Transcatheter Aortic Valve Replacement is Associated With a Higher Rate of Permanent Pacemaker Implantation Compared to Surgical Aortic Valve Replacement: A Propensity Matched Analysis (Poster).

Background Occurrence of conduction abnormalities requiring permanent pacemaker implantation (PPI) is a serious complication after both transcatheter (TAVR) & surgical (SAVR) aortic valve replacement. Methods Nationwide Inpatient Sample was queried from August 2011 to December 2012 using ICD-9 codes 35.05 & 35.06 for TAVR and 35.21 & 35.22 for SAVR. Patients undergoing other valve surgeries, bypass grafting & those with prior pacemakers or defibrillators were excluded. Propensity matching was performed (1:1) to match TAVR & SAVR cohorts on age, gender, right bundle branch block (RBBB), first degree AV block, bifascicular or trifascicular block, hospital region, teaching hospital status & hospital bed size. Logistic regression was performed to identify predictors of PPI. Differences in the two cohorts were tested using chi-square test. Results Total 2,990 patients (1,495 in TAVR group & 1,495 in SAVR group) were included, with mean age 80.2 +/- 9.0 years, 50.4% females & 83.2% Caucasians. RBBB (OR 2.3, 95% CI 1.4-4.0, p = 0.002) & bifascicular or trifascicular block (OR 6.9, 95% CI 2.8-17.0, p Conclusions PPI rates are higher after TAVR (with predominantly balloon expandable valves) compared to SAVR, after matching on demographic, EKG & hospital characteristics. This suggests greater damage to cardiac conduction system with TAVR compared to SAVR

The Transradial Approach for Cardiac Catheterization and Percutaneous Coronary Intervention: A Review

Cardiac catheterization and percutaneous coronary intervention play an important role in the management of coronary artery disease. Although the transfemoral approach has been the traditionally dominant method, there has been an increased utilization of the transradial approach. Multiple observational studies and randomized clinical trials have shown fewer bleeding complications, reduced morbidity and mortality, improved quality of life, and better economic outcomes when the transradial approach is utilized when compared to the transfemoral approach. Despite its many benefits, utilization of this approach in certain countries including the United States has been less than optimal due to a lower adoption rates mostly driven by lack of training opportunities and decreased awareness of clinical benefits of the transradial approach. In this review, the history, observational trends, efficacy, and technical aspects of transradial cardiac catheterization and percutaneous coronary intervention are discussed

TRANSCATHETER AORTIC VALVE REPLACEMENT (TAVR) IS ASSOCIATED WITH A HIGHER RATE OF PERMANENT PACEMAKER IMPLANTATION COMPARED TO SURGICAL AORTIC VALVE REPLACEMENT (SAVR): A PROPENSITY MATCHED ANALYSIS

Background Occurrence of conduction abnormalities requiring permanent pacemaker implantation (PPI) is a serious complication after both transcatheter (TAVR) & surgical (SAVR) aortic valve replacement. Methods Nationwide Inpatient Sample was queried from August 2011 to December 2012 using ICD-9 codes 35.05 & 35.06 for TAVR and 35.21 & 35.22 for SAVR. Patients undergoing other valve surgeries, bypass grafting & those with prior pacemakers or defibrillators were excluded. Propensity matching was performed (1:1) to match TAVR & SAVR cohorts on age, gender, right bundle branch block (RBBB), first degree AV block, bifascicular or trifascicular block, hospital region, teaching hospital status & hospital bed size. Logistic regression was performed to identify predictors of PPI. Differences in the two cohorts were tested using chi-square test. Results Total 2,990 patients (1,495 in TAVR group & 1,495 in SAVR group) were included, with mean age 80.2 +/- 9.0 years, 50.4% females & 83.2% Caucasians. RBBB (OR 2.3, 95% CI 1.4-4.0, p = 0.002) & bifascicular or trifascicular block (OR 6.9, 95% CI 2.8-17.0, p\u3c0.001) were predictors of PPI in TAVR group. 146 (9.8%) patients in the TAVR group underwent PPI compared to 98 (6.6%) patients in the SAVR group (p = 0.001). Conclusions PPI rates are higher after TAVR (with predominantly balloon expandable valves) compared to SAVR, after matching on demographic, EKG & hospital characteristics. This suggests greater damage to cardiac conduction system with TAVR compared to SAVR

Red cell Distribution Width and Risk of Cardiovascular Mortality: Insights from National Health and Nutrition Examination Survey (NHANES)-III.

INTRODUCTION: Red cell distribution width (RDW) has been linked to cardiovascular disease. We sought to determine whether addition of RDW improved the Framingham risk score (FRS) model to predict cardiovascular mortality in a healthy US cohort. METHODS: We performed a post-hoc analysis of the National Health and Nutritional Examination Survey-III (1988-94) cohort, including non-anemic subjects aged 30-79years. Primary endpoint was death from coronary heart disease (CHD). We divided the cohort into three risk categories:20%. RDW\u3e14.5 was considered high. Kaplan-Meier survival curves and Cox proportional hazards models were created. Discrimination, calibration and reclassification were used to assess the value of addition of RDW to the FRS model. RESULTS: We included 7005 subjects with a mean follow up of 14.1years. Overall, there were 233 (3.3%) CHD deaths; 27 (8.2%) in subjects with RDW\u3e14.5 compared to 206 (3.1%) in subjects with RDW≤14.5 (p CONCLUSIONS: Our study demonstrates that RDW is a promising biomarker which improves prediction of cardiovascular mortality over and above traditional cardiovascular risk factors

National Trends in Utilization, Mortality, Complications, and Cost of Care After Left Ventricular Assist Device Implantation From 2005 to 2011.

BACKGROUND: Left ventricular assist devices (LVADs) have shown survival benefit in end-stage heart failure patients. LVAD technology has evolved considerably with the development of continuous-flow devices. METHODS: The Nationwide Inpatient Sample was queried from 2005 to 2011 using International Classification of Diseases, 9th Edition procedure code 37.66, Insertion of Implantable Heart System, in any procedure field. Patients with primary diagnosis of orthotopic heart transplant or use of temporary mechanical circulatory support devices were excluded. Procedural complications were identified using International Classification of Diseases, 9th Edition codes and patient safety indicators. Cochran-Armitage and Cuzick tests for trend were used to identify time trends for categorical and continuous variables, respectively. RESULTS: There were 2,038 LVAD implantations from 2005 to 2011. LVAD use increased from 127 procedures in 2005 to 506 procedures in 2011, and in-hospital mortality declined from 47.2% to 12.7% (p \u3c 0.001), with sharp inflection points in the year 2008. Average length of stay decreased from 44 days in the pulsatile-flow era (2005 to 2007) to 36 days in the continuous-flow era (2008 to 2011). Cost of hospitalization increased from $194,380 in 2005 to$234,808 in 2011 but remained constant from 2008 to 2011. There was a trend of increased incidence of major bleeding and thromboembolism and decreased incidence of infectious and iatrogenic cardiac complications in the continuous-flow era. CONCLUSIONS: LVAD use has increased and in-hospital mortality and LOS after LVAD implantation have declined. These changes coincide with United States Food and Drug Administration (FDA) approval of continuous-flow devices in 2008

Etiologies, Trends, and Predictors of 30-Day Readmission in Patients With Heart Failure.

Heart failure (HF) is the most common discharge diagnosis across the United States, and these patients are particularly vulnerable to readmissions, increasing attention to potential ways to address the problem. The study cohort was derived from the Healthcare Cost and Utilization Project\u27s National Readmission Data 2013, sponsored by the Agency for Healthcare Research and Quality. HF was identified using appropriate International Classification of Diseases, Ninth Revision, Clinical Modification codes. Readmission was defined as a subsequent hospital admission within 30 days after discharge day of index admission. Readmission causes were identified using International Classification of Diseases, Ninth Revision, codes in primary diagnosis filed. The primary outcome was 30-day readmission. Hierarchical 2-level logistic models were used to evaluate study outcomes. From a total 301,892 principal admissions (73.4% age ≥65 years and 50.6% men), 55,857 (18.5%) patients were readmitted with a total of 64,264 readmissions during the study year. Among the etiologies of readmission, cardiac causes (49.8%) were most common (HF being most common followed by coronary artery disease and arrhythmias), whereas pulmonary causes were responsible for 13.1% and renal causes for 8.9% of the readmissions. Significant predictors of increased 30-day readmission included diabetes (odds ratio, 95% confidence interval, p value: 1.06, 1.03 to 1.08,

Impact of Annual Hospital Volume on Outcomes after Left Ventricular Assist Device (LVAD) Implantation in the Contemporary Era.

INTRODUCTION: There are few data in the literature regarding impact of annual hospital volume on outcomes such as mortality and length of stay (LOS) post-LVAD implantation. METHODS: We queried the nationwide inpatient sample from 2008 to 2011 using International Classification of Diseases, 9th Revision procedure code 37.66. We included patients ≥18 years without primary diagnosis of orthotopic heart transplant. Annual volume of LVAD implantation was computed for each hospital. Multivariable hierarchical mixed effect logistic regression models were used to determine predictors of in-hospital mortality and LOS. RESULTS: There were 1749 LVAD implants from 2008 to 2011; patients had a mean age of 55.4 years, and 23% were female. In-hospital mortality decreased from 20.9% in the first tertile (1-22 LVADs/y) to 13.7% in the third tertile (≥35 LVADs/y) of hospital volume. Median LOS decreased from 34 days in the first tertile to 28 days in third tertile of hospital volume. The adjusted odds ratios of the highest tertile of hospital volume in predicting in-hospital mortality and LOS were 0.41 (0.26-0.64, P \u3c .001) and 0.41 (0.23-0.73, P = .003), respectively. Restricted cubic spline analysis showed that a volume threshold of \u3e20 LVADs/year was associated with favorable mortality rates of \u3c10%. CONCLUSIONS: High annual LVAD volume is associated with significantly decreased in-hospital mortality and LOS after LVAD implantation. Center experience is an important determinant of optimal patient outcomes

Short-Term Outcomes of Atrial Flutter Ablation.

BACKGROUND: Understanding the factors associated with early readmissions following atrial flutter (AFL) ablation is critical to reduce the cost and improving the quality of life in AFL patients. METHOD: The study cohort was derived from the National readmission database 2013-14. International Classification of Diseases, 9th Revision (ICD-9-CM) diagnosis code 427.32 and procedure code 37.34 were used to identify AFL and catheter ablation respectively. The primary and secondary outcomes were 90-day readmission and complications including in-hospital mortality. Cox proportional regression and hierarchical logistic regression were used to generate the predictors of primary and secondary outcomes respectively. Readmission causes were identified by ICD-9-CM code in primary diagnosis field of readmissions. RESULT: Readmission rate of 18.19% (n = 1010 with1396 readmissions) was noted among AFL patients (n = 5552). Common etiologies for readmission were heart failure (12.23%), atrial fibrillation (11.13%), atrial flutter (8.93%), respiratory complications (9.42%), infections (7.4%), bleeding (7.39%, including GI bleed - 4.09% and Intracranial bleed - 0.79%) and stroke/TIA (1.89%). Multivariate predictors of 90-day readmission (Hazard ratio, 95% confidence interval, p-value) were preexisting heart failure (1.30, 1.13-1.49, p CONCLUSION: Cardiac etiologies remain the most common reason for the readmission after AFL ablation. Identifying high risk patients, careful discharge planning and close follow-up post-discharge can potentially reduce readmission rates in AFL ablation patients. This article is protected by copyright. All rights reserved

Trends in Incidence and Outcomes of Pregnancy-Related Acute Myocardial Infarction (From a Nationwide Inpatient Sample Database).

Acute myocardial infarction (AMI) during pregnancy is rare but fatal complication. Recent incidence of pregnancy related AMI and trends in the related outcomes are unknown. The Nationwide Inpatient Sample database was utilized from years 2005 to 2014. International Classification of Disease-Ninth Revision were used to identify pregnancy related admissions and AMI. Primary outcome was incidence and trend of AMI related to pregnancy and Secondary outcomes were trends in mortality, resource utilization, and predictors of AMI during pregnancy. Simple logistic regression model was used to calculate predictors of AMI during pregnancy. p Values for trends were generated by Cochrane-Armitage test for categorical variables and simple linear regression for continuous variables. A total of 43,437,621 pregnancy related hospitalization and 3,786 cases of AMI (86% ante-partum and 14% postpartum) were noted during study period. The incidence of AMI during the study period was 8.7 per 100,000 pregnancies with an overall increase in incidence during the study period (relative increase of 18.9%,