Independent Risk Factors for Thromboembolic Events in High-Risk Patients With Takotsubo Cardiomyopathy.

Takotsubo cardiomyopathy (TCM) is characteristically associated with left ventricular apical ballooning and regional wall motion abnormalities that predispose to the formation of left ventricular (LV) thrombi and subsequent thromboembolic events (VTE). There is limited data about the risk factors of developing stroke in the absence of LV thrombi in patients with TCM. Identify risk factors that predispose patients with TCM to develop VTE and stroke. We retrospectively reviewed all patients admitted with a primary diagnosis of stress induced or Takotsubo cardiomyopathy at a large tertiary care center from 2005 to 2019. Patients who met the echocardiographic criteria of TCM, had resolution of WMA on repeat echocardiogram, did not have coronary artery disease if angiography was performed and survived for \u3e 3 months after index presentation were included in the analysis. Patients were followed for up to a period of 1 year. Multivariate analysis was performed to identify predictors of thromboembolism. Among the 400 patients who presented with TCM, 146 patients were included in the analysis. A total of 13 patients (8.9%) had documented thromboembolic events. Patients with VTE more often had Atrial fibrillation (30.8% vs 6.8%, P = 0.018), higher LV mass (224.5g vs 184g, P = 0.04), lower EF on presentation (31.5% vs 40%, P = 0.011) and were less likely to have undergone coronary angiography following diagnosis (23.1% vs 54.9%, P = 0.04). On multivariate analysis, atrial fibrillation (OR 9.15, CI 1.15-72.70) and low ejection fraction on admission (OR 0.88, CI 0.81-0.97) were independent risk factors for the development of VTE. Atrial fibrillation and low ejection fraction on presentation were associated with higher risk of developing thromboembolic events in patients with TCM

Echocardiographic Versus Invasive Aortic Valve Gradients In Different Clinical Scenarios.

BACKGROUND The role of echocardiography in deriving transvalvular mean-gradients from transaortic velocities in aortic stenosis (AS) and in degenerated surgical bioprosthetic valves (SVD) is well established. However, reports following surgical aortic valve replacement (SAVR), post-transcatheter aortic valve replacement (TAVR), and valve-in-valve-TAVR (ViV-TAVR) have cautioned against the use of echocardiography-derived mean-gradients to assess normal functioning bioprosthesis due to discrepancy compared to invasive measures in a phenomenon called discordance. METHODS In a multicenter study, intra-procedural echocardiographic and invasive mean-gradients in AS, SVD, post-native-TAVR, and post-ViV-TAVR were compared, when obtained concomitantly, and discharge echocardiographic gradients were recorded. Absolute discordance (intra-procedural echocardiographic - invasive mean-gradient) and percent discordance (intra-procedural echocardiographic - invasive mean-gradient/echocardiographic mean-gradient) were calculated. Multivariable regression analysis to determine variables independently associated with elevated post-procedure invasive gradients ≥20mmHg, absolute discordance >10mmHg, and discharge echocardiographic mean-gradient ≥20mmHg RESULTS: 5027 patients were included in the registry; 4725 native-TAVR and 302 ViV-TAVR. Intra-procedural concomitant echocardiographic and invasive mean-gradients were obtained pre-TAVR in AS (N=2418), pre-ViV-TAVR in SVD (N=101), in 77 post-ViV-TAVR, and in 823 post-TAVR. Echocardiographic and invasive mean-gradients demonstrated strong correlation (r=0.69) and agreement (bias: 0.11, 95% confidence interval (CI) -0.4-0.62) in AS, moderate correlation (r=0.56) and agreement (bias:1.08, 95% CI -2.53-4.59) in SVD, moderate correlation (r=0.61) and weak agreement (bias:6.47, 95% CI 5.08-7.85) post-ViV-TAVR, and weak correlation (r=0.18) and agreement (bias:3.41, 95% CI 3.16-3.65) post-TAVR. Absolute discordance occurs primarily in ViV-TVR, is not explained by STJ size, and increases with increasing echocardiographic mean gradient. Percent discordance in AS and SVD (1.3% and 4%, respectively) was lower compared to post-TAVR/ViV-TAVR (66.7% and 100%, respectively). Compared to self-expanding valves, balloon-expandable valves were independently associated with elevated discharge echocardiographic but lower invasive mean-gradient (odds ratio=3.411, 95% CI:1.482-7.852, p= 0.004 vs. OR=0.308, 95% CI:0.130-0.731, p=0.008, respectively). CONCLUSIONS Post TAVR/ViV-TAVR, echocardiography is discordant from invasive mean-gradients and absolute discordance increases with increasing echocardiographic mean-gradient and is not explained by STJ size. Percent discordance is significantly higher post-TAVR/ViV-TAVR than in AS and SVD. Post-TAVR/ViV-TAVR, poor correlation and wide limits of agreement suggest echocardiographic and invasive mean-gradients may not be used interchangeably and a high residual echocardiographic mean-gradient should be confirmed invasively before considering any additional procedure to "correct" the gradient. TAVR valve types have variable impact on echocardiographic and invasive mean-gradients

Racial and Ethnic Disparities in Peripheral Vascular Disease Admissions Using a Nationally Representative Sample.

Our study aimed to identify clinical outcomes and resource utilization associated with race and ethnicity in patients admitted with peripheral vascular disease (PVD) across the United States. We queried the National Inpatient Sample database from 2015 to 2019 and identified 622,820 patients admitted with PVD. Patients across 3 major race and ethnic categories were compared in terms of baseline characteristics, inpatient outcomes, and resource utilization. Black and Hispanic patients were more likely to be younger and of the lowest median income but incur higher total hospital costs. Black race predicted higher rates of acute kidney injury, need for blood transfusion, and need for vasopressor but lower rates of circulatory shock, and mortality. Black and Hispanic patients were less likely to undergo limb-salvaging procedures and more likely to undergo amputation than White patients. In conclusion, our findings indicate that Black and Hispanic patients experience health disparities in resource utilization and inpatient outcomes for PVD admissions

Racial and Ethnic Disparities in Peripheral Vascular Disease Admissions Using a Nationally Representative Sample

Our study aimed to identify clinical outcomes and resource utilization associated with race and ethnicity in patients admitted with peripheral vascular disease (PVD) across the United States. We queried the National Inpatient Sample database from 2015 to 2019 and identified 622,820 patients admitted with PVD. Patients across 3 major race and ethnic categories were compared in terms of baseline characteristics, inpatient outcomes, and resource utilization. Black and Hispanic patients were more likely to be younger and of the lowest median income but incur higher total hospital costs. Black race predicted higher rates of acute kidney injury, need for blood transfusion, and need for vasopressor but lower rates of circulatory shock, and mortality. Black and Hispanic patients were less likely to undergo limb-salvaging procedures and more likely to undergo amputation than White patients. In conclusion, our findings indicate that Black and Hispanic patients experience health disparities in resource utilization and inpatient outcomes for PVD admissions