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Background: The association of ethnic ancestry with coronary artery calcifications suggests that mitral annulus calcification may also vary with ethnicity. We sought to compare prevalence and clinical correlates of mitral annulus calcification in non-Hispanic Whites, Hispanics, and African Americans. Design: This was a retrospective study of 857 patients age 40-75 years that included 217 (2 5%) African Americans, 349 (41%) Hispanics, and 291 (34%) non-Hispanic Whites referred for echocardiography. Multiple logistic regression was used to determine the interrelationships between mitral annulus calcification, risk factors, and ethnicity. Results: Mitral annulus calcification was detected in 181 (21.1%) patients including 35 116.1%) African Americans, 80 (22.9%) Hispanics, and 66 (22.7%) non-Hispanic whites. In univariate analysis, patients with mitral annulus calcification were older and more likely to have hypertension, diabetes, dyslipidemia, smoking history, and two or more risk factors than were those without calcification. In multivariate analysis, age and smoking history were independent predictors of mitral annulus calcification; dyslipidemia and diabetes were borderline significant predictors; and after adjusting for the remaining variables in the model, ethnicity was not an independent significant predictor of mitral annulus calcification. Conclusion: In a retrospective study of middle-aged and elderly African Americans, non- Hispanic Whites, and Hispanics referred for echocardiography, mitral annulus calcification is common in all three major ethnic groups but not significantly associated with ethnic ancestry. [ABSTRACT FROM AUTHOR]

Background: Patients with congestive heart failure (CHF) have alterations in the traditional and nonlinear indices of heart rate (HR) dynamics, which have been associated with an increased risk of mortality. This study was designed to test the effects of carvedilol, a nonselective beta-blocker with alpha-1 blocking properties, on HR dynamics in patients with CHF.Methods: We studied 15 patients with CHF secondary to ischemic or idiopathic cardiomyopathy who met the following inclusion criteria: NYHA functional class II-III, optimal conventional medical therapy, normal sinus rhythm, left ventricular ejection fraction (LVEF) of < 40%, and resting systolic blood pressure greater than 100 mmHg. The 6-minute corridor walk test, estimation of LVEF, and 24-hour Holter recording were performed at baseline and after 12 weeks of therapy with carvedilol. Traditional time and frequency domain measures and short-term fractal scaling exponent of HR dynamics were analyzed.Results: After 12 weeks of therapy with carvedilol, the mean LVEF improved significantly (from 0.27 +/- 0.08 to 0.38 +/- 0.08, P < 0.001). The average HR decreased significantly (from 86 +/- 11 to 70 +/- 8 beats/min, P < 0.001). The mean distance traveled in the 6-minute walk test increased significantly (from 177 +/- 44 to 273 +/- 55 m, P < 0.01). The frequency-domain indices (HF and LF), the time domain indices (rMSSD and PNN5 ), and the short-term fractal scaling exponent increased significantly. The scaling exponent increased particularly among the patients with the lowest initial values (< 1.0), and the change in the fractal scaling exponent correlated with the change in ejection fraction (r = 0.63, P < 0.01).Conclusion: Carvedilol improves time and frequency domain indices of HR variability and corrects the altered scaling properties of HR dynamics in patients with CHF. It also improves LVEF and functional capacity. These specific changes in HR behavior caused by carvedilol treatment may reflect the normalization of impaired cardiovascular neural regulation of patients with CHF. [ABSTRACT FROM AUTHOR]

Purpose: Clinical and radiographic examinations are commonly used for estimating severity and titrating therapy of chronic congestive heart failure. The purpose of this study was to establish the relationship between findings on history, physical examination, chest roentgenogram, and pulmonary capillary wedge pressure (PCWP).Patients and Methods: Fifty-two consecutive patients with chronic congestive heart failure, referred for evaluation for heart transplantation, were studied; all patients underwent history, physical examination, upright chest roentgenogram, and cardiac catheterization. The mean left ventricular ejection fraction was 0.19 +/- 0.06. Patients were divided into three groups according to their PCWP: Group 1, normal PCWP (less than or equal to 15 mm Hg, n = 19); Group 2, mild to moderately elevated PCWP (16 to 29 mm Hg, n = 15); Group 3, markedly elevated PCWP (greater than or equal to 30 mm Hg, n = 18).Results: Physical and radiographic signs of congestion were more common in the groups with higher PCWP, but they could not be used to reliably separate patients with different filling pressures. Physical findings (orthopnea, edema, rales, third heart sound, elevated jugular venous pressure) or radiographic signs (cardiomegaly, vascular redistribution, and interstitial and alveolar edema) had poor predictive value for identifying patients with PCWP values greater than or equal to 30 mm Hg. These findings had poor negative predictive value to exclude significantly elevated PCWP (greater than 20 mm Hg). Radiographic pulmonary congestion was absent in eight (53%) patients in Group 2 and seven (39%) in Group 3. In patients in Group 2 and 3, those without radiographic congestion were in a better New York Heart Association functional class (3.5 +/- 0.5 versus 2.8 +/- 0.6, p less than 0.01). There was good correlation between right atrial pressure and PCWP (r = 0.64, p less than 0.001). A normal right atrial pressure had no predictive value, but a pressure greater than 10 mm Hg was seen in all but one patient with a PCWP value greater than 20 mm Hg.Conclusion: Clinical, radiographic, and hemodynamic evaluations of chronic congestive heart failure yield conflicting results. Absence of radiographic or physical signs of congestion does not ensure normal PCWP values and may lead to inaccurate diagnosis and inadequate therapy. It is not known whether therapy aimed at normalizing PCWP is superior to relieving clinical and radiographic signs of congestion. [ABSTRACT FROM AUTHOR]

In patients with congestive heart failure, abnormal heart rate variability is a predictor of total mortality and sudden cardiac death. Drugs that improve heart rate variability may have a potential role for improving the survival among these patients. The effects of clonidine were studied in 24 patients with congestive heart failure, sinus rhythm, a left ventricular ejection fraction <0.40, and systolic blood pressure > 115 mm Hg. A 6-minute corridor walk test and 24-hour Holter monitoring were performed before and 42+/-24 days after initiation of clonidine therapy (Catapres-TTS patch, mean dose: 0.33+/-0.21 mg). Changes in other medications used at baseline were not allowed. One patient died suddenly. Two patients did not complete the protocol due to worsening congestive heart failure, which required changes in medications, 1 patient discontinued due to hypotension, and 2 for personal reasons. Among the 18 patients who completed the protocol, the mean RR interval of sinus beats increased from 760+/-106 to 822+/-125 ms (p=0.001) and the distance covered during the 6-minute walk test increased from 1,148+/-277 to 1,255+/-359 feet (p=0.042). Systolic blood pressure decreased from 139+/-15 to 119+/-10 mm Hg (p <0.0001). The following increases were noted in the heart rate variability measurements: high-frequency power in 0.15 to 0.40 Hz: 4.58+/-1.07 to 4.94+/-1.17 In (ms), p=0.002; SD: 47.0+/-16.9 to 52.5+/-18.4 ms, p=0.034; SD of the mean of all RR intervals in 24 hours: 116+/-94 to 130+/-19 ms, p=0.033; SD of all 5-minute mean RR intervals: 106+/-44 to 124+/-66 ms, p=0.042; root-mean square of difference of successive RR intervals: 28.8+/-10.7 to 34.1+/-14.2 ms, p=0.017. Clonidine improves heart rate variability in the patients with congestive heart failure by increasing the parasympathetic tone. It is well tolerated by most patients with heart failure and may have a beneficial effect on exercise capacity. [ABSTRACT FROM AUTHOR]

Background: Acute coronary syndrome (ACS) hospital admissions decreased during the start of the COVID-19 outbreak. Information is limited on how Google searches were related to patients' behaviour during this time., Methods: We examined de-identified data from 2019 through 2020 regarding the following monthly items: (i) admissions for ACS from the Veterans Affairs Healthcare System; (ii) out-of-hospital cardiac arrest (OHCA) from the National Emergency Medical Services Information System (NEMSIS) public dataset; and (iii) Google searches for "chest pain," "coronavirus," "chest pressure," and "hospital safe" from Google Trends. We analyzed the trends for ACS admissions, OHCA, and Google searches., Results: During the early months of the first COVID-19 outbreak, the following occurred: (i) Veterans Affairs data showed a significant reduction in ACS admissions at a national and regional (Florida) level; (ii) the NEMSIS database showed a marked increase in OHCA at a national level; and (iii) Google Trends showed a significant increase in the before-mentioned Google searches at a national and regional level., Conclusions: ACS hospital admissions decreased during the beginning of the pandemic, likely owing to delayed healthcare utilization secondary to patients fear of acquiring a COVID-19 infection. Concordantly, the volume of Google searches for hospital safety and ACS symptoms increased, along with OHCA events, during the same time. Our results suggest that Google Trends may be a useful tool to predict patients' behaviour and increase preparedness for future events, but statistical strategies to establish association are needed., (© 2024 The Authors.)

Pericardiocentesis (PC) in patients with pulmonary hypertension (PH) and pericardial effusions has unclear benefits because it has been associated with acute hemodynamic collapse and increased mortality. Data on in-hospital outcomes in this population are limited. The National Inpatient Sample database was used to identify adult patients who underwent PC during hospitalizations between 2016 and 2020. Data were stratified by the presence or absence of PH. A multivariate regression model and case-control matching was used to estimate the association of PH with PC in-hospital outcomes. A total of 95,665 adults with a procedure diagnosis of PC were included, of whom 7,770 had PH. Patients with PH tended to be older (aged 67 ± 15.7 years) and female (56%) and less frequently presented with tamponade (44.9% vs 52.4%). Patients with PH had significantly higher rates of chronic kidney disease, coronary artery disease, heart failure, and chronic lung disease, among other co-morbidities. In the multivariate analysis, PC in PH was associated with higher all-cause mortality (adjusted odds ratio [aOR] 1.40, confidence interval [CI] 1.30 to 1.51) and higher rates of postprocedure shock (aOR 1.53, CI 1.30 to 1.81) than patients without PH. Mortality was higher in those with pulmonary arterial hypertension than other nonpulmonary arterial hypertension PH groups (aOR 2.35, 95% CI 1.46 to 3.80, p <0.001). The rates of cardiogenic shock (aOR 1.49, 95% CI 1.38 to 1.61), acute respiratory failure (aOR 1.56, 95% CI 1.48 to 1.64), and mechanical circulatory support use (aOR 1.86, 95% CI 1.63 to 2.12) were also higher in patients with PH. There was no significant volume-outcome relation between hospitals with a high per-annum pericardiocentesis volume compared with low-volume hospitals in these patients. In conclusion, PC is associated with increased in-hospital mortality and higher rates of cardiovascular complications in patients with PH, regardless of the World Health Organization PH group., Competing Interests: Declaration of Competing Interest The authors have no competing interest to declare., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Takotsubo syndrome (TTS) largely affects postmenopausal women but has been shown to carry increased mortality risk in men. We sought to evaluate nationwide in-hospital outcomes between men and women admitted with TTS to better characterize these disparities. Using the National Inpatient Sample database from 2011 to 2018, we identified a total of 48,300 hospitalizations with the primary diagnosis of TTS. The primary end point was in-hospital all-cause mortality. Secondary end points included in-hospital complications, length of stay, and discharge disposition. Men with TTS accounted for 8.9% of hospitalizations, were younger in age (62.0 ± 15.1 vs 66.8 ± 12.1 years, p <0.001), and were more frequently Black (9.7% vs 5.8%, p <0.001). Nationwide TTS mortality rates were 1.1% overall and may be improving, but remained higher in men than in women (2.2% vs 1.0%, p <0.001). Male gender was associated with increased all-cause mortality (adjusted odds ratios 2.41, 95% confidence interval 1.88 to 3.10, p <0.001), greater length of stay, and discharge complexity. Men carried increased co-morbidity burden associated with increased cardiogenic shock or mortality, including atrial fibrillation, thrombocytopenia, chronic kidney disease, and chronic obstructive pulmonary disease. Men more frequently developed acute kidney injury, ventricular arrhythmias, cardiac arrest, and respiratory failure. Male gender remains associated with nearly 2.5-fold increase in in-hospital mortality risk. In conclusion, early identification of patients with high-risk co-morbidities and close monitoring for arrhythmias, renal injury, or cardiogenic shock may reduce morbidity and mortality., Competing Interests: Disclosures The authors have no conflicts of interest to declare., (Published by Elsevier Inc.)

Early discharge strategies are associated with lower cost and resource utilization during hospitalization, as such we sought to evaluate trends, predictors and outcomes of the next day discharge (NDD) approach after transcatheter mitral valve repair (TMVR) procedures with the MitraClip device. The National Inpatient Sample (NIS) was queried between 2013 and 2018 for patients undergoing TMVR using the International Classification of Diseases (ICD) 9 procedure code '3597' and ICD-10 procedure code '02UG3JZ'. Patients undergoing TMVR were stratified into two groups, determined by hospital length of stay (LOS) [≤1 day, NDD versus >1-day, non-NDD]. Overall, 22,035 patients underwent TMVR with 35.7% (n  = 7,870) belonging to the NDD group (mean age 78.1 ± 9.7 years, women 45%). From 2013 to 2018, the proportion of patients being discharged using the NDD approach trended upward from 18.3% to 46.0%. Amongst demographic and social factors, female sex, black race, and low median household income were predictive of non-NDD (p <0.05 for all). Amongst clinical factors, anemia, iron deficiency anemia, major depressive disorder, thrombocytopenia, obesity and end stage renal disease were some predictors of non-NDD (p <0.05 for all). In the non-NDD group there was a downward trend of pooled post-procedure complications, post procedure cardiogenic shock, vascular complications, acute kidney injury, mechanical circulatory support use, acute respiratory distress and postoperative ischemic stroke and (p for trend <0.001 for all). Despite the overall downward trend, complications began increasing in 2017-18. In conclusion, these trends may reflect improving operator experience, advancement in vascular access device closures and techniques, and prioritization of decreasing length of stay. Ideally, the feasibility and safety of this approach should be confirmed in larger-sized multicenter, randomized trials., Competing Interests: Declaration of interests The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: Select patients with atrial fibrillation and contraindication to anticoagulation may benefit from percutaneous left atrial appendage closure (pLAAC)., Objective: The purpose of this study was to evaluate racial disparities in the nationwide utilization and outcomes of pLAAC., Methods: We identified 16,830 hospitalizations for pLAAC between 2015 and 2017 using the National Inpatient Sample. Baseline characteristics, in-hospital mortality, complications, length of stay, and discharge disposition were assessed between White and Black/African American (AA) populations., Results: Black/AA patients represented 4.1% of nationwide pLAAC recipients and were younger, more likely to be female, and had greater prevalence of hypertension, heart failure, hyperlipidemia, obesity, chronic kidney disease, and prior stroke history (P <.001 for all). Black/AA patients had significantly increased length of stay and nonroutine discharge (P <.001 for both) but comparable in-hospital mortality to White patients. Black/AA patients suffered from greater postoperative stroke (0.7% vs 0.2%), acute kidney injury (4.5% vs 2.1%), bleeding requiring transfusion (4.5% vs 1.4%), and venous thromboembolism (0.7% vs 0.1%; P <.01 for all). After controlling for possible confounding factors, Black/AA race was independently associated with significantly increased odds of bleeding requiring blood transfusion, stroke, venous thromboembolism, and nonroutine discharge., Conclusion: Among pLAAC recipients nationwide, Black/AA populations were underrepresented and had greater complication rates, length of stay, and discharge complexity. This study highlights the importance of addressing ongoing racial disparities in both utilization and outcomes of pLAAC., (Published by Elsevier Inc.)

Background Right ventricular systolic dysfunction (RVSD) is a known risk factor for adverse outcome in surgical aortic valve replacement. Transcatheter aortic valve replacement (TAVR), on the other hand, has been shown to be either beneficial or have no effect on right ventricular systolic function. However, the prognostic significance of RVSD on TAVR has not been clearly determined. We conducted a systematic review and meta-analysis to define the impact of RVSD on outcomes in terms of 1-year mortality in patients with severe aortic stenosis undergoing TAVR. Methods and Results An extensive literature review was performed, with an aim to identify clinical studies that focused on the prognosis and short-term mortality of patients with severe symptomatic aortic stenosis who underwent TAVR. A total of 3166 patients from 8 selected studies were included. RVSD, as assessed with tricuspid annular plane systolic excursion, fractional area change or ejection fraction, was found to be a predictor of adverse procedural outcome after TAVR (hazard ratio, 1.31; 95% CI, 1.1-1.55; P =0.002). Overall, we found that RVSD did affect post-TAVR prognosis in 1-year mortality rate. Conclusions Patients with severe, symptomatic aortic stenosis and concomitant severe RVSD have a poor 1-year post-TAVR prognosis when compared with patients without RVSD. Right ventricular dilation and severe tricuspid regurgitation were associated with increased 1-year morality post-TAVR and should be considered as independent risk factors. Further evaluations of long-term morbidity, mortality, as well as sustained improvement in functional class and symptoms need to be conducted to determine the long-term effects.

Background: Valve-in-valve transcatheter aortic valve replacement (TAVR) is an option when a surgical valve demonstrates deterioration and dysfunction. This study reports 3-year results following valve-in-valve with self-expanding TAVR., Methods: The CoreValve US Expanded Use Study is a prospective, nonrandomized, single-arm study that evaluates safety and effectiveness of TAVR in extreme risk patients with symptomatic failed surgical biologic aortic valves. Study end points include all-cause mortality, need for valve reintervention, hemodynamic changes over time, and quality of life through 3 years. Patients were stratified by presence of preexisting surgical valve prosthesis-patient mismatch., Results: From March 2013 to May 2015, 226 patients deemed extreme risk (STS-PROM [Society of Thoracic Surgeons Predicted Risk of Mortality] 9.0±7%) had attempted valve-in-valve TAVR. Preexisting surgical valve prosthesis-patient mismatch was present in 47.2% of the cohort. At 3 years, all-cause mortality or major stroke was 28.6%, and 93% of patients were in New York Heart Association I or II heart failure. Valve performance was maintained over 3 years with low valve reintervention rates (4.4%), an improvement in effective orifice area over time and a 2.7% rate of severe structural valve deterioration. Preexisting severe prosthesis-patient mismatch was not associated with 3-year mortality but was associated with significantly less improvement in quality of life at 3-year follow-up ( P =0.01)., Conclusions: Self-expanding TAVR in patients with failed surgical bioprostheses at extreme risk for surgery was associated with durable hemodynamics and excellent clinical outcomes. Preexisting surgical valve prosthesis-patient mismatch was not associated with mortality but did limit patient improvement in quality of life over 3-year follow-up., Clinical Trial Registration: URL: http://www.clinicaltrials.gov. Unique identifier: NCT01675440.

Background: Despite improvements in acute care and survival after non-ST-elevation acute coronary syndrome (NSTE-ACS) hospitalization, early readmissions remain common, and have significant clinical and financial impact., Objectives: Determine the predictors and etiologies of 30-day readmissions in NSTE-ACS., Method: The study cohort was derived from the National Readmission Database 2014 identifying patients with a primary diagnosis of NSTE-ACS using ICD9 code., Results: We identified a total of 300,269 patients admitted with NSTE-ACS; 13.4% were readmitted within 30-day. The most common cause of readmission was heart failure (HF) (15.6%), followed by a recurrent myocardial infarction (MI) (10%). Predictors of increased readmissions were age ≥ 75 years (OR: 1.34, 95% CI: 1.30-1.39), female gender (OR 1.12, 95% CI 1.09-1.16), a Charlson Comorbidity Index (CCI) >3 (OR 2.11, 95% CI: 2.04-2.18), ESRD (OR 2.01, 95% CI 1.89-2.14), CKD (OR: 1.58, 95% CI: 1.51-1.64), length of stay ≥5 days (OR: 1.51, 95% CI 1.46-1.56) and adverse events during the index admission such as AKI (OR:1.31, 95% CI: 1.25-1.36), major bleeding (OR:1.20, 95% CI: 1.12-1.24); whereas admission to a teaching hospital (OR 0.92, 95% CI 0.89-0.95) and PCI (OR 0.70, 95% CI 0.67-0.72) were associated with less likelihood of 30-day readmission., Conclusion: Readmission rate at 30-days is high among NSTE-ACS patients and the most common readmission etiologies are HF and recurrent MI. A CCI more than 3 and ESRD were the most significant predictors for readmission; patients undergoing PCI had less odds of readmission., (© 2018 Wiley Periodicals, Inc.)

This systematic review and meta-analysis sought to summarize the available evidence on the use of transcatheter aortic valve replacement (TAVR) in patients with Native Aortic Valve Regurgitation (NAVR) and compare outcomes between first and second generation valves. Owing to the improvements in transcatheter heart valve design and procedural success, TAVR has become increasingly performed in broader aortic valve pathologies. We searched Medline, Embase, Cochrane, and Scopus databases from 2007 to 2018 and performed a systematic review on reports with at least 10 patients with aortic valve regurgitation undergoing TAVR procedure. The main outcome of interest was all-cause mortality at 30 days. A total of 638 patients across 12 studies were included. Mean age ranged from 68 to 84. Society of Thoracic Surgeons score ranged from 5.4% to 13.1% and Logistic EuroSCORE ranged from 18.2% to 33%. The incidence rate of all-cause mortality at 30 days was found to be 11% (95% CI 7%-16%; I 2 = 20.86%). All-cause mortality at 30 days for first generation valves had an incidence rate of 15% (95% CI 10%-20%; I 2 = 10%) compared to 7% (95% CI 3%-13%; I 2 = 37%) in second generation valves with subgroup interaction analysis P = 0.059. Device success incidence rate in second generation valves was 92% (95% CI 83%-99%; I 2 = 67%) vs 68% (95% CI 59%-77%; I 2 = 53%) in first generation valves with P = 0.001. TAVR appears to be a feasible treatment choice for NAVR patients at high risk for surgical valve replacement. Second generation valves show promising results in terms of short-term outcomes., (© 2018 Wiley Periodicals, Inc.)

Transcatheter aortic valve replacement (TAVR) with percutaneous coronary intervention (PCI) has emerged as a less-invasive therapeutic option for high surgical risk patients with aortic stenosis and coronary artery disease. The aim of this study was to determine the outcomes of TAVR when performed with PCI during the same hospitalization. We identified patients using the International Classification of Diseases, Ninth Revision, Clinical Modification procedure codes from the Nationwide Inpatient Sample between the years 2011 and 2013. A total of 22,344 TAVRs were performed between 2011 and 2013. Of these, 21,736 (97.3%) were performed without PCI (TAVR group) while 608 (2.7%) along with PCI (TAVR + PCI group). Among the TAVR + PCI group, 69.7% of the patients had single-vessel, 22.2% had 2-vessel, and 1.6% had 3-vessel PCI. Drug-eluting stents were more commonly used than bare-metal stents (72% vs 28%). TAVR + PCI group witnessed significantly higher rates of mortality (10.7% vs 4.6%) and complications: vascular injury requiring surgery (8.2% vs 4.2%), cardiac (25.4% vs 18.6%), respiratory (24.6% vs 16.1%), and infectious (10.7% vs 3.3%), p <0.001% for all, compared with the TAVR group. The mean length of hospital stay and cost of hospitalization were also significantly higher in the TAVR + PCI group. The propensity score-matched analysis yielded similar results. In conclusion, performing PCI along with TAVR during the same hospital admission is associated with higher mortality, complications, and cost compared with TAVR alone. Patients would perhaps be better served by staged PCI before TAVR., (Copyright © 2016. Published by Elsevier Inc.)

Objective: To compare monitored anesthesia care (MAC) and general anesthesia (GA) for transcatheter aortic valve implantation (TAVI)., Design: Retrospective, case-control study., Setting: A large university-affiliated hospital system., Participants: The study comprised patients who underwent TAVI with the Medtronic CoreValve (Medtronic, Minneapolis, MN) between 2011 and 2015., Interventions: None., Measurements and Main Results: MAC (n = 44) and GA (n = 21) were compared in 65 patients who underwent TAVI. Baseline characteristics/demographics, hospital stay, intraoperative conditions, and intensive care unit (ICU)/hospital stays were compared using the chi-square test, unpaired t-test, or binomial regression where appropriate. There were no significant differences between patient populations with regard to 30-day mortality, ICU/hospital stay, and complication rates. The GA group used more blood product. The rate of ICU readmission was greater in the GA group but did not reach statistical significance., Conclusions: GA provides no significant advantages over MAC during TAVI., (Copyright © 2016 Elsevier Inc. All rights reserved.)

The objective of our study was to assess patients with end-stage liver disease undergoing percutaneous coronary intervention (PCI) and determine the rates and trend of complications and in-hospital outcomes. Data were obtained from the Nationwide Inpatient Sample 2005 to 2012. We identified all PCIs performed in patients with diagnosis of cirrhosis during the study period by the International Classification of Diseases, Ninth Revision, Clinical Modification codes. Preventable procedural complications were identified by Patient Safety Indicators. Propensity scoring method was used to establish matched cohorts to control for imbalances and account for differences that may have influenced treatment outcomes. A total of 1,051,242 PCIs were performed during the study period, of these, 122,342 were done on subjects with a formal diagnosis of cirrhosis. Bare-metal stents (BMS) were more likely to be used in patients who presented with ST-elevation myocardial infarction (19.73 vs 13.58, p <0.001), in cardiogenic shock (5.58, vs 2.81, p <0.001), or required intraaortic balloon pump (4.73 vs 2.38, p <0.001). The overall rate of complications was 7.1%, whereas the overall mortality rate over these years was 3.63%. On a propensity-matched analysis the mortality rate was 2 times higher for BMS (5.18 vs 2.35, p <0.001) compared with drug-eluting stents. PCI remains a safe and plausible option for patients with cirrhosis albeit riskier than for the general population. The use of BMS is associated with increased mortality and bleeding complications compared with drug-eluting stents which likely is representative of preferential use of BMS in patients with more advanced end-stage liver disease who are also likely to experience higher postprocedural complications., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background: Prior studies have demonstrated endothelial and smooth muscle brachial artery dysfunction after transradial cardiac catheterization for diagnostic coronary angiography. The duration of this vascular dysfunction is unknown., Objective: To determine the time-course of endothelial and smooth muscle cell dysfunction in the upstream brachial artery after transradial cardiac catheterization., Methods: We studied 22 consecutive patients with suspected coronary artery disease (age 64.4 ± 7.7 years) undergoing diagnostic transradial cardiac catheterization. Using high-resolution vascular ultrasound, we measured ipsilateral brachial artery diameter changes during reactive hyperemia (endothelium-dependent dilatation) and administration of sublingual nitroglycerin (endothelium-independent dilatation). The measurements were taken at baseline (before cardiac catheterization), 6 h, 24 h, 1 week, and 1 month postprocedure. The contralateral brachial artery served as a control., Results: Ipsilateral brachial artery diameter during endothelium-dependent dilatation decreased significantly compared with the contralateral diameters at 6 h and 24 h after transradial cardiac catheterization (3.22 vs. 4.11 and 3.29 vs. 4.11, respectively, P < 0.001). The administration of nitroglycerin did not affect this difference. At 1 week and 1 month postprocedure there was no significant difference in diameter of the ipsilateral versus the contralateral brachial artery. As expected the contralateral brachial artery showed no significant changes in diameter., Conclusion: Our results showed that transradial cardiac catheterization causes transient vascular endothelial and smooth muscle dysfunction of the ipsilateral brachial artery, which resolves within 1 week postprocedure. These findings strongly suggest the absence of systemic vascular dysfunction after transradial catheterization both immediately postprocedure as well as 1 week postprocedure. © 2015 Wiley Periodicals, Inc., (© 2015 Wiley Periodicals, Inc.)

Background: The Trial of Routine Aspiration Thrombectomy with PCI versus PCI alone in patients with STEMI (TOTAL trial) refuted the salutary effect of routine aspiration thrombectomy (AT) in PPCI for patients with ST-elevation myocardial infarction (STEMI)., Objectives: We performed an updated meta-analysis to assess clinical outcomes with AT prior to PPCI compared with conventional PPCI alone including the additional trial data., Methods and Results: Clinical trials (n = 20) that randomized patients (n = 21,281) with STEMI between Routine AT (n = 10,619) and PPCI (n = 10,662) were pooled. There was no difference in all-cause mortality between the 2 groups (RR: 0.89, 95%CI: 0.78-1.01, P = 0.08). Stratifying by follow up at 1-month (RR: 0.87, 95%CI: 0.69-1.10, P = 0.25), up to 6 months (RR: 0.91, 95%CI: 0.74-1.13, P = 0.39 and beyond 6 months (RR: 0.88, 95%CI: 0.74-1.05, P = 0.16) yielded similar results. There was a statistically significant increase risk of stoke rate in the AT arm (RR: 1.51, 95%CI: 1.01-2.25, P = 0.04). The 2 groups were similar with regards to target vessel revascularization (0.94, 95%CI: 0.83-1.06, P = 0.28) recurrent MI (RR: 0.96, 95%CI: 0.80-1.16, P = 0.68, MACE events (RR: 0.91 95%CI: 0.81-1.02, P = 0.11), early (0.59, 95%CI: 0.23-1.50, P = 0.27) and late (RR: 0.91, 95%CI: 0.69-1.18, P = 0.47) stent thrombosis and net clinical benefit (RR 0.99, 95%CI: 0.91-1.07, P = 0.76)., Conclusion: Routine AT prior to PPCI in STEMI is associated with higher risk of stroke. There is no statistical difference in clinical outcome parameters of mortality, major adverse cardiac events, target vessel revascularization, stent thrombosis, and net clinical benefit between AT and PCI alone., (© 2015, Wiley Periodicals, Inc.)

Objectives: Direct aortic deployment of a transcatheter aortic valve eliminates the need to traverse the aortic arch with the valve delivery system, enables placement of large sheaths in the aorta and innominate artery, provides maximal precision during deployment and ensures a safe, conventional surgical aortotomy closure. We describe the initial experience with the Suprasternal Aortic Access System (SuprAA System, Aegis Surgical Ltd, Dublin, Ireland) for direct transaortic/innominate valve delivery., Methods: Patients with severe, symptomatic aortic stenosis who were candidates for transcatheter aortic valve replacement (TAVR) via a direct transaortic approach were enrolled in the SuprAA-TAVR First-in-Man Study. Under general anaesthesia, the innominate artery and aortic arch were exposed in each patient, using the SuprAA System via a 2.5-cm incision directly above the sternal notch. The TAVR delivery sheath was positioned and the transcatheter valve deployed routinely under fluoroscopic guidance. Upon sheath removal, haemostasis at the aortotomy site was confidently secured using a double purse-string suture closure. All were extubated immediately. A meta-analysis of the direct aortic approach was done for comparison., Results: Four male patients (mean 82.5 years) underwent SuprAA-TAVR (2 CoreValve; 2 SAPIEN). Anatomical visualization was excellent and suprasternal valve deployment was accurate regardless of sheath size with 100% Valve Academic Research Consortium-2 procedural success. The average total procedure time was 109.5 min without perioperative wound or vascular complications., Conclusions: The SuprAA System provides direct aortic/innominate access without sternal or thoracotomy incision. Patient recovery to normal activity is maximized, sheath size limitations are eliminated and valve deployment is precise. This innovative system creates a new and exciting minimally invasive approach for high-risk patients with aortic stenosis., (© The Author 2015. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Introduction: Both transfemoral (TF) and transapical (TA) routes are utilized for Transcatheter Aortic Valve Replacement (TAVR) using Edwards SAPIEN & SAPIEN XT valves. We intended to perform a meta-analysis comparing the complication rates between these two approaches in studies published before and after the standardized Valve Academic Research Consortium (VARC) definitions., Methods: We performed a comprehensive electronic database search for studies published until January 2014 comparing TF and TA approaches using the Edwards SAPIEN/SAPIEN XT aortic valve. Studies were analyzed based on the following endpoints: 1-year mortality, 30-day mortality, stroke, new pacemaker implantation, bleeding, and acute kidney injury., Results: Seventeen studies were included in the meta-analysis. Patients undergoing TA TAVR had a significantly higher logistic EuroSCORE (24.6 ± 12.9 vs. 21.3 ± 12.0; P < 0.001). The cumulative risks for 30-day mortality (RR 0.61; 95%CI 0.46-0.81; P = 0.001), 1-year mortality (RR 0.68; 95%CI 0.55-0.84; P < 0.001), and acute kidney injury (RR 0.53; 95%CI 0.38-0.73; P < 0.001) were significantly lower for patients undergoing TF as compared to TA approach. Both approaches had a similar incidence of 30-day stroke, pacemaker implantation, and major or life-threatening bleeding. Studies utilizing the VARC definitions and those pre-dating VARC yielded similar results., Conclusion: This meta-analysis demonstrates a decreased 30-day and 1-year mortality in TF TAVR as compared to TA TAVR. Post-procedure acute kidney injury and the need for renal replacement therapy are also significantly lower in the TF group. These differences hold true even after utilizing the standardized Valve Academic Research Consortium criteria., (© 2015, Wiley Periodicals, Inc.)

Background: Contemporary data regarding percutaneous closure of atrial septal defect/patent foramen ovale (ASD/PFO) are lacking. We evaluated the current trends in utilization of ASD/PFO closure in adults and investigated the effect of annual hospital volume on in-hospital outcomes., Methods: We queried the Nationwide Inpatient Sample between the years 2001 and 2010 using the International Classification of Diseases (ICD-9-CM) procedure code for percutaneous closure of ASD/PFO with device. Hierarchical mixed effects models were generated to identify the independent multivariate predictors of outcomes., Results: A total of 7,107 percutaneous ASD/PFO closure procedures (weighted n = 34,992) were available for analysis. A 4.7-fold increase in the utilization of this procedure from 3/million in 2001 to 14/million adults in 2010 in US (P < 0.001) was noted. Overall, percutaneous ASD/PFO closure was associated with 0.5% mortality and 12% in-hospital complications. The utilization of intracardiac echocardiography (ICE) increased 15 fold (P < 0.001) during the study period. The procedures performed at the high volume hospitals [2nd (14-37 procedures/year) and 3rd (>38 procedures/year) tertile] were associated with significant reduction in complications, length of stay and cost of hospitalization when compared to those performed at lowest volume centers (<13 procedures/year). Majority (70.5%) of the studied hospitals were found to be performing <10 procedures/year hence deviating from the ACC/AHA/SCAI clinical competency guidelines., Conclusions: Low hospital volume is associated with an increased composite (mortality and procedural complications) adverse outcome following ASD/PFO closure. In the interest of patient safety, implementation of the current guidelines for minimum required annual hospital volume to improve clinical outcomes is warranted., (© 2014 Wiley Periodicals, Inc.)

Objectives: This paper reviews the published data and reports 3 cases of thrombosis involving CoreValve (Medtronic, Minneapolis, Minnesota) and 1 involving Edward Sapien (Edwards Lifesciences, Irvine, California) devices. Three of these cases had pathological findings at autopsy., Background: Only a limited number of cases of valve dysfunction with rapid increase of transvalvular aortic gradients or aortic insufficiency post-transcatheter aortic valve replacement (TAVR) have been described. This nonstructural valvular dysfunction has been presumed to be because of early pannus formation or thrombosis., Methods: Through reviews of the published reports and 4 clinical cases, pathological and clinical findings of early valve thrombosis are examined to elucidate methods for recognition and identifying potential causes and treatments., Results: This paper presents 4 cases, 2 of which had increasing gradients post-TAVR. All 3 pathology cases showed presence of a valve thrombosis in at least 2 TAV leaflets on autopsy, but were not visualized by transthoracic echocardiogram or transesophageal echocardiogram. One case was medically treated with oral anti coagulation with normalization of gradients. The consequence of valve thrombosis in all 3 pathology patients either directly or indirectly played a role in their early demise. At least 18 case reports of early valve thrombosis have been published. In 12 of these cases, the early treatment with anticoagulation therapy resolved the thrombus formation and normalized aortic pressures gradients successfully., Conclusions: These 4 cases elucidate the occurrence of valve thrombosis post-TAVR. Consideration should be given to treatment with dual antiplatelet therapy and oral anticoagulation in patients post-TAVR with increasing mean pressure gradients and maximum aortic valve velocity. Further research should be conducted to create guidelines for antithrombotic therapy following TAVR procedure., (Copyright © 2015 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

The evaluation of aortic stenosis is not always straightforward. When symptoms of severe aortic stenosis are present with supporting Doppler echocardiographic or cardiac catheterization data, replacement of the aortic valve is recommended. Occasionally, Doppler- and catheter-derived data are discordant; appropriate treatment in such cases becomes less clear. We report a case in which a 66-year-old man's symptoms and Doppler data suggested severe aortic stenosis. However, heart catheterization data suggested otherwise, and ultimately it led to the diagnosis of a highly vascular renal tumor. Shunting within the tumor resulted in high cardiac output, which, in combination with a small aortic root, masqueraded as severe aortic stenosis.

Resistant hypertension is a common medical problem that is increasing with the advent of an increasingly older and heavier population. The etiology of resistant hypertension is almost always multifactorial, but the results of numerous studies indicate that renal sympathetic activation is a particularly common cause of resistance to antihypertensive treatment. Consistent with the belief in a pivotal role of renal sympathetic stimulation, there has been a growing interest in renal denervation (RDN) treatment strategies. The long-awaited results of SYMPLICITY HTN-3 study disclosed that the reduction in blood pressure by the SYMPLICITY device did not differ from that in the sham-procedure arm of the study. In the present article, we identify several factors that explain why the study failed to demonstrate any benefit from the intervention. The reasons are multifactorial and include inadequate screening at entry and frequent medication changes during the study. Additional problems include the lack of experience of many operators with the SYMPLICITY device and procedure variability, as attested to by a diminished number of ablation "quadrants." Also a factor was the inability of the first generation Medtronic device to allow four ablations to be performed simultaneously. We recommend that future RDN studies adhere to more rigorous screening procedures, and utilize newer multi-site denervation systems that facilitate four ablations simultaneously. Drug optimization should be achieved by monitoring adherence throughout the study. Nevertheless, we are optimistic about a future role of RDN. To optimize chances of success, increased efforts are necessary to identify the appropriate patients for RDN and investigators must use second and third generation denervation devices and techniques., (Copyright © 2015 American Society of Hypertension. Published by Elsevier Inc. All rights reserved.)

Background: Incidence and prevalence of mitral stenosis is declining in the US. We performed this study to determine recent trends in utilization, complications, mortality, length of stay, and cost associated with balloon mitral valvuloplasty., Methods: Utilizing the nationwide inpatient sample database from 1998 to 2010, we identified patients using the International Classification of Diseases, 9th Revision, Clinical Modification procedure code for "percutaneous valvuloplasty." Patients ≥18 years of age with mitral stenosis were included. Patients with concomitant aortic, tricuspid, or pulmonic stenosis were excluded. Primary outcome included death and procedural complications., Results: A total of 1308 balloon mitral valvuloplasties (weighted n = 6540) were analyzed. There was a 7.5% decrease in utilization of the procedure from 24.6 procedures/10 million population in 1998-2001 to 22.7 procedures/10 million population in 2008-2010 (P for trend = .098). We observed a 15.9% overall procedural complication rate and 1.7% mortality rate. The procedural complication rates have increased in recent years (P = .001), corresponding to increasing age and burden of comorbidities in patients. The mean cost per admission for balloon mitral valvuloplasty has gone up significantly over the 10 years, from $11,668 ± 1046 in 2001 to $23,651 ± 301 in 2010 (P <.001)., Conclusions: In a large cross-sectional study of balloon mitral valvuloplasty in the US, we have reported trends of decreasing overall utilization and increasing procedural complication rates and cost over a period of 13 years., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Background: The relationship between operator or institutional volume and outcomes among patients undergoing percutaneous coronary interventions (PCI) is unclear., Methods and Results: Cross-sectional study based on the Healthcare Cost and Utilization Project's Nationwide Inpatient Sample between 2005 to 2009. Subjects were identified by International Classification of Diseases, 9(th) Revision, Clinical Modification procedure code, 36.06 and 36.07. Annual operator and institutional volumes were calculated using unique identification numbers and then divided into quartiles. Three-level hierarchical multivariate mixed models were created. The primary outcome was in-hospital mortality; secondary outcome was a composite of in-hospital mortality and peri-procedural complications. A total of 457,498 PCIs were identified representing a total of 2,243,209 PCIs performed in the United States during the study period. In-hospital, all-cause mortality was 1.08%, and the overall complication rate was 7.10%. The primary and secondary outcomes of procedures performed by operators in 4(th) [annual procedural volume; primary and secondary outcomes] [>100; 0.59% and 5.51%], 3(rd) [45-100; 0.87% and 6.40%], and 2(nd) quartile [16-44; 1.15% and 7.75%] were significantly less (P<0.001) when compared with those by operators in the 1(st) quartile [≤15; 1.68% and 10.91%]. Spline analysis also showed significant operator and institutional volume outcome relationship. Similarly operators in the higher quartiles witnessed a significant reduction in length of hospital stay and cost of hospitalization (P<0.001)., Conclusions: Overall in-hospital mortality after PCI was low. An increase in operator and institutional volume of PCI was found to be associated with a decrease in adverse outcomes, length of hospital stay, and cost of hospitalization., (© 2014 American Heart Association, Inc.)

Background: We determined the contemporary trends of percutaneous aortic balloon valvotomy and its outcomes using the nation's largest hospitalization database. There has been a resurgence in the use of percutaneous aortic balloon valvotomy in patients at high surgical risk because of the development of less-invasive endovascular therapies., Methods: This is a cross-sectional study with time trends using the Nationwide Inpatient Sample database between the years 1998 and 2010. We identified patients using the International Classification of Diseases, 9th Revision, Clinical Modification procedure code for valvotomy. Only patients aged more than 60 years with aortic stenosis were included. Primary outcome included in-hospital mortality, and secondary outcomes included procedural complications and length of hospital stay., Results: A total of 2127 percutaneous aortic balloon valvotomies (weighted n = 10,640) were analyzed. The use rate of percutaneous aortic balloon valvotomy increased by 158% from 12 percutaneous aortic balloon valvotomies per million elderly patients in 1998-1999 to 31 percutaneous aortic balloon valvotomies per million elderly patients in 2009-2010 in the United States (P < .001). The hospital mortality decreased by 23% from 11.5% in 1998-1999 to 8.8% in 2009-2010 (P < .001). Significant predictors of in-hospital mortality were the presence of increasing comorbidities (P = .03), unstable patient (P < .001), any complication (P < .001), and weekend admission (P = .008), whereas increasing operator volume was associated with significantly reduced mortality (P = .03). Patients who were admitted to hospitals with the highest procedure volume and the highest volume operators had a 51% reduced likelihood (P = .05) of in-hospital mortality when compared with those in hospitals with the lowest procedure volume and lowest volume operators., Conclusion: This study comprehensively evaluates trends for percutaneous aortic balloon valvotomy in the United States and demonstrates the significance of operator and hospital volume on outcomes., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Objectives: This retrospective study sought to assess the safety and clinical efficacy of cryoplasty for treatment of side-branch stenoses following main vessel stenting in coronary bifurcation lesions., Background: Cryoplasty prevents restenosis by reducing smooth muscle proliferation and extracellular matrix synthesis. Clinical effectiveness has been demonstrated in the peripheral circulation. Treatment of coronary bifurcation lesions remains a challenge. We used a novel strategy of main vessel stenting combined with side-branch cryoplasty to treat high-grade stenoses following main vessel stenting., Methods: Eighteen patients with bifurcation lesions had significant plaque shift into a side branch after main vessel intervention. Drug-eluting stents were placed in the main vessel and cryoplasty was performed on the side-branch vessel. Quantitative coronary analysis was performed on all side-branch vessels both pre- and post-main vessel stenting. All patients had clinical follow-up 3 months or more after cryoplasty including either nuclear stress testing or diagnostic coronary angiogram., Results: Mean percent stenosis decreased from 80.6% post main vessel stenting to 24.8% following cryoplasty (P < 0.0001). Of the 17 patients who had pre-cryoplasty nuclear stress testing 1 patient had ischemia identified in the distribution of the treated vessel at follow-up. Five patients had follow up angiography. One patient had restenosis, the other 2 were unchanged. There was a low incidence of MACE., Conclusions: In this first report of its use in the coronary circulation, cryoplasty for bifurcation side-branch disease was safe and associated with a low rate of clinical recurrence in carefully selected patients., (© 2013, Wiley Periodicals, Inc.)

Objectives: To determine the prevalence of mitral regurgitation (MR) in the U.S. adult population by classifying its mechanisms according to Carpentier's functional class., Background: MR is the most common clinically recognizable valvular heart condition in the U.S. affecting 2 to 2.5 million people in 2000. A true estimate of the prevalence of MR in accordance to the functional class and etiology is unavailable., Methods: We conducted a Medline search regarding prevalence and etiologies of MR. Etiologies were grouped by Carpentier's functional classification, and estimated prevalence numbers were projected to U.S. adult population of 200 million. Moderate-to-severe grades of MR were included., Results: Carpentier type I, including congenital MR and endocarditis, has a prevalence of less than 20 per million. Myxomatous infiltration leading to mitral valve prolapse is the largest group associated with a type II mechanism with 15,000 per million prevalence. Type IIIa includes rheumatic heart disease, systemic lupus erythematosus (SLE), antiphospholipid syndrome (APS), and rare infiltrative and tropical disorders. SLE and APS have a mean prevalence of 10,520 per million. Carpentier IIIb is the largest group leading to MR, which is mostly functional, and includes ischemic cardiomyopathy, left ventricular (LV) dysfunction, and dilated cardiomyopathies. The estimated prevalence of MR in ischemic cardiomyopathy is 7500 to 9000 per million, and in LV dysfunction, 16,250 per million., Conclusions: The largest number of people with MR is in type IIIb. Certain etiologies show overlap within functional classes due to multiple mechanisms of MR. We attempted to classify etiologies of MR by a functional class to determine the disease burden., (© 2011 Wiley Periodicals, Inc.)

Objective: False tendons in the left ventricle are commonly observed. Preliminary observations associate false tendons with less functional mitral regurgitation., Methods: Echocardiograms demonstrating severe cardiomyopathy (ejection fraction < or =30%) were retrospectively examined for left ventricular false tendons. The ejection fraction, cause of left ventricular systolic dysfunction, left ventricular diastolic dimensions, severity of mitral regurgitation, mitral annular diameter, mitral valve coaptation depth, mitral valve coaptation area, and orientation of false tendon were evaluated. The patients with false tendons were compared with a control group with cardiomyopathy without false tendons., Results: A cohort of patients (n = 82) with severe left ventricular systolic dysfunction (mean ejection fraction, 21%) and false tendons were compared with a control group with similar left ventricular dysfunction and no false tendons (n = 121; mean ejection fraction, 20%; P = .10). The patients with false tendons had similar left ventricular diastolic internal dimensions compared with the control group (5.99 and 6.18 cm, respectively; P = .086). Yet patients with false tendons had a very low incidence of severe functional mitral regurgitation compared with the control group (4.9% vs 27%, P < .001). Patients with false tendons had significantly smaller mitral annular diameters (3.57 vs 4.03 cm, P < .001), shorter mitral valve coaptation depths (0.89 vs 1.24 cm, P < .001), and reduced coaptation areas (1.61 vs 2.52 cm(2), P < .001) than the control group. The reduction of mitral regurgitation was more significant for patient with transverse midcavity false tendons., Conclusions: Patients with false tendons and cardiomyopathy have less severe mitral regurgitation. The mechanism for the reduction in functional mitral regurgitation might be less mitral valve deformation, specifically lower coaptation depth and coaptation area when a false tendon is present.