all-cause mortality. Secondary outcomes included major bleeding, major vascular complications, stroke, myocardial infarction, permanent pacemaker implantation, and peri-aortic valve insufficiency. We included 22 observational studies with a total of 11,896 patients. Outcomes were reported during hospitalization and at 1-month follow-up. The transcarotid approach had higher mortality at 1 month (3.7% vs 2.6%, p = 0.02) but lower major vascular complications during hospitalization (1.5% vs 3.4%, p = 0.04) than did transfemoral access. The transcarotid approach had lower major vascular complications (2% vs 2.3%, p = 0.04) than did the transaxillary/subclavian but higher major bleeding (5.3% vs 2.6%, p = 0.03). The transaortic approach was associated with higher in-hospital (11.7% vs 1.9%, p = 0.02) and 1-month mortality (14.4% vs 3.9%, p = 0.007) rates than was transcarotid access. The transcarotid approach numerically reduced mortality and the risk of major vascular complications and major bleeding compared with the transapical approach; however, this did not reach statistical significance. The transcarotid approach did not increase the risk of stroke compared with transfemoral or the other alternative accesses. In conclusion, the transcarotid or transaxillary/subclavian approach had associated comparable outcomes that were better than those of the transapical and transaortic approaches. There was no difference in stroke risk between transcarotid access and other accesses., Competing Interests: Disclosures The authors have no conflicts of interest to declare., (Copyright © 2023 Elsevier Inc. All rights reserved.)

The data on the safety and feasibility of performing concomitant or staged transcatheter edge-to-edge repair (TEER) of the mitral valve with transcatheter aortic valve implantation (TAVI) remains limited. The Nationwide Readmission Database was used to identify TEER and TAVI procedures from October 1, 2015 to December 31, 2019, using the International Classification of Diseases, Tenth Revision, Clinical Modification administrative data. A total of 627 weighted cases of TEER and TAVI procedures were included in the analysis. Of those cases, 453 underwent staged TEER after TAVI, whereas 174 had concomitant TAVI and TEER during the same admission. Patients who underwent staged procedures were mostly men (64.8%, p = 0.02) and had a higher median age of 85 years (interquartile range 79 to 88) versus 82 years (interquartile range 72 to 86) in the concomitant procedure group. The adjusted propensity-matched mortality rate was similar for staged versus same-admission procedures (6.1% vs 7.0%, p = 0.79). In-hospital complication rates, including acute kidney injury, vascular complications, need for percutaneous coronary intervention, mechanical support, and pacemaker implantation, were higher for the same-admission TEER and TAVI group than TEER performed as a staged procedure. Nonhome facility discharges and length of hospital stay (15 vs 4 days) were also significantly higher for the concomitant same-admission TEER and TAVI groups. In conclusion, there was no difference in in-hospital mortality rate between patients who underwent concomitant or staged TEER and TAVI procedures, whereas complication rates were significantly higher in the concomitant group., Competing Interests: Disclosures The authors have no conflicts of interest to declare., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Contemporary data on gender differences in outcomes after transcatheter aortic valve implantation (TAVI), after stratification by age, remain limited. We studied age-stratified (60 to 70, 71 to 80, and 81 to 90 years) inhospital outcomes by gender after TAVI from the National Inpatient Sample database between 2012 and 2018. We analyzed National Inpatient Sample data using the International Classification of Diseases, Clinical Modification, Ninth Revision, and Tenth Revision claims codes. Between the years 2012 and 2018, a total of 188,325 weighted hospitalizations for TAVI were included in the analysis. A total of 21,957 patients were included in the 60 to 70 age group (44% females), 60,770 (45% females) in the 71 to 80 age group, and 105,580 (50% females) in the 81 to 90 age groups, respectively. Propensity-matched inhospital mortality rates were significantly higher for females than males for the age group of 81 to 90 years (3.0% vs 2.1%, p <0.01). Vascular complications and a need for blood transfusions remained significantly higher for females on propensity-matched analysis across all categories of ages. Conversely, acute kidney injury and the need for pacemaker implantation remained significantly higher for males across all age groups. In conclusion, we report that mortality is higher in female patients who underwent TAVI between the ages of 81 to 90. Moreover, the female gender was associated with higher vascular complications and bleeding requiring transfusions. Conversely, the male gender was associated with higher rates of pacemaker implantation and acute kidney injury., Competing Interests: Disclosures Dr. Depta discloses the following relations—Consultant and/or Advisory Board: Edwards Lifesciences, Boston Scientific, WL Gore & associates, Abbott, and V-Wave-Ltd. Dr. Michos reports Advisory Board participation for AstraZeneca, Amarin, Novartis, Novo Nordisk, Bayer, and Esperion. The remaining authors have no conflicts of interest to declare., (Copyright © 2021 Elsevier Inc. All rights reserved.)

There are limited data on the outcomes of chronic liver disease (CLD) patients admitted for percutaneous coronary intervention (PCI). All PCI hospitalizations from the Nationwide Inpatient Sample (2004 to 2015) were analyzed and stratified by the presence, cause and severity of CLD, as well as the indication for PCI. Multivariable logistic regression analysis was performed to determine the adjusted odds ratios (aOR) of in-hospital adverse outcomes in patients with CLD compared with those without CLD. Among 7,296,679 PCI admissions, 54,368 (0.7%) had a CLD diagnosis. Among patients with CLD, 36,853 (67.8%) had severe CLD. Patients with CLD had higher likelihood of adverse outcomes including major adverse cardiovascular and cerebrovascular events (MACCE) (aOR 1.25, 95%CI 1.20 to 1.30), mortality (aOR 1.43, 95%CI 1.35 to 1.51), major bleeding (aOR 2.22, 95%CI 2.12 to 2.32). When accounting for severity, only severe CLD subgroup was more likely to have MACCE and all-cause mortality compared to no-CLD patients (p <0.001). Among CLD etiologic subgroups, those with 'alcohol-related liver disease' and 'other CLD' were consistently more likely to develop MACCE, all-cause mortality and major bleeding in comparison to no-CLD patients, while 'chronic viral hepatitis' subgroup had only increased odds of major bleeding (p <0.001). In conclusion, CLD patients admitted for PCI are more likely to have worse in-hospital outcomes, particularly in the severe CLD subgroup and 'alcohol-related liver disease' and 'other CLD' etiologic subgroups., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Data on emergency coronary artery bypass surgery (CABG) are limited. We studied patients who underwent isolated CABG at Mayo Clinic between 1993 and 2019. Baseline characteristics and in-hospital outcomes of emergent CABG were described in consecutive eras (1993 to 2000, 2001 to 2010, and 2011 to 2019). Cumulative survival was estimated by the Kaplan Meier method for the overall group, and stratified by the indication of surgery. In the 14,455 isolated CABG included, 427 (2.95%) were emergent. The number of emergent CABG decreased from 222 to 150 and 55 in the consecutive study eras. There was a temporal increase in the prevalence of heart failure, but no change in mean age, and prevalence of hypertension, diabetes, renal failure, or atrial fibrillation. The proportion of patients with failed/complicated percutaneous coronary intervention decreased from 38.2% in 1993 to 2000 to 22.7% in 2001 to 2010 and 25.5% in 2011 to 2019 (p = 0.003). In 2011 to 2019, 100% of patient received an internal mammary graft compared with 75.6% in 1993 to 2000 (p < 0.001). Operative mortality was 8.7% overall (8.6% in 1993 to 2000, 10.0% in 2001 to 2010, and 5.5% in 2011 to 2019, p = 0.56). There were no differences in postoperative complications except for the incidence of renal failure and new dialysis which increased over time. Predicted 10-year survival was 57.0% and was not different according to CABG indication (p = 0.12). In conclusion, we documented a temporal decrease in the incidence of emergent CABG between 1993 and 2019, especially those performed due to complications of coronary interventions. Despite the higher prevalence of left ventricular dysfunction and the more complete revascularization in more recent years, in-hospital mortality did not increase., Competing Interests: Declaration of interests The authors declare that they have no known competing financial interests or personal relations that could have appeared to influence the work reported in this study., (Copyright © 2020. Published by Elsevier Inc.)

Semisupervised machine-learning methods are able to learn from fewer labeled patient data. We illustrate the potential use of a semisupervised automated machine-learning (AutoML) pipeline for phenotyping patients who underwent transcatheter aortic valve implantation and identifying patient groups with similar clinical outcome. Using the Transcatheter Valve Therapy registry data, we divided 344 patients into 2 sequential cohorts (cohort 1, n = 211, cohort 2, n = 143). We investigated patient similarity analysis to identify unique phenogroups of patients in the first cohort. We subsequently applied the semisupervised AutoML to the second cohort for developing automatic phenogroup labels. The patient similarity network identified 5 patient phenogroups with substantial variations in clinical comorbidities and in-hospital and 30-day outcomes. Cumulative assessment of patients from both cohorts revealed lowest rates of procedural complications in Group 1. In comparison, Group 5 was associated with higher rates of in-hospital cardiovascular mortality (odds ratio [OR] 35, 95% confidence interval [CI] 4 to 309, p = 0.001), in-hospital all-cause mortality (OR 9, 95% CI 2 to 33, p = 0.002), 30-day cardiovascular mortality (OR 18, 95% CI 3 to 94, p <0.001), and 30-day all-cause mortality (OR 3, 95% CI 1.2 to 9, p = 0.02) . For 30-day cardiovascular mortality, using phenogroup data in conjunction with the Society of Thoracic Surgeon score improved the overall prediction of mortality versus using the Society of Thoracic Surgeon scores alone (AUC 0.96 vs AUC 0.8, p = 0.02). In conclusion, we illustrate that semisupervised AutoML platforms identifies unique patient phenogroups who have similar clinical characteristics and overall risk of adverse events post-transcatheter aortic valve implantation., (Copyright © 2020 Elsevier Inc. All rights reserved.)

This study sought to examine the differences in the characteristics and outcomes between men and women who underwent percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) for acute myocardial infarction (AMI) in contemporary US practice. The Nationwide Inpatient Sample was used to identify patients who underwent revascularization for AMI between January 1, 2003 and December 31, 2016. The primary outcome was in-hospital mortality. Propensity score matching was utilized to account for differences in baseline characteristics. In total, 3,603,142 patients were included, of whom only 1,180,436 (33%) were women. Compared with men, women were older and had higher prevalence of key co-morbidities including diabetes, hypertension, congestive heart failure, and chronic kidney and lung disease (p <0.001). In the PCI cohort, women were significantly less likely to undergo multivessel PCI, to receive mechanical circulatory support, or to undergo atherectomy. In the CABG group, women were more likely to have concomitant valve surgery. In the propensity-matched cohorts, in-hospital mortality was higher for women than men regardless of revascularization strategy: 7.6% versus 6.6% for PCI in ST-elevation myocardial infarction, 2.0% versus 1.9% for PCI in non-ST-elevation myocardial infarction, and 5.7% versus 4.3% for CABG in any AMI (p <0.001). Women also had higher rates of major complications, longer hospitalizations, higher costs, and were less likely to be discharged home (vs nursing facility). These sex-based differences persisted over the study 14-year period. In conclusion, in a contemporary nationwide analysis of propensity score-matched patients, women who undergo revascularization for AMI have worse in-hospital outcomes than men regardless of revascularization mode., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Data on the efficacy of left atrial appendage occlusion (LAAO) in clinical practice are limited. We performed a systematic review and meta-analysis of observational studies that reported observed versus expected rates of ischemic strokes and/or major bleeding following LAAO. Our primary end points were the pooled relative risk reduction (RRR) in ischemic stroke and major bleeding with corresponding 95% confidence intervals compared with what was expected by the CHA2DS2-VASc and HASBLED scores, respectively. Twenty-nine studies including 11,071 patients (age 74.0 ± 8.7 years, 60% males) met the inclusion criteria. The mean CHA2DS2-VASc score was 4.22 ± 1.48, and the mean HASBLED score was 3.04 ± 1.16. During 19,567 patient-year follow-up, 290 of 11,071 patients (2.62%) suffered an acute ischemic stroke. This represented a 73.6% (95% confidence interval 68.9-78.2%) RRR in ischemic strokes compared with what was expected based on the CHA2DS2-VASc score. A total of 26 studies reported observed versus expected major bleeding (10,056 patients; age 74.0 ± 8.7, 60% males). During 16,967 patient-year follow-up, 404 of 10,056 patients (4.0%) suffered a major bleeding event. This represented a 55% (95% confidence interval 44.2% to -65.9%) RRR in major bleeding compared with what was expected based on the HASBLED score. These estimates were consistent across subgroups stratified according to age, CHADS2VASc, HASBLED scores and type of LAAO device used. In conclusion, LAAO is associated with a favorable observed/expected ratio with regards to ischemic stroke and major bleeding in clinical practice. Future clinical trials remain essential to further assess the efficacy of LAAO via a direct comparison with oral anticoagulation., (Copyright © 2020 Elsevier Inc. All rights reserved.)

The impact of body mass index (BMI) on cardiovascular outcomes in patients receiving intensive low-density lipoprotein cholesterol (LDL-C) lowering therapy is uncertain. We performed meta-analysis of 29 randomized controlled trials using PubMed, Embase, and CENTRAL through April 2019. Therapies were grouped as more intensive LDL-C lowering therapy (statins, ezetimibe + statin or PCSK9 inhibitors) and less intensive LDL-C lowering therapy (less potent active control or placebo). Random effects meta-regressions and meta-analyses were performed to evaluate association of BMI with cardiovascular endpoints. In 265,766 patients, for every 1 kg/m 2 increase in BMI, more intensive therapy compared with less intensive therapy was associated with hazard ratio (HR) of 1.07 for cardiovascular mortality (95% confidence interval 1.02 to 1.13); HR of 1.03 for all-cause mortality (0.99 to 1.06) HR of 1.06 for myocardial infarction (1.02 to 1.09), HR of 1.08 (1.03 to 1.12) for revascularization and HR of 1.04 for MACE (1.01 to 1.07). Meta-analysis showed that patients with BMI <25 kg/m 2 had the highest risk reduction in mortality and cardiovascular outcomes compared with patients with BMI ≥30 kg/m 2 (p-interaction ≤0.05). In conclusion, patients with normal BMI treated with intensive LDL-C lowering regimens may derive a larger clinical benefit compared with patients with larger BMI. The results could be due to the higher mortality rate of obese patients that may artificially lower the efficacy of therapy, or due to a true therapeutic limitation in these patients., (Copyright © 2019 Elsevier Inc. All rights reserved.)

A strategy of complete revascularization (CR) versus infarct-related artery revascularization (IRA) in patients with ST-elevation myocardial infarction (STEMI) continues to be a subject of debate. We performed an updated meta-analysis to compare the 2 strategies. Outcomes of interest included major adverse cardiovascular events (MACE), cardiovascular mortality, all-cause mortality, stroke, repeat revascularization, myocardial infarction, and contrast-induced nephropathy. Ten randomized trials including 7,423 patients (CR = 3,574 and IRA = 3,849), with a follow-up of 2.0 ± 0.8 years were included. There was a significant reduction in MACE with CR versus IRA (10.7% vs 18.6%, relative risk [RR] 0.64, 95% confidence interval [CI] 0.51 to 0.81, p = 0.002, I 2  = 66%), with higher risk reduction with immediate versus stages revascularization (RR 0.40, 95% CI 0.32 to 0.5 vs RR 0.69, 95% CI 0.54 to 0.89, P-interaction = 0.002). Complete revascularization was associated with lower rates of repeat revascularization (4.0% vs 11.7%, RR 0.44, 95% CI 0.28 to 0.70, p <0.0001, I 2  = 81%), and a nonsignificant trend toward lower cardiovascular mortality (2.8% vs 3.7%, RR 0.78, 95% CI 0.60 to 1.03, p = 0.08, I 2  = 0%). However, there was no difference between the 2 strategies in all-cause mortality (4.6% vs 4.8%, RR 0.90, 95% CI 0.73 to 1.12, p = 0.36, I 2  = 0%), myocardial infarction (5.2% vs 6.5%, RR 0.73, 95% CI, 0.58 to 1.08, p = 0.08, I 2  = 30%), stroke (1.5% vs 1.2%, RR 1.14, 95% CI 0.56 to 2.29, p = 0.33, I 2  = 14%), or contrast-induced nephropathy (1.6% vs 1.2%, RR 1.35, 95% CI 0.85 to 2.15, p = 0.78, I 2  = 0%). In conclusion, CR in patients with STEMI is associated with significant reduction in MACE compared with IRA. This reduction is derived mainly by the low rates of repeat revascularization in the CR group., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Comparative data on the incidence and outcomes of stroke after percutaneous coronary interventions (PCI) between men and women are limited. We identified hospitalizations for PCI in the National-Inpatient-Sample between January 1, 2003 and December 31, 2016. We compared the incidence of post-PCI stroke and in-hospital complications, mortality, and cost of post-PCI strokes between men and women. Among 8,753,574 weighted hospitalizations for PCI, 49,097 (0.56%) were complicated with ischemic stroke. The incidence of post-PCI stroke was higher in women than men following PCI for ST-elevation myocardial infarction (STEMI) 1.4% versus 0.8% (odds ratio [OR] 1.69, 95% confidence interval [CI] 1.62 to 1.77, p <0.001), non-ST-elevation myocardial infarction (NSTEMI) 1.1% versus 0.7% (OR 1.59, 95% CI 1.52 to 1.63, p <0.001), and unstable angina/stable ischemic heart disease (US/SIHD) (0.5% vs 0.3%, OR 1.66, 95% CI 1.61 to 1.72, p <0.001). These differences remained significant after risk adjustment. Among patients with post-PCI stroke, women had worse on-hospital mortality, and major complications compared with men. However, after propensity score matching, post-PCI mortality was similar in men and women who suffered a stroke after STEMI (23.0% vs 25.7%, p = 0.34), and NSTEMI (9.9% vs 9.1%, p = 0.56), but higher in women who suffered a stroke after PCI for UA/SIHD (12.5% vs 10.4%, p = 0.042). Surrogates of disabling stroke, length of stay, and cost were similar in men and women. However, women had more vascular complications and blood transfusion across all indications. In conclusion, women are more likely to suffer post-PCI stroke than males regardless of the PCI indication. Among those with post-PCI strokes, women have higher adjusted rates of vascular complications and blood transfusion., (Copyright © 2019 Elsevier Inc. All rights reserved.)

We performed a systemic review and meta-analysis of studies evaluating transcarotid vascular access for transcatheter aortic valve implantation (TAVI). Published studies evaluating transcarotid vascular access for TAVI were included in this analysis. Outcomes of interest included 30-day mortality, stroke/transient ischemic attack (TIA), new pacemaker implantation, acute kidney injury (AKI), major vascular complication, major bleeding, and myocardial infarction. Pooled estimate for 30-day mortality was 5.3% (95% confidence interval [CI] 4.0% to 6.8%; I 2  = 4%), stroke/TIA was 3.4% (95% CI 2.4% to 4.6%; I 2  = 0%), new pacemaker implantation was 15.3% (95% CI 10.8% to 19.7%; I 2  = 72%), AKI was 3.4% (95% CI 1.3% to 6.5%; I 2  = 58%), major vascular complication was 2.4% (95% CI 1.1% to 3.7%; I 2  = 46%), major bleeding was 4.3% (95% CI 2.8% to 6.1%; I 2  = 11%), and myocardial infarction was 1.1% (95% CI 0.4% to 2.0%; I 2  = 0%). Metaregression was carried out to study the association of effect size with the continuous study-level covariates that included average age, proportion of males, and mean STS score. In this regard, mean STS score showed association with major vascular complications (coefficient: 0.008; p = 0.049). Cumulative meta-analysis carried out showed that there was temporal trend of decreasing incidence of stroke/TIA, major vascular complications, and AKI for transcarotid TAVI. In conclusion, transcarotid access for TAVI is a reasonable choice in patients requiring alternate access to transfemoral route., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Temporal and surgical risk dependent associations with clinical outcomes in patients receiving transcatheter versus surgical aortic valve implantation (TAVI vs SAVI) are uncertain. In this meta-analysis, 7 randomized controlled trials (7,771 patients) were included to investigate trends in outcomes in TAVI versus SAVI up to 5 years, and variation in outcomes with respect to low-, intermediate-, and high-surgical risk of the patients up to 1 year. Estimates were calculated as random effects hazard ratios (HRs) with 95% confidence intervals (CI). All-cause mortality was similar in TAVI and SAVI at 30 days (HR 0.81, 95% CI 0.55 to 1.21, p = 0.31), 1 year (HR 0.97, 95% CI 0.89 to 1.06, p = 0.49), 2 years (HR 0.96, 95 CI 0.85 to 1.09, p = 0.54), and 5 years (HR 1.04, 95% CI 0.89 to 1.21, p = 0.62). Cardiac mortality, myocardial infarction and stroke were similar in both interventions up to 5 years. TAVI was associated with lower risk of atrial fibrillation, but higher risk of vascular complications, pacemaker implantation, and paravalvular leak up to 5 years. The lower risks of major bleeding and acute kidney injury with TAVI versus SAVI were limited to 1 and 2 years, respectively. Compared with SAVI, TAVI was superior in reducing all-cause mortality in low surgical risk patients at 30 days only, whereas TAVI was noninferior to SAVI in intermediate- and high-risk patients at 30 days and across all risks at 1 year. In conclusion, TAVI was noninferior to SAVI in terms of mortality, myocardial infarction, and stroke up to 5 years. TAVI improved survival versus SAVI in low-risk patients at 30 days., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Two transcatheter aortic valve systems are currently in use in the United States; balloon-expandable valves (BEV) and the self-expanding valve (SEV). However, comparative data outcomes between the 2 systems are limited, as only one randomized trial (RCT) performed a head-to-head comparison between BEVs and SEVs. However, there are several RCTs comparing BEV or SEV to surgical valve replacement. In this analysis, we used Bayesian network meta-analysis techniques to compare BEVs and SEVs. The primary outcome was all-cause mortality at maximum follow-up. Secondary outcomes were cardiovascular mortality, stroke, pacemaker implantation, reintervention, heart failure hospitalization, and moderate-severe paravalvular leak (PVL.). Eight RCTs with 8,095 patients were included. With the exception of less pacemaker implantation in BEV versus SEV (odds ratio [OR] 0.29, 95% confidence interval [CI] 0.11 to 0.77, I 2  = 51%), there was no difference between BEV and SEV in 30-day outcomes. During long-term follow-up (mean 3 ± 2 years); there was no difference between BEV and SEV in all-cause mortality (hazard ratio [HR] 1.1, 95% CI 0.87 to 1.5, I 2  = 19.6%), cardiovascular mortality (HR 1.1, 95% CI 0.73 to 1.6, I 2  = 18.5%), stroke (HR 1.3, 95% CI 0.73 to 2.1, I 2  = 16.9%), hospitalization (HR 0.87, 95% CI 0.41 to 1.6, I 2  = 62%), and reintervention (HR 0.68, 95% CI 0.2 to 2.3, I 2  = 62%). New pacemaker implantation and PVL were significantly less in BEV group (HR 0.45, 95% CI 0.24 to 0.80, I 2  = 38.2%), and (HR 0.03, 95% CI 0.0004 to 0.28, I 2  = 79%), respectively. In conclusion, similar outcomes were seen following transcatheter aortic valve implantation with BEV and SEV with the exception of higher rates of pacemaker implantation and PVL in SEV group., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Large-scale data on early postdischarge acute myocardial infarction (AMI) after coronary artery bypass grafting (CABG) are lacking. We queried the National Readmission Database (2015 to 2016) to identify patients who underwent CABG between January 1 and June 31 (i.e., had 6 months of follow-up). The study's end points were the incidence, predictors, and outcomes of early post-CABG AMI. Of the 203,760 included patients, 3,829 (1.8%) were readmitted for AMI. Compared with patients without readmissions for AMI, those with AMI were younger (65 ± 11 vs 66 ± 10 years), had more females (35.5% vs 25.1%), and higher prevalence of hypertension, diabetes, obstructive lung disease, anemia, vascular disease, renal insufficiency, and liver cirrhosis, but less atrial fibrillation (p <0.001). They also had a distinctive profile of their index CABG surgery. The strongest predictors of post-CABG AMI readmission were female gender (odds ratio [OR] 1.46, 95% confidence interval [CI] = 1.36 to 1.57), heart failure (OR 1.37, 95% CI = 1.27 to 1.50), dialysis (OR 1.5%, 95% CI = 1.25 to 1.78), cirrhosis (OR 1.61, 95% CI = 1.14 to 2.27), nonelective CABG (OR 1.70, 95% CI = 1.57 to 1.84), perioperative mechanical circulatory support (OR 1.37, 95% CI = 1.23 to 1.51), low-volume centers (OR 1.36, 95% CI = 1.18 to 1.56), and nonhome discharge after CABG (OR 1.47, 95% CI = 1.35 to 1.59). In the patients who were readmitted for AMI, 86.3% had non-ST-elevation AMI and 13.7% had ST-elevation AMI. Coronary angiography was performed in 2,096 patients (54.7%). Of those, 63.5% received percutaneous coronary intervention, and 1.7% had redo-CABG. Readmissions for AMI were associated with significant in-hospital mortality (5.7%), acute kidney injury (22.1%), and new dialysis (2.1%). Median length-of-stay was 3 days (25th/75th percentile 2,6), and the mean hospital cost was $22,207 ± 29,071., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Gastrointestinal bleeding (GIB) complicating ST-elevation myocardial infarction (STEMI) poses significant management challenges and may be associated with poor outcomes. We sought to evaluate the incidence and outcomes of GIB in STEMI patients using a nationwide database. We identified adults admitted with STEMI between in the National Inpatient Sample (2003 to 2016), and compared the morbidity, mortality, resource utilization, and cost in patients with and without GIB. We assessed rates of endoscopy referral and its associated with mortality. Among 1,450,696 weighted STEMI hospitalizations, 32,624 (2.2%) were complicated with GIB. Patients with GIB were older, and had distinctive characteristics compared to those without GIB. Older age, cardiogenic shock; history of peptic ulcer disease, cirrhosis, anemia, or alcohol use disorder were the strongest predictors of GIB during STEMI hospitalizations. In-hospital mortality was higher in the GIB group (28.2% vs 11.1%, p <0.001). The excess mortality associated with GIB persisted after propensity-score matching, and in sensitivity analyses excluding patients who underwent coronary intervention >24-hours after admission, and those transferred to another hospital. Post-STEMI GIB was associated with more strokes and acute kidney injury, longer hospitalizations, and higher cost. In a logistic regression analysis, GIB was independently associated with mortality (odds ratios [OR] 1.91, 95% confidence interval [CI] 1.85 to 1.97, p <0.001). There was a correlation between undergoing endoscopy and lower in-hospital mortality (unadjusted OR 0.27; 95% CI, 0.24 to 0.29; adjusted-OR 0.30; 95% CI, 0.27 to 0.33; p <0.001). In conclusion, GIB complicating STEMI is uncommon but is associated with excess morbidity, mortality, resource utilization and cost. Referral to endoscopy in this cohort may be associated with reduced in-hospital mortality., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Transcatheter aortic valve implantation (TAVI) has emerged as an effective therapy for patients with severe aortic stenosis (AS). However, data on TAVI outcomes in patients with low gradient (LG) AS are limited. We performed a meta-analysis of studies comparing TAVI outcomes between patients with classic high gradient (HG) and LG AS through November 2018. The 30-day mortality, mid-term all-cause, and cardiovascular mortality at maximum follow-up were compared between patients with HG and LG AS (Pairwise meta-analysis), and between the three distinct groups of AS including HG, paradoxical low-flow low-gradient and low gradient with reduced ejection fraction (rEF-LG) (Network meta-analysis). Nineteen studies (n = 27,204 patients) met the inclusion criteria. The HG group had less 30-day, mid-term all-cause and cardiovascular mortality compared with the low-gradient AS group overall, (6% vs 7.5%, OR 0.76, 95% CI 0.66 to 0.87, I 2  = 18%), (21% vs 29%, OR 0.59, 95% CI 0.52 to 0.67, I 2  = 62%), and (12.6% vs 18.7%, OR 0.61, 95% CI 0.49 to 0.76, I 2  = 62%), respectively, p <0.0001. These outcomes were confirmed in a trial sequential analysis in which the cumulative Z-curve crossed the conventional test boundary as well as the trial sequential monitoring boundary for all outcomes. The network meta-analysis revealed that patients with rEF-LG had similar outcomes to those with pLFLG, and both had worse outcomes than patients with classic HG AS. In conclusion patients with classic HG have better 30-day mortality, mid-term all-cause and cardiovascular mortality compared with LG patients following TAVI. Among patients with LG severe AS, TAVI outcomes were similar in patients with rEF-LG and pLFLG., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Data on Motor Vehicle Accidents (MVA) associated acute myocardial infarctions (AMI) are scares. We aimed to examine the frequency, characteristics, and outcomes of AMI among patients admitted with MVA. Patients hospitalized with Motor Vehicle Traffic Accidents (ICD-9-CM codes e810-e819) in 2003 to 2014 were identified in the national inpatient sample. The primary end point was crude and risk-adjusted in-hospital mortality in patients with and without AMI. Secondary end-points were major morbidities, and resource utilization metrics. A total of 573,717 patients were hospitalized after MVAs in 2003 to 2014, of whom 2,793 (0.5%) suffered an AMI (26% STEMI and 74% NSTEMI). Patients who suffered AMI were older, and had higher rates of hypertension, diabetes, hyperlipidemia, renal insufficiency, and vascular disease. In the AMI group, angiography was performed in 26.7%, and among those, 42.2% received percutaneous intervention and 9.2% underwent coronary artery bypass surgery during the same admission. In-hospital mortality was higher in patients with AMI compared with patients without MI (21.7% vs 2.7%, p <0.001). After adjusting for age, gender, race, co-morbidities, and hospital characteristics, AMI remained associated with significantly higher mortality (adjusted overall [OR] 6.3, 95% confidence interval [CI] 5.98 to 6.57, p< 0.001). Patients with AMI had higher incidences of cardiac arrest (11.9% vs 0.7%, p <0.001), new dialysis (2.2% vs 0.1%, p <0.001), and stroke (4.1% vs 0.5%, p <0.001). They also had longer hospitalizations (12 ± 17 vs 6 ± 10 days, p <0.001), higher cost ($48046 ± 56316 vs $20820 ± 31758, p <0.001), and higher rates of nonhome discharges (55.5% vs 15.4%, p <0.001). In conclusion: AMI in patients admitted with MVA is uncommon but is associated with substantial morbidity, mortality, and cost., (Copyright © 2018. Published by Elsevier Inc.)

Single center studies suggested that non-ST elevation myocardial infarction (NSTEMI) in patients admitted with acute decompensated diabetes is associated with poor long-term prognosis. We hypothesize that acute decompensated diabetes is also associated with worse early morbidity and mortality in patients admitted with NSTEMI. Adult patients with a primary discharge diagnosis of diabetic ketoacidosis (DKA) or hyperosmolar hyperglycemic state (HHS) were identified in the national inpatient sample. We then assessed contemporary trends in the incidence and management patents of NSTEMI in patients admitted with DKA/HHS and compared in-hospital morbidity and mortality, resource utilization, and cost between DKA/HHS patients with and without NSTEMI. In 431,037 patients admitted with decompensated diabetes from 2003 to 2014, 13,069 (3.03%) suffered a NSTEMI during their hospitalization. Patients with NSTEMI were older and had higher prevalence of atherosclerotic and nonatherosclerotic comorbidities. After propensity score matching, NSTEMI was associated with a 60% increase in in-hospitalmortality (9.1% vs 5.5%; p < 0.001), higher incidences of stroke, acute kidney injury, blood transfusion, longer hospitalizations, and higher costs. A minority (35%) ofNSTEMI patients underwent invasive coronary assessment, and those had lower in-hospitalmortality compared with NSTEMI patients who did not undergo invasive assessment(3.3% vs 12.2%, adjusted OR 0.30, 95%CI 0.24 to 0.36, p < 0.001). About 3% of patients admitted with decompensated diabetes suffer a NSTEMI and those experience higher in-hospital morbidity and mortality, longer hospitalization, and higher cost., (Copyright © 2018. Published by Elsevier Inc.)

Stroke is one of the most feared complications of aortic valve replacement. Although the outcomes of transcatheter aortic valve implantation (TAVI) improved substantially over time, concerns remained about a potentially higher incidence of stroke with TAVI compared with surgical replacement (SAVR). However, comparative data are sparse. We performed a meta-analysis comparing the incidence of stroke among patients undergoing TAVI versus SAVR. Of the 5067 studies screened, 28 eligible studies (22 propensity-score matched studies and 6 randomized trials) were analyzed. Primary endpoints were 30-day stroke and disabling stroke. Secondary endpoints were 1-year stroke and disabling stroke. A total of 23,587 patients were included, of whom 47.27% underwent TAVI and 52.72% underwent SAVR. For each endpoint, pooled estimates of odds ratio (OR) with 95% confidence interval (CI) were calculated. The pooled estimates for stroke (2.7% vs 3.1%, OR 0.86; 95% CI 0.72 to 1.02; p=0.08) and disabling stroke (2.5% vs 2.9%, OR 0.96; 95% CI 0.57 to 1.62; p=0.89) were comparable following TAVI versus SAVR at 30 days. Similarly, the pooled estimates for stroke (5.0% vs 4.6%, OR 1.01; 95% CI 0.79 to 1.28; p=0.96) and disabling stroke (4.1% vs 4.5%, OR 0.92; 95% CI 0.92 to 1.39; p=0.71) were similar at 1 year. A sensitivity analysis including only RCTs yielded similar results. Our meta-analysis documents comparable rates of strokes and disabling strokes following TAVI or SAVR both at 30 days and 1 year., (Copyright © 2018. Published by Elsevier Inc.)

Electrocardiographic (ECG) strain has been linked to excess cardiovascular morbidity and mortality in asymptomatic patients with aortic stenosis. We aim to determine the differential impact of baseline ECG-strain on long-term mortality after transcatheter aortic valve implantation (TAVI). Patients who underwent TAVI from January 2012 to March 2016 at Mayo Clinic were included. Left ventricular (LV) strain was defined as the presence of ≥1mm convex ST-segment depression with asymmetrical T-wave inversion in leads V5 to V6 on baseline ECG. Primary end point was all-cause long-term mortality. Of the 520 patients screened, 130 were excluded due to left bundle branch block or paced rhythm. Median follow-up was 1.5 years, IQR (0.9 to 2.7). In the 390 included patients, 47 (12%) had strain pattern on pre-TAVI ECG. Patients in the strain group had higher prevalence of peripheral vascular disease (83% vs 68%, p = 0.04), and atrial fibrillation/flutter (51% vs 37%, p = 0.06). They also had lower mean LV-ejection fraction (51 ± 16% vs 58±12%, p = 0.003, larger LV-internal diameter in systole (3.71 ± 1.04cm vs 3.26 ± 0.75 cm), higher LV-mass-index (136 ± 44 vs 121 ± 29 g/m 2 ; p = 0.044), and higher estimated pulmonary artery systolic pressure (50 ± 13 vs 43 ± 15mm Hg; p = 0.02). Kaplan-Meier survival analysis showed a cumulative probability of survival at 3 years of 35.4% ± 8% in patients with LV-strain compared with 67% ± 3.4% in patients without LV-strain (log-rank p <0.001). In a multivariate logistic regression analysis, ECG-strain was an independent predictor of long-term mortality (Hazard ratio 2.67, 95% CI [1.72 to 4.05]; p <0.001). In conclusion, ECG strain is an independent predictor of long-term mortality post TAVI. Systematic strain measurements might aid in risk-stratifying patients who underwent TAVI., (Copyright © 2018. Published by Elsevier Inc.)

Percutaneous paravalvular leak (PVL) closure has emerged as a feasible alternative to redo valve surgery. However, comparative data on percutaneous and surgical treatment of PVL are scarce. We performed a systematic review and a meta-analysis of studies on percutaneous and surgical treatments of PVL. Of the 2,267 studies screened, 22 eligible studies were analyzed. Primary end points were technical success, 30-day mortality, stroke, and length of stay. Secondary end points were 1-year mortality, readmission for heart failure, reoperation, and symptomatic improvement at follow-up. A total of 2,373 patients were included, of whom 1,511 (63.7%) underwent percutaneous closure. Technical success was higher with surgery (96.7% vs 72.1%, odds ratio [OR] 9.7, p <0.001) but at the cost of higher 30-day mortality (8.6% vs 6.8%, OR 1.90, p <0.001), a trend toward higher stroke (3.3% vs 1.4%, OR 1.94, p = 0.069), and longer hospitalizations. However, surgery was associated with similar 1-year mortality (17.3% vs 17.2%, OR 1.07, p = 0.67), reoperation (9.1% vs 9.9%, OR 0.72, p = 0.1), readmission for heart failure (13.3% vs 26.4%, OR 0.51, p = 0.29), and improvement in New York Heart Association classification (67.4% vs 56%, OR 1.37, p = 0.74), compared with percutaneous closure. A sensitivity analysis including comparative studies only yielded similar results. Surgical treatment of PVL achieves higher technical success rates but is associated with higher early morbidity and mortality compared with percutaneous closure. Nevertheless, mortality rates and clinical efficacy parameters were similar at midterm with both procedures. Further studies are warranted to identify the ideal management approach to patients with symptomatic PVL., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: The introduction of transcatheter aortic valve replacement (TAVR) expanded definitive therapy of aortic stenosis to many high-risk patients, but it has not been fully evaluated in the dialysis population. We aimed to evaluate the current trend and in-hospital outcome of surgical aortic valve replacement (SAVR) and TAVR in the dialysis population., Methods: Severe aortic stenosis patients on maintenance dialysis who underwent SAVR or TAVR in the Nationwide Inpatient Sample database from January 1, 2005, through December 31, 2014, were included in our comparative analysis. The trends of SAVR and TAVR were assessed. In-hospital mortality, rates of major adverse events, hospital length of stay, cost of care, and intermediate care facility utilization were compared between the 2 groups using both unadjusted and propensity-matched data., Results: Utilization of aortic valve replacement in dialysis patients increased 3-fold; a total of 2531 dialysis patients who underwent either SAVR (n = 2264) or TAVR (n = 267) between 2005 and 2014 were identified. Propensity score matching yielded 197 matched pairs. After matching, a 2-fold increase in in-hospital mortality was found with SAVR compared with TAVR (13.7% vs 6.1%, P = .021). Patients who underwent TAVR had more permanent pacemaker implantation (13.2% vs 5.6%, P = .012) but less blood transfusion (43.7% vs 56.8%, P = .02). Rates of other key morbidities were similar. Hospital length of stay (19 ± 16 vs 11 ± 11 days, P <.001) and non-home discharges (44.7% vs 31.5%, P = .002) were significantly higher with SAVR. Cost of hospitalization was 25% less with TAVR., Conclusion: In patients on maintenance dialysis, TAVR is associated with lower hospital mortality, resource utilization, and cost in comparison with SAVR., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Hemodialysis (HD) patients with aortic stenosis are less likely to undergo aortic valve replacement (AVR) due to their excess perioperative mortality. We aimed to evaluate contemporary utilization and outcomes of combined and isolated AVR in HD patients. The Nationwide Inpatient Sample was used to identify 142,046 patients who underwent AVR in 2005 to 2014, of whom 2,264 (1.6%) were on HD. Crude and adjusted in-hospital outcomes and costs were assessed in unmatched and propensity-matched cohorts of HD and non-HD patients, respectively. The utilization of AVR in HD patients increased significantly (p = 0.047), with a significant decrease in mortality (p = 0.013). Compared with patients not on HD, crude in-hospital mortality in HD patients was twice higher (11.8% vs 6.2%, p <0.0001). HD patients had more blood transfusion and a trend toward more strokes. Lengths of stay and hospital charges, and rates of nonhome discharges were also higher in the HD group. In the propensity-matched cohorts of HD versus non-HD patients, in-hospital mortality rates after AVR remained twofold higher in the HD group (8.1% vs 3.9%, p <0.001). Rates of blood transfusion, cardiac tamponade, length of stay, hospital charges, and nonhome discharges were also higher in HD patients. In conclusion, AVR utilization in HD patients increased and its associated mortality decreased over the last decade. However, AVR mortality in HD patients remained twofold higher compared with non-HD patients. Also, AVR in HD patients was associated with higher cost, longer hospitalizations, and more frequent nonhome discharges., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Current risk prediction tools for transcatheter aortic valve implantation (TAVI) or surgical aortic valve replacement (SAVR) do not include variables associated with clinically significant hepatic disease. Accordingly, outcome data of TAVI or SAVR in patients with liver cirrhosis are limited. We sought to assess contemporary trends and outcomes of TAVI and SAVR in patients with liver cirrhosis using a national database. The Nationwide Inpatient Sample was used to identify patients with liver cirrhosis who underwent TAVI or SAVR between 2003 and 2014. Outcomes of propensity-matched groups of patients undergoing TAVI or SAVR were assessed. The reported number of TAVI and SAVR procedures in patients with liver cirrhosis increased from 376 cases in 2003 to 1,095 cases in 2014. A total of 1,766 patients with liver cirrhosis who underwent TAVI (n = 174) or SAVR (n = 1,592) were included in the analysis. In-hospital mortality was higher in patients who underwent SAVR versus TAVI (20.2% vs 8%, p <0.001). Major adverse events were also more frequent after SAVR. Propensity matching attained 2 groups of 268 patients who underwent TAVI (n = 134) or SAVR (n = 134). Following propensity matching, in-hospital mortality remained higher in the SAVR group (18.7% vs 8.2%, p = 0.018), but major adverse events were not different between the 2 groups. Hospital length of stay was longer, and nonhome disposition rates were higher in the SAVR group. In conclusion, the number of reported TAVI and SAVR in patients with liver cirrhosis and aortic stenosis increased 3-folds between 2003 and 2014. In these patients, TAVI was associated with lower in-hospital mortality when compared with SAVR., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Transcatheter aortic valve replacement (TAVR) emerged as a promising alternative to surgical aortic valve replacement (SAVR) in extreme-aged patients with severe aortic stenosis (AS). Data on the outcomes of TAVR or SAVR in nonagenarians are limited. The Nationwide Inpatient Sample was used to identify patients aged 90 years or older who underwent TAVR or SAVR from 2004 to 2013. In-hospital morbidity and mortality were assessed. From 2004 to 2013, 9,066 (national estimate) nonagenarians underwent aortic valve replacement. After the introduction of TAVR, most nonagenarians were treated with TAVR (76%) compared with SAVR (24%). A total of 1,847 nonagenarians who underwent SAVR (n = 1,152) or TAVR (n = 695) were included in the analysis. In-hospital mortality was similar between patients who underwent SAVR (6.4%) compared with TAVR (6.5%; p = 0.29). Vascular complications were more common after TAVR (11.9% vs 6.3%, p <0.001), whereas blood transfusion (46.2% vs 33.7%, p <0.001), and acute kidney injury (25.8% vs 20.4%, p = 0.009) were more common after SAVR. Pacemaker implantation and stroke rates were similar between the 2 groups. In a propensity-matched analysis of 630 patients who underwent isolated TAVR (n = 315) or SAVR (n = 315), in-hospital mortality was similar for (6.0% for SAVR vs 7.9% for TAVR, p = 0.35). SAVR was associated with higher rates of acute kidney injury (24.1% vs 16.8%, p = 0.02) and blood transfusion (46.0% vs 35.2%, p = 0.001), whereas TAVR was associated with increased rates of vascular complications (10.2% vs 6.0%, p = 0.07). Stroke (4.1% vs 4.1%, p = 0.99) and pacemaker implantation rates were also similar (13.0% vs 9.2%, p = 0.12) between the TAVR and SAVR groups, respectively. In conclusion, in nonagenarians, both SAVR and TAVR can be performed with acceptable in-hospital outcomes. Referral for aortic valve replacement in these patients should not be precluded based on age alone., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Identifying the coronary branch that supplies the basal septum is the cornerstone for successful alcohol septal ablation (ASA). The basal septum is often supplied by septal perforator artery/arteries (SPA/SPAs) not originating from the left anterior descending (LAD) coronary artery. We aim to investigate the prevalence and significance of non-LAD septal "culprit" in patients undergoing ASA. A retrospective review of patients who underwent ASA from 2006 to 2014 was conducted. Procedural and midterm outcomes of patients who had ASA of LAD and non-LAD culprit SPA were reported. A total 89 patients were included in the analysis; 13 patients (15%) had ASA of non-LAD SPA. These patients were more likely to have a history of failed ASA, more than one SPA treated, more ethanol dose injected, longer procedures, and higher contrast use compared with those who had ASA of LAD-SPA. In-hospital outcomes, residual gradient, symptom improvement, and midterm mortality were similar in the 2 groups. In conclusion, in a cohort of patients undergoing ASA, 15% had ablation of SPA culprit that did not originate from the LAD. Half of these patients had previous unsuccessful ASA. Systematic screening for the ideal culprit SPA with nonselective coronary injection of echo contrast should be used to avoid incomplete or failed ASA., (Copyright © 2016 Elsevier Inc. All rights reserved.)