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Acute right heart failure (RHF) is an important presentation of acute pulmonary artery thromboembolism (PE). The hemodynamic nature of acute right ventricular failure is fundamentally different from that of chronic right ventricular failure. Recognizing important clinical signs, along with imaging modalities such as Transthoracic echocardiogram, lung ventilation/perfusion scintigraphy scan and computed tomographic pulmonary angiography (CTPA), can help to make an early diagnosis. Early treatment with anticoagulants and/or thrombolysis, helps to improve in-hospital survival and reduce long-term pulmonary arterial hypertension. Systemic or catheter directed thrombolysis plays a vital role in patients with hemodynamic instability. The role of advanced hemodynamic support devices as an adjuvant therapy is limited to only specialized centers with experienced operators.

Ventricular septal myomectomy (VSM) is the primary modality for left ventricular outflow tract gradient reduction in patients with obstructive hypertrophic cardiomyopathy with refractory symptoms. Comprehensive postprocedural data for VSM from a large multicenter registry are sparse. The primary objective of this study was to evaluate postprocedural mortality, complications, length of stay (LOS), and cost of hospitalization after VSM and to further appraise the multivariate predictors of these outcomes. The Healthcare Cost and Utilization Project's Nationwide Inpatient Sample was queried from 1998 through 2010 using International Classification of Diseases, Ninth Revision, procedure codes 37.33 for VSM and 425.1 for hypertrophic cardiomyopathy. The severity of co-morbidities was defined using the Charlson co-morbidity index. Hierarchical mixed-effects models were generated to identify independent multivariate predictors of in-hospital mortality, procedural complications, LOS, and cost of hospitalization. The overall mortality was 5.9%. Almost 9% (8.7%) of patients had postprocedural complete heart block requiring pacemakers. Increasing Charlson co-morbidity index was associated with a higher rate of complications and mortality (odds ratio 2.41, 95% confidence interval 1.17 to 4.98, p = 0.02). The mean cost of hospitalization was $41,715 ± $1,611, while the average LOS was 8.89 ± 0.35 days. Occurrence of any postoperative complication was associated with increased cost of hospitalization (+$33,870, p0.001) and LOS (+6.08 days, p0.001). In conclusion, the postoperative mortality rate for VSM was 5.9%; cardiac complications were most common, specifically complete heart block. Age and increasing severity of co-morbidities were predictive of poorer outcomes, while a higher burden of postoperative complications was associated with a higher cost of hospitalization and LOS.

Background— The relationship between operator or institutional volume and outcomes among patients undergoing percutaneous coronary interventions (PCI) is unclear. Methods and Results— Cross-sectional study based on the Healthcare Cost and Utilization Project’s Nationwide Inpatient Sample between 2005 to 2009. Subjects were identified by International Classification of Diseases, 9 th Revision, Clinical Modification procedure code, 36.06 and 36.07. Annual operator and institutional volumes were calculated using unique identification numbers and then divided into quartiles. Three-level hierarchical multivariate mixed models were created. The primary outcome was in-hospital mortality; secondary outcome was a composite of in-hospital mortality and peri-procedural complications. A total of 457 498 PCIs were identified representing a total of 2 243 209 PCIs performed in the United States during the study period. In-hospital, all-cause mortality was 1.08%, and the overall complication rate was 7.10%. The primary and secondary outcomes of procedures performed by operators in 4 th [annual procedural volume; primary and secondary outcomes] [>100; 0.59% and 5.51%], 3 rd [45–100; 0.87% and 6.40%], and 2 nd quartile [16–44; 1.15% and 7.75%] were significantly less ( P st quartile [≤15; 1.68% and 10.91%]. Spline analysis also showed significant operator and institutional volume outcome relationship. Similarly operators in the higher quartiles witnessed a significant reduction in length of hospital stay and cost of hospitalization ( P Conclusions— Overall in-hospital mortality after PCI was low. An increase in operator and institutional volume of PCI was found to be associated with a decrease in adverse outcomes, length of hospital stay, and cost of hospitalization.

The increase in the number of carotid artery stenting (CAS) procedures over the last decade has necessitated critical appraisal of procedural outcomes and patterns of utilization including cost analysis. The main objectives of our study were to evaluate the postprocedural mortality and complications after CAS and the patterns of resource utilization in terms of length of stay (LOS) and cost of hospitalization. We queried the Healthcare Cost and Utilization Project's Nationwide Inpatient Sample from 2006 to 2010 using the International Classification of Diseases, Ninth Revision, procedure code of 00.63 for CAS. Hierarchical mixed-effects models were generated to identify the independent multivariate predictors of in-hospital mortality, procedural complications, LOS, and cost of hospitalization. A total of 13,564 CAS procedures (weighted n = 67,344) were analyzed. The overall postprocedural mortality was low at 0.5%, whereas the complication rate was 8%, both of which remained relatively steady over the time frame of the study. Greater postoperative mortality and complications were noted in symptomatic patients, women, and those with greater burden of baseline co-morbidities. A greater operator volume was associated with a lower rate of postoperative mortality and complications, as well as shorter LOS and lesser hospitalization costs. In conclusion, the postprocedural mortality after CAS has remained low over the recent years. Operator volume is an important predictor of postprocedural outcomes and resource utilization.

Background Atrial fibrillation (AF) patients with left ventricular hypertrophy (LVH) and diastolic dysfunction may derive benefit from being in sinus rhythm but no data are available to support this strategy in them. We sought to investigate effect of left ventricular remodeling on cardiovascular outcomes in AF patients undergoing rhythm control strategy. Methods We identified 1088 patients with echocardiographic data on left ventricular mass (LVM) enrolled in the AFFIRM trial. Using the American Society of Echocardiography (ASE) criteria, patients were divided into 4 categories: 1) normal geometry, 2) concentric remodeling, 3) eccentric hypertrophy, and 4) concentric hypertrophy. The primary endpoint was AF recurrence and the secondary endpoint was cardiovascular hospitalization (CVH). Results In rhythm control arm, median time to recurrence in patients with concentric LVH was 13.3months (95% CI 8.2–24.5) vs. 28.3months (95% CI 20.2–48.6) in patients without LVH. Concentric left ventricular hypertrophy (LVH) was independently predictive of AF recurrence (HR 1.49, 95% CI 1.10–2.01, p=0.01) in rhythm control arm, but not in overall population or rate control arm. Both concentric and eccentric LVH were independently predictive of cardiovascular hospitalization (CVH) in the overall population, with respective HRs of 1.36 (1.04–1.78, p=0.03) and 1.38 (1.02–1.85, p=0.04). Conclusion Concentric LVH is predictive of AF recurrences when a predominantly pharmacologic rhythm-control strategy is employed. Different patterns of LVH seem to be important determinants of outcomes (AF recurrence and CVH). These findings may have important clinical implications for the management of patients with AF and LVH. Further studies are warranted to confirm our findings.

Although left ventricular (LV) hypertrophy has been proposed as a factor predisposing to atrial fibrillation (AF), its relevance to prognosis and selection of therapeutic strategies is unclear. We identified 2,105 patients with echocardiographic data on LV mass enrolled in the Atrial Fibrillation Follow-up Investigation of Rhythm Management (AFFIRM) trial. LV hypertrophy was defined as increased LV mass, stratified by American Society of Echocardiography criteria. The primary end point was all-cause mortality, secondary end point was as per AFFIRM trial definition, and tertiary end point was cardiovascular hospitalizations. We compared "strict" versus "lenient" rate control in patients with increased LV mass, and studied association of heart failure (HF) with preserved and decreased systolic function in patients with increased LV mass. Over 6 years, 332 deaths (15.7%) were reported. Adjusted hazard ratio (HR) of severely increased LV mass for all-cause mortality was 1.34 (95% confidence interval [CI] 1.01 to 1.79, p=0.045) for the overall population and 1.61 (95% CI 1.09 to 2.37, p=0.016) for the rhythm-control arm. Increased LV mass was a predictor of cardiovascular hospitalizations in the lenient rate-control group (HR 1.72, 95% CI 1.05 to 2.82, p=0.03) but not in the strict rate-control group. Severely increased LV mass was predictive of cardiovascular hospitalizations in patients with HF with preserved (HR 1.8, 95% CI 1.0 to 3.2, p=0.03) and decreased LV systolic function (HR 2.4, 95% CI 1.1 to 5.2, p=0.02). Thus, LV hypertrophy is a significant independent predictor of mortality in patients with AF, especially those managed with rhythm control. In patients with LV hypertrophy, strict rate control may be associated with better outcomes than lenient rate control. LV hypertrophy portends higher cardiovascular morbidity in patients with AF and HF.

Background— Atrial fibrillation ablation has made tremendous progress with respect to innovation, efficacy, and safety. However, limited data exist regarding the burden and trends in adverse outcomes arising from this procedure. The aim of our study was to examine the frequency of adverse events attributable to atrial fibrillation (AF) ablation and the influence of operator and hospital volume on outcomes. Methods and Results— With the use of the Nationwide Inpatient Sample, we identified AF patients treated with catheter ablation. We investigated common complications including cardiac perforation and tamponade, pneumothorax, stroke, transient ischemic attack, vascular access complications (hemorrhage/hematoma, vascular complications requiring surgical repair, and accidental arterial puncture), and in-hospital death described with AF ablation, and we defined these complications by using validated International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis codes. An estimated 93 801 AF ablations were performed from 2000 to 2010. The overall frequency of complications was 6.29% with combined cardiac complications (2.54%) being the most frequent. Cardiac complications were followed by vascular complications (1.53%), respiratory complications (1.3%), and neurological complications (1.02%). The in-hospital mortality was 0.46%. Annual operator ( Conclusions— The overall complication rate was 6.29% in patients undergoing AF ablation. There was a significant association between operator and hospital volume and adverse outcomes. This suggests a need for future research into identifying the safety measures in AF ablations and instituting appropriate interventions to improve overall AF ablation outcomes.

Electrocardiographic lead aVR is often ignored in clinical practice. The aim of this study was to investigate whether ST-T wave amplitude in lead aVR predicts cardiovascular (CV) mortality and if this variable adds value to a traditional risk prediction model. A total of 7,928 participants enrolled in the National Health and Nutrition Examination Survey (NHANES) III with electrocardiographic data available were included. Each participant had 13.5 ± 3.8 years of follow-up. The study sample was stratified according to ST-segment amplitude and T-wave amplitude in lead aVR. ST-segment elevation (8 μV) in lead aVR was predictive of CV mortality in the multivariate analysis when not accounting for T-wave amplitude. The finding lost significance after including T-wave amplitude in the model. A positive T wave in lead aVR (0 mV) was the strongest multivariate predictor of CV mortality (hazard ratio 3.37, p0.01). The addition of T-wave amplitude in lead aVR to the Framingham risk score led to a net reclassification improvement of 2.7% of subjects with CV events and 2.3% of subjects with no events (p0.01). Furthermore, in the intermediate-risk category, 20.0% of the subjects in the CV event group and 9.1% of subjects in the no-event group were appropriately reclassified. The absolute integrated discrimination improvement was 0.012 (p0.01), and the relative integrated discrimination improvement was 11%. In conclusion, T-wave amplitude in lead aVR independently predicts CV mortality in a cross-sectional United States population. Adding T-wave abnormalities in lead aVR to the Framingham risk score improves model discrimination and calibration with better reclassification of intermediate-risk subjects.

The relation of bundle branch block (BBB) with adverse outcome is controversial. We hypothesized that increased QRS duration is an independent predictor of cardiovascular (CV) mortality in a cross-sectional US population. This is a retrospective cohort study on prospectively collected data to assess the relationship between QRS duration on routine ECG and CV mortality. Participants included 8,527 patients with ECG data available from the National Health and Nutrition Examination Survey data set, representing 74,062,796 individuals in the United States. Mean age was 60.5 ± 13.6 years. Most subjects were white (87%) and women (53%). During the follow-up period of 106,244.6 person-years, 1,433 CV deaths occurred. Multivariate analysis revealed that the highest quartile of QRS duration was associated with higher CV mortality than lowest quartile (hazard ratio [HR] 1.3, 95% confidence interval [CI] 1.01 to 1.7, p = 0.04) after adjustment for established risk factors. Both left BBB (HR 2.4, 95% CI 1.3 to 4.7, p = 0.009) and right BBB (HR 1.90, 95% CI 1.2 to 3.0, p = 0.008) were significantly associated with increased CV mortality. The addition of the QRS duration in 10-millisecond increments to the Framingham Risk Score model resulted in 4.4% overall net reclassification improvement (95% CI 0.02 to 0.04; p = 0.00006). In conclusion, increased QRS duration was found to be an independent predictor of CV mortality in this cross-sectional US population. A model including QRS duration in addition to traditional risk factors was associated with improved CV risk prediction.

Background Spontaneous coronary artery dissection is an uncommon syndrome. Its prevalence among patients with polycystic kidney disease is very rare, with no previously reported involvement of the right posterior descending coronary artery. Case presentation We describe the case of a middle-aged Caucasian woman with polycystic kidney disease who presented with a non-ST elevation myocardial infarction. Cardiac catheterization revealed a dissection of her right posterior descending coronary artery. She was treated with dual antiplatelet therapy and had a favorable outcome. Conclusion We report a rare and interesting case of spontaneous coronary artery dissection of the right posterior descending coronary artery in a patient with polycystic kidney disease. It is important to consider spontaneous coronary artery dissection in the differential diagnosis of patients with polycystic kidney disease who present with an acute coronary syndrome.

We appreciate Khera and colleagues for their interest in our study on the percutaneous coronary intervention (PCI) volume–outcome relationship.1 Khera and colleagues point out the limitations of using administrative claims data, some of which we have acknowledged in our article. Despite the inconsistencies and deficiencies in operator identification in the Nationwide Inpatient Sample (NIS) data set, our methodology has been well validated in previous studies.2,3 Among 457 498 PCIs identified in our data set, only 820 procedures (0.2%) were performed in hospitals that reported a single operator. Likewise, the operator volume–outcome relationship did not change in a subgroup analysis by different operator variable identifiers in states that consistently reported unique physician identifiers for the study time period. More than 92% of the procedures identified in our study were listed …

Background— Safety data on percutaneous left atrial appendage closure arises from centers with considerable expertise in the procedure or from clinical trial, which might not be reproducible in clinical practice. We sought to estimate the frequency and predictors of adverse outcomes and costs of percutaneous left atrial appendage closure procedure in the US. Methods and Results— The data were obtained from the Nationwide Inpatient Sample from the years 2006 to 2010. The Nationwide Inpatient Sample is the largest all-payer inpatient data set in the US. Complications were calculated using patient safety indicators and International Classification of Diseases -Ninth Revision, Clinical Modification codes. Annual hospital volume was calculated using unique hospital identifiers. Weights provided by the Nationwide Inpatient Sample were used to generate national estimates. A total of 268 (weighted=1288) procedures were analyzed. The overall composite rate of mortality or any adverse event was 24.3% (65), with 3.4% patients required open cardiac surgery after procedure. Average length of stay was 4.61±1.05 days and cost of care was 26 024±34 651. Annual hospital procedural volume was significantly associated with reduced complications and mortality (every unit increase: odds ratio, 0.89; 95% confidence interval, 0.85–0.94; P P P Conclusions— Our study demonstrates that the frequency of inhospital adverse outcomes associated with percutaneous left atrial appendage closure is higher in the real-world population than in clinical trials. We also demonstrate that higher annual hospital volume is associated with safer procedures, with lower length of stay and cost.

Contemporary large-scale data, regarding in-hospital outcomes depending on the types of stent used for percutaneous coronary intervention (PCI) is lacking. We queried the Healthcare Cost and Utilization Project's Nationwide Inpatient Sample from 2006 to 2011 using the International Classification of Diseases, Ninth Revision, Clinical Modification procedure code 36.06 (bare-metal coronary artery stent, BMS) or 36.07 (drug-eluting coronary artery stent, DES) for PCI. All analyses were performed using the designated weighting specified to the Nationwide Inpatient Sample database to minimize bias. Primary outcome was in-hospital mortality. Wald's chi-square test was used for categorical variables. We built a hierarchical 2 level model adjusted for multiple confounding factors, with hospital identification incorporated as random effects in the model and propensity match analyses were used to adjust confounding variables. A total of 665,804 procedures were analyzed, which were representative of 3,277,884 procedures in the United States. Use of bare-metal stents (BMS) was associated with greater occurrence of in-hospital mortality compared with that of drug-eluting stents (DES; 1.4% vs 0.5%, p0.001). The association stayed significant after adjustment of various possible confounding factors (odds ratio for DES versus BMS 0.59 [0.54 to 0.64, p0.001]) and also in propensity matched cohorts (1.2% vs 0.7%, p0.001). The results continued to be similar in the following high-risk subgroups: diabetes (0.57 [0.50 to 0.64,0.001]), acute myocardial infarction and/or shock (0.53 [0.49 to 0.57,0.001]), age80 (0.66 [0.58 to 0.74,0.001]), and multivessel PCI (0.55 [0.46 to 0.66,0.001]). In conclusion, DES use was associated with lesser in-hospital mortality compared with BMS. This outcome benefit was seen across subgroups in various subgroups including elderly, diabetics, and acute myocardial infarction as well as multivessel interventions.

Many medications used to treat atrial fibrillation (AF) also reduce blood pressure (BP). The relation between BP and mortality is unclear in patients with AF. We performed a post hoc analysis of 3,947 participants from the Atrial Fibrillation Follow-Up Investigation of Rhythm Management trial. Systolic blood pressure (SBP) and diastolic blood pressure (DBP) at baseline and follow-up were categorized by 10-mm Hg increments. The end points were all-cause mortality (ACM) and secondary outcome (combination of ACM, ventricular tachycardia and/or fibrillation, pulseless electrical activity, significant bradycardia, stroke, major bleeding, myocardial infarction, and pulmonary embolism). SBP and DBP followed a "U-shaped" curve with respect to primary and secondary outcomes after multivariate analysis. A nonlinear Cox proportional hazards model showed that the incidence of ACM was lowest at 140/78 mm Hg. Subgroup analyses revealed similar U-shaped curves. There was an increased ACM observed with BP110/60 mm Hg (hazard ratio 2.4, p0.01, respectively, for SBP and DBP). In conclusion, in patients with AF, U-shaped relation existed between BP and ACM. These data suggest that the optimal BP target in patients with AF may be greater than the general population and that pharmacologic therapy to treat AF may be associated with ACM or adverse events if BP is reduced to110/60 mm Hg.

Digoxin significantly improves all-cause mortality in atrial fibrillation patients with severely reduced left ventricular systolic function☆☆☆ Nileshkumar J. Patel , Michael Hoosien , Abhishek Deshmukh , Apurva O. Badheka , PeeyushM. Grover , Neeraj Shah , Vikas Singh , KathanMehta , Ankit Chothani , Ghanshyambhai T. Savani , Shilpkumar Arora , Vipulkumar Bhalara , Nilay Patel , Dhaval Khalpada , Ankit Rathod , Thomas J. Vazzana , James Lafferty , Juan F. Viles-Gonzalez , Raul D. Mitrani b,⁎

We assessed the trend, predictors and operator volume influence of complication related to Percutaneous closure of atrial septal defect (ASD) and patent foramen ovale (PFO). We examined the Healthcare Cost and Utilization Project's Nationwide Inpatient Sample (NIS) database from 2001 to 2010 using

Statin therapy has been associated with a reduction in ventricular and supra-ventricular tachyarrhythmias [1,2]. Statin therapy has also been associated with a lower risk of new onset AF in the elderly [3]. However, a recent meta-analysis showed reduction of secondary AF events but no reduction of new onset AF with statin use [4] .T here is considerable debate with respect to the antiarrhythmic effects of statin therapy in AF. We determined the association of lipid lowering therapy (LLT) in prevention of AF recurrence in a large high-risk patient population with AF, most of whom were on statin [5]. We performed a post hoc analysis of patients enrolled in the atrial fibrillation Follow-up Investigation of Rhythm Management (AFFIRM) trial. A public-use limited-access dataset that was devoid of all patient identifiers was obtained from the National Heart, Lung and Blood Institute (NHLBI). AFFIRM was a prospective trial (n = 4060) comparing survival in patients with AF and at least one risk factor for stroke randomized to a strategy of rate control (n = 2027) versus a strategy of rhythm control (n = 2033) [6,7]. Our inclusion criteria included subjects in sinus rhythm at baseline (n = 2095). The primary end point of our analysis was the time to first AF recurrence (in months). AF recurrence was determined on basis of electrocardiograms done duringeach followup visit. Follow-up datawas available at 2, 4, 8, and 12 months and then 3 visits per year until a period of 6 years or study termination. At each visit, vital signs, information onprimary or secondaryend points, medications, NYHA (New York Heart Association) class, hospitalizations and presence of documented AF or atrial flutter were collected.

Background: Prior studies have investigated the effect of influenza vaccination on cardiovascular mortality (CVM). The influence of vaccinations other than influenza and CVM has not been investigated before. Methods: The public dataset of National Health and Nutrition Examination Survey III (NHANES III) between the years 1988-1994 and continuous NHANES from 1999-2004 was used for this analysis. From NHANES III, we included patients >18 years old with available data on positive antibody against measles, mumps, rubella, diphtheria, pertussis or tetanus. From continuous NHANES, we included patients >18 years with available titers and vaccination history on hepatitis A, hepatitis B and pneumococcus. Protective titers were analyzed as per standardized cut offs. The primary outcome was CVM per National Death Index. Traditional cardiac risk factors along with CRP and social class (insurance, income and education level) were adjusted for in the multivariable analysis. Results: There were 1,848 (9.7%) cardiovascular deaths with a mean follow up of 13 years for NHANES III. There were 366 (2.3%) cardiovascular deaths with a mean follow up of 4.7 years for continuous NHANES. Multivariable analysis from NHANES III and continuous NHANES did not show any influence of individual seroprotective titers of routine vaccinations on CV mortality. In the multivariable model, significant predictors of mortality were age (p Conclusion: Our observational study in a large database suggests that presence of non-influenza vaccination antibodies is not associated with decreased cardiovascular mortality in a nationally representative cohort.

Background: Utilization of intra-aortic balloon pump (IABP) and left ventricular assist device (LVAD) during percutaneous coronary intervention (PCI) has increased in recent years. We analyzed the trends and predictors of hospitalization cost associated with high risk PCI in US over a 5 year period (2005-2010). Methods: We queried the Healthcare Cost and Utilization Project’s Nationwide Inpatient Sample (NIS) between 2005 and 2010 using the ICD9 procedure code of 36.07 and 36.06 for PCI. The NIS represents 20% of all hospitals in the US and is the largest all payer hospital discharge database. We defined high risk PCI as PCI plus LVAD (ICD-9 code 37.68, 37.62) or IABP placement (ICD-9 code 37.61) during the same hospital admission. We examined the selective contribution of patient demographics, insurance type, and hospital characteristics, Deyo modification of Charlson comorbidity index (CCI) and hospital PCI volume (split into quartiles with first quartile as referent) to hospitalization cost. For each year, cost was adjusted for inflation according to the 2010 cost. The independent predictors of hospitalization cost were calculated by mixed effects linear regression modeling incorporating hospital ID as random effects. Results: 26,300 (weighted n = 130,151) number of patients were identified. Overall hospitalization cost associated with high risk PCI increased from $137,354 in 2005 to $160,736 in 2010 (P Conclusion: In this observational study we demonstrated that increased hospitalization cost for high risk PCI is associated with teaching hospital, CCI, presence of MI or shock and occurrence of periprocedural complications. We also found use of IABP, female sex, having private, self-pay or no insurance to be associated with a decreased hospitalization cost related to high risk PCI in the US over a 5 year period from 2005-2010.

Background: Prior studies analyzing the effect of infection and cardiovascular events have met with contradictory results. We investigated whether infectious burden increases cardiovascular mortality in a cross sectional US population. Methods: The public dataset of the National Health and Nutrition Examination Survey III (NHANES III) between the years 1988-1994 was used for the analysis. We included patients >18 years with data on positive antibodies against Hepatitis A, Hepatitis B, Hepatitis C, Hepatitis E, Herpes simplex virus 1 and 2, Toxoplasma, Varicella, Cytomegalovirus (CMV), Human herpes virus -8 and Toxocara (n= 7,876). These infections were combined to create a total infection burden variable. This variable was split into quartiles. The primary outcome was cardiovascular (CV) mortality. Traditional cardiac risk factors along with C-reactive protein (CRP) and social class (insurance, income and education level) were adjusted for in the multivariable analysis. Results: 431 (5.5%) of cardiovascular deaths were reported with a mean follow up of 14.5 years. On a univariable analysis only positive toxoplasma antibody (HR, 95% CI, p-value) were predictive of CV mortality (1.18.,1.03-1.36, 0.02). Independent predictors of CV mortality in the multivariable model were age, female gender, CRP titers, hypertension, smoking, and diabetes. Social class (insurance, income and education level) and total infection burden, quartiles 2 (p = 0.1), 3 (p = 0.4) and 4 (p = 0.1) were not predictive of CV mortality when keeping quartile 1 as the referent. Conclusion: Our observational study in a large database suggests that presence of antibodies against certain viral and parasitic infections is not associated with increased cardiovascular mortality in a nationally representative cohort.

Background: High Risk Percutaneous Coronary Intervention (PCI) is increasingly being performed with the availability of hemodynamic support. The aim of this study was to determine the predictors of length of stay (LOS) for high risk PCI in US. Methods: We explored the Healthcare Cost and Utilization Project’s Nationwide Inpatient Sample (NIS) using the ICD9 procedure code of 36.07 and 36.06 for PCI. NIS is largest all-payer dataset that represents 20% of all US hospitals. We included patients who had PCI from 2005 through 2010 who also underwent Percutaneous Circulatory Assist Device (PCAD) or Intra-aortic Balloon Pump (IABP) placement during the same hospital admission. Severity of comorbidities was defined by Deyo modification of Charlson’s Comorbidity Index (CCI). Hospitals were identified by a unique hospital identification number and hospital volume was determined by calculating the total number of PCI performed by an institution on year to year basis. Complications were based on Patient Safety Indicators (PSI) recognized by Agency for Health Care Research and Quality to monitor in hospital complications. We examined the predictors of LOS by a mixed effects linear regression model including patient demographics, admission characteristics, CCI quartiles with first quartile as a reference, hospital PCI volume quartiles, IABP or PCAD use and periprocedural complications. Hospital ID was incorporated as random effects in the model. Results: A total of 26,300 High Risk PCIs (weighted n = 130,151) were available for analysis. Factors associated with increased LOS were the use of IABP as compared to PCAD (+0.86 days, p=0.03), occurrence of any complication (+4.67 days, P < 0.001), high CCI (+2.5 days for CCI=2 and +4.1 days for CCI≥3, p Conclusion: In our observational study based on a large database, use of IABP as compared to PCAD, occurrence of complications, CCI, teaching hospital, presence of MI or shock and high PCI volume were associated with increased LOS & having private insurance and self pay or no insurance was associated with decreased LOS.

Background: Utilization of balloon aortic valvulopasty (BAV) has increased in recent years. We aimed to explore the relationship between hospital and operator experience on mortality. Methods: We queried Healthcare Cost and Utilization Project’s Nationwide Inpatient Sample (NIS) between 1998 and 2010 using the ICD9 procedure code of 35.96 for valvuloplasty. The NIS represents 20% of all hospitals in the US. Patients with age > 60years with aortic stenosis were included and those with concomitant mitral, tricuspid or pulmonic stenosis were excluded. Severity of co-morbid conditions was defined with Deyo modification of Charlson’s comorbidity index. Primary outcome was in-hospital mortality. Annual operator and hospital procedure volume were calculated based on the unique operator and hospital identification numbers and were split into tertiles of the total volume per year. Mixed effects logistic regression modeling incorporating hospital ID as random effects was constructed to find out the independent predictors of in-hospital mortality. Results: A total of 2,127 BAV (weighted n= 9,686) were identified for hospital volume analysis and 1,030 BAV (weighted n = 5,125) were available for both operator and hospital volume analysis. In models incorporating either operator or hospital volume alone (hazard ratio (HR), 95% CI, p value) both operator volume (HR 0.5 per every unit increase in operator volume, 0.3-0.9, p Conclusion: We demonstrated that both annual operator and hospital procedure volume significantly impact in-hospital mortality for BAV, with operator volume playing a more significant role.

Background: Limited data is available on health care cost of balloon aortic valvuloplasty (BAV). We analyzed trends and predictors of cost for BAV over the last decade (2001-2010). Methods: The analysis is based on Healthcare Cost and Utilization Project’s Nationwide Inpatient Sample (NIS) between 2001 and 2010 using the ICD9 procedure code of 35.96 for valvuloplasty. Only patients with age > 60 years with aortic stenosis were included & those with concomitant mitral, tricuspid or pulmonic stenosis were excluded. NIS represents 20% of all hospitals in US. We examined selective contribution of patient demographics, hospital characteristics, Charlson Comorbidity Index (CCI) and peri-procedural complications to hospitalization cost by using mixed effects linear regression modeling. For each year, cost was adjusted for inflation according to 2010 cost. Operator & hospital volume were calculated based on the unique operator and hospital identification numbers. Operator volume data were available for only 50% of the population. Results: Total 1,525 (weighted n = 7,595) BAV were performed from 2001 to 2010 with available cost data. Weighted cost of hospitalization for BAV increased from $21,562 in 2001 to $29,559 in 2010 (p for trend < 0.001). In a multivariable model including operator volume, 748 (weighted n = 3,708) BAV were available for analysis. The independent predictors of increased cost of hospitallization were occurrence of periprocedural complications ($22,509; p < 0.001), unstable patient, defined as having ICD-9 code for shock or ventilator dependence ($24,856; p < 0.001) and weekend admission ($11,416; p=0.002). Predictors of decreased cost for BAV were increase in operator volume (-$1,929 per every unit increase, p = 0.006). Increase in hospital valvuloplasty volume (-$1,644 per every 10 units increase, p = 0.2) showed a trend of decreasing cost, but this was statistically non-significant. Conclusion: In our current observational study we identified peri-procedural complications, unstable patient & weekend admission to be associated with increased cost & increase in operator volume to be associated with decreased cost of hospitalization for BAV. We also found a significant trend of increase in cost of hospitalization from 2001 to 2010.

Heart failure (HF) is associated with a high incidence of stroke. The role of warfarin or aspirin in reducing this burden remains unclear. We searched MEDLINE (1966–10/2012), WEB OF SCIENCE (1980–10/2012), The Cochrane Library (Central and Dare) (Issue 10, 2012). We also searched BIOSIS (1969

outcomes from real world to contemporary randomized control trials☆ Naga Venkata K. Pothineni , Abhishek Deshmukh ⁎, Sadip Pant , Nileshkumar J. Patel , Apurva Badheka , Ankit Chothani , Neeraj Shah , KathanMehta , Ghanshyambhai T. Savani , Vikas Singh , Peeyush Grover , Vipulkumar Bhalara , Nilay Patel , Shilpkumar Arora , Ankit Rathod , Juan Viles-Gonzalez , Hakan Paydak a a University of Arkansas, Little Rock, AR, United States b Staten Island University Hospital, Staten Island, NY, United States c Detroit Medical Center, Detroit, MI, United States d MedStar Washington Hospital Center, Washington, DC, United States e UPMC Shadyside Hospital, Pittsburgh, PA, United States f University of Miami Miller School of Medicine, Miami, FL, United States g Cedar-Sinai Medical Center, Los Angeles, CA, United States

Apurva O. Badheka , Nileshkumar J. Patel , Vikas Singh , Abhishek Deshmukh , Neeraj Shah , Peeyush Grover , Ankit Rathod , Ankit Chothani , KathanMehta , Ghanshyam Savani , Robert J. Myerburg , Raul D. Mitrani , Mauricio G. Cohen a,⁎ a University of Miami Miller School of Medicine, Miami, FL, United States b Staten Island University Hospital, NY, United States c University of Arkansas, Little Rock, AR, United States d Cedars-Sinai Medical Centre, LA, CA, United States e Washington Hospital Center, Washington, DC, United States f Drexel University School of Public Health, Philadelphia, PA, United States

B-type natriuretic peptide (BNP) is released in response to increased myocardial wall stress and its levels are known to increase in diastolic and systolic heart failure. Heart failure related to severe aortic stenosis is expected to improve after valve replacement. We examined the relationship

Background Incidence and prevalence of mitral stenosis is declining in the US. We performed this study to determine recent trends in utilization, complications, mortality, length of stay, and cost associated with balloon mitral valvuloplasty. Methods Utilizing the nationwide inpatient sample database from 1998 to 2010, we identified patients using the International Classification of Diseases, 9th Revision, Clinical Modification procedure code for "percutaneous valvuloplasty." Patients ≥18 years of age with mitral stenosis were included. Patients with concomitant aortic, tricuspid, or pulmonic stenosis were excluded. Primary outcome included death and procedural complications. Results A total of 1308 balloon mitral valvuloplasties (weighted n = 6540) were analyzed. There was a 7.5% decrease in utilization of the procedure from 24.6 procedures/10 million population in 1998-2001 to 22.7 procedures/10 million population in 2008-2010 ( P for trend = .098). We observed a 15.9% overall procedural complication rate and 1.7% mortality rate. The procedural complication rates have increased in recent years ( P = .001), corresponding to increasing age and burden of comorbidities in patients. The mean cost per admission for balloon mitral valvuloplasty has gone up significantly over the 10 years, from $11,668 ± 1046 in 2001 to $23,651 ± 301 in 2010 ( P Conclusions In a large cross-sectional study of balloon mitral valvuloplasty in the US, we have reported trends of decreasing overall utilization and increasing procedural complication rates and cost over a period of 13 years.

Presently, an operator volume of >10 LVADs over 3 years is required for advanced certification in LVADs. We aim to see if any relation exists between operator volume & mortality using nationwide inpatient sample (NIS) database. We included patients >18 years in 1998-2009 NIS with ICD-9 procedure

A74-year-oldmanwithahistoryofheart transplantpresentedwith alteredmental status. On admission, his bloodpressurewas96/63 mm Hg and his heart rate was 72/min. On examination, he was in no immediate distress and had clear lung fields. Therewere no gallopsonexamination, andhehadno focalneurologicaldeficits.Amedian sternotomy scar and a left upper chest medical device were noted. The patient was unable to provide any history. His relatives confirmed prior heart transplant. Figure 1 shows the initial electrocardiogram (ECG) at theemergency department. Question:Given theclinical historyand thisECG,what initial differential diagnoses should be considered and what should be the initial therapy?

The exact relationship between blood pressure (BP) and mortality is unclear in a population of patients with atrial fibrillation (AF). We performed a post hoc analysis of 3,947 participants from the Atrial Fibrillation Follow-Up Investigation of Rhythm Management (AFFIRM) Trial. Systolic (SBP) and