Publications by authors named "Sudarshan Balla"

68 Publications

Familial hypercholesterolemia related admission for acute coronary syndrome in the United States: Incidence, predictors, and outcomes.

J Clin Lipidol 2021 May-Jun;15(3):460-465. Epub 2021 Apr 29.

Section on Cardiovascular Medicine, Wake Forest University School of Medicine, Winston-Salem, NC, USA. Electronic address:

Background: Individuals with Familial Hypercholesterolemia (FH) are at high risk for atherosclerotic cardiovascular disease (ASCVD) events.

Objectives: The purpose of this study was to evaluate the incidence, predictors, and outcomes of admissions for acute coronary syndromes (ACS) in this high-risk group.

Methods: Utilizing the National Readmission Databases, we identified individuals with or without FH admitted to participating hospitals for ACS. The primary outcome was admission for recurrent ACS at 11 month follow-up.

Results: There were a total of 1,697,513 ACS admissions from 10/2016 to 12/2017 (non-FH=1,696,979 and FH=534). Individuals with FH admitted for ACS were younger (median age 57 vs 69 y), had fewer comorbidities (hypertension 74.7% vs 79.6%; diabetes mellitus 30.5% vs 39.0%;p<0.01), were more likely to present with ST-elevation-myocardial infarction (32.8% vs 22.6%;p<0.01) and more likely to undergo multivessel percutaneous coronary intervention (11.4% vs 7.6%;p<0.01) than patients without FH. After propensity-score matching, FH patients more commonly experienced in-hospital VT arrest (11.8% vs 8.0%;p<0.01) and required more mechanical circulatory support (8.6% vs 3.3%; p<0.01). The 30-day readmission in those with FH was more frequently for cardiovascular disease (81.5% vs 46.5%; =p<0.01). At 11-month follow-up, FH patients were more likely to be readmitted with recurrent ACS compared to those without FH (hazard ratio=2.34; 95% confidence interval=1.30-4.23; p<0.01).

Conclusions: Individuals with FH admitted for ACS are younger, have fewer comorbidities, and more frequently present with STEMIs compared to those without FH. FH patients were more likely to suffer in-hospital cardiac complications and have a higher incidence of recurrent ACS.
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http://dx.doi.org/10.1016/j.jacl.2021.04.005DOI Listing
April 2021

Contemporary Trends and Outcomes of Prosthetic Valve Infective Endocarditis in the United States: Insights From the Nationwide Inpatient Sample.

Am J Med Sci 2021 May 22. Epub 2021 May 22.

Division of Cardiovascular Medicine, West Virginia University Heart & Vascular Institute, Morgantown, WV, USA.

Background: Prosthetic valve endocarditis (PVE) carries high mortality and morbidity as compared to native valve endocarditis (NVE). Contemporary data on PVE are lacking, we aimed to study contemporary trends, outcomes, and burden of PVE using nationally representative data.

Methods: We used the National Inpatient Sample from 2000 to 2017 to identify patients admitted with PVE using ICD-9-CM and ICD-10 codes. Risk-adjusted rates were calculated using an Analysis of Covariance (ANCOVA) with the Generalized Linear Model (GLM). Trends were assessed with linear regression and Pearson's Chi-square when appropriate. Binomial logistic regression was used to assess predictors of in-hospital mortality.

Results: We identified 43,602 hospitalizations for PVE. PVE hospitalizations increased from 1803 in 2000 to 3450 in 2017. Risk-adjusted mortality decreased from 10.7% in 2002 to 7.3% in 2017 (P<0.01). Logistic regression analysis on mortality showed increase association with age (OR, 1.021, 95%CI[1.017-1.024], p<0.01), Hispanics (OR, 1.493, 95%CI[1.296-1.719], p<0.01) and patients with drug abuse(OR, 1.233, 95%CI[1.05-1.449], p=0.01). Co-morbid conditions like congestive heart failure (OR, 1.511, 95%CI[1.366-1.673], p<0.01), renal failure (OR, 1.572, 95%CI[1.427-1.732], p<0.01) and weight loss (OR, 1.425, 95%CI [1.093-1.419], p<0.01) were also associated with higher mortality.

Conclusions: Over the years the adjusted in-hospital mortality in PVE has trended down but the average cost of stay has increased despite decrease in length of stay.
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http://dx.doi.org/10.1016/j.amjms.2021.05.014DOI Listing
May 2021

Pericardial effusion requiring intervention in patients undergoing percutaneous left atrial appendage occlusion: Prevalence, predictors, and associated in-hospital adverse events from 17,700 procedures in the United States.

Heart Rhythm 2021 May 18. Epub 2021 May 18.

Section of Electrophysiology, Division of Cardiology, University of California San Diego, La Jolla, California. Electronic address:

Background: Left atrial appendage occlusion has shown promise in mitigating the risk of stroke in selected patients with atrial fibrillation.

Objective: The purpose of this study was to determine the real-world prevalence and in-hospital outcomes in left atrial appendage occlusion (Watchman) recipients complicated by pericardial effusion requiring percutaneous drainage or open cardiac surgery-based intervention.

Methods: Data were derived from the National Inpatient Sample database from January 2015 to December 2017. The primary outcomes assessed were the prevalence of pericardial effusion requiring intervention and in-hospital outcomes including mortality, other major complications, hospital stay > 1 day, and hospitalization costs. Predictors of pericardial effusion requiring intervention were also analyzed.

Results: Pericardial effusion requiring intervention occurred in 220 total patients (1.24%). After multivariable adjustment, pericardial effusion requiring intervention was associated with in-hospital mortality (adjusted odds ratio [aOR] 511.6; 95% confidence interval [CI] 122-2145.3), other Watchman-related major complications (aOR 1.35; 95% CI 0.83-2.19), length of stay > 1 day (aOR 17.64; 95% CI 12.56-24.77), and hospitalization cost above the median of $24,327 (aOR 3.58; 95% CI 2.61-4.91). Independent patient predictors of pericardial effusion requiring intervention from the procedure included advanced age (aOR 1.029 per 1-year increase; 95% CI 1.009-1.05 per 1-year increase), higher CHADS-VASc score (aOR 1.221 per 1-point increase; 95% CI 1.083-1.377 per 1-point increase), and obesity (aOR 2.033; 95% CI 1.464-2.823).

Conclusion: In a large, contemporary real-world cohort of Watchman recipients in US practice, the prevalence of pericardial effusion requiring intervention was 1.24%. Pericardial effusion requiring intervention was associated with several adverse events including increased in-hospital mortality, other major complications, prolonged hospital stay, and hospitalization costs.
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http://dx.doi.org/10.1016/j.hrthm.2021.05.017DOI 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

Reviving Invasive Hemodynamic Monitoring in Cardiogenic Shock. Invasive Hemodynamic Monitoring in Cardiogenic Shock.

Am J Cardiol 2021 Jul 8;150:128-129. Epub 2021 May 8.

Division of Cardiology, Department of Medicine, Henry Ford Health System, Detroit, Michigan.

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http://dx.doi.org/10.1016/j.amjcard.2021.03.033DOI Listing
July 2021

Racial Disparities in In-Hospital Adverse Events Among Patients With Atrial Fibrillation Implanted With a Watchman Left Atrial Appendage Occlusion Device: A US National Perspective.

Circ Arrhythm Electrophysiol 2021 May 28;14(5):e009691. Epub 2021 Apr 28.

Section of Electrophysiology, Division of Cardiology, University of California San Diego, La Jolla (M.B.M., D.D., F.T.H., R.R., J.C.H.).

[Figure: see text].
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http://dx.doi.org/10.1161/CIRCEP.120.009691DOI Listing
May 2021

Index admission and thirty-day readmission outcomes of patients with cancer presenting with STEMI.

Cardiovasc Revasc Med 2021 Apr 16. Epub 2021 Apr 16.

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

Background: National-level data of cancer patients' readmissions after ST-segment elevation myocardial infarction (STEMI) are lacking.

Objectives: The primary aim of this study was to compare the rates and causes of 30-day readmissions in patients with and without cancer.

Methods: Among patients admitted with STEMI in the United States National Readmission Database (NRD) from October 2015-December 2017, we identified patients with the diagnosis of active breast, colorectal, lung, or prostate cancer. The primary endpoint was the 30-day unplanned readmission rate. Secondary endpoints included in-hospital outcomes during the index admission and causes of readmissions. A propensity score model was used to compare the outcomes of patients with and without cancer.

Results: A total of 385,522 patients were included in the analysis: 5956 with cancer and 379,566 without cancer. After propensity score matching, 23,880 patients were compared (Cancer = 5949, No Cancer = 17,931). Patients with cancer had higher 30-day readmission rates (19% vs. 14%, p < 0.01). The most common causes for readmission among patients with cancer were cardiac (31%), infectious (21%), oncologic (17%), respiratory (4%), stroke (4%), and renal (3%). During the first readmission, patients with cancer had higher adjusted rates of in-hospital mortality (15% vs. 7%; p < 0.01) and bleeding complications (31% vs. 21%; p < 0.01), compared to the non-cancer group. In addition, cancer (OR 1.5, 95% CI 1.2-1.6, p < 0.01) was an independent predictor for 30-day readmission.

Conclusions: About one in five cancer patients presenting with STEMI will be readmitted within 30 days. Cardiac causes predominated the reason for 30-day readmissions in patients with cancer.
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http://dx.doi.org/10.1016/j.carrev.2021.04.015DOI Listing
April 2021

Gender, racial, ethnic and socioeconomic disparities in palliative care encounters in ischemic strokes admissions.

Cardiovasc Revasc Med 2021 Apr 8. Epub 2021 Apr 8.

Division of Cardiovascular Medicine, West Virginia University Heart & Vascular Institute, Morgantown, WV, USA.

Background: There is a scarcity of data on disparities in palliative care encounters in ischemic stroke patients. We have sought to answer these questions using the national inpatient database (NIS) data between 2002 and 2017. We aim to study gender, racial, regional, and socioeconomic disparities in palliative care encounters in ischemic stroke patients.

Methods: We have analyzed the NIS data from January 2002 to December 2017 using the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM), and ICD-10-CM codes. Linear regression was used for trend analysis and multiple logistic regression was used for adjusted analysis.

Results: A total of 9,542,169 discharge encounters with a diagnosis of ischemic stroke were recorded from 2002 to 2017. Out of these 412,394 (4.3%) had a palliative care (PC) encounter. The median age for patients with a PC encounter was 81 (Interquartile range [IQR 79-88]). PC encounters have shown a rapid increase over the years (from 0.5% in 2002 to 8.3% in 2017, p < 0.01). Adjusted multivariate analysis showed that African Americans (OR, 0.726 [95%CI, 0.716-0.736], p < 0.01), and Hispanics (OR, 0.738 [95%CI, 0.725-0.751]) were less likely to have a PC encounters. Females (OR, 1.18 7 [95% CI, 1.177-1.197], p < 0.01) were more likely to have PC encounters. Patients with better socio-economic status (OR, 1.034 [95%CI, 1.011-1.034], p < 0.01), having private insurance (OR, 1.562 [95%CI, 1.542-1.583], p < 0.01) and being in urban centers (OR, 1.815 [95%CI, 1.788-1.843], p < 0.01) were more likely to receive a PC encounter.

Conclusions: Significant racial, ethnic and socioeconomic disparities exist in PC encounters in ischemic stroke patients. The underlying reasons for this need to be explored further.
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http://dx.doi.org/10.1016/j.carrev.2021.04.004DOI Listing
April 2021

Burden of Infective Endocarditis in Homeless Patients in the United States: A National Perspective.

Am J Med Sci 2021 Mar 30. Epub 2021 Mar 30.

Division of Cardiovascular Medicine, West Virginia University Heart and Vascular Institute, Morgantown, WV, United States.

Background: Earlier studies have shown disparate cardiovascular care in homeless patients. Limited data exist on burden of infective endocarditis (IE) in homeless patients and in this study, we aimed to analyze it using a nationally representative United States population sample.

Methods: Data were extracted from National Inpatient Sample database from January 2000 to December 2017. Patients with endocarditis were sampled using International Classification of Diseases, 9th Revision, Clinical Modification codes of 421.0, 421.1 or 421.9 and International Classification of Diseases, 10th Revision, Clinical Modification codes of I33.0 or I33.9. Homeless patients were identified using codes of V60 and Z59. Linear regression was used for trend analysis and logistic regression was utilized to identify predictors of mortality. 1:1 propensity score (PS) matching was also done to balance confounders and outcomes were assessed in both unmatched and matched cohorts.

Results: We found an increase in proportion of homeless patients admitted with endocarditis from 0.2% in year 2000 to 2.4% in year 2017. Mortality was not statistically significant in PS matched homeless and non-homeless cohorts (4.7% vs 6.6%, p = 0.072). There was a trend towards increased mortality in homeless endocarditis patients over our study years with lower utilization of valvular surgeries. Advanced age, alcohol abuse and admission to large hospitals were independently associated with mortality in homeless endocarditis patients.

Conclusion: Homeless patients have rising trend of IE and IE related mortality and also found to have low utilization of life saving valvular surgeries when compared to general population.
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http://dx.doi.org/10.1016/j.amjms.2021.03.011DOI Listing
March 2021

Baseline characteristics and outcomes of end-stage renal disease patients after in-hospital sudden cardiac arrest: a national perspective.

J Interv Card Electrophysiol 2021 Mar 16. Epub 2021 Mar 16.

Section of Electrophysiology, Division of Cardiovascular Medicine, Sulpizio Cardiovascular Center, University of California San Diego, 9452 Medical Center Dr., MC 7411, La Jolla, CA, 92037, USA.

Purpose: End-stage renal disease (ESRD) is a well-recognized risk factor for the development of sudden cardiac arrest (SCA). There is limited data on baseline characteristics and outcomes after an in-hospital SCA event in ESRD patients.

Methods: For the purpose of this study, data were obtained from the National Inpatient Sample from January 2007 to December 2017. In-hospital SCA was identified using the International Classification of Disease, 9th Revision, Clinical Modification and International Classification of Disease, 10th Revision, Clinical Modification codes of 99.60, 99.63, and 5A12012. ESRD patients were subsequently identified using codes of 585.6 and N18.6. Baseline characteristics and outcomes were compared among ESRD and non-ESRD patients in crude and propensity score (PS)-matched cohorts. Predictors of mortality in ESRD patients after an in-hospital SCA event were analyzed using a multivariate logistic regression model.

Results: A total of 1,412,985 patients sustained in-hospital SCA during our study period. ESRD patients with in-hospital SCA were younger and had a higher burden of key co-morbidities. Mortality was similar in ESRD and non-ESRD patients in PS-matched cohort (70.4% vs. 70.7%, p = 0.45) with an overall downward trend over our study years. Advanced age, Black race, and key co-morbidities independently predicted increased mortality while prior implantable defibrillator was associated with decreased mortality in ESRD patients after an in-hospital SCA event.

Conclusions: In the context of in-hospital SCA, mortality is similar in ESRD and non-ESRD patients in adjusted analysis. Adequate risk factor modification could further mitigate the risk of in-hospital SCA among ESRD patients.
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http://dx.doi.org/10.1007/s10840-021-00977-1DOI Listing
March 2021

Regional Variation in the Adoption of Invasive Hemodynamic Monitoring for Cardiogenic Shock in the United States.

Am J Cardiol 2021 Jun 3;148:174-175. Epub 2021 Mar 3.

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

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http://dx.doi.org/10.1016/j.amjcard.2021.02.028DOI Listing
June 2021

In-hospital outcomes of transcatheter mitral valve repair in patients with and without end stage renal disease: A national propensity match study.

Catheter Cardiovasc Interv 2021 Feb 1. Epub 2021 Feb 1.

Division of Cardiovascular Medicine, West Virginia University Heart and Vascular Institute, Morgantown, West Virginia, USA.

Objectives: To study trends of utilization, outcomes, and cost of care in patients undergoing undergoing transcatheter mitral valve repair (TMVr) with end-stage renal disease (ESRD).

Background: Renal disease has been known to be a predictor of poor outcome in patients with mitral valve disease. Outcome data for patients with ESRD undergoing TMVr remains limited. Therefore, our study aims to investigate trends of utilization, outcomes, and cost of care among patients with ESRD undergoing TMVr.

Methods: We analyzed NIS data from January 2010 to December 2017 using the ICD-9-CM codes ICD-10-CM to identify patients who underwent TMVr. Baseline characteristics were compared using a Pearson 𝜒 test for categorical variables and independent samples t-test for continuous variables. Propensity matched analysis was done for adjusted analysis to compare outcomes between TMVr with and without ESRD. Markov chain Monte Carlo was used to account for missing values.

Results: A total of 15,260 patients (weighted sample) undergoing TMVr were identified between 2010 and 2017. Of these, 638 patients had ESRD compared to 14,631 patients who did not have ESRD. Adjusted in-hospital mortality was lower in non-ESRD group (3.9 vs. <1.8%). Similarly, ESRD patients were more likely to have non-home discharges (85.6 vs. 74.9%). ESRD patients also had a longer mean length of stay (7.9 vs. 13.5 days) and higher mean cost of stay ($306,300 vs. $271,503).

Conclusion: ESRD is associated with higher mortality, complications, and resource utilization compared to non-ESRD patients. It is important to include this data in shared decision-making process and patient selection.
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http://dx.doi.org/10.1002/ccd.29517DOI Listing
February 2021

10-Year community prevalence and trends of severe asymptomatic hypertension among patients with hypertension in the USA: 2007-2016.

Int J Cardiol Hypertens 2020 Dec 3;7:100066. Epub 2020 Nov 3.

Department of Cardiology and Cardiothoracic Surgery, West Virginia University, Morgantown, WV, 26505, USA.

Background: Severe asymptomatic hypertension (SAH) is associated with significant health cost, morbidity and mortality.

Aim: Establish the nationwide prevalence, trends and associated sociodemographic characteristics of SAH among patients with hypertension in the USA.

Methods: We utilized the National Health and Nutrition Examination data collected over five survey cycles (2007-2016). Included were participants aged 20-80 years with self-reported diagnosis of hypertension. SAH was defined as having a mean systolic blood pressure (SBP) ≥180 mmHg and/or mean diastolic blood pressure (DBP) ≥120 mmHg at the time of examination. The Chi square test was used to compare prevalence across different categories. Associations between sociodemographic variables and SAH were assessed using multivariate binary logistic regression.

Results: The prevalence of SAH among patients with hypertension is 2.15% (95% CI 1.80-2.56), mainly explained by isolated mean SBP≥180 mmHg (86% of all cases), with no statistically significant change between 2007: 2.66% (95% CI 2.10-3.36) and 2016:2.61% [95% CI 1.73-3.94), p-trend = 0.17. Increasing age (OR 1.07, 95% CI 1.04-1.09), NH Blacks (OR 2.20, 95% CI 1.37-3.54), BMI< 25 (OR 2.52, 95% CI 1.48-4.28), lack of health insurance OR 4.92% (95% CI 2.53-9.54) and never married individuals (OR = 2.59%, 95% CI 1.20-5.60) were more likely to have SAH, comparatively. There was no significant association between duration of hypertension and SAH.

Conclusion: The prevalence of SAH in the USA is 2.15% and has been stable over the past decade. Our study underscores the importance of identifying barriers to screening and treatment of hypertension which is a major treatable risk factor for cardiovascular disease.
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http://dx.doi.org/10.1016/j.ijchy.2020.100066DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7803022PMC
December 2020

Trends in Microbiology Data and Association With Mortality in Infective Endocarditis (2002-2017).

Am J Cardiol 2021 03 30;142:155-156. Epub 2020 Dec 30.

West Virginia University, Morgantown, West Virginia. Electronic address:

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http://dx.doi.org/10.1016/j.amjcard.2020.12.055DOI Listing
March 2021

CT assessment of the left atrial appendage post-transcatheter occlusion - A systematic review and meta analysis.

J Cardiovasc Comput Tomogr 2020 Dec 15. Epub 2020 Dec 15.

Heart and Vascular Institute, West Virginia University School of Medicine, Morgantown, WV, USA. Electronic address:

Background: Transesophageal echocardiography (TEE) is the standard imaging modality used to assess the left atrial appendage (LAA) after transcatheter device occlusion. Cardiac computed tomography angiography (CCTA) offers an alternative non-invasive modality in these patients. We aimed to conduct a comparison of the two modalities.

Methods: We performed a comprehensive systematic review of the current literature pertaining to CCTA to establish its usefulness during follow-up for patients undergoing LAA device closure. Studies that reported the prevalence of inadequate LAA closure on both CCTA and TEE were further evaluated in a meta-analysis. 19 studies were used in the systematic review, and six studies were used in the meta-analysis.

Results: The use of CCTA was associated with a higher likelihood of detecting LAA patency than the use of TEE (OR, 2.79, 95% CI 1.34-5.80, p ​= ​0.006, I ​= ​70.4%). There was no significant difference in the prevalence of peridevice gap ≥5 ​mm (OR, 3.04, 95% CI 0.70-13.17, p ​= ​0.13, I ​= ​0%) between the two modalities. Studies that reported LAA assessment in early and delayed phase techniques detected a 25%-50% higher prevalence of LAA patency on the delayed imaging.

Conclusion: CCTA can be used as an alternative to TEE for LAA assessment post occlusion. Standardized CCTA acquisition and interpretation protocols should be developed for clinical practice.
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http://dx.doi.org/10.1016/j.jcct.2020.12.003DOI Listing
December 2020

Transcatheter Aortic Valve Replacement vs Surgical Replacement in Patients With Pure Aortic Insufficiency.

Mayo Clin Proc 2020 12;95(12):2655-2664

Division of Cardiovascular Medicine, West Virginia University Heart and Vascular Institute, Morgantown, WV.

Objective: To compare the outcomes of transcatheter aortic valve replacement (TAVR) with surgical aortic valve replacement (SAVR) in patients with pure aortic insufficiency (PAI).

Background: The treatment of choice for patients with severe symptomatic PAI is SAVR. However, not all patients are candidates for surgery because of comorbidities or are deemed high risk for surgery. As a result, TAVR is being used as an off-label procedure in some patients with PAI.

Patients And Methods: We analyzed the National Inpatient Sample database from January 1, 2016, to December 31, 2017, using the International Classification of Diseases, 10th Revision. Inclusion criteria were patients with aortic valve insufficiency undergoing either TAVR or SAVR. Patients with concomitant aortic stenosis, or history of infective endocarditis, and those below the age of 18 years were excluded.

Results: A total of 14,720 patients with PAI underwent valve replacement. Of those, 6.2% underwent TAVR. The TAVR group was significantly older (median age 78 years vs 64 years; P <.001). There was no evidence of a difference in in-hospital mortality between the 2 groups. However, after adjustment, patients in the TAVR group were associated with favorable outcomes in terms of acute kidney injury, cardiogenic shock, postoperative respiratory complications, and length of stay. On the other hand, those in the SAVR group were less likely to need permanent pacemakers.

Conclusion: There was no evidence of a significant statistical difference in in-hospital mortality between patients with PAI treated by either SAVR or TAVR, both in unmatched and propensity-matched cohorts. TAVR could be considered for patients with PAI who are not candidates for surgery.
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http://dx.doi.org/10.1016/j.mayocp.2020.07.030DOI Listing
December 2020

A Meta-analysis of Intravenous Iron Therapy for Patients With Iron Deficiency and Heart Failure.

Am J Cardiol 2021 02 29;141:152-153. Epub 2020 Nov 29.

Division of Cardiology, West Virginia University School of Medicine, Morgantown, West Virgina. Electronic address:

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http://dx.doi.org/10.1016/j.amjcard.2020.11.025DOI Listing
February 2021

High Prevalence of Pericardial Involvement in College Student Athletes Recovering From COVID-19.

JACC Cardiovasc Imaging 2021 03 4;14(3):541-555. Epub 2020 Nov 4.

Division of Cardiology, West Virginia University Heart & Vascular Institute, Morgantown, West Virginia, USA. Electronic address:

Objectives: This study sought to explore the spectrum of cardiac abnormalities in student athletes who returned to university campus in July 2020 with uncomplicated coronavirus disease 2019 (COVID-19).

Background: There is limited information on cardiovascular involvement in young individuals with mild or asymptomatic COVID-19.

Methods: Screening echocardiograms were performed in 54 consecutive student athletes (mean age 19 years; 85% male) who had positive results of reverse transcription polymerase chain reaction nasal swab testing of the upper respiratory tract or immunoglobulin G antibodies against severe acute respiratory syndrome coronavirus type 2. Sequential cardiac magnetic resonance imaging was performed in 48 (89%) subjects.

Results: A total of 16 (30%) athletes were asymptomatic, whereas 36 (66%) and 2 (4%) athletes reported mild and moderate COVID-19 related symptoms, respectively. For the 48 athletes completing both imaging studies, abnormal findings were identified in 27 (56.3%) individuals. This included 19 (39.5%) athletes with pericardial late enhancements with associated pericardial effusion. Of the individuals with pericardial enhancements, 6 (12.5%) had reduced global longitudinal strain and/or an increased native T. One patient showed myocardial enhancement, and reduced left ventricular ejection fraction or reduced global longitudinal strain with or without increased native T values was also identified in an additional 7 (14.6%) individuals. Native T findings were normal in all subjects, and no specific imaging features of myocardial inflammation were identified. Hierarchical clustering of left ventricular regional strain identified 3 unique myopericardial phenotypes that showed significant association with the cardiac magnetic resonance findings (p = 0.03).

Conclusions: More than 1 in 3 previously healthy college athletes recovering from COVID-19 infection showed imaging features of a resolving pericardial inflammation. Although subtle changes in myocardial structure and function were identified, no athlete showed specific imaging features to suggest an ongoing myocarditis. Further studies are needed to understand the clinical implications and long-term evolution of these abnormalities in uncomplicated COVID-19.
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http://dx.doi.org/10.1016/j.jcmg.2020.10.023DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7641597PMC
March 2021

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

Catheter Cardiovasc Interv 2021 Mar 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
March 2021

Contemporary procedural trends of Watchman percutaneous left atrial appendage occlusion in the United States.

J Cardiovasc Electrophysiol 2021 01 11;32(1):83-92. Epub 2020 Nov 11.

Section of Electrophysiology, Division of Cardiology, University of California San Diego, La Jolla, California, USA.

Objective: To determine trends in real-world utilization and in-hospital adverse events from Watchman implantation since its approval by the Food and Drug Administration in 2015.

Background: The risk of embolic stroke caused by atrial fibrillation is reduced by oral anticoagulants, but not all patients can tolerate long-term anticoagulation. Left atrial appendage occlusion with the Watchman device has emerged as an alternative therapy.

Methods: This was a retrospective cohort study utilizing data from National Inpatient Sample for calendar years 2015-2017. The outcomes assessed in this study were associated complications, in-hospital mortality, and resource utilization trends after Watchman implantation. Trends analysis were performed using analysis of variance. Multivariable adjusted logistic regression analysis was performed to determine predictors of mortality.

Results: A total of 17 700 patients underwent Watchman implantation during the study period. There was a significantly increased trend in the number of Watchman procedures performed over the study years (from 1195 in 2015 to 11 165 devices in 2017, p < .01). A significant decline in the rate of complications (from 26.4% in 2015% to 7.9% in 2017, p < .01) and inpatient mortality (from 1.3% in 2015% to 0.1% in 2017, p < .01) were noted. Predictors of in-hospital mortality included a higher CHA DS -VASc score (odds ratio [OR]: 2.61 per 1-point increase, 95% confidence interval [CI]: 1.91-3.57), chronic blood loss anemia (OR: 3.63, 95% CI: 1.37-9.61) and coagulopathy (OR: 4.90, 95% CI: 2.32-10.35).

Conclusion: In contemporary United States clinical practice, Watchman utilization has increased significantly since approval in 2015, while complications and in-patient mortality have declined.
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http://dx.doi.org/10.1111/jce.14804DOI Listing
January 2021

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

Catheter Cardiovasc Interv 2021 Apr 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
April 2021

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

Catheter Cardiovasc Interv 2021 Apr 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

Meta-Analysis of Aspirin Monotherapy Versus Dual Antiplatelet Therapy After Transcatheter Aortic Valve Implantation.

Am J Cardiol 2020 11 19;135:187-188. Epub 2020 Sep 19.

Knight Cardiovascular Institute, Oregon Health and Science University, Portland, Oregon.

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http://dx.doi.org/10.1016/j.amjcard.2020.09.024DOI Listing
November 2020

Comparison of Outcomes in Patients With Takotsubo Syndrome With-vs-Without Cardiogenic Shock.

Am J Cardiol 2020 12 15;136:24-31. Epub 2020 Sep 15.

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

There is limited data on the in-hospital outcomes of cardiogenic shock (CS) secondary to takotsubo syndrome (TS). We aimed to assess the incidence, predictors, and outcomes of CS in hospitalized patients with TS. All patients with TS were identified from the National Inpatient Sample database from September 2006 to December 2017. The cohort was divided into those with versus without CS and logistic regression analysis was used to identify predictors of CS and mortality in patients admitted with TS. A total of 260,144 patients with TS were included in our study, of whom 14,703 (6%) were diagnosed with CS. In-hospital mortality in patients with CS was approximately six-fold higher compared with those without CS (23% vs 4%, p <0.01). TS patients with CS had a higher incidence of malignant arrhythmias like ventricular tachycardia or ventricular fibrillation (15.0% vs 4%, p <0.01) and non-shockable cardiac arrests (12% vs 2%, p <0.01). Independent predictors of CS were male gender, Asian and Hispanic ethnicity, increased burden of co-morbidities including congestive heart failure, chronic pulmonary disease, and chronic diabetes. Independent predictors of mortality were male gender, advanced age, history of congestive heart failure, chronic renal failure, and chronic liver disease. In conclusion, CS occurs in approximately 6% of patients admitted with TS, in-hospital mortality in TS patients with CS was approximately six-fold higher compared with those without CS (23% vs 4%, p <0.01), male gender and increased burden of co-morbidities at baseline were independent predictors of CS and mortality.
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http://dx.doi.org/10.1016/j.amjcard.2020.09.014DOI Listing
December 2020

Gender Disparities in Percutaneous Mitral Valve Repair (from the National Inpatient Sample).

Am J Cardiol 2020 10 16;132:179-181. Epub 2020 Jul 16.

Division of Cardiovascular Medicine, West Virginia University Heart and Vascular Institute, Morgantown, West Virginia.

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http://dx.doi.org/10.1016/j.amjcard.2020.07.021DOI Listing
October 2020

Meta-analysis of the Safety and Efficacy of Bempedoic Acid.

Am J Cardiol 2020 09 27;131:130-132. Epub 2020 Jun 27.

Department of Medicine, West Virginia University, Morgantown, West Virginia.

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http://dx.doi.org/10.1016/j.amjcard.2020.06.028DOI Listing
September 2020

Trends, Predictors and Outcomes After Utilization of Targeted Temperature Management in Cardiac Arrest Patients With Anoxic Brain Injury.

Am J Med Sci 2020 10 21;360(4):363-371. Epub 2020 May 21.

Division of Cardiovascular Medicine, West Virginia University Heart & Vascular Institute, Morgantown, West Virginia; Section of Electrophysiology, Division of Cardiology, University of California San Diego, La Jolla, California. Electronic address:

Background: Targeted Temperature Management (TTM) is a class I recommendation for the management of sudden cardiac arrest (SCA) patients with presumed brain injury. We aimed to study trends, predictors and outcomes in SCA patients from a nationally represented US population sample.

Methods: We utilized the National Inpatient Sample from years 2005 to 2014 for the purpose of our study. Patients with SCA and anoxic brain injury were selected using relevant ICD-9 codes. Data were analyzed for trends over the years and key outcomes were assessed. Logistic regression analysis was done to determine predictors of TTM utilization in our study population.

Results: A total of 78,465 patients with SCA and anoxic brain injury were identified from January 2005 to December 2014. Out of these, approximately 4,481 (5.7%) patients underwent TTM. Patients that underwent TTM were younger compared to patients without TTM utilization (60.67 vs. 63.27 years, P < 0.01). African Americans, Hispanics and women were less likely to undergo TTM. Myocardial infarction, electrolyte disorders and cardiogenic shock were associated with higher odds of TTM utilization. Sepsis, renal failure and diabetes were associated with underutilization of TTM. Inpatient mortality was higher in patients who did not undergo TTM when compared to patients who underwent TTM (67.30% vs. 65.10%, P < 0.01).

Conclusions: Although TTM utilization increased over our study period, the overall application of TTM was still dismal. Factors that circumvent TTM utilization need to be addressed in future studies so more eligible patients could benefit from this life saving therapy.
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http://dx.doi.org/10.1016/j.amjms.2020.05.025DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7530122PMC
October 2020

Induced Hypothermia in Patients with Cardiac Arrest and a Non-shockable Rhythm: Meta-analysis and Trial Sequential Analysis.

Neurocrit Care 2021 02;34(1):279-286

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

Background: Controversy surrounds utilization of induced hypothermia (IHT) in comatose cardiac arrest (CA) survivors with a non-shockable rhythm.

Methods: We conducted a meta-analysis and trial sequential analysis (TSA) comparing IHT with no IHT approaches in patients with CA and a non-shockable rhythm. The primary outcome of interest was favorable neurological outcomes (FNO) defined using the Cerebral Performance Category (CPC) score of 1 or 2. Secondary endpoints were survival at discharge and survival beyond 90 days.

Results: A total of 9 studies with 10,386 patients were included. There was no difference between both groups in terms of FNO (13% vs. 13%, RR 1.34, 95% CI 0.96-1.89, p = 0.09, I = 88%), survival at discharge (20% vs. 22%, RR 1.09, 95% CI 0.88-1.36, p = 0.42, I = 76%), or survival beyond 90 days (16% vs. 15%, RR 0.92, 95% CI 0.61-1.40, p = 0.69, I = 83%). The TSA showed firm evidence supporting the lack of benefit of IHT in terms of survival at discharge. However, the Z-curves failed to cross the conventional and TSA (futility) boundaries for FNO and survival beyond 90 days, indicating lack of sufficient evidence to draw firm conclusions regarding these outcomes.

Conclusion: In this meta-analysis of 9 studies, the utilization of IHT was not associated with a survival benefit at discharge. Although the meta-analysis showed lack of benefit of IHT in terms of FNO and survivals beyond 90 days, the corresponding TSA showed high probability of type-II statistical error, and therefore more randomized controlled trials powered for these outcomes are needed.
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http://dx.doi.org/10.1007/s12028-020-01034-xDOI Listing
February 2021

Targeted temperature management in cardiac arrest patients with a non-shockable rhythm: A national perspective.

Am Heart J 2020 07 3;225:129-137. Epub 2020 May 3.

Division of Cardiovascular Medicine, West Virginia University Heart and Vascular Institute, Morgantown, WV, USA; Division of Cardiovascular Medicine, University of California San Diego, La Jolla, CA, USA. Electronic address:

Introduction: Retrospective studies have shown conflicting benefit of utilizing targeted temperature management (TTM) in cardiac arrest (CA) patients with a non-shockable rhythm and presently there is only one randomized trial in this realm. We sought to determine trends and outcomes of TTM utilization in these patients from a large nationally representative United States population database.

Methods And Results: Data were derived from National Inpatient Sample (NIS) from January 2006 to December 2013. All patients were identified using the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) codes. Patients with evidence of shockable rhythm (ventricular tachycardia, ventricular flutter and ventricular fibrillation) were excluded. Trends in TTM utilization and mortality were assessed over our study period. Various outcomes were measured in patients receiving TTM and no TTM in unmatched and propensity matched cohorts. Logistic regression analysis was done to determine predictors of mortality. A total of 1,185,479 CA patients were identified in whom cause of arrest was a non-shockable rhythm. Overall, there was a steady increase in TTM utilization over our study period. In propensity-matched groups, mortality was higher in patients in whom TTM was utilized compared to non-TTM group (72.9% vs 68.7%, P < .01). In adjusted analysis, TTM remains an independent predictor of increased mortality in our group. Mortality remained high with TTM utilization regardless of location of CA.

Conclusions: TTM utilization was associated with increased mortality in CA patients with a non-shockable rhythm. These findings merit further confirmation in a large randomized trial before application into clinical practice.
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http://dx.doi.org/10.1016/j.ahj.2020.04.023DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7457429PMC
July 2020

Contemporary Trends and Outcomes in Patients With ST-Segment Elevation Myocardial Infarction and End-Stage Renal Disease on Dialysis: Insight from the National Inpatient Sample.

Cardiovasc Revasc Med 2020 12 11;21(12):1474-1481. Epub 2020 May 11.

Division of Cardiovascular Medicine, Heart & Vascular Institute, West Virginia University, Morgantown, WV, USA.

Background: Cardiovascular disease is the major cause of mortality in end stage renal disease (ESRD) patients on dialysis and myocardial infarction constitutes almost 20% of such deaths. We assessed the trends, characteristics and in-hospital outcomes in patients with ESRD.

Methods: We used national inpatient sample (NIS) to identify patients with ESRD presenting with ST-segment elevation myocardial infarction (STEMI) for calendar years 2012-2016. Multiple logistic regression analysis and propensity matched data was used to compare outcomes for the purpose of our study.

Results: Patients on dialysis who presented with STEMI were less likely to be treated with emergent reperfusion therapies including percutaneous coronary intervention, bypass graft surgery and thrombolytics with in first 24 h. In propensity-matched cohort, the mortality was nearly double in patients who have ESRD compared to patients without ESRD (29.7% vs. 15.9%, p < 0.01). In-patient morbidity such as utilization of tracheostomy, mechanical ventilation and feeding tubes was also more prevalent in propensity matched ESRD cohort. In multivariate regression analysis, ESRD remains a strong predictor of increased mortality in STEMI patients (OR 2.65, 95% CI, 2.57-2.75, p < 0.01).

Conclusion: Our study showed low utilization of evidence-based prompt reperfusion therapies in ESRD patients with STEMI along with concomitant increased poor outcomes and resource utilization. Future research specifically targeting this extremely high-risk patient population is needed to identify the role of prompt reperfusion therapies in improving outcomes in these patients.
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http://dx.doi.org/10.1016/j.carrev.2020.05.004DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7988892PMC
December 2020