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Background: This study sought to investigate health and healthcare disparities in the management of severe mitral regurgitation with transcatheter edge-to-edge repair using MitraClip and how racial differences impact resource utilization and costs., Methods: We retrospectively analyzed the National Inpatient Sample (NIS) for patients who underwent Transcatheter Edge-to-Edge Repair (TEER) using MitraClip between 2016 and 2018. The patients were stratified into four racial cohorts and study outcomes included high resource utilization (HRU), periprocedural complications, and total procedural costs. High resource utilization (HRU) was defined as length of stay (LOS) ≥7 days or a nonhome disposition at discharge. Multivariate logistic regression models were utilized to determine independent predictors of HRU., Results: 17,100 weighted TEER patients were segregated by race: Caucasian (n = 13,270), others (n = 1510), African Americans, AA (n = 1245) and Hispanics (n = 1075). More African Americans and Hispanics had TEER at Urban facilities (P < 0.001), which were teaching hospitals as well (P < 0.001) but were less likely to be covered by public insurance options -Medicare or Medicaid (P < 0.001). More AA (52.2 %) and Hispanics (27.6 %) were likely to be in the lowest median annual income quartile versus Caucasians (19.2 %) (P = 0.003). AA and Hispanics had higher resource utilization (HRU), prolonged length of stay, nonhome disposition at discharge, higher procedural costs and periprocedural complications versus Caucasians. The logistic regression model revealed acute kidney injury (AKI) and actual procedural costs as independent predictors of HRU in both African American and Hispanic groups., Conclusion: Significant Health and healthcare disparities do exist among underrepresented, racial minority patients undergoing transcatheter edge-to-edge repair in the US. These disparities were associated with higher resource utilization and actual costs in patients with mitral regurgitation treated with TEER., Competing Interests: Declaration of competing interest The authors declare no actual or potential conflicts of interest relevant to the conduct of this research and its subsequent publication., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Objective: Coronary heart disease is a leading cause of death and disability. Although psychological stress has been identified as an important potential contributor, mechanisms by which stress increases risk of heart disease and mortality are not fully understood. The purpose of this study was to assess mechanisms by which stress acts through the brain and heart to confer increased CHD risk., Methods: Coronary Heart Disease patients (N=10) underwent cardiac imaging with [Tc-99m] sestamibi single photon emission tomography at rest and during a public speaking mental stress task. Patients returned for a second day and underwent positron emission tomography imaging of the brain, heart, bone marrow, aorta (indicating inflammation) and subcutaneous adipose tissue, after injection of [ 18 F]2-fluoro-2-deoxyglucose for assessment of glucose uptake followed mental stress. Patients with (N=4) and without (N=6) mental stress-induced myocardial ischemia were compared for glucose uptake in brain, heart, adipose tissue and aorta with mental stress., Results: Patients with mental stress-induced ischemia showed a pattern of increased uptake in the heart, medial prefrontal cortex, and adipose tissue with stress. In the heart disease group as a whole, activity increase with stress in the medial prefrontal brain and amygdala correlated with stress-induced increases in spleen (r=0.69, p=0.038; and r=0.69, p=0.04 respectfully). Stress-induced frontal lobe increased uptake correlated with stress-induced aorta uptake (r=0.71, p=0.016). Activity in insula and medial prefrontal cortex was correlated with post-stress activity in bone marrow and adipose tissue. Activity in other brain areas not implicated in stress did not show similar correlations. Increases in medial prefrontal activity with stress correlated with increased cardiac glucose uptake with stress, suggestive of myocardial ischemia (r=0.85, p=0.004)., Conclusions: These findings suggest a link between brain response to stress in key areas mediating emotion and peripheral organs involved in inflammation and hematopoietic activity, as well as myocardial ischemia, in Coronary Heart Disease patients., Competing Interests: Conflict: The authors have no conflicts of interest to declare in reference to this research.

Objective: Racial, gender, and socioeconomic status have been shown to impact the delivery of care. How this impacts the management of hypertensive crisis remains unclear. We aim to identify disparities on admission frequency and length of stay (LOS) among those presenting with hypertensive crisis, as a function of household income., Methods: This is a cross-sectional analysis of 2016 emergency department visits and supplemental inpatient data from the Nationwide Emergency Department Sample. Median household income quartiles were established. A multivariable logistic regression model was used to estimate odds of admission in each income quartile. A multivariable linear regression model was used to predict LOS., Results: After applying sample weighting, the total number of emergency department visits was 33 727 with 6906, 25 443, and 1378 visits for hypertensive emergency, hypertensive urgency, and unspecified crisis, respectively. There were 13 191, 8889, 6400, 5247 visits in the (first) lowest, second, third , and fourth (highest) income quartiles, respectively. The median age for the study population was 60. The most common comorbidity was chronic kidney disease. Individuals with the highest income, had a lower likelihood of admission, compared with the lowest quartile (adjusted odds ratio: 0.41, 95% CI 0.22-0.74). There was a significant association between income quartile and LOS among hypertensive emergency patients (beta coefficient: 0.407, P value = 0.019)., Conclusion: In this study, patients with lower income were more likely to be admitted, whereas those with higher income exhibited a longer LOS. Clinicians must be made aware these disparities to ensure equitable delivery of care., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Background: The "July effect", the perception of worse outcomes in the first month of training, has been previously demonstrated in critical care medicine and general surgery. However, the July effect in the context of structural heart interventions (i.e., transcatheter aortic valve replacement [TAVR] and MitraClip) remains unknown., Methods: All adult patients undergoing TAVR or MitraClip in the 2012-2016 National Inpatient Sample were included. Outcomes were compared by procedure month and academic year quartiles (i.e., between the first academic year quartile [Q1] vs. the fourth quartile [Q4]). Outcomes between teaching and nonteaching hospitals were compared using risk-adjusted logistic difference-in-difference regression., Results: During the study period, 94,170 TAVR (Q1: 25,250; Q4: 23,170) and 8750 MitraClip (Q1: 2220; Q4: 2150) procedures were performed. In-hospital mortality did not vary as per academic year quartiles for either procedure, even after risk adjustment. These findings persisted in sensitivity analysis by procedure month and newer device era (2015-2016; all p > 0.05). In the subgroup analysis, the unadjusted and adjusted Q1 vs. Q4 in-hospital mortality between teaching and nonteaching hospitals were similar for either procedure. In-hospital mortality also did not vary by procedure month when stratified by hospital teaching status for both procedures. However, postprocedural complication rates appeared to be improving among the TAVR teaching hospitals for stroke, major bleeding, and vascular complications (all p < 0.05)., Conclusions: In this large, nationwide study, the July effect was not evident for structural heart interventions. With increasing interest and growth in transcatheter procedures, early resident and fellow teaching can be achieved with appropriate supervision., Competing Interests: C.K.Z. is supported by 10.13039/100000002NIH Medical Scientist Training Program Training Grant T32GM007205. She is the PI of an F30 award through the National Institute on Aging F30AG066371 entitled “The ED.TRAUMA Study: Evaluating the Discordance of Trauma Readmission And Unanticipated Mortality in the Assessment of hospital quality.” M.J.R. served as a study investigator, a consultant, and a proctor for Edwards Lifesciences, Boston Scientific, and Abbott. P.O. has been a consultant to Medtronic and Edwards Lifesciences. P.S. reports receiving compensation as a proctor for Edwards and educational grants from Edwards, Medtronic, and Abbott. He also reports that his wife is an employee of Thermo Fisher. T.K. is a speaker for Edwards Life Sciences, Medtronic, Abbott, and Baylis Medical and is a consultant for 4C Medical. There are no other potential conflicts that exist., (© 2022 The Author(s).)

The study investigates the incidence of change in renal function and its impact on survival in renal dysfunction patients who were bridged to heart transplantation with a left ventricular assist device (BTT-LVAD). BTT-LVAD patients with greater than or equal to moderately reduced renal function (estimated glomerular filtration rate [eGFR] ≤ 60 ml/min/1.73 m2) at the time of listing between 2008 and 2018 were identified from a prospectively maintained database of the United Network for Organ Sharing. Patients with a baseline eGFR less than or equal to 15 ml/min/1.73 m2 or on dialysis were excluded. Patients were divided into three groups based on percent change ([Pretransplant eGFR - listing eGFR/listing glomerular filtration rate (GFR)] × 100) in eGFR: Improvement greater than or equal to 10%, no change, decline greater than or equal to 10%, and their operative outcomes were compared. Posttransplant survival was estimated and compared among the three groups with the Kaplan-Meier survival curves and the log-rank test. Cox proportional hazards modeling was used to identify predictors of posttransplant survival. Out of 14,395 LVAD patients, 1,622 (11%) met the inclusion criteria. At the time of transplant, 900 (55%) had reported an improvement in eGFR greater than or equal to 10%, 436 (27%) had no change, and 286 (18%) experienced a decline greater than or equal to 10%. Postoperatively, the incidence of dialysis was higher in the decline than in the unchanged or improved groups (22% vs. 12% vs. 12%; p = 0.002). After a median follow-up of 5 years, there was no difference in posttransplant survival among the stratified groups (improved eGFR: 24.8%, unchanged eGFR: 23.2%, declined eGFR: 20.3%; p = 0.680). On Cox proportional hazard modeling, independent predictors of worse survival were: [hazard ratio: 95% CI; p] history of diabetes (1.43 [1.13-1.81]; p = 0.002) or tobacco use (1.40 [1.11-1.79]; p = 0.005) and ischemic time greater than 4 hours (1.36 [1.03-1.76]; p = 0.027). More than half of the patients with compromised renal function who undergo BTT-LVAD demonstrate an improvement in renal function at the time of transplant. A 10% change in GFR while listed was not associated with worse posttransplant survival., Competing Interests: Disclosure: The authors have no conflicts of interest to report., (Copyright © ASAIO 2021.)

The impact of atrial fibrillation (AF) on the hospitalization outcomes in patients ≥ 60 years of age with implantable cardioverter defibrillators (ICD) is not well studied. We queried the National Inpatient Sample database for all patients aged ≥ 60 who had a history of ICD placement, and were admitted with a primary diagnosis of heart failure (HF) during the years 2016-2017. Patients were stratified into 2 groups based on their history of AF. The primary outcome of the study was all-cause in-hospital mortality. Secondary outcomes included cardiogenic shock, myocardial infarction (MI), ventricular fibrillation (VF), stroke and acute kidney injury (AKI). The association between different age strata and outcomes was investigated. The hospitalization outcomes were modeled using logistic regression. A total of 178,045 patients were included, of whom 56.2% had AF. AF correlated with increased mortality (A-OR 1.22 (95% CI: 1.06-1.4), p=0.005), cardiogenic shock (A-OR 1.21 (95%CI: 1.08-1.36), p<0.001), AKI (A-OR 1.12 (95%CI: 1.06-1.17), p<0.001 and lower risk for MI (A-OR 0.79 (95% CI: 0.68-0.9), p<0.001. There was no correlation between AF and risk for VF or stroke. A significant correlation between AF and higher risk for mortality, cardiogenic shock and AKI was demonstrated in ages ≤ 75, ≤ 75, and ≤ 80 years, respectively. In contrast, a significant correlation between AF and lower risk for MI is only demonstrated at age > 70 years. We conclude that AF is an independent predictor for increased all-cause in-hospital mortality and cardiogenic shock. Such risk is influenced by age., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Objective: The current study aims to report trends of early discharges and identify associated direct costs using a nationally representative database of real-world data experience., Methods: We used nationally weighted data on all patients who had transfemoral transcatheter aortic valve replacement (TAVR) from 2012 to 2017 and discharged alive from the National Inpatient Sample. Patients were divided into early (discharge ≤3 days of admission) and late discharge. Demographics and clinical characteristics were compared. Trends in early discharge and costs associated with admissions were analyzed over the study period., Results: Of the 125,188 patients identified, 59,424 (46.9%) were discharged early. The proportion of early discharge increased from 15% in early 2012 to 68% in late 2017 ( P < 0.001), with the largest increase occurring from 2014 to 2015. Overall, the average cost of TAVR decreased from $58,408 in 2012 to $49,875 in 2017 ( P < 0.001). Compared to late discharge, patients discharged early reported costs savings of ≥$20,000 over the study period. Among the early discharge group, no significant differences in costs were observed for patients discharged on 0 to 1, 2, or 3 days after the procedure., Conclusions: Postoperative length of stay after TAVR has decreased dramatically within the last decade with an observed reduction in procedural costs. While discharge within 3 days appeared cost effective, no differences in costs were noted among patients discharged ≤3 days.

Objective: We investigated health and healthcare disparities in the treatment of aortic stenosis with transcatheter aortic valve replacement (TAVR) and how they affect resource utilization and costs., Methods: We retrospectively reviewed all patients who were discharged alive after TAVR between 2012 and 2017 from the National Inpatient Sample. Patients were stratified by race and outcomes investigated were in-hospital complications, total procedural costs, and resource utilization. High resource utilization (HRU) was defined as length of stay (LOS) ≥7 days or discharge to a nonhome location. Multivariable regression models were used to identify predictors of HRU., Results: TAVR patients ( N = 29,464) were stratified into Caucasians ( n = 25,691), others ( n = 1,274), Hispanics ( n = 1,267), and African Americans (AA, n = 1,232). More AA and Hispanics had TAVR at urban teaching centers ( P = 0.003) and were less likely to be Medicare beneficiaries ( P < 0.001). Distribution of TAVR patients in the lowest income quartile showed AA (50%) versus Caucasian (20%) versus Hispanic (33%, P < 0.001). In-hospital complications were higher among Hispanics and AA than Caucasians with prolonged LOS, procedural costs, and HRU. On multivariable analysis, independent predictors of HRU were TAVR year ( P < 0.001), advanced age ( P < 0.001), female sex ( P < 0.001), non-Caucasian race ( P = 0.038), history of coronary artery bypass grafting ( P < 0.001), smoking ( P < 0.001), chronic lung disease ( P = 0.003), stroke ( P < 0.001), and lowest income quartile ( P = 0.002)., Conclusions: There exist significant healthcare and health disparities among patients undergoing TAVR in the United States. Consequently, this unequal access to care and determinants of heath translate into higher resource utilization and costs.

The present study is a sub-analysis of the Systolic Blood Pressure Intervention Trial (SPRINT) that aimed to evaluate the role of intensive vs. standard hypertensive treatment on cardiovascular outcomes according to the body mass indices of trial participants. SPRINT participants were categorized according to their baseline BMI values into normal (BMI ≥ 18.5 to <25), overweight (BMI ≥ 25 to <30), and obese (BMI ≥ 30) groups. The primary cardiovascular outcome was a composite of myocardial infarction, acute coronary syndrome not resulting in myocardial infarction, stroke, acute decompensated heart failure, or death from cardiovascular cause. Cox regression analysis was used to calculate hazard ratios for the study outcome in intensive and standard BP treatment among those with varying BMI. Among 9237 participants with, 1682, 3599, and 3956 were normal, overweight and obese, respectively. After a median follow-up of 3.26 years, the hazard ratios for the primary endpoint were 0.82 (95% CI 0.58, 1.16), 0.71 (95% CI 0.54, 0.94), and 0.76 (95% CI 0.59, 0.98) for the normal, overweight, and obese participants, respectively (P value for interaction 0.79). The effect of intensive versus standard SBP treatment for the other secondary endpoints and serious adverse events were all similar in participants of different BMI (all P-interaction > 0.05). In this sub-analysis of the SPRINT trial, intensive blood pressure control had a beneficial effect in reducing the primary endpoint and all-cause mortality irrespective of the participants' BMI.

Background: To examine the incidence and trends of peri-procedural complications after TAVR and their impact on resource utilization., Methods: The incidence of complications by type [acute kidney injury (AKI), permanent pacemaker (PPM), vascular, paravalvular leak, in-hospital mortality, others] was calculated for TAVR patients at a high-volume center between 2012 and 2018. Clinical data were matched with hospital-billing data of patients. Trends in high resource utilization (discharge to a rehabilitation facility or PLOS >7 days) (HRU) and complication rates were assessed. Multivariable logistic regression models were used to determine predictors of HRU., Results: Out of 1163 patients, 966 (83%) had no complications, others in 95 (8%), PPM in 56 (5%), AKI alone in 32 (3%), vascular in 31 (3%), in-hospital mortality in 28 (2%) and PVL in 10 (1%). A significant decreasing trend in the incidence of complications (29% vs 10%; p trend <0.001) and HRU (75% vs 12%; p trend <0.001) was observed between 2012 and 2018 respectively. Mean ± SD direct procedure cost of having a complication was $58,234 ± $24,568, was associated with an incremental cost of $10, 649 and a prolonged stay of 3-days. On multivariable logistic regression analysis, PPM, vascular complications, high STS risk score, NYHA class III/IV, frailty and ≥ moderate tricuspid regurgitation were significantly associated with HRU. TAVR year was protective against HRU., Conclusions: We established that, post-TAVR resource utilization and morbidity is high among frail and patients with higher STS risk scores. However, these rates decrease over time with experience., Competing Interests: Declaration of competing interest None to declare., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Left atrial appendage (LAA) closure devices are alternative treatments recently approved for patients with atrial fibrillation. Due to the novelty of these devices, limited postapproval surveillance data on LAA closure devices have been published. Thus, we analyzed the United States Food and Drug Administration Manufacturer and User Facility Device Experience (MAUDE) database to report these findings. The primary endpoint was final event outcome, and secondary endpoints included management strategies of reported events.

Background: The purpose of this study is to report the clinical features and outcomes of Black/African American (AA) and Latino Hispanic patients with Coronavirus disease 2019 (COVID-19) hospitalized in an inter-city hospital in the state of New Jersey., Methods: This is a retrospective cohort study of AA and Latino Hispanic patients with COVID-19 admitted to a 665-bed quaternary care, teaching hospital located in Newark, New Jersey. The study included patients who had completed hospitalization between March 10, 2020, and April 10, 2020. We reviewed demographics, socioeconomic variables and incidence of in-hospital mortality and morbidity. Logistic regression was used to identify predictor of in-hospital death., Results: Out of 416 patients, 251 (60%) had completed hospitalization as of April 10, 2020. The incidence of In-hospital mortality was 38.6% (n = 97). Most common symptoms at initial presentation were dyspnea 39% (n = 162) followed by cough 38%(n = 156) and fever 34% (n = 143). Patients were in the highest quartile for population's density, number of housing units and disproportionately fell into the lowest median income quartile for the state of New Jersey. The incidence of septic shock, acute kidney injury (AKI) requiring hemodialysis and admission to an intensive care unit (ICU) was 24% (n = 59), 21% (n = 52), 33% (n = 82) respectively. Independent predictors of in-hospital mortality were older age, lower serum Hemoglobin < 10 mg/dl, elevated serum Ferritin and Creatinine phosphokinase levels > 1200 U/L and > 1000 U/L., Conclusions: Findings from an inter-city hospital's experience with COVID-19 among underserved minority populations showed that, more than one of every three patients were at risk for in-hospital death or morbidity. Older age and elevated inflammatory markers at presentation were associated with in-hospital death.

Background: This study sought to describe a single center's experience with transcatheter mitral valve-in-valve (TM-ViV) implantation., Methods: Consecutive patients who had TM-ViV due to degenerative biological valve prosthesis at a single center during a 4-year period were identified from a prospectively maintained database. Operative outcomes were assessed both in-hospital and at 30 days. The primary outcome was in-hospital mortality. Secondary outcomes included valve function, functional status, and quality of life at follow-up., Results: Mean (± standard deviation) patient age was 69 ± 12 years and all patients were high risk for redo surgery (STS risk score, 9.6 ± 6.2%). The primary mechanism of bioprosthetic valve failure was stenosis in 7 patients (47%) and regurgitation in 8 patients (53%). Mean duration between mitral valve replacement (MVR) and transcatheter MVR was 89 months (range, 66-72 months). Failed bioprosthetic valves were replaced with Sapien XT (n = 10; 67%), Sapien (n = 4; 26%), or Sapien S3 valves (n = 1; 7%) (all valves manufactured by Edwards Lifesciences). Procedural success was 100%. No intraoperative deaths were recorded. Postimplantation valve hemodynamics was satisfactory, with a significant improvement in mean valvular gradient (Δ = -12 mm Hg; P<.001) and mitral valve area (Δ = 0.9 cm²; P<.01). At 30-day follow-up, no reports of death, disabling stroke, or rehospitalization for cardiac reasons was recorded. Health status scores were available for 11 of the 15 study patients (73%). Except for 1 patient, significant improvements were seen for all components of the health assessment survey., Conclusions: TM-ViV for failing biological mitral prosthesis can be performed with minimal operative morbidity and acceptable mid-term clinical and hemodynamic outcomes.

Objective: The transapical (TA) approach is an alternative access technique for transcatheter aortic valve replacement (TAVR) in patients with symptomatic aortic valve stenosis. The impact of prior coronary artery bypass graft (CABG) surgery and how it affects left ventricular function recovery is not well defined., Methods: Patients who had TAVR at a single center between June 2012 and December 2016 were reviewed. High-risk patients who underwent the procedure via a TA approach were divided into 2 groups based on their history of CABG surgery. Postoperative outcomes were compared between groups. CABG/TA-TAVR patients were subdivided into 2 per baseline left ventricular ejection fraction (LVEF) <50%. The changes in LVEF and valve function at follow-up (1 to 12 months) were analyzed using paired t -tests., Results: Of 923 cases in total, 183 (19.8%) were performed via a TA approach. The mean ± SD Society of Thoracic Surgeons risk score of TA patients was 10.2 ± 4.6. Forty-nine (27%) had a surgical history of CABG. Overall all-cause mortality rates at 30 days, 1 year, and 2 years were similar for both groups ( P = 0.59, P = 0.64, P = 0.78). Subgrouping of CABG-TAVR patients ( n = 49) identified 24 patients (49%) with LVEF ≥50% vs. 25 (51%) with LVEF <50%. At 1-year follow-up, significant improvements in LVEF (low LVEF group) and valve function for both groups were observed. LVEF ≥50% group (LVEF: ∆ : -3%, P = 0.878; aortic valve area [AVA]: ∆ : 1.3 cm 2, P < 0.001; mean gradient: ∆ : -38 mmHg, P < 0.001); LVEF <50% group (LVEF: ∆ : 10%, P = 0.01; AVA: ∆ : 1.3 cm 2 , P < 0.001; MG: ∆ : -31 mmHg, P < 0.001)., Conclusions: TA-TAVR can be safely performed with acceptable postoperative outcomes in patients with a history of CABG surgery. In those with reduced EF, significant improvements in LV and valve functions are seen at 1-year follow-up.

The study aims to investigate the incidence of immediate renal function improvement in renal dysfunction patients who had transcatheter aortic valve implantation (TAVI). TAVI patients with ≥ moderate reduced renal function [estimated GFR ≤ 60 ml/min/1.73 m 2 ] at baseline were identified from a prospectively maintained database. Patients were divided into 3 groups based on percent change [(discharge eGFR - baseline eGFR/baseline GFR) × 100] in eGFR post-TAVR. Improvement ≥ 10%, no change, Decline ≥ 10%. Multivariable logistic regression was performed to identify factors that predicted improvement/decline in GFR postprocedure. Out of 677 patients, 359 (53%) had eGFR ≤ 60 ml/min/1.73 m 2 . Of these, 188 (52%) had an improvement in eGFR ≥ 10%, 125 (34%) had no change and 48 (14%) observed decline ≥ 10%. All groups had similar proportions of females and age was comparable in patient groups. Patients in whom a decline in eGFR was observed had significantly higher Society of thoracic Surgeons scores (10.7 vs 8.2 vs 8.2; p = 0.007) and incidence of liver disease (6% vs, 0% vs 2%; p = 0.014) than the no-change or improved groups respectively. On multivariable analysis, independent predictors of decline/improvement in eGFR were being female, low left ventricular ejection fraction and baseline liver dysfunction. In conclusion, over half of patients with compromised renal function who underwent TAVI experience an immediate improvement in kidney function post-TAVI. Being female, baseline liver dysfunction and a low left ventricular ejection fraction is associated with an immediate decline in eGFR., (Published by Elsevier Inc.)

Objective: We sought to investigate outcomes after left ventricular assist device (LVAD) implantation in advanced heart failure patients stratified by race., Methods: Patients who had LVADs inserted at a single center as a bridge to transplant (BTT) or destination therapy (DT) were divided into 3 groups based on race: Caucasian, African American (AA), and Hispanic. Postoperative outcomes including complications, discharge disposition, and survival at defined time points were compared. Cox proportional hazards were used to identify factors associated with 1-year all-cause survival., Results: A total of 158 patients who had LVADs as BTT ( n = 63) and DT ( n = 95) were studied. Of these, 56% ( n = 89) were Caucasians, 35% ( n = 55) were AA, and 9% ( n = 14) were Hispanics. AA patients had higher BMI and lower socioeconomic status and educational level, and were more likely to be single or divorced. Operative outcomes were similar among all 3 groups. Unadjusted 30-day, 6-month, 1-year, and 2-year survival rates for Caucasians versus AA versus Hispanics were 82% versus 89% versus 93%, P = 0.339; 74% versus 80% versus 71%, P = 0.596; 67% versus 76% versus 71%, P = 0.511; and 56% versus 62% versus 68%, P = 0.797. On multivariate analysis, device-related infection, malfunction, and abnormal rhythm were factors associated with overall all-cause mortality., Conclusion: AA patients who undergo LVAD implantation as BTT or DT have lower socioeconomic status and educational level compared to their Caucasian or Hispanic counterparts. These differences, however, do not translate into postimplant survival outcomes.

Background: The current study aims to identify predictors of extended postoperative length of stay (PLOS) after uncomplicated transcatheter aortic valve replacement (TAVR)., Methods: Patients who underwent TAVR at a single center between June 2012 and June 2016 were analyzed. Patients were stratified by time into an early cohort (EC; 2012-2014) and current cohort (CC; 2015-2016). Those who had complications post procedure were excluded. The CC group was dichotomized based on its median PLOS. Factors associated with a longer PLOS were investigated by using multivariable logistic regression analysis., Results: Mean age of the 686 patients (299 in the EC group and 387 in the CC group) was 82 ± 8 years. PLOS in the CC group was significantly lower than in the EC group (4 days vs 6 days, respectively; P<.001). Median PLOS in the CC group was 2 days. Dichotomizing the CC group by median PLOS resulted in 148 patients (54%) ≤2 days vs 128 patients (46%) >2 days. Of these, PLOS was 1 day in 71 patients (26%) and 2 days in 61 patients (28%). Independent predictors of PLOS >2 days were non-transfemoral approach, non-elective admission, female sex, low mean transaortic gradient, presence of chronic renal failure, and pulmonary hypertension., Conclusion: Experience coupled with improvements in TAVR technology over the past few years have led to a significant decrease in PLOS after TAVR. In the current TAVR era, 1 out of every 2 patients stays for a day or two in the absence of perioperative adverse events.

The world celebrates over 50 years since the first human-to-human heart transplant. Bibliometric analysis is a statistical concept that has recently evolved, enabling scientists to study citation patterns and identify characteristics of highly cited scholarly work in different fields. Although it has been widely utilized, such analyses have not been conducted to date on heart transplant literature. We sought to assess the characteristics of the top 100 most referenced citations in the field of heart transplantation. We searched the Scopus database (www.scopus.com) to identify all articles relating to heart transplantation. The articles were arranged in descending order from most cited to least cited and selected articles were scrutinized for data extraction. One hundred articles were included in the final list. Of the total 40,660 citations identified, 3,210 (8.0%) were self-citations, which impacted the final rank order. The articles were published in 25 different journals between 1960 and 2013. The most productive 5-year time period was between 2000 and 2005, when 24 of the 100 most cited publications were produced. There was no correlation between the journals' impact factors and the number of articles produced per journal. The presence and type of funding were not associated with the number of citations. Over 85% of first and senior investigators were men. In conclusion, our study highlights key features of the most highly cited scientific literature on heart transplantation and provides insights into trends of published work in this field. Additionally, this work may serve as a useful guide to researchers and funding bodies by highlighting the most prolific areas of cardiac transplant research to date., (Copyright © 2018. Published by Elsevier Inc.)

Background: We analyzed the utility of repeated sestambi scans in patients with primary hyperparathyroidism and its effects on operative referral., Methods: We carried out a retrospective review of patients with primary hyperparathyroidism who underwent repeated sestambi scans exclusively within our health system between 1996-2015. Patient demographic, presentation, laboratory, imaging, operative, and pathologic data were reviewed. Univariate analysis with JMP Pro v12 was used to identify factors associated with conversion from an initial negative to a subsequent positive scan., Results: After exclusion criteria (including reoperations), we identified 49 patients in whom 59% (n = 29) of subsequent scans remained negative and 41% (n = 20) converted to positive. Factors associated with an initial negative to a subsequent positive scan included classic presentation and second scans with iodine subtraction (P = .04). Nonsurgeons were less likely to order an iodine-subtraction scan (P < .05). Fewer patients with negative imaging were referred to surgery (33% vs 100%, P = .005), and median time to operation after the first negative scan was 25 months (range 1.4-119). Surgeon-performed ultrasonography had greater sensitivity and positive predictive value than repeated sestamibi scans., Conclusion: Negative sestambi scans decreased and delayed operative referral. Consequently, we identified several process improvement initiatives, including education regarding superior institutional imaging. Combining all findings, we created an algorithm for evaluating patients with primary hyperparathyroidism after initially negative sestamibi scans, which incorporates surgeon-performed ultrasonography., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Purpose: The effects of inflammation on the prognosis, life expectancy and several parameters such as response to treatment of breast cancer have been previously studied. The purpose of this study was to investigate the effect of inflammatory markers on prognosis in patients with metastatic breast cancer., Methods: This study was conducted on 81 patients with metastatic breast cancer who have been followed up at the Department of Medical Oncology, Hacettepe University Institute of Oncology, between December, 2009 and March, 2014. For all studied parameters Kaplan-Meier survival estimates and p values computed by log-rank test were calculated. A p value < 0.05 was considered statistically significant., Results: Median follow-up time was 26 months. There were 38 deaths due to disease progression during the follow up. The levels of serum albumin, and erythrocyte sedimentation rate (ESR) were not associated with a significant effect on overall survival (OS). Among patients with a higher serum C-reactive protein (CRP), the estimated mean survival was 84±36 months, compared to 278±113 months among patients with a normal serum CRP (p=0.032). When patients with higher and normal lactate dehydrogenase (LDH) levels were compared, their 2-year OS survival rates were 68.2 and 87.7%, respectively (p=0.034). Among patients with higher serum ferritin levels, the estimated mean survival was 29±10 months, compared to 212±113 months for normal serum ferritin (p=0.01). Among patients with higher serum beta-2 microglobulin (β2-M), the estimated mean OS survival was 28±8 months, compared to 84±57 months for those with normal levels (p<0.01)., Conclusion: Serum CRP, ferritin and β2-M can be useful prognostic factors for OS in patients with metastatic breast cancer.

Recent advances in technology and the need to decrease surgical morbidity have led a rapid progress in laparoscopic adrenalectomy (LA) over the past decade. Robotics is attractive to the surgeon owing to the 3-dimensional image quality, articulating instruments, and stable surgical platform. The safety and efficacy of robotic adrenalectomy (RA) have been demonstrated by several reports. In addition, RA has been shown to provide similar outcomes compared to LA. Development of adrenal surgery has involved the description of several surgical approaches including the anterior transperitoneal, lateral transperitoneal (LT) and posterior retroperitoneal (PR). Among these, the most frequently preferred technique is LT adrenalectomy, primarily due to the surgeon's familiarity of the operative field, wider working space and visibility. The LT technique is suitable for the resection of larger, unilateral tumors and in scenarios where conversion to an open transperitoneal approach is warranted, it offers a lesser burden. Also, the larger view of the entire abdominal cavity and excellent exposure of both adrenal glands and surrounding structures provided by the LT technique render it safe and feasible in pediatric and pregnant individuals.

Background: Infections and sepsis remain the leading cause of morbidity and mortality in secondary peritonitis. Clinicians are still challenged with the task of finding an early and reliable diagnosis of septic complications. The role of inflammatory markers (Procalcitonin (PCT), C-reactive Protein (CRP) and thyroid hormones in determining the severity of secondary peritonitis was evaluated in this study., Methods: On the preoperative and first, third, fifth, seventh, and fourteenth postoperative days, PCT, CRP, and thyroid hormone concentrations were measured in serum taken from eighty-four consecutive patients who were operated on for secondary peritonitis between January 2008 and January 2010. All data was entered and analyzed using the Statistical Package for Social Sciences, version 15.0 and clinical parameters were compared using the student's t-test., Results: For the groups diagnosed with perforated viscus, PCT concentrations were significantly low in contrast to high thyroid hormone levels in patients who developed postoperative complications or died when compared to patients whose postoperative course was uneventful or discharged. The PCT concentration significantly correlated with the CRP concentration and WBC count., Conclusion: In the absence of postoperative complications, PCT is a better predictor of outcome than CRP in secondary peritonitis. Our study showed that a low thyroid hormone level can serve as an important prognostic parameter of disease severity in secondary peritonitis.

Purpose: To investigate the effect of inflammatory markers on the prognosis of patients with operable breast cancer., Methods: This study was conducted on breast cancer patients followed up between December 2009 and December 2012 at the Division of Medical Oncology, Department of Internal Medicine, Hacettepe University Medical School. A total of 704 patients with stages I to III disease whose inflammatory markers were assessed at the time of diagnosis were included the study. Serum C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), albumin, ferritin, β2 microglobulin (β2-M), and lactate dehydrogenase (LDH) levels were evaluated as inflammatory markers., Results: The median age at diagnosis was 50 years (range 25-92). Of the patients 42.8% were premenopausal and 48.2 % postmenopausal. Invasive ductal carcinoma was the most common histology (76.5 %). Serum ferritin, LDH, β2-M, ESR, and CRP were higher than the normal values in 1.0, 4.3, 9.5, 32.4 and 36.4 % of the patients, respectively. Serum albumin levels were lower than the normal values in 1.7 % of the patients. The median patient follow-up period was 22 months (range 3-227). During follow-up, metastatic disease developed in 31 patients (4.4%) and 11 patients (1.56%) died due to disease progression. Two-year overall survival (OS) and disease free survival (DFS) rates were not statistically different among patients with normal and abnormal values with respect to albumin, ferritin, LDH, β2-M, CRP, and ESR., Conclusion: Our study is the first study to investigate the effect of inflammatory markers on the prognosis of operable breast cancer patients. We showed that inflammatory markers such as ESR, CRP, ferritin, β2-M, albumin and LDH have no effect on prognosis.