The impact of peripheral arterial disease on patients with mechanical circulatory support.

Background: Left ventricular assist devices (LVAD) are indicated as bridging or destination therapy for patients with advanced (Stage D) heart failure and reduced ejection fraction (HFrEF). Due to the clustering of the mutual risk factors, HFrEF patients have a high prevalence of peripheral arterial disease (PAD). This, along with the fact that continuous flow LVAD influence shear stress on the vasculature, can further deteriorate the PAD. Methods: We queried the National Inpatient Sample (NIS) database (2002-2014) to identify the burden of pre-existing PAD cases, its association with LVAD, in-hospital mortality, and other complications of LVAD. The adjusted odds ratio (aOR) and 95% confidence interval (CI) were calculated using the Cochran-Mantel-Haenszel test. Results: A total of 20,817 LVAD patients, comprising of 1,625 (7.8%) PAD and 19,192 (91.2%) non-PAD patients were included in the study. The odds of in-hospital mortality in PAD patients were significantly higher compared to non-PAD group (OR 1.29, CI, 1.07-1.55, P = 0.007). The PAD group had significantly higher adjusted odds as compared to non-PAD group for acute myocardial infarction (aOR 1.29; 95% CI, 1.07-1.55, P = 0.007), major bleeding requiring transfusion (aOR, 1.286; 95% CI, 1.136-1.456, P \u3c 0.001), vascular complications (aOR, 2.360; 95% CI, 1.781-3.126, P \u3c 0.001), surgical wound infections (aOR, 1.50; 95% CI, 1.17-1.94, P = 0.002), thromboembolic complications (aOR, 1.69; 95% CI, 1.36-2.10, P \u3c 0.001), implant-related complications (aOR, 1.47; 95% CI, 1.19-1.80, P \u3c 0.001), and acute renal failure (aOR, 1.26; 95% CI, 1.12-1.43, P \u3c 0.001). Conclusion: PAD patients can have high LVAD associated mortality as compared to non-PAD

Outcomes of nonemergent percutaneous coronary intervention requiring mechanical circulatory support in patients without cardiogenic shock

BACKGROUND: The utilization of mechanical circulatory support (MCS) for percutaneous coronary intervention (PCI) using percutaneous ventricular assist device (PVAD) or intra-aortic balloon pump (IABP) has been increasing. We sought to evaluate the outcome of coronary intervention using PVAD compared with IABP in noncardiogenic shock and nonacute myocardial infarction patients. METHOD: Using the National Inpatient Sampling (NIS) database from 2005 to 2014, we identified patients who underwent PCI using ICD 9 codes. Patients with cardiogenic shock, acute coronary syndrome, or acute myocardial infarction were excluded. Patient was stratified based on the MCS used, either to PVAD or IABP. Univariate and multivariate logistic regression were performed to study PCI outcome using PVAD compared with IABP. RESULTS: Out of 21,848 patients who underwent PCI requiring MCS, 17,270 (79.0%) patients received IABP and 4,578 (21%) patients received PVAD. PVAD patients were older (69 vs. 67, p \u3c .001), were less likely to be women (23.3% vs. 33.3%, p \u3c .001), and had higher rates of hypertension, diabetes, hyperlipidemia prior PCI, prior coronary artery bypass graft surgery, anemia, chronic lung disease, liver disease, renal failure, and peripheral vascular disease compared with IABP group (p ≤ .007). Using Multivariate logistic regression, PVAD patients had lower in-hospital mortality (6.1% vs. 8.8%, adjusted odds ratio [aOR] 0.62; 95% CI 0.51, 0.77, p \u3c .001), vascular complications (4.3% vs. 7.5%, aOR 0.78; 95% CI 0.62, 0.99, p = .046), cardiac complications (5.6% vs. 14.5%, aOR 0.29; 95% CI 0.24, 0.36, p \u3c .001), and respiratory complications (3.8% vs. 9.8%, aOR 0.37; 95% CI 0.28, 0.48, p \u3c .001) compared with patients who received IABP. CONCLUSION: Despite higher comorbidities, nonemergent PCI procedures using PVAD were associated with lower mortality compared with IABP

Ultrasound-Guided Versus Palpation-Guided Radial Artery Catheterization In Adult Population: A Systematic Review And Meta-Analysis Of Randomized Controlled Trials

Background: The radial artery (RA) is routinely used for both hemodynamic monitoring and for cardiac catheterization. Although cannulation of the RA is usually undertaken through manual palpation, ultrasound (US)-guided access has been advocated as a mean to increase cannulation success rates and to lower RA complications; however, the published data are mixed. We sought to evaluate the impact of US-guided RA access compared with palpation alone on first-pass success to access RA. Methods and Results: Meta-analysis of 12 randomized controlled trials comparing US-guided with palpation-guided radial access in 2,432 adult participants was done. Hemodynamic monitoring was the most common reason for RA catheterization. Only 2 randomized controlled trials evaluated patients undergoing cardiac catheterization. Ultrasound-guided radial access was associated with increased first-attempt success rate (risk ratio [RR] 1.35, 95% CI 1.16-1.57]) and decreased failure rate (RR 0.52, 95% CI 0.32-0.87). There were no significant differences in the risk of hematoma (RR 0.43, 95% CI 0.27-1.06), the mean time to first successful attempt (mean difference 25.13 seconds, 95% CI −1.06 to 51.34) or to any successful attempt (mean difference −4.74 seconds; 95% CI −22.67 to 13.18) between both groups. Conclusions: Ultrasound-guided technique for RA access has higher first-attempt success and lower failure rate compared with palpation alone, with no significant differences in access site hematoma or time to a successful attempt. These findings support the routine use of US guidance for RA access

Transcatheter aortic valve replacement in patients with bicuspid aortic valve stenosis: national trends and in-hospital outcomes

Background: Bicuspid aortic valve (BAV) disease is considered the most common congenital heart disease and the main etiology of aortic valve stenosis (AS) in young adults. Although transcatheter aortic valve replacement (TAVR) is routinely used in high- and intermediate-risk patients with AS, BAV patients with AS were excluded from all pivotal trials that led to TAVR approval. We sought, therefore, to examine in-hospital outcomes of patients with BAV who underwent TAVR in comparison with surgical aortic valve replacement (SAVR). Methods: Using the National Inpatient Sample from 2011 to 2014, we identified patients with BAV with International Classification of Diseases-Ninth Revision-CM code 746.4. Patients who underwent TAVR were identified using ICD-9 codes 35.05 and 35.06 and those who underwent SAVR were identified using codes 35.21 and 35.22 during the same period. Results: A total of 37,052 patients were found to have BAV stenosis. Among them, 36,629 patients (98.8%) underwent SAVR, whereas 423 patients (1.14%) underwent TAVR. One-third of enrolled patients were female, and the majority of the patients were White with a mean age of 65.9 ± 15.1 years. TAVR use for BAV stenosis significantly increased from 0.39% in 2011 to 4.16% in 2014 (P < 0.001), which represents a 3.77% overall growth in procedure rate. The median length of stay decreased significantly throughout the study period (mean 12.2 ± 8.2 days to 7.1 ± 5.9 days, P < 0.001). There was no statistically significant difference between SAVR and TAVR groups in the in-hospital mortality (0% vs. 5.9%; adjusted P = 0.119). Conclusion: There is a steady increase in TAVR use for BAV stenosis patients along with a significant decrease in length of stay

The role of B-type natriuretic peptide in diagnosing acute decompensated heart failure in chronic kidney disease patients

Introduction: Chronic kidney disease (CKD) and congestive heart failure (CHF) patients have higher serum B-type natriuretic peptide (BNP), which alters the test interpretation. We aim to define BNP cutoff levels to diagnose acute decompensated heart failure (ADHF) in CKD according to CHF subtype: heart failure with preserved ejection fraction (HFpEF) and heart failure with reduced ejection fraction (HFrEF). Material and methods: We reviewed 1,437 charts of consecutive patients who were admitted for dyspnea. We excluded patients with normal kidney function, without measured BNP, echocardiography, or history of CHF. BNP cutoff values to diagnose ADHF for CKD stages according to CHF subtype were obtained for the highest pair of sensitivity (Sn) and specificity (Sp). We calculated positive and negative likelihood ratios (LR+ and LR–, respectively), and diagnostic odds ratios (DOR), as well as the area under the receiver operating characteristic curves (AUC) for BNP. Results: We evaluated a cohort of 348 consecutive patients: 152 had ADHF, and 196 had stable CHF. In those with HFpEF with CKD stages 3–4, BNP 670 pg/ml rules in ADHF (Sp90%, LR+ = 4 and DOR = 6), with an AUC = 0.79 (95% CI: 0.71–0.87). In contrast, in those with HFrEF with CKD stages 3–4, BNP 1166.5 pg/ml rules in ADHF (Sp87%, LR+ = 3.9 and DOR = 6.97) with an AUC = 0.78 (95% CI: 0.69–0.86). All LRs and DOR were statistically significant. Conclusions: BNP cutoff values for the diagnosis of ADHF in HFrEF were higher than those in HFpEF across CKD stages 3–4, with moderate discriminatory diagnostic ability.Revisión por pare