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Subclinical leaflet thrombosis (SLT) is a potentially serious complication of aortic valve replacement with a bioprosthetic valve in which blood clots form on the replacement valve. SLT is associated with increased risk of transient ischemic attacks and strokes and can progress to clinical leaflet thrombosis. SLT following aortic valve replacement also may be related to subsequent structural valve deterioration, which can impair the durability of the valve replacement. Because of the difficulty in clinical imaging of SLT, models are needed to determine the mechanisms of SLT and could eventually predict which patients will develop SLT. To this end, we develop methods to simulate leaflet thrombosis that combine fluid-structure interaction and a simplified thrombosis model that allows for deposition along the moving leaflets. Additionally, this model can be adapted to model deposition or absorption along other moving boundaries. We present convergence results and quantify the model's ability to realize changes in valve opening and pressures. These new approaches are an important advancement in our tools for modeling thrombosis because they incorporate both adhesion to the surface of the moving leaflets and feedback to the fluid-structure interaction.

Background: In September 2022, UNC Hospitals was awarded a Regional Emerging Special Pathogens Treatment Center (RESPTC) grant by the U.S. Department of Health and Human Services Administration for Strategic Preparedness and Response (ASPR) to care for up to two patients with viral hemorrhagic fever, or similar pathogen, and up to ten patients with novel respiratory pathogens. Intensive infection prevention efforts and timely multidisciplinary commitment was required to develop the Space, Strategy, Staff, and Stuff needed to care for patients with a special pathogen. Methods: Multiple space needs assessments were undertaken to acquire spaces for the care of patients, simulation training, and a dedicated laboratory. Strategies for developing the response plan required collaboration with hospital executives, nursing leadership, public health leaders, and regional partners. Staff were recruited across various disciplines to join the response team and were provided hands-on skills training which was assessed by post-training surveys. Specialized ‘stuff’ (i.e., PPE, training equipment, and waste management devices) were researched and procured for use by the team. Results: Patient care and dedicated laboratory space was identified within existing infrastructure, and renovation plans were developed to adapt the space for these specialized activities. A waste management plan that benefits the hospital for routine waste and allows for Category A waste management was approved. Fifty-three staff members were recruited from 3 main disciplines (RNs, MDs, Paramedics), and across numerous settings (Medicine Acute Care & ICU, Pediatric ICU & Stepdown, Air Care/Transport, Burn ICU, Surgery Stepdown, Emergency Medicine, Infection Prevention, Infectious Disease) were trained during five 4-hour training sessions, culminating in an exercise involving transporting a rule–out Ebola patient to the hospital’s special pathogens unit. Post-training evaluations demonstrated a very high level of confidence (‘strongly agree’) in staffs’ knowledge about the RESPTC site (92.3%), special pathogens (80.8%), collaboration needed for managing patient care (80.8%), and in their comfort with special PPE donning and doffing (73.1%). Conclusions: Using a systematic approach to develop Space, Strategy, Staff, and Stuff, a large academic hospital readied itself to become a new RESPTC site. Key lessons learned include the importance of a multidisciplinary response team; local, state, and regional coordination for care planning and delivery; and early community partnership development. Logistical infrastructure and waste management challenges continue to require partnership with hospital leadership to optimize workflows and patient care. Holistic decision-making around infrastructure has led to changes that benefit all hospital patients and offer efficiencies to

Background: Inequities in healthcare-associated infections (HAI) incidence and prevention measures are critically important to understand (Chen,2021). While evaluations are beginning to characterize these disparities by infection type (Gettler, 2023), our work expands this by characterizing disparities by prevention strategies. By better understanding how evidence-based prevention strategies are implemented at the patient level, infection preventionists and hospital epidemiologists can better design strategies that provide equitable care to all patients. Methods: Beginning January 2023, gender, race, ethnicity, spoken language, and age group fields were added to daily chlorhexidine gluconate (CHG) treatment and C. difficile test order compliance data captured via electronic medical record. In July 2023, fields on recorded race, ethnicity, and gender were added to well-established foley and vascular access real-time peer audit tools that are used by infection preventionists (IPs). Each prevention strategy variable was summarized by demographic variables and differences in compliance were measured using chi-square tests. Results: 899 vascular audits and 420 foley audits were completed by IPs between July – December 2023. In 2023, there were 114,066 opportunities for CHG Treatment and 1,991 C. difficile test orders. Missing data varied by metric but ranged from 0-60%. Statistically significant differences by race were found in 3 of 8 components (i.e., intact seal, secured catheter and absence of dependent loop) in the foley audit (p < 0 .01) and compliance with C. difficile test ordering (p < 0 .01). No differences in race were found in vascular access audits or CHG treatment. No differences in gender or ethnicity were noted in foley, vascular access audits, CHG treatment compliance, or C. difficile testing. Differences in gender and age were found in CHG treatment compliance (p < 0 .001). Conclusions: By focusing more on patient level process measures rather than only presenting stratified outcomes data, we can identify targeted opportunities for improvement in health equity before our patients develop an HAI. Further evaluations should also focus on assessing the clinical relevance of statistical findings to better inform intervention strategies. Separately, efforts are needed to improve completeness and integrity of demographic data in the electronic medical record.

Background: The National Healthcare Safety Network (NHSN) provides detailed surveillance case definitions for healthcare-associated infections (HAI), including central line-associated bloodstream infections (CLABSI). CLABSI data are used for several purposes, including improving patient safety, value-based purchasing, and comparing hospitals’ performance. Our Infection Prevention (IP) team conducts house-wide HAI surveillance. To ensure that our hospital CLABSI reporting is accurate and that staff are implementing case definitions consistently and systematically, we conducted an internal validation of CLABSI. This undertaking allowed us to identify educational opportunities for IPs and improve surveillance data consistency. Methods: At UNC Hospitals, data on all positive blood cultures collected in the inpatient setting from July 2022 – June 2023 were obtained from electronic medical records. A random number generator was used to select 16 records per quarter. Each record was then randomly assigned to two different IPs (out of 8 total inpatient IPs) for review. Concordance of CLABSI classification was summarized across the two reviews and compared to the initial review. Discordant cases were then reviewed by the Associate IP Director (a certified IP with 15 years of experience) for final adjudication. A summary of findings and discordant cases details were discussed at regular IP educational meetings. Results: From July 2022-June 2023, there were 1658 positive blood cultures collected in the inpatient setting. Of the 64 randomly selected blood cultures, total concordance amongst all reviewers occurred 65.6% of the time. Concordance improved in the 2nd half of FY23 compared to the 1st half (72% vs, 59%, p>0.05). Amongst the 33% of blood culture results with reviewer discrepancy, the most common reasons were related to distinction of a bloodstream infection secondary to another infection site (32%) and application of the repeat infection timeframe (18%). Importantly, there was only one instance where a blood culture result was categorized by all 3 reviewers as present on admission, but upon Associate Director review, actually represented a CLABSI (i.e., false negative). Conclusions: Standardized case definitions remain open to interpretation. At our hospital, we experienced discordance in approximately one-third of instances during review of blood culture data amongst trained infection preventionists. Reviewing all blood culture data is key for validation so that both false positives and false negative CLABSIs can be identified. Identifying the most common reasons for discordance and using specific examples when case disagreement occurred for educational purposes may lead to improved reliability and accuracy of application of the NHSN surveillance defintions.

Background and aimsThis study aimed to explore the complex phenomenon of emotional dysregulation, particularly in adolescence, which is associated with many mental health disorders and problems. Increasing the knowledge of clinicians and researchers in this area can be helpful in guiding future treatment plans. The aim of the study was to investigate, from an exploratory perspective, which structural aspects of adolescent functioning (assessed using the Rorschach test and administered and scored according to the Comprehensive System, CS, by Exner) were associated with different dimensions of emotional dysregulation (evaluated using the Difficulties in Emotion Dysregulation Scale, DERS).MethodSecondary data were used for the study, which included 100 adolescents, with 50 in the clinical group (patients with complex trauma histories residing in therapeutic and socio-rehabilitative communities) and 50 in the nonclinical group (recruited from a scout group and middle and high schools). The two groups were compared on terms of the mean scores obtained in the DERS scales (one-tailed t-test) and the proportions of cases that obtained pathological values for selected Rorschach CS indicators (z-test). Partial correlations were calculated between the DERS scales and the Rorschach CS variables to explore which structural dimensions of functioning were associated with different characteristics of emotional dysregulation.ResultsThe results indicated that the two groups differed in their outcomes on all DERS scales, except for Awareness and Goals, and on four Rorschach CS variables (EgoIndex, a:p, Wsum6, and MOR). Some significant positive and negative correlations between the Rorschach CS variables and the DERS scales also emerged.ConclusionThese results suggest that the dimensions of functioning associated with emotional dysregulation are related to self-representation, relational immaturity, and thought processes character and characterize membership in a therapeutic community. The correlations described in the article warrants further consideration. Finally, the study’s limitations and future research prospects are presented.

BackgroundThe burden of amyloidosis among hospitalized patients is increasing over time. However, amyloidosis remains an underdiagnosed cause of heart failure (HF) hospitalization among older adults.ObjectivesWe investigated the prevalence and prognostic implications of amyloidosis among patients hospitalized with HF.MethodsAll hospitalizations for primary diagnosis of HF between January 1, 2010, and August 31, 2015, identified in the Nationwide Readmissions Database were categorized into those with and without a secondary diagnosis of amyloidosis. HF hospitalizations with amyloidosis were then matched in a 3:1 fashion to HF hospitalizations without amyloidosis using the year of admission, discharge quarter, age, sex, and Charlson comorbidity index. Primary outcomes were inpatient mortality and 30-day readmission. Multivariable logistic regression was used to estimate the association between HF with amyloidosis and clinical outcomes.ResultsOf 1,593,360 HF hospitalizations that met inclusion criteria, 2,846 (0.18%) had HF with a secondary diagnosis of amyloidosis and were matched to 8,515 hospitalizations for HF without amyloidosis. Hospitalizations for HF with amyloidosis were associated with higher prevalence of kidney disease (56% vs. 45%), malignancy (20% vs. 4%), and higher inpatient mortality (6% vs. 3%) as compared with HF without amyloidosis. In adjusted analyses, HF with amyloidosis was associated with higher odds of in-hospital mortality (odds ratio: 1.46; 95% confidence interval [CI]: 1.17 to 1.82), 30-day readmission (odds ratio: 1.17; 95% CI: 1.05 to 1.31), and longer mean length of stay (least-squares mean difference: 1.46; 95% CI: 1.12 to 1.80).ConclusionsIn patients hospitalized with decompensated HF, presence of amyloidosis was associated with higher risk of inpatient mortality and 30-day readmission.

Background: Central-line–associated bloodstream infections (CLABSIs) are linked to increased morbidity and mortality, longer hospital stays, and significantly higher healthcare costs. Infection prevention guidelines recommend line placement in specific insertion locations over others because of the relative risk of infection. The purpose of this study was to assess CLABSI rates by line type to determine whether some central lines had a lower risk of infection and should be recommended over others given similar clinical indications. Methods: At UNC Hospitals, data were obtained on central lines across a 3-year period (FY20–FY22) from the EMR (Epic Systems). Central lines were categorized as apheresis catheters, CVC lines (single, double, or triple lumen), hemodialysis catheters, introducer lines, pulmonary artery (PA) catheters, PICC lines (single, double, or triple lumen), port-a-catheters, trialysis catheters, or umbilical lines. The line type(s) associated with each CLABSI during the same period were recorded, and CLABSI rates by line type per 1,000 central-line days were calculated using SAS software. If an infection had >1 central-line device type associated, the infection was counted twice when calculating the CLABSI rate by line type. We calculated 95% CIs for each point estimate to assess for statistically significant differences in rates by line type. Results: During FY20–FY22, there were 264,425 central-line days and 458 CLABSIs, for an overall CLABSI rate of 1.73 CLABSIs per 1,000 central-line days. Also, 16% of patients with a CLABSI had >1 type of central line in place. Stratified data on CLABSI rates by each central-line type is presented in the Figure. CLABSI rates were highest in patients with apheresis lines (6.22; 95% CI, 3.96–9.35) and PA catheters (6.22; 95% CI, 3.54–10.20), and the lowest CLABSI rates occurred in patients with PICC lines (1.44; 95% CI, 1.19–1.73) and port-a-catheters (1.14; 95% CI, 0.89, 1.45). For both CVC and PICC lines, as the number of lumens increased from single to triple, CLABSI rates increased, from 0.91 to 2.63 and from 0.57 to 1.20, respectively. Conclusions: At our hospital, different types of central lines were associated with statistically higher CLABSI rates. Additionally, a higher number of lumens (triple vs single) in CVC and PICC lines were also associated with statistically higher CLABSI rates. These findings reinforce the importance of considering central-line type and number of lumens to minimize risk of CLABSI while ensuring that patients have the best line type based on their clinical needs.

Background: Clostridioides difficile infection (CDI) is a serious healthcare-associated infection responsible for >12,000 US deaths annually. Overtesting can lead to antibiotic overuse and potential patient harm when patients are colonized with C. difficile, but not infected, yet treated. National guidelines recommend when testing is appropriate; occasionally, guideline-noncompliant testing (GNCT) may be warranted. A multidisciplinary group at UNC Medical Center (UNCMC) including the antimicrobial stewardship program (ASP) used a best-practice alert in 2020 to improve diagnostic stewardship, to no effect. Evidence supports use of hard stops for this purpose, though less is known about provider acceptance. Methods: Beginning in May 2022, UNCMC implemented a hard stop in its electronic medical record system (EMR) for C. difficile GNCT orders, with exceptions to be approved by an ASP attending physician. Requests were retrospectively reviewed May–November 2022 to monitor for adverse patient outcomes and provider hard-stop compliance. The team exported data from the EMR (Epic Systems) and generated descriptive statistics in Microsoft Excel. Results: There were 85 GNCT orders during the study period. Most tests (62%) were reviewed by the ASP, and 38% sought non-ASP or no approval. Of the tests reviewed by the ASP, 33 (62%) were approved and 20 (38%) were not. Among tests not approved by the ASP, no patients subsequently received CDI-directed antibiotics, and 1 patient (5%) warranted same-admission CDI testing (negative). Of tests that circumvented ASP review, 18 (56%) ordering providers received a follow-up email from an associate chief medical officer to determine the rationale. No single response type dominated: 3 (17%) were unaware of the ASP review requirement, 2 (11%) indicated their patient’s uncharted refusal of laxatives, 2 (11%) indicated another patient-specific reason. Provider avoidance of the ASP approval mechanism decreased 38%, from 53% of noncompliant tests in month 1 to 33% of tests in month 6. Total tests orders dropped 15.5% from 1,129 during the same period in 2021 to 954 during the study period (95% CI, 13.4%–17.7%). Compliance with the guideline component requiring at least a 48-hour laxative-free interval prior to CDI testing increased from 85% (95% CI, 83%–87%) to 95% (95% CI, 93%–96%). CDI incidence rates decreased from 0.52 per 1,000 patient days (95% CI, 0.41–0.65) to 0.41 (95% CI, 0.32–0.53), though the change was neither significant at P = .05 nor attributable to any 1 intervention. Conclusions: Over time and with feedback to providers circumventing the exception process, providers accepted and used the hard stop, improving diagnostic stewardship and avoiding unneeded treatment.

Atrial fibrillation (AF) is the most common arrhythmia encountered clinically, and as the population ages, its prevalence is increasing. Although the CHA2DS2−VASc score is the most used risk-stratification system for stroke risk in AF, it lacks personalization. Patient-specific computer models of the atria can facilitate personalized risk assessment and treatment planning. However, a challenge faced in creating such models is the complexity of the atrial muscle arrangement and its influence on the atrial fiber architecture. This work proposes a semi-automated rule-based algorithm to generate the local fiber orientation in the left atrium (LA). We use the solutions of several harmonic equations to decompose the LA anatomy into subregions. Solution gradients define a two-layer fiber field in each subregion. The robustness of our approach is demonstrated by recreating the fiber orientation on nine models of the LA obtained from AF patients who underwent WATCHMAN device implantation. This cohort of patients encompasses a variety of morphology variants of the left atrium, both in terms of the left atrial appendages (LAAs) and the number of pulmonary veins (PVs). We test the fiber construction algorithm by performing electrophysiology (EP) simulations. Furthermore, this study is the first to compare its results with other rule-based algorithms for the LA fiber architecture definition available in the literature. This analysis suggests that a multi-layer fiber architecture is important to capture complex electrical activation patterns. A notable advantage of our approach is the ability to reconstruct the main LA fiber bundles in a variety of morphologies while solving for a small number of harmonic fields, leading to a comparatively straightforward and reproducible approach.

Objective: Bioprosthetic heart valves (BHVs) are commonly used in surgical and percutaneous valve replacement. The durability of percutaneous valve replacement is unknown, but surgical valves have been shown to require reintervention after 10 to 15 years. Further, smaller-diameter surgical BHVs generally experience higher rates of prosthesis–patient mismatch, which leads to higher rates of failure. Bioprosthetic aortic valves can flutter in systole, and fluttering is associated with fatigue and failure in flexible structures. The determinants of flutter in BHVs have not been well characterized, despite their potential to influence durability. Methods: We use an experimental pulse duplicator and a computational fluid-structure interaction model of this system to study the role of device geometry on BHV dynamics. The experimental system mimics physiological conditions, and the computational model enables precise control of leaflet biomechanics and flow conditions to isolate the effects of variations in BHV geometry on leaflet dynamics. Results: Both experimental and computational models demonstrate that smaller-diameter BHVs yield markedly higher leaflet fluttering frequencies across a range of conditions. The computational model also predicts that fluttering frequency is directly related to leaflet thickness. A scaling model is introduced that rationalizes these findings. Conclusions: We systematically characterize the influence of BHV diameter and leaflet thickness on fluttering dynamics. Although this study does not determine how flutter influences device durability, increased flutter in smaller-diameter BHVs may explain how prosthesis–patient mismatch could induce BHV leaflet fatigue and failure. Ultimately, understanding the effects of device geometry on leaflet kinematics may lead to more durable valve replacements.

Background: SARS-CoV-2 N95 mask contamination in healthcare providers (HCPs) treating patients with COVID-19 is poorly understood. Method: We performed a prospective observational study of HCP N95 respirator SARS-CoV-2 contamination during aerosol-generating procedures (AGPs) on SARS-CoV-2–positive patients housed in a COVID-19–specific unit at an academic medical center. Medical masks were used as surrogates for N95 respirators to avoid waste and were worn on top of HCP N95 respirators during study AGPs. Study masks were provided to HCPs while donning PPE and were retrieved during doffing. Additionally, during doffing, face shields were swabbed with Floq swabs premoistened with viral transport media (VTM) prior to disinfection. Medical masks were cut into 9 position-based pieces, placed in VTM, vortexed, and centrifuged (Fig. 1). RNA extraction and RT-PCR were completed on all samples. RT-PCR–positive samples underwent cell culture infection to detect cytopathic effects (CPE). Contamination was characterized by mask location and front and back of face shields. Patient COVID-19 symptoms were collected from routine clinical documentation. Study HCPs completed HCP-role–specific routine care (eg, assessing, administering medications, and maintaining oxygen supplementation) while in patient rooms and were observed by study team members. Results: We enrolled 31 HCPs between September and December 2021. HCP and patient characteristics are presented in Table 1. In total, 330 individual samples were obtained from 31 masks and 26 face shields among 12 patient rooms. Of the 330 samples, 0 samples were positive for SARS-CoV-2 via RT-PCR. Positive controls were successfully performed in the laboratory setting to confirm that the virus was recoverable using these methods. Notably, all samples were collected from HCPs caring for COVID-19 patients on high-flow, high-humidity Optiflow (AGP), with an average of 960 seconds (IQR, 525–1,680) spent in each room. In addition to Optiflow and routine care, study speech pathologists completed an additional AGP of fiberoptic endoscopic evaluation of swallowing. Notably, 29 (94%) of 31 study HCP had physical contact with their patient. Conclusions: Overall, mask contamination in HCPs treating patients with COVID-19 undergoing AGPs was not detectable while wearing face shields, despite patient contact and performing AGP.

Background: Although vaccine hesitancy has been an issue for many years, it has become a major point of contention in the effort to mitigate the COVID-19 pandemic. In August 2021, a large academic medical facility began capturing the vaccination status of admitted COVID-19–positive patients, as well as their interest in the COVID-19 vaccine. We performed a descriptive analysis on the characteristics of unvaccinated patients who contracted COVID-19 and their interest in receiving the COVID-19 vaccine. Methods: Patient history and physical (H&P) notes and demographic data were collected using the internal data warehouse sourced from the electronic medical record for all SARS-COV-2–positive inpatient admissions to UNC Medical Center and UNC Chatham from August 1, 2021, to January 11, 2022. Manual chart reviews of progress notes were completed for patients whose history was not recorded in the initial H&P. Demographic data were summarized by vaccine status overall and by interest in COVID-19 vaccine among unvaccinated patients. We performed χ2 to determine demographic differences between the interested and uninterested unvaccinated groups. Results: In total, 536 patients were admitted with COVID-19 from August 1, 2021, to January 11, 2022. Of these, 15% were fully vaccinated (2 doses mRNA plus 1 dose J&J); 5.4% were partially vaccinated; 75.7% were unvaccinated; and 2.9% had an unknown vaccination status. Demographic characteristics are presented in Table 1. The most common demographics were consistent among the fully vaccinated and unvaccinated groups, with the exception of sex and age group (Table 1). For those whose interest data were available (n = 164), 34% were uninterested in receiving the COVID-19 vaccine. Importantly, race and age were statistically significantly different (P < .05) between the unvaccinated interested and unvaccinated uninterested groups. Conclusions: Even after experiencing COVID-19 firsthand and being hospitalized, some people who remain uninterested in receiving the COVID-19 vaccine. This population had a statistically higher proportion of white and older individuals than the unvaccinated interested group. Recommendations from healthcare providers might not be effective in persuading this population to be vaccinated. Instead, grassroots alternatives might be more successful. Additional analysis should be considered on whether patients who expressed interest in COVID-19 vaccine received immunization.

Background and aims: This study aimed to explore the complex phenomenon of emotional dysregulation, particularly in adolescence, which is associated with many mental health disorders and problems. Increasing the knowledge of clinicians and researchers in this area can be helpful in guiding future treatment plans. The aim of the study was to investigate, from an exploratory perspective, which structural aspects of adolescent functioning (assessed using the Rorschach test and administered and scored according to the Comprehensive System, CS, by Exner) were associated with different dimensions of emotional dysregulation (evaluated using the Difficulties in Emotion Dysregulation Scale, DERS). Method: Secondary data were used for the study, which included 100 adolescents, with 50 in the clinical group (patients with complex trauma histories residing in therapeutic and socio-rehabilitative communities) and 50 in the nonclinical group (recruited from a scout group and middle and high schools). The two groups were compared on terms of the mean scores obtained in the DERS scales (one-tailed t-test) and the proportions of cases that obtained pathological values for selected Rorschach CS indicators (z-test). Partial correlations were calculated between the DERS scales and the Rorschach CS variables to explore which structural dimensions of functioning were associated with different characteristics of emotional dysregulation. Results: The results indicated that the two groups differed in their outcomes on all DERS scales, except for Awareness and Goals, and on four Rorschach CS variables (EgoIndex, a:p, Wsum6, and MOR). Some significant positive and negative correlations between the Rorschach CS variables and the DERS scales also emerged. Conclusion: These results suggest that the dimensions of functioning associated with emotional dysregulation are related to self-representation, relational immaturity, and thought processes character and characterize membership in a therapeutic community. The correlations described in the article warrants further consideration. Finally, the study's limitations and future research prospects are presented. [ABSTRACT FROM AUTHOR]

Background. Since transcatheter aortic valve replacement (TAVR) first became approved for inoperable patients followed by high, intermediate-, and low-risk patients, referrals to TAVR centers have rapidly increased. The purpose of this study was to investigate referral patterns to a large academic TAVR center in the state of North Carolina and evaluate differences between externally and internally referred patients. Methods. Data for all patients who underwent TAVR at our institution between November 2014 and March 2020 were pulled from the Transcatheter Valve Therapy Registry. The electronic medical record was used to determine the referral source. The descriptive statistical analysis was performed using Excel (Microsoft, Redmond, Washington). Results. 491 patients underwent TAVR at our institution between November 2014 and March 2020. Half of the patients were referred by a cardiologist within the same health system (N = 250, 50.9%). Other referral sources included a cardiologist external to the health system (N = 210, N = 42.8%) and a surgeon or proceduralist (such as urologist, surgeon, or gastroenterologist) during the workup for another procedure (N = 26, 5.3%). Over time, there was a trend toward an increasing proportion of patients referred by a cardiologist external to our system, but this trend did not reach statistical significance (20.0% in 2014, 29.2% in 2015, 30.7% in 2016, 53.0% in 2017, 36% in 2018, 48.4% in 2019, and 56.8% in 2020, p=0.06 using the Mann–Kendall trend test). Externally referred patients were less likely to have private insurance and were more likely to have a reduced ejection fraction and had a higher mean gradient across the valve. Postprocedure, externally referred patients were more likely to have the procedure under moderate sedation and less likely to be discharged home. Conclusions. This study presents the referral pattern to a large TAVR center in North Carolina. Over time, there was an increase in external referrals suggesting that TAVR is increasingly adopted as an important component of the management of aortic valve stenosis. Internally and externally referred patients have differences in baseline demographic and clinical characteristics which may have an impact on clinical outcomes.

Transcatheter aortic valve replacement (TAVR) has developed substantially since its inception. Improvements in valve design, valve deployment technologies, preprocedural imaging and increased operator experience have led to a gradual decline in length of hospitalisation after TAVR. Despite these advances, the need for permanent pacemaker implantation for post-TAVR high-degree atrioventricular block (HAVB) has persisted and has well-established risk factors which can be used to identify patients who are at high risk and advise them accordingly. While most HAVB occurs within 48 hours of the procedure, there is a growing number of patients developing HAVB after initial hospitalisation for TAVR due to the trend for early discharge from hospital. Several observation and management strategies have been proposed. This article reviews major known risk factors for HAVB after TAVR, discusses trends in the timing of HAVB after TAVR and reviews some management strategies for observing transient HAVB after TAVR.

Objective: Little is known about the effect of government-issued State of Emergency (SOE) and Reopening orders on health care behaviors. We aimed to determine the effect of SOE and Phase 1 of Reopening orders on hospitalizations for acute myocardial infarction (AMI) or acute decompensated heart failure (ADHF). Methods: Hospitalizations for AMI and ADHF in the UNC Health system, which includes 10 hospitals in both urban and rural counties, were identified. An interrupted time series design was used to compare weekly hospitalization rates for eight weeks before the March 10th SOE declaration, eight weeks between the SOE order and Phase 1 of Reopening order, and the subsequent eight weeks. Results: Overall, 3,792 hospitalizations for AMI and 7,223 for ADHF were identified. Rates before March 10th were stable. AMI/ADHF hospitalizations declined about 6% per week in both urban and rural hospitals from March 11th to May 5th. Larger declines in hospitalizations were seen in adults ≥65 years old (-8% per week), women (-7% per week), and White individuals (-6% per week). After the Reopening order, AMI/ADHF hospitalizations increased by 8% per week in urban centers and 9% per week in rural centers, including a significant increase in each demographic group. The decline and rebound in acute CV hospitalizations were most pronounced in the two weeks following the government orders. Conclusions: AMI and ADHF hospitalization rates closely correlated to SOE and Reopening orders. These data highlight the impact of public health measures on individuals seeking care for essential services; future policies may benefit from clarity regarding when individuals should present for care.

Background Patients with cancer and severe aortic stenosis are often ineligible for surgical aortic valve replacement (SAVR). Patients with cancer may likely benefit from emerging transcatheter aortic valve replacement (TAVR), given its minimally invasive nature. Methods and Results The US‐based National Inpatient Sample was queried between 2012 and 2015 using International Classification of Diseases, Ninth Revision, Clinical Modification (ICD‐9‐CM), codes to identify all hospitalized adults (aged ≥50 years), who had a primary diagnosis of aortic stenosis. We examined the effect modification of cancer on the relative use rate, outcomes, and dispositions associated with propensity‐matched cohort TAVR versus SAVR. Overall, 47 295 TAVRs (22.6% comorbid cancer) and 113 405 SAVRs (15.2% comorbid cancer) were performed among admissions with aortic stenosis between 2012 and 2015. In the year 2015, patients with cancer saw relatively higher rates of TAVR use compared with SAVR (relative use rateTAVR versus relative use rateSAVR, 67.8% versus 57.2%; P