Search

Risk-averse behavior has been reported among physicians and facilities treating cardiogenic shock in states with public reporting. Our objective was to evaluate if public reporting leads to a lower use of mechanical circulatory support in cardiogenic shock. We conducted a retrospective study with the use of the National Inpatient Sample from 2005 to 2011. Hospitalizations of patients ≥18 years old with a diagnosis of cardiogenic shock were included. A regional comparison was performed to identify differences between reporting and nonreporting states. The main outcome of interest was the use of mechanical circulatory support. A total of 13043 hospitalizations for cardiogenic shock were identified of which 9664 occurred in reporting and 3379 in nonreporting states (age 69.9 ± 0.4 years, 56.8% men). Use of mechanical circulatory support was 32.8% in this high-risk population. Odds of receiving mechanical circulatory support were lower (OR 0.50; 95% CI 0.43–0.57; p<0.01) and in-hospital mortality higher (OR 1.19; 95% CI 1.06–1.34; p<0.01) in reporting states. Use of mechanical circulatory support was also lower in the subgroup of patients with acute myocardial infarction and cardiogenic shock in reporting states (OR 0.61; 95% CI 0.51–0.72; p<0.01). In conclusion, patients with cardiogenic shock in reporting states are less likely to receive mechanical circulatory support than patients in nonreporting states.

IMPORTANCE: While many features of stable ischemic heart disease vary by sex, differences in ischemia, coronary anatomy, and symptoms by sex have not been investigated among patients with moderate or severe ischemia. The enrolled ISCHEMIA trial cohort that underwent coronary computed tomographic angiography (CCTA) was required to have obstructive coronary artery disease (CAD) for randomization. OBJECTIVE: To describe sex differences in stress testing, CCTA findings, and symptoms in ISCHEMIA trial participants. DESIGN, SETTING, AND PARTICIPANTS: This secondary analysis of the multicenter ISCHEMIA randomized clinical trial analyzed baseline characteristics of patients with stable ischemic heart disease. Individuals were enrolled from July 2012 to January 2018 based on local reading of moderate or severe ischemia on a stress test, after which blinded CCTA was performed in most. Core laboratories reviewed stress tests and CCTAs. Participants with no obstructive CAD or with left main CAD of 50% or greater were excluded. Those who met eligibility criteria including CCTA (if performed) were randomized to a routine invasive or a conservative management strategy (N = 5179). Angina was assessed using the Seattle Angina Questionnaire. Analysis began October 1, 2018. INTERVENTIONS: CCTA and angina assessment. MAIN OUTCOMES AND MEASURES: Sex differences in stress test, CCTA findings, and symptom severity. RESULTS: Of 8518 patients enrolled, 6256 (77%) were men. Women were more likely to have no obstructive CAD (

Secondary mitral regurgitation (MR), also known as functional MR, arises from changes in left ventricular geometry and function resulting in abnormal leaflet coaptation due to tethering of the mitral valve in patients with left ventricular dysfunction. Secondary MR is an independent risk factor for patients with heart failure (1,2). The 2017 AHA/ACC guidelines give a class IIb recommendation (level of evidence B) to isolated surgical mitral valve repair or replacement for patients with severe secondary MR who remain symptomatic (NYHA class III or IV) despite maximum tolerated guideline-directed medical therapy for heart failure (3). Meanwhile, the 2017 ESC/EACTS guidelines offer percutaneous repair as an alternative for these patients (class IIb recommendation; level of evidence C) (4). Percutaneous mitral valve repair with the use of MitraClip (Abbott Vascular, Santa Clara, CA, USA) has proven feasible, safe, and effective as an alternative for patients with severe symptomatic secondary MR and a high surgical risk in non-randomized studies (5). However, randomized data on hard clinical outcomes is lacking.

Objective To analyze trends in management and outcomes of patients infected with the human immunodeficiency virus (HIV) undergoing percutaneous coronary intervention (PCI) for an acute myocardial infarction (AMI) in the United States. Background Infection with HIV is an independent risk factor for accelerated atherosclerosis associated with higher rates of AMI. Current trends and outcomes of HIV-infected individuals presenting with AMI in the United States remain unknown. Methods Using the Healthcare Cost and Utilization Project National Inpatient Sample database we identified HIV-infected individuals who underwent PCI for an AMI from 2002 to 2013. Multivariable logistic regression and propensity-score matching were performed to analyze outcomes. Results We identified a total of 59 194 patients of which 7841 underwent PCI during index hospitalization (13.3%). Most patients were men (71%), ≥50 years of age (82%), and white (74%). ST-elevation myocardial infarction was present in 21% of cases. Charlson comorbidity index (CCI) was 5.67 ± 0.4. Predictors of post-procedural complications included female sex, black race, higher CCI, and placement of a bare metal stent, whereas predictors of mortality included occurrence of a complication, ST-elevation myocardial infarction, age ≥70 years, and higher CCI. Conversely, placement of a drug-eluting stent was associated with a reduced risk of complications and mortality. After propensity-score matching, HIV-infected individuals were less likely to undergo PCI and receive a drug-eluting stent, while having longer length of stay, higher hospitalization costs, and higher in-hospital mortality when compared to non-infected individuals. Conclusion Significant disparities continue to affect HIV-infected individuals undergoing PCI for AMI in the United States.

Reports on the role of hemodynamic support devices in patients with severe aortic stenosis (AS) and left ventricular (LV) dysfunction undergoing balloon aortic valvuloplasty (BAV) are limited.Patients were identified from the cVAD registry, an ongoing multicenter voluntary registry at selected sites in North America that have used Impella in10 patients.A total of 116 patients with AS who underwent BAV with Impella support were identified. Mean age was 80.41±9.03years and most patients were male. Mean STS score was 18.77%±18.32, LVEF was 27.14%±16.07, and 42% underwent concomitant PCI. In most cases Impella was placed electively prior to BAV, whereas 26.7% were placed as an emergency. The two groups had similar baseline characteristics except for higher prevalence of CAD and lower LVEF in the elective group, and higher STS score in the emergency group. Elective strategy was associated higher 1-year survival compared to emergency placement (56% vs. 29.2%, p=0.003). One-year survival was higher when BAV was used as a bridge to definitive therapy as opposed to palliative treatment (90% vs. 28%, p0.001). On multivariate analysis, STS score and aim of BAV (bridge to definitive therapy vs. palliative indication) were independent predictors of mortality.In this large cohort of patients with AS and severe LV dysfunction undergoing BAV, our results demonstrates feasibility and promising long-term outcomes using elective Impella support with the intention to bridge to a definitive therapy.

Transcatheter edge-to-edge mitral valve repair (TMVr) with MitraClip has proved to be safe and effective for high-risk surgical patients with severe symptomatic degenerative mitral regurgitation. There is paucity of data regarding its use in functional mitral regurgitation (FMR). The objective of this study was to evaluate the use of MitraClip in patients with symptomatic moderate or severe FMR and a high surgical risk. Medical libraries were systematically searched for studies assessing the use of MitraClip for patients with symptomatic moderate or severe FMR and a high surgical risk. Studies reporting safety and efficacy outcomes at 12 months were included in the analysis. A total of 12 studies including 1,695 patients (age 73 [interquartile range [IQR] 70.5 to 74], 69.8% men, left ventricular ejection fraction 32.5% [IQR 29.5 to 36], New York Heart Association class II to IV) who underwent TMVr with MitraClip were included in the analysis. Acute procedural success was 89% (IQR 85.5 to 92). Ischemic cardiomyopathy was the most common cause of left ventricular dysfunction. Over 2/3 of patients had known coronary artery disease, 35% a previous myocardial infarction, and 38.5% had a previous cardiac surgery. Survival to hospital discharge was 98% (IQR 97 to 100) and 30-day survival 97% (IQR 96 to 98). Overall survival at 12 months was 82% (IQR 77 to 87). Mitral valve re-intervention at 12 months was infrequent (3%; IQR 2 to 6.5). In conclusion, our pooled analysis suggests that TMVr with MitraClip is feasible, safe, and carries a low rate of mitral valve re-intervention at 12 months in patients with symptomatic moderate or severe FMR and a high surgical risk.

Objective Evaluate the use of mechanical circulatory support (MCS) devices in high-risk patients undergoing transcatheter aortic valve replacement (TAVR). Background The use of MCS devices in elderly patients with multiple comorbidities undergoing TAVR is underexplored. Methods All patients undergoing TAVR at a single tertiary academic center who required MCS during index procedure between 2008 and 2015 were included in a prospective database. Results MCS was used in 9.4% (54/577) of all TAVRs (n = 52 Edwards Sapien and n = 2 CoreValves) of which 68.5% (n = 37) were used as part of a planned strategy, and 31.5% (n = 17) were used in emergency "bail-out" situations. IABP was the most commonly used device (87%) followed by Impella and ECMO (6% each). Among the MCS group, 22% required cardiopulmonary resuscitation during the procedure (n = 4 elective [11%] vs. n = 8 emergent [47%]) and 15% upgrade to a second device (Impella or CPB after IABP; n = 5 elective [14%] vs. n = 3 emergent [18%]). Median duration of support was 1-day. Device related complications were low (4%). In-hospital mortality in this extremely high-risk population was 24% (13/54) (11% [4/37] for elective cases and 53% [9/17] for emergency cases). Cardiogenic shock (50%) was the most common cause of in-hospital death. Cumulative all-cause 1-year mortality was 35% (19/54) (19% 97/370 for elective and 71% [12/17] for emergency cases). Conclusion Emergent use of MCS during TAVR in extremely high-risk population is associated with high short and long-term mortality rates. Early identification of patients at risk for hemodynamic compromise may rationalize elective utilization of MCS during TAVR.

Cryoballoon vs. Radiofrequency AF AblationIntroduction Radiofrequency (RF) and cryoballoon (CB) catheter ablation are effective for pulmonary vein isolation (PVI) in atrial fibrillation (AF). This report presents an updated meta-analysis comparing the efficacy and safety of CB versus RF ablations in AF. Methods Databases and conference abstracts were systematically searched for studies that directly compared CB and RF PVI, and reported safety or efficacy outcomes in follow-up ≥12 months. Recurrent atrial tachyarrhythmias (AT) were defined as AF, atrial flutter, or atrial tachycardia. Results Twenty-two studies and 8,668 patients were included. Freedom from AT was not significantly different between CB and RF ablations in the pooled population (OR 1.12; 95%CI 0.97–1.29; P = 0.13) and in randomized trials (OR 1.0; 95%CI 0.65–1.56; P = 0.99). Second-generation CB (CB2; 78.1%) and contact-force (CF) sensing RF (78.2%) have improved procedure success rate as compared to first-generation technology (57.9% CB, 58.1% RF). As compared to CF-RF, CB2 demonstrated similar freedom from recurrent AT (OR 1.04; 95%CI 0.71–1.51; P = 0.84). The incidence of pericardial effusions (OR 0.44; 95%CI 0.28–0.69; P < 0.01), tamponade (OR 0.31; 95%CI 0.15–0.64; P < 0.01), and non-AF AT (OR 0.46; 95%CI 0.26–0.83; P < 0.01) were significantly lower with CB ablation, whereas transient phrenic nerve palsy was more incident after CB (OR 7.40; 95%CI 2.56–21.34; P < 0.01). Conclusion There was comparable freedom from AT between CB and RF in patients with AF undergoing PVI. Additionally, freedom from AT was similar between CB2 and CF-RF. However, CB was associated with a lower incidence of pericardial effusions or tamponade, albeit with a higher rate of transient phrenic nerve palsies.

Advanced liver disease is a risk factor for cardiac surgery. However, liver dysfunction is not included in cardiac risk assessment models. We sought to identify trends in utilization, complications, and outcomes of patients with cirrhosis who underwent coronary artery bypass graft surgery (CABG). Using the National Inpatient Sample database, we identified patients with cirrhosis who underwent CABG from 2002 to 2014. Propensity-score matching was used to identify differences in in-hospital mortality and postoperative complications in cirrhosis and noncirrhosis patients. We identified a total of 698,799 CABG admissions of which 2,231 (0.3%) had cirrhosis (mean age 63.6 ± 9.6 years, 74% men, 63% white, mean Charlson co-morbidity index 3.3 ± 1.8). Cardiopulmonary bypass was used in 71% of patients. Mean length of stay was 13.7 ± 11.4 days and hospitalization cost $67,744.6 ± 58,320.4. One or more complications occurred in 44% of cases. After propensity-score matching, patients with cirrhosis had a higher rate of complications (43.9% vs 38.93%; p < 0.001) and in-hospital mortality (7.2% vs 4.07%; p < 0.001) than noncirrhosis patients. On multivariate analysis, cirrhosis and ascites were associated with increased in-hospital mortality (odds ratio 2.87; 95% confidence intervals 2.37 to 3.48) and postoperative complications (odds ratio 5.11; 95% confidence intervals 3.88 to 6.72). In conclusion, patients with cirrhosis constitute a small portion of patients who underwent CABG in the United States but have a higher rate of complications and in-hospital mortality compared with noncirrhosis patients. In-hospital mortality remains high for this subset of patients but has decreased in recent years.

The goal of this review is to discuss the effects of Impella (Abiomed, Danvers, MA), to support in the hemodynamics of patients with severe aortic stenosis, and to explore the clinical scenarios in which the use of Impella may be beneficial in this setting. The management of patients with severe aortic stenosis who go on to develop left ventricular failure and cardiogenic shock remains an important clinical challenge associated with increased morbidity and mortality. Once considered a relative contraindication, the use of Impella in severe aortic stenosis has now been proven feasible and demonstrated promising results in selected high-risk patients. The use of Impella to provide hemodynamic support maybe considered in patients with aortic stenosis in cardiogenic shock or those with severe left ventricular dysfunction and CAD who require high-risk PCI and or balloon aortic valvuloplasty. Impella is also an attractive option in selected cases of hemodynamic collapse during TAVR.

Mitral regurgitation (MR) is the most common valvular disorder and its prevalence is increasing in the aging population. MR is classically managed surgically or conservatively depending on its etiology and patient characteristics, however severe comorbidities preclude surgery in up to 50% of patients with severe MR (1). The development and widespread acceptance of transcatheter aortic valve replacement for patients with severe aortic stenosis over the past two decades has created a paradigm shift in the management of valvular heart disease.

Introduction: Limited research has explored heart transplantation (HT) outcomes in patients with sex-mismatched organ donors and recipients. Findings on which type of sex-mismatch has worse post-transplant outcomes have been contradictory. Methods: We searched Medline, Embase, Scopus and Cochrane for publications reporting HT outcomes according to donor/recipient sex mismatch through May 2017. Sex mismatched HT male recipients were compared to non-mismatched male recipients, and sex mismatched HT female recipients were compared to non-mismatched female recipients. Outcomes were compared under the random-effects model and heterogeneity examined via Chi 2 and I 2 statistics. Sensitivity analyses were performed. Results: A total of 8 studies including 110211 patients were included in the analysis. Of these, 80% were male recipients and 29% had sex-mismatched transplants. In male recipients, sex mismatch was associated with a higher rate of rejection (OR 1.25; 95% CI 1.19-1.32; p Conclusions: Our analysis suggests that sex-mismatch in HT may affect the incidence of rejection without necessarily having clear impact on mortality. Sex-mismatch in HT remains an area in need of investigation and further studies are needed to determine if sex-mismatch truly influences HT outcomes.

Continuous-flow left ventricular assist devices (CF-LVADs) decrease mortality and improve quality of life in patients with advanced heart failure (HF). Their widespread utilization has led to concerns regarding increased adverse effects, especially in women. Nevertheless, sex-specific data remain limited. We searched Medline, Embase, Scopus, and the Cochrane Library for publications reporting sex-specific outcomes after CF-LVADs from January 2008 through January 2017. Outcomes were compared under the random-effects model and heterogeneity examined via χ test and I statistics. A total of 10 studies including 4,493 CF-LVAD recipients were included in the analysis (23.5% women). The overall rate of stroke was significantly higher in women (odds ratio [OR] 1.94; 95% confidence interval [CI] 1.32-2.84; p = 0.0007). This was true for ischemic strokes (OR 2.03; 95% CI 1.21-3.42; p = 0.008) and hemorrhagic strokes (OR 2.03; 95% CI 1.21-3.42; p = 0.008). Women were also more likely to develop right HF necessitating right ventricular assist device (RVAD) implantation (OR 2.12; 95% CI 1.08-4.15; p = 0.03). Other adverse events including renal failure, bleeding, and device-related infection were comparable for both genders. The overall mortality while on CF-LVAD was similar in both groups (OR 1.05; 95% CI 0.81-1.36; p = 0.71). Our analysis suggests that women are at greater risk of significant complications such as cerebrovascular events and right HF necessitating RVAD after CF-LVAD implantation. Further research is needed to better understand the mechanisms underlying these sex-specific outcome disparities.

Native heart endomyocardial biopsy (NH-EMB) is an infrequently performed procedure. The objective of this study is to describe utilization trends, indications, and complications associated with NH-EMB in the United States and compare them with transplanted heart endomyocardial biopsy (TH-EMB). Using the Healthcare Cost and Utilization Project National Inpatient Sample database, we identified 71,105 adult patients undergoing EMB in the inpatient setting in participating hospitals from 2002 to 2014. A total of 20,770 (29%) were performed on NHs (mean age 52.2 ± 15.3, 61% men). Approximately half of patients were white and mean Charlson co-morbidity index was 1.97 ± 1.6. Common indications for NH-EMB included a suspected primary cardiomyopathy (disorder confined to the myocardium), heart failure without cardiogenic shock, and acute myocarditis. Less common indications included heart failure with cardiogenic shock, unexplained heart failure with ventricular tachycardia or high-degree atrioventricular block, and cardiac neoplasms. Complications included pericardial effusion (3.8%), third-degree atrioventricular block (2.7%), vascular complications (1.9%), and deep venous thrombosis (3.5%), in others. Predictors of complications included presence of a cardiac malignant neoplasm, use of hemodynamic support, heart failure with ventricular tachyarrhythmias, and female gender. Compared with NH-EMB, TH-EMB was associated with lower rates of pericardial effusion, third-degree atrioventricular block, ventricular tachyarrhythmias requiring cardioversion, and higher rates of deep venous thrombosis, infections, and pneumothorax. NH-EMB utilization is low in the United States and constitutes less than 1/3 of all EMBs performed.

A 32-year-old man presented with a 10-day history of fever, chills, nausea, vomiting, myalgia, nonproductive cough, and worsening dyspnea after freshwater swimming in the Caribbean 1 week prior to presentation. Shortly after arrival at the hospital, the patient developed severe respiratory distress with massive hemoptysis. Based on serologic workup, he was diagnosed with leptospirosis pulmonary hemorrhage syndrome leading to diffuse alveolar hemorrhage, severe hypoxemic respiratory failure, and multiorgan failure. He received appropriate antibiotic coverage along with hemodynamic support with norepinephrine and vasopressin, mechanical ventilation, and renal replacement therapy in an intensive care unit. Introduction of extracorporeal membrane oxygenation was initiated to provide lung-protective ventilation supporting the recovery of his pulmonary function. Aminocaproic acid was used to stop and prevent further alveolar hemorrhage. He fully recovered thereafter; however, it is uncertain whether it was the use of aminocaproic acid that led to the resolution of his disease.

We present the case of a 27-year-old male presenting with sudden-onset retrosternal chest pain, dyspnea, and cardiac tamponade due to erosion of an Amplatzer Atrial Septal Occluder (ASO) through the left atrial wall 4 years after placement. Emergent surgical management of the hemopericardium, followed by surgical removal of the device, repair of the left atrial wall perforation, and patch closure of the atrial septal defect (ASD) were performed successfully. Tissue erosion leading to hemopericardium and cardiac tamponade should be suspected in subjects with a history of transcatheter ASD closure who present with acute chest pain or dyspnea and signs of hemodynamic instability © 2015 Wiley Periodicals, Inc.

Evaluate the use of mechanical circulatory support (MCS) devices in high-risk patients undergoing transcatheter aortic valve replacement (TAVR).The use of MCS devices in elderly patients with multiple comorbidities undergoing TAVR is underexplored.All patients undergoing TAVR at a single tertiary academic center who required MCS during index procedure between 2008 and 2015 were included in a prospective database.MCS was used in 9.4% (54/577) of all TAVRs (n = 52 Edwards Sapien and n = 2 CoreValves) of which 68.5% (n = 37) were used as part of a planned strategy, and 31.5% (n = 17) were used in emergency "bail-out" situations. IABP was the most commonly used device (87%) followed by Impella and ECMO (6% each). Among the MCS group, 22% required cardiopulmonary resuscitation during the procedure (n = 4 elective [11%] vs. n = 8 emergent [47%]) and 15% upgrade to a second device (Impella or CPB after IABP; n = 5 elective [14%] vs. n = 3 emergent [18%]). Median duration of support was 1-day. Device related complications were low (4%). In-hospital mortality in this extremely high-risk population was 24% (13/54) (11% [4/37] for elective cases and 53% [9/17] for emergency cases). Cardiogenic shock (50%) was the most common cause of in-hospital death. Cumulative all-cause 1-year mortality was 35% (19/54) (19% 97/370 for elective and 71% [12/17] for emergency cases).Emergent use of MCS during TAVR in extremely high-risk population is associated with high short and long-term mortality rates. Early identification of patients at risk for hemodynamic compromise may rationalize elective utilization of MCS during TAVR.

Background: Safety outcomes of percutaneous epicardial ventricular tachycardia (VT) ablations vary widely in the literature. This is likely related to small sample sizes and heterogeneous patient and substrate characteristics between different studies. We aimed to perform a systematic review of

Background: Dilated cardiomyopathy (DCM) is the most common cause of heart failure in the young, and is familial in at least 1/3 of cases. Autosomal dominant mutations in RNA-binding motif protein 20 (RBM20), located on chromosome 10, account for ∼3% of DCM. RBM20 is a cardiac-enriched RNA binding

The MitraClip percutaneous mitral valve repair system is evolving as a minimally invasive technique to repair mitral valve regurgitation in high risk patients. There is very limited data to guide physicians regarding the appropriate approach following unsuccessful mitral valve clipping, whether