Deshmukh, Abhishek

Introduction: Short-term use of Mechanical Circulatory Support (MCS) has the potential to benefit the patients undergoing Transcatheter Aortic Valve Replacement (TAVR) who may be high-risk or suffer complications. The present study was conducted to address the contemporary use of MCS in TAVR procedures. Methods: The study included a total of 1794 TAVR procedures in the years 2011-2012 from Nationwide Inpatient Sample (NIS) database. Use of MCS was identified using ICD-9-CM codes. The patients were divided based on use of MCS devices. The primary outcome of the study was in-hospital mortality and the secondary outcomes were complications, length of stay (LOS) and cost. Multi-variate simple logistic regression models were used to identify independent predictors of the outcomes. Results: Out of total 1794 TAVR procedures, 190 (10.6 %) utilized a MCS device (MCS group) and 1,604 (89.4%) did not (non-MCS group). The use of MCS devices with TAVR was associated with increase in the in-hospital mortality (14.9% vs. 3.5%, p<0.01) with same results obtained in multi-variate models. The rates of complications were significantly higher in MCS group so as the mean length of stay (11.8±0.8 vs. 8.1±0.2 days, p<0.01) and cost ($68,997±3,656 vs. $55,878±653, p=0.03). Conclusion: Use of MCS in TAVR predicts increase in-hospital mortality, complications, LOS and cost of care.

Background: Contemporary outcome data regarding effects of atherectomy in lower extremity arterial revascularization is lacking. Methods: We queried HCUP’s Nationwide Inpatient Sample (NIS) for 2012 using the appropriate primary ICD 9-CM diagnostic code for peripheral vascular disease and procedural codes 39.90 (bare metal stent - BMS), 00.55 (drug eluting stent - DES), 17.56 (peripheral artherectomy) and 39.50 for angioplasty. Only procedures performed in patients >= 18 years were included. Hierarchical mixed effects logistic regression models were generated to evaluate multivariate predictors of outcomes. Results: In total 13,206 (weighted: 66,030) lower extremity arterial revascularization were analyzed (65.5% white, 56.2% Male & 97.4% angioplasty). Atherectomy utilization (23.2%) was associated with significant reduction in amputation (11.5% vs 13.4%), any complications (13.2% vs 16.3%) and in hospital morality (0.8% vs 1.4%) compared to no atherectomy group (p < 0.001). Multivariate analysis showed similar results with decrease amputation (OR, 95% CI; p - value) (0.83, 0.71 - 0.97, p = 0.02) and in hospital mortality/any complication (0.79, 0.69 - 0.90, p = 0.001) with atherectomy (similar results were observed with propensity score matching). “Atherectomy only” was utilized only in 2.3%. post-hoc analysis also shows better outcomes when atherectomy was used with either angioplasty or stenting (figure a & b). subgroup multivariate analysis shows significant reduction in amputation when atherectomy was utilized in chronic limb ischemia (0.74, 0.59 - 0.93, p = 0.01) and with angioplasty (0.72, 0.60 - 0.87, p = 0.001) and trend towards advantage while used along with stents but not reaching statistical significant. Conclusion: Lower extremity atherectomy utilization was associated with significant reduction in amputation and overall complication. We observed better outcomes when atherectomy was used in conjunction with angioplasty.

Introduction: The availability, national scope and perceived unbiased nature of administrative claims data makes it an attractive choice by health care policy makers for evaluating quality and outcomes. We calculated Ventricular tachycardia (VT) ablation complication rates from national administrative data and compared them with data from randomized trials and prospective studies. Methods: A PUBMED database search was done to identify existing studies of VT ablation. Studies were divided into clinical (randomized controlled trials (RCTs) and prospective studies). Pooled rates of vascular, cardiac, neurological complications and procedure related mortality were computed and compared to reported complication rates from administrative database studies Results: We identified two administrative database studies of VT ablation that included a total of 14,352 procedures and 18 clinical studies with a total of 1,705 procedure. Overall complication rate in administrative studies was higher than in clinical studies (9.39% vs. 7.97%). Rates of cardiac/pericardial (4.47% vs. 2.29%) and vascular access complications (6.9% vs. 3.0%) were higher in real world studies. Neurological complications (1.17% vs. 0.45%) and procedure related mortality (1.53% vs. 1.29%) were higher in clinical studies. Among clinical studies, RCTs had the lowest reported complication rate. Conclusion: Despite substantial improvement, “real-world” complication rates from administrative data remain higher than those reported in RCTs. The discrepancy may be attributable to differences in operator skills, selection bias and variation in data quality. Use of large databases provides an important analytical resource as we embark on improving national health care efficacy and safety in the current challenging environment.

Introduction: With the technical advancements and expanding indications, utilization of TAVR is on the rise among various institutions in the United States .While appropriate patient selection and better techniques are essential to improving outcomes, the impact of institutional design (or hospital setting) on outcomes with TAVR has yet to be examined. Objective: The objective of our study is to compare TAVR complication rates among teaching vs non-teaching centers in the United States Methods: We used Healthcare Cost and Utilization Project - National Inpatient Sample (NIS) data , the largest all payer database of hospital inpatient stay available in United States, to identify patients (age ≥18 years) who underwent TAVR from Jan-Dec 2012. We constructed multivariable models to determine independent predictors (age, sex, race, Charlson’s comorbidity index, hospital size, hospital location and TAVR approach) of TAVR-associated complications. Statistical analysis was performed using Stata IC 11.0 (Stata-Corp, College Station, TX). Results: We identified 7,405 TAVR procedures performed in the United States in 2012. 88% of TAVR were performed in teaching centers. There was no difference in mortality following TAVR between teaching and non-teaching centers. The occurrence of any in-hospital complication was lower in teaching centers as compared to non-teaching centers (42% vs. 50%, p<0.001). Rates of individual complications in teaching vs. non-teaching centers are illustrated in the figure. In adjusted analysis, hemorrhage requiring transfusion (13.2% vs. 20.8%, p<0.001), renal complications requiring dialysis (1.2% vs. 2.3%, p=0.009), respiratory complications (7.5% vs. 11%, p<0.001) and complications requiring open-heart surgery (2% vs. 4.6%, p<0.001) were lower in teaching centers as compared to non-teaching centers. Vascular access site complications, pacemaker insertion, pericardial and neurological complications were similar between teaching and non-teaching centers (Figure). Conclusion: Institutional design impacts TAVR complication rates albeit no difference in mortality. In general, complication rates are lower in teaching centers compared to non-teaching centers.

Introduction: As the US population ages and indications for cardiac device implantation expand, there is a concomitant increase in patients undergoing lead removal/extraction (LR/E).. We sought to examine trends in outcomes and complications associated with LR/E. Methods: We conducted a retrospective analysis using data from a large U.S. commercial insurance database (privately insured and Medicare Advantage patients) identifying all patients undergoing LR/E between 2004 and 2013 with at least one year continuous medical plan enrollment prior to LR/E (to identify baseline comorbidities). Using ICD9 codes and CPT codes, major complications (hemorrhage requiring transfusion, vascular injury, pericardial complications, respiratory complications, cerebrovascular complications, and requirement for cardiac surgery) associated with LR/E and 30-day readmission rates were evaluated. Results: Among 42,878 patients who underwent LR/E (median age of 62 ( 54, 72) years, 70% male); approximately 1 in 40 experienced a major adverse event (2.4%) during the study period. Respiratory complications were the most common complication and 311 patients required cardiac surgery. 30-day readmission occurred in 11.1% of the total population. The most common reasons for readmission were heart failure exacerbation (18.7%) and device related complications (13.2%). Conclusion: The observed complication rates after LE/R in clinical practice are similar to those seen in recent clinical trials and have been relatively stable over the past 10 years.

Introduction: Right ventricular apical (RVA) pacing appears to have detrimental effects on cardiac function and long term outcomes. Right ventricular non-apical (RVNA) pacing, especially in the septal position, has been postulated as an alternative that may lead to less morbidity and mortality. Prior studies have shown conflicting results and been limited by small numbers and short follow-up. We aimed to determine if right ventricular septal lead position was associated with a reduction in long-term mortality compared to RVA lead position. Methods: Patients who underwent dual-chamber pacemaker implantation from 2004 through 2013 were evaluated for right ventricular lead position based on chest radiographs. Lead positions were divided in to apical or non-apical. Non-apical lead positions were subdivided to isolate a septal lead position group. Mortality was compared between these groups. Results: During the study period, 3456 patients underwent dual-chamber pacemaker placement and had images appropriate for lead position evaluation. The group was 53.5% male with a mean age of 74 ± 13 years. RVNA lead position was found in 976 (28.2%) patients, including 243 (7.0%) with a septal position. There was no significant difference in age or prior heart failure diagnosis between groups. Kaplan-Meier survival analysis did not reveal a significant difference in mortality between patients with RVA versus RVNA lead position during 5 year follow-up (p = 0.82). However, septal lead position was associated with a significantly lower mortality compared with RVA position (p = 0.03) (figure). Conclusions: Right ventricular septal lead position is associated with a lower long-term mortality than RVA lead position. This has substantial implications regarding the preferred site for ventricular pacing lead placement.

Introduction: Risk stratification of the pregnant population is critical to improving outcomes associated with pregnancy-related Acute myocardial infarction (AMI). Methods: Pregnancy-related hospitalizations (antepartum as well as postpartum) and AMI were identified using appropriate International classification of disease-Ninth revision (ICD-9) codes from nationwide inpatient sample database (2005-2014). Simple logistic regression was used to calculate predictors of AMI during pregnancy. Results: We identified 3,786 cases of AMI from a total of 43,437,621 pregnancy related hospitalization during study period. Compared to pregnant women <20-year, we noted more than 10-fold risk of AMI among patients ≥ 40 years (OR 10.1, 95% CI 5.3-19.0, p<0.001). Other significant predictors of AMI during pregnancy were black race compared to white ( OR 1.6, 95% CI 1.3-1.9, p<0.001), co-existing comorbidities such as hypertension (OR 1.9, 95% CI 1.5-2.5, p<0.001),, thrombophilia (OR 4.8, 95% CI 2.7-8.5, p<0.001), diabetes milletus (OR 1.4, 95% CI 1.0-1.9, p<0.027),hyperlipidemia (OR 13.2, 95% CI 9.9-17.6, p<0.001),smoking (OR 3.3, 95% CI 2.3-4.6, p<0.001), substance abuse (OR 1.7, 95% CI 1.2-2.6, p=0.007), congestive heart failure (OR 26.0, 95% CI 20.3-33.2 p<0.001), deep venous thrombosis (OR 2.8, 95% CI 1.3-6.2, p=0.010) as well as obstetric condition including postpartum hemorrhage (OR 1.8, 95% CI 1.3-2.4, p<0.001),, transfusion during pregnancy (OR 3.2, 95% CI 2.4-4.2, p<0.001), postpartum infection (OR 2,7, 95% CI 1.9-3.9, p<0.001),, fluid and electrolyte imbalance (OR 5.2, 95% CI 4.2- 6.6, p<0.001), and postpartum depression (OR 1.4, 95% CI 1.1-1.9 p=0.013). Conclusions: We identified certain patient-level characteristics which correlated to high risk of AMI. This information can be utilized to decide resource allocation and the introduction of early multidisciplinary intervention among high-risk population

Introduction: Acute myocardial infarction (AMI) during pregnancy is a rare but fatal complication. Recent trends in incidence of pregnancy-related AMI and associated outcomes are unclear. Methods: Nationwide inpatient sample (NIS) database was utilized for years 2005-2014. International classification of disease-Ninth revision (ICD-9) was used to identify pregnancy-related (antepartum as well as postpartum) admissions and acute myocardial infarction (AMI). The primary outcome was incidence and trend of AMI related to pregnancy during the study period. Secondary outcomes were trends in mortality and resource utilization. P-values for trends were generated by Cochrane-Armitage test for categorical variables and simple linear regression for continuous variables. Results: We identified a total of 43,437,621 pregnancy-related hospitalization and 3,786 cases of AMI (86% antepartum and 14% post-partum) were noted during the study period. The incidence of AMI during the study period was 8.7 per 100,000 pregnancies with an overall increase in incidence during study period (relative increase of 18.9%, p <0.001) and concomitant decrease in mortality (relative decrease of 40.05%, p <0.001), cost of care (relative decrease of 8.70%, p<0.001) and length of stay (relative decrease of 13.53%, p<0.001). Conclusions: Incidence of AMI during the period is on the rise in recent years with concomitant improvement in mortality and resource utilization. This reflects improved diagnostic capability and a better understanding of non-atherosclerotic mechanisms of AMI during pregnancy such as spontaneous coronary artery dissection, coronary spasm, and coronary thrombus.

Introduction: Recent trials have suggested potential benefits of performing multivessel percutaneous coronary intervention (MVPCI) on non-infarct related artery (non-IRA) in ST-segment elevation myocardial infarction (STEMI) patients with multivessel disease. Methods: National Readmissions Database (NRD) 2010-14 was utilized to select study cohort. Appropriate International Classification of Diseases, 9th Revision (ICD-9-CM) diagnostic and procedural codes were utilized to identify STEMI patients undergoing multivessel PCI and infarct-related artery only PCI (IRA-PCI). Propensity score matched cohorts using greedy matching algorithm were generated for comparison of outcomes. Results: We identified 116592 IRA-PCI (83.97%) and 22257 MVPCI (16.03%) cases. With 1:3 propensity matched cohorts accounting for confounders such as age, gender, race and comorbidities, in comparison to IRA-PCI, MVPCI patients have higher 30-day readmission rate (10.40% vs 9.40%, p=0.001), in-hospital mortality (1.96% vs 1.57%,p<0.001), mechanical circulatory support utilization (4.27 vs 2.44%,p<0.001) as well as higher complication including vascular (0.51% vs 0.28%, p<0.001), cardiac (5.97% vs 3.97%, p<0.001), respiratory (4.89% vs 4.02%,p<0.001), neurologic complications (0.77% vs 0.58%,p=0.003), major bleeding (1.01% vs 0.79%, p=0.002) and cardiac arrest(3.48% vs 3.17%, p=0.027). We also noted higher cost of care ($27100 vs $20900, p<0.001) and length of stay (3.8 days vs 3.4 days, p<0.001) in MVPCI group compared to IRA-PCI group. Conclusions: We noted higher 30- day readmission rate, in-hospital mortality, complications and resource utilization with MVPCI compared to IRA-PCI approach among STEMI patients which further demands large-scale randomized control trials to determine the utility of MVPCI in the “real world”.

Background: Data regarding ventricular tachycardia (VT) or premature ventricular complex (PVC) ablation following MVS is limited.) CA can be challenging given perivalvular substrate in the setting of mitral annuloplasty or prosthetic valves. Objective: To investigate the characteristics, safety, and outcomes of radiofrequency catheter ablation (CA) in patients with prior mitral valve surgery (MVS) and ventricular arrhythmias (VA). Methods: We identified consecutive patients with prior MVS who underwent CA for VT or PVC between January 2013- December 2018. We investigated the mechanism of arrhythmia, ablation approach, peri-operative complications, and outcomes. Results: In our cohort of 31 patients (77% men, mean age 62.3±10.8 years, left ventricular ejection fraction 39.2±13.9%) with prior MVS underwent CA (16 VT; 15 PVC). Access to the left ventricle was via transseptal approach in 17 patients, and a retrograde aortic approach was used in 13 patients. A combined transseptal and retrograde aortic approach was used in one patient, and a percutaneous epicardial approach was combined with trans-septal approach in 1patient. Heterogenous scar regions were present in 94% of VT patients and scar-related reentry was the dominant mechanism of VT. Clinical VA substrates involved the peri-mitral area in 6 patients with VT and 5 patients with PVC ablation. No procedure-related complications were reported. The overall recurrence-free rate at 1-year was 72.2%; 67% in the VT group and 78% in the PVC group. No arrhythmia-related death was documented on long-term follow-up. Conclusion: CA of VAs can be performed safely and effectively in patients with MVS