Publications by authors named "Tanush Gupta"

75 Publications

Association of Acute Kidney Injury with Outcomes in Patients Undergoing Transcatheter Mitral Valve Repair.

Cardiology 2021;146(4):501-507. Epub 2021 Jun 15.

Division of Cardiology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA.

Introduction: Although transcatheter mitral valve repair (TMVr) is a contrast-free procedure, prior single-center studies have demonstrated a high incidence of acute kidney injury (AKI) following TMVr. The main objective of this study was to examine risk factors for AKI, and its association with outcomes in patients undergoing TMVr.

Methods: We queried the National Readmission Database to identify TMVr procedures performed between January 2014 and December 2017. Complex samples multivariable logistic and linear regression models were used to identify risk factors associated with AKI, as well as to determine the association between AKI and clinical outcomes (in-hospital mortality, index length of stay (LOS), 30-day all-cause readmissions, and 30-day heart failure [HF] readmissions).

Results: Of 14,623 patients who underwent TMVr during the study period, 2,001 (13.6%) had a diagnosis of AKI. HF, chronic kidney disease, chronic liver disease, fluid/electrolyte disorder, weight loss, nonelective admission, cardiogenic shock, and bleeding/transfusion were independently associated with an increased risk of AKI. In patients undergoing TMVr, AKI was associated with an increased risk of in-hospital mortality (adjusted odds ratio [aOR], 4.94; 95% confidence interval [CI], 2.92-8.34), 30-day all-cause readmissions (aOR, 1.91; 95% CI, 1.49-2.46), 30-day HF readmissions (aOR, 2.30; 95% CI, 1.38-3.84), and longer index LOS (adjusted parameter estimate, 5.78; 95% CI, 5.26-6.41).

Conclusion: AKI in the setting of TMVr is common and is associated with worse clinical outcomes. Further studies are needed to determine if optimizing renal function prior to TMVr may improve outcomes, as well as to understand the impact of TMVr itself on renal function.
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http://dx.doi.org/10.1159/000516377DOI Listing
June 2021

Association of Peri-Procedural Major Bleeding With Outcomes in Patients Undergoing Transcatheter Mitral Edge-To-Edge Repair.

Am J Cardiol 2021 Aug 3;152:172-174. Epub 2021 Jun 3.

Department of Cardiology, Houston Methodist DeBakey Heart & Vascular Center, Houston, Texas. Electronic address:

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http://dx.doi.org/10.1016/j.amjcard.2021.04.025DOI Listing
August 2021

QCA to guide treatment of inter-clip mitral regurgitation between two previously implanted MitraClips.

Cardiovasc Revasc Med 2021 May 27. Epub 2021 May 27.

Houston Methodist DeBakey Heart & Vascular Center, Houston, TX, United States of America. Electronic address:

Treatment of recurrent MR after initially successful MitraClip procedure can pose therapeutic challenges. We report a successful case of redo MitraClip to treat recurrent inter-clip MR due to progression of underlying degenerative valvular pathology with prolapsing posterior mitral leaflet between the two prior clips. In this vignette, we describe the novel use of quantitative coronary arteriography (QCA) to select redo MitraClip as the treatment strategy.
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http://dx.doi.org/10.1016/j.carrev.2021.05.020DOI Listing
May 2021

Association of Post-discharge Service Types and Timing with 30-Day Readmissions, Length of Stay, and Costs.

J Gen Intern Med 2021 May 13. Epub 2021 May 13.

Department of Health Sciences, University of Missouri, Columbia, MO, USA.

Background: Although early follow-up after discharge from an index admission (IA) has been postulated to reduce 30-day readmission, some researchers have questioned its efficacy, which may depend upon the likelihood of readmission at a given time and the health conditions contributing to readmissions.

Objective: To investigate the relationship between post-discharge services utilization of different types and at different timepoints and unplanned 30-day readmission, length of stay (LOS), and inpatient costs.

Design, Setting, And Participants: The study sample included 583,199 all-cause IAs among 2014 Medicare fee-for-service beneficiaries that met IA inclusion criteria.

Main Measures: The outcomes were probability of 30-day readmission, average readmission LOS per IA discharge, and average readmission inpatient cost per IA discharge. The primary independent variables were 7 post-discharge health services (institutional outpatient, primary care physician, specialist, non-physician provider, emergency department (ED), home health care, skilled nursing facility) utilized within 7 days, 14 days, and 30 days of IA discharge. To examine the association with post-discharge services utilization, we employed multivariable logistic regressions for 30-day readmissions and two-part models for LOS and inpatient costs.

Key Results: Among all IA discharges, the probability of unplanned 30-day readmission was 0.1176, the average readmission LOS per discharge was 0.67 days, and the average inpatient cost per discharge was $5648. Institutional outpatient, home health care, and primary care physician visits at all timepoints were associated with decreased readmission and resource utilization. Conversely, 7-day and 14-day specialist visits were positively associated with all three outcomes, while 30-day visits were negatively associated. ED visits were strongly associated with increases in all three outcomes at all timepoints.

Conclusion: Post-discharge services of different types and at different timepoints have varying impacts on 30-day readmission, LOS, and costs. These impacts should be considered when coordinating post-discharge follow-up, and their drivers should be further explored to reduce readmission throughout the health care system.
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http://dx.doi.org/10.1007/s11606-021-06708-6DOI Listing
May 2021

Oral Anticoagulation and Adverse Outcomes after Ischemic Stroke in Heart Failure Patients without Atrial Fibrillation.

J Card Fail 2021 May 4. Epub 2021 May 4.

Division of Cardiology, University of California, Los Angeles, Los Angeles, CA.

Background: The safety and effectiveness of oral anticoagulation (OAC) after an ischemic stroke in older patients with heart failure (HF) without atrial fibrillation remains uncertain.

Methods: Utilizing Get With The Guidelines Stroke national clinical registry data linked to Medicare claims from 2009-2014, we assessed the outcomes of eligible patients with a history of HF who were initiated on OAC during a hospitalization for an acute ischemic stroke. The cumulative incidences of adverse events were calculated using Kaplan-Meier curves and adjusted Cox proportional hazard ratios were compared between patients discharged on or off OAC.

Results: A total of 8,261 patients from 1,370 sites were discharged alive after an acute ischemic stroke and met eligibility criteria. Of those, 747 (9.0%) were initiated on OAC.  Patients on OAC were younger (77.2±8.0 vs. 80.5±8.9 years, p<0.01). After adjustment for clinical covariates, the likelihood of 1 year mortality was higher in those on OAC (aHR: 1.22, 95% CI 1.05-1.41, p<0.01), while no significant differences were noted for ICH (aHR: 1.34, 95% CI 0.69-2.59, p=0.38) and recurrent ischemic stroke (aHR: 0.78, 95% CI 0.54-1.15, p = 0.21).  The likelihood of all-cause bleeding (aHR: 1.59, 95% CI 1.29-1.96, p<0.01) and all-cause re-hospitalization (aHR: 1.14, 95% CI 1.02-1.27, p = 0.02) was higher for those on OAC.

Conclusion: Initiation of OAC after an ischemic stroke in older patients with HF in the absence of atrial fibrillation is associated with death, bleeding and re-hospitalization without an associated reduction in recurrent ischemic stroke. If validated, these findings raise caution for prescribing OAC to such patients.
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http://dx.doi.org/10.1016/j.cardfail.2021.02.017DOI Listing
May 2021

Outcomes of transcatheter aortic valve replacement in patients with cognitive dysfunction.

J Am Geriatr Soc 2021 May 11;69(5):1363-1369. Epub 2021 Feb 11.

Section of Cardiovascular Research, Heart, Vascular and Thoracic Department, Cleveland Clinic Akron General, Akron, Ohio, USA.

Importance: The impact of pre-existing cognitive dysfunction on outcomes after transcatheter aortic valve replacement (TAVR) remains unclear.

Objective: To study the association between dementia and post-TAVR outcomes.

Design: Cohort study with propensity-score matching was conducted using the Nationwide Inpatient Sample.

Exposures: History of dementia at the time of undergoing TAVR.

Main Outcomes: All-cause in-hospital mortality, stroke, bleeding requiring transfusion, acute kidney injury, post-procedural vascular complications, post-procedural pacemaker implantation, length of stay, in-hospital delirium, and discharge disposition in patients with and without dementia undergoing TAVR.

Results: Of 57,805 patients undergoing TAVR, 2910 (5.0%) had a diagnosis of dementia. Propensity-score matching yielded 2895 matched pairs of patients. TAVR was associated with an increased risk of bleeding requiring transfusion (14.7% vs 8.6%, odd ratio (OR) 1.82 [95% confidence interval (CI) 1.26-2.63]; p < 0.01), discharge to a rehabilitation facility (45.8% vs 31.6%, OR 2.27 [95% CI 1.67-3.08]; p < 0.001), in-hospital delirium (7.4% vs 3.6%, OR 2.13 [95% CI 1.26-3.61]; p < 0.01), increased length of stay (6.75 ± 0.07 days vs 6.11 ± 0.06 days, slope = 1.11 [95% CI 1.03-1.19]; p < 0.01), but comparable in-hospital mortality (2.1% vs 2.6%, OR 1.26 [95% CI 0.57-2.79]; p = 0.57] in patients with dementia compared with patients without dementia.

Conclusions And Relevance: This study found that patients with dementia undergoing TAVR had a longer hospital stay as well as higher rates of discharge to a rehabilitation facility and in-hospital delirium, which may indicate debility and functional decline during hospitalization; however, in-hospital mortality and other outcomes were comparable between the two groups. TAVR candidates should be subjected to a comprehensive geriatric and cognitive assessment to help risk-stratify them for potential post-procedural functional decline. Prospective studies aimed at standardizing cognitive scoring and evaluating the post-procedural quality of life are needed.
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http://dx.doi.org/10.1111/jgs.17048DOI Listing
May 2021

Predicting and measuring mortality risk after transcatheter aortic valve replacement.

Expert Rev Cardiovasc Ther 2021 Mar 2;19(3):247-260. Epub 2021 Mar 2.

Department of Cardiology, Houston Methodist DeBakey Heart & Vascular Center, Houston, TX, USA.

Over the last decade, transcatheter aortic valve replacement (TAVR) has emerged as a treatment option for most patients with severe symptomatic aortic stenosis (AS). With growing indications and exponential increase in the number of TAVR procedures, it is important to be able to accurately predict mortality after TAVR.: Herein, we review the surgical and TAVR-specific mortality prediction models (MPMs) and their performance in their original derivation and external validation cohorts. We then discuss the role of other important risk assessment tools such as frailty, echocardiographic parameters, and biomarkers in patients, being considered for TAVR.: Conventional surgical MPMs have suboptimal predictive performance and are mis-calibrated when applied to TAVR populations. Although a number of TAVR-specific MPMs have been developed, their utility is also limited by their modest discriminative ability when applied to populations external to their original derivation cohorts. There is an unmet need for robust TAVR MPMs that accurately predict post TAVR mortality. In the interim, heart teams should utilize the currently available TAVR-specific MPMs in conjunction with other prognostic factors, such as frailty, echocardiographic or computed tomography (CT) imaging parameters, and biomarkers for risk assessment of patients, being considered for TAVR.
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http://dx.doi.org/10.1080/14779072.2021.1888715DOI Listing
March 2021

Impact of the COVID-19 pandemic on interventional cardiology training in the United States.

Catheter Cardiovasc Interv 2020 11 26;96(5):997-1005. Epub 2020 Aug 26.

Society for Cardiovascular Angiography and Intervention, Washington, District of Columbia.

Objectives: We sought to determine the effect of COVID-19 related reduction in elective cardiac procedures and acute coronary syndrome presentations on interventional cardiology (IC) training.

Background: The COVID-19 pandemic has significantly disrupted healthcare in the United States, including cardiovascular services. The impact of COVID-19 on IC fellow training in the United States has not been assessed.

Methods: The Society for Cardiovascular Angiography and Interventions (SCAI) surveyed IC fellows training in both accredited and advanced non-accredited programs, as well as their program directors (PD).

Results: Responses were received from 135 IC fellows and 152 PD. All respondents noted reductions in procedural volumes beginning in March 2020. At that time, only 43% of IC fellows had performed >250 PCI. If restrictions were lifted by May 15, 2020 78% of IC fellows believed they would perform >250 PCI, but fell to only 70% if restrictions persisted until the end of the academic year. 49% of IC fellows felt that their procedural competency was impaired by COVID-19, while 97% of PD believed that IC fellows would be procedurally competent at the end of their training. Most IC fellows (65%) noted increased stress at work and at home, and many felt that job searches and/or existing offers were adversely affected by the pandemic.

Conclusion: The COVID-19 pandemic has substantially affected IC training in the United States, with many fellows at risk of not satisfying current program procedural requirements. These observations support a move to review current IC program requirements and develop mitigation strategies to supplement gaps in education related to reduced procedural volume.
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http://dx.doi.org/10.1002/ccd.29198DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7436398PMC
November 2020

Influence of Influenza Infection on In-Hospital Acute Myocardial Infarction Outcomes.

Am J Cardiol 2020 09 7;130:7-14. Epub 2020 Jun 7.

Brigham and Women's Hospital Heart and Vascular Center, Harvard Medical School, Boston, Massachusetts. Electronic address:

Influenza is associated with significant morbidity in the United States but its influence on in-hospital outcomes in patients with AMI has not been well studied. The Nationwide Readmission Database (NRD) from 2010 to 2014 was queried using the International Classification of Diseases-Ninth edition, Clinical Modification (ICD-9-CM) codes to identify all patients ≥18 years who were admitted for AMI with and without concurrent influenza. Propensity score matching was used to adjust patients' baseline characteristics and co-morbidities. In-hospital mortality, 30-day readmission rates, in-hospital complications, and resource utilization were analyzed. We identified a total of 2,428,361 patients admitted with AMI, of whom 3,006 (0.12%) had coexisting influenza. We noted significantly higher in-hospital mortality (7.7% vs 5.6%, p <0.01) and 30-day readmission rates (15.8% vs 14.1%, p <0.01) in patients with influenza compared with those without it. After propensity matching, the differences in in-hospital mortality and 30-day readmission were no longer statistically significant between the groups. Patients with influenza had a higher incidence of acute kidney injury (30.9% vs 24.6%, p <0.01), acute respiratory failure (50.2% vs 32.2%, p <0.01), need for mechanical ventilation (13.9% vs 9.2%, p <0.01), and sepsis (10% vs 3.8%, p <0.01) in the matched cohort. Patients with influenza had longer hospital stays (8.4 days vs 6.4 days, p <0.01) and mean costs of care (26,200USD vs 23,400USD, p <0.01). In conclusion, AMI patients with concomitant influenza infection had higher in-hospital mortality, 30-day readmission, in-hospital complications, and higher resource utilization compared with those without influenza.
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http://dx.doi.org/10.1016/j.amjcard.2020.05.045DOI Listing
September 2020

Impact of the COVID-19 pandemic on interventional cardiology fellowship training in the New York metropolitan area: A perspective from the United States epicenter.

Catheter Cardiovasc Interv 2021 02 16;97(2):201-205. Epub 2020 May 16.

New York-Presbyterian Hospital/Columbia University Irving Medical Center, New York, New York, USA.

Background: The healthcare burden posed by the coronavirus disease 2019 (COVID-19) pandemic in the New York Metropolitan area has necessitated the postponement of elective procedures resulting in a marked reduction in cardiac catheterization laboratory (CCL) volumes with a potential to impact interventional cardiology (IC) fellowship training.

Methods: We conducted a web-based survey sent electronically to 21 Accreditation Council for Graduate Medical Education accredited IC fellowship program directors (PDs) and their respective fellows.

Results: Fourteen programs (67%) responded to the survey and all acknowledged a significant decrease in CCL procedural volumes. More than half of the PDs reported part of their CCL being converted to inpatient units and IC fellows being redeployed to COVID-19 related duties. More than two-thirds of PDs believed that the COVID-19 pandemic would have a moderate (57%) or severe (14%) adverse impact on IC fellowship training, and 21% of the PDs expected their current fellows' average percutaneous coronary intervention (PCI) volume to be below 250. Of 25 IC fellow respondents, 95% expressed concern that the pandemic would have a moderate (72%) or severe (24%) adverse impact on their fellowship training, and nearly one-fourth of fellows reported performing fewer than 250 PCIs as of March 1st. Finally, roughly one-third of PDs and IC fellows felt that there should be consideration of an extension of fellowship training or a period of early career mentorship after fellowship.

Conclusions: The COVID-19 pandemic has caused a significant reduction in CCL procedural volumes that is impacting IC fellowship training in the NY metropolitan area. These results should inform professional societies and accreditation bodies to offer tailored opportunities for remediation of affected trainees.
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http://dx.doi.org/10.1002/ccd.28977DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7276744PMC
February 2021

Increased Risk of Perioperative Ischemic Stroke in Patients Who Undergo Noncardiac Surgery with Preexisting Atrial Septal Defect or Patent Foramen Ovale.

J Cardiothorac Vasc Anesth 2020 Aug 16;34(8):2060-2068. Epub 2020 Jan 16.

Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Phoenix, AZ. Electronic address:

Objectives: To evaluate whether a preoperative diagnosis of atrial septal defect (ASD) or patent foramen ovale (PFO) is associated with perioperative stroke in noncardiac surgery and their outcomes.

Design: Retrospective cohort analysis.

Setting: United States hospitals.

Participants: Adults patients (≥18 years old) who underwent major noncardiac surgery from 2010 to 2015 were identified using the Healthcare Cost and Utilization Project's National Readmission Database.

Interventions: Preoperative diagnosis of ASD or patent foramen ovale.

Measurements And Main Results: Among the 19,659,161 hospitalizations for major noncardiac surgery analyzed, 12,248 (0.06%) had a preoperative diagnosis of ASD/PFO. Perioperative ischemic stroke occurred in 723 (5.9%) of patients with ASD/PFO and 373,291 (0.02%) of those without ASD/PFO (adjusted odds ratio [aOR], 16.7; 95% confidence interval [CI]: 13.9-20.0). Amongst the different types of noncardiac surgeries, obstetric, endocrine, and skin and burn surgery were associated with higher risk of stroke in patients with pre-existing ASD/PFO. Moreover, patients with ASD/PFO also had an increased in-hospital mortality (aOR, 4.6, 95% CI: 3.6-6.0), 30-day readmission (aOR, 1.2, 95% CI: 1.04-1.38), and 30-day stroke (aOR, 7.2, 95% CI: 3.1-16.6). After adjusting for atrial fibrillation, ischemic stroke remained significantly high in the ASD/PFO group (aOR: 23.7, 95%CI 19.4-28.9), as well as in-hospital mortality (aOR: 5.6, 95% CI 4.1-7.7), 30-day readmission (aOR: 1.19, 95%CI 1.0-1.4), and 30-day stroke (aOR: 9.3, 95% CI 3.7-23.6).

Conclusions: Among adult patients undergoing major noncardiac surgery, pre-existing ASD/PFO is associated with increased risk of perioperative ischemic stroke, in-hospital mortality, 30-day stroke, and 30-day readmission after surgery.
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http://dx.doi.org/10.1053/j.jvca.2020.01.016DOI Listing
August 2020

Comparison of Incidence and Outcomes of Cardiogenic Shock Complicating Posterior (Inferior) Versus Anterior ST-Elevation Myocardial Infarction.

Am J Cardiol 2020 04 7;125(7):1013-1019. Epub 2020 Jan 7.

Division of Cardiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York; Cardiovascular Research Foundation, New York, New York. Electronic address:

Cardiogenic shock (CS) is a catastrophic consequence of ST-elevation myocardial infarction (STEMI). CS has been reported to be associated less often with inferior wall (IWMI) than anterior wall STEMI (AWMI). We queried the National Inpatient Sample databases from January 2010 to September 2015 to identify all patients aged ≥18 years admitted with AWMI or IWMI. Patients with a concomitant diagnosis of CS were then identified. Complex samples multivariable logistic regression models were used to compare the incidence, management, and in-hospital mortality of CS complicating IWMI versus AWMI. The incidence of CS was lower in IWMI (9.5%) versus AWMI (14.1%), adjusted OR (aOR) 0.84 (95% confidence interval [CI] 0.81 to 0.87). Revascularization rates with either percutaneous coronary intervention or coronary artery bypass grafting were similar in CS complicating IWMI versus AWMI (80.9% vs 80.3%; aOR 1.05; 95% CI 0.97 to 1.14). The reported use of percutaneous mechanical circulatory support devices was lower in patients with CS-IWMI versus CS-AWMI (44.7% vs 61.0%; aOR 0.55; 95% CI 0.52 to 0.59). In-hospital mortality was modestly lower in patients with CS complicating IWMI versus AWMI (30.3% vs 31.9%; aOR, 0.80; 95% CI 0.75 to 0.86). Use of percutaneous mechanical circulatory support was not associated with lower in-hospital mortality in either CS-AWMI (30.0% vs 34.7; aOR 1.04; 95% CI 0.94 to 1.14) or CS-IWMI (31.0% vs 29.8%; aOR 1.20; 95% CI 1.08 to 1.33). In conclusion, the incidence of CS in the contemporary era is lower in patients with IWMI compared with those with AWMI. CS complicating STEMI is associated with higher in-hospital mortality in AWMI versus IWMI, and outcomes were not different with or without percutaneous circulatory support.
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http://dx.doi.org/10.1016/j.amjcard.2019.12.052DOI Listing
April 2020

Rotational Atherectomy: A Contemporary Appraisal.

Interv Cardiol 2019 Nov 18;14(3):182-189. Epub 2019 Nov 18.

Division of Cardiology, Department of Medicine, Montefiore Medical Center, Albert Einstein College of Medicine Bronx, NY, US.

Rotational atherectomy (RA) is an atheroablative technology that enables percutaneous coronary intervention for complex, calcified coronary lesions. RA works on the principle of 'differential cutting' and preferentially ablates hard, inelastic, calcified plaque. The objective of RA use has evolved from plaque debulking to plaque modification to enable balloon angioplasty and optimal stent expansion. The clinical experience over the past 30 years has informed the current best practices for RA with use of smaller burr sizes, short ablation runs a 'pecking' motion, and avoidance of sudden decelerations. This has led to significant improvements in procedural safety and a reduced rate of associated complications. This article reviews the principles, clinical indications, contemporary evidence, technical considerations and complications associated with the use of RA.
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http://dx.doi.org/10.15420/icr.2019.17.R1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6918488PMC
November 2019

Weekend Operation and Outcomes of Patients Admitted for Nonelective Coronary Artery Bypass Surgery.

Ann Thorac Surg 2020 07 23;110(1):152-157. Epub 2019 Nov 23.

Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio. Electronic address:

Background: The "weekend effect" is a purported phenomenon whereby patients admitted for time-sensitive medical and surgical conditions on a weekend suffer worse outcomes than those admitted on a weekday. There are limited data on the weekend effect for nonelective coronary artery bypass grafting (CABG).

Methods: We studied outcomes for weekend vs weekday operations for all adult patients in the 2013 to 2014 National Inpatient Sample (NIS) undergoing nonelective CABG.

Results: Of 101,510 patients undergoing nonelective CABG, 12,795 patients (12.6%) underwent CABG on the day of admission (n = 1230 for weekend and 11,565 for weekday admission, respectively). Patients undergoing surgical procedures on a weekend were more likely to have a diagnosis of ST-elevation acute coronary syndrome (47.2% vs 20.2%, P < .001), require intraaortic balloon pump support (46.3% vs 23.1%, P < .001), and undergo same-day coronary angiography (66.7% vs 41.8%; P < .001) or same-day percutaneous coronary intervention (11.8% vs 7.1%; P = .01). Weekend admission was associated with increased mortality in unadjusted analysis (6.1% vs 3.2%; odds ratio, 1.99; 95% confidence interval, 1.13-3.52; P = .02), but this effect was attenuated in the adjusted model (adjusted odds ratio, 1.22; 95% confidence interval, 0.63-2.33; P = .47).

Conclusions: Patients undergoing CABG on a weekend had higher crude mortality but similar risk-adjusted mortality compared with their weekday counterparts. Some of the excess mortality observed for weekend operations is likely attributable to a sicker cohort of patients undergoing CABG on the weekend.
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http://dx.doi.org/10.1016/j.athoracsur.2019.09.098DOI Listing
July 2020

Aortic Valve Replacement in Bioprosthetic Failure: Insights From The Society of Thoracic Surgeons National Database.

Ann Thorac Surg 2020 11 23;110(5):1637-1642. Epub 2019 Sep 23.

Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio. Electronic address:

Background: This study was conducted to determine the current nationwide trends and outcomes of reoperative surgical aortic valve replacement (SAVR) performed for a degenerated bioprosthesis.

Methods: Data from The Society of Thoracic Surgeons (STS) Adult Cardiac Surgery Database were used. All patients who underwent isolated reoperative SAVR for a degenerated aortic bioprosthesis between January 2012 and December 2016 were included. Patients who had other concomitant cardiac surgery procedures or active endocarditis were excluded. Changes during this period were tracked with trend analyses.

Results: The number of patients undergoing SAVR for bioprosthetic failure increased substantially between 2012 and 2014 (782 in 2012 to 844 in 2013 and to 900 in 2014; relative change, +7.25%); this trend reversed significantly between 2015 and 2016 (decreased to 873 in 2015 and to 840 in 2016; relative change, -3.4%; P = .005). Patients were older in 2012-2014 (65.80 ± 13.52 years) compared with 2015-2016 (64.45 ± 12.91 years; P = .001). Mean STS-predicted mortality risk score decreased from 4.55% in 2012-2014 to 4.25% in 2015-2016 (P = .001). There was no difference in postoperative stroke (1.80% vs 1.80%, P = .87), renal failure requiring dialysis (2.7% vs 2.8%, P = .69), or operative mortality (3.5% vs 4.0%, P = .36) after reoperative SAVR in 2012-2014 and 2015-2016, respectively.

Conclusions: The number of patients undergoing SAVR for a degenerated bioprosthesis is decreasing in the United States, particularly among older and high-risk patients. These trends may reflect the adoption of valve-in-valve transcatheter aortic valve replacement for a degenerated bioprosthesis after its United States Food and Drug Administration approval in 2015.
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http://dx.doi.org/10.1016/j.athoracsur.2019.08.023DOI Listing
November 2020

Association of Acute Venous Thromboembolism With In-Hospital Outcomes of Coronary Artery Bypass Graft Surgery.

J Am Heart Assoc 2019 10 19;8(19):e013246. Epub 2019 Sep 19.

Department of Surgery Harrington Heart & Vascular Institute University Hospitals Cleveland Medical Center Case Western Reserve University School of Medicine Cleveland OH.

Background While venous thromboembolism (VTE) prophylaxis is a strong recommendation after most surgeries, it is controversial in cardiac surgeries such as coronary artery bypass grafting (CABG), because of perceived low VTE incidence and increased bleeding risk. Prior studies may not have been adequately powered to study outcomes of VTE in this population. We sought to investigate the postoperative incidence and outcomes of CABG patients using a large national inpatient database. Methods and Results We utilized the 2013 to 2014 National Inpatient Sample to identify all patients >18 years of age who underwent CABG (without concomitant valvular procedures), and had VTE during the hospital stay. We then compared clinically relevant outcomes in patients with and without VTE. We identified 331 950 CABG procedures. Of these, 1.3% (n=4205) had VTE. Patients with VTE were more likely to be older (mean 67.2±10.4 years versus 65.2±10.4 years, <0.001). VTE was associated with higher incidence of inpatient mortality (6.8% versus 1.7%; adjusted odds ratio 1.92 [95% CI 1.40-2.65]; <0.001) and complications. VTE was also associated with higher cost (mean±SE $81 995±$923 versus $48 909±$55) and longer length of stay (mean±SE 17.06±0.16 days versus 8.52±0.01 days). Conclusions Our analysis of >330 000 CABG procedures suggests that while postoperative VTE after CABG is rare, it is associated with increased morbidity and mortality. Randomized controlled trials are needed to identify optimal strategies for VTE prophylaxis in these patients.
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http://dx.doi.org/10.1161/JAHA.119.013246DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6806036PMC
October 2019

The changing landscape of aortic valve replacement in the USA.

EuroIntervention 2019 12 6;15(11):e968-e974. Epub 2019 Dec 6.

Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA.

Aims: The aim of this study was to analyse the real-world national data on parallel utilisation of transcatheter (TAVR) and surgical (SAVR) aortic valve replacement.

Methods And Results: We queried an all-payer, administrative United States in-patient database to identify all AVR hospitalisations in patients aged ≥18 years from January 2012 to December 2016 and examined the temporal changes in the number of AVR procedures and in-hospital mortality. A total of 463,675 AVRs were performed - 363,275 (78.4%) SAVR and 100,400 (21.6%) TAVR. AVR linearly increased (from 78,985 in 2012 to 103,415 in 2016; +30.9%; ptrend<0.001) largely due to a marked increase in TAVR (from 7,655 to 33,545; +338%; ptrend<0.001), whereas the absolute number of SAVRs remained relatively stable (from 71,330 to 69,870; -1%; ptrend<0.001). The number of TAVRs increased in all pre-specified age groups (<75, 75-79, 80-85, and ≥85 years; ptrend<0.001 for all). In contrast, the number of SAVRs increased modestly in patients aged <75 years (ptrend<0.001) and declined in those aged 75-79 years, 80-84 years, or ≥85 years (ptrend<0.001 for all). Age- and sex-adjusted in-hospital mortality after isolated (aOR 1.00 [0.95-1.05]; ptrend=0.96) or combined SAVR (aOR 1.01 [0.97-1.05]; ptrend=0.66) remained unchanged during the study period, whereas in-hospital mortality after TAVR declined (aOR 0.75 [0.70-0.79]; ptrend<0.001). Similar trends in in-hospital mortality were seen in the age subgroups.

Conclusions: The number of AVRs markedly increased in the USA from 2012 to 2016, mainly due to the widespread adoption of TAVR, whereas the number of SAVRs remained relatively stable. In-hospital mortality after TAVR declined, whereas that after SAVR has remained unchanged.
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http://dx.doi.org/10.4244/EIJ-D-19-00381DOI Listing
December 2019

Machine Learning Prediction Models for In-Hospital Mortality After Transcatheter Aortic Valve Replacement.

JACC Cardiovasc Interv 2019 07;12(14):1328-1338

Center for Collaborative Research in Health Disparities, University of Puerto Rico School of Medicine, San Juan, Puerto Rico.

Objectives: This study sought to develop and compare an array of machine learning methods to predict in-hospital mortality after transcatheter aortic valve replacement (TAVR) in the United States.

Background: Existing risk prediction tools for in-hospital complications in patients undergoing TAVR have been designed using statistical modeling approaches and have certain limitations.

Methods: Patient data were obtained from the National Inpatient Sample database from 2012 to 2015. The data were randomly divided into a development cohort (n = 7,615) and a validation cohort (n = 3,268). Logistic regression, artificial neural network, naive Bayes, and random forest machine learning algorithms were applied to obtain in-hospital mortality prediction models.

Results: A total of 10,883 TAVRs were analyzed in our study. The overall in-hospital mortality was 3.6%. Overall, prediction models' performance measured by area under the curve were good (>0.80). The best model was obtained by logistic regression (area under the curve: 0.92; 95% confidence interval: 0.89 to 0.95). Most obtained models plateaued after introducing 10 variables. Acute kidney injury was the main predictor of in-hospital mortality ranked with the highest mean importance in all the models. The National Inpatient Sample TAVR score showed the best discrimination among available TAVR prediction scores.

Conclusions: Machine learning methods can generate robust models to predict in-hospital mortality for TAVR. The National Inpatient Sample TAVR score should be considered for prognosis and shared decision making in TAVR patients.
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http://dx.doi.org/10.1016/j.jcin.2019.06.013DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6650265PMC
July 2019

Corrigendum to `Trends in Utilization of Surgical and Transcatheter Mitral Valve Repair in the United States☆' [The American Journal of Cardiology 123/7 (2019) 1187-1189].

Am J Cardiol 2019 Jul 26;124(1):168. Epub 2019 Apr 26.

Division of Cardiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York; Cardiovascular Research Foundation, New York, New York.

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http://dx.doi.org/10.1016/j.amjcard.2019.04.001DOI Listing
July 2019

Association of peripheral artery disease with in-hospital outcomes after endovascular transcatheter aortic valve replacement.

Catheter Cardiovasc Interv 2019 Aug 25;94(2):249-255. Epub 2019 Apr 25.

Brigham and Women's Hospital Heart & Vascular Center, Harvard Medical School, Boston, Massachusetts.

Objectives: The aim of this study was to determine the prevalence of peripheral artery disease (PAD) and its association with in-hospital outcomes after endovascular transcatheter aortic valve replacement (EV-TAVR).

Background: TAVR is an established treatment for patients at prohibitive, high, or intermediate surgical risk. PAD is a significant comorbidity in the determination of surgical risk. However, data on association of PAD with outcomes after EV-TAVR are limited.

Methods: Patients in the National Inpatient Sample who underwent EV-TAVR between January 1, 2012 and September 30, 2015 were evaluated. The primary outcome was in-hospital mortality.

Results: A total of 51,685 patients underwent EV-TAVR during the study period. Of these, 12,740 (24.6%) had a coexisting diagnosis of PAD. The adjusted odds for in-hospital mortality [OR 1.08 (95% CI 0.83-1.41)], permanent pacemaker implantation [OR 0.98 (0.85-1.14)], conversion to open aortic valve replacement [OR 1.05 (0.49-2.26)], or acute myocardial infarction [OR 1.31(0.99-1.71)] were not different in patients with versus without PAD. However, patients with PAD had greater adjusted odds of vascular complications [OR 1.80 (1.50-2.16)], major bleeding [OR 1.20 (1.09-1.34)], acute kidney injury (AKI) [OR 1.19 (1.05-1.36)], cardiac complications [aOR 1.21 (1.01-1.44)], and stroke [OR 1.39(1.10-1.75)] compared with patients without PAD. Length of stay (LOS) was significantly longer for patients with PAD [7.23 (0.14) days vs. 7.11 (0.1) days, p < 0.001].

Conclusion: Of patients undergoing EV-TAVR, ~25% have coexisting PAD. PAD was not associated with increased risk of in-hospital mortality but was associated with higher risk of vascular complications, major bleeding, AKI, stroke, cardiac complications, and longer LOS.
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http://dx.doi.org/10.1002/ccd.28310DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6832693PMC
August 2019

Transcatheter mitral valve repair with MitraClip in a large real-world experience: lessons from Germany.

EuroIntervention 2019 Apr;14(17):1716-1719

Division of Cardiology, Department of Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA.

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http://dx.doi.org/10.4244/EIJV14I17A296DOI Listing
April 2019

Relation of Concomitant Heart Failure to Outcomes in Patients Hospitalized With Influenza.

Am J Cardiol 2019 05 8;123(9):1478-1480. Epub 2019 Feb 8.

Division of Cardiovascular Medicine, Harrington Heart & Vascular Institute, University Hospitals Cleveland Medical Center, Case Western Reserve University School of Medicine, Cleveland, Ohio. Electronic address:

Influenza is a major public health challenge. Patients hospitalized with influenza who also have heart failure (HF) may be at risk for worse outcomes compared with patients without HF. There is a lack of large studies examining this issue. We queried the 2013 to 2014 National Inpatient Sample for all adult patients (aged ≥ 18 years) admitted with influenza with and without concomitant HF. Using propensity score matching, patients were matched across demographics, discharge weights, and comorbidities. Outcomes included in-hospital mortality, complications, length of stay, and average hospital costs. Of 218,540 influenza hospitalizations, 45,460 (20.8%) had concomitant HF. Patients with HF had higher in-hospital mortality (6.1% vs 3.8%, adjusted odds ratio [aOR] 1.66 [95% confidence interval [CI] 1.44 to 1.91]; p <0.001), acute kidney injury (29.5% vs 22.2%, aOR 1.47 [95% CI 1.37 to 1.57]; p <0.001), acute kidney injury requiring dialysis (2.0% vs 1.0%, aOR 2.08 [1.62 to 2.67], acute respiratory failure (36.2% vs 23.5%, aOR 1.85 [1.73 to 1.97]; p <0.001), and acute respiratory failure requiring mechanical ventilation (17.1% vs 9.3%, OR 2.01 [1.84 to 2.21]; p <0.001), longer length of stay (5.70 ± 0.02 days vs 4.60 ± 0.01 days, p <0.001) and higher average hospital costs ($11,609 ± $52 vs $9,003 ± $38, p <0.001). In conclusion, in patients hospitalized with influenza, HF is associated with increased risk of in-hospital mortality and complications. Our results highlight a need for early recognition and aggressive treatment of HF in these patients to try to improve outcomes.
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http://dx.doi.org/10.1016/j.amjcard.2019.01.046DOI Listing
May 2019

Derivation and external validation of a simple risk tool to predict 30-day hospital readmissions after transcatheter aortic valve replacement.

EuroIntervention 2019 Jun;15(2):155-163

Columbia University Medical Center, New York, NY, USA.

Aims: Patients undergoing transcatheter aortic valve replacement (TAVR) possess a higher risk of recurrent healthcare resource utilisation due to multiple comorbidities, frailty, and advanced age. We sought to devise a simple tool to identify TAVR patients at increased risk of 30-day readmission.

Methods And Results: We used the Nationwide Readmissions Database from January 2013 to September 2015. Complex survey methods and hierarchical regression in R were implemented to create a prediction tool to determine probability of 30-day readmission. Boot-strapped internal validation and cross-validation were performed to assess model accuracy. External validation was performed using a single-centre data set. Of 39,305 patients who underwent endovascular TAVR, 6,380 (16.2%) were readmitted within 30 days. The final 30-day readmission risk prediction tool included the following variables: chronic kidney disease, end-stage renal disease on dialysis (ESRD), anaemia, chronic lung disease, chronic liver disease, atrial fibrillation, length of stay, acute kidney injury, and discharge disposition. ESRD (OR 2.11, 95% CI: 1.7-2.63), length of stay ≥5 days (OR 1.64, 95% CI: 1.50-1.79), and short-term hospital discharge disposition (OR 1.81, 95% CI: 1.2-2.7) were the strongest predictors. The c-statistic of the prediction model was 0.63. The c-statistic in the external validation cohort was 0.69. On internal calibration, the tool was extremely accurate in predicting readmissions up to 25%.

Conclusions: A simple and easy-to-use risk prediction tool utilising standard clinical parameters identifies TAVR patients at increased risk of 30-day readmission. The tool may consequently inform hospital discharge planning, optimise transitions of care, and reduce resource utilisation.
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http://dx.doi.org/10.4244/EIJ-D-18-00954DOI Listing
June 2019

Trends in Utilization of Surgical and Transcatheter Mitral Valve Repair in the United States.

Am J Cardiol 2019 04 16;123(7):1187-1189. Epub 2019 Jan 16.

Division of Cardiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York; Cardiovascular Research Foundation, New York, New York.

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http://dx.doi.org/10.1016/j.amjcard.2019.01.005DOI Listing
April 2019

Effect of Influenza on Outcomes in Patients With Heart Failure.

JACC Heart Fail 2019 Feb 2;7(2):112-117. Epub 2019 Jan 2.

Division of Cardiovascular Medicine, Harrington Heart and Vascular Institute, University Hospitals Cleveland Medical Center, Case Western Reserve University School of Medicine, Cleveland, Ohio.

Objectives: This study sought to determine whether influenza infection increases morbidity and mortality in patients hospitalized with heart failure (HF).

Background: Patients with HF may be at increased risk of morbidity and mortality from influenza infection. However, there are limited data for the associated hazards of influenza infection in patients with HF.

Methods: We queried the 2013 to 2014 National Inpatient Sample database for all adult patients (18 years of age or older) admitted with HF with and without concomitant influenza infection. Propensity score matching was used to match patients across age, race, sex, and comorbidities. Outcomes included in-hospital mortality, in-hospital complications, length of stay, and average hospital costs.

Results: Of 8,189,119 all-cause hospitalizations in patients with HF, 54,590 (0.67%) had concomitant influenza infection. Patients with concomitant influenza had higher incidence of in-hospital mortality (6.2% vs. 5.4%, respectively; odds ratio [OR]: 1.15 [95% confidence interval [CI]: 1.03 to 1.30]; p = 0.02), acute respiratory failure (36.9% vs. 23.1%, respectively; OR: 1.95 [95% CI: 1.83 to 2.07]; p < 0.001), acute respiratory failure requiring mechanical ventilation (18.2% vs. 11.3%, respectively; OR: 1.75 [95% CI: 1.62 to 1.89]; p < 0.001), acute kidney injury (AKI) (30.3% vs. 28.7%, respectively; OR: 1.08 [95% CI: 1.02 to 1.15]; p = 0.01), and AKI requiring dialysis (2.4% vs. 1.8%, respectively; OR: 1.37 [95% CI: 1.14 to 1.65]; p = 0.001). Patients with influenza had longer mean lengths of stay (5.9 days vs. 5.2 days, respectively; p <0.001) but similar average hospital costs ($12,137 vs. $12,003, respectively; p = 0.40).

Conclusions: Influenza infection is associated with increased in-hospital morbidity and mortality in patients with HF. Our results emphasize the need for efforts to mitigate the incidence of influenza, specifically in this high-risk patient cohort.
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http://dx.doi.org/10.1016/j.jchf.2018.10.011DOI Listing
February 2019

Intracardiac vs transesophageal echocardiography for percutaneous left atrial appendage occlusion: A meta-analysis.

J Cardiovasc Electrophysiol 2019 04 9;30(4):461-467. Epub 2019 Jan 9.

Structural Heart and Valve Center, Center for Interventional Vascular Therapy, Division of Cardiology, Columbia University Medical Center, New York, New York.

Introduction: Percutaneous left atrial appendage closure (LAAC) is typically performed utilizing transesophageal echocardiography (TEE) and fluoroscopy. Intracardiac echocardiography (ICE) can be a suitable alternative to guide implantation. Given the limited data, we performed a meta-analysis of all studies that compared ICE vs TEE for percutaneous LAAC.

Methods: A comprehensive literature search was performed in PubMed, Embase, Scopus, Google Scholar, and major scientific conference sessions for published abstracts and manuscripts until 1 August 2018. Studies reporting clinical outcomes comparing TEE vs ICE for endocardial LAAC in human subjects aged greater than or equal to 18 years were included. Two investigators independently extracted the data and individual quality assessment was performed. The analysis was performed using Cochrane Collaboration software, RevMan 5.3.

Results: Five eligible studies consisting of 1157 patients (ICE-391 patients and TEE-766 patients) were included. Four studies were retrospective and one was prospective, nonrandomized. Two studies included Watchman, two included the Amplatzer Cardiac Plug/Amulet device, and one included both devices. There was no significant difference in CHA2DS2VASC or HAS-BLED scores between both groups. There was no significant difference in acute procedural success between ICE vs TEE (risk ratio, 1.01; 95% CI, 0.99-1.04; P = 0.24). There was no significant difference in fluoroscopy time (mean difference [MD], 1.84 minutes; 95% CI, 0.59-4.27; P = 0.14) and total procedure time (MD, -5.06 minutes; 95% CI, -24.6-14.4; P = 0.61) between both groups. There was also no significant difference in complications including pericardial tamponade, device embolization, and stroke between both groups.

Conclusion: In our meta-analysis, ICE was as effective as TEE during percutaneous LAAC.
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http://dx.doi.org/10.1111/jce.13820DOI Listing
April 2019

Temporal Trends and Outcomes of Percutaneous Coronary Interventions in Nonagenarians: A National Perspective.

JACC Cardiovasc Interv 2018 09;11(18):1872-1882

Mayo Clinic, Rochester, Minnesota. Electronic address:

Objectives: This study sought to assess temporal trends and outcomes of percutaneous coronary intervention (PCI) in nonagenarians.

Background: With increasing life expectancy, nonagenarians requiring PCI are increasing even though outcomes data are limited.

Methods: The National Inpatient Sample was used to identify all hospitalizations for PCI in patients aged ≥90 years from January 1, 2003, to December 31, 2014. The primary outcome was in-hospital mortality.

Results: Nonagenarians (n = 69,271) constituted 0.9% of all PCI hospitalizations, increasing from 0.6% in 2003 to 2004 to 1.4% in 2013 to 2014 (p < 0.001). From 2003-2004 to 2013-2014, the proportion of PCIs performed for ST-segment elevation myocardial infarction (STEMI) (23.1% to 30.9%) and non-ST-segment elevation acute coronary syndromes (49.6% to 52.6%) increased, whereas those for stable ischemic heart disease (SIHD) decreased (27.3% to 16.5%), respectively (p < 0.001 for all). Overall in-hospital mortality after PCI for STEMI, non-ST-segment elevation acute coronary syndromes, and SIHD were 16.4%, 4.2%, and 1.8%, respectively. After multivariable risk adjustment for demographics, comorbidities, and hospital-level characteristics, in-hospital mortality remained unchanged in STEMI (odds ratio: 1.04; 95% confidence interval: 0.98 to 1.11; p = 0.20) and non-ST-segment elevation acute coronary syndromes (odds ratio: 0.99; 95% confidence interval: 0.91 to 1.08; p = 0.82), but increased in SIHD (odds ratio: 1.21; 95% confidence interval: 1.01 to 1.44; p = 0.04) from 2003 to 2004 to 2013 to 2014. The rates of bleeding and vascular complications decreased or remained stable in all 3 subgroups, whereas risk-adjusted incidence of stroke increased in patients with STEMI or SIHD.

Conclusions: The rate of in-hospital mortality, major bleeding, vascular complications, and stroke after PCI in nonagenarians changed significantly from 2003 to 2014. This study provides a benchmark for discussion of PCI-related risks among physicians, patients, and families.
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http://dx.doi.org/10.1016/j.jcin.2018.06.026DOI Listing
September 2018

Long-Term Outcomes of Drug-Eluting Stents Versus Bare-Metal Stents in End-Stage Renal Disease Patients on Dialysis: A Systematic Review and Meta-Analysis.

Cardiol Rev 2018 Nov/Dec;26(6):277-286

Division of Cardiology, New York Medical College and Westchester Medical Center, Valhalla, NY.

There are no dedicated data to guide drug-eluting stent (DES) versus bare-metal stent (BMS) selection in patients with end-stage renal disease undergoing dialysis (ESRD-D). It is unclear whether long-term benefits of a specific stent type outweigh risks in this population at high risk for both bleeding and ischemic events. We performed a meta-analysis of nonrandomized studies extracted from PubMed, Scopus, and EMBASE, assessing the safety and effectiveness of DES versus BMS in ESRD-D patients. Odds ratios (OR) and 95% confidence intervals (CI) were computed with the Mantel-Haenszel method. Random-effects model was used for all analyses. A total of 17 nonrandomized studies (N = 63,157; 41,621 DES and 21,536 BMS) met the inclusion criteria and were included for the final quantitative analysis: median follow-up of 1 year (range: 9 months to 6 years). The use of DES in ESRD-D patients was associated with lower all-cause mortality (OR 0.75, 95% CI 0.64-0.89, P < 0.001) compared with BMS. The use of DES was also associated with lower rates of cardiovascular mortality (OR 0.75, 95% CI 0.60-0.99, P = 0.047) and target lesion/vessel revascularization (OR 0.78, 95% CI 0.64-0.94, P = 0.01). However, there were no differences in noncardiovascular mortality, myocardial infarction, stent thrombosis, stroke, or major bleeding in DES versus BMS. In this largest meta-analysis of long-term outcomes after percutaneous coronary intervention in ESRD-D patients, DES was associated with lower rates of all-cause mortality, target lesion/vessel revascularization, and cardiovascular death.
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http://dx.doi.org/10.1097/CRD.0000000000000192DOI Listing
November 2018

Case report and systematic review of pulmonary embolism mimicking ST-elevation myocardial infarction.

Vascular 2019 Feb 30;27(1):90-97. Epub 2018 Jul 30.

2 Division of Cardiology, Department of Medicine, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, New York, USA.

Background: To study trends in the clinical presentation, electrocardiograms, and diagnostic imaging in patients with pulmonary embolism presenting as ST segment elevation.

Methods: We performed a systematic literature search for all reported cases of pulmonary embolism mimicking ST-elevation myocardial infarction. Pre-specified data such as clinical presentation, electrocardiogram changes, transthoracic echocardiographic findings, cardiac biomarkers, diagnostic imaging, therapy, and outcomes were collected.

Results: We identified a total of 34 case reports. There were 23 males. Mean age of the population was 56.5 ± 15.5 years. Patients presented with dyspnea (76.4%), chest pain (63.6%), and tachycardia (71.4%). All patients presented with ST-elevations, with the most common location being in the anterior-septal distribution, lead V3 (74%), V2 (71%), V1 (62%) and V4 (47%). ST-segment elevations in the inferior distribution were present in lead II (12%), III (18%), and aVF (21%). Presentation was least likely in the lateral distribution. Troponin was elevated in 78.9% of cases. Right ventricular strain was the most common echocardiographic finding. Over 80% of patients had findings consistent with elevated right ventricular pressure, with 50% reported RV dilatation and 20% RV hypokinesis. The most commonly used imaging modality was contrast-enhanced pulmonary angiography. There was a greater incidence of bilateral compared to unilateral pulmonary emboli (72.4% vs. 10%). About 65% patients received anticoagulation and 36.3% were treated with thrombolytics. Forty-six percent of patients required intensive care and 18.7% intubation. Overall mortality was 25.8%.

Conclusions: A review of the literature reveals that in patients presenting with pulmonary embolism, electrocardiogram findings of ST-segment elevations will occur predominantly in the anterior-septal distribution.
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http://dx.doi.org/10.1177/1708538118791917DOI Listing
February 2019

Temporal Trends and Factors Associated With Prolonged Length of Stay in Patients With ST-Elevation Myocardial Infarction Undergoing Primary Percutaneous Coronary Intervention.

Am J Cardiol 2018 07 11;122(2):185-191. Epub 2018 Apr 11.

Department of Internal Medicine, Cardiovascular Disease, Brown University, Providence, Rhode Island. Electronic address:

Improved procedural techniques and process of care initiatives have decreased length of stay (LOS) after primary percutaneous coronary intervention (PPCI) for ST-elevation myocardial infarction (STEMI). However, there remains a subset of patients who continue to require longer LOS. We used the 2005 to 2014 National Inpatient Sample databases to identify all hospitalizations for PPCI for STEMI in patients ≥18 years of age. Hospitalizations in which patients were discharged home alive were included. Multivariable linear and logistic regression models were used to examine temporal trends in LOS and to identify independent predictors of longer LOS (LOS >3 days). In 678,545 hospitalizations for PPCI for STEMI, mean ± standard error of mean LOS decreased significantly from 3.3 (±0.04) days to 2.7 (±0.02) days (p<0.001). There was a marked decrease in the proportion of STEMI hospitalizations with LOS >3 days from 31.9% in 2005 to 16.9% in 2014 (p<0.001). Patient demographics, co-morbidities, hospital region, use of mechanical circulatory support, and periprocedural complications were independently associated with longer LOS. In conclusion, LOS for hospitalizations for PPCI for STEMI has decreased significantly over time. Targeting strategies to reduce procedure-related risk may translate into shorter LOS.
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http://dx.doi.org/10.1016/j.amjcard.2018.03.365DOI Listing
July 2018
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