Publications by authors named "Mohamad Alkhouli"

275 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

Doppler Mean Gradient Is Discordant to Aortic Valve Calcium Scores in Patients with Atrial Fibrillation Undergoing Transcatheter Aortic Valve Replacement.

J Am Soc Echocardiogr 2021 Sep 8. Epub 2021 Sep 8.

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

Background: Doppler mean gradient (MG) may underestimate aortic stenosis (AS) severity when obtained during atrial fibrillation (AF) because of lower forward flow compared with sinus rhythm (SR). Whether AS is more advanced at the time of referral for aortic valve intervention in AF compared with SR is unknown. The aim of this study was to examine flow-independent computed tomographic aortic valve calcium scores (AVCS) and their concordance to MG in AF versus SR in patients undergoing transcatheter aortic valve replacement (TAVR).

Methods: Patients who underwent TAVR from 2016 to 2020 for native valve severe AS with left ventricular ejection fraction ≥ 50% were identified from an institutional TAVR database. MGs during AF and SR in high-gradient AS (HGAS) and low-gradient AS (LGAS) were compared with AVCS (AVCS/MG ratio). AVCS were obtained within 90 days of pre-TAVR echocardiography.

Results: Six hundred thirty-three patients were included; median age was 82 years (interquartile range [IQR], 76-86 years), and 46% were women. AF was present in 109 (17%) and SR in 524 (83%) patients during echocardiography. Aortic valve area index was slightly smaller in AF versus SR (0.43 cm/m [IQR, 0.39-0.47 cm/m] vs 0.46 cm/m [IQR, 0.41-0.51 cm/m], P = .0003). Stroke volume index, transaortic flow rate, and MG were lower in AF (P < .0001 for all). AVCS were higher in men with AF compared with SR (3,510 Agatston units [AU] [IQR, 2,803-4,030 AU] vs 2,722 AU [IQR, 2,180-3,467 AU], P < .0001) in HGAS but not in LGAS. AVCS were not different in women with AF versus SR. Overall AVCS/MG ratios were higher in AF versus SR in HGAS and LGAS (P < .03 for all), except in women with LGAS.

Conclusions: AVCS were higher than expected by MG in AF compared with SR. The very high AVCS in men with AF and HGAS at the time of TAVR suggests late diagnosis of severe AS because of underestimated AS severity during progressive AS and/or late referral to TAVR. Additional studies are needed to examine the extent to which echocardiography may be underestimating AS severity in AF.
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http://dx.doi.org/10.1016/j.echo.2021.08.024DOI Listing
September 2021

Optimal management of acute decompensated aortic stenosis.

Catheter Cardiovasc Interv 2021 09;98(3):613-614

Department of Medicine, Division of Cardiology, Baylor College of Medicine, Houston, Texas, USA.

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http://dx.doi.org/10.1002/ccd.29878DOI Listing
September 2021

Utility of Intracardiac Echocardiography in the Early Experience of Transcatheter Edge to Edge Tricuspid Valve Repair.

Circ Cardiovasc Interv 2021 Oct 3;14(10):e011118. Epub 2021 Sep 3.

Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN (M.F.E., M.A., J.J.T., M.G., G.S.R., C.S.R.).

[Figure: see text].
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http://dx.doi.org/10.1161/CIRCINTERVENTIONS.121.011118DOI Listing
October 2021

First-in-Human Use of a Novel Live 3D Intracardiac Echo Probe to Guide Left Atrial Appendage Closure.

JACC Cardiovasc Interv 2021 Aug 18. Epub 2021 Aug 18.

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

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http://dx.doi.org/10.1016/j.jcin.2021.07.024DOI Listing
August 2021

Effect of eliminating pre-discharge transthoracic echocardiogram on outcomes after TAVR.

Catheter Cardiovasc Interv 2021 Aug 13. Epub 2021 Aug 13.

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

Objectives: The aim of this study was to determine the safety of eliminating the pre-discharge transthoracic echocardiogram (TTE) on 30-day outcomes in patients undergoing transcatheter aortic valve replacement (TAVR).

Background: TTE is utilized before, during, and after TAVR. Post-procedural, pre-discharge TTE assists in assessment of prosthesis function and detection of clinically significant paravalvular leak (PVL) after TAVR.

Methods: Patients who underwent TAVR at Mayo Clinic from July 2018 to July 2019 were included in a prospective institutional registry. Patients undergoing TAVR prior to February 2019 received a pre-discharge TTE, while those undergoing TAVR after February 2019 did not. Both cohorts were evaluated with TTE at 30 days post-TAVR.

Results: A total of 330 consecutive patients were included. Of these, 160 patients (age 81.1 ± 7.6) had routine pre-discharge TTE, while 170 patients (age 78.9 ± 7.5) were dismissed without routine pre-discharge TTE. Mortality at 30 days was similar between the two groups (0% and 1.2%, respectively). One episode of PVL requiring intervention (0.6%) occurred in the pre-discharge TTE group and none in the group without pre-discharge TTE at 30-day follow-up. There was a similar incidence of total composite primary and secondary adverse events between the cohort receiving a pre-discharge TTE and those without (28.1% vs. 25.3%, P = 0.56) at 30 days. The most common event was need for permanent pacemaker or ICD implantation in both groups (13.1% vs. 11.8%, P = 0.71).

Conclusions: Elimination of the pre-discharge TTE is safe and associated with comparable 30-day outcomes to routine pre-discharge TTE. These findings have implication for TAVR practice cost-efficiency and health care utilization.
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http://dx.doi.org/10.1002/ccd.29929DOI Listing
August 2021

Comparison of Outcomes of Patients With Versus Without Chronic Liver Disease Undergoing Percutaneous Coronary Intervention.

Am J Cardiol 2021 10 2;156:32-38. Epub 2021 Aug 2.

Keele Cardiovascular Research Group, Keele University, Stoke on Trent, United Kingdom; Department of Cardiology, Thomas Jefferson University, Philadelphia, Pennsylvania. Electronic address:

There are limited data on the outcomes of chronic liver disease (CLD) patients admitted for percutaneous coronary intervention (PCI). All PCI hospitalizations from the Nationwide Inpatient Sample (2004 to 2015) were analyzed and stratified by the presence, cause and severity of CLD, as well as the indication for PCI. Multivariable logistic regression analysis was performed to determine the adjusted odds ratios (aOR) of in-hospital adverse outcomes in patients with CLD compared with those without CLD. Among 7,296,679 PCI admissions, 54,368 (0.7%) had a CLD diagnosis. Among patients with CLD, 36,853 (67.8%) had severe CLD. Patients with CLD had higher likelihood of adverse outcomes including major adverse cardiovascular and cerebrovascular events (MACCE) (aOR 1.25, 95%CI 1.20 to 1.30), mortality (aOR 1.43, 95%CI 1.35 to 1.51), major bleeding (aOR 2.22, 95%CI 2.12 to 2.32). When accounting for severity, only severe CLD subgroup was more likely to have MACCE and all-cause mortality compared to no-CLD patients (p <0.001). Among CLD etiologic subgroups, those with 'alcohol-related liver disease' and 'other CLD' were consistently more likely to develop MACCE, all-cause mortality and major bleeding in comparison to no-CLD patients, while 'chronic viral hepatitis' subgroup had only increased odds of major bleeding (p <0.001). In conclusion, CLD patients admitted for PCI are more likely to have worse in-hospital outcomes, particularly in the severe CLD subgroup and 'alcohol-related liver disease' and 'other CLD' etiologic subgroups.
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http://dx.doi.org/10.1016/j.amjcard.2021.06.044DOI Listing
October 2021

Double-Envelope Mitral Continuous-Wave Doppler: Pressure, Velocity, or Else?

J Cardiothorac Vasc Anesth 2021 Nov 31;35(11):3445-3446. Epub 2021 May 31.

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

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http://dx.doi.org/10.1053/j.jvca.2021.05.051DOI Listing
November 2021

Anatomic Approach to Transseptal Puncture for Structural Heart Interventions.

JACC Cardiovasc Interv 2021 Jul;14(14):1509-1522

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

The use of transseptal puncture continues to rise given the increase in left atrial cardiac interventions. The authors review an anatomic approach to transseptal puncture incorporating multimodality imaging both pre- and intraprocedurally with stepwise escalation algorithms to ensure safe and efficacious large-bore transseptal puncture.
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http://dx.doi.org/10.1016/j.jcin.2021.04.037DOI Listing
July 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

Clinical predictors and impact of postoperative mean gradient on outcome after transcatheter edge-to-edge mitral valve repair.

Catheter Cardiovasc Interv 2021 Jul 10. Epub 2021 Jul 10.

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

Background: The predictors and clinical significance of increased Doppler-derived mean diastolic gradient (MG) following transcatheter edge-to-edge mitral valve repair (MVTEER) remain controversial.

Objective: We sought to examine baseline correlates of Doppler-derived increased MG post-MVTEER and its impact on intermediate-term outcomes.

Methods: Patients undergoing MVTEER were analyzed retrospectively. Post-MVTEER increased MG was defined as >5 mmHg or aborted clip implantation due to increased MG intraprocedurally. Baseline MG and 3D-guided mitral valve area (MVA) by planimetry were retrospectively available in 233 and 109 patients.

Results: 243 patients were included; 62 (26%) had MG > 5 mmHg post-MVTEER or aborted clip insertion, including 7 (11%) that had aborted clip implantation. Mortality occurred in 63 (26%) during a median follow up of 516 days (IQR 211, 1021). Increased post-MVTEER MG occurred more frequently in females (44% vs. 16%, p <  0.001), those with baseline MVA <4.0 cm (71% vs. 16%), baseline MG ≥4 mmHg (61% vs. 20%), or multiple clips implanted (33% vs. 21%, p = 0.04). Increased post-MVTEER MG was associated with increased subsequent mortality compared to those with normal gradient (HR 1.91 95% CI 1.15-3.18 p = 0.016) as was aborted clip insertion compared to all others (HR 5.23 95% CI 2.06-13.28 p <  0.001).

Conclusions: Smaller baseline MVA and increased baseline MG are associated with increased MG post-MVTEER and patients with a Doppler-derived post-MVTEER MG >5 mmHg suffered excess subsequent mortality. In high risk patients considered for MVTEER, identification of those at risk of iatrogenic mitral stenosis with MVTEER is important as they may be optimally treated with alternate surgical or transcatheter therapies.
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http://dx.doi.org/10.1002/ccd.29867DOI Listing
July 2021

Coronary Artery Fistulas: Indications, Techniques, Outcomes, and Complications of Transcatheter Fistula Closure.

JACC Cardiovasc Interv 2021 Jul;14(13):1393-1406

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

Coronary artery fistulas (CAFs) are rare coronary anomalies that are usually diagnosed incidentally with cardiac imaging. Small CAFs are generally asymptomatic and can close over time, while some untreated medium or large CAFs can enlarge, leading to clinical sequelae such as cardiac chamber enlargement or myocardial ischemia. With the advancement of transcatheter equipment and techniques, CAFs have been increasingly closed using a percutaneous approach. However, the procedure is not free of limitations given the risk for myocardial infarction, device embolization, and fistula recanalization. In this review, the authors illustrate the contemporary procedural considerations, techniques, and outcomes of transcatheter CAF closure.
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http://dx.doi.org/10.1016/j.jcin.2021.02.044DOI Listing
July 2021

Safety and Feasibility of Peri-device Leakage Closure after LAAO: An International, Multi-center Collaborative Study.

EuroIntervention 2021 07 6. Epub 2021 Jul 6.

Cardiovascular Center (CVC) Frankfurt, Frankfurt, Germany.

Background: Residual peri-device leakage (PDL) is frequent after left atrial appendage occlusion (LAAO). Little is known about management strategies, procedural aspects and outcomes of interventional PDL closure.

Aims: To assess safety and feasibility of PDL closure after LAAO.

Methods: Fifteen centers contributed data on baseline characteristics, in-hospital and follow-up outcomes of patients who underwent PDL closure after LAAO. Outcomes of interest included acute success and complication rates and long-term efficacy of the procedure.

Results: A total of 95 patients were included and a cumulative number of 104 leaks were closed. Majority of PDL were detected within 90 days [range 41-231]. Detachable coils were the most frequent approach (42.3%), followed by the use of Amplatzer™Vascular Plug II (Abbott, Chicago, IL, 29.8%) and the Amplatzer™ Duct Occluder II (Abbott, Chicago, IL, 17.3%). Technical success was 100% with 94.2% of devices placed successfully within the first attempt. There were no major complications requiring surgical or transcatheter interventions. During follow-up (96 days [range 49-526]), persistent leaks were found in 18 patients (18.9%), yielding a functional success rate of 82.7%, although PDLs were significantly reduced in size (pre-leak sizemax: 6.1±3.6 mm vs. post-leak sizemax: 2.5±1.3 mm, p<0.001). None of the patient had a leak >5mm. Major adverse events during follow-up occurred in 5 patients (2 ischemic strokes, 2 intracranial hemorrhages, and 1 major gastrointestinal bleeding).

Conclusions: Several interventional techniques have become available to achieve PDL closure. They are associated with high technical and functional success and low complication rates.
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http://dx.doi.org/10.4244/EIJ-D-21-00286DOI Listing
July 2021

Stroke-Related Mortality in the United States-Mexico Border Area of the United States, 1999 to 2018.

J Am Heart Assoc 2021 07 2;10(13):e019993. Epub 2021 Jul 2.

Department of Cardiovascular Medicine Mayo Clinic Rochester MN.

BACKGROUND The United States (US)-Mexico border is a socioeconomically underserved area. We sought to investigate whether stroke-related mortality varies between the US border and nonborder counties. METHODS AND RESULTS We used death certificates from the Centers for Disease Control and Prevention Wide-Ranging Online Data for Epidemiologic Research database to examine stroke-related mortality in border versus nonborder counties in California, Texas, New Mexico, and Arizona. We measured average annual percent changes (AAPCs) in age-adjusted mortality rates (AAMRs) per 100 000 between 1999 and 2018. Overall, AAMRs were higher for nonborder counties, older adults, men, and non-Hispanic Black adults than their counterparts. Between 1999 and 2018, AAMRs reduced from 55.8 per 100 000 to 34.4 per 100 000 in the border counties (AAPC, -2.70) and 64.5 per 100 000 to 37.6 per 100 000 in nonborder counties (AAPC, -2.92). The annual percent change in AAMR initially decreased, followed by stagnation in both border and nonborder counties since 2012. The AAPC in AAMR decreased in all 4 states; however, AAMR increased in California's border counties since 2012 (annual percent change, 3.9). The annual percent change in AAMR decreased for older adults between 1999 and 2012 for the border (-5.10) and nonborder counties (-5.01), followed by a rise in border counties and stalling in nonborder counties. Although the AAPC in AAMR decreased for both sexes, the AAPC in AAMR differed significantly for non-Hispanic White adults in border (-2.69) and nonborder counties (-2.86). The mortality decreased consistently for all other ethnicities/races in both border and nonborder counties. CONCLUSIONS Stroke-related mortality varied between the border and nonborder counties. Given the substantial public health implications, targeted interventions aimed at vulnerable populations are required to improve stroke-related outcomes in the US-Mexico border area.
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http://dx.doi.org/10.1161/JAHA.120.019993DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8403284PMC
July 2021

Distribution, management and outcomes of AMI according to principal diagnosis priority during inpatient admission.

Int J Clin Pract 2021 Oct 29;75(10):e14554. Epub 2021 Jun 29.

Keele Cardiovascular Research Group, Centre for Prognosis Research, Keele University, Keele, UK.

Background: In recent years, there has been a growing interest in outcomes of patients with acute myocardial infarction (AMI) using large administrative datasets. The present study was designed to compare the characteristics, management strategies and acute outcomes between patients with primary and secondary AMI diagnoses in a national cohort of patients.

Methods: All hospitalisations of adults (≥18 years) with a discharge diagnosis of AMI in the US National Inpatient Sample from January 2004 to September 2015 were included, stratified by primary or secondary AMI. The International Classification of Diseases, ninth revision and Clinical Classification Software codes were used to identify patient comorbidities, procedures and clinical outcomes.

Results: A total of 10 864 598 weighted AMI hospitalisations were analysed, of which 7 186 261 (66.1%) were primary AMIs and 3 678 337 (33.9%) were secondary AMI. Patients with primary AMI diagnoses were younger (median 68 vs 74 years, P < .001) and less likely to be female (39.6% vs 48.5%, P < .001). Secondary AMI was associated with lower odds of receipt of coronary angiography (aOR 0.19; 95%CI 0.18-0.19) and percutaneous coronary intervention (0.24; 0.23-0.24). Secondary AMI was associated with increased odds of MACCE (1.73; 1.73-1.74), mortality (1.71; 1.70-1.72), major bleeding (1.64; 1.62-1.65), cardiac complications (1.69; 1.65-1.73) and stroke (1.68; 1.67-1.70) (P < .001 for all).

Conclusions: Secondary AMI diagnoses account for one-third of AMI admissions. Patients with secondary AMI are older, less likely to receive invasive care and have worse outcomes than patients with a primary diagnosis code of AMI. Future studies should consider both primary and secondary AMI diagnoses codes in order to accurately inform clinical decision-making and health planning.
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http://dx.doi.org/10.1111/ijcp.14554DOI Listing
October 2021

Meta-Analysis of Racial Disparity in Utilization of Oral Anticoagulation for Stroke Prevention in Atrial Fibrillation.

Am J Cardiol 2021 08 18;153:147-149. Epub 2021 Jun 18.

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

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http://dx.doi.org/10.1016/j.amjcard.2021.05.008DOI Listing
August 2021

Carotid Intraplaque Hemorrhage: An Underappreciated Cause of Unexplained Recurrent Stroke.

JACC Cardiovasc Interv 2021 Sep 16;14(17):1950-1952. Epub 2021 Jun 16.

Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA.

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http://dx.doi.org/10.1016/j.jcin.2021.04.033DOI Listing
September 2021

Intracardiac echocardiography for guidance of transcatheter left atrial appendage occlusion: An expert consensus document.

Catheter Cardiovasc Interv 2021 10 4;98(4):815-825. Epub 2021 Jun 4.

Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark.

Transcatheter left atrial appendage occlusion (LAAO) is an increasingly used alternative to oral anticoagulation in selected patients with atrial fibrillation. Intraprocedural imaging is a crucial for a successful intervention, with transesophageal echocardiography (TEE) as the current gold standard. Since some important limitations may affect TEE use, intracardiac echocardiography (ICE) is increasingly used as an alternative to TEE for guiding LAAO. The lack of a standardized imaging protocol has slowed the adoption of ICE into clinical practice. On the basis of current research and expert consensus, this paper provides a protocol for ICE support of left atrial appendage occlusion.
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http://dx.doi.org/10.1002/ccd.29791DOI Listing
October 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

Pre- and Postprocedural CT of Transcatheter Left Atrial Appendage Closure Devices.

Radiographics 2021 May-Jun;41(3):680-698

From the Department of Radiology (P. Rajiah, T.F., E.W.) and Department of Cardiology (M.A., J.T.), Mayo Clinic, 200 1st St SW, Rochester, MN 55905; and Department of Radiology, UT Southwestern Medical Center, Dallas, Tex (P. Ranganath).

Transcatheter left atrial appendage (LAA) closure is an alternative to long-term anticoagulation therapy in selected patients with nonvalvular atrial fibrillation who have an increased risk for stroke. LAA closure devices can be implanted by means of either an endocardial or a combined endocardial and epicardial approach. Preprocedural imaging is key to identifying contraindications, accurately sizing the device, and minimizing complications. Transesophageal echocardiography (TEE) has been the reference standard imaging modality to assess the anatomy for LAA closure and to provide intraprocedural guidance. However, CT has emerged as a less-invasive alternative to TEE for pre- and postprocedural imaging. CT is comparable to TEE for exclusion of thrombus but is superior to TEE for the delineation of complex LAA anatomy, measurement for device sizing, and evaluation of pulmonary venous and extracardiac structures. CT provides accurate measurements of the LAA ostial diameter, landing zone diameter, and LAA length, which are vital for accurate sizing of the device. CT allows evaluation of the relationship with the pulmonary veins and other adjacent structures that can be injured during the procedure. CT also simulates procedural fluoroscopic angles and provides evaluation of the interatrial septum, which is punctured during LAA closure. CT also provides a more convenient method for the evaluation of postprocedural complications such as incomplete closure, peridevice leaking, device-related thrombus, and device dislodgement. RSNA, 2021.
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http://dx.doi.org/10.1148/rg.2021200136DOI Listing
May 2021

Multivessel Versus Culprit-Vessel Percutaneous Coronary Intervention in Patients With Non-ST-Segment Elevation Myocardial Infarction and Cardiogenic Shock.

JACC Cardiovasc Interv 2021 May 28;14(10):1067-1078. Epub 2021 Apr 28.

Saint Luke's Mid America Heart Institute and the University of Missouri-Kansas City, Kansas City, Missouri, USA.

Objectives: The aim of this study was to compare in-hospital outcomes and long-term mortality of multivessel versus culprit vessel-only percutaneous coronary intervention (PCI) in patients with non-ST-segment elevation myocardial infarction (NSTEMI), multivessel disease (MVD) and cardiogenic shock.

Background: The clinical benefits of complete revascularization in patients with NSTEMI, MVD, and cardiogenic shock remain uncertain.

Methods: Among 25,324 patients included in the National Cardiovascular Data Registry CathPCI Registry from July 2009 to March 2018, the rates of in-hospital procedural outcomes were compared between those undergoing multivessel PCI and those undergoing culprit vessel-only PCI after 1:1 propensity score matching. Among patients aged ≥65 years matched to the Centers for Medicare and Medicaid Services database, long-term mortality was compared using proportional hazards analysis.

Results: Multivessel PCI was performed in 9,791 patients (38.7%), which increased from 32.2% in 2010 to 44.2% in 2017 (p for trend <0.001). After 1:1 propensity matching (n = 7,864 in each group), those undergoing multivessel PCI had a 3.5% (95% confidence interval [CI]: 2.0% to 5.0%) lower absolute rate of in-hospital mortality (30.9% vs. 34.4%; p < 0.001; odds ratio [OR]: 0.85; 95% CI: 0.80 to 0.91), but a higher risk for bleeding (13.2% vs. 10.8%; p < 0.001; OR: 1.26; 95% CI: 1.15 to 1.40) and new requirement for dialysis (5.7% vs. 4.6%; p = 0.001; OR: 1.26; 95% CI: 1.10 to 1.46). Among those surviving to discharge, all-cause mortality was similar through 7 years (conditional hazard ratio: 0.95; 95% CI: 0.87 to 1.03; p = 0.20).

Conclusions: Nearly 40% of patients with NSTEMI with MVD and cardiogenic shock underwent multivessel PCI, which was associated with lower in-hospital mortality but greater peri-procedural complications. Among those surviving to discharge, multivessel PCI did not confer additional long-term mortality benefit.
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http://dx.doi.org/10.1016/j.jcin.2021.02.021DOI Listing
May 2021

Racial and ethnic disparities in coronary, vascular, structural, and congenital heart disease.

Catheter Cardiovasc Interv 2021 08 19;98(2):277-294. Epub 2021 May 19.

Cardiology, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, USA.

Cardiovascular disease (CVD) remains the leading cause of death in the United States. However, percutaneous interventional cardiovascular therapies are often underutilized in Blacks, Hispanics, and women and may contribute to excess morbidity and mortality in these vulnerable populations. The Society for Cardiovascular Angiography and Interventions (SCAI) is committed to reducing racial, ethnic, and sex-based treatment disparities in interventional cardiology patients. Accordingly, each of the SCAI Clinical Interest Councils (coronary, peripheral, structural, and congenital heart disease [CHD]) participated in the development of this whitepaper addressing disparities in diagnosis, treatment, and outcomes in underserved populations. The councils were charged with summarizing the available data on prevalence, treatment, and outcomes and elucidating potential reasons for any disparities. Given the huge changes in racial and ethnic composition by age in the United States (Figure 1), it was difficult to determine disparities in rates of diagnosis and we expected to find some racial differences in prevalence of disease. For example, since the average age of patients undergoing transcatheter aortic valve replacement (TAVR) is 80 years, one may expect 80% of TAVR patients to be non-Hispanic White. Conversely, only 50% of congenital heart interventions would be expected to be performed in non-Hispanic Whites. Finally, we identified opportunities for SCAI to advance clinical care and equity for our patients, regardless of sex, ethnicity, or race.
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http://dx.doi.org/10.1002/ccd.29745DOI Listing
August 2021

Predictors of Use and Outcomes of Mechanical Valve Replacement in the United States (2008-2017).

J Am Heart Assoc 2021 05 19;10(9):e019929. Epub 2021 Apr 19.

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

Background Contemporary nationwide data on the use, predictors, and outcomes of mechanical valve replacement in patients less than 70 years of age are limited. Methods and Results We identified hospitalizations for aortic valve replacement (AVR) or mitral valve replacement (MVR) in the Nationwide Inpatient Sample between January 1, 2008, and December 31, 2017. The study's end points included predictors of mechanical valve replacement and risk-adjusted in-hospital mortality. Among 253 100 hospitalizations for AVR, the use rate of mechanical prosthesis decreased from 45.3% in 2008 to 17.0% in 2017. Among 284 962 hospitalizations for MVR, mechanical prosthesis use decreased from 59.5% in 2008 to 29.2% in 2017 ( for trend<0.001). In multilogistic regression analyses, female sex, prior sternotomy, prior defibrillator, and South/West geographic location were predictive of mechanical valve use. The presence of bicuspid valve was a negative predictor of mechanical AVR (odds ratio [OR], 0.68; 95% CI, 0.66-0.69; <0.001), whereas mitral stenosis was associated with higher mechanical MVR (OR, 1.28; 95% CI, 1.22-1.33; <0.001). Unadjusted in-hospital mortality decreased over time with AVR but not with MVR, regardless of prosthesis choice. Using years 2008 and 2009 as a reference, risk-adjusted mortality also decreased over time with AVR but did not decrease after MVR. Conclusions There is a substantial decline in the use of mechanical valve replacement among patients aged ≤70 years in the United States. Long-term durability data on bioprosthetic valve replacement are needed to better define the future role of mechanical valves in this age group.
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http://dx.doi.org/10.1161/JAHA.120.019929DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8200758PMC
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

Utility of the CHA2DS2-VASc score for predicting ischaemic stroke in patients with or without atrial fibrillation: a systematic review and meta-analysis.

Eur J Prev Cardiol 2021 Mar 9. Epub 2021 Mar 9.

Department of Cardiovascular Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA.

Aims: Anticoagulants are the mainstay treatment for stroke prevention in patients with non-valvular atrial fibrillation (NVAF), and the CHA2DS2-VASc score is widely used to guide anticoagulation therapy in this cohort. However, utility of CHA2DS2-VASc in NVAF patients is debated, primarily because it is a vascular scoring system, which does not incorporate atrial fibrillation related parameters. Therefore, we conducted a meta-analysis to estimate the discrimination ability of CHA2DS2-VASc in predicting ischaemic stroke overall, and in subgroups of patients with or without NVAF.

Methods And Results: PubMed and Embase databases were searched till June 2020 for published articles that assessed the discrimination ability of CHA2DS2-VASc, as measured by C-statistics, during mid-term (2-5 years) and long-term (>5 years) follow-up. Summary estimates were reported as random effects C-statistics with 95% confidence intervals (CIs). Seventeen articles were included in the analysis. Nine studies (n = 453 747 patients) reported the discrimination ability of CHA2DS2-VASc in NVAF patients, and 10 studies (n = 138 262 patients) in patients without NVAF. During mid-term follow-up, CHA2DS2-VASc predicted stroke with modest discrimination in the overall cohort [0.67 (0.65-0.69)], with similar discrimination ability in patients with NVAF [0.65 (0.63-0.68)] and in those without NVAF [0.69 (0.68-0.71)] (P-interaction = 0.08). Similarly, at long-term follow-up, CHA2DS2-VASc had modest discrimination [0.66 (0.63-0.69)], which was consistent among patients with NVAF [0.63 (0.54-0.71)] and those without NVAF [0.67 (0.64-0.70)] (P-interaction = 0.39).

Conclusion: This meta-analysis suggests that the discrimination power of the CHA2DS2-VASc score in predicting ischaemic stroke is modest, and is similar in the presence or absence of NVAF. More accurate stroke prediction models are thus needed for the NVAF population.
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http://dx.doi.org/10.1093/eurjpc/zwab018DOI Listing
March 2021

Efficacy and safety for the achievement of guideline-recommended lower low-density lipoprotein cholesterol levels: a systematic review and meta-analysis.

Eur J Prev Cardiol 2020 Nov 28. Epub 2020 Nov 28.

Division of Cardiology, Department of Medicine, Johns Hopkins School of Medicine, 600 North Wolfe Street, Blalock 524-D1, Baltimore, MD 21287.

Aim: The 2018 American Heart Association/American College of Cardiology/Multi-Society Cholesterol Guidelines recommended the addition of non-statins to statin therapy for high-risk secondary prevention patients above a low-density lipoprotein cholesterol (LDL-C) threshold of ≥70 mg/dL (1.8 mmol/L). We compared effectiveness and safety of treatment to achieve lower (<70) vs. higher (≥70 mg/dL) LDL-C among patients receiving intensive lipid-lowering therapy (statins alone or plus ezetimibe or proprotein convertase subtilisin/kexin type 9 inhibitors).

Methods And Results: Eleven randomized controlled trials (130 070 patients), comparing intensive vs. less-intensive lipid-lowering therapy, with follow-up ≥6 months and sample size ≥1000 patients were selected. Meta-analysis was reported as random effects risk ratios (RRs) [95% confidence intervals] and absolute risk differences (ARDs) as incident cases per 1000 person-years. The median LDL-C levels achieved in lower LDL-C vs. higher LDL-C groups were 62 and 103 mg/dL, respectively. At median follow-up of 2 years, the lower LDL-C vs. higher LDL-C group was associated with significant reduction in all-cause mortality [ARD -1.56; RR 0.94 (0.89-1.00)], cardiovascular mortality [ARD -1.49; RR 0.90 (0.81-1.00)], and reduced risk of myocardial infarction, cerebrovascular events, revascularization, and major adverse cardiovascular events (MACE). These benefits were achieved without increasing the risk of incident cancer, diabetes mellitus, or haemorrhagic stroke. All-cause mortality benefit in lower LDL-C group was limited to statin therapy and those with higher baseline LDL-C (≥100 mg/dL). However, the RR reduction in ischaemic and safety endpoints was independent of baseline LDL-C or drug therapy.

Conclusion: This meta-analysis showed that treatment to achieve LDL-C levels below 70 mg/dL using intensive lipid-lowering therapy can safely reduce the risk of mortality and MACE.
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http://dx.doi.org/10.1093/eurjpc/zwaa093DOI Listing
November 2020

Effect of primary percutaneous coronary intervention on in-hospital outcomes among active cancer patients presenting with ST-elevation myocardial infarction: a propensity score matching analysis.

Eur Heart J Acute Cardiovasc Care 2021 Feb 4. Epub 2021 Feb 4.

Keele Cardiovascular Research Group, Centre for Prognosis Research, Institutes of Applied Clinical Science and Primary Care and Health Sciences, Keele University, UK.

Aims: Primary percutaneous coronary intervention (pPCI) is the gold standard, guideline-recommended revascularization strategy in patients presenting with ST-elevation myocardial infarction (STEMI). However, there are limited data on its use and effectiveness among patients with active cancer presenting with STEMI.

Methods And Results: All STEMI hospitalizations between 2004 and 2015 from the National Inpatient Sample were retrospectively analysed, stratified by cancer type. Propensity score matching was performed to estimate the average treatment effect of pPCI in each cancer on in-hospital adverse events, including major adverse cardiovascular and cerebrovascular events (MACCE) and its individual components, and compare treatment effect between cancer and non-cancer patients. Out of 1 870 815 patients with STEMI, 38 932 (2.1%) had a current cancer diagnosis [haematological: 11 251 (28.9% of all cancers); breast: 4675 (12.0%); lung: 9538 (24.5%); colon: 3749 (9.6%); prostate: 9719 (25.0%)]. Patients with cancer received pPCI less commonly than those without cancer (from 54.2% for lung cancer to 70.6% for haematological vs. 82.3% in no cancer). Performance of pPCI was strongly associated with lower adjusted probabilities of MACCE and all-cause mortality in the cancer groups compared with the no cancer group. There was no significant difference in estimated average pPCI treatment effect between the cancer groups and non-cancer group.

Conclusion: Primary percutaneous coronary intervention is underutilized in STEMI patients with current cancer despite its significantly lower associated rates of in-hospital all-cause mortality and MACCE that is comparable to patients without cancer. Further work is required to assess the long-term benefit and safety of pPCI in this high-risk group.
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http://dx.doi.org/10.1093/ehjacc/zuaa032DOI Listing
February 2021
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