The Mortality Burden of Untreated Aortic Stenosis

BACKGROUND

The American College of Cardiology/American Heart Association guidelines recommend the assessment and grading of severity of aortic stenosis (AS) as mild, moderate, or severe, per echocardiogram, and recommend aortic valve replacement (AVR) when the AS is severe.

OBJECTIVES

The authors sought to describe mortality rates across the entire spectrum of untreated AS from a contemporary, large, real-world database.

METHODS

We analyzed a deidentified real-world data set including 1,669,536 echocardiographic reports (1,085,850 patients) from 24 U.S. hospitals (egnite Database, egnite). Patients >18 years of age were classified by diagnosed AS severity. Untreated mortality and treatment rates were examined with Kaplan-Meier (KM) estimates, with results compared using the log-rank test. Multivariate hazards analysis was performed to assess associations with all-cause mortality.

RESULTS

Among 595,120 patients with available AS severity assessment, the KM-estimated 4-year unadjusted, untreated, all-cause mortality associated with AS diagnosis of none, mild, mild-to-moderate, moderate, moderate-to-severe, or severe was 13.5% (95% CI: 13.3%-13.7%), 25.0% (95% CI: 23.8%-26.1%), 29.7% (95% CI: 26.8%-32.5%), 33.5% (95% CI: 31.0%-35.8%), 45.7% (95% CI: 37.4%-52.8%), and 44.9% (95% CI: 39.9%-49.6%), respectively. Results were similar when adjusted for informative censoring caused by treatment. KM-estimated 4-year observed treatment rates were 0.2% (95% CI: 0.2%-0.2%), 1.0% (95% CI: 0.7%-1.3%), 4.2% (95% CI: 2.0%-6.3%), 11.4% (95% CI: 9.5%-13.3%), 36.7% (95% CI: 31.8%-41.2%), and 60.7% (95% CI: 58.0%-63.3%), respectively. After adjustment, all degrees of AS severity were associated with increased mortality.

CONCLUSIONS

Patients with AS have high mortality risk across all levels of untreated AS severity. Aortic valve replacement rates remain low for patients with severe AS, suggesting that more research is needed to understand barriers to diagnosis and appropriate approach and timing for aortic valve replacement.

The impact of catheter ablation in patient's heart failure and atrial fibrillation: a meta-analysis of randomized clinical trials

BACKGROUND

Recent trial data suggest a benefit to catheter ablation (CA) compared to medical therapy for atrial fibrillation (AF) in patients with heart failure (HF). Nevertheless, because of mixed trial evidence, contemporary guidelines give it a class 2 recommendation. Accordingly, we sought to assess the currently available evidence for CA in HF with AF.

METHODS

Electronic databases were searched to identify randomized clinical trials (RCTs) comparing CA to medical therapy in patients with AF and HF. Study data was pooled using fixed and random effects, and the number needed to treat (NNT) was calculated to gauge absolute risk differences. Heterogeneity was quantified using I2. Our primary outcome was all-cause mortality.

RESULTS

Nine trials (CA 1075 patients; medical therapy 1083 patients) were included. Ablation reduced the relative risk of all-cause mortality by 31.5% (95% CI 13.7 to 45.6%; NNT = 23), cardiovascular mortality by 39.3% (95% CI 10.9 to 58.7%; NNT = 31), cardiovascular hospitalization by 29.1% (95% CI 9.4 to 44.6%; NNT = 9), and heart failure hospitalization by 28.5% (95% CI 6.5 to 45.4%; NNT = 22). Improvements in quality of life were observed with CA using the Minnesota Living with Heart Failure Questionnaire (mean difference - 5.26; 95% CI - 2.73 to - 7.78) and the Atrial Fibrillation Effect on Quality of Life (mean difference 5.36; 95% CI 2.72 to 8.00).

CONCLUSION

Compared to medical therapy, CA for AF in patients with HF reduces all-cause mortality, cardiovascular mortality, cardiovascular hospitalizations, and heart failure hospitalizations, and may improve quality of life.

Tissue plasminogen activator for axillary Impella 5.0 with heparin-induced thrombocytopenia as a treatment of choice for acute Impella thrombosis: a case report

Background

Patients with cardiogenic shock requiring temporary support with percutaneous ventricular assist device, such as Impella (Abiomed, Inc.), can develop heparin-induced thrombocytopenia (HIT) which requires use of alternative purge solution anticoagulation. There are limited recommendations on use of anticoagulation other than standard Unfractionated Heparin in 5% dextrose solution.

Case summary

This case describes 69-year-old female who presented with symptoms of decompensated systolic heart failure and was found to be in cardiogenic shock and despite use of inotropes and vasopressors maintained low systolic blood pressure and low mixed venous oxygen saturation which lead to use of axillary Impella 5.0 (Abiomed, Inc.) who developed HIT. Purge solution anticoagulation was switched to Argatroban, but due to increased motor pressures, tissue plasminogen activator (tPA) was successfully used to maintain proper motor pressures. Ultimately, patient was transferred to an outside facility for a transplant evaluation.

Discussion

This case demonstrates successful and safe use of tPA as an alternative purge solution although more data needed to support this finding.

Abstract P556: Temporal and Global Trends of the Incidence of Sudden Cardiac Death in Hypertrophic Cardiomyopathy: A Meta-Analysis

Introduction: Since hypertrophic cardiomyopathy(HCM) initial description, sudden cardiac death (SCD) has been the most feared complication of HCM.

Hypothesis: Temporal, geographical, and age-related trends of SCD rates in HCM have drastically decreased over time.

Methods: Databases were systematically searched to Nov 2021 for studies reporting on SCD event rates in HCM. Patients with SCD equivalents (appropriate ICD shocks and non-fatal SCD) were excluded. Random-e!ects model was utilized to pool study estimates calculating the overall incidence rates(IR) for each time-era, geographical region, and age-group. We analyzed 2 eras (before vs. after 2000, following implementation of ICD in HCM). Following 2000, 5-year intervals were used to reflect the temporal change in SCD.

Results: 98 studies(N=70,510patients and 431,407patient-years) met inclusion criteria. Overall rate of HCM SCD was 0.43%/year (95% CI: 0.37-0.50%; I2=75%; SCD events:1,938; person-years of follow-up: 408,715), with young patients(<18 years) demonstrating a>2-fold-risk for SCD vs. adults(18- 60years) (IR:1.09%; 95% CI: 0.69-1.73% vs. IR: 0.43%; 95% CI: 0.37-0.50%)(P-value for subgroup di!erences:<0.01). Contemporary SCD rates from 2015-present were 0.32%/year; significantly lower compared to 2000 or earlier (IR: 0.32%; 95% CI:0.20-0.52%, vs. IR: 0.73%; 95% CI:0.53-1.02%,respectively). Reported HCM-SCD rates were lowest in North America (IR: 0.28%;95% CI:0.18-0.43%) and highest in Asia(IR: 0.67%; 95% CI:0.54-0.84%).

Conclusions: Contemporary HCM-related SCD are low (0.32%/year) representing a 2-fold decrease compared to prior treatment eras, with young HCM patients at the highest risk. SCD risk stratification maturation and primary prevention ICD application are likely responsible for the notable decline in SCD trends. Moreover, worldwide geographical disparities in SCD was evident, underscoring the need to increase access to SCD prevention for all HCM patients.

Consensus recommendations for COVID-19-related myocarditis in athletes: proof of concept-case report

Background

Post-viral myocarditis has been associated with sudden cardiac death in athletes. Since the beginning of the COVID-19 pandemic, the concern of post-viral myocarditis impacting the professional athletic community has been present.

Case summary

An elite-level basketball player presented after a positive COVID-19 test with findings consistent with ventricular tachycardia related to myocardial fibrosis/scar from a COVID-19-related myocarditis. Although rare, COVID-19 myocarditis can occur. This case illustrates how the consensus guidelines for return-to-play correctly identified the player as high risk with appropriate downstream evaluation by cardiac magnetic resonance (CMR) imaging. The stepwise approach is illustrated in this case and highlights the utility and success of the algorithm when approaching athletes with COVID-19-related myocarditis risk and determining a return to exercise.

Discussion

Diligence is required to identify competitive athletes with features suggestive of myocarditis at the initial presentation and with the return to exercise. Cardiopulmonary symptoms in the setting of recent COVID-19 infection should prompt additional testing in a stepwise fashion and often benefit from CMR in addition to the triad testing with electrocardiography, echocardiography, and cardiac troponin measurement to further investigate clinical presentations of COVID-19-related myocarditis.

Meta-Analysis of Provisional Versus Systematic Double-Stenting Strategy for Left Main Bifurcation Lesions

OBJECTIVE

We sought to compare the clinical outcomes with provisional versus double-stenting strategy for left main (LM) bifurcation percutaneous coronary intervention (PCI).

BACKGROUND

Despite two recent randomized controlled trials (RCTs) and several observational reports, the optimal LM bifurcation PCI technique remains controversial.

METHODS

PubMed, Cochrane Central Register of Controlled-Trials (CENTRAL), Clinicaltrials.gov, International Clinical Trial Registry Platform were leveraged for studies comparing PCI bifurcation techniques for LM coronary lesions using second-generation drug eluting stents (DES). The primary outcome was major adverse cardiovascular events (MACE). Secondary outcomes of interest were all-cause mortality, cardiovascular mortality, myocardial infarction (MI), target vessel or lesion revascularization, and stent thrombosis.

RESULTS

Two RCTs and 10 observational studies with 7105 patients were included. Median follow-up duration was 42 months (IQR: 25.7). Double stenting was associated with a trend towards higher incidence of MACE (odds ratio [OR] 1.20; 95 % confidence interval [CI] 0.94 to 1.53) compared with provisional stenting. This was mainly driven by higher rates of target lesion revascularization (TLR) (OR 1.50; 95 % CI 1.07 to 2.11). There were no statistically significant differences in the incidence of all-cause mortality, cardiovascular mortality, MI, or stent thrombosis. On subgroup analysis according to the study type, provisional stenting was associated with lower MACE and TLR in observational studies, but not in RCTs.

CONCLUSION

For LM bifurcation PCI using second-generation DES, a provisional stenting strategy was associated with a trend towards lower incidence of MACE driven by statistically significant lower rates of TLR, compared with systematic double stenting. These differences were primarily driven by observational studies. Further RCTs are warranted to confirm these findings.

Temporal and Global Trends of the Incidence of Sudden Cardiac Death in Hypertrophic Cardiomyopathy

BACKGROUND

Since the initial clinical description of hypertrophic cardiomyopathy (HCM) over 60 years ago, sudden cardiac death (SCD) has been the most visible and feared complication of HCM.

OBJECTIVES

This study sought to characterize the temporal, geographic, and age-related trends of reported SCD rates in adult HCM patients.

METHODS

Electronic databases were systematically searched up to November 2021 for studies reporting on SCD event rates in HCM patients. Patients with SCD equivalents (appropriate implantable cardioverter-defibrillator [ICD] shocks and nonfatal cardiac arrests) were not included. A random-effects model was used to pool study estimates calculating the overall incidence rates (IR) for each time-era, geographic region, and age group. We analyzed 2 periods (before vs after 2000, following clinical implementation of ICD in HCM). Following 2000, 5-year intervals were used to demonstrate the temporal change in SCD rates.

RESULTS

A total of 98 studies (N = 70,510 patients and 431,407 patient-years) met our inclusion criteria. The overall rate of HCM SCD was 0.43%/y (95% CI: 0.37-0.50%/y; I² = 75%; SCD events: 1,938; person-years of follow-up: 408,715), with young patients (<18 years of age) demonstrating a >2-fold-risk for sudden death vs adult patients 18-60 years of age (IR: 1.09%; 95% CI: 0.69%-1.73% vs IR: 0.43%; 95% CI: 0.37%-0.50%) (P value for subgroup differences <0.01). Contemporary SCD rates from 2015 to present were 0.32%/y and significantly lower compared with 2000 or earlier (IR: 0.32%; 95% CI: 0.20%-0.52% vs IR: 0.73%; 95% CI: 0.53%-1.02%, respectively). Reported SCD rates for HCM were lowest in North America (IR: 0.28%; 95% CI: 0.18%-0.43%,) and highest in Asia (IR: 0.67%; 95% CI: 0.54%-0.84%).

CONCLUSIONS

Contemporary HCM-related SCD rates are low (0.32%/y) representing a 2-fold decrease compared with prior treatment eras. Young HCM patients are at the highest risk. The maturation of SCD risk stratification strategies and the application of primary prevention ICD to HCM are likely responsible for the notable decline over time in SCD events. In addition, worldwide geographic disparities in SCD rates were evident, underscoring the need to increase access to SCD prevention treatment for all HCM patients.

Conduction Disturbance, Pacemaker Rates, and Hospital Length of Stay Following Transcatheter Aortic Valve Implantation with the Sapien 3 Valve

Background

In the absence of randomized data, an expert panel recently proposed an algorithm for conduction disturbance management in transcatheter aortic valve implantation (TAVI) recipients. However, external validations of its recommendations are limited.

Methods

We retrospectively identified 808 patients without a pre-existing pacing device who underwent transfemoral TAVI with the Sapien 3 valve at our institution in 2018-2019. Patients were grouped based on pre-existing conduction disturbance and immediate post-TAVI electrocardiogram. Timing of temporary pacemaker (TPM) removal and hospital discharge were compared with those of the expert panel recommendations to evaluate the associated risk of TPM reinsertion and permanent pacemaker (PPM) implantation.

Results

In most group 1 patients (no electrocardiogram changes without pre-existing right bundle branch block), the timing of TPM removal and discharge were concordant with those of the expert panel recommendations, with low TPM reinsertion (0.8%) and postdischarge PPM (0.8%) rates. In the majority of group 5 patients (procedural high-degree/complete atrioventricular block), TPM was maintained, followed by PPM implantation, compatible with the expert panel recommendations. In contrast, in groups 2-4 (pre-existing/new conduction disturbances), earlier TPM removal than recommended by the expert panel (mostly, immediately after procedure) was feasible in 97.5%-100% of patients, with a low TPM reinsertion rate (0.0%-1.8%); earlier discharge was also feasible in 50.0%-65.5%, with a low 30-day postdischarge PPM rate (0.0%-2.8%) and no 30-day death.

Conclusions

Early TPM removal and discharge after TAVI appear safe and feasible in the majority of cases. These data may provide a framework for an early, streamlined hospital discharge plan for TAVI recipients, optimizing both cost savings and patient safety.

Omecamtiv mecarbil in heart failure with reduced ejection fraction: systematic review and meta-analysis

Funding Acknowledgements

Type of funding sources: None.

Background

Heart failure (HF) is a growing public health challenge worldwide, with high rates of mortality and morbidity. Omecamtiv Mecarbil (OM) is a cardiac myosin activator and the first of a novel class of myotropes, agents that directly improve myocardial function by selectively improving cardiac sarcomere function. Data on its effect on cardiovascular outcomes remains scarce.

Objectives

To evaluate the safety and efficacy of Omecamtiv Mecarbil in Heart Failure with Reduced Ejection Fraction (HFrEF) and its effect on mid-term clinical outcomes.

Methods

We systematically searched MEDLINE/Pubmed, CENTRAL, clinicaltrials.gov, and the International Clinical Trials Registry Platform for randomized clinical trials (RCTs) evaluating OM safety and efficacy in HFrEF. Outcomes of interest included all-cause mortality, cerebrovascular events, hospitalization, myocardial infarction (MI), anginal events, atrial fibrillation (AF) or flutter, and hypotension. Data screening and extraction was performed by two independent reviewers. We used a random-effects model using the Dersimonian-Laird and Mantel-Haenszel methods to calculate the risk ratio (RR) with 95% confidence intervals.

Results

A total of 232 records were identified, of which six RCTs (N = 9,547; Omecamtiv: 4,889; Placebo: 4,658) met inclusion criteria. The average age was 64.4 years (standard deviation (SD): 0.82), and 79.0% (N = 7,538) were males. The weighted follow-up duration was 19.4 months. OM was associated with a significant reduction in the incidence of cerebrovascular events (RR: 0.68; 95% CI: 0.51 to 0.91). Moreover, OM was associated with a significant increase in the risk of hypotension (RR: 1.45; 95% CI: 1.03 to 2.02), compared to placebo when utilized as an adjuvant therapy to HF guideline-directed medical therapy (GDMT). No statistically significant difference was noted with all-cause mortality (RR: 1.00; 95% CI: 0.93 to 1.07), hospitalization (RR: 0.96; 95% CI: 0.90 to 1.03), incidence of atrial fibrillation or flutter (RR: 0.79; 95% CI: 0.61 to 1.02), anginal events (RR: 1.32; 95% CI: 0.92 to 1.88) or myocardial infarction (RR: 1.07; 95% CI: 0.84 to 1.36). Heterogeneity was low (I2 = 0%) in all analyses.

Effectiveness of empiric cardioprotective therapy in patients receiving cardiotoxic chemotherapies: systematic review & bayesian network meta-analysis

Funding Acknowledgements

Type of funding sources: None.

Background

Cardioprotective therapies represent an important avenue to reduce these limiting toxicities, including serious heart failure (HF) events. However, due to conflicting isolated reports, the true efficacy and optimal cardioprotective therapy at the time of anticancer treatment initiation is unclear. Therefore, we undertook a network meta-analysis to elucidate the most effective therapies at cardiotoxic HF prevention.

Purpose

To determine the efficacy, and optimal cardioprotective strategy in patients receiving cardiotoxic chemotherapies.

Methods

Leveraging the MEDLINE/Pubmed, CENTRAL, and clinicaltrials.gov databases, we identified all randomized controlled trials (RCTs) investigating cardioprotective therapies from inception to November 2021. Eligible cardioprotective classes included ACEIs, ARBs, Beta-blockers, dexrazoxane (DEX), statins, and mineralocorticoid receptor antagonists (MRA). The primary endpoint was the prevention of new-onset HF. The secondary outcomes were the mean difference in left ventricular ejection fraction (LVEF) change, the incidence of hypotension, and all-cause mortality. Network meta-analyses were used to assess the cardioprotective effects of each therapy to deduce the most effective therapies. Both analyses were undertaken using a Bayesian random-effects model to estimate risk ratios (RR) and 95% credible intervals (95% CrI).

Results

Overall, from 726 articles, 39 studies evaluating 5,931 participants (38.0±19.1 years, 72.0% females) were identified. Over a median follow-up of 6 months, use of any cardioprotective strategy was associated with a significant reduction in new-onset HF (RR:0.32; 95% CrI:0.19-0.55), improved LVEF (mean difference: 3.92%; 95% CrI:2.81-5.07), and increased hypotension (RR:3.27; 95% CrI:1.38-9.87); there was no difference in mortality (RR:1.03; 95% CrI:0.84-1.22). Based on the median risk of incident HF in the control groups being 3.28%, the number need to treat (NNT) for "any" cardioprotective therapy to prevent one incident HF event was 45 patients. For dexrazoxane and neurohormonal agents, the median NNT was 36 and 53 patients, respectively. In this network analysis, dexrazoxane was most effective at HF prevention [Surface Under the Cumulative Ranking curve (SUCRA): 81.47%] and MRA most effective at preserving LVEF (SUCRA: 99.22%). ARBs most greatly increased hypotension (RR:7.20; 95% CrI:2.46-26.94).

Conclusion

Cardiotoxicity remains a challenge for cancer patients requiring life-saving cancer therapies. The initiation of a cardioprotective strategy reduces incident HF. Additional head-to-head trials are needed to confirm the optimal preventative strategy.

Long-term effectiveness of empiric cardio-protection in patients receiving cardiotoxic chemotherapies: A systematic review & bayesian network meta-analysis

BACKGROUND

Cardioprotective therapies represent an important avenue to reduce treatment-limiting cardiotoxicities in patients receiving chemotherapy. However, the optimal duration, strategy and long-term efficacy of empiric cardio-protection remains unknown.

METHODS

Leveraging the MEDLINE/Pubmed, CENTRAL and clinicaltrials.gov databases, we identified all randomised controlled trials investigating cardioprotective therapies from inception to November 2021 (PROSPERO-ID:CRD42021265006). Cardioprotective classes included ACEIs, ARBs, Beta-blockers, dexrazoxane (DEX), statins and mineralocorticoid receptor antagonists. The primary end-point was new-onset heart failure (HF). Secondary outcomes were the mean difference in left ventricular ejection fraction (LVEF) change, hypotension and all-cause mortality. Network meta-analyses were used to assess the cardioprotective effects of each therapy to deduce the most effective therapies. Both analyses were performed using a Bayesian random effects model to estimate risk ratios (RR) and 95% credible intervals (95% CrI).

RESULTS

Overall, from 726 articles, 39 trials evaluating 5931 participants (38.0 ± 19.1 years, 72.0% females) were identified. The use of any cardioprotective strategy associated with reduction in new-onset HF (RR:0.32; 95% CrI:0.19-0.55), improved LVEF (mean difference: 3.92%; 95% CrI:2.81-5.07), increased hypotension (RR:3.27; 95% CrI:1.38-9.87) and no difference in mortality. Based on control arms, the number-needed-to-treat for 'any' cardioprotective therapy to prevent one incident HF event was 45, including a number-needed-to-treat of 21 with ≥1 year of therapy. Dexrazoxane was most effective at HF prevention (Surface Under the Cumulative Ranking curve: 81.47%), and mineralocorticoid receptor antagonists were most effective at preserving LVEF (Surface Under the Cumulative Ranking curve: 99.22%).

CONCLUSION

Cardiotoxicity remains a challenge for patients requiring anticancer therapies. The initiation of extended duration cardioprotection reduces incident HF. Additional head-to-head trials are needed.

Risk Stratification and Management of Advanced Conduction Disturbances Following TAVI in Patients With Pre-Existing RBBB

Background

Pre-existing right bundle branch block (RBBB) is a strong predictor of increased need for a permanent pacemaker (PPM) following transcatheter aortic valve implantation (TAVI). Yet, further risk stratification and management remain challenging in patients with pre-existing RBBB owing to limited data. Therefore, we sought to investigate the incidence, predictors, and management of advanced conduction disturbances after TAVI in patients with pre-existing RBBB.

Methods

We retrospectively reviewed 261 consecutive patients with pre-existing RBBB (median age 81 years; 28.0% female; 95.0% received a balloon-expandable valve) without a pre-existing PPM who underwent TAVI at our institution in 2015-2019. Outcomes were high-degree atrioventricular block/complete heart block (HAVB/CHB) and PPM requirement.

Results

Overall, the 30-day HAVB/CHB rate was 28.0%, of which 76.7% occurred during the TAVI procedure. The delayed HAVB/CHB rate was 8.3%. Implantation depth below aortic annulus (per 1-mm increase) was significantly associated with increased risk of procedural HAVB/CHB (adjusted odds ratio = 1.25, 95% confidence interval = 1.07-1.46), delayed HAVB/CHB (1.34 [1.01-1.79]), and 30-day PPM (1.32 [1.11-1.55]). Predilation was associated with delayed HAVB/CHB (4.02 [1.22-13.23]). The combination of no predilation and implantation depth of ≤2.0 mm had lower rates of procedural HAVB/CHB (11.2% vs. 26.7%-30.4%, p = 0.011), delayed HAVB/CHB (2.1% vs. 7.6%-28.1%, p < 0.001), and 30-day PPM (10.3% vs. 20.0%-43.5%, p < 0.001) than the other strategies of valve deployment. Complete HAVB/CHB recovery after PPM implantation was uncommon at 7.1%.

Conclusions

In patients with pre-existing RBBB, the majority of HAVB/CHB events occurred during the TAVI procedure. Avoidance of predilation coupled with high valve deployment may result in relatively low rates of procedural and delayed HAVB/CHB, along with 30-day PPM rates.

Factors Associated With Revascularization in Women With Spontaneous Coronary Artery Dissection and Acute Myocardial Infarction

In contrast to atherosclerotic acute myocardial infarction (AMI), conservative therapy is considered preferable in the acute management of spontaneous coronary artery dissection (SCAD) if clinically possible. The present study aimed to investigate factors associated with treatment strategy for SCAD. Women aged ≤60 years with AMI and SCAD were retrospectively identified in the Nationwide Readmissions Database 2010 to 2015 and were divided into revascularization and conservative therapy groups. The revascularization group (n = 1,273, 68.0%), compared with the conservative therapy group (n = 600, 32.0%), had ST-elevation AMI (STEMI) (anterior STEMI, 20.3% vs 10.5%; inferior STEMI, 25.1% vs 14.5%; p <0.001) and cardiogenic shock (10.8% vs 1.8%; p <0.001) more frequently. Multivariable logistic regression analysis demonstrated that anterior STEMI (vs non-STEMI, odds ratio 2.89 [95% confidence interval 2.08 to 4.00]), inferior STEMI (2.44 [1.85 to 3.21]), and cardiogenic shock (5.13 [2.68 to 9.80]) were strongly associated with revascularization. Other factors associated with revascularization were diabetes mellitus, dyslipidemia, smoking, renal failure, and pregnancy/delivery-related conditions; whereas known fibromuscular dysplasia and admission to teaching hospitals were associated with conservative therapy. Propensity-score matched analyses (546 pairs) found no significant difference in in-hospital death, 30-day readmission, and recurrent AMI between the groups. In conclusion, STEMI presentation, hemodynamic instability, co-morbidities, and setting of treating hospital may affect treatment strategy in women with AMI and SCAD. Further efforts are required to understand which patients benefit most from revascularization over conservative therapy in the setting of SCAD causing AMI.

Impact of post-procedural length of stay on short-term outcomes and readmissions after TAVR and MitraClip

Background

Post-procedural hospital length of stay (P-LOS) is an important determinant of cost-related outcomes. In the present study, we aimed to assess the impact of P-LOS on short-term outcomes after transcatheter aortic valve replacement (TAVR) and MitraClip.

Methods

We performed a retrospective cohort study, retrieving data from the National Readmissions Database (NRD) for patients who underwent transfemoral TAVR and MitraClip between January 2014 and December 2017. We employed multivariable logistic regression to evaluate the association between P-LOS and 30-day all-cause mortality and readmissions.

Results

A total of 65,726 and 7347 patients underwent TAVR and MitraClip, respectively within the study period. After 30 days of discharge, 13.7% and 15.1% of TAVR and MitraClip patients were readmitted for any reason, while 0.5% and 0.9% died within the readmission hospitalization. A longer P-LOS was associated with an increased risk of 30-day all-cause readmission in both TAVR (OR = 1.027, 95% CI [1.023-1.032]) and MitraClip (OR = 1.025, 95%CI [1.012-1.038]) patients. This finding remained true for patients who developed or did not develop complications after both procedures. In terms of 30-day inhospital mortality, a longer P-LOS was associated with a higher risk in TAVR patients (OR = 1.039, 95%CI [1.028-1.049]), but no increased risk in MitraClip patients (OR = 1.014, 95%CI [0.985-1.044]). Other predictors of 30-day readmission after both procedures included heart failure, post-procedural acute kidney injury, and discharge with disability.

Conclusion

The current study shows that shorter P-LOS was associated with reduced risk of short-term readmission after both TAVR and MitraClip and reduced short-term mortality after TAVR (mainly in patients who developed post-procedural complications). Shorter P-LOS is a predictor of readmission and sicker patient group. Patients requiring longer LOS should be followed closely to prevent readmission and enhance better outcomes. Future studies evaluating P-LOS impact on long-term and patient-oriented outcomes are needed.

Bayesian network meta-analysis comparing cryoablation, radiofrequency ablation, and antiarrhythmic drugs as initial therapies for atrial fibrillation

BACKGROUND

Antiarrhythmic drugs (AADs) and catheter ablation are first line treatments of paroxysmal atrial fibrillation (PAF), however, there exists a paucity of data regarding the potential benefit of different catheter ablation technologies versus AADs as an early rhythm strategy.

OBJECTIVE

To assess the safety and efficacy of cryoablation versus radiofrequency ablation (RFA) versus AADs as a first line therapy of PAF.

METHODS

MEDLINE, Embase, Scopus and CENTRAL were searched to retrieve randomized clinical trials (RCTs) comparing cryoablation, RFA or AADs to one another as first line therapies for atrial fibrillation (AF). The primary outcome was overall freedom from arrhythmia recurrence (AF, atrial flutter [AFL], atrial tachycardia). Secondary outcomes included freedom from symptomatic arrhythmia recurrence, hospitalization, and serious adverse events. A random-effects Bayesian network meta-analysis was used to calculate odds ratios (OR) and 95% credible intervals (CrI).

RESULTS

Six RCTs (N = 1212) met the inclusion criteria (605 AADs, 365 Cryoablation, and 245 RFA). Compared with AADs, overall recurrence was reduced with RFA (OR: 0.31; 95% CrI: 0.10-0.71) and cryoablation (OR: 0.39; 95% CrI: 0.16-1.00). Comparing ablation (cryoablation and RFA) with AADs in respect to freedom from symptomatic AF recurrence, neither cryoablation (OR: 0.35; 95% CrI: 0.06-1.96) nor RFA (OR: 0.34; 95% CrI: 0.07-1.27) resulted in statistically significant reductions individually compared to AADs, though pooled ablation with both technologies showed lower odds of arrhythmia recurrence (OR: 0.35; 95% CrI: 0.13-0.79). In terms of serious adverse events rates, neither cryoablation (OR: 0.77; 95% CrI: 0.44-1.39) nor RFA (OR: 1.45; 95% CrI: 0.67-3.23) were significantly different to AADs. RFA resulted in a statistically significant reduction in hospitalizations compared to AAD (OR: 0.08; 95% CrI: 0.01-0.99), whereas cryoablation did not (OR: 0.77; 95% CrI: 0.44-1.39). The surface under the cumulative ranking curve showed RFA to be the most effective treatment at reducing overall rates of recurrence, symptomatic recurrence and hospitalizations; whereas cryoablation was most likely to reduce serious adverse events.

CONCLUSION

Cryoablation and RFA are both effective and safe first line therapies for AF compared to AADs, with RFA being the most effective at reducing recurrences.

Utilization and outcomes of transcatheter coil embolization for various coronary artery lesions: Single-center 12-year experience

OBJECTIVE

Determining the outcomes of transcatheter coil embolization (TCE) for several coronary artery lesions.

BACKGROUND

TCE has been used as a treatment modality for various lesions in the coronary circulation. However, data on the efficacy and safety of TCE to treat coronary artery fistula (CAF), left internal mammary artery (LIMA) side-branch, coronary artery perforation (CAP), coronary artery aneurysm (CAA), and coronary artery pseudoaneurysm (CAPA) are limited.

METHODS

We conducted a retrospective, descriptive analysis of all TCE devices in coronary lesions at our center from 2007 to 2019. Forty-one studied lesions included 25 CAF, 7 LIMA side-branch, 5 CAP, 2 CAA, and 2 CAPA. Short- and 1-year mortality and hospital readmission were reported, in addition to coil-related complications and procedural success.

RESULTS

The utilization rate of TCE in coronary artery lesions at our center was found to be 33.8 per 100,000 percutaneous coronary intervention procedures over 12 years. Successful angiographic closure was achieved in 37 out of 41 (87.8%) cases (88, 100, 60, 100, and 100% of CAF, LIMA side-branch, CAP, CAA, and CAPA, respectively). No adverse events were directly related to TCE among the LIMA, CAA, and CAPA cases, and only one patient with CAF required reintervention at 3 months due to coil migration.

CONCLUSIONS

Coil embolization in our institution was safe and effective in treating different coronary circulation abnormalities with a 87.8% overall success rate. Further study on the use of vascular plug devices in cases such as CAF or LIMA side-branch would be beneficial to understand the treatment options better.

Are direct oral anticoagulants preferable to warfarin for the treatment of left ventricular thrombi? A Bayesian meta-analysis of randomized controlled trials

Background

There is no clear consensus on the optimal choice of anticoagulant in patients with left ventricular thrombi (LVT). Given the potentially fatal complications associated with this disease entity, we performed a systematic review and meta-analysis of recent randomized clinical trials (RCTs) to synthesize the latest evidence on this topic.

Methods

We performed a comprehensive search of electronic databases to identify RCTs comparing warfarin to direct oral anticoagulants (DOACs) in patients with LVT. A random-effects Bayesian analysis using a binomial-normal hierarchical model was performed to compare the two treatment options with regards to the risk of mortality, stroke, LVT resolution, and major bleeding.

Results

In an analysis comprising 3 RCTs (N = 139), there were no statistically significant differences regarding mortality (OR: 0.68; 95% CrI: 0.10 to 4.43), stroke (OR: 0.14; 95% CrI: 0.01 to 1.27), or LVT resolution (OR: 1.17; 95% CrI: 0.37 to 3.45). Major bleeding was significantly lower in the DOAC group (OR: 0.16; 95% CrI: 0.02 to 0.82).

Conclusion

In patients with LVT, the currently available evidence from RCTs supports the use of DOACs rather than warfarin due to lower major bleeding risks and no evidence of inferiority with respect to mortality, stroke or LVT resolution.

Left atrial appendage closure during cardiac surgery for atrial fibrillation: A meta-analysis

BACKGROUND

Left atrial appendage closure (LAAC) during cardiac surgery in atrial fibrillation (AF) patients has been investigated in multiple studies with variable safety and efficacy results.

METHODS

A comprehensive review was performed of all studies comparing LAAC and placebo arm during cardiac surgery in AF patients. A random-effect model was used to calculate risk ratios, mean differences, and 95% confidence intervals.

RESULTS

Five randomized controlled trials and 22 observational studies were included with a total of 540,111 patients. The LAAC group had significantly decreased postoperative stroke/embolic events as compared to the no LAAC group with all cardiac surgeries (3.74% vs 4.88%, p = 0.0002), isolated valvular surgery (1.95% vs 4.48%, p = 0.002). However, CABG insignificantly favored the LAAC group for stroke/embolic events (6.72% vs 8.30%, p = 0.07). There was no difference between both groups in all-cause mortality in the perioperative period (p = 0.42), but was significantly lower in the LAAC arm after two years (14.1% vs 18.3%, p = 0.02). There was no difference in major bleeding, all-cause rehospitalizations, or cross-clamp time between both groups (p = 0.53 and p = 0.45). The bypass and the cross-clamp time were longer in the LAAC group (4 and 9 min, respectively).

CONCLUSION

In AF patients, LAAC during cardiac surgery had a decreased risk of stroke and long-term all-cause mortality. Additionally, there was no difference in major bleeding, all-cause rehospitalizations, or cross-clamp time.

Incidence, treatment, and outcomes of acute myocardial infarction following transcatheter or surgical aortic valve replacement

OBJECTIVES

This study aimed to evaluate the incidence, treatment, and outcomes of acute myocardial infarction (AMI) following transcatheter or surgical aortic valve replacement (TAVR or SAVR).

BACKGROUND

Coronary artery disease is common in patients who undergo aortic valve replacement. However, little is known about differences in clinical features of post-TAVR or post-SAVR AMI.

METHODS

We retrospectively identified post-TAVR or post-SAVR (including isolated and complex SAVR) patients admitted with AMI using the Nationwide Readmissions Database 2012-2017. Incidence, invasive strategy (coronary angiography or revascularization), and in-hospital outcomes were compared between post-TAVR and post-SAVR AMIs.

RESULTS

The incidence of 180-day AMI was higher post-TAVR than post-SAVR (1.59% vs. 0.72%; p < 0.001). Post-TAVR AMI patients (n = 1315), compared with post-SAVR AMI patients (n = 1344), were older, had more comorbidities and more frequent non-ST-elevation AMI (NSTEMI: 86.6% vs. 78.0%; p < 0.001). After propensity-score matching, there was no significant difference in in-hospital mortality between post-TAVR and post-SAVR AMIs (14.7% vs. 16.1%; p = 0.531), but the mortality was high in both groups, particularly in ST-elevation AMI (STEMI: 38.8% vs. 29.2%; p = 0.153). Invasive strategy was used less frequently for post-TAVR AMI than post-SAVR AMI (25.6% vs. 38.3%; p < 0.001). Invasive strategy was associated with lower mortality in both post-TAVR (adjusted odds ratio = 0.40; 95% confidence interval = [0.24-0.66]) and post-SAVR groups (0.60 [0.41-0.88]).

CONCLUSIONS

AMI, albeit uncommon, was more frequent post-TAVR than post-SAVR. Patients commonly presented with NSTEMI, but the mortality of STEMI was markedly high. Further studies are needed to understand why a substantial percentage of patients do not receive invasive coronary treatment, particularly after TAVR, despite seemingly better outcomes with invasive strategy.

Association of hospital procedural volume with incidence and outcomes of surgical bailout in patients undergoing transcatheter aortic valve replacement

OBJECTIVES

This study sought to examine the association of hospital procedural volume with the incidence and outcomes of surgical bailout (SB) in patients who undergo transcatheter aortic valve replacement (TAVR).

BACKGROUND

SB is required for serious complications during or after TAVR. It remains unclear whether hospital experiences affect the incidence and outcomes of SB.

METHODS

We retrospectively identified patients who underwent endovascular TAVR using the Nationwide Readmissions Database 2012-2017. We examined the association of annual hospital procedural volume (annual number of endovascular TAVR cases in each hospital in each year) with the incidence and in-hospital mortality of SB using multivariable logistic regressions and restricted cubic splines.

RESULTS

Among 82,764 eligible patients, the incidence of SB was 0.95% (n = 789) and decreased from 2012 to 2017 (from 2.66% to 0.49%; P_trend  < 0.001), while in-hospital mortality of SB remained high over years (from 26.0% to 23.5%; P_trend  = 0.773). Very-high-volume hospitals (≥200 cases/year), as compared with low-volume hospitals (≤49 cases/year), showed significantly a lower incidence of SB (0.49% vs. 1.81%; adjusted OR = 0.28, 95% CI = 0.21-0.38), but similar in-hospital mortality of SB (26.2% vs. 25.6%; adjusted OR = 0.88, 95% CI = 0.47-1.66). There was a significant nonlinear, inverse association of hospital volume with the incidence of SB, but not with the in-hospital mortality of SB.

CONCLUSIONS

Hospitals with higher TAVR volumes have a lower risk of SB, but the in-hospital mortality after SB does not change with hospital TAVR volume. Our findings highlight the importance that physicians should always be aware of the high mortality risk of SB following TAVR regardless of hospital procedural experiences.

Quality Assessment of Published Systematic Reviews in High Impact Cardiology Journals: Revisiting the Evidence Pyramid

Objective: Systematic reviews are increasingly used as sources of evidence in clinical cardiology guidelines. In the present study, we aimed to assess the quality of published systematic reviews in high impact cardiology journals.

Methods: We searched PubMed for systematic reviews published between 2010 and 2019 in five general cardiology journals with the highest impact factor (according to Clarivate Analytics 2019). We extracted data on eligibility criteria, methodological characteristics, bias assessments, and sources of funding. Further, we assessed the quality of retrieved reviews using the AMSTAR tool.

Results: A total of 352 systematic reviews were assessed. The AMSTAR quality score was low or critically low in 71% (95% CI: 65.7–75.4) of the assessed reviews. Sixty-four reviews (18.2%, 95% CI: 14.5–22.6) registered/published their protocol. Only 221 reviews (62.8%, 95% CI: 57.6–67.7) reported adherence to the EQUATOR checklists, 208 reviews (58.4%, 95% CI: 53.9–64.1) assessed the risk of bias in the included studies, and 177 reviews (52.3%, 95% CI: 45.1–55.5) assessed the risk of publication bias in their primary outcome analysis. The primary outcome was statistically significant in 274 (79.6%, 95% CI: 75.1–83.6) and had statistical heterogeneity in 167 (48.5%, 95% CI: 43.3–53.8) reviews. The use and sources of external funding was not disclosed in 87 reviews (24.7%, 95% CI: 20.5–29.5). Data analysis showed that the existence of publication bias was significantly associated with statistical heterogeneity of the primary outcome and that complex design, larger sample size, and higher AMSTAR quality score were associated with higher citation metrics.

Conclusion: Our analysis uncovered widespread gaps in conducting and reporting systematic reviews in cardiology. These findings highlight the importance of rigorous editorial and peer review policies in systematic review publishing, as well as education of the investigators and clinicians on the synthesis and interpretation of evidence.

Short-Term Outcomes of Transcatheter Aortic Valve Implantation Versus Surgical Aortic Valve Replacement in Kidney Transplant Recipients (from the US Nationwide Representative Study)

Kidney transplant recipients (KTRs) are considered high-risk patients for surgical interventions. Transcatheter aortic valve implantation (TAVI) has been introduced as an alternative to surgical aortic valve replacement (SAVR) in patients with aortic stenosis (AS) at high operative risk. However, the outcomes of TAVI compared with SAVR KTRs have not been well-studied in nationally representative data. Patients with prior history of functioning kidney transplant who were hospitalized for TAVI and SAVR between January 2012 and December 2017 were identified retrospectively in the Nationwide Readmissions Database. Our study included 762 TAVI and 1,278 SAVR KTRs. Compared with SAVR, TAVI patients generally had higher rates of co-morbidities with lower risk of in-hospital mortality (3.1% vs 6.3, p = 0.002), blood transfusion (11.5% vs 38.6%, p <0.001), acute myocardial infarction (3.9% vs 6.5%, p = 0.16), acute kidney injury (24.5% vs 42.1%, p <0.001), sepsis (3.9% vs 9.5%, p <0.001) and discharge with disability (42.6% vs 68.4%, p <0.001). However, the rate of permanent pacemaker implantation was significantly higher in TAVI group (11.4% vs 3.9%, p <0.001). Of note, in-hospital stroke and 30-day readmission were comparable between both groups. These findings were confirmed after adjusting for other co-morbidities. TAVI is growing as a valid and safe alternative for KTRs with severe AS.

Abstract P869: Racial Disparities in Pregnancy-Associated Stroke, a US Nationwide Cohort Study

Introduction: Pregnancy-associated stroke (PAS) is a rare event but is associated with high morbidity and mortality. Understanding racial disparities in outcomes may help improve care in susceptible populations and shed light on areas of possible targeted improvement.

Methods: Pregnant and post-partum women hospitalized from January 2002 to December 2017 were identified from the Nationwide Inpatient Sample. White and Black women were included in the current study. PAS was identified using the International Classification of Diseases (ICD) 9 and 10 revisions. In-hospital mortality was the primary outcome. Multivariate regression analysis was used for Adjusted Odds Ratio (aOR) and 95% Confidence Interval (CI) to adjust for differences in baseline and pregnancy-related comorbidities.

Results: Among 38,797,752 pregnant and post-partum women, 21.9% were black. A total of 10,959 women (0.03%) suffered from PAS. Of women with PAS, 4,521 (41.3%) were Black. Black women with PAS had a higher in-hospital mortality rate compared to white women (7.8% vs. 5.0%, P< 0.001). A significant disparity was noted in the risk of mortality by age groups where black women of ages 18-24 with PAS had a higher aOR of mortality 2.10, 95% (confidence interval) CI (1.88-2.35) compared to white women, ages 25-29 had aOR of 2.75, 95% CI (2.46-3.07), ages 30-34 had aOR of 3.94, 95% CI (3.50-4.43), ages 35-40 had aOR of 3.73, 95% CI (3.25-4.29), and ages 40 and older had aOR of 1.27, 95% CI (1.08-1.51). A significant difference was noted when stratifying outcome by income as black women in the lowest quartile of income had an aOR of 1.91, 95% CI (1.74-2.10), while those in the highest quartile of income had OR of 2.38, 95% CI (2.02-2.80).

Conclusions: Black women with PAS were associated with higher in-hospital mortality compared with the White counterparts. These differences were observed mainly among the younger age groups. Targeted interventions are needed to minimize these observed racial differences.

Fasting-Evoked En Route Hypoglycemia in Diabetes (FEEHD): From Guidelines to Clinical Practice

BACKGROUND

Lipid profiles have been used for the purposes of health screening and monitoring of the effects of lipid-lowering medications, especially in patients with diabetes who are prone to hyperlipidemia. Fasting for lipid profiles has been the norm for the past decades. This long-lasting tradition poses a risk of hypoglycemia, especially in patients with diabetes.

OBJECTIVE

Our aim is to review the overlooked occurrence of hypoglycemia in patients who fast for laboratory tests, especially lipid profile tests, and commute to the laboratory facility while fasting; a condition we titled "Fasting-Evoked En route Hypoglycemia in Diabetes patients" or "FEEHD". We also review its prevalence and clinical impact on patients with diabetes.

METHODS

We undertook an extensive literature search using search engines such as PubMed and Google Scholar. We used the following keywords for the search: Fasting, Non-fasting; Hypoglycemia; Hypoglycemic Agents; Laboratory Tests; Glucose, Hypoglycemia, Lipid Profiles, FEEHD.

RESULTS

Our literature review has shown that the prevalence of FEEHD is alarmingly high (17-21% of patients at risk). This form of hypoglycemia is under recognized in the clinical practice despite its frequent occurrence. Recent changes in various international guidelines have uniformly endorsed the utilization of non-fasting lipid profiles as the new standard for obtaining lipid profiles with the exception of certain conditions. Multiple studies showed the efficacy of non-fasting lipid tests in comparison to fasting lipid tests, in routine clinical practice.

CONCLUSION

We hope to increase awareness among clinicians about this overlooked and potentially harmful form of hypoglycemia in patients with diabetes, which can be easily avoided. We also hope to call upon clinicians to consider changing the habit of ordering lipid profiles in the fasting state, which has been recently shown to be largely unnecessary in routine clinical settings, with few exceptions in selected cases.