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Aim: We sought to determine if opioid exposure may have a detrimental effect on the course of Clostridioides difficile infection (CDI). Materials & methods: We compared opioid exposure in patients with well-defined severe CDI and non-severe CDI. Results: Following exclusions, 403 records were reviewed. Of this group, 128/403 (31.7%) were determined to have severe CDI by strict criteria, and 275/403 (68.3%) were found to have non-severe CDI. Full multivariate regression and reduced model of potential predictors for severe CDI showed no association with opioids prescribed. Conclusion: Opioid exposure (predominantly in modest range) does not appear to be a risk factor for severe healthcare-associated CDI.

To evaluate the contemporary trends in outcomes and resource use associated with transcatheter aortic valve replacement (TAVR) in the United States.We identified patients who underwent TAVR between January 1, 2012, and December 31, 2017, in the National Readmission Database. We assessed temporal trends in clinical outcomes, length-of-stay, non-home discharges, and cost of the index TAVR hospitalization. We also evaluated the changes in the burden of hospitalizations before and after TAVR.A total of 89,202 patients were included. In-hospital mortality decreased from 5.3% (188) in 2012 to 1.6% (484) in 2017 (adjusted odds ratio: 0.37, 95% CI: 0.30 to 0.46). Risk-adjusted incidences of new dialysis, vascular complications, blood transfusion, and mechanical ventilation decreased, but strokes and pacemaker implantations remained unchanged. Length of stay decreased from median of 7 (interquartile range [IQR]: 4 to 11) to 2 (IQR: 2 to 5) days (P.001). Risk-adjusted non-home discharges decreased from 32.2% (1134) to 15.5% (386) (P.001). Median cost of the TAVR hospitalization decreased from $56,022 (IQR: $43,690 to $75,174) to $46,101 (IQR: $36,083 to $59,752) (P.001). Pre-TAVR admissions at 30, 90, and 180 days decreased from 21.6% (713), 39.5% (1160), and 50.5% (1009) in 2012 to 15.5% (4451), 30.2% (7186), and 36.8% (5928) in 2017, respectively (P.001). Similarly, re-hospitalizations at 30, 90, and 180 days post-TAVR decreased from 17.5% (531), 27.9% (657), and 34.2% (521) to 12.4% (3486), 21.1% (4783), and 29.1% (4306), respectively (P.001). The expenditure on index, pre-, and post-TAVR hospitalizations increased from $0.53 to $2.8 billion between 2012 and 2017.This study reflects the changes in the characteristics and outcomes of TAVR in the United States between 2012 and 2017. It also shows the temporal decrease in resource use, cost, and burden of hospitalizations among patients undergoing TAVR in the United States, but an increase in the overall expenditure on TAVR-related hospitalizations.

OBJECTIVES AND BACKGROUND There is insufficient current evidence about whether sex impacts outcomes of percutaneous left atrial appendage occlusion (LAAO). The aim of this study was to investigate the association between sex and short-term outcomes of LAAO. METHODS Patients who were hospitalized and underwent LAAO from October 2015 to December 2017 in the National Readmission Database were queried. The primary endpoint of interest was major in-hospital adverse events. Secondary endpoints included, 30-day readmission rate, nonhome discharge, and cost of hospitalization. Propensity score matching (1:1) was performed to compare the outcomes among women and men. RESULTS A total of 9,281 patients were included in the current analysis [women = 3,659 (39%); men = 5,622 (61%)]. Comparing women to men, women had lower prevalence of diabetes mellitus (30.6% vs 35.7%, p

Objectives This study sought to use a national representative database to assess the incidence, predictors, and outcomes of balloon aortic valvuloplasty (BAV) as a bridge to transcatheter aortic valve replacement (TAVR) in contemporary practice. Background Nationwide data on the use and outcomes of BAV as a bridge to TAVR are limited. Methods Patients who underwent BAV between January and June in 2015 and 2016 were identified in the National Readmission Database. We assessed rate of subsequent TAVR following BAV, and predictors and timing of subsequent TAVR. We then identified a group of patients who had direct TAVR (without prior BAV) in the original 2015 to 2016 National Readmission Database dataset. We compared in-hospital outcomes following TAVR between patients with prior bridging BAV and those undergoing direct TAVR. Results Among the 3,691 included patients 1,426 (38.6%) had subsequent TAVR. Timing of TAVR was pre-discharge in 7.4%, within 30 days in 35%, between 31 and 90 days in 47%, between 91 and 180 days in 14%, and >180 days in 4%. Negative predictors of subsequent TAVR included prior defibrillator (odds ratio [OR]: 0.56; 95% confidence interval [CI]: 0.36 to 0.85), dementia (OR: 0.60; 95% CI: 0.46 to 0.79), malnutrition (OR: 0.64; 95% CI: 0.45 to 0.90), and malignancy (OR: 0.62; 95% CI: 0.47 to 0.82). In propensity-score matched cohorts of patients who underwent direct TAVR versus those with prior BAV, in-hospital mortality during TAVR admission was similar (3.7% vs. 3.5%; p = 0.91). Major complications, length of stay, and discharge disposition were also comparable. However, cost of the hospitalization was higher in the direct TAVR group. Conclusions About 40% of BAV patients undergo subsequent TAVR mostly within 90 days. In-hospital outcomes of TAVR in these patients were comparable with propensity-score matched patients who underwent TAVR without prior BAV. Further investigations are needed to define the role of BAV in contemporary practice.

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, p0.001), non-ST-elevation myocardial infarction (NSTEMI) 1.1% versus 0.7% (OR 1.59, 95% CI 1.52 to 1.63, p0.001), and unstable angina/stable ischemic heart disease (US/SIHD) (0.5% vs 0.3%, OR 1.66, 95% CI 1.61 to 1.72, p0.001). 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.

Though infrequent, incomplete left atrial appendage closure (LAAC) may result from residual leaks. Percutaneous closure has been described though data is limited.We compiled a registry from four centers of patients undergoing percutaneous closure of residual leaks following LAAC via surgical means or with the Watchman device. Leak severity was classified as none (no leak), mild (1-2 mm), moderate (3-4 mm), or severe (≥5 mm). Procedural and clinical success was defined as the elimination of leak or mild residual leak at the conclusion of the procedure or follow-up, respectively.Of 72 (age 72.2 ± 9.2 years; 67% male) patients, 53 had undergone prior LAAC using the Watchman device and 19 patients surgical LAAC. Mean CHADSPercutaneous closure of residual leaks following left atrial appendage closure is feasible and associated with good outcomes. The procedural risk appears to be satisfactory.

Introduction: Device related thrombosis (DRT) is an indication for continuation of anticoagulation for patients undergoing left atrial appendage (LAA) occlusion. There is a paucity of data in regards to the definition of DRT on coronary CT angiography (CTA) in patients with WATCHMAN FLX TM (Boston scientific) device implantation. Methods: This is a single center experience of using CTA for follow up in patients post WATCHMAN FLX TM implantation. 37 consecutive patients who underwent WATCHMAN FLX TM implantation at our center and had CTA performed at first follow up were included. CTA images were analyzed for the presence of hypo-attenuated thickening (HAT) on the device, device positioning, peridevice gap, angulation, compression percentage, depth of implant from coumadin ridge and enhancement in the LAA compared to left atrium (LA). Results: Among 37 patients with CTA follow up, HAT was noted in 28 patients (75%). 38% of these patients had HAT >3 mm. LAA patency (LAA/LA ratio of >25%) was seen in 7 patients (10%), 4 with gaps around the device and the rest secondary to trans-fabric leak. Gap around the device was noted in 13 patients (35%). 6 of these 13 patients had >4 mm gap; 5/6 patients had HAT and 3/6 patients had >25% enhancement in the LAA compared to LA. Increased compression % on both CTA and intraprocedural TEE was associated with absence of HAT (p=0.0003) as well as better sealing on CTA (LAA/LA ratio of >25%) (p=0.04). 6 months follow up is available on only 18 patients; only one of these patients had stoke and that patient did not have HAT on the CT scan. Conclusions: Definition of thrombus on WATCHMAN FLX TM device is not clearly defined on CTA. HAT on CTA could be artifact from the device knob and gutter or visible endothelialization around the device. Further studies with multimodality imaging and clinical correlation are needed to help determine normal cut offs for HAT on these CTAs.

Pre-procedural chronic kidney disease (CKD) and in-hospital acute kidney injury (AKI) are associated with worse outcomes following transcatheter aortic valve replacement (TAVR). We tested the feasibility of reducing overall AKI by avoiding pre-procedural cardiac CT angiography (CCTA) by using direct 3D-TEE guidance in TAVR patients with known CKD.An institutional TAVR database was examined from January 2016 to June 2020 to identify 396 patients in whom CCTA sizing was performed and 54 patients with creatinine (Cr) of1.6 mg/dL in whom direct 3D-TEE, without prior CCTA, was used for TAVR guidance. Baseline demographics, procedural, echocardiographic, and clinical endpoints were compared as defined by the Valve Academic Research Consortium-2 criteria.Baseline demographics and risk factors were similar in both groups other than the creatinine level in CCTA vs. TEE groups (1.33 ± 1.1 vs 1.76 ± 0.7 mg/dL, p = 0.005). Procedural contrast volume was significantly lower in the TEE group compared to the CCTA group. No differences were noted in echocardiographic and clinical endpoints for both groups. Despite higher baseline Cr, patents in the TEE group experienced a similar pattern of changes in Cr compared to the CCTA group, with an overall renal improvement noted at the time of discharge for both groups.In patients with baseline CKD, careful avoidance of large contrast loads associated with CCTA and intra-procedural aortography by using TEE guidance may help reduce AKI following TAVR.

Fragmented postoperative care following elective procedures has been associated with poor outcomes. However, the association between interhospital readmission (IHR) and clinical outcomes after transcatheter edge-to-edge repair (TEER) is unknown.Adults who underwent TEER between 2014 and 2018 were identified in the National Readmission Database (NRD). We classified patients who were re-hospitalized within 90-days after TEER as: patients admitted to the index hospital (same hospital readmission; SHR) and those admitted to a different hospital (interhospital readmission; IHR). We compared 90-day outcomes, cause of readmission, length of stay (LOS), and costs between the two groups. Moreover, we tested whether IHR was an independent predictor of 180-day morality using logistic regression.Of the 12,716 patients who underwent TEER, 2444 were hospitalized within 90-days; among those, 1179 (48.2%) were admitted to a different hospital (IHR). Cardiovascular causes of readmission were more common in the SHR group (63.5% vs 56.7%, P0.001). After PSM, major adverse events were higher in the SHR group during both the index admission and during rehospitalization. Also, during the readmission, LOS and cost of care were both higher in the SHR group, while non-home discharge rates were higher in the IHR group. In the logistic regression model, IHR was not independently associated with 180-day mortality.Admission to a different hospital post TEER was not associated with higher adverse event rate. The current system of care wherein patients requiring TEER are referred to tertiary centers of excellence appears appropriate.

Data comparing outcomes of distal radial (DR) and traditional radial (TR) access of coronary angiography and percutaneous coronary intervention (PCI) are limited. Online databases including Medline and Cochrane Central databases were explored to identify studies that compared DR and TR access for PCI. The primary outcome was the rate of radial artery occlusion (RAO) and access failure. Secondary outcomes included access site hematoma, access site bleeding, access site pain, radial artery spasm, radial artery dissection, and crossover. Unadjusted odds ratios (ORs) with a random-effect model, 95% confidence interval (CI), and p0.05 were used for statistical significance. Metaregression was performed for 16 studies with 9,973 (DR 4,750 and TR 5,523) patients were included. Compared with TR, DR was associated with lower risk of RAO (OR 0.51, 95% CI 0.29 to 0.90, I

Background\ud Women are less likely to receive primary percutaneous coronary intervention (pPCI) than men. A potential reason is risk aversion because of the worse outcomes with pPCI among women. However, whether pPCI is associated with a comparable mortality benefit in men and women remains unknown.\ud \ud Methods and Results\ud We selected patients admitted with a principal diagnosis of ST‐segment–elevation myocardial infarction in the National Inpatient Sample (2016–2018). We used propensity‐score matching to calculate average treatment effects of pPCI for in‐hospital mortality, major complications, length of stay, and cost. As a sensitivity analysis, we used logit models followed by a marginal command to calculate the average marginal effect. We included 413 500 weighted hospitalizations (30.7% women, 69.3% men). Women had more comorbidities except smoking and prior sternotomy. Compared with men, women were less likely to undergo angiography (81.0% versus 87.0%; adjusted odds ratio [OR], 0.77; 95% CI, 0.74–0.81; P

Background Women are less likely to receive primary percutaneous coronary intervention (pPCI) than men. A potential reason is risk aversion because of the worse outcomes with pPCI among women. However, whether pPCI is associated with a comparable mortality benefit in men and women remains unknown. Methods and Results We selected patients admitted with a principal diagnosis of ST‐segment–elevation myocardial infarction in the National Inpatient Sample (2016–2018). We used propensity‐score matching to calculate average treatment effects of pPCI for in‐hospital mortality, major complications, length of stay, and cost. As a sensitivity analysis, we used logit models followed by a marginal command to calculate the average marginal effect. We included 413 500 weighted hospitalizations (30.7% women, 69.3% men). Women had more comorbidities except smoking and prior sternotomy. Compared with men, women were less likely to undergo angiography (81.0% versus 87.0%; adjusted odds ratio [OR], 0.77; 95% CI, 0.74–0.81; P P P P P interaction=0.16). This persisted in age‐stratified analyses (≥85, 65–84, 45–64, Conclusions pPCI results in a comparable reduction in in‐hospital mortality in men and women. Nonetheless, risk‐adjusted rates of pPCI remain lower in women in contemporary US practice.

Introduction Despite the growth in transcatheter edge-to-edge repair (TEER) volume in the United States, data on the temporal changes in procedural outcomes are lacking. Methods We utilized the National Readmission Database to assess the annual changes in patient's characteristics, in-hospital outcomes, cost, and readmissions for patients who underwent TEER between January 1, 2014 and December 31, 2018. Outcomes of interest included mortality, major adverse cardiovascular events (MACE) and any adverse event (AE). We also assessed length of stay and cost. Results A total of 22,692 hospitalizations were included. The mean age increased from 75.2 ± 12.9 in 2014 to 78.1 ± 9.8 years in 2018. Changes in the prevalence of risk factors were heterogenous. The incidence of in-hospital mortality decreased from 4.0% in 2014 to 2.0% in 2018. Both MACE and any AE decreased significantly. Although the incidence of 30-day readmission remained stable, there was a trend towards a temporal increase in both 90-day and 180-day. The adjusted median length of stay of the index admission decreased by 50% and this trend was associated with a $2100 reduction in risk and inflation adjusted in-hospital cost, however, this reduction was offset by the increased total cost of readmissions within the first 6 months resulting in similar net-cost. Conclusion The volume of TEER has grown substantially between 2014 and 2018 coupled with a temporal improvement in in-hospital outcomes and reduction in cost and length of stay. Re-hospitalization rates after TEER remained steady at 30-day and trended towards worsening overtime at 90- and 180-days.

Background Transcatheter mitral valve repair (TMVr) is currently offered at selected centers that meet certain operator and institutional requirements. We sought to explore the hypothesis that the availability of TMVr is associated with improved outcomes of MV surgery. Methods and Results We used the Nationwide Readmissions Database to identify patients who underwent MV surgery at centers with or without TMVr capabilities between January 1 and December 31, 2017. The primary end point was in‐hospital mortality. Secondary end points were postoperative complications, resource use, and 30‐day readmissions. A total of 24 477 patients from 595 centers (446 TMVr, 149 non‐TMVr) were included. There were modest but statistically significant differences in the prevalence of comorbidities between the groups. Patients at non‐TMVr centers had higher unadjusted in‐hospital mortality than those at TMVr centers (5.6% versus 3.6%, P P P =0.002). Conclusions Mitral valve surgery at TMVr centers is associated with improved in‐hospital outcomes compared with non‐TMVr centers.

BACKGROUND There is a paucity of data focusing on women's outcomes after percutaneous coronary interventions (PCI) for coronary bifurcation lesions (CBLs). METHODS Patients who received PCI for CBLs in the context of acute coronary syndrome (ACS) during the period of 01 October 2015- 31 December 2017, were identified from the United States National Readmission Database. The primary endpoint of this study was in-hospital major adverse events (MAEs). The secondary endpoints were in-hospital mortality, vascular complications, major bleeding, post-procedural bleeding, need for blood transfusion, severe disability surrogates (non-home discharge and need for mechanical ventilation), resources utilization surrogates (length of stay and cost of hospitalization), and 30-day readmission rate. A 1:1 propensity score matching was used to compare the outcomes between women and men. RESULTS A total of 25,050 (women = 7,480; men = 17,570) patients were included in the current analysis. After propensity score matching, women had higher in-hospital MAEs (7 vs 5.2%, p

Background Whether the poor outcomes of isolated tricuspid valve surgery are related to the operation itself or to certain patient characteristics including late referral is unknown. Methods and Results Adult patients who underwent isolated tricuspid valve surgery were identified in the Nationwide Readmissions Database (2016–2017). Patients who had redo tricuspid valve surgery, endocarditis, or congenital heart disease were excluded. Multivariable logistic regression was performed to identify contributors to postoperative mortality. A total of 1513 patients were included (mean age 55.7±16.6 years, 49.6% women). Surrogates of late referral were frequent: 41% of patients were admitted with decompensated heart failure, 44.3% had a nonelective surgery status, 16.8% had advanced liver disease, and 31% had an unplanned hospitalization in the prior 90 days. The operation was performed on day 0 to 1 of the hospitalization in only 50% of patients, and beyond day 10 in 22% of patients. In‐hospital mortality occurred in 8.7% of patients. Median length of stay was 14 days (7–35 days), and median cost was $87 223 ($43 122–$200 872). In multivariable logistic regression analysis, surrogates for late referrals (acute heart failure decompensation, nonelective surgery status, or advanced liver disease) were the strongest predictors of in‐hospital mortality (odds ratio [OR], 4.75; 95% CI, 2.74–8.25 [ P P Conclusions The poor outcomes of isolated tricuspid valve surgery may be largely explained by the late referral for intervention. Studies are needed to determine the role of early intervention for severe isolated tricuspid regurgitation.

There is a paucity of data on sex differences in outcomes after surgical myectomy (SM) for hypertrophic cardiomyopathy (HCM).Patients who received SM for HCM during October 1, 2015, through December 31, 2018, were identified from the US National Readmission Database. The primary end point of this study was in-hospital mortality. The secondary end points were major bleeding, acute kidney injury, new pacemaker implantation, severe disability surrogates (non-home discharge and need for mechanical ventilation), resources utilization surrogates (length of stay and cost of hospitalization), and 30-day outcomes (readmission rate, mortality, and new pacemaker insertion).A total of 3031 patients were included in the current analysis. Using propensity score matching, 2 well matched cohorts were compared (women = 1170 and men = 1127). Women had a higher requirement for new pacemaker insertion compared with men (10.9% vs 6.8%; P = .029), higher number of non-home discharges (13.8% vs 7.9%; P .01), and longer length of hospital stay (median = 7 [interquartile range, 5-9] days) versus (median = 6 [interquartile range, 5-8] days). There was no difference in in-hospital mortality, major bleeding, blood transfusion, acute kidney injury, or hospitalization costs for women versus men. At 30 days, women continued to show a higher need for pacemaker insertion (11.3% vs 7.1%; P = .03) and had a higher readmission rate than men (10.9% vs 7.1%; P = .02). There was no difference in 30-day mortality between women and men (3% vs 2.4%; P = .54).Among the HCM cohort who received SM, significant sex-based differences in the outcomes were observed. Women had higher new pacemaker insertion rate, higher non-home discharge rate, and higher rate of 30-day readmission compared with men.