Akintoye, Emmanuel

Background: We sought to investigate temporal trends in patient characteristics, waitlist, and posttransplant outcomes after heart transplantation in the United States. Methods: Using data from the United Network of Organ Sharing, we identified adults listed for heart transplantation between 1991 and 2019. Patients were divided into 4 eras based on the 3 time points in which changes were made to the patient selection/allocation policy (Era 1=January 1991–January 1999; Era 2=January 1999–July 2006; Era 3=July 2006–October 2018; and Era 4=October 2018–March 2020), and patient characteristics, waitlist, and posttransplant outcomes were evaluated for each era. Results: Between 1991 and 2019, 95 179 patients were added to the heart transplantation waitlist. Compared with Era 1, patients listed in Era 4 were older (mean age: 50 versus 52 years) and with higher risk comorbidities (eg, 10% versus 28.8% diabetes, 23.3% versus 35.6% obese). Over the study period, 22 738 patients died or were permanently delisted for deterioration on the waitlist while 61 687 were transplanted. Compared with the preceding era, there was significant decrease in death or deterioration in the last 2 eras (sub-hazard ratio, 0.67 [95% CI, 0.65–0.70] for Era 3 versus Era 2 and sub-hazard ratio, 0.65 [95% CI, 0.58–0.73] for Era 4 versus 3). Across the years, 27.1% to 40.5% of those on the waitlist were transplanted. Among those transplanted, there was increase in the rates of in-hospital stroke (2.8% in Era 1 to 3.7% in Era 4), renal failure requiring dialysis (7.2%–17.1%), and length-of-stay (14–17days), P <0.001. However, this did not negatively impact short-term survival when compared with the preceding era (1-year graft survival from Era 1 to Era 4=84.1%, 86.4%, 90.4%, and 89.7%, respectively). Conclusions: There have been significant changes in the characteristics of patients listed for heart transplantation. Although transplant volume has increased, the wide supply-demand gap persisted. The last two changes in the allocation policy achieved their primary objective of reducing waitlist mortality.

Abstract Background The landscape of heart transplantation (HT) has changed significantly with respect to patient selection, surgical techniques, and patient outcomes. We sought to investigate temporal trends in patient characteristics, waitlist and post-transplant outcomes after HT in the U.S. Methods We queried the national database of the United Network of Organ Sharing (UNOS) to identify adults listed for HT in the U.S. between 1991 and 2019. Patients were divided into four eras based on the three time points in which changes were made to the patient selection/allocation policy (1999, 2006, and 2018), and patient characteristics as well as waitlist and post-transplant outcomes were evaluated for each era. Results Between 1991 and 2019, a total of 95,179 patients were added to the waitlist for HT in the U.S. Compared to era 1, patients listed in era 4 were older (mean age: 52.4 years), more female (27.6%) and ethnic minorities (40%), and with higher-risk comorbidities (28.8% diabetes, 35.6% obese). Over the study period, there were 22,070 waitlist deaths and 61,687 transplants. Compared to the preceding era, there was significant decrease in waitlist mortality in the last 2 eras (e.g., sub-hazard ratio for era 4 vs era 3 =0.37, 95% CI=0.32–0.44). For each year, only 27.1% to 40.5% of those on the waitlist were transplanted. Among those who were transplanted, there was increase in the rates of in-hospital stroke (2.8% in era 1 to 3.7% in era 4), renal failure requiring dialysis (7.2% to 17.1%), and hospital length of stay (14 to 17 days), p-values&lt;0.001 for all. However, this has not negatively impacted short-term survival when compared to the preceding era (1-year graft survival = 89.7% in era 4). Based on a projection model, we predict a 47% increase in living adult heart transplant recipients to to 44,366 in 2040. Conclusion There have been significant changes in the characteristics of patients listed for HT in the U.S., including an increasing proportion of high-risk co-morbidities. Although the transplant volume has increased, the wide supply-demand gap persisted. The last 2 changes in the allocation policy in 2006 and 2018 achieved their primary objective of reducing waitlist mortality. Funding Acknowledgement Type of funding sources: None.

Background: Prior studies have shown that hospital case volume is not associated with survival in patients with out-of-hospital cardiac arrest (OHCA). However, how case volume impact on survival for in-hospital cardiac arrest (IHCA) is unknown Methods: We queried the National Inpatient Sample (NIS) in the U.S. 2005-2011 to identify cases in which in-hospital CPR was performed for IHCA. Years > 2011 were excluded due to redesign of NIS that precludes case volume calculation. Restricted cubic spine was used to evaluate the association between hospital annual CPR volume and survival to hospital discharge. Further analysis was conducted with case volume in quartiles. Results: Across more than 1000 hospitals in NIS, we identified 137,466 cases (mean age 67, 45% female) of IHCA for which CPR was performed over the study period. Median [Q1, Q3] case volume was 68 [34, 100]. Compared to those in the 1 st quartile (q1) of case volume, hospitals in the 4 th quartile (q4) tends to have younger patients (mean=66 vs 68 yrs), higher comorbidities (median Elixhauser score=4 vs 3), large bed size (89 vs 37%), and in low income areas (37 vs 32%). After adjustment for patient and hospital factors, higher hospital case volume was inversely associated with lower rates of survival (Fig1). Risk-adjusted rates of survival from q1 through q4 were: 28.1%, 25.5%, 25.4% and 23.7%. We arrived at similar results when analysis was stratified by age, gender and hospital bed size (not shown) except that the difference across quartiles was more pronounced among small bed size hospitals (survival rate=27.4% in q1 vs 8.1% in q4). However, among those who survived to hospital discharge, nonroutine home discharge was higher among patients in q1 (73.9%) vs q4 (69.6%) Conclusion: Unlike OHCA, hospital case volume is inversely associated with survival to hospital discharge in patients undergoing CPR for IHCA. Hence, quality measures to reduce the incidence of CPR/IHCA have the potential to reduce in-hospital mortality

Contrast-induced nephropathy (CIN) is a type of acute kidney injury associated with intravascular administration of iodinated contrast, usually reversible. Contrast agents are an essential component of invasive and noninvasive coronary angiography. These agents have been modified over time to enhance patient safety and tolerability, but adverse reactions still occur. CIN has been variably defined, as a rise in serum creatinine of 0.5 mg/dl, or a 25% increase in serum creatinine above baseline within 24-72 hours after the procedure. The incidence of CIN varies based on the definition used and risk profile of the patients. CIN is rare among patients with normal renal function at baseline. In low-risk patients, CIN occurs in 1-5%, whereas in higher-risk populations, the incidence can be as high as 30%. CIN is also associated with a 5- to 20-fold increased risk of other early adverse events including in-hospital myocardial infarction, target vessel occlusion, and early mortality. The main prevention strategies are adequate intravenous hydration before, during and after the procedure as well as restriction of contrast load with maximum volume approximately no more than three times the serum creatinine clearance. Recent observational and small prospective randomized trials demonstrate the reduction of CIN incidence with HMG-CoA enzyme inhibitors. In this systematic review and meta-analysis we explore the effects of statin administration in prevention of CIN.

Background National prevalence and outcomes of Fontan operation in the USA is unknown. Study objective was to determine trends (temporal change) in the annual volume of Fontan operations, in-hospital mortality, postoperative complications and type of hospital discharge. Methods Review of the Nationwide Inpatient Sample for patients that underwent Fontan operation from 2001 to 2014 using the International Classification of Diseases-Ninth Revision, Clinical Modification procedure code for Fontan operation, that is, 35.94. To evaluate for change in patients’ demographics over the years, we divided the patient population into four groups based on procedure year (2001–2004, 2005–2008, 2009–2011 and 2012–2014). Results An estimated 15 934 Fontan operations were performed in the USA from 2001 to 2014. Median (Q1–Q3) age was 3 (2–4) years and 39.8% were female. Hypoplastic left heart syndrome was the most common (29%) congenital heart disease diagnosis. An estimated 1175 procedures were performed in 2001 and 1340 in 2014, but there was no significant change in the number of procedures per year (p=0.47). There was significant decline in in-hospital mortality from 4.5% (53/1175) in 2001 to 1.1% (15/1340) in 2014 (p=0.009). When we compared event rates between 2001–2004 and 2012–2014 periods, there was significant decline in postoperative cardiac complications (12.6% (459/3640) to 8% (378/4706), p=0.007) and respiratory complications (17.1% (623/3640) to 10.2% (481/4706), p<0.001). However, there was increase in the number of patients discharged to home with healthcare assistance or transferred to another acute care facility (5.8% (211/3640) to 9.4% (443/4706), p=0.01) and inflation-adjusted hospitalisation cost (US$46 978 to US$60 383, p<0.001), but no significant change in length of stay (p=0.73). Conclusion On the average, 1062 Fontan operations are performed annually in the USA with no change in volume of procedures but a decrease in in-hospital mortality and postoperative complications over a 15-year period.

Background Evidence exists for racial/ethnic differences in left ventricular mass index (LVMI). How this translates to future cardiovascular disease (CVD) events is unknown. Hypothesis The impact of racial/ethnic differences in LVMI on incident cardiovascular outcomes could have potential implications for the optimization of risk stratification strategies. Methods Using the prospectively collected database of the Multi‐Ethnic Study of Atherosclerosis (MESA) involving 4 racial/ethnic groups (non‐Hispanic Whites, Chinese, Blacks, and Hispanics) free of CVD at baseline, we assessed for racial/ethnic differences in the relationship between LVMI and incident CVD using a Cox model. Results 5004 participants (mean age, 62 ± 10 years; 48% male) were included in this study. After an average follow‐up of 10.2 years, 369 (7.4%) CVD events occurred. Significant racial/ethnic differences existed in the relationship between LVMI and incident CVD ( P for interaction = 0.04). Notably, the relationship was strongest for Chinese (HR per 10‐unit increase in LVMI: 1.7, 95% CI: 1.1–2.8) and Hispanics (HR per 10‐unit increase in LVMI: 1.9, 95% CI: 1.5–2.2). Non‐Hispanic Whites demonstrated the lowest relationship (HR: 1.3, 95% CI: 1.1–1.5). LVMI values of 36.9 g/m 2.7 , 31.8 g/m 2.7 , 39.9 g/m 2.7 , and 41.7 g/m 2.7 were identified as optimal cutpoints for defining left ventricular hypertrophy (LVH) for non‐Hispanic Whites, Chinese, Blacks, and Hispanics, respectively. In secondary analysis of LVH (vs no LVH) using these optimal cutpoints, we found a similar pattern of association as above ( P for interaction = 0.04). For example, compared with those without LVH, Chinese with LVH had HR: 5.3, 95% CI: 1.6–17, whereas non‐Hispanic Whites with LVH had HR: 1.6, 95% CI: 1.2–2.1 for CVD events. Conclusions Among 4 races/ethnicities studied, LVMI has more prognostic utility predicting future CVD events for Chinese and Hispanics and is least significant for non‐Hispanic Whites.

Background To investigate heart failure ( HF ) hospitalization trends in the United States and change in trends after publication of management guidelines. Methods and Results Using data from the National Inpatient Sample and the US Census Bureau, annual national estimates in HF admissions and in‐hospital mortality were estimated for years 2001 to 2014, during which an estimated 57.4 million HF ‐associated admissions occurred. Rates (95% confidence intervals) of admissions and in‐hospital mortality among primary HF hospitalizations declined by an average annual rate of 3% (2.5%–3.5%) and 3.5% (2.9%–4.0%), respectively. Compared with 2001 to 2005, the average annual rate of decline in primary HF admissions was more in 2006 to 2009 (ie, 3.4% versus 1.1%; P =0.02). In 2010 to 2014, primary HF admission continued to decline by an average annual rate of 4.3% (95% confidence interval, 3.9%–5.1%), but this was not significantly different from 2006 to 2009 ( P =0.14). In contrast, there was no further decline in in‐hospital mortality trend after the guideline‐release years. For hospitalizations with HF as the secondary diagnosis, there was an upward trend in admissions in 2001 to 2005. However, the trend began to decline in 2006 to 2009, with an average annual rate of 2.4% (95% confidence interval, 0.8%–4%). Meanwhile, there was a consistent decline in in‐hospital mortality by an average annual rate of 3.7% (95% confidence interval, 3.3%–4.2%) during the study period, but the decline was more in 2006 to 2009 compared with 2001 to 2005 (ie, 5.4% versus 3.4%; P <0.001). Beyond 2009, admission and in‐hospital mortality rates continued to decline, although this was not significantly better than the preceding interval. Conclusions From 2001 to 2014, HF admission and in‐hospital mortality rates declined significantly in the United States; the greatest improvements coincided with the publication of the 2005 American College of Cardiology/American Heart Association HF guidelines.

AbstractObjectivesTo assess the in‐hospital mortality and complications in female between transcatheter aortic valve replacement (TAVR) and surgical aortic valve replacement (SAVR).BackgroundFemale is one of the risk factors for increased adverse events in cardiac surgery.Methods and resultsNationwide Inpatient Sample database was queried from 2011 to 2014 for patients who underwent TAVR or SAVR in female patients. The primary endpoint was in‐hospital all‐cause mortality and second endpoints were perioperative complications. We performed a propensity score analysis to calculate the adjusted odds ratio (OR) for each outcome. Patients who had concomitant cardiac surgery and those who had TAVR or SAVR mainly for aortic regurgitation were excluded. Our query from 2011 to 2014 resulted in a total of 3,067 TAVR and 18,594 SAVR in female patients. TAVR patients were in general elder and had a higher burden of comorbidities. The primary endpoint was similar between TAVR and SAVR (4.2% vs. 3.9%, OR 1.0, P = 0.89). Compared to SAVR, female TAVR patients had less hemorrhage requiring transfusion (12% vs. 21%, OR 0.41, P < 0.001), perioperative cardiac arrest and nonfatal myocardial infarction (9.8% vs. 17%, OR 0.38, P < 0.001), respiratory complication (1.6% vs. 4.4%, OR 0.28, P < 0.001), post‐op sepsis (1.7% vs. 2.9%, OR 0.65, P = 0.03), acute myocardial infarction (3.0% vs. 4.9%, OR 0.60, P < 0.001), and acute kidney injury (15% vs. 18%, OR 0.62, P < 0.001). Conversely, female TAVR patients had significantly increased risk of new pacemaker implantation (11% vs. 5.9%, OR 1.7, P < 0.001) and use of extracorporeal membrane oxygenation (0.66% vs. 0.24%, OR 2.8, P < 0.001). TAVR patients had less nonroutine discharge. The median hospital cost was significantly higher in TAVR than SAVR (median $51,274 vs. $43,677, P < 0.001) but the length of stay was shorter (mean 7.8 days vs. 10.5 days).ConclusionsTAVR may be a better option for those patients with underlying comorbidities that predispose them at higher risk for complications that was less observed in TAVR group. However, higher cost and increased risk of need for extracorporeal membrane oxygenation, although rare, should be taken into consideration upon deciding the optimal mode for aortic valve replacement.

BackgroundThere is lack of evidence of the impact of varying season on heart failure (HF) hospitalization outcomes in the U.S.HypothesisHF hospitalization outcomes exhibit significant seasonal variation in the U.S.MethodsUsing data from the National Inpatient Sample (2011‐2013), seasonal variation was classified based on meteorological classification of Northern Hemisphere–Spring, Summer, Fall, & Winter–and analysis was conducted via multivariable‐adjusted mixed‐effect model.ResultsAn estimated 2.8 million adults were hospitalized for HF in the U.S. from 2011 to 2013. Of all hospitalizations, admissions were highest in Winter (27%), followed by Spring (26%), Fall (24%), and Summer (23%). The overall mortality rate was 3.1%. Compared with Spring, there was significantly lower mortality in Summer (odds ratio [OR]: 0.95, 95% CI: 0.91‐0.99) and Fall (OR: 0.94, 95% CI: 0.89‐0.98), but the highest mortality was in Winter (OR: 1.06, 95% CI: 1.02‐1.11). In addition, mean length of stay and median cost of hospitalization were highest in Winter (5.3 days, USD7459, respectively) and lowest in Summer (5.1 days, USD7181, respectively). However, age and sex differences existed (e.g. seasonal variation in inpatient mortality was only significant for patients age ≥65 years, and, comparedwith the Spring season, males had higher risk of inpatient mortality in Winter (OR: 1.10, 95% CI: 1.04‐1.17) and females had lower risk of inpatient mortality in Summer (OR: 0.94, 95% CI: 0.88‐1.00) and Fall (OR: 0.92, 95% CI: 0.87‐0.98).ConclusionsAmong HF patients in the U.S., hospitalization outcomes were worse in Winter but better in Summer.