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Importance: There has been limited research on patients with ST-segment elevation myocardial infarction (STEMI) and COVID-19.Objective: To compare characteristics, treatment, and outcomes of patients with STEMI with vs without COVID-19 infection.Design, Setting, and Participants: Retrospective cohort study of consecutive adult patients admitted between January 2019 and December 2020 (end of follow-up in January 2021) with out-of-hospital or in-hospital STEMI at 509 US centers in the Vizient Clinical Database (N = 80 449).Exposures: Active COVID-19 infection present during the same encounter.Main Outcomes and Measures: The primary outcome was in-hospital mortality. Patients were propensity matched on the likelihood of COVID-19 diagnosis. In the main analysis, patients with COVID-19 were compared with those without COVID-19 during the previous calendar year.Results: The out-of-hospital STEMI group included 76 434 patients (551 with COVID-19 vs 2755 without COVID-19 after matching) from 370 centers (64.1% aged 51-74 years; 70.3% men). The in-hospital STEMI group included 4015 patients (252 with COVID-19 vs 756 without COVID-19 after matching) from 353 centers (58.3% aged 51-74 years; 60.7% men). In patients with out-of-hospital STEMI, there was no significant difference in the likelihood of undergoing primary percutaneous coronary intervention by COVID-19 status; patients with in-hospital STEMI and COVID-19 were significantly less likely to undergo invasive diagnostic or therapeutic coronary procedures than those without COVID-19. Among patients with out-of-hospital STEMI and COVID-19 vs out-of-hospital STEMI without COVID-19, the rates of in-hospital mortality were 15.2% vs 11.2% (absolute difference, 4.1% [95% CI, 1.1%-7.0%]; P = .007). Among patients with in-hospital STEMI and COVID-19 vs in-hospital STEMI without COVID-19, the rates of in-hospital mortality were 78.5% vs 46.1% (absolute difference, 32.4% [95% CI, 29.0%-35.9%]; P < .001).Conclusions and Relevance: Among patients with out-of-hospital or in-hospital STEMI, a concomitant diagnosis of COVID-19 was significantly associated with higher rates of in-hospital mortality compared with patients without a diagnosis of COVID-19 from the past year. Further research is required to understand the potential mechanisms underlying this association. [ABSTRACT FROM AUTHOR]

Background: Patients with rheumatic aortic stenosis (AS) were excluded from transcatheter aortic valve replacement (TAVR) trials.Objectives: The authors sought to examine outcomes with TAVR versus surgical aortic valve replacement (SAVR) in patients with rheumatic AS, and versus TAVR in nonrheumatic AS.Methods: The authors identified Medicare beneficiaries who underwent TAVR or SAVR from October 2015 to December 2017, and then identified patients with rheumatic AS using prior validated International Classification of Diseases, Version 10 codes. Overlap propensity score weighting analysis was used to adjust for measured confounders. The primary study outcome was all-cause mortality. Multiple secondary outcomes were also examined.Results: The final study cohort included 1,159 patients with rheumatic AS who underwent aortic valve replacement (SAVR, n = 554; TAVR, n = 605), and 88,554 patients with nonrheumatic AS who underwent TAVR. Patients in the SAVR group were younger and with lower prevalence of most comorbidities and frailty scores. After median follow-up of 19 months (interquartile range: 13 to 26 months), there was no difference in all-cause mortality with TAVR versus SAVR (11.2 vs. 7.0 per 100 person-year; adjusted hazard ratio: 1.53; 95% confidence interval: 0.84 to 2.79; p = 0.2). Compared with TAVR in nonrheumatic AS, TAVR for rheumatic AS was associated with similar mortality (15.2 vs. 17.7 deaths per 100 person-years (adjusted hazard ratio: 0.87; 95% confidence interval: 0.68 to 1.09; p = 0.2) after median follow-up of 17 months (interquartile range: 11 to 24 months). None of the rheumatic TAVR patients, <11 SAVR patients, and 242 nonrheumatic TAVR patients underwent repeat aortic valve replacement (124 redo-TAVR and 118 SAVR) at follow-up.Conclusions: Compared with SAVR, TAVR could represent a viable and possibly durable option for patients with rheumatic AS. [ABSTRACT FROM AUTHOR]

Background: Distal transradial artery access (dTRA) through the anatomical snuffbox is a novel approach for performing coronary angiography and interventions. However, the safety and efficacy of dTRA as compared to conventional TRA (cTRA) remains unknown. We aim to evaluate the outcomes of dTRA versus cTRA for coronary angiography and intervention.Methods: Electronic search of the National Library of Medicine PubMed and Cochrane Library databases was performed until April 2019 for studies comparing the clinical outcomes of dTRA approach versus conventional TRA (cTRA) approach in coronary angiography and interventions. Random-effects DerSimonian-Laird risk ratios (RR) were calculated. The main outcome was failure of access site utilization. Other outcomes included access site hematoma, radial artery spasm, dissection, and occlusion.Results: Five studies (4 observational and 1 randomized controlled) with a total of 6746 patients (dTRA n = 3209 and cTRA n = 3537) were available for analysis. The failure rate was similar in dTRA and cTRA groups (5.26% versus 3.75%; RR = 1.36; 95%CI 0.41-4.48; p = 0.62). Similarly, no difference was observed between dTRA and cTRA in regards to access site hematoma (1.20% versus 1.24%, RR = 1.01; 95%CI 0.49-2.07; p = 0.99), radial artery spasm (1.42 versus 3.84%, RR = 0.91; 95%CI 0.32-2.62; p = 0.86), or radial artery dissection (0.11 versus 0.20%, RR = 0.63; 95%CI 0.18-2.16; p = 0.46). The rate of radial artery occlusion was lower with dTRA (2.30 versus 4.86%, RR = 0.51; 95%CI 0.32-0.81; p = 0.004) as compared to cTRA.Conclusion: Distal TRA appears to be a safe and effective alternative to conventional TRA. The outcomes of this novel technique warrant further randomized studies. [ABSTRACT FROM AUTHOR]

Background: The efficacy and safety of aspirin for primary prevention of cardiovascular disease (CVD) remain debatable.Objectives: The purpose of this study was to examine the clinical outcomes with aspirin for primary prevention of CVD after the recent publication of large trials adding >45,000 individuals to the published data.Methods: Randomized controlled trials comparing clinical outcomes with aspirin versus control for primary prevention with follow-up duration of ≥1 year were included. Efficacy outcomes included all-cause death, cardiovascular (CV) death, myocardial infarction (MI), stroke, transient ischemic attack (TIA), and major adverse cardiovascular events. Safety outcomes included major bleeding, intracranial bleeding, fatal bleeding, and major gastrointestinal (GI) bleeding. Random effects DerSimonian-Laird risk ratios (RRs) for outcomes were calculated.Results: A total of 15 randomized controlled trials including 165,502 participants (aspirin n = 83,529, control n = 81,973) were available for analysis. Compared with control, aspirin was associated with similar all-cause death (RR: 0.97; 95% confidence interval [CI]: 0.93 to 1.01), CV death (RR: 0.93; 95% CI: 0.86 to 1.00), and non-CV death (RR: 0.98; 95% CI: 0.92 to 1.05), but a lower risk of nonfatal MI (RR: 0.82; 95% CI: 0.72 to 0.94), TIA (RR: 0.79; 95% CI: 0.71 to 0.89), and ischemic stroke (RR: 0.87; 95% CI: 0.79 to 0.95). Aspirin was associated with a higher risk of major bleeding (RR: 1.5; 95% CI: 1.33 to 1.69), intracranial bleeding (RR: 1.32; 95% CI: 1.12 to 1.55), and major GI bleeding (RR: 1.52; 95% CI: 1.34 to 1.73), with similar rates of fatal bleeding (RR: 1.09; 95% CI: 0.78 to 1.55) compared with the control subjects. Total cancer and cancer-related deaths were similar in both groups within the follow-up period of the study.Conclusions: Aspirin for primary prevention reduces nonfatal ischemic events but significantly increases nonfatal bleeding events. [ABSTRACT FROM AUTHOR]

Background: The optimal stent for use in saphenous vein graft (SVG) intervention is still debatable. Multiple randomized trials have compared drug-eluting stents (DES) to bare metal stents (BMS) in SVG interventions with conflicting results.Methods: Authors searched the online databases for randomized controlled trials (RCTs) comparing DES to BMS in SVG percutaneous coronary interventions (PCI). We performed a meta-analysis using a random effects model to calculate the odds ratio for outcomes of interest.Results: Authors studied six RCTs that included 1592 patients undergoing PCI of SVG. The mean follow up was 42 months. Patients mean age was the same in both groups: 70.3 years in the DES group (approximately 93.3% male) and 70.3 years in the BMS group (approximately 93.8% male). Vein graft age was 13.4 years in the DES PCI arm vs. 13.4 years in the BMS PCI arm. Four of the six trials reported data on embolic protection device use: 67% (303/452) in the DES arm vs. 67.9% (309/455) in the BMS arm. The primary outcome of long-term all-cause mortality was not different between DES vs. BMS (15.2% vs. 14.1%, OR 1.12, 95% CI 0.67-1.88; P = 0.66). Secondary outcomes were also similar between DES and BMS: major adverse cardiovascular events (31.6% vs. 33.1%, OR 0.79, 95% CI 0.45-1.38; P = 0.41); cardiac death (9% vs. 8.6%, OR 1.12, 95% CI 0.55-2.30; P = 0.75); myocardial infarction (8% vs. 9.5%, OR 0.84, 95% CI 0.47-1.51; P = 0.57); target lesion revascularization (16.4% vs. 14.4%, OR 0.98, 95% CI 0.50-1.92; P = 0.95); and target vessel revascularization (19% vs. 19.4%, OR 0.75, 95% CI 0.41-1.34; P = 0.33).Conclusion: At a mean follow-up of 42 months, no difference was observed in clinical outcomes between DES and BMS in SVG interventions. [ABSTRACT FROM AUTHOR]

Background: We sought to examine the impact of coronary chronic total occlusion (CTO) percutaneous coronary intervention (PCI) on left ventricular (LV) function.Methods: We performed a systematic review and meta-analysis of studies published between January 1980 and November 2017 on the impact of successful CTO PCI on LV function.Results: A total of 34 observational studies including 2735 patients were included in the meta-analysis. Over a weighted mean follow-up of 7.9 months, successful CTO PCI was associated with an increase in LV ejection fraction by 3.8% (95%CI 3.0-4.7, P < 0.0001, I2  = 45%). In secondary analysis of 15 studies (1248 patients) that defined CTOs as occlusions of at least 3-month duration and reported follow-up of at least 3-months after the procedure, successful CTO PCI was associated with improvement in LV ejection fraction by 4.3% (95%CI [3.1, 5.6], P < 0.0001). In the 10 studies (502 patients) that reported LV end-systolic volume, successful CTO PCI was associated with a decrease in LV end-systolic volume by 4 mL, (95%CI -6.0 to -2.1, P < 0.0001, I2  = 0%). LV end-diastolic volume was reported in 9 studies with 403 patients and did not significantly change after successful CTO PCI (-2.3 mL, 95%CI -5.7 to 1.2 mL, P = 0.19, I2  = 0%).Conclusions: Successful CTO PCI is associated with a statistically significant improvement in LV ejection fraction and decrease in LV end-systolic volume, that may reflect a beneficial effect of CTO recanalization on LV remodeling. The clinical implications of these findings warrant further investigation. [ABSTRACT FROM AUTHOR]

Objectives: To examine whether routine thrombus aspiration (TA) is associated with improved myocardial salvage in patients with ST-elevation myocardial infarction (STEMI) presenting ≥12 h after onset of symptoms.Background: TA is a recognized treatment option in patients with STEMI undergoing primary percutaneous coronary intervention (PPCI) especially in the setting of heavy thrombus burden. However, data on the role of TA in STEMI patients presenting late after onset of symptoms are limited.Methods: In this single-center prospective randomized study, patients with subacute STEMI presenting ≥12 and ≤48 h after symptom onset were randomized to primary PCI with or without manual TA in a 1:1 ratio. The primary endpoint was the myocardial salvage index assessed with Single Photon Emission Computed Tomography (SPECT) on admission and 4 days later.Results: A total of 60 patients underwent randomization. Baseline characteristics were comparable between groups. TA was associated with improved myocardial salvage index compared with control group (60.1 ± 11.1% vs 28.1 ± 21.3%; P = <0.001). Furthermore, TA was associated with improved post-procedural TIMI flow (2.9 ± 0.3 vs 2.5 ± 0.6; P = 0.003), myocardial blush grade (2.9 ± 0.3 vs 2.2 ± 0.8, P = <0.001), and reduction in left ventricular end-diastolic dimensions (50.4 ± 4.3 mm vs 54.4 ± 5.8 mm, P = 0.004) compared with the control group. Clinical outcomes at 30 days and 6 months were similar between both groups.Conclusions: TA might be associated with improved reperfusion and myocardial salvage especially in STEMI patients presenting after 12 h from symptom onset who are likely to have a heavy thrombus burden. [ABSTRACT FROM AUTHOR]

Background Current ventricular tachycardia (VT) management in patients with ischemic cardiomyopathy (ICM) includes optimal medical therapy, ICDs device therapy, and antiarrhythmic medications. Data about outcomes of catheter ablation (CA) in these patients is scarce. We aimed to perform a meta-analysis of RCTs to compare outcomes of CA vs conventional management of VT in ICM patients who had ICD. Methods A systematic review and meta-analysis of published RCTs between January 1970 and December 2016 were performed. Random effects DerSimonian-Laird risk ratios (RR) were calculated. Sensitivity analyses using fixed-effects summary odds ratios (OR) were performed using Peto model. Outcomes of interest were: all-cause mortality (ACM), cardiovascular death (CVD), CV disease-related hospitalization, VT storms, and ICD shocks. Results 4 RCTs were identified (521 patients (261 had CA), mean age: 66.4 ± 1.7 years, 91.5% male, mean follow-up: 19 months). No difference observed between VT ablation and conventional management regarding ACM (RR 0.94, 95% CI, 0.66–1.32, p = 0.70) or CVD (RR 0.82, 95% CI, 0.52–1.29, p = 0.39). VT ablation was associated with less CV disease-related hospitalization (RR 0.72, 95% CI, 0.54–0.96, p = 0.02), VT storms (RR 0.71, 95% CI, 0.52–0.97, p = 0.03), and trend towards reducing ICD shocks (RR 0.59, 95% CI, 0.34–1.05, p = 0.07). In sensitivity analysis using fixed-effects OR, CA was associated with significant reduction in ICD shocks. Conclusion In patients with ICM, VT ablation reduced CV disease-related hospitalization, VT storms, and ICD shocks when compared to conventional management with no mortality benefit over a relatively short mean follow-up period. [ABSTRACT FROM AUTHOR]

Background: The anticoagulant of choice during percutaneous coronary intervention (PCI) in women is not well established.Methods: An electronic search was conducted for trials that randomized patients undergoing PCI to bivalirudin versus heparin, and reported outcomes of interest in women. Random effects DerSimonian-Laird risk ratios (RR) were calculated. Main outcome was net adverse clinical events (NACE) at 30-days. Other outcomes included major adverse cardiac events (MACE), all-cause mortality, myocardial infarction (MI), target vessel revascularization (TVR), and major bleeding at 30-days. 1-year all-cause mortality and MACE were also examined.Results: Nine trials that randomized women undergoing PCI to bivalirudin (n=3960) versus heparin (n=4050) were included. At 30-days, bivalirudin was associated with reduced risk of NACE (RR=0.85; 95% CI 0.73-0.98; p=0.03), mainly driven by reduction in major bleeding (RR=0.59; 95% CI 0.49-0.71; p<0.001) compared with heparin. No difference in MACE (p=0.92), all-cause mortality (p=0.23), MI (p=0.86); or TVR (p=0.53) was demonstrated between both groups. At 1-year, the risk of MACE and all-cause mortality was similar in both groups. On a subgroup analysis, the benefit associated with bivalirudin appeared to be less evident when Glycoprotein IIb/IIIa inhibitors (GPI) was used as bailout therapy with heparin, however without significant interaction. Furthermore, in STEMI population, no difference in NACE, MACE, or major bleeding was observed between both groups.Conclusion: In women undergoing PCI, bivalirudin is associated with reduced risk of major bleeding and NACE compared with heparin especially when GPI is routinely used. [ABSTRACT FROM AUTHOR]

Background The impact of sodium–glucose cotransporter-2 (SGLT-2) inhibitors on cardiovascular outcomes in patients with type II diabetes mellitus (DM) is not well established. Methods We searched electronic databases from inception through July 2016 for randomized, placebo-controlled trials, involving SGLT-2 inhibitors. Fixed-effects summary odds ratios (OR) were constructed using Peto model. Results Eighty-one trials with a total of 37,195 patients were included. The mean follow-up was 89 weeks. Compared with placebo, SGLT-2 inhibitors were associated with a lower risk of all-cause mortality (OR 0.72; 95% CI 0.59–0.86; P < 0.001), cardiovascular mortality (OR 0.67; 95% CI 0.53–0.84; P = 0.001), and heart failure (OR 0.67; 95% CI 0.51–0.87; P = 0.003), but a similar risk of myocardial infarction (OR 0.89; 95% CI 0.74–1.09; P = 0.29) and stroke/transient ischemic attack (OR 1.09; 95% CI 0.87–1.37; P = 0.47). The reduction in all-cause mortality was noticed with empagliflozin (OR 0.66; 95% CI 0.54–0.81; P < 0.001), but not with other SGLT-2 inhibitors (OR dapagliflozin 1.37; 95% CI 0.71–2.62; P = 0.35; OR canagliflozin 0.82; 95% CI 0.41–1.68; P = 0.59; OR luseogliflozin 4.6; 95% CI 0.07–284.25; P = 0.47; and OR ipragliflozin 4.73; 95% CI 0.08–283.14; P = 0.46) (P interaction = 0.19). Potential harm was observed with dapagliflozin on cardiovascular mortality (OR 2.15, 95% CI 0.92–5.04, P = 0.08). Conclusions In patients with type II DM, SGLT-2 inhibitors appeared to reduce both all-cause and cardiovascular mortality, primarily due to reduction in the risk of heart failure. The benefit was only seen with empagliflozin. There was suggestion of potential harm with dapagliflozin, thus future trials are needed to ascertain the cardiovascular safety of other agents in this class. [ABSTRACT FROM AUTHOR]

For decades, unfractionated heparin ( UFH) has been widely used in catheterization laboratories for anticoagulation for percutaneous coronary intervention ( PCI). The direct thrombin inhibitors, bivalirudin, has emerged as an alternative to UFH for PCI procedures, due to its lower bleeding risk. More recently, randomized trials and meta-analyses questioned the efficacy of bivalirudin, and demonstrated that bivalirudin might be associated with a higher incidence of ischemic events and in particular stent thrombosis. In this review, we discuss the pharmacology of bivalirudin along with the clinical evidence comparing bivalirudin versus UFH in patients undergoing PCI for various indications. [ABSTRACT FROM AUTHOR]

Acute ST-elevation myocardial infarction (STEMI) with simultaneous multiple coronary thrombosis has been described, however; the available information about the clinical presentation and management of this condition is scarce. We searched the Medline and Web of Science databases from 1990 until August 2014 for all case reports, case series, and observational studies that reported simultaneous multi-vessel thrombosis at the time of the primary percutaneous coronary intervention (PCI). We excluded the articles that reported an identifiable cause for coronary thrombosis. A total of 29 articles were retrieved yielding 56 patients. Patients were predominantly males (88%) with a mean age of 59 years. Cardiogenic shock was the predominant presentation (41%). Simultaneous thrombosis of the left anterior descending and right coronary arteries was the commonest angiographic finding (50%). Primary PCI was the main treatment modality and an intra-aortic balloon pump was utilized in 38% of the cases. The in-hospital mortality was 5%. Simultaneous multi-vessel thrombosis at the time of STEMI presents a rare condition. The cases reported in the literature presented with a high incidence of cardiogenic shock. Larger studies are needed to address the proper management and evaluate the outcomes associated with this condition. [ABSTRACT FROM AUTHOR]

Background: Characteristics and outcomes of patients with in-hospital cardiac arrest (IHCA) in the cardiac catheterization laboratory (CCL) have not been well-described. Thus, we compared the outcomes of patients with an IHCA in the CCL versus those in the intensive care unit (ICU) and operating rooms (OR).Methods: Within the American Heart Association's Get With the Guidelines®-Resuscitation registry, we identified patients ≥ 18 years old with IHCA in the CCL, ICU, or OR between 2000-2019. Using hierarchical multivariable logistic regression, we compared rates of survival to discharge for patients with IHCA in the CCL versus ICU and OR.Results: Across 428 hospitals, 193,950 patients had IHCA, of whom 6865, 181,905 and 5180 were in the CCL, ICU and OR, respectively. Overall, 2614 (38.1%) patients with IHCA in the CCL survived to discharge, whereas 30,830 (16.9%) and 2096 (40.5%) survived to discharge from the ICU and OR, respectively. After adjustment, patients with IHCA in CCL were more likely to survive to discharge as compared to those with IHCA in the ICU (odds ratio, 1.37 [95%CI: 1.29-1.46], p < 0.001). In contrast, those who had IHCA in the CCL were less likely to survive to discharge as compared to patients with IHCA in the OR (odds ratio, 0.81 [95%CI: 0.69-0.94], p = 0.006).Conclusion: IHCA in the CCL is not uncommon and has a lower survival rate when compared with IHCA in the OR. The reasons for this difference deserve further study given that cardiac arrest in both settings is witnessed and response time should be similar. [ABSTRACT FROM AUTHOR]

Amiodarone is reported to cause a wide continuum of serious clinical effects. It is often challenging to detect Amiodarone-induced pulmonary toxicity (AIPT). Typically, the diagnosis is made based on the clinical settings and may be supported by histopathology results, if available. We describe a 57-year-old patient who developed severe rapidly progressive respiratory failure secondary to AIPT with acute bilateral infiltrates and nodular opacities on chest imaging. Interestingly, Amiodarone was discontinued 3 weeks prior to his presentation. He had normal cardiac filling pressures confirmed by echocardiography. To our knowledge, this is the first case of isolated acute lung injury induced by Amiodarone, three weeks after therapy cessation, with adequate clinical improvement after supportive management and high dose steroid therapy. [ABSTRACT FROM AUTHOR]

Left atrial wall dissection is a rare condition; most cases are iatrogenic after mitral valve surgery. A few have been reported as sequelae of blunt chest trauma, acute myocardial infarction, and invasive cardiac procedures. On occasion, infective endocarditis causes left atrial wall dissection. We report a highly unusual case in which a 41-year-old man presented with native mitral valve infective endocarditis that had caused left atrial free-wall dissection. Although our patient died within an hour of presentation, we obtained what we consider to be a definitive diagnosis of a rare sequela, documented by transthoracic and transesophageal echocardiography. [ABSTRACT FROM AUTHOR]

There has been an evolution in the disease severity and complexity of patients presenting to the cardiac intensive care unit (CICU). There are limited data evaluating the role of palliative care in contemporary CICU practice. PubMed Central, CINAHL, EMBASE, Medline, Cochrane Library, Scopus, and Web of Science databases were evaluated for studies on palliative care in adults (≥18 years) admitted with acute cardiovascular conditions – acute myocardial infarction, cardiogenic shock, cardiac arrest, advanced heart failure, post-cardiac surgery, spontaneous coronary artery dissection, Takotsubo cardiomyopathy, and pulmonary embolism – admitted to the CICU, coronary care unit or cardiovascular intensive care unit from 1/1/2000 to 8/8/2022. The primary outcome of interest was the utilization of palliative care services. Secondary outcomes of included studies were also addressed. Meta-analysis was not performed due to heterogeneity. Of 5711 citations, 30 studies were included. All studies were published in the last seven years and 90 % originated in the United States. Twenty-seven studies (90 %) were retrospective analyses, with a majority from the National Inpatient Sample database. Heart failure was the most frequent diagnosis (47 %), and in-hospital mortality was reported in 67 % of studies. There was heterogeneity in the timing, frequency, and background of the care team that determined palliative care consultation. In two randomized trials, there appeared to be improvement in quality of life without an impact on mortality. Despite the growing recognition of the role of palliative care, there are limited data on palliative care consultation in the CICU. • Palliative care has been studied infrequently in the cardiac intensive care unit (CICU). • The CICU population has undergone a significant shift in disease severity and complexity. • Multiple barriers to palliative care utilization exist in contemporary literature. [ABSTRACT FROM AUTHOR]

Background: The impact of pre-existing atrial fibrillation (AF) on outcomes after noncardiac surgery is not clear.Objectives: We aimed to study the impact of AF on the risk of adverse outcomes after noncardiac surgery in a nationwide cohort.Methods: We identified Medicare beneficiaries admitted for noncardiac surgery from 2015 to 2019 and divided the study cohort into 2 groups: with and without AF. Noncardiac surgery was classified into vascular, thoracic, general, genitourinary, gynecological, orthopedics and neurosurgery, breast, head and neck, and transplant. We used propensity score matching on exact age, sex, race, urgency and type of surgery, revised cardiac risk index (RCRI) and CHA2DS2-VASc score, and tight caliper on other comorbidities. The study outcomes were 30-day mortality, stroke, myocardial infarction, and heart failure. We examined the incremental utility of AF in addition to RCRI to predict adverse events after noncardiac surgery.Results: The study cohort included 8,635,758 patients who underwent noncardiac surgery (16.4% with AF). Patients with AF were older, more likely to be men, and had higher prevalence of comorbidities. After propensity score matching, AF was associated with higher risk of mortality (OR: 1.31; 95% CI: 1.30-1.32), heart failure (OR: 1.31; 95% CI: 1.30-1.33), and stroke (OR: 1.40; 95% CI: 1.37-1.43) and lower risk of myocardial infarction (OR: 0.81; 95% CI: 0.79-0.82). Results were consistent in subgroup analysis by sex, race, type of surgery, and all strata of RCRI and CHA2DS2-VASc score. AF improved the discriminative ability of RCRI (C-statistic 0.73 to 0.76).Conclusion: Pre-existing AF is independently associated with postoperative adverse outcomes after NCS. [ABSTRACT FROM AUTHOR]

Background: The use of drug-coated balloons (DCBs) in small-vessel coronary artery disease (SVD) remains controversial.Methods: We performed a meta-analysis of all randomized controlled trials (RCTs) reporting the outcomes of DCB vs. DES in de-novo SVD. We included a total of 5 RCTs (1459 patients), with (DCB n = 734 and DES n = 725).Results: Over a median follow-up duration of 6 months, DCB was associated with smaller late lumen loss (LLL) compared with DES (mean difference -0.12 mm) (95% confidence intervals (CI) [-0.21, -0.03 mm], p = 0.01). Over a median follow-up of 12 months, both modalities had similar risk of major adverse cardiovascular events (MACE) (8.7% vs. 10.2%; odds ratio (OR): 0.94, 95% CI [0.49-1.79], p = 084), all-cause mortality (1.17% vs. 2.38%; OR: 0.53, 95% CI [0.16-1.75], p = 0.30), target lesion revascularization (TLR) (7.9% vs. 3.9%; OR: 1.26, 95% CI [0.51-3.14], p = 0.62), and target vessel revascularization (TVR) (8.2% vs. 7.8%; OR: 1.06, 95% CI [0.40-2.82], p = 0.91). DCBs were associated with lower risk of myocardial infarction (MI) compared with DES (1.55% vs. 3.31%; OR: 0.48, 95% CI [0.23-1.00], p = 0.05, I2 = 0%).Conclusion: PCI of SVD with DCBs is associated with smaller LLL, lower risk of MI, and similar risk of MACE, death, TLR, and TVR compared with DES over one year. DCB appears as an attractive alternative to DES in patients with de-novo SVD, but long-term clinical data are still needed. [ABSTRACT FROM AUTHOR]

Nationwide Inpatient Sample data between 2008 and 2019 showing the trends (A) and predictors (B) of patients transferred with acute pulmonary embolism (PE).The odds ratio (OR) for age is for every 1-year increase. Keywords: mortality; pulmonary embolism (PE); hosptial transfer EN mortality pulmonary embolism (PE) hosptial transfer 587 589 3 12/12/22 20221201 NES 221201 Acute pulmonary embolism (PE) is associated with high rates of morbidity and mortality.[1] Timely management of acute decompensated PE improves pulmonary artery pressure and right ventricular function for patients with intermediate- and high-risk PE,[2],[3] although not all hospitals offer comprehensive PE care services.[4] Despite the potential role for a multidisciplinary PE rapid response team in facilitating the transfer process for this high-risk population,[5] systematic transfer protocols for PE care have not been widely developed or endorsed by societal guidelines.[4],[5] We aimed to examine trends, outcomes, and predictors of patients transferred with PE. [Extracted from the article]

Background: Acute myocardial infarction complicated by cardiogenic shock (AMICS) is associated with high mortality rates. Data has shown that intra-aortic balloon pump (IABP) support does not provide a survival benefit over optimal medical therapy in AMICS. Despite lack of supportive evidence, IABP is still commonly used in these clinical situations. The Impella percutaneous ventricular assist device (PVAD) (Abiomed, Denver, MA) rapidly deploys superior mechanical circulatory support (MCS) in patients with AMICS. However, the safety and efficacy of Impella in AMICS is a matter of ongoing investigation, and its role in AMICS management is not yet fully established.Methods: The databases of Pubmed, EMBASE and Cochrane Central databases were searched from inception to March 2020. Relevant randomized trials and observational studies comparing Impella versus IABP in AMICS were identified and a meta-analysis was performed using the random effect model. The efficacy endpoint of interest was short-term mortality (defined as in-hospital or 30-day mortality). The safety endpoints of interest were major bleeding, limb complications, stroke and hemolysis.Results: A total of 2 randomized trials and 5 observational studies with 3921 patients were included. No difference in short-term mortality between the two groups [RR 1.08, 95% CI 0.87-1.33, P = 0.49] was found. For safety endpoints, Impella was associated with significantly higher incidence of major bleeding [RR: 2.03, 95% CI 1.56-2.64, P < 0.0001], limb complications [RR: 3.67, 95% CI 1.56-8.65, P = 0.003] as well as hemolysis [RR: 9.46, 95% CI 1.75-51.22, P = 0.009] compared with IABP. No significant difference was observed for the incidence of stroke [RR: 1.07 95% CI 0.34-3.31 P = 0.91].Conclusion: Impella support in AMICS patients was associated with a significantly increased risk of bleeding, limb complications and hemolysis without an improved short-term survival advantage compared with IABP. [ABSTRACT FROM AUTHOR]

A 53-year-old woman presented to our hospital with dizziness and low-grade fever. She underwent percutaneous coronary intervention to the obtuse marginal artery with a drug-eluting stent 20 months prior to this presentation. Physical examination was remarkable for bradycardia. Electrocardiogram showed a junctional rhythm with heart rate of 35 bpm. Blood and urine cultures were negative. Despite successful urgent pacemaker placement, she had cardiac arrest the following day with unsuccessful cardiopulmonary resuscitation attempt. Cardiac autopsy report revealed multiple abscesses involving the obtuse marginal and left anterior descending arteries as well as the adjacent myocardial regions. [ABSTRACT FROM AUTHOR]

Transcatheter aortic valve replacement (TAVR) has proven to be a safe, effective, and less invasive approach to aortic valve replacement in patients with aortic stenosis. In patients who underwent prior aortic valve replacement, transcatheter and surgical bioprosthetic valve dysfunction may occur as a result of structural deterioration or nonstructural causes such as prosthesis–patient mismatch (PPM) and paravalvular regurgitation. Valve-in-Valve (ViV) TAVR is a procedure that is being increasingly utilized for the replacement of failed transcatheter or surgical bioprosthetic aortic valves. Data regarding long-term outcomes are limited due to the recency of the procedure's approval, but available data regarding the short- and long-term outcomes of ViV TAVR are promising. Studies have shown a reduction in perioperative and 30-day mortality with ViV TAVR procedures compared to redo surgical repair of failed bioprosthetic aortic valves, but 1-year and 5-year mortality rates are more controversial and lack sufficient data. Despite the reduction in 30-day mortality, PPM and rates of coronary obstruction are higher in ViV TAVR as compared to both redo surgical valve repair and native TAVR procedures. New transcatheter heart valve designs and new procedural techniques have been developed to reduce the risk of PPM and coronary obstruction. Newer generation valves, new procedural techniques, and increased operator experience with ViV TAVR may improve patient outcomes; however, further studies are needed to better understand the safety, efficacy, and durability of ViV TAVR. [ABSTRACT FROM AUTHOR]

Background: There is a paucity of data regarding outcomes with transfemoral (TF) versus transapical (TA) access for transcatheter aortic valve replacement (TAVR) in patients with peripheral artery disease (PAD).Methods: We queried the national inpatient sample database (NIS) (2012-2013) to identify patients with PAD who underwent TAVR. We conducted a propensity matching analysis using 25 clinical variables to compare TF-TAVR versus TA-TAVR. The main outcome was in-hospital mortality.Results: The analysis included 22,349 patients who underwent TAVR, among those 6692 (29.9%) had PAD. In the matched cohort, in-hospital mortality was similar between TF-TAVR and TA-TAVR groups (4.8% vs. 5.1%, OR 0.95; 95%CI 0.74-1.21). TF-TAVR was associated with lower rates of cardiogenic shock (OR 0.64; 95%CI 0.50-0.82), use of mechanical circulatory support (OR 0.56; 95%CI 0.42-0.75), acute kidney injury (OR 0.76; 95%CI 0.67-0.86), hemodialysis (OR 0.51; 95%CI 0.36-0.71), major bleeding (OR 0.72; 95%CI 0.64-0.80), blood transfusion (OR 0.65; 95%CI 0.58-0.73), discharge to a skilled nursing facility (OR 0.61; 95%CI 0.54-0.68) as well as shorter length of hospital stay (8.13 ± 6.76 vs. 10.11 ± 7.80 days) compared with TA-TAVR. However, TF-TAVR was associated with higher rate of vascular complications (11.7% vs. 3.7%, OR 3.40; 95%CI 2.63-4.38), complete heart block (OR 1.52; 95%CI 1.23-1.87), and pacemaker insertion (OR = 1.58; 95%CI: 1.28-1.94). There was no difference between both groups in the rate of cerebrovascular accidents (OR 1.26; 95%CI 0.93-1.72).Conclusion: In this observational analysis from a large national database, there was no difference in in-hospital mortality between TF-TAVR and TA-TAVR among patients with PAD. Further studies are encouraged to identify the optimal access for TAVR in patients with PAD. [ABSTRACT FROM AUTHOR]

The role of cilostazol after endovascular therapy (EVT) of peripheral artery disease (PAD) remains unclear. We conducted a meta-analysis for all studies reporting the outcomes of cilostazol after EVT of PAD from January 2000 through November 2018 with the outcomes of interest including primary patency, major adverse limb events (MALE), target lesion revascularization (TLR), and major amputation. We included eight studies (three randomized controlled trials (RCTs) and five observational studies) with a total of 3846 patients (4713 lesions). During a mean follow-up duration of 12.5 ± 5 months, the use of cilostazol was associated with higher primary patency (OR 2.28, 95% CI (1.77, 2.94), p < 0.001, I2 = 24%), lower risk of TLR (OR 0.37, 95% CI (0.26, 0.52), p < 0.001, I2 = 0%), and lower risk of major amputation (OR 0.15, 95% CI (0.04, 0.62), p = 0.008, I2 = 0%). The use of cilostazol in RCTs was associated with significantly higher odds of primary patency compared with observational studies (OR 3.37 vs 2.28, p -interaction = 0.03). After further subgroup analysis, cilostazol remained associated with higher primary patency regardless of the use of anticoagulants (warfarin) (p -interaction = 0.49). We conclude that the use of cilostazol after EVT of femoropopliteal and iliac lesions is associated with improved primary patency and lower risk of major amputation and TLR. The favorable impact of cilostazol is independent of the use of warfarin. PROSPERO identifier: CRD42018092715. [ABSTRACT FROM AUTHOR]

Introduction: Although a large recent trial had shown improved cardiovascular outcomes of diabetic patients on sodium glucose co-transporter-2 (SGLT-2) inhibitors, the influence of gender differences on such outcomes is not known. Thus, we aimed to assess the impact of gender on such outcomes in the patients with type 2 diabetes mellitus receiving SGLT-2 inhibitors. Methods: A search of electronic databases was conducted for all randomized trials comparing SGLT-2 inhibitors with placebo in patients with diabetes mellitus. Primary outcomes were all-cause mortality and cardiovascular mortality. Random effects meta-regression was conducted using the percentage of women included in the SGLT-2 inhibitor arm of each trial with a P value of <0.1 for statistical significance. Results: A total of 22,256 patients from 26 trials were included. The overall odds ratio (OR) of all-cause mortality [OR = 0.72, 95% confidence interval (CI) 0.60-0.86, P<0.001, I2 = 0%], and cardiovascular mortality (OR = 0.67, 95% CI 0.53-0.84, P = 0.001, I2 = 23%) were lower with SGLT-2 inhibitors. Meta-regression suggested a possible incremental increase in the OR for all-cause mortality and cardiovascular mortality as the percentage of women in the SGLT-2 inhibitor arm increased (P = 0.07 and 0.08, respectively). Conclusion: Gender might influence the cardiovascular benefits observed with SGLT-2 inhibitors in patients with type 2 diabetes mellitus. [ABSTRACT FROM AUTHOR]

Background: Studies evaluating the role of midodrine as an adjunctive therapy to liberate patients with shock from intravenous (IV) vasopressors have yielded mixed results. The aim of our study was to evaluate the efficacy and safety of midodrine as an adjunctive therapy to liberate patients with shock from IV vasopressors. Methods: Electronic searches of the MEDLINE, EMBASE, and Cochrane databases through April 2022 for randomized controlled trials (RCTs) that evaluated the use of midodrine versus control in patients with shock and a low dose of IV vasopressors. The primary outcome was total IV vasopressor time, while the secondary outcomes included time-to-IV vasopressor discontinuation, IV vasopressor restart, intensive care unit (ICU) length of stay (LOS), hospital LOS, and incidence of bradycardia. Results: The final analysis included four RCTs with a total of 314 patients: 158 in the midodrine group and 156 in the control group, with a weighted mean age of 64 years (54.2% men). There was no significant difference in the total IV vasopressor time between the midodrine and control groups (standardized mean difference [SMD] − 0.53; 95% confidence interval [CI] − 1.38 to 0.32, p = 0.22; I2 = 92%). Also, there were no significant differences between the two groups in the time-to-IV vasopressor discontinuation (SMD − 0.05; 95% CI − 0.57 to 0.47, p = 0.09), IV vasopressor restart (19.3 vs. 28.3%; risk ratio [RR] 0.74; 95% 0.25–2.20, p = 0.59), ICU LOS (SMD − 0.49; 95% CI − 1.30 to 0.33, p = 0.24), and hospital LOS (SMD 0.01; 95% CI − 0.27 to 0.29, p = 0.92). However, compared with the control group, the midodrine group had a higher risk of bradycardia (15.3 vs. 2.1% RR 5.56; 95% CI 1.54–20.05, p = 0.01). Conclusions: Among patients with vasopressor-dependent shock, midodrine was not associated with early liberation of vasopressor support or shorter ICU or hospital length of stay. Adding midodrine increased the risk of bradycardia. Further large RCTs are needed to better evaluate the efficacy and safety of midodrine in liberating patients from IV vasopressors. [ABSTRACT FROM AUTHOR]

Background: Assessing hospital performance for cardiac surgery necessitates consistent and valid care quality metrics. The association of hospital-level risk-standardized home time for cardiac surgeries with other performance metrics such as mortality rate, readmission rate, and annual surgical volume has not been evaluated previously.Methods: The study included Medicare beneficiaries who underwent isolated or concomitant coronary artery bypass graft, aortic valve, or mitral valve surgery from January 1, 2013, to October 1, 2019. Hospital-level performance metrics of annual surgical volume, 90-day risk-standardized mortality rate, 90-day risk-standardized readmission rate, and 90-day risk-standardized home time were estimated starting from the day of surgery using generalized linear mixed models with a random intercept for the hospital. Correlations between the performance metrics were assessed using the Pearson correlation coefficient. Patient-level clinical outcomes were also compared across hospital quartiles by 90-day risk-standardized home time. Last, the temporal stability of performance metrics for each hospital during the study years was also assessed.Results: Overall, 919 698 patients (age 74.2±5.8 years, 32% women) were included from 1179 hospitals. Median 90-day risk-standardized home time was 71.2 days (25th-75th percentile, 66.5-75.6), 90-day risk-standardized readmission rate was 26.0% (19.5%-35.7%), and 90-day risk-standardized mortality rate was 6.0% (4.0%-8.8%). Across 90-day home time quartiles, a graded decline was observed in the rates of in-hospital, 90-day, and 1-year mortality, and 90-day and 1-year readmission. Ninety-day home time had a significant positive correlation with annual surgical volume (r=0.31; P<0.001) and inverse correlation with 90-day risk-standardized readmission rate (r=-0.40; P <0.001) and 90-day risk-standardized mortality rate (r=-0.60; P <0.001). Use of 90-day home time as a performance metric resulted in a meaningful reclassification in performance ranking of 22.8% hospitals compared with annual surgical volume, 11.6% compared with 90-day risk-standardized mortality rate, and 19.9% compared with 90-day risk-standardized readmission rate. Across the 7 years of the study period, 90-day home time demonstrated the most temporal stability of the hospital performance metrics.Conclusions: Ninety-day risk-standardized home time is a feasible, comprehensive, patient-centered metric to assess hospital-level performance in cardiac surgery with greater temporal stability than mortality and readmission measures. [ABSTRACT FROM AUTHOR]

Background: Intravascular lithotripsy (IVL) is a novel endovascular treatment for calcified common femoral artery disease (CFA). Data on midterm effectiveness for clinically driven target lesions revascularization (CD-TLR) is lacking. This study investigated CD-TLR during 18-month follow-up in patients requiring IVL for CFA disease treatment.Methods: In a single-center retrospective cohort study, electronic medical record of patients undergoing IVL for CFA disease from January 2018 to March 2020 were reviewed. Primary outcome was CD-TLR estimated by Kaplan-Meier method during 18-month follow-up. Univariate logistic regression was used to compare differences in CD-TLR by the type of adjunct therapy used.Results: Among 54 CFA lesions in 50 patients, mean age (SD) was 75(8) years, gender and race were predominantly male (74%, n = 37) and white (94%, n = 47), respectively. Rutherford class III claudication was most common (70%, n = 35) with mean ABI of 0.66 (0.26) and mean angiographic stenosis of 77% (13%). Adjunct use of drug-coated balloon (DCB) angioplasty was 83% (n = 45) and atherectomy was 39% (n = 21). Residual angiographic stenosis was <30% in all cases. Complications included dissection requiring stent placement (2%, n = 1). After 18-months, 18% (n = 9) died unrelated to procedural complications and 6% (n = 3) were lost to follow-up. 18-month cumulative freedom from CD-TLR was 80.6% (95% CI: 69.1%, 92%). Univariate logistic regression did not reveal a statistically significant difference in CD-TLR with type of adjunct therapy used (p > 0.05).Conclusion: IVL with adjunct use of DCB and/or atherectomy is safe and effective in treatment of calcified CFA disease. Randomized studies are required to confirm these findings. [ABSTRACT FROM AUTHOR]

Background: To describe the national trends and outcomes of contemporary thrombectomy use for primary percutaneous coronary intervention (PCI) from 2016 to 2018.Methods: We queried the Nationwide Readmission Database (NRD) from January 2016 to December 2018 to identify patients who underwent primary PCI and thrombectomy. We conducted a multivariate regression analysis to identify variables associated with in-hospital mortality and stroke in patients undergoing primary PCI and those who underwent thrombectomy.Results: We identified 409,910 total hospitalizations who underwent primary PCI. Thrombectomy was used in 62,446 records (15.2%) with no change in the trend over the study period (p trend = 0.52). Thrombectomy was more utilized in patients who had more cardiogenic shock and use of mechanical circulatory devices. The overall incidence of in-hospital mortality and stroke were 5.6% and 1.1%, respectively. The incidence of in-hospital mortality (6.7% vs. 5.4%, p < 0.001) and strokes (1.3% vs. 1.0%, p < 0.001) were higher in the thrombectomy group. On multivariable regression analysis adjusting for high-risk features, thrombectomy was not independently associated with in-hospital mortality [1.036, 95% CI (0.993-1.080), p = 0.100], but was associated with a higher risk of stroke [OR 1.186, 95% CI (1.097-1.283), p < 0.001].Conclusion: During primary PCI, thrombectomy was used in 1 of 6 cases, and its use has been stable over 2016-2018. The use of thrombectomy was associated with a higher risk of stroke, but not in-hospital death. [ABSTRACT FROM AUTHOR]

Introduction: The coronavirus disease 2019 (COVID-19) pandemic's impact on vascular procedural volumes and outcomes has not been fully characterized. Methods: Volume and outcome data before (1/2019 – 2/2020), during (3/2020 – 4/2020), and following (5/2020 – 6/2020) the initial pandemic surge were obtained from the Vascular Quality Initiative (VQI). Volume changes were determined using interrupted Poisson time series regression. Adjusted mortality was estimated using multivariable logistic regression. Results: The final cohort comprised 57,181 patients from 147 US and Canadian sites. Overall procedure volumes fell 35.2% (95% CI 31.9%, 38.4%, p < 0.001) during and 19.8% (95% CI 16.8%, 22.9%, p < 0.001) following the surge, compared with presurge months. Procedure volumes fell 71.1% for claudication (95% CI 55.6%, 86.4%, p < 0.001) and 15.9% for chronic limb-threatening ischemia (CLTI) (95% CI 11.9%, 19.8%, p < 0.001) but remained unchanged for acute limb ischemia (ALI) when comparing surge to presurge months. Adjusted mortality was significantly higher among those with claudication (0.5% vs 0.1%; OR 4.38 [95% CI 1.42, 13.5], p = 0.01) and ALI (6.4% vs 4.4%; OR 2.63 [95% CI 1.39, 4.98], p = 0.003) when comparing postsurge with presurge periods. Conclusion: The first North American COVID-19 pandemic surge was associated with a significant and sustained decline in both elective and nonelective lower-extremity vascular procedural volumes. When compared with presurge patients, in-hospital mortality increased for those with claudication and ALI following the surge. [ABSTRACT FROM AUTHOR]