Bashir, Riyaz

Abstract Objective We sought to evaluate the association between the institutional volume of catheter‐directed thrombolysis (CDT) for pulmonary embolism and in‐hospital mortality. Background CDT is an increasingly utilized therapy in patients with intermediate/high‐risk PE. However, data on the relationship between hospital volume and clinical outcomes remain limited. Methods Patients who underwent CDT between October 1, 2015, and March 31, 2021, were identified in the Vizient Clinical Database. The primary outcome was in‐hospital mortality. Secondary outcome were major complications, length of stay, and cost. Hospitals were dichotomized into <8 and 8 cases/year following restricted cubic spline analysis. Results A total of 6741 CDT procedures at 171 hospitals were included with a median annual hospital volume of 4.1 cases (IQR = 1.9–8.3). A total of 44 hospitals (25.7%) were classified as high‐volume (8 cases/year) and performed 60.9% of all CDT cases. CDT at high‐volume centers was associated with lower in‐hospital mortality (6.0% vs. 11.3%; p < 0.0001). Stroke and bleeding rates were similar, but pulmonary complications were more frequent at low‐volume centers. CDT at high volume centers was associated with a significantly shorter length of stay and lower cost. The association between high CDT volume and in‐hospital mortality persisted after adjustment for demographics (odds ratio [OR] = 0.49, [0.41–0.58]), demographics and risk factors (OR = 0.52 [0.44–0.62]), and demographics, risk factors, and troponin elevation (OR = 0.51 [0.40–0.66]). Conclusion In a large contemporary cohort of patients undergoing CDT in the United States, low annual institutional volume of CDT was associated with higher in‐hospital mortality.

Background— The introduction of transcatheter aortic valve replacement (TAVR) led to renewed interest in balloon aortic valvuloplasty (BAV). We sought to assess contemporary trends in BAV utilization and their outcomes. Methods and Results— The Nationwide Inpatient Sample was used to identify patients who underwent BAV between 2004 and 2013. In-hospital morbidity and mortality, and predictors of death after BAV were assessed. Outcomes of propensity-matched groups of patients undergoing elective BAV or TAVR were evaluated. BAV utilization increased from 707 cases in 2004 to 3715 cases in 2013 (national estimates). Procedural and in-hospital mortality were 1.4% and 8.5%, respectively. Vascular complications occurred in 7.0% of cases, blood transfusion in 17.5%, clinical stroke in 1.8%, and pacemaker implantation in 3.0%. The strongest predictors of in-hospital death were cardiogenic shock (odds ratio, 6.01; 95% confidence interval, 4.19–8.61; P <0.001), need for left ventricular assist device (odds ratio, 3.48; 95% confidence interval, 2.25–5.36; P <0.001), coagulopathy (odds ratio, 2.19; 95% confidence interval, 1.51–3.18; P <0.001), and low institutional volume of BAV (odds ratio, 1.58; 95% confidence interval, 1.06–2.37; P =0.03). In propensity-matched patients undergoing elective BAV or TAVR, rates of in-hospital mortality (2.9% versus 3.5%; P =0.60), clinical stroke (1.6% versus 3.1%; P =0.10), and vascular complications (8.2% versus 10.9%; P =0.14) were similar. However, BAV was associated with lower rates of pacemaker implantation (2.9% versus 8.0%; P <0.001) and blood transfusion (12.8% versus 22.9%; P <0.001). Conclusions— In a contemporary national registry, BAV is associated with significant morbidity and mortality that are similar to TAVR. With the substantial increase in BAV utilization and the continuous improvement in TAVR outcomes, these data have important implications to aid clinicians in the selection of appropriate BAV candidates.

Catheter-directed thrombolysis (CDT) is being increasingly used for the treatment of proximal lower extremity (LE) deep venous thrombosis (DVT). However, sex differences in utilization and safety outcomes of CDT in these patients are unknown. The Nationwide Inpatient Sample (NIS) database was used to identify all patients with a principal discharge diagnosis of proximal LE or caval DVT who underwent CDT between January 2005 and December 2011 in the United States. We evaluated the comparative safety outcomes of CDT among a propensity-matched group of 1731 men versus 1731 women. Among 108,243 patients with proximal LE or caval DVT, 4826 patients (4.5%) underwent CDT. Overall, women underwent CDT less often compared to men (4.1% vs 4.9%, p<0.01, respectively). The rates of CDT increased between 2005 and 2011 for both women (2.1% to 5.9%, p<0.01) and men (2.5% to 7.5%, p<0.01). There was no significant difference in in-hospital mortality (1.2% vs 1.3%, p=0.76). Women were noted to have higher rates of blood transfusions (11.7% vs 8.8%, p<0.01), but lower rates of intracranial hemorrhage (0.5% vs 1.2%, p=0.03) and gastrointestinal bleeding (0.9% vs 2.2%, p<0.01) compared with men. Women were more likely to undergo inferior vena cava filter placement (37.0% vs 32.1%, p<0.01). In this large nationwide cohort, women with proximal DVT were less likely to receive CDT compared to men. Although mortality rates were similar, women were noted to have higher blood transfusion rates while men had more episodes of intracranial and gastrointestinal bleeding.

Background— The use of catheter-directed thrombolysis (CDT) in the treatment of acute proximal lower-extremity deep vein thrombosis is increasing in the United States and has been linked to higher bleeding rates. Whether this relationship is interrelated with institution volume of CDT is unknown. Methods and Results— The Nationwide Inpatient Sample database was used to identify all patients admitted with a principal diagnosis of proximal or inferior vena caval deep vein thrombosis and treated with CDT from 2005 to 2010. Institutions were divided into high-volume (≥6 procedures a year) and low-volume (<6 procedures a year) centers. Propensity score matching was used to create 2 matched groups for comparative analysis. A total of 90 618 patients were hospitalized for proximal lower-extremity deep vein thrombosis, and 3649 patients (4.1%) underwent CDT. In-hospital mortality was significantly lower at high-volume centers (0.6% versus 1.5%; P =0.04) with a trend toward lower intracranial hemorrhage rates compared with low-volume centers (0.4% versus 1%; P =0.07). No significant difference was seen with blood transfusion (10.4% versus 10.8%; P =0.70), gastrointestinal bleeding (1.4% versus 1.8%; P =0.35), or pulmonary embolism rates (18.4% versus 17.9%; P =0.72). Median length of stay was similar (6 days) and hospital charges were higher ($65 500 versus $75 870) at high-volume centers. Conclusions— In this observational study, we found that an increase in institutional volume of CDT was associated with lower in-hospital mortality and lower intracranial hemorrhage rates. Further studies are needed to assess whether standardization of CDT protocols across all institutions in the United States improves outcomes.