Crusan, Daniel J.

Introduction: We aim to elucidate the incidence of major complications related to right heart catheterization (RHC) and ascertain if there are unique risks with right ventricular biopsy. Methods: Diagnostic RHC procedures from 1/1/2002 through 12/31/2013 were identified using the clinical scheduling system at Mayo Clinic, Rochester. Major complications were identified through electronic records using International Classification of Diseases, Ninth Revision billing codes. All events were recorded and adjudicated. Analysis was performed on four separate patient categories (RHC/RV angiography alone, RV biopsy alone, multiple RHC procedures, and concurrent RHC/LHC procedures) and the overall group. Primary outcomes are described in Table 1. Outcomes were measured within 7 days of the procedure, except for death (same day events) and tricuspid regurgitation (variable time endpoints). Results: There were 17,696 RHC procedures (5,556 RHC/RV angiography, 3,846 RV biopsy alone, 776 multiple RHC procedures, and 7,518 combined RHC/LHC). Patient population had a mean age of 56.5 years (15.3) and was predominantly male (58.5%). Same-day death related to RHC procedure occurred in 1 procedure or 0.6 of 10,000 RHCs. There was no significant difference in the risk of complications across RHC procedure categories except for worsening tricuspid regurgitation, which was significantly (p<0.001) more prevalent with RV biopsy (392 cases, 6.0%) than without (136 cases, 1.2%). Conclusion: The incidence of major complications related to right heart catheterization is rare. Worsening tricuspid regurgitation is the most frequently identified change with a significantly higher prevalence with biopsies.

Background: Between 1990-2006, there was a tremendous increase in utilization of single photon emission computed tomography myocardial perfusion imaging (SPECT). Characteristics of the observed increase of SPECT utilization have never been studied. Methods: Using the Mayo Clinic nuclear cardiology database, we examined all SPECT tests performed between 1/1/1991-12/31/2007 in patients without prior coronary artery disease (CAD). Patients with history of CAD, left bundle branch block, paced rhythm, bicycle/ rest-only tests, cardiomyopathy, valvular heart disease, and technically unsatisfactory studies were excluded. The study cohort was divided into 4 time periods: 1991-5, 1996-2000, 2001-5, and 2006-7. Results: There were 29255 eligible SPECT tests (mean age 62.4 ± 12y, 54% men). Annual utilization of SPECT studies increased from 682 in 1992 to a peak of 2738 in 2002, and then decreased to 2134 in 2007, Fig 1. There were very modest changes in CAD risk factors over time. Testing of asymptomatic patients nearly doubled (21.9% in 1991-5 to 42.7% in 2006-7). Tests on patients with typical angina decreased dramatically (18.3% in 1991-5 to 5.3% in 2006-7), Fig 2. Summed stress score, summed difference score, and high risk SPECT tests decreased over time, Fig 3. Normal SPECT studies and negative study ECG increased for both pharmacologic and exercise tests. Conclusions: In Mayo Clinic Rochester, annual SPECT utilization in patients without prior CAD increased between 1992 and 2002, but then decreased in advance of national trends. Normal tests increased, while summed stress score, summed difference score, and high risk tests all decreased. These data suggest that SPECT was increasingly utilized in patients with a lower prevalence of CAD.

Background: Over the past 20 years, there has been an increasing decline in the prevalence of abnormal stress single-photon emission computed tomography myocardial perfusion imaging (SPECT) studies among patients with no history of coronary artery disease (CAD). The trend of SPECT studies among patients with known CAD has not been evaluated before. Methods: Using the Mayo Clinic nuclear cardiology database, we examined all stress SPECT tests performed between 1/1991-12/2012 in patients with prior history of CAD defined as having prior myocardial infarction, percutaneous coronary intervention, and/or coronary artery bypass grafting. Patients with left bundle branch block, paced rhythm, bicycle or rest-only tests, cardiomyopathy, valvular heart disease, and technically unsatisfactory studies were excluded. The study cohort was divided into 5 time periods: 1991-5, 1996-2000, 2001-5, 2006-10, and 2011-12. Results: There were 19373 eligible SPECT tests (mean age 66.2 ± 10.9y, 75.4% men). Annual utilization of SPECT studies in patients with history of CAD increased from an average of 495 tests per year between 1991-1995 to a peak of 1425 in 2003; and then decreased to 552 tests in 2012. Asymptomatic patients comprised 33% in 1991-1995, peaked at 48% in 2006, and then decreased back to 31% in 2012. Over time, patients with typical angina decreased while patients with dyspnea increased, P <0.001 (Fig 1). The percentage of high risk SPECT tests significantly decreased, and the percentage of low-risk SPECT tests significantly increased despite the overall decline of SPECT utilization between 2003 and 2012. Almost 80% of all tests performed in 2012 had a low risk summed stress score compared to 29% in 1991, P <0.001 (Fig 2). Conclusions: In Mayo Clinic Rochester, annual SPECT utilization in patients with prior CAD increased between 1992 and 2003, but then decreased significantly after 2003. Fewer patients had typical angina while patients with dyspnea increased over time. High risk SPECT tests declined while low risk tests increased dramatically. These data suggest that stress SPECT was being increasingly utilized in CAD patients without typical angina who are at low risk.

Background: Left ventricular global longitudinal strain (GLS) is associated with long-term outcomes of patients with severe aortic stenosis. However, its prognostic value in patients with moderate aortic stenosis remains unknown. Methods: Patients diagnosed with moderate aortic stenosis (1.0< aortic valve area ≤1.5 cm 2 ) and left ventricular ejection fraction ≥50% were identified. GLS was assessed by 2-dimensional strain imaging using speckle-tracking method. All-cause mortality was assessed according to the median GLS value. Results: Two hundred eighty-seven patients were included (median age 76 years; 47% male). Mean aortic valve area was 1.25 cm 2 , left ventricular ejection fraction 62%, and median GLS −15.2%. During a median follow-up of 3.9 years, there were 103 deaths (36%). Mortality was higher in patients with GLS>−15.2% (hazard ratio 2.62 [95% CI 1.69–4.06]) compared with patients with GLS ≤−15.2% even after adjusting for confounders. Mortality rates at 1, 3, 5 years were 21%, 35%, 48%, respectively, in patients with GLS >−15.2%, and 6%, 15%, 19% in those with GLS ≤−15.2%. Even among those with left ventricular ejection fraction ≥60%, GLS discriminated higher-risk patients ( P =0.0003). During follow-up, 106 (37%) patients underwent aortic valve replacement with median waiting-time of 2.4 years, and their survival was better than patients without aortic valve replacement. Among those patients undergoing aortic valve replacement, prognosis was still worse in patients with GLS >−15.2% ( P =0.04). Mortality rates at 1, 3, 5 years were 2%, 10%, 20%, respectively, in patients with GLS >-15.2% and 2%, 5%, 6% in those with GLS ≤−15.2%. Conclusions: Impaired GLS in moderate aortic stenosis patients is associated with higher mortality rates even among those undergoing aortic valve replacement.

Abstract Background Currently data on the risk stratification of patients with moderate aortic stenosis (AS) are very limited. Method Patients diagnosed with moderate AS in 2012 (aortic valve area [AVA]: >1 and ≤1.5cm2) were identified. Patients were stratifying by LV diastolic function (normal vs high filling pressure), left ventricular ejection fraction (LVEF ≥50 vs <50%) and stroke volume index (SVI ≥35 vs <35 ml/m2). High filling pressure was defined as average E/e' ≥14 or septal E/e' ≥11 when atrial fibrillation was present. The prognosis was compared to age- and sex-matched general population. Results 898 patients were included (age 74 years, 58% male, AVA 1.25 cm2). During a median follow-up of 2.9 years, there were 346 deaths. In patients with moderate AS, mortality was higher than expected (P<0.001, Fig 1A). LV high filling pressure, LVEF<50% and SVI<35ml/m2 were present in 416 (55%), 140 (17%) and 81 (9%) patients, respectively. Those with normal filling pressure had similar prognosis when compared to controls (Fig 1C, P=0.35); whereas mortality rates remained higher than reference even when LVEF≥50% or SVI≥35ml/m2 (Fig 1E, 1G, P<0.001). Amongst all groups, mortality rates were the highest in patients with LVEF <50% or SVI <35 ml/m2 (Fig 1D, 1F, P<0.001); mortality ratios were 3.78 (95% CI 3.01–4.67) and 6.91 (95% CI 5.13–9.11), respectively. Noteworthy, high filling pressure allowed further risk stratification when LVEF or SVI was preserved (Fig 2, P<0.001). Figures 1 & 2 Conclusions Patients with moderate AS showed poor survival. A clinical trial examining role of aortic valve replacement would be beneficial not only in patients with reduced LVEF or SVI but also in those with high LV filling pressures.

Abstract Introduction: Hospitalization-associated VTE attack (incident plus recurrent VTE) rates over the 6-year period, 2005-2010, did not change significantly despite achieving near-universal in-hospital VTE prophylaxis; 75% of these VTE events occurred after hospital discharge with a median of 19.5 days from hospital discharge to VTE. The median durations of hospitalization and in-hospital prophylaxis were 3 days and 70 hours, respectively, suggesting that VTE prophylaxis was inadequate. However, the hospital population that would benefit most from post-hospitalization VTE prophylaxis is uncertain. Our study aim was to test hospital length of stay (LOS) as a potential predictor of post-hospital-discharge incident or recurrent VTE. Methods: Using the resources of the Rochester Epidemiology Project, we identified all unique Olmsted County, MN residents hospitalized at least once at a Rochester, MN Mayo Clinic hospital and all such residents with objectively-diagnosed occurrence of first or recurrent VTE during hospitalization or within 92 days after hospital discharge, 2005-2010. We tested LOS as a potential predictor of post-hospital-discharge VTE (conditional on surviving to hospital discharge free of VTE) using the Anderson-Gill version of Cox regression modeling and adjusting for age, sex, any surgery performed during that hospitalization, and Charlson Comorbidity Index calculated from conditions recorded from 1/1/2005 until the day of hospital discharge. Results: Over the period, 2005-2010, 31,588 unique Olmsted County residents were hospitalized at least once at a Rochester Mayo Clinic hospital. The distribution of LOS was: 1-2 (3.8%), 3 (24.2%), 4 (23.3%), 5 (16.4%), 6 (8.8%), 7-9 (12.4%), 10-19 (8.4%) and 20+ (2.3%). Of the 253 VTE events identified within 92 days post-hospital discharge, 6, 29, 31, 38, 38, 53, 42 and 16 had been hospitalized for 1-2, 3, 4, 5, 6, 7-9, 10-19 and 20+ days, respectively. The hazard ratios (HR) for post-hospital-discharge VTE were similar for hospital LOS ≤4 days; compared to LOS ≤3 days, the HRs were significantly increased for hospital LOS of 5 (HR=1.78), 6 (HR=2.86), 7-9 (HR=2.71), 10-19 (HR=3.16) and 20+ (HR=4.20) days (Table 1). Conclusions: The adjusted hazards of post-hospital discharge VTE for hospital LOS > 4 days were significantly increased 1.8 to 4.2-fold compared to LOS ≤3 days, suggesting that hospital LOS may be useful for identifying hospitalized patients suitable for longer duration VTE (including post-discharge) prophylaxis. Future studies should be aimed at identifying additional predictors of post-hospital-discharge VTE such that extended prophylaxis can be targeted to those patients who would benefit most. Disclosures No relevant conflicts of interest to declare.