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Background Although the published literature has reported an inverse association between hospital volume and outcomes of coronary interventions, sparse data are available for percutaneous peripheral atherectomy (PPA). The aim of our study was to examine the effect of hospital volume on outcomes of PPA. Methods Using the Nationwide Inpatient Sample (NIS) database of the year 2012, PPA with ICD-9 code of 17.56 was identified. The primary outcomes were mortality and amputation rates; secondary outcomes were peri-procedural complications, cost, and length of hospitalization and discharge disposition of the patient. Multivariate models were generated for predictors of the outcomes. Results We identified a total of 21,015 patients with mean age of 69.53 years, with 56% males. Higher hospital volume centers were associated with a significantly lower mortality (OR 0.42, 95% CI 0.30–0.57, p Conclusion Hospital procedure volume is an independent predictor of mortality, amputation rates, complications, LOS, and costs in patients undergoing PPA with an inverse relationship.

PURPOSE: Obstructive sleep apnea hypopnea syndrome (OSAHS) is highly prevalent in patients undergoing coronary artery bypass surgery (CABG). OSAHS is a risk factor for the development of atrial fibrillation (AF) but the risk of AF in patients who are high-risk for OSAHS is unclear. METHODS: A retrospective study was conducted on consecutive patients undergoing CABG from 2013-2015 without AF pre-operatively. Patients were categorized as low-risk for OSAHS, high-risk for OSAHS, or diagnosed OSAHS based on medical records review. All diagnosed OSAHS patients were on active treatment with positive airway pressure. Outcomes assessed were postoperative AF (POAF), postoperative length of stay, re-intubation, in-hospital mortality and cost of hospitalization. RESULTS: Out of 209 eligible patients, 66.5% were low-risk for OSAHS, 18.7% high-risk for OSAHS, and 14.8% diagnosed/treated for OSAHS. POAF developed in 96 patients (45.9%) with greater frequency in high-risk OSAHS patients (69.2% high-risk, 41.9% low-risk, 40.3% diagnosed/treated, p=0.01). In analyses adjusted for age, sex, ethnicity and comorbidities, high-risk for OSAHS was associated with 2.9 greater odds (95% CI [1.2, 7.3], p=0.02) for POAF while diagnosed/treated OSAHS was not associated with elevated risk (OR=1.4, 95% CI [0.6, 3.6], p=0.50) compared to patients at low risk for OSAHS. CONCLUSIONS: High risk for OSAHS is an independent predictor for POAF in patients undergoing CABG. In contrast, patients diagnosed and treated for their OSAHS are not at elevated risk of POAF. These findings support evaluation of a standardized OSAHS screening and treatment program as part of the pre-operative evaluation for elective CABG.

Rationale: Acute kidney injury (AKI) is common during high-risk percutaneous coronary intervention (PCI), particularly in those with severely reduced left ventricular ejection fraction. The impact of partial hemodynamic support with a microaxial percutaneous left ventricular assist device (pLVAD) on renal function after high-risk PCI remains unknown. Objective: We tested the hypothesis that partial hemodynamic support with the Impella 2.5 microaxial pLVAD during high-risk PCI protected against AKI. Methods and Results: In this retrospective, single-center study, we analyzed data from 230 patients (115 consecutive pLVAD-supported and 115 unsupported matched-controls) undergoing high-risk PCI with ejection fraction ≤35%. The primary outcome was incidence of in-hospital AKI according to AKI network criteria. Logistic regression analysis determined the predictors of AKI. Overall, 5.2% (6) of pLVAD-supported patients versus 27.8% (32) of unsupported control patients developed AKI ( P P P P =0.04 and adjusted odds ratio, 0.16; 95% confidence intervals, 0.12–0.28; P Conclusions: Impella 2.5 (pLVAD) support protected against AKI during high-risk PCI. This renal protective effect persisted despite the presence of underlying CKD and decreasing ejection fraction.

Atrial flutter (AFL) ablation has been increasingly offered as first-line therapy and safely performed over the last decades. However, limited data exist regarding current utilization and trends in adverse outcomes arising from this procedure.The aim of our study was to examine the frequency of adverse events attributable to AFL ablation and influence of hospital volume on safety outcomes.Data were obtained from the Nationwide Inpatient Sample, the largest all-payer inpatient dataset in the United States. Patients with AFL who underwent catheter ablation from 2000 to 2011 were identified using ICD-9 codes. In-hospital death and common complications were identified, including cardiac perforation and tamponade, pneumothorax, stroke, transient ischemic attack, and vascular access complications.A total of 89,638 AFL patients were treated with catheter ablation during our study period. Total number of ablations performed increased by 154% from 2000 to 2011. The in-hospital mortality rate was 0.17% and the overall complication rate was 3.17%. Cardiac complications (1.44%) were the most frequent, followed by respiratory (0.88%), vascular (0.78%), and neurological complications (0.05%). Low hospital volume (50 procedures/year) was significantly associated with increased adverse outcomes. Overall frequency of complications per 100 ablation procedures increased from 2.86 in 2000 to 5.39 in 2011 (P.001).The overall complication rate was 3.17% in patients undergoing AFL ablation. There was a significant association between low hospital volume and increased adverse outcomes. This suggests a need for future research into identifying the safety measures in AFL ablations and instituting appropriate interventions to improve overall AFL ablation outcomes.

To assess the trends of inpatient resource use and mortality in pediatric hospitalizations for fever with neutropenia in the US from 2007 to 2014.Using National (Nationwide) Inpatient Sample (NIS) and International Classification of Diseases, Ninth Revision, Clinical Modification codes, we studied pediatric cancer hospitalizations with fever with neutropenia between 2007 and 2014. Using appropriate weights for each NIS discharge, we created national estimates of median cost, length of stay, and in-hospital mortality rates.Between 2007 and 2014, there were 104 315 hospitalizations for pediatric fever with neutropenia. The number of weighted fever with neutropenia hospitalizations increased from 12.9 (2007) to 18.1 (2014) per 100 000 US population. A significant increase in fever with neutropenia hospitalizations trend was seen in the 5- to 14-year age group, male sex, all races, and in Midwest and Western US hospital regions. Overall mortality rate remained low at 0.75%, and the 15- to 19-year age group was at significantly greater risk of mortality (OR 2.23, 95% CI 1.36-3.68, P = .002). Sepsis, pneumonia, meningitis, and mycosis were the comorbidities with greater risk of mortality during fever with neutropenia hospitalizations. Median length of stay (2007: 4 days, 2014: 5 days, P .001) and cost of hospitalization (2007: $8771, 2014: $11 202, P .001) also significantly increased during the study period.Our study provides information regarding inpatient use associated with fever with neutropenia in pediatric hospitalizations. Continued research is needed to develop standardized risk stratification and cost-effective treatment strategies for fever with neutropenia hospitalizations considering increasing costs reported in our study. Future studies also are needed to address the greater observed mortality in adolescents with cancer.

Objectives To compare the utilization and outcomes in patients who had percutaneous coronary interventions (PCIs) performed with intra-aortic balloon pump (IABP) versus percutaneous ventricular assist devices (PVADs) such as Impella and TandemHeart and identify a sub-group of patient population who may derive the most benefit from the use of PVADs over IABP. Background Despite the lack of clear benefit, the use of PVADs has increased substantially in the last decade when compared to IABP. Methods We performed a cross sectional study including using the Nationwide Inpatient Sample. Procedures performed with hemodynamic support were identified through appropriate ICD-9-CM codes. Results We identified 18,094 PCIs performed with hemodynamic support. IABP was the most commonly utilized hemodynamic support device (93%, n = 16, 803) whereas 6% (n = 1069) were performed with PVADs and 1% (n = 222) utilized both IABP and PVAD. Patients in the PVAD group were older in age and had greater burden of co-morbidities whereas IABP group had higher percentage of patients with cardiac arrest. On multivariable analysis, the use of PVAD was a significant predictor of reduced mortality (OR 0.55, 0.36–0.83, P = 0.004). This was particularly evident in sub-group of patients without acute MI or cardiogenic shock. The propensity score matched analysis also showed a significantly lower mortality (9.9% vs 15.1%; OR 0.62, 0.55–0.71, P

High-risk surgical patients undergoing transcatheter aortic valve implantation (TAVI) represent an emerging population, which may benefit from short-term use of mechanical circulatory support (MCS) devices. The aim of this study was to determine the practice and inhospital outcomes of MCS utilization in patients undergoing TAVI. We analyzed data from Nationwide Inpatient Sample (2011 and 2012) using the International Classification of Diseases, Ninth Revision, Clinical Modification procedure codes. A total of 1,794 TAVI procedures (375 hospitals in the United States) were identified of which 190 (10.6%) used an MCS device (MCS group) and 1,604 (89.4%) did not (non-MCS group). The use of MCS devices with TAVI was associated with significant increase in the inhospital mortality (14.9% vs 3.5%, p

We hypothesized that the availability of a transcatheter aortic valve implantation (TAVI) program in hospitals impacts the overall management of patients with aortic valve disease and hence may also improve postprocedural outcomes of conventional surgical aortic valve replacement (SAVR). The aim of the present study was to compare the inhospital outcomes of SAVR in centers with versus without availability of a TAVI program in an unrestricted large nationwide patient population >50 years of age. SAVRs performed on patients aged >50 years were identified from the Nationwide Inpatient Sample (NIS) for the years 2011 and 2012 using the International Classification of Diseases, Ninth Revision, Clinical Modification procedure codes. SAVR cases were divided into 2 categories: those performed at hospitals with a TAVI program (SAVR-TAVI) and those without (SAVR-non-TAVI). A total of 9,674 SAVR procedures were identified: 4,526 (46.79%) in the SAVR-TAVI group and 5,148 (53.21%) in SAVR-non-TAVI group. The mean age of the study population was 70.2 ± 0.1 years with majority (53%) of the patients aged >70 years. The mean Charlson's co-morbidity score for patients in SAVR-TAVI group was greater (greater percentage of patients were aged >80 years, had hypertension, congestive heart failure, renal failure, and peripheral arterial disease) than that of patients in SAVR-non-TAVI group (1.6 vs 1.4, p

Patients with bicuspid aortic valve (BAV) have traditionally been excluded from large randomized clinical trials involving transcatheter aortic valve replacements (TAVR). Technical enhancements, availability of new generation devices and improved outcomes have led to a marked increase in TAVR volume across the world including off label use in patients with BAV stenosis. Areas covered: In this manuscript, we have reviewed the currently available data regarding safety, efficacy, and outcomes of TAVR in patients with BAV stenosis. 11 large observational studies with near 1300 patients with BAV stenosis were included to summarizes outcomes of TAVR. Expert Commentary: The present review suggested that TAVR may be a safe and feasible treatment modality in BAV stenosis patients. New generation devices were associated with high device success rate whereas higher adverse procedural events were observed in early generation devices. There are no differences in post procedural outcomes with new generation TAVR devices for BAV when compared to tricuspid aortic anatomy. Larger studies are needed to evaluate the long-term outcome and durability of TAVR in patients with BAV.

To determine the temporal trends in the epidemiology of acute disseminated encephalomyelitis (ADEM) and hospitalization outcomes in the US from 2006 through 2014.Pediatric (≤18 years of age) hospitalizations with ADEM discharge diagnosis were identified from the National (Nationwide) Inpatient Sample (NIS) for years 2006 through 2014. Trends in the incidence of ADEM with respect to age, sex, race, and region were examined. Outcomes of ADEM in terms of mortality, length of stay (LOS), cost of hospitalization, and seasonal variation were analyzed. NIS includes sampling weight. These weights were used to generate national estimates. P value of .05 was considered significant.Overall incidence of ADEM associated pediatric hospitalizations from 2006 through 2014 was 0.5 per 100 000 population. Between 2006 through 2008 and 2012 through 2014, the incidence of ADEM increased from 0.4 to 0.6 per 100 000 (P-trend.001). Black and Hispanic children had a significantly increased incidence of ADEM during the study period (0.2-0.5 per 100 000 population). There was no sex preponderance and 67% of ADEM hospitalizations were in patients9 years old. From 2006 through 2008 to 2012 through 2014 (1.1%-1.5%; P-trend 0.07) and median LOS (4.8-5.5 days; PIn this large nationwide cohort of ADEM hospitalizations, the incidence of ADEM increased during the study period. Mortality and LOS have remained stable over time, but inflation adjusted cost of hospitalizations increased.

Introduction The incidence and prevalence of peripheral arterial disease (PAD) has been increasing and it accounts for major morbidity and mortality. Although surgical endarterectomy of arterial occlusive disease remains the gold standard for plaque removal, recent advances in percutaneous endovascular interventions have made this option more viable. Recently there has been advancements in the techniques which claim to provide superior results. Ever since the invention of coronary atherectomy device by John Simpson in 1984 [1], there has been innovations in the endovascular intervention at a tremendous pace. Soon, the technology was used in peripheral arteries for revascularization but the results were not satisfactory in the peripheral arterial circulation [2,3]. Numerous studies have been published citing the influence of hospital volume on the outcomes in the various structural heart diseases but not many studies have been out comparing that with PAD [4]. Methods Hospital procedural volume is an important quality metric in regards to outcomes of procedure [4]. This is especially true in non-emergent, more complicated and less commonly performed procedures such as peripheral endovascular interventions [4,5]. The basis hypothesis that higher procedure volume is associated with better experience has formed the crux of the volume outcome relationships for about four decades now. We present an overview of the available literatures that underscores the importance of hospital volume in peripheral angioplasty, atherectomy and endovascular stenting.

Atrial fibrillation (AF) is one of the commonest arrhythmias in clinical practice and has major healthcare and economic implications. It is a growing epidemic with prevalence all set to double to 12 million by 2050. After adjusting for other associated conditions, hypertension confers a 1.5- and 1.4-fold risk of developing AF, for men and women respectively. Furthermore, in patients with AF, the presence of hypertension has a cumulative effect on the risk of stroke. Growing evidence suggests reversal or attenuation of various structural and functional changes predisposing to AF with the use of antihypertensive medications. Randomized trials have shown major reduction in the risk of stroke and heart failure with blood pressure reduction. However, such trials are lacking in AF patients specifically. The Joint National Committee-8 guidelines have not addressed the threshold or goal BP for patients with known AF. Furthermore, "J-shaped" or "U-shaped" curves have been noted during hypertension management in patients with AF with published data demonstrating worse outcomes in patients with strict BP control to

BACKGROUND Since elective transcatheter aortic valve replacements (TAVRs) can be performed on the day of admission, i.e., Day 0, or on the next day of admission, i.e., Day 1, we sought to investigate if there is an advantage to either approach. METHODS We performed a retrospective cohort study, using the Healthcare Cost and Utilization Project's Nationwide Inpatient Sample database of 2012 and identified subjects undergoing endovascular (Transfemoral/Transaortic) TAVRs using the ICD-9-CM procedure code of 35.05. The cohort was divided based on the day of the TAVR performed, i.e., Day 0 or 1. The cost of the hospitalization and length of stay were the primary outcomes, with in-hospital mortality and procedural complications as the secondary outcomes. We identified a total of 843 TAVRs. Propensity matched models were created. The mean age of the study cohort was 82 years. RESULTS In a propensity-matched dataset, TAVRs performed on Day 0 were associated with a lower cost ($51,126 ± 1184 vs $57,703 ± 1508, p

Hospital volume is regarded amongst many in the medical community as an important quality metric. This is especially true in more complicated and less commonly performed procedures such as structural heart disease interventions. Seminal work on hospital volume relationships was done by Luft et al more than 4 decades ago, when they demonstrated that hospitals performing > 200 surgical procedures a year had 25%-41% lower mortality than those performing fewer procedures. Numerous volume-outcome studies have since been done for varied surgical procedures. An old adage "practice makes perfect" indicating superior operator and institutional experience at higher volume hospitals is believed to primarily contribute to the volume outcome relationship. Compelling evidence from a slew of recent publications has also highlighted the role of hospital volume in predicting superior post-procedural outcomes following structural heart disease interventions. These included transcatheter aortic valve repair, transcatheter mitral valve repair, septal ablation and septal myectomy for hypertrophic obstructive cardiomyopathy, left atrial appendage closure and atrial septal defect/patent foramen ovale closure. This is especially important since these structural heart interventions are relatively complex with evolving technology and a steep learning curve. The benefit was demonstrated both in lower mortality and complications as well as better economics in terms of lower length of stay and hospitalization costs seen at high volume centers. We present an overview of the available literature that underscores the importance of hospital volume in complex structural heart disease interventions.

The incidence and prevalence of peripheral vascular disease has been increasing. When coexistent with coronary artery disease (CAD), it has shown to predict higher mortality along with poorer quality-of-life consequently leading to a marked increase in healthcare costs. Broadly, there has been an increase in utilization of endovascular techniques in the management of peripheral vascular diseases. An inverse relation between volume and outcomes has been noted in these procedures. Additionally, improved resource utilization has also been noted with higher hospital and operator volumes. This has led to proposals to regionalize these procedures to high volume hospitals. There have also been calls to introduce the idea of having a set threshold of procedures for providers. This review presents an overview of published literature on the volume-outcome relationship affecting the outcomes of peripheral endovascular procedures.

To compare the utilization and outcomes in patients who had percutaneous coronary interventions (PCIs) performed with intra-aortic balloon pump (IABP) versus percutaneous ventricular assist devices (PVADs) such as Impella and TandemHeart and identify a sub-group of patient population who may derive the most benefit from the use of PVADs over IABP.Despite the lack of clear benefit, the use of PVADs has increased substantially in the last decade when compared to IABP.We performed a cross sectional study including using the Nationwide Inpatient Sample. Procedures performed with hemodynamic support were identified through appropriate ICD-9-CM codes.We identified 18,094 PCIs performed with hemodynamic support. IABP was the most commonly utilized hemodynamic support device (93%, n = 16, 803) whereas 6% (n = 1069) were performed with PVADs and 1% (n = 222) utilized both IABP and PVAD. Patients in the PVAD group were older in age and had greater burden of co-morbidities whereas IABP group had higher percentage of patients with cardiac arrest. On multivariable analysis, the use of PVAD was a significant predictor of reduced mortality (OR 0.55, 0.36-0.83, P = 0.004). This was particularly evident in sub-group of patients without acute MI or cardiogenic shock. The propensity score matched analysis also showed a significantly lower mortality (9.9% vs 15.1%; OR 0.62, 0.55-0.71, P 0.001) rate associated with PVADs when compared to IABP.This largest and the most contemporary study on the use of hemodynamic support demonstrates significantly reduced mortality with PVADs when compared to IABP in patients undergoing PCI. The results are largely driven by the improved outcomes in non-AMI and non-cardiogenic shock patients.

Introduction: Short-term use of Mechanical Circulatory Support (MCS) has the potential to benefit the patients undergoing Transcatheter Aortic Valve Replacement (TAVR) who may be high-risk or suffer complications. The present study was conducted to address the contemporary use of MCS in TAVR procedures. Methods: The study included a total of 1794 TAVR procedures in the years 2011-2012 from Nationwide Inpatient Sample (NIS) database. Use of MCS was identified using ICD-9-CM codes. The patients were divided based on use of MCS devices. The primary outcome of the study was in-hospital mortality and the secondary outcomes were complications, length of stay (LOS) and cost. Multi-variate simple logistic regression models were used to identify independent predictors of the outcomes. Results: Out of total 1794 TAVR procedures, 190 (10.6 %) utilized a MCS device (MCS group) and 1,604 (89.4%) did not (non-MCS group). The use of MCS devices with TAVR was associated with increase in the in-hospital mortality (14.9% vs. 3.5%, p Conclusion: Use of MCS in TAVR predicts increase in-hospital mortality, complications, LOS and cost of care.

Introduction: The data regarding use of different Mechanical Circulatory Support (MCS) devices in TAVR is limited. The present study was performed to analyze the complications and outcomes of different MCS in TAVR. Methods: The subjects under study were obtained from Nationwide Inpatient Sample (NIS) for the years 2011-12 using ICD-9-CM procedure codes for TAVR and MCS. The use of MCS was divided into Intra-aortic balloon pump (IABP), percutaneous ventricular assist devices (PVADs) including Impella and TandemHeart, Extracorporeal membrane oxygenation (ECMO) and percutaneous cardiopulmonary support and cardiopulmonary bypass (CBP) using ICD-9-CM codes. The incidence of in-hospital mortality and occurrence of procedure related complications were analyzed. Results: Out of total 1794 TAVR procedures, MCS was utilized in 190 (10.6%) procedures. CBP was the most commonly utilized 136 (71.6%) followed by IABP 36 (18.9%), ECMO 14 (7.4%) and 4 (2.1%). In-hospital mortality was highest with use of IABP (36.6%), followed by ECMO (14.3%), CBP (9.6%) and PVAD (0%) with p-value Conclusion: Being retrospective in design, the present study has no information regarding indications and individual patient related variables in which each of the MCS devices used. Overall, CBP was observed as the most extensive used MCS modality with less mortality (9.6%) and least complications (59.4%).

Background: There is lack of data regarding impact of atherectomy on the length of stay (LOS) and cost of hospitalization in lower extremity arterial revascularization. Methods: HCUP’s Nationwide Inpatient Sample (NIS) 2012 was queried using the ICD-9- CM code for peripheral vascular disease and procedural codes 39.90 (bare metal stent - BMS), 00.55 (drug eluting stent - DES), 17.56 (peripheral atherectomy) and 39.50 for angioplasty. Only procedures performed in patients ≥18 years of age were included. Hierarchical mixed effects linear regression models were generated to evaluate multivariate predictors of LOS and hospitalization costs. Results: A total of 13,206 (weighted: 66,030) lower extremity arterial revascularizations were identified (43.8% female & 65.5% white). Out of these, atherectomy was utilized in 23.2%. Atherectomy utilization was associated with significant reduction in LOS (4.96 ± 0.11 days vs. 5.78 ± 0.07 days, p Conclusion: Our study demonstrates that atherectomy utilization is associated with significant reduction in length of stay, which was counterbalanced by a slight increase in hospitalization costs following lower extremity arterial revascularization.

Background: Contemporary outcome data regarding effects of atherectomy in lower extremity arterial revascularization is lacking. Methods: We queried HCUP’s Nationwide Inpatient Sample (NIS) for 2012 using the appropriate primary ICD 9-CM diagnostic code for peripheral vascular disease and procedural codes 39.90 (bare metal stent - BMS), 00.55 (drug eluting stent - DES), 17.56 (peripheral artherectomy) and 39.50 for angioplasty. Only procedures performed in patients >= 18 years were included. Hierarchical mixed effects logistic regression models were generated to evaluate multivariate predictors of outcomes. Results: In total 13,206 (weighted: 66,030) lower extremity arterial revascularization were analyzed (65.5% white, 56.2% Male & 97.4% angioplasty). Atherectomy utilization (23.2%) was associated with significant reduction in amputation (11.5% vs 13.4%), any complications (13.2% vs 16.3%) and in hospital morality (0.8% vs 1.4%) compared to no atherectomy group (p < 0.001). Multivariate analysis showed similar results with decrease amputation (OR, 95% CI; p - value) (0.83, 0.71 - 0.97, p = 0.02) and in hospital mortality/any complication (0.79, 0.69 - 0.90, p = 0.001) with atherectomy (similar results were observed with propensity score matching). “Atherectomy only” was utilized only in 2.3%. post-hoc analysis also shows better outcomes when atherectomy was used with either angioplasty or stenting (figure a & b). subgroup multivariate analysis shows significant reduction in amputation when atherectomy was utilized in chronic limb ischemia (0.74, 0.59 - 0.93, p = 0.01) and with angioplasty (0.72, 0.60 - 0.87, p = 0.001) and trend towards advantage while used along with stents but not reaching statistical significant. Conclusion: Lower extremity atherectomy utilization was associated with significant reduction in amputation and overall complication. We observed better outcomes when atherectomy was used in conjunction with angioplasty.

Contemporary data on clinical outcomes after utilization of atherectomy in lower extremity endovascular revascularization are sparse. The study cohort was derived from Healthcare Cost and Utilization Project nationwide inpatient sample database from the year 2012. Peripheral endovascular interventions including atherectomy were identified using appropriate International Classification of Diseases, Ninth Revision, Clinical Modification diagnostic and procedural codes. The subjects were divided and compared in 2 groups: atherectomy versus no atherectomy. Two-level hierarchical multivariate mixed models were created. The coprimary outcomes were in-hospital mortality and amputation; secondary outcome was a composite of in-hospital mortality and periprocedural complications. Hospitalization costs were also assessed. Atherectomy utilization (odds ratio, 95% CI, p value) was independently predictive of lower in-hospital mortality (0.46, 0.28 to 0.75, 0.002) and lower amputation rates (0.83, 0.71 to 0.97, 0.020). Atherectomy use was also predictive of significantly lower secondary composite outcome of in-hospital mortality and complications (0.79, 0.69 to 0.90, 0.001). In the propensity-matched cohort, atherectomy utilization was again associated with a lower rate of amputation (11.18% vs 12.92%, p = 0.029), in-hospital mortality (0.71% vs 1.53%, p 0.001), and any complication (13.24% vs 16.09%, p 0.001). However, atherectomy use was also associated with higher costs ($24,790 ± 397 vs $22635 ± 251, p

Contemporary real-world data on clinical outcomes after utilization of coronary atherectomy are sparse. The study cohort was derived from Healthcare Cost and Utilization Project Nationwide Inpatient Sample database from year 2012. Percutaneous coronary interventions including atherectomy were identified using appropriate International Classification of Diseases, 9th Revision diagnostic and procedural codes. Two-level hierarchical multivariate mixed models were created. The primary outcome was a composite of in-hospital mortality and periprocedural complications; the secondary outcome was in-hospital mortality. Hospitalization costs were also assessed. A total of 107,131 procedures were identified in 2012. Multivariate analysis revealed that atherectomy utilization was independently predictive of greater primary composite outcome of in-hospital mortality and complications (odds ratio 1.34, 95% confidence interval 1.22 to 1.47, p

Our primary objective was to study postprocedural outcomes and hospitalization costs after peripheral endovascular interventions and the multivariate predictors affecting the outcomes with emphasis on hospital volume. The study cohort was derived from Healthcare Cost and Utilization Project Nationwide Inpatient Sample database (2006 to 2011). Peripheral endovascular interventions were identified using appropriate International Classification of Diseases, Ninth Revision diagnostic and procedural codes. Annual institutional volumes were calculated using unique identification numbers and then divided into quartiles. Two-level hierarchical multivariate mixed models were created. The primary outcome was inhospital mortality; secondary outcome was a composite of inhospital mortality and postprocedural complications. Amputation rates and hospitalization costs were also assessed. Multivariate analysis (odds ratio, 95% confidence interval, p value) revealed age (1.46, 1.37 to 1.55, p0.001), female gender (1.28, 1.12 to 1.46, p0.001), baseline co-morbidity status as depicted by a greater Charlson co-morbidity index score (≥2: 4.32, 3.45 to 5.40, p0.001), emergent or urgent admissions(2.48, 2.14 to 2.88, p0.001), and weekend admissions (1.53, 1.26 to 1.86, p0.001) to be significant predictors of primary outcome. An increasing hospital volume quartile was independently predictive of improved primary (0.65, 0.52 to 0.82, p0.001 for the fourth quartile) and secondary (0.85, 0.73 to 0.97, 0.02 for the fourth quartile) outcomes and lower amputation rates (0.52, 0.45 to 0.61, p0.001). A significant reduction hospitalization costs ($-3,889, -5,318 to -2,459, p0.001) was also seen in high volume centers. In conclusion, a greater hospital procedural volume is associated with superior outcomes after peripheral endovascular interventions in terms of inhospital mortality, complications, and hospitalization costs.

Transcatheter aortic valve implantation (TAVI) is associated with a significant learning curve. There is paucity of data regarding the effect of hospital volume on outcomes after TAVI. This is a cross-sectional study based on Healthcare Cost and Utilization Project's Nationwide Inpatient Sample database of 2012. Subjects were identified by International Classification of Diseases, Ninth Revision, Clinical Modification procedure codes, 35.05 (Trans-femoral/Trans-aortic Replacement of Aortic Valve) and 35.06 (Trans-apical Replacement of Aortic Valve). Annual hospital TAVI volumes were calculated using unique identification numbers and then divided into quartiles. Multivariate logistic regression models were created. The primary outcome was inhospital mortality; secondary outcome was a composite of inhospital mortality and periprocedural complications. Length of stay (LOS) and cost of hospitalization were assessed. The study included 1,481 TAVIs (weighted n = 7,405). Overall inhospital mortality rate was 5.1%, postprocedural complication rate was 43.4%, median LOS was 6 days, and median cost of hospitalization was $51,975. Inhospital mortality rates decreased with increasing hospital TAVI volume with a rate of 6.4% for lowest volume hospitals (first quartile), 5.9% (second quartile), 5.2% (third quartile), and 2.8% for the highest volume TAVI hospitals (fourth quartile). Complication rates were significantly higher in hospitals with the lowest volume quartile (48.5%) compared to hospitals in the second (44.2%), third (39.7%), and fourth (41.5%) quartiles (p0.001). Increasing hospital volume was independently predictive of shorter LOS and lower hospitalization costs. In conclusion, higher annual hospital volumes are significantly predictive of reduced postprocedural mortality, complications, shorter LOS, and lower hospitalization costs after TAVI.

Background: Laparoscopic treatment of acutely incarcerated inguinal hernia is uncommon and still controversial. Those being performed almost all use the transabdominal (TAPP) approach. The authors here present their experience with totally extraperitoneal (TEP) repair of acutely incarcerated hernia. Methods: A retrospective review was undertaken to evaluate the authors’ experience with this procedure over a 4-year period. There were 16 cases, 5 of which were performed using a conventional anterior repair. These 5 cases were excluded from the review. The surgery for all of the remaining 11 acutely incarcerated hernias was started laparoscopically using the TEP approach. Eight of the cases were completed this way, whereas three were converted to the open procedure. In addition to standard TEP repair techniques, a releasing incision is required for acutely incarcerated direct, indirect, or femoral hernias. With a direct hernia, the opening of the defect is enlarged to allow safe dissection of its contents. A releasing incision is made at the anteromedial aspect of the defect to avoid injury to the epigastric or iliac vessels. With an indirect hernia, several additional steps are required. The epigastric vessels may be divided; an additional trocar may be placed laterally below the linea semicircularis to facilitate dissection of the sac and to assist with suturing of the divided sac; and the deep internal ring is divided anteriorly at the 12 o’clock position toward the external ring, facilitating dissection of the indirect sac. With a femoral hernia, a releasing incision is made by carefully incising the insertion of the iliopubic tract into Cooper’s ligament at the medial portion of the femoral ring. Results: The mean operative time was 50 min (range, 20–120 min), and the length of hospital stay was 5.4 days (range, 1–29 days). During a follow-up period of 9 to 69 months, there was no recurrence, and only two complications. One of these complications was an infected mesh that occurred in a case involving cecal injury. It was treated with continuous irrigation and salvaged. The other complication was a midline wound infection after a small bowel resection for a strangulated obturator hernia. Conclusions: Familiarity with the anatomy involved leads to the conclusion that the laparoscopic approach, specifically the TEP procedure, can be used without hesitation even in cases of acutely incarcerated hernia.

In experienced hands, laparoscopic inguinal hernia repair has a low rate of recurrence, but it still can recur, and a number of reasons for this have been identified. In published studies, the majority of such cases seem to result from inadequate dissection leading to missed hernias or suboptimal mesh placement. But even with adequate dissection and proper placement of a sufficiently large mesh, recurrence sometimes happens. A number of investigators have cited mesh migration or dislocation as a possible cause, and this study examined how hip flexion affects the position of newly placed meshes and staples in totally extraperitoneal (TEP) repair of inguinal hernia.After completion of the dissection and reduction of discovered hernias, a 15 x 15-cm polypropylene mesh was placed either unilaterally or bilaterally, as indicated. The preperitoneal space then was desufflated. The operating table, in an extended -20 degrees position during surgery, was placed in a 90 degrees position for approximately 15 s. After reinsufflation, the possibility of mesh migration and folding was investigated. Finally, the mesh was stapled, the table again extended and flexed, and the possibility of mesh migration and staple dislodgement investigated once more.The mesh did not migrate or become displaced from any potential hernia area, nor did any of the staples become dislodged.Concern about mesh migration attributable to patients sitting up immediately after surgery appears to be unfounded, at least according to the findings for the current, small, simulated study group.

Background The intraoperative quick parathyroid hormone assay, the intraoperative gamma probe, and endoscopic parathyroidectomy are three very new techniques developed to facilitate parathyroid surgery. Some hospitals do not have the necessary equipment, and many, like ours, continue to operate in the time-honored way. Study design We performed a retrospective chart review of 34 such operations, done with the use of Sestamibi scans, but entirely without the newer modalities. Results Four-gland exploration was carried out on all patients. Operative times ranged from 15 to 165 minutes, with a mean of 47 minutes, and incision lengths ranged from 2 to 3 cm, with a mean of 2.8 cm. There was no mortality, no reoperation, and no vocal cord or recurrent laryngeal nerve injury. Our cure rate was 100%, as determined by a fall in postoperative calcium and parathormone levels. Conclusions In our view, the intraoperative parathyroid hormone assay, gamma probe, and endoscopic parathyroidectomy add an entirely unnecessary cost to an operation that can be completed satisfactorily with a preoperative Sestamibi scan and a thorough four-gland exploration.

There are only scant published reports of totally extraperitoneal (TEP) repair of recurrence after a primary TEP procedure. Furthermore, at least two authors have made the statement that such an operation is virtually impossible. We have been performing TEP repair of recurrence after TEP since we 1996, and here we present a retrospective review of our experience with the procedure. We employ a method not varying greatly from the standard TEP done for primary hernia. All cases were started laparoscopically, and only one of 20 had to be converted to open. Of these cases, 12 were for same-side recurrence and eight for a contralateral new hernia. With a follow-up of 28–74 months, there have been no fatalities, no complications, and no re-recurrence. We have found that TEP repair of recurrent inguinal hernia after a primary TEP repair is entirely feasible technically as well as entirely safe.

SESSION TITLE: Cardiothoracic SurgerySESSION TYPE: Original Investigation PosterPRESENTED ON: Wednesday, October 26, 2016 at 01:30 PM - 02:30 PMPURPOSE: There has been an increasing incidence of Obstructive Sleep Apnea (OSA) with increasing obesity. Previous studies shown that OSA increases health c

Purpose Because most surgery patients now recover at home rather than in the hospital, we wanted to determine whether postoperative home visits by the operating surgeon would improve medical outcomes, and whether this innovation would strengthen resident training. Methods A surgeon who had performed 347 procedures during a 7-month period attempted to do a home visit to each patient within 48 hours after surgery. Results Many patients had to be disqualified for various reasons, leaving 143 candidates. Of these, 44 declined to be seen, and others could not be located, so that 82 were actually visited. There were no readmissions, and no findings that might have altered the course of postoperative treatment. Conclusions These visits seemed to reinforce patient–physician relationships, but they did not influence medical outcomes. It was felt that a phone call would probably have done as well. In addition, because of new regulations governing resident working hours, it did not appear that this was a feasible educational experience.

One distinct advantage of the 1aparoscopic inguinal hernia repair is the opportunity for clear visualization of the direct, indirect, femoral, and obturator spaces. The surgeon should routinely inspect all of them. Obturator hernia accounts for as few as 0.073% of all hernias, but the mortality rate when it is acutely incarcerated can be as high as 70%. There is only one previous report of a totally extraperitoneal repair for obturator hernia. Five such procedures are described.A retrospective review was undertaken to evaluate one surgeon's experience with the totally extraperitoneal repair of obturator hernia over a 4-year period. Four of five cases were completed, and the remaining case was converted to an open procedure.Three hernias were on the right side, and two on the left. One patient presented with an acutely incarcerated obturator hernia and underwent a small bowel resection for strangulated bowel within the obturator space. The other four hernias were found during totally extraperitoneal repair, and the patients were discharged home several hours later. There was one complication, a midline wound infection in the patient with strangulated bowel. It was treated with dressing changes. There were no other complications, and during a follow-up period of 3 to 48 months, there was no recurrence.The laparoscopic totally extraperitoneal approach allows inspection and repair of direct, indirect, femoral, and obturator hernias. This study found this procedure to be feasible, safe, and highly effective for the diagnosis and repair of obturator hernias.

Background: To be certified for laparoscopic placement of adjustable gastric banding, surgeons must have advanced laparoscopic experience. Despite previous exposure to other kinds of laparoscopy, there may a learning curve specific to Lap-Band placement. Methods: Sixty consecutive patients were prospectively separated into two groups: the first 30 patients operated on (group 1) and the second 30 patients operated on (group 2). Results: Both groups were similar statistically in regard to gender, age, and body mass index. Operative time for group 1 was 79 ± 31.1 min. There were 11 (37%) complications in 10 patients. Operative time for group 2 was 59 ± 19.9 min. There were two complications (7%). All operations were completed laparoscopically. Operative time was significantly lower in group 2 (t-test; p = 004). Complications were also significantly lower (chi-square; p = 0.005). The number of reoperations was also reduced and approached statistical significance (chi-square; p = 0.054). Readmissions, although reduced, were not statistically significant. There were no deaths in either group. Conclusions: Despite a surgeon’s history of advanced laparoscopic experience, there is a definite learning curve associated with the laparoscopically placed adjustable gastric band.

Atrial fibrillation (AF) is the most common type of sustained arrhythmia, which is now on course to reach epidemic proportions in the elderly population. AF is a commonly encountered comorbidity in patients with cardiac and major non-cardiac diseases. Morbidity and mortality associated with AF makes it a major healthcare burden. The objective of our article is to determine the prognostic impact of AF on acute coronary syndromes, heart failure and chronic kidney disease. Multiple studies have been conducted to determine if AF has an independent role in the overall mortality of such patients. Our review suggests that AF has an independent adverse prognostic impact on the clinical outcomes of acute coronary syndromes, heart failure and chronic kidney disease.