Publications by authors named "Akram Kawsara"

34 Publications

Treatment Effect of Percutaneous Coronary Intervention in Men Versus Women With ST-Segment-Elevation Myocardial Infarction.

J Am Heart Assoc 2021 Sep 17;10(18):e021638. Epub 2021 Sep 17.

Department of Cardiovascular Disease Mayo Clinic Rochester MN.

Background Women are less likely to receive primary percutaneous coronary intervention (pPCI) than men. A potential reason is risk aversion because of the worse outcomes with pPCI among women. However, whether pPCI is associated with a comparable mortality benefit in men and women remains unknown. Methods and Results We selected patients admitted with a principal diagnosis of ST-segment-elevation myocardial infarction in the National Inpatient Sample (2016-2018). We used propensity-score matching to calculate average treatment effects of pPCI for in-hospital mortality, major complications, length of stay, and cost. As a sensitivity analysis, we used logit models followed by a marginal command to calculate the average marginal effect. We included 413 500 weighted hospitalizations (30.7% women, 69.3% men). Women had more comorbidities except smoking and prior sternotomy. Compared with men, women were less likely to undergo angiography (81.0% versus 87.0%; adjusted odds ratio [OR], 0.77; 95% CI, 0.74-0.81; <0.001) or pPCI (74.0% versus 82.0%; adjusted OR, 0.76; 95% CI, 0.73-0.79; <0.001). There were no significant differences in average treatment effects of pPCI on mortality between men (-8.4% [-9.3% to -7.6%], <0.001), and women (-9.5% [-10.8% to -8.3%], <0.001) ( interaction=0.16). This persisted in age-stratified analyses (≥85, 65-84, 45-64, <45 years) and sensitivity analysis, excluding emergent admissions. The average treatment effects of pPCI on major complications were comparable except for acute stroke, leaving against medical advice, and palliative encounter. There were no differences in the average treatment effects of pPCI on length of stay, but the proportional increase in cost with pPCI was higher in women. Conclusions pPCI results in a comparable reduction in in-hospital mortality in men and women. Nonetheless, risk-adjusted rates of pPCI remain lower in women in contemporary US practice.
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http://dx.doi.org/10.1161/JAHA.121.021638DOI Listing
September 2021

Trends in outcomes, cost, and readmissions of transcatheter edge to edge repair in the United States (2014-2018).

Catheter Cardiovasc Interv 2021 Sep 14. Epub 2021 Sep 14.

Division of Cardiology, Department of Medicine, West Virginia University, Morgantown, West Virginia, USA.

Introduction: Despite the growth in transcatheter edge-to-edge repair (TEER) volume in the United States, data on the temporal changes in procedural outcomes are lacking.

Methods: We utilized the National Readmission Database to assess the annual changes in patient's characteristics, in-hospital outcomes, cost, and readmissions for patients who underwent TEER between January 1, 2014 and December 31, 2018. Outcomes of interest included mortality, major adverse cardiovascular events (MACE) and any adverse event (AE). We also assessed length of stay and cost.

Results: A total of 22,692 hospitalizations were included. The mean age increased from 75.2 ± 12.9 in 2014 to 78.1 ± 9.8 years in 2018. Changes in the prevalence of risk factors were heterogenous. The incidence of in-hospital mortality decreased from 4.0% in 2014 to 2.0% in 2018. Both MACE and any AE decreased significantly. Although the incidence of 30-day readmission remained stable, there was a trend towards a temporal increase in both 90-day and 180-day. The adjusted median length of stay of the index admission decreased by 50% and this trend was associated with a $2100 reduction in risk and inflation adjusted in-hospital cost, however, this reduction was offset by the increased total cost of readmissions within the first 6 months resulting in similar net-cost.

Conclusion: The volume of TEER has grown substantially between 2014 and 2018 coupled with a temporal improvement in in-hospital outcomes and reduction in cost and length of stay. Re-hospitalization rates after TEER remained steady at 30-day and trended towards worsening overtime at 90- and 180-days.
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http://dx.doi.org/10.1002/ccd.29957DOI Listing
September 2021

Predictors of Device-Related Thrombus Following Percutaneous Left Atrial Appendage Occlusion.

J Am Coll Cardiol 2021 Jul;78(4):297-313

Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Korea.

Background: Device-related thrombus (DRT) has been considered an Achilles' heel of left atrial appendage occlusion (LAAO). However, data on DRT prediction remain limited.

Objectives: This study constructed a DRT registry via a multicenter collaboration aimed to assess outcomes and predictors of DRT.

Methods: Thirty-seven international centers contributed LAAO cases with and without DRT (device-matched and temporally related to the DRT cases). This study described the management patterns and mid-term outcomes of DRT and assessed patient and procedural predictors of DRT.

Results: A total of 711 patients (237 with and 474 without DRT) were included. Follow-up duration was similar in the DRT and no-DRT groups, median 1.8 years (interquartile range: 0.9-3.0 years) versus 1.6 years (interquartile range: 1.0-2.9 years), respectively (P = 0.76). DRTs were detected between days 0 to 45, 45 to 180, 180 to 365, and >365 in 24.9%, 38.8%, 16.0%, and 20.3% of patients. DRT presence was associated with a higher risk of the composite endpoint of death, ischemic stroke, or systemic embolization (HR: 2.37; 95% CI, 1.58-3.56; P < 0.001) driven by ischemic stroke (HR: 3.49; 95% CI: 1.35-9.00; P = 0.01). At last known follow-up, 25.3% of patients had DRT. Discharge medications after LAAO did not have an impact on DRT. Multivariable analysis identified 5 DRT risk factors: hypercoagulability disorder (odds ratio [OR]: 17.50; 95% CI: 3.39-90.45), pericardial effusion (OR: 13.45; 95% CI: 1.46-123.52), renal insufficiency (OR: 4.02; 95% CI: 1.22-13.25), implantation depth >10 mm from the pulmonary vein limbus (OR: 2.41; 95% CI: 1.57-3.69), and non-paroxysmal atrial fibrillation (OR: 1.90; 95% CI: 1.22-2.97). Following conversion to risk factor points, patients with ≥2 risk points for DRT had a 2.1-fold increased risk of DRT compared with those without any risk factors.

Conclusions: DRT after LAAO is associated with ischemic events. Patient- and procedure-specific factors are associated with the risk of DRT and may aid in risk stratification of patients referred for LAAO.
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http://dx.doi.org/10.1016/j.jacc.2021.04.098DOI Listing
July 2021

Differences in the characteristics and outcomes of isolated tricuspid and mitral valve surgery for valvular regurgitation.

Cardiovasc Revasc Med 2021 May 14. Epub 2021 May 14.

Department of Cardiovascular Diseases, Mayo Clinic School of Medicine, Rochester, MN, United States of America. Electronic address:

Background: Isolated tricuspid valve (TV) surgery is associated with markedly worse outcomes than isolated mitral valve (MV) surgery. We hypothesized that this is related to late referral of patients with isolated TV disease.

Methods: Adult patients who underwent isolated TV or MV surgery in 2016-2017 were identified in the National-Readmission-Database. We compared the outcomes of isolated TV and MV surgery before and after adjustment for surrogates of late referral.

Results: A total of 21,446 patients who had isolated MV (n = 19,933), or TV surgery (n = 1153) were included. Patients in the TV group were younger (55.7 ± 16.6 vs. 63.4 ± 12.3 years), had lower socioeconomic status, but higher prevalence of surrogates for late referral [acute HF 41.0% vs. 22.0%, advanced liver disease 16.8% vs. 2.6%, non-elective surgery status 44.3% vs. 23.5%, need for peri-operative mechanical circulatory support 27.7% vs. 4.7%, and unplanned admissions in the 90 days before surgery 31.0% vs. 18.8%, (P < 0.001 for all)]. Surgery was performed on day 0/1 of the admission in 80% of patients in the MV group and 52% in the TV group, P < 0.001. Repair rate was 63.5% in the TV group and 56.3% in the MV group (P < 0.001). In-hospital mortality was 3-folds higher after TV surgery (8.7% vs. 2.5%; OR = 3.41, 95%CI 2.73-4.25, p < 0.001). However, this difference became non-significant after adjusting for baseline characteristics including surrogates for late referral (OR = 1.24, 95%CI 0.85-1.82, p = 0.27).

Conclusion: The poor outcomes of isolated TV surgery compared with isolated MV surgery may be largely explained by the late referral for intervention in patients with isolated TR.
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http://dx.doi.org/10.1016/j.carrev.2021.05.008DOI Listing
May 2021

Gender-based outcomes of coronary bifurcation stenting: A report from the National Readmission Database.

Catheter Cardiovasc Interv 2021 May 15. Epub 2021 May 15.

Division of Cardiology, West Virginia University School of Medicine, Morgantown, West Virginia, USA.

Background: There is a paucity of data focusing on women's outcomes after percutaneous coronary interventions (PCI) for coronary bifurcation lesions (CBLs).

Methods: Patients who received PCI for CBLs in the context of acute coronary syndrome (ACS) during the period of 01 October 2015- 31 December 2017, were identified from the United States National Readmission Database. The primary endpoint of this study was in-hospital major adverse events (MAEs). The secondary endpoints were in-hospital mortality, vascular complications, major bleeding, post-procedural bleeding, need for blood transfusion, severe disability surrogates (non-home discharge and need for mechanical ventilation), resources utilization surrogates (length of stay and cost of hospitalization), and 30-day readmission rate. A 1:1 propensity score matching was used to compare the outcomes between women and men.

Results: A total of 25,050 (women = 7,480; men = 17,570) patients were included in the current analysis. After propensity score matching, women had higher in-hospital MAEs (7 vs 5.2%, p < .01), major bleeding (1.8 vs 0.8%, p < .01), post-procedural bleeding (6.1 vs 3.4%, p < .01), need for blood transfusion (6.4 vs 4.2%, p < .01), non-home discharges (10.2 vs 7.1%; p < .01), longer length of hospital stay (3 days [IQR 2-6] vs. 3 days [IQR 2-5], p < .01) and higher 30-day readmission rate compared to men (14.2 vs. 11.5%, p < .01).

Conclusions: Among all-comers who received PCI for CBLs in the context of ACS, women suffered higher MAEs and 30-day readmission rates compared to their men' counterparts. The higher MAEs in the women were mainly driven by higher postprocedural bleeding rates and the need for blood transfusion.
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http://dx.doi.org/10.1002/ccd.29704DOI Listing
May 2021

Association of Transcatheter Mitral Valve Repair Availability With Outcomes of Mitral Valve Surgery.

J Am Heart Assoc 2021 04 23;10(7):e019314. Epub 2021 Mar 23.

Department of Cardiovascular Surgery Mayo Clinic School of Medicine Rochester MN.

Background Transcatheter mitral valve repair (TMVr) is currently offered at selected centers that meet certain operator and institutional requirements. We sought to explore the hypothesis that the availability of TMVr is associated with improved outcomes of MV surgery. Methods and Results We used the Nationwide Readmissions Database to identify patients who underwent MV surgery at centers with or without TMVr capabilities between January 1 and December 31, 2017. The primary end point was in-hospital mortality. Secondary end points were postoperative complications, resource use, and 30-day readmissions. A total of 24 477 patients from 595 centers (446 TMVr, 149 non-TMVr) were included. There were modest but statistically significant differences in the prevalence of comorbidities between the groups. Patients at non-TMVr centers had higher unadjusted in-hospital mortality than those at TMVr centers (5.6% versus 3.6%, <0.001). They also had higher rates of postoperative complications, longer hospitalizations, higher cost, and fewer home discharges but similar 30-day readmission rates. After propensity matching, mortality remained higher at non-TMVr centers (5.5% versus 4.0%, <0.001). Rates of postoperative complications, prolonged hospitalizations, and nonhome discharges also remained higher. Postoperative mortality was consistently higher at non-TMVr centers in multiple risk-adjustment analyses incrementally accounting for differences in risk factors, surgical volume, availability of surgical repair, and excluding concomitant procedures. In the most comprehensive model, surgery at non-TMVr centers was associated with higher odds of death (odds ratio, 1.41; 95% CI, 1.14-1.73; =0.002). Conclusions Mitral valve surgery at TMVr centers is associated with improved in-hospital outcomes compared with non-TMVr centers.
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http://dx.doi.org/10.1161/JAHA.120.019314DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8174333PMC
April 2021

National Trends in Mechanical and Bioprosthetic Valve Replacement Among Women of Childbearing Age.

Am J Cardiol 2021 05 5;146:137-138. Epub 2021 Feb 5.

Department of Cardiology, Mayo Clinic School of Medicine, Rochester, Minnesota. Electronic address:

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http://dx.doi.org/10.1016/j.amjcard.2021.01.009DOI Listing
May 2021

Determinants of Morbidity and Mortality Associated With Isolated Tricuspid Valve Surgery.

J Am Heart Assoc 2021 01 5;10(2):e018417. Epub 2021 Jan 5.

Department of Cardiovascular Diseases Mayo Clinic School of Medicine Rochester MN.

Background Whether the poor outcomes of isolated tricuspid valve surgery are related to the operation itself or to certain patient characteristics including late referral is unknown. Methods and Results Adult patients who underwent isolated tricuspid valve surgery were identified in the Nationwide Readmissions Database (2016-2017). Patients who had redo tricuspid valve surgery, endocarditis, or congenital heart disease were excluded. Multivariable logistic regression was performed to identify contributors to postoperative mortality. A total of 1513 patients were included (mean age 55.7±16.6 years, 49.6% women). Surrogates of late referral were frequent: 41% of patients were admitted with decompensated heart failure, 44.3% had a nonelective surgery status, 16.8% had advanced liver disease, and 31% had an unplanned hospitalization in the prior 90 days. The operation was performed on day 0 to 1 of the hospitalization in only 50% of patients, and beyond day 10 in 22% of patients. In-hospital mortality occurred in 8.7% of patients. Median length of stay was 14 days (7-35 days), and median cost was $87 223 ($43 122-$200 872). In multivariable logistic regression analysis, surrogates for late referrals (acute heart failure decompensation, nonelective surgery status, or advanced liver disease) were the strongest predictors of in-hospital mortality (odds ratio [OR], 4.75; 95% CI, 2.74-8.25 [<0.001]). This was also consistent in a second model incorporating unplanned hospitalizations in the 90 days before surgery as a surrogate for late referral (OR, 5.50; 95% CI, 2.28-10.71 [<0.001]). Conclusions The poor outcomes of isolated tricuspid valve surgery may be largely explained by the late referral for intervention. Studies are needed to determine the role of early intervention for severe isolated tricuspid regurgitation.
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http://dx.doi.org/10.1161/JAHA.120.018417DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7955319PMC
January 2021

Transcatheter Mitral Valve Repair Following Ring Annuloplasty: Technical Challenges and the Role of Invasive Hemodynamics.

JACC Cardiovasc Interv 2020 12 11;13(23):e207-e209. Epub 2020 Nov 11.

Department of Cardiovascular Disease, Mayo Clinic School of Medicine, Rochester, Minnesota, USA.

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http://dx.doi.org/10.1016/j.jcin.2020.09.046DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8371991PMC
December 2020

The state of renal sympathetic denervation for the management of patients with hypertension: A systematic review and meta-analysis.

Catheter Cardiovasc Interv 2021 03 12;97(4):E438-E445. Epub 2020 Nov 12.

Division of Cardiology, West Virginia University School of Medicine, Morgantown, West Virginia.

Background: Sympathetic nervous system plays a central role in the development and persistence of essential hypertension. In recent years renal sympathetic denervation (RSD) has emerged as a promising option for the treatment of patients with hypertension.

Methods: We conducted a literature search of PubMed, EMBASE, Cochrane library and Clinicaltrials.gov from inception through April 20, 2020. Outcomes of interest were change in 24-hour ambulatory systolic (ASBP) or diastolic blood pressure (ADBP) and change in office systolic (OSBP) or diastolic blood pressure (ODBP). We pooled data from randomized controlled trials (RCTS) comparing RSD to sham procedures in the management of hypertension using the random effect model.

Results: A total of 1,363 patients from eight studies were included in the current meta-analysis. The mean age of the included patients was 56 ± 2.6 years, 29% were women and the median duration of maximum follow up was 6-month (range 3-12 month). There was more reduction favoring RSD in ASBP (Weighted mean difference [WMD] -3.55; 95% CI -4.91 - -2.19, p < .001, I = 0%), ADBP (WMD -1.87; 95% CI -3.07 - -0.66, p = .002, I = 43%), OSBP (WMD -5.5; 95% CI -7.59 - -3.40, p < .001, I = 7%) and ODBP (WMD -3.20; 95% CI -4.47 - -1.94, p < .001, I = 14%).

Conclusion: The use of RSD for the management of hypertension resulted in effective reduction in the ambulatory and office blood pressure compared to sham procedure. Adequately powered RCTs of RSD are needed to confirm safety, reproducibility and assess the impact on clinical outcomes.
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http://dx.doi.org/10.1002/ccd.29384DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8381272PMC
March 2021

Temporal Trends in Resource Use, Cost, and Outcomes of Transcatheter Aortic Valve Replacement in the United States.

Mayo Clin Proc 2020 12 6;95(12):2665-2673. Epub 2020 Nov 6.

Department of Cardiovascular Medicine, Mayo Clinic School of Medicine, Rochester, MN. Electronic address:

Objective: To evaluate the contemporary trends in outcomes and resource use associated with transcatheter aortic valve replacement (TAVR) in the United States.

Methods: We identified patients who underwent TAVR between January 1, 2012, and December 31, 2017, in the National Readmission Database. We assessed temporal trends in clinical outcomes, length-of-stay, non-home discharges, and cost of the index TAVR hospitalization. We also evaluated the changes in the burden of hospitalizations before and after TAVR.

Results: A total of 89,202 patients were included. In-hospital mortality decreased from 5.3% (188) in 2012 to 1.6% (484) in 2017 (adjusted odds ratio: 0.37, 95% CI: 0.30 to 0.46). Risk-adjusted incidences of new dialysis, vascular complications, blood transfusion, and mechanical ventilation decreased, but strokes and pacemaker implantations remained unchanged. Length of stay decreased from median of 7 (interquartile range [IQR]: 4 to 11) to 2 (IQR: 2 to 5) days (P<.001). Risk-adjusted non-home discharges decreased from 32.2% (1134) to 15.5% (386) (P<.001). Median cost of the TAVR hospitalization decreased from $56,022 (IQR: $43,690 to $75,174) to $46,101 (IQR: $36,083 to $59,752) (P<.001). Pre-TAVR admissions at 30, 90, and 180 days decreased from 21.6% (713), 39.5% (1160), and 50.5% (1009) in 2012 to 15.5% (4451), 30.2% (7186), and 36.8% (5928) in 2017, respectively (P<.001). Similarly, re-hospitalizations at 30, 90, and 180 days post-TAVR decreased from 17.5% (531), 27.9% (657), and 34.2% (521) to 12.4% (3486), 21.1% (4783), and 29.1% (4306), respectively (P<.001). The expenditure on index, pre-, and post-TAVR hospitalizations increased from $0.53 to $2.8 billion between 2012 and 2017.

Conclusion: This study reflects the changes in the characteristics and outcomes of TAVR in the United States between 2012 and 2017. It also shows the temporal decrease in resource use, cost, and burden of hospitalizations among patients undergoing TAVR in the United States, but an increase in the overall expenditure on TAVR-related hospitalizations.
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http://dx.doi.org/10.1016/j.mayocp.2020.05.043DOI Listing
December 2020

Trends in the Use of Isolated Surgical and Transcatheter Aortic Valve Replacement in Patients Younger Than 70 Years of Age.

Mayo Clin Proc 2020 11;95(11):2571-2572

Department of Cardiovascular Diseases, Mayo Clinic School of Medicine, Rochester, MN.

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http://dx.doi.org/10.1016/j.mayocp.2020.09.018DOI Listing
November 2020

Gender-based outcomes of impeller pumps percutaneous ventricular assist devices.

Catheter Cardiovasc Interv 2021 04 15;97(5):E627-E635. Epub 2020 Oct 15.

Division of Cardiology, West Virginia University School of Medicine, Morgantown, West Virginia, USA.

Background: There is paucity of data focusing on females' outcomes after the use of impeller pumps percutaneous ventricular assist devices (IPVADs).

Methods: Patients who received IPVADs during the period of October 1st, 2015-December 31, 2017, were identified from the United States National Readmission Database. A 1:1 propensity score matching was used to compare the outcomes between females and males.

Results: A total of 19,278 (Female = 5,456; Male = 13,822) patients were included in the current analysis. After propensity score matching and among all-comers who were treated with IPVADs, females had higher in-hospital major adverse events (MAEs) (38 vs. 32.6%, p < .01), mortality (31 vs. 28%, p < .01), vascular complications (3.3 vs. 2.1%, p < .01), major bleeding (7.8 vs. 4.8%, p < .01), nonhome discharges (21.6 vs. 16.3%; p < .01), and longer length of stay (7 days [IQR 2-12] vs. 6 days [IQR 2-12], p = .02) with higher 30-day readmission rate compared to males (20.5 vs.16.4%, p < .01). Furthermore, among patients who received the IPVADs for high-risk percutaneous coronary intervention (HRPCI), females continued to have worse MAEs, which was driven by high rates of major bleeding. However, among patients who received IPVADs for cardiogenic shock (CS) the outcomes of females and males were comparable.

Conclusions: Among all-comers who received IPVADs, females suffered higher morbidity and mortality compared to males. Higher morbidity driven mainly by higher rates of major bleeding was seen among females who received IPVADs for the hemodynamic support during HRPCI and comparable outcomes were observed when the IPVADs were used for CS.
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http://dx.doi.org/10.1002/ccd.29222DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8381270PMC
April 2021

Sex-stratified analysis of the safety of percutaneous left atrial appendage occlusion.

Catheter Cardiovasc Interv 2021 04 13;97(5):885-892. Epub 2020 Oct 13.

Department of Cardiovascular Diseases, Mayo Clinic School of Medicine, Rochester, Minnesota, USA.

Objectives And Background: There is insufficient current evidence about whether sex impacts outcomes of percutaneous left atrial appendage occlusion (LAAO). The aim of this study was to investigate the association between sex and short-term outcomes of LAAO.

Methods: Patients who were hospitalized and underwent LAAO from October 2015 to December 2017 in the National Readmission Database were queried. The primary endpoint of interest was major in-hospital adverse events. Secondary endpoints included, 30-day readmission rate, nonhome discharge, and cost of hospitalization. Propensity score matching (1:1) was performed to compare the outcomes among women and men.

Results: A total of 9,281 patients were included in the current analysis [women = 3,659 (39%); men = 5,622 (61%)]. Comparing women to men, women had lower prevalence of diabetes mellitus (30.6% vs 35.7%, p < .01), heart failure (28.6% vs 30.8%, p = .03), vascular disease (55.5% vs 69.6%, p < .01) and renal failure (18.3% vs 21.2%, p < .01), and higher CHA DS VASc score (5 [IQR4-6] vs 4 [IQR3-6], p < .01). After propensity-score matching, women had higher rate of major in-hospital adverse events (2.8% vs 1.9%; p < .01), and nonhome discharges (11.4% vs 6.7%; p < .01). Additionally, 30-day readmission rate was higher among women (10% vs 8.6%, p = .03).

Conclusion: Among hospitalized patients undergoing LAAO, women carry higher risk for major in-hospital adverse events, nonhome discharge, and 30-day readmission rates.
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http://dx.doi.org/10.1002/ccd.29282DOI Listing
April 2021

Temporal Trends in the Incidence and Outcomes of Pacemaker Implantation After Transcatheter Aortic Valve Replacement in the United States (2012-2017).

J Am Heart Assoc 2020 09 31;9(18):e016685. Epub 2020 Aug 31.

Department of Cardiovascular Diseases Mayo Clinic School of Medicine Rochester MN.

Background Nationwide studies documenting temporal trends in permanent pacemaker implantation (PPMI) following transcatheter aortic valve replacement (TAVR) are limited. Methods and Results We selected patients who underwent TAVR between 2012 and 2017 in the National Readmission Database. The primary end point was the 6-year trend in post-TAVR PPMI at index hospitalization and at 30, 90, and 180 days after discharge. The secondary end point was the association between PPMI and in-hospital mortality, stroke, cost, length of stay, and disposition. Among the 89 202 patients who underwent TAVR, 77 405 (86.8%) with no prior pacemaker or defibrillator were included. Patients who required PPMI had a higher prevalence of atrial fibrillation (43.6% versus 38.7%, <0.001) and conduction abnormalities (28.4% versus 15.3%, <0.001). The incidence of PPMI during index admission increased from 8.7% in 2012 to 13.2% in 2015, and then decreased to 9.6% in 2017. The incidence of inpatient PPMI within 30 days after discharge increased from 0.5% in 2012 to 1.25% in 2017 (<0.001). Inpatient PPMI beyond 30 days remained rare (<0.5%) during the study period. After risk adjustment, PPMI was not associated with in-hospital mortality or stroke but was associated with increased nonhome discharge, longer hospitalization, and higher cost. The incremental expenditure associated with post-TAVR PPMI during index admission increased from $9.6 million to $72.2 million between 2012 and 2017. Conclusions After an upward trend, rates of PPMI after TAVR in the United States stabilized at ~10% in 2016 to 2017, but there was a notable increase in PPMI within 30 days after the index admission. PPMI was not associated with increased in-hospital morbidity or mortality but led to longer hospitalization, higher cost, and more nonhome discharges.
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http://dx.doi.org/10.1161/JAHA.120.016685DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7726966PMC
September 2020

Validation of Acute Myocardial Infarction Codes Using the InternationalClassification of Diseases, Tenth Revision.

Cardiovasc Revasc Med 2020 07 13;21(7):929-930. Epub 2020 Mar 13.

Division of Cardiology, Department of Medicine, West Virginia University, Morgantown, WV, United States of America; Department of Cardiology, Mayo Clinic School of Medicine, Rochester, MN, United States of America. Electronic address:

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http://dx.doi.org/10.1016/j.carrev.2020.03.018DOI Listing
July 2020

Balloon Aortic Valvuloplasty as a Bridge to Aortic Valve Replacement: A Contemporary Nationwide Perspective.

JACC Cardiovasc Interv 2020 03 12;13(5):583-591. Epub 2020 Feb 12.

Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota. Electronic address:

Objectives: This study sought to use a national representative database to assess the incidence, predictors, and outcomes of balloon aortic valvuloplasty (BAV) as a bridge to transcatheter aortic valve replacement (TAVR) in contemporary practice.

Background: Nationwide data on the use and outcomes of BAV as a bridge to TAVR are limited.

Methods: Patients who underwent BAV between January and June in 2015 and 2016 were identified in the National Readmission Database. We assessed rate of subsequent TAVR following BAV, and predictors and timing of subsequent TAVR. We then identified a group of patients who had direct TAVR (without prior BAV) in the original 2015 to 2016 National Readmission Database dataset. We compared in-hospital outcomes following TAVR between patients with prior bridging BAV and those undergoing direct TAVR.

Results: Among the 3,691 included patients 1,426 (38.6%) had subsequent TAVR. Timing of TAVR was pre-discharge in 7.4%, within 30 days in 35%, between 31 and 90 days in 47%, between 91 and 180 days in 14%, and >180 days in 4%. Negative predictors of subsequent TAVR included prior defibrillator (odds ratio [OR]: 0.56; 95% confidence interval [CI]: 0.36 to 0.85), dementia (OR: 0.60; 95% CI: 0.46 to 0.79), malnutrition (OR: 0.64; 95% CI: 0.45 to 0.90), and malignancy (OR: 0.62; 95% CI: 0.47 to 0.82). In propensity-score matched cohorts of patients who underwent direct TAVR versus those with prior BAV, in-hospital mortality during TAVR admission was similar (3.7% vs. 3.5%; p = 0.91). Major complications, length of stay, and discharge disposition were also comparable. However, cost of the hospitalization was higher in the direct TAVR group.

Conclusions: About 40% of BAV patients undergo subsequent TAVR mostly within 90 days. In-hospital outcomes of TAVR in these patients were comparable with propensity-score matched patients who underwent TAVR without prior BAV. Further investigations are needed to define the role of BAV in contemporary practice.
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http://dx.doi.org/10.1016/j.jcin.2019.11.041DOI Listing
March 2020

Mechanical Circulatory Support in Patients with Cardiogenic Shock.

Curr Treat Options Cardiovasc Med 2020 Jan 30;22(2). Epub 2020 Jan 30.

Division of Cardiology, West Virginia University School of Medicine, Morgantown, WV, USA.

Purpose Of Review: To provide a contemporary concise overview of the currently available mechanical circulatory support (MCS) devices and the emerging concepts in the management of cardiogenic shock (CS).

Recent Findings: New classification of CS has emerged and is hoped to allow a unified approach to research and clinical management of CS. A number of MCS devices have also become available for clinical use in the last 2 decades. Those devices have different hemodynamic targets, provide various levels of support, and are associated with specific requirements and potential complications. Data on the utility of MCS in CS remains conflicting with randomized trials showing no benefit of MCS, and observational data suggesting an incremental value for MCS over medical therapy. However, the early use and escalation of MCS in a standardized approach do appear to provide a remarkable improvement in short-term outcomes of patients with CS. MCS devices afforded lifesaving treatment for many patients with CS. However, optimal utilization of such devices requires familiarity with their clinical data, and technical characteristics, and mandates their integration in an algorithmic team-based approach to CS.
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http://dx.doi.org/10.1007/s11936-020-0804-6DOI Listing
January 2020

Validation of Acute Ischemic Stroke Codes Using the International Classification of Diseases Tenth Revision.

Am J Cardiol 2020 04 8;125(7):1135. Epub 2020 Jan 8.

Division of Cardiology, Department of Medicine, West Virginia University, Morgantown, West Virginia; Department of Cardiology, Mayo Clinic School of Medicine, Rochester, Minnesota. Electronic address:

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http://dx.doi.org/10.1016/j.amjcard.2020.01.004DOI Listing
April 2020

Thirty-Day Readmissions After Chronic Total Occlusion Percutaneous Coronary Intervention in the United States: Insights From the Nationwide Readmissions Database.

Cardiovasc Revasc Med 2020 08 26;21(8):992-997. Epub 2019 Dec 26.

Division of Cardiology, Department of Medicine, West Virginia University, Morgantown, WV, United States of America; Department of Cardiovascular Diseases, Mayo Clinic College of Medicine, Rochester, MN, United States of America. Electronic address:

Background: Several studies have investigated early readmissions after percutaneous coronary interventions (PCIs). However, studies investigating 30-day readmission following PCI for chronic total occlusion (CTO) are lacking.

Methods: The National-Readmission-Database (NRD) was queried to identify patients undergoing elective CTO PCI between January 1, 2016 and December 31, 2016. We assessed the incidence, predictors, and cost of 30-day readmissions.

Results: A total of 30,579 CTO PCIs were identified in the NRD. After excluding patients who had acute myocardial infarction (n = 14,852), the final cohort included 15,907 patients. In this group of patients, 254 patients (1.5%) expired during their index admission and, 1600 patients (10%) had an unplanned readmission within 30 days. Cardiac causes constituted 54.2% of all causes of readmission. During the readmission, 15.8% of patients had coronary angiography, 8.4% underwent PCI, and 0.9% underwent bypass grafting. Independent predictors of 30-day readmission included baseline characteristics [age (OR 0.99, 95%CI 0.98-0.99), female (OR 1.14, 95%CI 1.01-1.28), lung disease (OR 1.36, 95%CI 1.20-1.55), heart failure (OR 1.42, 95%CI 1.24-1.62), anemia (OR 1.30, 95%CI 1.12-1.50), vascular disease (OR 1.18, 95%CI 1.03-1.35), history of stroke (OR 1.50, 95%CI 1.28-1.76) and the presence of a defibrillator (OR 1.68, 95%CI 1.39-2.03)], and procedural complications [acute kidney injury (OR 1.55, 95%CI 1.33-1.80) and gastrointestinal bleeding (OR 1.67, 95%CI 1.03-2.71)].

Conclusions: One-tenth of patients undergoing CTO PCI are readmitted within 30-days, mostly for cardiac causes. The majority undergo angiography but <10% receive revascularization. Certain patient and procedural characteristics independently predicted 30-day readmission.
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http://dx.doi.org/10.1016/j.carrev.2019.12.025DOI Listing
August 2020

Incidence and Outcomes of Acute Ischemic Stroke Following Percutaneous Coronary Interventions in Men Versus Women.

Am J Cardiol 2020 02 7;125(3):336-340. Epub 2019 Nov 7.

King Fahd Armed Forces Hospital, Jeddah, Saudi Arabia.

Comparative data on the incidence and outcomes of stroke after percutaneous coronary interventions (PCI) between men and women are limited. We identified hospitalizations for PCI in the National-Inpatient-Sample between January 1, 2003 and December 31, 2016. We compared the incidence of post-PCI stroke and in-hospital complications, mortality, and cost of post-PCI strokes between men and women. Among 8,753,574 weighted hospitalizations for PCI, 49,097 (0.56%) were complicated with ischemic stroke. The incidence of post-PCI stroke was higher in women than men following PCI for ST-elevation myocardial infarction (STEMI) 1.4% versus 0.8% (odds ratio [OR] 1.69, 95% confidence interval [CI] 1.62 to 1.77, p <0.001), non-ST-elevation myocardial infarction (NSTEMI) 1.1% versus 0.7% (OR 1.59, 95% CI 1.52 to 1.63, p <0.001), and unstable angina/stable ischemic heart disease (US/SIHD) (0.5% vs 0.3%, OR 1.66, 95% CI 1.61 to 1.72, p <0.001). These differences remained significant after risk adjustment. Among patients with post-PCI stroke, women had worse on-hospital mortality, and major complications compared with men. However, after propensity score matching, post-PCI mortality was similar in men and women who suffered a stroke after STEMI (23.0% vs 25.7%, p = 0.34), and NSTEMI (9.9% vs 9.1%, p = 0.56), but higher in women who suffered a stroke after PCI for UA/SIHD (12.5% vs 10.4%, p = 0.042). Surrogates of disabling stroke, length of stay, and cost were similar in men and women. However, women had more vascular complications and blood transfusion across all indications. In conclusion, women are more likely to suffer post-PCI stroke than males regardless of the PCI indication. Among those with post-PCI strokes, women have higher adjusted rates of vascular complications and blood transfusion.
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http://dx.doi.org/10.1016/j.amjcard.2019.10.045DOI Listing
February 2020

Temporal trends in the utilization and outcomes of percutaneous coronary interventions in patients with liver cirrhosis.

Catheter Cardiovasc Interv 2020 10 12;96(4):802-810. Epub 2019 Nov 12.

Division of Cardiology, West Virginia University, Morgantown, West Virginia.

Objectives: We sought to assess the national trends in the utilization and outcomes of percutaneous coronary interventions (PCI) in patients with cirrhosis.

Background: Contemporary data on PCI in patients with liver cirrhosis are limited.

Methods: The National-Inpatient-Sample was used to identify patients who underwent PCI between 2003 and 2016. We examined the annual PCI rate, and compared the in-hospital morbidity, mortality, resource utilization, and cost following PCI in patients with and without cirrhosis.

Results: A total of 8,860,178 PCI hospitalizations were identified, of those, 20,339 (0.2%) were performed in patients with cirrhosis. Annual PCI rates decreased overtime in patients without liver cirrhosis but increased in those with cirrhosis (P < .001). Patients with cirrhosis had a characteristic clinical, demographic, and socioeconomic profile compared with those without cirrhosis. The use of bare-metal stents decreased from 69.1 to 11.4% in the noncirrhosis group, and from 81.9 to 21.3% in the cirrhosis group. Compared with propensity-matched patients without cirrhosis, PCI in cirrhotic patients was associated with higher in-hospital mortality across all indications (STEMI 19.1 vs. 11.5%, p = .002; NSTEMI 8.7 vs. 5.6%, p = .002; and UA/SIHD 7.7 vs. 4.3%, p < .001). Cirrhotic patients also had significantly higher rates of acute kidney injury, but similar rates of vascular complications and stroke. Additionally, cirrhotic patients had longer hospitalizations, were less likely to be discharged home, and accrued higher cost across all PCI indications.

Conclusions: Patients with cirrhosis who are deemed "suitable PCI candidates" in current practice remain at high-risk for worse short-term morbidity and mortality, and higher cost of care.
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http://dx.doi.org/10.1002/ccd.28593DOI Listing
October 2020

Management of Coronary Artery Aneurysms.

JACC Cardiovasc Interv 2018 07;11(13):1211-1223

Division of Cardiology, Department of Medicine, West Virginia University, Morgantown, West Virginia; Department of Cardiology, Mayo Clinic, Rochester, Minnesota. Electronic address:

Aneurysmal dilation of coronary arteries is observed in up to 5% of patients undergoing coronary angiography. Due to their poorly elucidated underlying mechanisms, their variable presentations, and the lack of largescale outcome data on their various treatment modalities, coronary artery aneurysms and coronary ectasia pose a challenge to the managing clinician. This paper aims to provide a succinct review of aneurysmal coronary disease, with a special emphasis on the challenges associated with its interventional treatment.
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http://dx.doi.org/10.1016/j.jcin.2018.02.041DOI Listing
July 2018

Iatrogenic Circumflex Artery Stenosis Following Mitral Valve Repair.

Cureus 2017 Sep 12;9(9):e1680. Epub 2017 Sep 12.

Division of Cardiovascular Disease, West Virginia University School of Medicine/Ruby Memorial Hospital.

Injury of the left circumflex coronary artery is a potentially serious complication of mitral valve surgery due to the proximity of the vessel to the posterior segment of the mitral annulus. Suture-related distortion of the artery with partial or subtotal occlusion is the most commonly implicated mechanism. Herein, we present a case of symptomatic iatrogenic circumflex coronary artery stenosis following mitral valve annuloplasty for degenerative mitral valve regurgitation.
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http://dx.doi.org/10.7759/cureus.1680DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5679764PMC
September 2017

Outcomes of Transcatheter Versus Surgical Aortic Valve Implantation for Aortic Stenosis in Patients With Hepatic Cirrhosis.

Am J Cardiol 2017 Oct 14;120(7):1193-1197. Epub 2017 Jul 14.

Division of Cardiovascular Disease, West Virginia University, Morgantown, West Virginia; Department of Cardiovascular Disease, Mayo Clinic, Rochester, Minnesota. Electronic address:

Current risk prediction tools for transcatheter aortic valve implantation (TAVI) or surgical aortic valve replacement (SAVR) do not include variables associated with clinically significant hepatic disease. Accordingly, outcome data of TAVI or SAVR in patients with liver cirrhosis are limited. We sought to assess contemporary trends and outcomes of TAVI and SAVR in patients with liver cirrhosis using a national database. The Nationwide Inpatient Sample was used to identify patients with liver cirrhosis who underwent TAVI or SAVR between 2003 and 2014. Outcomes of propensity-matched groups of patients undergoing TAVI or SAVR were assessed. The reported number of TAVI and SAVR procedures in patients with liver cirrhosis increased from 376 cases in 2003 to 1,095 cases in 2014. A total of 1,766 patients with liver cirrhosis who underwent TAVI (n = 174) or SAVR (n = 1,592) were included in the analysis. In-hospital mortality was higher in patients who underwent SAVR versus TAVI (20.2% vs 8%, p <0.001). Major adverse events were also more frequent after SAVR. Propensity matching attained 2 groups of 268 patients who underwent TAVI (n = 134) or SAVR (n = 134). Following propensity matching, in-hospital mortality remained higher in the SAVR group (18.7% vs 8.2%, p = 0.018), but major adverse events were not different between the 2 groups. Hospital length of stay was longer, and nonhome disposition rates were higher in the SAVR group. In conclusion, the number of reported TAVI and SAVR in patients with liver cirrhosis and aortic stenosis increased 3-folds between 2003 and 2014. In these patients, TAVI was associated with lower in-hospital mortality when compared with SAVR.
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http://dx.doi.org/10.1016/j.amjcard.2017.06.067DOI Listing
October 2017

A Case of Transient ST Elevation and Polymorphic Tachycardia without Angina Diagnosed by Holter Monitoring.

Cureus 2017 May 25;9(5):e1273. Epub 2017 May 25.

Division of Cardiovascular Disease, West Virginia University School of Medicine/Ruby Memorial Hospital.

We report the case of 52-year-old female with recurrent episodes of palpitations and dizziness. Holter monitoring revealed transient ST elevations followed by episodes of polymorphic ventricular tachycardia associated with episodes of palpitations and dizziness. Coronary angiography revealed mildly irregular right coronary artery with 90% stenosis. The patient underwent percutaneous coronary intervention with successful placement of a stent to the mid-right coronary artery. The patient has been followed closely over a period of 12 months. There haven't been any recorded episodes of tachycardia, and the patient has remained symptom-free.
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http://dx.doi.org/10.7759/cureus.1273DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5481187PMC
May 2017
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