Sulaiman, Samian

Introduction: Data on clinical outcomes of percutaneous closure of iatrogenic atrial septal defect (PC-ASD) in patients undergoing transcatheter edge-to-edge repair (TEER) or mitral valve replacement (TMVR) remains limited. We used a real-world USA database to evaluate the differences in the in-hospital outcomes between both groups. Hypothesis: Is there a clinical significance for PC-ASD in patients undergoing TEER or TMVR? Methods: We used the National Inpatient Sample (2015-2020) by utilizing ICD-10 codes to identify all patients who underwent TEER or TMVR with or without PC-ASD. Multivariate logistic regression was used for adjusted outcomes (adjusted odds ratio [aOR]). Results: A total of 44,065 eligible weighted hospitalizations were included: 39,625 (89.9%) of the patients underwent TEER and 4,440 (10.1%) underwent TMVR. Rates of PC-ASD were higher in TMVR group compared to TEER group (10.7% vs. 2.0%, p<0.01). In patients who underwent TEER without PC-ASD, PC-ASD was more associated with acute heart failure (AHF) (aOR 1.42 [1.19-1.68], p<0.01) and longer hospitalizations (aOR 1.64 [1.41-1.89], p<0.01), without significant difference in inpatient mortality (aOR 0.97 [0.61-1.54], p<0.01), cardiogenic shock (aOR 1.13 [0.85-1.51], p=0.21), need for mechanical circulatory support (MCS) (aOR 0.98 [0.61-1.54], p=0.18), and stroke. Compared to patients who underwent TMVR without PC-ASD, PC-ASD was associated with higher inpatient morality (aOR 1.65 [1.13-2.4], p<0.01), need for MCS (aOR 1.91 [1.33-2.73], p<0.01) without significant difference in AHF (aOR 1.19 [0.94-1.51], p=0.18] and cardiogenic shock (aOR 0.83 [0.56-1.22], p=0.43). Remarkably, PC-ASD was less associated with stroke (aOR 0.27 [0.10-0.72], p<0.01). Conclusions: Rates of PC-ASD after TEER were lower than after TMVR and were associated with worse in-hospital mortality and need for MCS in TMVR but not in TEER. Also, PC-ASD was less associated with stroke after TMVR.

Introduction: Data on clinical outcomes of early transcatheter aortic valve replacement (TAVR) (<48 hours) compared to late (≥48 hours) TAVR in patients hospitalized with acute heart failure (AHF) and aortic stenosis (AS) remains limited. We aim to evaluate the differences between early vs. late TAVR regarding major clinical outcomes using a real-world US database. Hypothesis: There is no differences in the clinical outcomes based on the timing of TAVR procedural intervention in patients with acute heart failure. Methods: We used the National Inpatient Sample database by utilizing ICD-10 codes to identify all hospitalizations with a diagnosis of AHF and TAVR (2015-2020). The associations between the time of TAVR and outcomes were examined using multivariable logistic regression. Propensity-score matched (PSM) analysis was utilized to determine the adjusted odds ratio (aOR) of major clinical outcomes. Results: A total of 25,285 weighted hospitalizations of AHF were identified, of which 6,855 patients (27.1%) underwent early TAVR and 18,430 (72.9%) had late TAVR. Compared with early TAVR, Late TAVR was associated with less need for mechanical circulatory support (MCS) (aOR 0.97 [0.96-0.98], p<0.01) and acute hypoxic respiratory failure (aOR 0.99 [0.98-0.99], p<0.01), but higher odds of developing septic shock (aOR 2.06 [1.52-2.80], p <0.01). However, there was no significant difference between both procedures regarding in-hospital mortality (aOR 1.01 [1.00-1.02], p=0.14), cardiac arrest (aOR 0.99 [0.98-1.00], p=0.21), and stroke (aOR 1.01 [1.00-1.02], p=0.18). Conclusions: Most patients with AHF and AS undergo TAVR after 48 hours of their presentation. After PSM, there was no difference in inpatient mortality, cardiac arrest, and stroke between both procedures. Late TAVR was associated with lower odds for MCS and acute hypoxic respiratory failure. The optimal timing of TAVR in patients with AHF and AS needs further study.

Abstract OBJECTIVES This study describes coronary revascularization strategies used by sex and age in the USA. METHODS A sex-stratified cohort study from the National Inpatient Sample from the Agency for Healthcare Research and Quality (USA) including patients admitted for coronary revascularization with primary or secondary diagnoses of chronic coronary syndrome or non-ST elevation myocardial infarction who underwent ≥3-vessel coronary artery bypass grafting or percutaneous coronary intervention from January 2019 to December 2020. The primary outcome was the use rate of coronary artery bypass grafting or multivessel percutaneous coronary intervention. Prespecified subgroups included age and non-ST elevation myocardial infarction. RESULTS Among 121 150 patients (21.7% women), there were no sex differences in age (women: 66.6 [66.5–66.7], men: 67.6 [67.5–67.7], standardized mean difference: 0.1) or non-ST elevation myocardial infarction incidence (women: 37.4%, men: 45.7%, standardized mean difference: 0.17). The majority of women (74.2%) and men (84.9%) underwent bypass grafting, which was unaffected by age, race or non-ST elevation myocardial infarction. Women were less likely to undergo bypass grafting than percutaneous intervention (adjusted odds ratio 0.49, 95% confidence interval 0.44–0.54; P &lt; 0.001) and a disparity most pronounced in patients &gt;80 years old (adjusted odds ratio 0.31, 95% confidence interval 0.22–0.45; P &lt; 0.001). CONCLUSIONS Most patients with multivessel coronary artery disease needing revascularization undergo bypass grafting, irrespective of sex, age or clinical presentation. The sex disparity in the use of bypass grafting is mostly seen among patients &gt;80 years old.

Background Patient‐reported outcome measures have been shown to have important prognostic value after various cardiac interventions. We assessed the association between the change in Kansas City Cardiomyopathy Questionnaire 12 (KCCQ‐12) score after transcatheter aortic valve replacement and mortality. Methods and Results We included patients who underwent transcatheter aortic valve replacement at Mayo Clinic between February 2012 to June 2022 and who completed a KCCQ‐12 before and 30 to 45 days after the procedure. Patients were categorized into 3 groups: those who experienced significant (>+19 points; group 1), modest (1–19 points; group 2), and no (≤0 points; group 3) improvement. A total of 1124 patients were included: 60.8% men; 97.6% White. Mean age was 79.4±8.3 years, baseline KCCQ‐12 score was 53.9±24.5, and median Society of Thoracic Surgeons score was 4.9% (interquartile range, 3.1–8.0). At 45 days, the mean change in KCCQ‐12 score was 19±24 points; 46.3% (n=520) of patients had a significant improvement in their KCCQ‐12 score, while 33.4% (n=375) and 20.4% (n=229) had modest and no improvement, respectively. Median survival was higher in group 1 (5.7±0.2 years) compared with groups 2 and 3 (5.1±0.3 and 4.1±0.4 years, respectively; P <0.001). Compared with patients in group 1, those in groups 2 and 3 had higher long‐term risk‐adjusted mortality (adjusted hazard ratios, 1.54 [95% CI, 1.20–1.96], and 2.30 [95% CI, 1.74–3.04], respectively). Conclusions Patients who experience modest or no improvement in KCCQ‐12 score after transcatheter aortic valve replacement have substantially higher long‐term mortality. Delta KCCQ‐12 is a cost‐effective, efficient tool that can identify patients at increased risk of death at long‐term follow‐up post‐transcatheter aortic valve replacement.

AbstractObjectivesThe aim of this study was to describe the use pattern and outcomes of protamine administration for heparin reversal among sites performing percutaneous left atrial appendage occlusion (LAAO).MethodsWe identified 45,135 patients who underwent LAAO at 243 hospitals participating in Vizient® Clinical Database between January 1, 2016 and December 31, 2021. Patients were stratified according to protamine administration after the procedure. Outcomes of interest included vascular complications, major bleeding, ischemic events, and same‐day discharge.ResultsA total of 40,278 patients were included in the propensity‐matched comparison, of whom 50% received protamine after the LAAO procedure. The use of protamine varied across hospitals, with 88 hospitals (36.2%) using protamine in >75% of cases and 32 hospitals (13.1%) not using protamine at all. Major bleeding occurred less frequently in the protamine group compared with the control group (2.4% vs. 2.8%, p = 0.03). Major vascular complications and pericardial tamponade were rare but slightly higher in the protamine group (0.8% vs. 0.6%, p = 0.04) and (1.0% vs. 0.8%, p = 0.01), respectively. There were no differences in the rates of ischemic or hemorrhagic stroke, all‐cause mortality, or the rate of any major adverse event between the two groups. Same‐day discharge was more frequent in the protamine group (12.3% vs 9.4%, p ≤ 0.001).ConclusionsProtamine is used in approximately 50% of LAAO procedures and is associated with lower bleeding events and higher rates of same‐day discharge. The higher vascular complication and tamponade is likely due to its ad‐hoc use as a reversal agent in these patients.

Background Women are less likely to receive primary percutaneous coronary intervention (pPCI) than men. A potential reason is risk aversion because of the worse outcomes with pPCI among women. However, whether pPCI is associated with a comparable mortality benefit in men and women remains unknown. Methods and Results We selected patients admitted with a principal diagnosis of ST‐segment–elevation myocardial infarction in the National Inpatient Sample (2016–2018). We used propensity‐score matching to calculate average treatment effects of pPCI for in‐hospital mortality, major complications, length of stay, and cost. As a sensitivity analysis, we used logit models followed by a marginal command to calculate the average marginal effect. We included 413 500 weighted hospitalizations (30.7% women, 69.3% men). Women had more comorbidities except smoking and prior sternotomy. Compared with men, women were less likely to undergo angiography (81.0% versus 87.0%; adjusted odds ratio [OR], 0.77; 95% CI, 0.74–0.81; P <0.001) or pPCI (74.0% versus 82.0%; adjusted OR, 0.76; 95% CI, 0.73–0.79; P <0.001). There were no significant differences in average treatment effects of pPCI on mortality between men (−8.4% [−9.3% to −7.6%], P <0.001), and women (−9.5% [−10.8% to −8.3%], P <0.001) ( P interaction=0.16). This persisted in age‐stratified analyses (≥85, 65–84, 45–64, <45 years) and sensitivity analysis, excluding emergent admissions. The average treatment effects of pPCI on major complications were comparable except for acute stroke, leaving against medical advice, and palliative encounter. There were no differences in the average treatment effects of pPCI on length of stay, but the proportional increase in cost with pPCI was higher in women. Conclusions pPCI results in a comparable reduction in in‐hospital mortality in men and women. Nonetheless, risk‐adjusted rates of pPCI remain lower in women in contemporary US practice.

AbstractIntroductionDespite the growth in transcatheter edge‐to‐edge repair (TEER) volume in the United States, data on the temporal changes in procedural outcomes are lacking.MethodsWe utilized the National Readmission Database to assess the annual changes in patient's characteristics, in‐hospital outcomes, cost, and readmissions for patients who underwent TEER between January 1, 2014 and December 31, 2018. Outcomes of interest included mortality, major adverse cardiovascular events (MACE) and any adverse event (AE). We also assessed length of stay and cost.ResultsA total of 22,692 hospitalizations were included. The mean age increased from 75.2 ± 12.9 in 2014 to 78.1 ± 9.8 years in 2018. Changes in the prevalence of risk factors were heterogenous. The incidence of in‐hospital mortality decreased from 4.0% in 2014 to 2.0% in 2018. Both MACE and any AE decreased significantly. Although the incidence of 30‐day readmission remained stable, there was a trend towards a temporal increase in both 90‐day and 180‐day. The adjusted median length of stay of the index admission decreased by 50% and this trend was associated with a $2100 reduction in risk and inflation adjusted in‐hospital cost, however, this reduction was offset by the increased total cost of readmissions within the first 6 months resulting in similar net‐cost.ConclusionThe volume of TEER has grown substantially between 2014 and 2018 coupled with a temporal improvement in in‐hospital outcomes and reduction in cost and length of stay. Re‐hospitalization rates after TEER remained steady at 30‐day and trended towards worsening overtime at 90‐ and 180‐days.

Background Nationwide studies documenting temporal trends in permanent pacemaker implantation (PPMI) following transcatheter aortic valve replacement (TAVR) are limited. Methods and Results We selected patients who underwent TAVR between 2012 and 2017 in the National Readmission Database. The primary end point was the 6‐year trend in post‐TAVR PPMI at index hospitalization and at 30, 90, and 180 days after discharge. The secondary end point was the association between PPMI and in‐hospital mortality, stroke, cost, length of stay, and disposition. Among the 89 202 patients who underwent TAVR, 77 405 (86.8%) with no prior pacemaker or defibrillator were included. Patients who required PPMI had a higher prevalence of atrial fibrillation (43.6% versus 38.7%, P <0.001) and conduction abnormalities (28.4% versus 15.3%, P <0.001). The incidence of PPMI during index admission increased from 8.7% in 2012 to 13.2% in 2015, and then decreased to 9.6% in 2017. The incidence of inpatient PPMI within 30 days after discharge increased from 0.5% in 2012 to 1.25% in 2017 ( P trend <0.001). Inpatient PPMI beyond 30 days remained rare (<0.5%) during the study period. After risk adjustment, PPMI was not associated with in‐hospital mortality or stroke but was associated with increased nonhome discharge, longer hospitalization, and higher cost. The incremental expenditure associated with post‐TAVR PPMI during index admission increased from $9.6 million to $72.2 million between 2012 and 2017. Conclusions After an upward trend, rates of PPMI after TAVR in the United States stabilized at ~10% in 2016 to 2017, but there was a notable increase in PPMI within 30 days after the index admission. PPMI was not associated with increased in‐hospital morbidity or mortality but led to longer hospitalization, higher cost, and more nonhome discharges.