Kalra, Ankur

AbstractObjectivesThe aim of this study was to determine the prevalence of peripheral artery disease (PAD) and its association with in‐hospital outcomes after endovascular transcatheter aortic valve replacement (EV‐TAVR).BackgroundTAVR is an established treatment for patients at prohibitive, high, or intermediate surgical risk. PAD is a significant comorbidity in the determination of surgical risk. However, data on association of PAD with outcomes after EV‐TAVR are limited.MethodsPatients in the National Inpatient Sample who underwent EV‐TAVR between January 1, 2012 and September 30, 2015 were evaluated. The primary outcome was in‐hospital mortality.ResultsA total of 51,685 patients underwent EV‐TAVR during the study period. Of these, 12,740 (24.6%) had a coexisting diagnosis of PAD. The adjusted odds for in‐hospital mortality [OR 1.08 (95% CI 0.83–1.41)], permanent pacemaker implantation [OR 0.98 (0.85–1.14)], conversion to open aortic valve replacement [OR 1.05 (0.49–2.26)], or acute myocardial infarction [OR 1.31(0.99–1.71)] were not different in patients with versus without PAD. However, patients with PAD had greater adjusted odds of vascular complications [OR 1.80 (1.50–2.16)], major bleeding [OR 1.20 (1.09–1.34)], acute kidney injury (AKI) [OR 1.19 (1.05–1.36)], cardiac complications [aOR 1.21 (1.01–1.44)], and stroke [OR 1.39(1.10–1.75)] compared with patients without PAD. Length of stay (LOS) was significantly longer for patients with PAD [7.23 (0.14) days vs. 7.11 (0.1) days, p < 0.001].ConclusionOf patients undergoing EV‐TAVR, ~25% have coexisting PAD. PAD was not associated with increased risk of in‐hospital mortality but was associated with higher risk of vascular complications, major bleeding, AKI, stroke, cardiac complications, and longer LOS.

Background Studies have shown that chronic total occlusion ( CTO ) in a noninfarct‐related artery in patients with ST‐segment–elevation myocardial infarction is linked to increased mortality. It remains unclear whether staged revascularization of a noninfarct‐related artery CTO in patients with ST‐segment–elevation myocardial infarction translates to improved outcomes. We performed a meta‐analysis to compare outcomes between patients presenting with ST‐segment–elevation myocardial infarction with concurrent CTO who underwent percutaneous coronary intervention of noninfarct‐related artery CTO versus those who did not. Method and Results We conducted an electronic database search of all published data. The primary end point was major adverse cardiovascular events. Secondary end points were all‐cause mortality, cardiovascular mortality, myocardial infarction, repeat revascularization with either percutaneous coronary intervention or coronary artery bypass grafting, stroke, and heart failure readmission. Odds ratios ( ORs ) and 95% confidence intervals ( CIs ) were computed. Random effects model was used and heterogeneity was considered if I 2 >25. Six studies (n=1253 patients) were included in the analysis. There was a significant difference in major adverse cardiovascular events ( OR , 0.54; 95% CI , 0.32–0.91), cardiovascular mortality ( OR , 0.43; 95% CI , 0.20–0.95), and heart failure readmissions ( OR , 0.57; 95% CI , 0.36–0.89), favoring the patients in the CTO percutaneous coronary intervention group. No significant differences were observed between the 2 groups for all‐cause mortality ( OR , 0.47; 95% CI , 0.22–1.00), myocardial infarction ( OR , 0.78; 95% CI , 0.41–1.46), repeat revascularization ( OR , 1.13; 95% CI , 0.56–2.27), and stroke ( OR , 0.51; 95% CI , 0.20–1.33). Conclusions In this meta‐analysis, CTO percutaneous coronary intervention of the noninfarct‐related artery in patients presenting with ST‐segment–elevation myocardial infarction was associated with a significant reduction in major adverse cardiovascular events, cardiovascular mortality, and heart failure readmissions.

Background— A significant proportion of patients requiring aortic valve replacement (AVR) have undergone prior coronary artery bypass grafting (CABG). Reoperative heart surgery is associated with increased risk. Data on relative utilization and comparative outcomes of transcatheter (TAVR) versus surgical AVR (SAVR) in patients with prior CABG are limited. Methods and Results— We queried the 2012 to 2014 National Inpatient Sample databases to identify isolated AVR hospitalizations in adults with prior CABG. In-hospital outcomes of TAVR versus SAVR were compared using propensity-matched analysis. Of 147 395 AVRs, 15 055 (10.2%) were in patients with prior CABG. The number of TAVRs in patients with prior CABG increased from 1615 in 2012 to 4400 in 2014, whereas the number of SAVRs decreased from 2285 to 1895 ( P trend <0.001). There were 3880 records in each group in the matched cohort. Compared with SAVR, TAVR was associated with similar in-hospital mortality (2.3% versus 2.4%; P =0.71) but lower incidence of myocardial infarction (1.5% versus 3.4%; P <0.001), stroke (1.4% versus 2.7%; P <0.001), bleeding complications (10.6% versus 24.6%; P <0.001), and acute kidney injury (16.2% versus 19.3%; P <0.001). Requirement for prior permanent pacemaker was higher in the TAVR cohort, whereas the incidence of vascular complications and acute kidney injury requiring dialysis was similar in the 2 groups. Average length of stay was shorter in patients undergoing TAVR. Conclusions— TAVR is being increasingly used as the preferred modality of AVR in patients with prior CABG. Compared with SAVR, TAVR is associated with similar in-hospital mortality but lower rates of in-hospital complications in this important subset of patients.