Sex-Specific Outcome Disparities in Patients Receiving Continuous-Flow Left Ventricular Assist Devices: A Systematic Review and Meta-analysis

Continuous-flow left ventricular assist devices (CF-LVADs) decrease mortality and improve quality of life in patients with advanced heart failure (HF). Their widespread utilization has led to concerns regarding increased adverse effects, especially in women. Nevertheless, sex-specific data remain limited. We searched Medline, Embase, Scopus, and the Cochrane Library for publications reporting sex-specific outcomes after CF-LVADs from January 2008 through January 2017. Outcomes were compared under the random-effects model and heterogeneity examined via χ test and I statistics. A total of 10 studies including 4,493 CF-LVAD recipients were included in the analysis (23.5% women). The overall rate of stroke was significantly higher in women (odds ratio [OR] 1.94; 95% confidence interval [CI] 1.32-2.84; p = 0.0007). This was true for ischemic strokes (OR 2.03; 95% CI 1.21-3.42; p = 0.008) and hemorrhagic strokes (OR 2.03; 95% CI 1.21-3.42; p = 0.008). Women were also more likely to develop right HF necessitating right ventricular assist device (RVAD) implantation (OR 2.12; 95% CI 1.08-4.15; p = 0.03). Other adverse events including renal failure, bleeding, and device-related infection were comparable for both genders. The overall mortality while on CF-LVAD was similar in both groups (OR 1.05; 95% CI 0.81-1.36; p = 0.71). Our analysis suggests that women are at greater risk of significant complications such as cerebrovascular events and right HF necessitating RVAD after CF-LVAD implantation. Further research is needed to better understand the mechanisms underlying these sex-specific outcome disparities

The Role of Impella for Hemodynamic Support in Patients With Aortic Stenosis

PURPOSE OF REVIEW: The goal of this review is to discuss the effects of Impella (Abiomed, Danvers, MA), to support in the hemodynamics of patients with severe aortic stenosis, and to explore the clinical scenarios in which the use of Impella may be beneficial in this setting. RECENT FINDINGS: The management of patients with severe aortic stenosis who go on to develop left ventricular failure and cardiogenic shock remains an important clinical challenge associated with increased morbidity and mortality. Once considered a relative contraindication, the use of Impella in severe aortic stenosis has now been proven feasible and demonstrated promising results in selected high-risk patients. The use of Impella to provide hemodynamic support maybe considered in patients with aortic stenosis in cardiogenic shock or those with severe left ventricular dysfunction and CAD who require high-risk PCI and or balloon aortic valvuloplasty. Impella is also an attractive option in selected cases of hemodynamic collapse during TAVR

Frequency of Complications Including Death from Coronary Artery Bypass Grafting in Patients With Hepatic Cirrhosis

Advanced liver disease is a risk factor for cardiac surgery. However, liver dysfunction is not included in cardiac risk assessment models. We sought to identify trends in utilization, complications, and outcomes of patients with cirrhosis who underwent coronary artery bypass graft surgery (CABG). Using the National Inpatient Sample database, we identified patients with cirrhosis who underwent CABG from 2002 to 2014. Propensity-score matching was used to identify differences in in-hospital mortality and postoperative complications in cirrhosis and noncirrhosis patients. We identified a total of 698,799 CABG admissions of which 2,231 (0.3%) had cirrhosis (mean age 63.6 ± 9.6 years, 74% men, 63% white, mean Charlson co-morbidity index 3.3 ± 1.8). Cardiopulmonary bypass was used in 71% of patients. Mean length of stay was 13.7 ± 11.4 days and hospitalization cost $67,744.6 ± 58,320.4. One or more complications occurred in 44% of cases. After propensity-score matching, patients with cirrhosis had a higher rate of complications (43.9% vs 38.93%; p < 0.001) and in-hospital mortality (7.2% vs 4.07%; p < 0.001) than noncirrhosis patients. On multivariate analysis, cirrhosis and ascites were associated with increased in-hospital mortality (odds ratio 2.87; 95% confidence intervals 2.37 to 3.48) and postoperative complications (odds ratio 5.11; 95% confidence intervals 3.88 to 6.72). In conclusion, patients with cirrhosis constitute a small portion of patients who underwent CABG in the United States but have a higher rate of complications and in-hospital mortality compared with noncirrhosis patients. In-hospital mortality remains high for this subset of patients but has decreased in recent years

Abstract 20220: Comparison of MitraClip vs Conservative Management for Inoperable Functional Mitral Regurgitation

BackgroundTranscatheter edge-to-edge mitral valve repair with the use of the MitraClip device has proven to be safe and effective for patients with inoperable severe symptomatic primary mitral regurgitation. Its use in functional mitral regurgitation (FMR) remains controversial.HypothesisMitraClip is feasible and improves mortality when compared to optimal medical therapy (OMT) alone for patients with inoperable severe symptomatic FMR.MethodsWe searched MEDLINE, EMBASE, and Cochrane Library through June 2016 for prospective studies comparing the use of MitraClip vs. OMT alone. Only studies with FMR etiology found in > 75% of patients were included in the analysis. Outcomes were compared under the random-effects model and heterogeneity examined via Chi and I statistics. RevMan 5.3 was used for statistical analysis.ResultsA total of 3 studies including 796 patients with inoperable severe symptomatic mitral regurgitation (age 74 ± 10 years, 60% men, 87% FMR, NYHA II-IV) managed with MitraClip (n=438) or OMT (n=358) were included in the analysis. Procedural success was high (86%) in the MitraClip group. Thirty-day overall mortality was comparable for MitraClip and OMT (OR 0.55; 95% CI 0.25 to 1.20; p=0.13). Twelve-month overall mortality was found to be significantly reduced with MitraClip compared to OMT (OR 0.48; 95% CI 0.34 to 0.66; p<0.001). Additionally, 12-month cardiovascular mortality was also decreased with the use of MitraClip (OR 0.13; 95% CI 0.07 to 0.24; p<0.001).ConclusionOur pooled analysis suggests that MitraClip is not only feasible, but also improves mortality at 12-months when compared to OMT alone for patients with inoperable FMR. Larger randomized trials in patients with severe symptomatic FMR are needed to confirm these findings. The ongoing COAPT trial will most likely shed further light on this topic

Use of Aminocaproic Acid in Combination With Extracorporeal Membrane Oxygenation in a Case of Leptospirosis Pulmonary Hemorrhage Syndrome

A 32-year-old man presented with a 10-day history of fever, chills, nausea, vomiting, myalgia, nonproductive cough, and worsening dyspnea after freshwater swimming in the Caribbean 1 week prior to presentation. Shortly after arrival at the hospital, the patient developed severe respiratory distress with massive hemoptysis. Based on serologic workup, he was diagnosed with leptospirosis pulmonary hemorrhage syndrome leading to diffuse alveolar hemorrhage, severe hypoxemic respiratory failure, and multiorgan failure. He received appropriate antibiotic coverage along with hemodynamic support with norepinephrine and vasopressin, mechanical ventilation, and renal replacement therapy in an intensive care unit. Introduction of extracorporeal membrane oxygenation was initiated to provide lung-protective ventilation supporting the recovery of his pulmonary function. Aminocaproic acid was used to stop and prevent further alveolar hemorrhage. He fully recovered thereafter; however, it is uncertain whether it was the use of aminocaproic acid that led to the resolution of his disease

Transcatheter Mitral Valve Repair With MitraClip for Symptomatic Functional Mitral Valve Regurgitation

Transcatheter edge-to-edge mitral valve repair (TMVr) with MitraClip has proved to be safe and effective for high-risk surgical patients with severe symptomatic degenerative mitral regurgitation. There is paucity of data regarding its use in functional mitral regurgitation (FMR). The objective of this study was to evaluate the use of MitraClip in patients with symptomatic moderate or severe FMR and a high surgical risk. Medical libraries were systematically searched for studies assessing the use of MitraClip for patients with symptomatic moderate or severe FMR and a high surgical risk. Studies reporting safety and efficacy outcomes at 12 months were included in the analysis. A total of 12 studies including 1,695 patients (age 73 [interquartile range [IQR] 70.5 to 74], 69.8% men, left ventricular ejection fraction 32.5% [IQR 29.5 to 36], New York Heart Association class II to IV) who underwent TMVr with MitraClip were included in the analysis. Acute procedural success was 89% (IQR 85.5 to 92). Ischemic cardiomyopathy was the most common cause of left ventricular dysfunction. Over 2/3 of patients had known coronary artery disease, 35% a previous myocardial infarction, and 38.5% had a previous cardiac surgery. Survival to hospital discharge was 98% (IQR 97 to 100) and 30-day survival 97% (IQR 96 to 98). Overall survival at 12 months was 82% (IQR 77 to 87). Mitral valve re-intervention at 12 months was infrequent (3%; IQR 2 to 6.5). In conclusion, our pooled analysis suggests that TMVr with MitraClip is feasible, safe, and carries a low rate of mitral valve re-intervention at 12 months in patients with symptomatic moderate or severe FMR and a high surgical risk

Association between public reporting of outcomes and the use of mechanical circulatory support in patients with cardiogenic shock

Risk-averse behavior has been reported among physicians and facilities treating cardiogenic shock in states with public reporting. Our objective was to evaluate if public reporting leads to a lower use of mechanical circulatory support in cardiogenic shock. We conducted a retrospective study with the use of the National Inpatient Sample from 2005 to 2011. Hospitalizations of patients ≥18 years old with a diagnosis of cardiogenic shock were included. A regional comparison was performed to identify differences between reporting and nonreporting states. The main outcome of interest was the use of mechanical circulatory support. A total of 13043 hospitalizations for cardiogenic shock were identified of which 9664 occurred in reporting and 3379 in nonreporting states (age 69.9 ± 0.4 years, 56.8% men). Use of mechanical circulatory support was 32.8% in this high-risk population. Odds of receiving mechanical circulatory support were lower (OR 0.50; 95% CI 0.43-0.57; p\u3c0.01) and in-hospital mortality higher (OR 1.19; 95% CI 1.06-1.34; p\u3c0.01) in reporting states. Use of mechanical circulatory support was also lower in the subgroup of patients with acute myocardial infarction and cardiogenic shock in reporting states (OR 0.61; 95% CI 0.51-0.72; p\u3c0.01). In conclusion, patients with cardiogenic shock in reporting states are less likely to receive mechanical circulatory support than patients in nonreporting states

Cryoballoon versus Radiofrequency Catheter Ablation in Atrial Fibrillation: A Meta-Analysis

Radiofrequency (RF) and cryoballoon (CB) catheter ablation are effective for pulmonary vein isolation (PVI) in atrial fibrillation (AF). This report presents an updated meta-analysis comparing the efficacy and safety of CB versus RF ablations in AF. Databases and conference abstracts were systematically searched for studies that directly compared CB and RF PVI, and reported safety or efficacy outcomes in follow-up ≥12 months. Recurrent atrial tachyarrhythmias (AT) were defined as AF, atrial flutter, or atrial tachycardia. Twenty-two studies and 8,668 patients were included. Freedom from AT was not significantly different between CB and RF ablations in the pooled population (OR 1.12; 95%CI 0.97-1.29; P = 0.13) and in randomized trials (OR 1.0; 95%CI 0.65-1.56; P = 0.99). Second-generation CB (CB2; 78.1%) and contact-force (CF) sensing RF (78.2%) have improved procedure success rate as compared to first-generation technology (57.9% CB, 58.1% RF). As compared to CF-RF, CB2 demonstrated similar freedom from recurrent AT (OR 1.04; 95%CI 0.71-1.51; P = 0.84). The incidence of pericardial effusions (OR 0.44; 95%CI 0.28-0.69; P < 0.01), tamponade (OR 0.31; 95%CI 0.15-0.64; P < 0.01), and non-AF AT (OR 0.46; 95%CI 0.26-0.83; P < 0.01) were significantly lower with CB ablation, whereas transient phrenic nerve palsy was more incident after CB (OR 7.40; 95%CI 2.56-21.34; P < 0.01). There was comparable freedom from AT between CB and RF in patients with AF undergoing PVI. Additionally, freedom from AT was similar between CB2 and CF-RF. However, CB was associated with a lower incidence of pericardial effusions or tamponade, albeit with a higher rate of transient phrenic nerve palsies