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Objective: To identify outcomes of patients undergoing emergency transcatheter aortic valve replacement (TAVR) and determine predictors of in-hospital mortality., Background: Emergency TAVR has emerged as a viable treatment strategy for patients with decompensated severe aortic stenosis and/or regurgitation; however, data on patients undergoing emergency TAVR are limited., Methods: All emergency TAVR procedures were identified from a single tertiary academic center between January 2015 and August 2018., Results: 31 patients underwent emergency TAVR due to cardiogenic shock (26 patients), electrical instability with incessant ventricular tachycardia (2 patients), severe refractory angina (2 patients), and decompensated heart failure with hypoxemic respiratory failure requiring mechanical ventilation (1 patient). Mechanical circulatory support (MCS) was used in 16 (51.6%). MCS initiation occurred immediately prior to TAVR in 10 patients and placed post-TAVR in 6 patients. 6 patients died before hospital discharge (in-hospital mortality 19.4%). 1-year and 2-year survival rates were 61.0% and 55.9%, respectively. Univariate predictors of in-hospital mortality were preprocedural pulmonary artery pulsatility index (PAPi) ≤1.8 (66.7% vs. 20.0%, p =0.01), intraprocedural cardiopulmonary resuscitation (CPR) (83.3% vs 4.0%, p ≤ 0.001), acute kidney injury post-TAVR (80.0% vs. 4.2%, p ≤ 0.001), initiation of dialysis post-TAVR (60.0% vs. 4.2%, p ≤ 0.001), and MCS initiation post-TAVR (50.0% vs. 12.0%, p =0.03). MCS initiation before TAVR was associated with improved survival compared with post-TAVR initiation., Conclusion: Emergency TAVR in extreme risk patients with acute decompensated heart failure or cardiogenic shock secondary to severe aortic valve disease is associated with high in-hospital mortality rates. Careful patient selection taking into account right heart function, assessed by PAPi, and early utilization of MCS may improve survival following emergency TAVR., Competing Interests: The authors declare that there are no conflicts of interest regarding the publication of this paper., (Copyright © 2019 Hans Huang et al.)

Objectives: The authors sought to define the feasibility and performance of 3-dimensional (3D) vena contracta area (VCA) measurement in evaluating total residual mitral regurgitation (MR) following percutaneous edge-to-edge clip (E-EC) mitral valve repair., Background: Residual MR severity after percutaneous repair is not only a determinant of procedural success, but also a major prognostic factor. To date, no single echocardiographic method has been recommended for post-procedural MR quantification, with the evaluation currently relying on a complex, multiparametric appraisal., Method: The authors performed a retrospective study of patients undergoing the E-EC procedure, for which baseline and post-repair 3D color Doppler transesophageal echocardiogram datasets were available. Total VCA was recorded as the sum of individual VCAs (if more than 1) and compared with an expert multiparametric appraisal of MR severity as the reference standard. Receiver-operating characteristic analysis was performed., Results: 155 patient studies were available for review. Total VCA correlated with hemodynamic parameters and was significantly reduced after E-EC. Receiver-operating characteristic analysis demonstrated a VCA threshold of 0.27 cm 2 for identification of ≥moderate MR, with good diagnostic accuracy (area under the curve 0.81) and a negative predictive value of 92%. Smaller VCA was associated with clinical New York Heart Association functional class improvement at 30-day follow-up., Conclusions: Measurement of VCA is feasible using 3D color Doppler transesophageal echocardiography and provides reliable quantification of MR following E-EC transcatheter mitral valve repair., (Copyright © 2019 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Background: Percutaneous coronary intervention (PCI) is used with increasing frequency in patients with diabetes and multivessel disease. This study investigated evolving revascularization strategies in the State of Washington., Methods: The Clinical Outcomes Assessment Program captures all revascularization in the State of Washington and was used to compare diabetic patients with multivessel disease undergoing first-time revascularization from 1999 to 2007. Categorical variables were compared with the chi-squared test and continuous variables were compared with the student's t-test. Results were risk-adjusted using a logistic regression., Results: A total of 11,602 patients with diabetes and multivessel disease underwent revascularization from 1999 to 2007 and were nearly equally divided between coronary artery bypass grafting (CABG) (51%) and PCI (49%). Patients undergoing CABG had a higher (p < 0.0001) prevalence of congestive heart failure, cerebrovascular disease, peripheral vascular disease, three-vessel coronary artery disease (CAD), and intraaortic balloon pump insertion, but a lower prevalence of female gender, cardiogenic shock, and emergency procedures. Patients undergoing CABG had more (p < 0.0001) three-vessel CAD and more complete revascularization (3.7 vs. 1.5 lesions treated). Short-term risk-adjusted mortality was equivalent. The prevalence of PCI increased from 34.1% in 1999 to 59.4% in 2007., Conclusions: PCI is applied with increasing frequency to patients with diabetes mellitus (DM) and multivessel disease. PCI is used most commonly in two-vessel CAD or with acute coronary syndromes with more limited and targeted revascularization. CABG is more commonly applied to extensive disease with more complete revascularization. Both the prevalence and percentage of patients undergoing PCI as primary therapy for multivessel disease with DM is increasing. A multidisciplinary approach may be warranted to ensure optimal outcomes., (© 2010 Wiley Periodicals, Inc.)

Published mortality models for percutaneous coronary intervention (PCI), including the Clinical Outcomes Assessment Program (COAP) model, have not considered the effect of out-ofhospital cardiac arrest. The primary objective of this study was to determine if the inclusion of out-of-hospital cardiac arrest altered the COAP mortality model for PCI. The COAP PCI database contains extensive demographic, clinical, procedural and outcome information, including out-of-hospital cardiac arrest, which was added to the data collection form in 2006. This study included 15,586 consecutive PCIs performed in 31 Washington State hospitals in 2006. Using development and test sets, the existing COAP PCI logistic regression mortality model was examined to assess the effect of out-of-hospital arrest on in-hospital mortality. Overall, 2% of individuals undergoing PCI had cardiac arrest prior to hospital arrival. Among 8 hospitals with PCI volumes < 120 cases per year, 4 had cardiac arrest volumes that exceeded 10% of total volume, whereas none of the centers with > 120 cases per year did. In-hospital mortality was 19% in the arrest group and was 1.0% in remaining procedures (p < 0.0001). In the new multivariate model, out-of-hospital cardiac arrest was highly associated with mortality (odds ratio = 5.50; 95% confidence interval [CI] = 3.28-9.25). When evaluated in the test set, the new model had excellent discrimination (c-statistic = 0.89; 95% CI = 0.85-0.93). Out-of-hospital cardiac arrest is an important determinant of risk-adjusted in-hospital mortality for PCI, particularly for hospitals with low volumes and relatively high volumes of cardiac arrest cases.

Background: Several states have implemented mandatory public reporting of outcomes of cardiac revascularization procedures. Washington is the first to develop a nonmandatory, physician-led reporting program with public accountability and universal hospital participation. The purpose of this study was to determine whether quality improvement interventions resulted in the correction of data deficiencies and performance outliers for cardiac revascularization procedures., Methods: From 1999 through 2003, there were 18 hospitals with coronary bypass surgery and interventional cardiology programs and 12 with only the latter. All patients > or =18 years undergoing 24372 isolated coronary bypass surgeries and 59,656 percutaneous coronary interventions were included. After 1999 to 2001 data were analyzed in early 2002, the Clinical Outcomes Assessment Program implemented a 6-step quality-improvement intervention to measure and remeasure data quality, process compliance, and performance., Results: In 2003, 4 of the 18 surgery programs had 1 statistical outlier with respect to 4 performance measures, whereas 2 of 30 coronary intervention programs were mortality outliers. For bypass surgery, all programs maintained full compliance with program standards by adhering to timely and reliable submission of data, developing plans to address performance outliers, and demonstrating that outlier status did not persist from baseline to remeasurement. For coronary interventions, 1 program was a persistent outlier for mortality in 2002 and 2003., Conclusions: The Clinical Outcomes Assessment Program has successfully monitored cardiac care patterns in Washington State over a 5-year period. Most hospitals that perform coronary revascularization procedures meet acceptable performance standards.