Comparison of Contemporary Treatment Strategies in Patients With Cardiogenic Shock Due to Severe Aortic Stenosis

BACKGROUND

The aims of this study were to understand the incidence and outcomes of patients with cardiogenic shock (CS) due to severe aortic stenosis (AS), and the impact of conventional treatment strategies in this population.

METHODS AND RESULTS

All patients admitted to the Cleveland Clinic cardiac intensive care unit between January 1, 2010 and December 31, 2021 with CS were retrospectively identified and categorized into those with CS in the setting of severe AS versus CS without AS. The impact of various treatment strategies on mortality was further assessed. We identified 2754 patients with CS during the study period, of whom 216 patients (8%) had CS in the setting of severe AS. Medical management was associated with the highest 30-day mortality when compared with either balloon aortic valve replacement or aortic valve replacement (surgical or transcatheter aortic valve replacement) (hazard ratio, 3.69 [95% CI, 2.04-6.66]; P<0.0001). Among patients who received transcatheter therapy, 30-day mortality was significantly higher in patients who received balloon aortic valvuloplasty versus transcatheter aortic valve replacement (26% versus 4%, P=0.02). Both surgical and transcatheter aortic valve replacement had considerably lower mortality than medical management and balloon aortic valvuloplasty at 30 days and 1 year (P<0.05 for both comparisons).

CONCLUSIONS

CS due to severe AS is associated with high in-hospital and 30-day mortality, worse compared with those with CS without AS. In suitable patients, urgent surgical aortic valvuloplasty or transcatheter aortic valve replacement is associated with favorable short- and long-term outcomes. Although balloon aortic valvuloplasty may be used to temporize patients with CS in the setting of severe AS, mortality is ≈50% if not followed by definitive aortic valve replacement within 90 days.

A comparative evaluation of fluoride release and rechargeability in conventional GIC (type II), pediatric GIC (type IX), and Cention-N: an in vitro study

PURPOSE

A comparative evaluation of fluoride release and re-chargeability in conventional glass ionomer cement (GIC) (type II), Pediatric GIC (type IX), and Cention-N-an in vitro study at an interval of first, fourteenth, and twenty first days.

METHODS

Three groups of test materials, each with twenty samples, were prepared. Measurements of the cumulative fluoride release [parts per million (ppm)] and re-release measured on the first, fourteenth, and twenty first days. Analysis of variance (ANOVA) was used to compare the means for different readings, and Tukey's post hoc analysis was used to compare each group with each other.

RESULTS

Initial and subsequent fluoride release of Cention-N at days one, fourteen, and twenty-one were all noticeably higher than those of conventional and pediatric GIC.

CONCLUSION

Compared to the Conventional and Pediatric GIC restorative materials, Cention-N was more effective in the initial and fluoride re-release.

Estimating meaningful change thresholds for Skin Pain-Numeric Rating Scale, Sleep-Numeric Rating Scale and Dermatology Life Quality Index in patients with prurigo nodularis

BACKGROUND

Prurigo nodularis (PN) is characterized by intensely itchy nodules/lesions and skin pain, which can have a substantial impact on health-related quality of life (HRQoL). Treatment benefits on such symptoms and impacts are best assessed in trials using patient-reported outcome (PROs) instruments such as Skin Pain Numerical Rating Scale (NRS), Sleep-NRS and Dermatology Life Quality Index (DLQI). However, no guidance exists for interpreting meaningful changes in scores using these PROs in patients with PN.

OBJECTIVES

The main objective was to derive within-patient (responder definition) and between-group improvement thresholds for interpreting Skin Pain-NRS, Sleep-NRS and DLQI total scores in patients with PN. The measurement properties of the three PROs were also evaluated.

METHODS

Intention-to-treat (ITT), blinded and pooled data were used from the Phase 3 PRIME (NCT04183335) and PRIME2 (NCT04202679) studies evaluating the efficacy of dupilumab in adult patients with PN. Anchor- and distribution-based methods were applied to derive responder definition and between-group thresholds for Skin Pain-NRS, Sleep-NRS and DLQI. Data were additionally used to examine the instrument measurement properties, including reliability, validity and responsiveness.

RESULTS

A total of 311 patients (mean age 49.5 years, 65.3% female) were included in the pooled ITT population. The within-patient improvement threshold for Skin Pain-NRS was estimated as 4.0 points, 2.0 points for Sleep-NRS and 9.0 points for DLQI total score. A 1.5-point improvement in Skin Pain-NRS scores, 1.0-point in Sleep-NRS and 4.0-point in DLQI indicated a between-group meaningful change. Adequate to good psychometric properties were demonstrated for all three instruments.

CONCLUSIONS

The results of this study can aid interpretation of Skin Pain-NRS, Sleep-NRS and DLQI scores in patients with PN in both clinical trials and clinical practice to better understand and treat PN-related skin pain and the impact of PN on sleep quality and HRQoL.

Sex Differences in the Progression and Long-Term Outcomes of Native Mild to Moderate Aortic Stenosis

BACKGROUND

There are limited data on the sex differences in the hemodynamic progression and outcomes of early-stage aortic stenosis (AS).

OBJECTIVES

The authors sought to determine sex differences in hemodynamic progression and outcomes of mild to moderate native AS.

METHODS

This was a retrospective observational cohort study including patients with mild to moderate native tricuspid AS from the Cleveland Clinic echocardiographic database between 2008 and 2016 and followed until 2018. All-cause mortality, aortic valve replacement (AVR), and disease progression assessed by annualized changes in echocardiographic parameters were analyzed based on sex.

RESULTS

The authors included 2,549 patients (mean age, 74 ± 7 years and 42.5% women) followed over a median duration of 5.7 years. There was no difference in all-cause mortality between sexes irrespective of age, baseline disease severity, progression to severe AS, and receipt of AVR. Relative to men, women had similar all-cause mortality but lower risk of AVR (adjusted HR: 0.81 [95% CI: 0.67-0.91]; P = 0.009) at 10 years. On 1:1 propensity-matched analysis, men had a significantly faster disease progression represented by greater increases in the median of annualized change in mean gradient (2.10 vs 1.15 mm Hg/y, respectively, P < 0.001), maximum transvalvular velocity (0.42 vs 0.28 m/s/y), left ventricular end-diastolic diameters (0.15 vs 0.048 mm/m2.7/y) (P = 0.014). Women have significantly higher left ventricular ejection fraction, filling pressures, and left ventricular septum thickness over time on follow-up echocardiograms compared with men.

CONCLUSIONS

Women with mild to moderate AS had slower hemodynamic progression of AS, were more likely to have preserved left ventricular ejection fraction and concentric left ventricular hypertrophy in addition to lower incidence of AVR compared with men despite similar mortality. These findings provide further evidence that there are distinct sex-specific longitudinal echocardiographic and clinical profiles in patients with AS.

Impact of Psychosocial Risk Factors on Outcomes of Atrial Fibrillation Patients undergoing Left Atrial Appendage Occlusion Device Implantation

BACKGROUND

The impact of psychosocial risk factors (PSRFs) on outcomes in patients undergoing percutaneous left atrial appendage occlusion (LAAO) device implantation is unclear. We aimed to analyze the association of psychosocial risk factors with outcomes in patients undergoing LAAO.

METHODS

Data were extracted from the Nationwide readmissions database for the calendar years 2016-2019. LAAO device implantations were identified using ICD-10-CM code 02L73DK. The outcomes of interest included procedural complications, inpatient mortality, resource utilization, and 30-day readmissions. Patients were divided into two cohorts based on the absence or presence of PSRFs.

RESULTS

Our cohort included a total of 54,900 patients, of which, 19,984 (36.4%) had ≥ 1 PSRF as compared to 34,916 (63.6%) with no PSRFs. The prevalence of major complications (3.3% vs 2.8%, p=0.03) was significantly higher in patients with ≥ 1 PSRF as compared to no PSRFs. Furthermore, patients with ≥ 1 PSRF had a significantly higher 30-day readmission rate (6.9% vs 6.2%, p=0.02). In the multivariable model, the presence of ≥ 1 PSRF was associated with significantly higher odds of overall complications [adjusted odds ratio (aOR):1.11; 95% confidence interval (CI): 1.01-1.21; p=0.02]. Additionally, the presence of ≥ 1 PSRF was associated with higher odds of prolonged hospital stay for more than one day (aOR: 1.30; 95% CI: 1.21-1.40; p<0.01).

CONCLUSION

The high prevalence of PSRFs may be associated with poorer outcomes in patients with AF patients undergoing LAAO device implantations. These data merit further study to help in the selection process of patients for LAAO for improved outcomes.

MitraCox Score Predicts In-Hospital Mortality in Patients Admitted for Transcatheter Edge-to-Edge Mitral Valve Repair

As mitral valve transcatheter edge-to-edge repair (M-TEER) is evolving as an effective treatment for high-risk surgical patients with mitral regurgitation, there is a pressing need for cardiologists to optimize resources through risk stratification of in-hospital mortality for this patient population. Although current risk-prediction models have been shown to predict adverse outcomes with reasonable accuracy, models trained using the US nationwide population are lacking. This study aimed to identify clinical, demographic, and procedural features that predict in-hospital mortality, and to derive and validate an in-hospital mortality risk-prediction tool in patients who have undergone M-TEER. A total of 9,373 admissions from the Nationwide Readmissions Database of patients who underwent M-TEER between 2015 and 2018 were used to develop and validate the model. We first performed least absolute shrinkage and selection operator (LASSO) regularization of Cox regression (Coxnet) that is 10-fold cross-validated. The non-zero coefficients were multiplied with the respective values of each observation of the predictors to build the scoring formula. Out of 9,373 admissions, 196 patients (2%) died in-hospital during index admission. In descending order, the top variables that were most predictive of in-hospital mortality were higher age, presence of fluid and electrolyte disturbance, and large metropolitan location of the hospital. The validation C-statistic of the MitraCox score was 0.82. Using X-tile software (Yale School of Medicine, New Haven, Connecticut), 2 cutoffs of the score were determined on the basis of in-hospital mortality and length of stay, and the survival of the population was classified into 3 risk groups: low, intermediate, and high. The scoring system deployed online as a web-based calculator can be accessed at https://kathavs.shinyapps.io/Mitracox_Kapadia/. In conclusion, MitraCox score is easy to calculate and predicts in-hospital mortality depending on length of stay in a dynamic manner.

A Systematic Review and Meta-Analysis of Prevalence, Characteristics, and Impact of Mitral Annular Calcification on Outcomes After Transcatheter Aortic Valve Implantation

There is a paucity of data on the prognostic impact of mitral annular calcification (MAC) in patients who underwent transcatheter aortic valve implantation (TAVI) with conflicting results being reported by the studies that are published. Therefore, we performed a meta-analysis to assess the short-term and long-term outcomes of MAC in patients after TAVI. Of 25,407 studies identified after the initial database search, 4 observational studies comprising 2,620 patients (2,030 patients in the nonsevere MAC arm and 590 patients in the severe MAC arm) were included in the final analysis. Compared with patients with nonsevere MAC, the severe MAC group was associated with significantly higher incidences of overall bleeding (0.75 [0.57 to 0.98], p = 0.03, I² = 0%) at 30 days. However, no significant difference was observed between the 2 groups for the rest of the 30-day outcomes: all-cause mortality (0.79 [0.42 to 1.48], p = 0.46, I² = 9%), myocardial infarction (1.62 [0.37 to 7.04], p = 0.52, I² = 0%), cerebrovascular accident or stroke (1.22 [0.53 to 2.83], p = 0.64, I² = 0%), acute kidney injury (1.48 [0.64 to 3.42], p = 0.35, I² = 0%), and pacemaker implantation (0.70 [0.39 to 1.25], p = 0.23, I² = 68%). Similarly, follow-up outcomes also showed no significant difference between the 2 groups: all-cause mortality (0.69 [0.46 to 1.03], p = 0.07, I² = 44%), cardiovascular mortality (0.52 [0.24 to 1.13], p = 0.10, I² = 70%) and stroke (0.83 [0.41 to 1.69], p = 0.61, I² = 22%). The sensitivity analysis, however, demonstrated significant results for all-cause mortality (0.57 [0.39 to 0.84], p = 0.005, I² = 7%) by removing the study by Okuno et al⁵ and cardiovascular mortality (0.41 [0.21 to 0.82], p = 0.01, I² = 66%) by removing the study by Lak et al.⁷ In conclusion, our meta-analysis corroborates the notion that isolated MAC is not an independent predictor of long-term mortality after TAVI and determines severe MAC to be a predictor of mortality at follow-up because of the higher incidence of mitral valve dysfunction associated with it.

Cost-Effectiveness of Unrelated Umbilical Cord Blood vs. HLA Haploidentical Related Bone Marrow Transplant: Evidence from BMT CTN 1101

BACKGROUND

BMT CTN 1101 was a Phase III randomized controlled trial comparing reduced intensity conditioning followed by double unrelated umbilical cord blood (UCB) versus HLA-haploidentical related donor bone marrow (haplo-BM) transplantation for patients with high-risk hematologic malignancies.

OBJECTIVE

The objective of this study is to report the results of a parallel cost-effectiveness analysis.

STUDY DESIGN

Three hundred sixty-eight patients were randomized to unrelated UCB (n=186) or haplo-BM (n=182) transplant. We estimated healthcare utilization and costs using propensity score-matched BMT patients from the OptumLabs^Ⓡ Data Warehouse for trial participants <65 years and Medicare claims for participants ≥65 years. Weibull models were used to estimate 20-year survival. EQ-5D surveys by trial participants were used estimate Quality-Adjusted Life Years (QALYs).

RESULTS

At 5-year follow-up, survival was 42% for haplo-BM versus 36% for UCB (P=.06). Over a 20-year time horizon, haplo-BM is expected to be more effective (+0.63 QALY) and more costly +$118,953) for persons under 65. For those over 65, haplo-BM is expected to be more effective and less costly. In one-way uncertainty analyses, for persons <65, the cost per QALY result was most sensitive to life years and health state utilities. For persons ≥65, life years were more influential than costs and health state utilities.

CONCLUSION

Compared to UCB, haplo-BM was moderately cost-effective for patients aged <65 years, and less costly and more effective for persons ≥65 years. Haplo-BM is a fair value choice for commercially insured patients with high-risk leukemia and lymphoma who require HCT. For Medicare enrollees, haplo-BM is a preferred choice when considering costs and outcomes.

Advances in multi-modality imaging for constrictive pericarditis and pericardial inflammation: role of imaging-guided therapy

INTRODUCTION

Constrictive pericarditis (CP) can result from uncontrolled inflammation of the pericardium. This can be due to various etiologies. CP can lead to both left- and right-sided heart failure with associated poor quality of life, so early recognition is key. The evolving role of multimodality cardiac imaging allows for earlier diagnosis and facilitates management to help mitigate this adverse outcome.

AREAS COVERED

This review discusses the pathophysiology of constrictive pericarditis, chronic inflammation and autoimmune etiologies, clinical presentation of CP, and advances in multimodality cardiac imaging for diagnosis and management. Echocardiography and cardiac magnetic resonance (CMR) imaging remain cornerstone modalities to evaluate this condition, whereas additional imaging modalities such as computed tomography and FDG-positron emission tomography can provide complementary information.

EXPERT OPINION

Advances in multimodality imaging allow for a more precision diagnosis of constrictive pericarditis. There has been a paradigm shift in pericardial disease management with advances in multimodality imaging, especially CMR, to detect subacute and chronic inflammation. This has enabled imaging-guided therapy (IGT) to both help prevent and potentially reverse established constrictive pericarditis.

Role of Serum Soluble Interleukin-2 Receptor Level in the Diagnosis of Sarcoidosis: A Systematic Review and Meta-Analysis

BACKGROUND AND AIM

Serum Soluble Interleukin-2 Receptor (sIL-2R) levels are used clinically as a disease activity marker for systemic sarcoidosis. Studies have investigated the diagnostic role of serum soluble interleukin-2 receptor (sIL-2R) level for sarcoidosis relative to biopsy. We performed a systematic review and meta-analysis of studies evaluating the diagnostic utility of sIL-2R.

METHODS

We carried out an electronic search in Medline, Embase, Google Scholar, and Cochrane databases using keyword and Medical Subject Heading (MeSH) terms: sarcoidosis and sIL-2R. Studies evaluating the sIL-2R levels as a diagnostic tool in clinically diagnosed or biopsy-proven sarcoidosis patients compared to control groups with non-sarcoidosis patients were included. Forest plots were constructed using a random effect model depicting pooled sensitivity, specificity, positive and negative predictive values, and diagnostic accuracy.

RESULTS

We selected ten studies comprising 1477 patients, with 592 in the sarcoidosis group and 885 in the non- sarcoidosis group. Pooled sensitivity and specificity of sIL-2R levels were 0.88 (95% CI: 0.75-0.95) and 0.87 (95% CI 0.73-0.94) respectively. Pooled negative predictive value and positive predictive value were 0.91 (95% CI 0.77-0.97) and 0.85 (95% CI 0.59-0.96) respectively with diagnostic accuracy of 0.86 (95% CI 0.71- 0.93).

CONCLUSION

In addition to its utility as a marker of sarcoidosis disease activity, sIL-2R has high diagnostic accuracy. Despite the limitations of the heterogenous sarcoidosis population and different sIL-2R cutoffs, our results suggest that sIL-2R is an important biomarker that can be used to confirm sarcoidosis diagnosis in unconfirmed or unclear cases.

Googling "Anatomy dissection": Pre-pandemic, pandemic, and current scenario

OBJECTIVES

The present study was proposed to assess if the online search behavior for Anatomy dissection was affected by actual dissection being performed in the labs. The interest in dissection was ascertained and compared between pre-pandemic, pandemic, and current times.

METHODS

Online web search behavior for key terms related to "Anatomy dissection" was noticed worldwide using Google Trends Tool. Relative search volume (RSV) was downloaded for these keywords worldwide using all categories, and web search settings during a period from January 1, 2018, to July 31, 2022.

RESULTS

There was almost a similar google trend for the first three months in years 2018 and 2020, with a slightly lower RSV in March and a noticeable RSV decrease from April onwards in 2020. During the pre-pandemic period, the peak for RSV in the month of May was noticed. These peaks were missing in 2020 and 2021. In May 2022, RSV again increased. The top five countries with the highest search hit for "Anatomy Dissection" web were the Philippines, the United States, Canada, Australia, and India.

CONCLUSIONS

There was lower search trend for "Anatomy dissection" during the pandemic period as compared to pre-pandemic period. The search trends may be associated with the closure of dissection labs and it may be concluded that Anatomy learners search for this term more often, if they are actually performing the dissections. The future integrated multi-country data and analysis from different set-ups about their ways of dissection and labs before and after the pandemic may further clarify.

The effectiveness of prenatal and postnatal home visits by paramedical professionals and women's group meetings in improving maternal and child health outcomes in low and middle-income countries: a systematic review and meta-analysis

OBJECTIVE

To assess the effectiveness of prenatal and postnatal home visits (HVs) and women group meetings (WGMs) by paramedical professionals to improve maternal and child health outcomes in low- and middle-income countries (LMICs).

STUDY DESIGN

Systematic review and meta-analysis.

METHODS

We conducted a systematic review of trials published till December 2020, as per registered protocol in The International Prospective Register of Systematic Reviews (PROSPERO) (CRD42018091968). Outcomes were neonatal mortality rate (NMR), maternal mortality ratio (MMR), the incidence of low birth weight, and still birth rate (SBR). The Cochrane Pregnancy and Childbirth Group's Trials Register, Cochrane Central Register of Controlled Trials, PubMed, and Excerpta Medica Database (EMBASE) were searched. Pooled results were estimated using random-effects meta-analysis in RevMan version 5.2.

RESULTS

Twenty-five trials met the inclusion criteria. HVs were the key intervention in 12, WGMs in 11, and both interventions in 2 trials. The pooled estimates have shown that NMR was significantly reduced by HVs (OR 0.77, confidence interval [CI]: 0.67-0.90, P = 0.0007, I² = 77%) and WGMs (OR 0.76, CI: 0.65-0.90, P = 0.001, I² = 71%). SBR was significantly reduced by HVs (OR 0.77, CI: 0.70-0.85; P < 0.001, I² = 0%). Subgroup analysis of studies in which more than 10% of pregnant women participated in the WGMs showed significant reduction in NMR (OR 0.67, CI 0.58-0.77, P = 0.00001, I² = 31%) and MMR (OR 0.55, CI 0.36-0.84, P = 0.005, I² = 27%). Two studies reported improvement in birth weight by HVs.

CONCLUSIONS

HVs and WGMs (with >10% pregnant women) by paramedical professionals are effective strategies in reducing the NMR and MMR in LMICs. HVs were also effective in reducing SBR.

Prevalence and determinants of sexual abuse among adolescent girls during the COVID-19 lockdown and school closures in Ghana: A mixed method study

BACKGROUND

In the wake of the COVID-19 pandemic, concerns have been raised that the pandemic may derail global efforts against child sexual abuse (CSA).

OBJECTIVES

This study examines the prevalence and associated factors of sexual abuse among adolescent girls in the context of the COVID-19 pandemic in Ghana.

PARTICIPANTS AND SETTING

The sample comprised 853 adolescent girls aged 13-19 (16.03 ± 2.04 years) in Ghana.

METHODS

The study employed a concurrent mixed-method design.

RESULTS

Overall, the prevalence of CSA during the COVID-19 lockdown and school closures was 32.5 %. Protective factors for CSA were feeling safe in neighbourhood (AOR = 0.526, 95 % CI = [0.325, 0.850]) and parents often listen to opinions (AOR = 0.446, 95 % CI = [0.241, 0.826]). Risk factors for CSA were physical activity (AOR = 1.649, OR = 1.783, 95 % CI_AOR = [1.093, 2.487, 95 % CI_OR = [1.241, 2.561]), parents sometimes listen to opinions (AOR = 1.199, OR = 1.924, 95 % CI_AOR = [0.504, 2.853], 95 % CI_OR = [1.034, 3.582]), living with another relative (AOR = 2.352, OR = 2.484, 95 % CI_AOR = [0.270, 20.523], 95 % CI_OR = [0.317, 19.475]), Akan ethnicity (AOR = 1.576, OR = 1.437, 95 % CI_AOR = [0.307, 8.091], 95 % CI_OR = [0.316, 6.534]), having no disability (AOR = 1.099, OR = 1.138, 95 % CI_AOR = [0.679, 1.581], 95 % CI_OR = [0.786, 1.649]) and having a close relationship with parents (AOR = 1.334, OR = 1.752, 95 % CI_AOR = [0.746, 2.385], 95 % CI_OR = [1.096, 2.802]).

CONCLUSION

Knowledge of the risk and protective factors identified in this study can guide and inform the development of CSA prevention programmes during disruptive occurrences like school closures and lockdown.

Use of Machine Learning to Develop Prediction Models for Mortality and Stroke in Patients Undergoing Balloon Aortic Valvuloplasty

OBJECTIVE

To develop an artificial intelligence, machine learning prediction model for estimating in-hospital mortality and stroke in patients undergoing balloon aortic valvuloplasty (BAV).

METHODS

The National Inpatient Sample (NIS) database was used to identify patients who underwent BAV from 2005 to 2017. Outcomes analyzed were in-hospital all-cause mortality and stroke after BAV. Predictors of mortality and stroke were selected using LASSO regularization. A conventional logistic regression and a random forest machine learning algorithm were used to train the models for predicting outcomes. The performance of all the modeling algorithms for predicting in-hospital mortality and stroke was compared between models using c-statistic, F1 score, brier score loss, diagnostic accuracy, and Kolmogorov-Smirnov plots.

RESULTS

A total of 6962 patients with severe aortic stenosis who underwent BAV were identified. The performance of random forest classifier was comparable with logistic regression for predicting in-hospital mortality for all measures of performance (F1 score 0.422 vs 0.409, ROC-AUC 0.822 [95 % CI 0.787-0.855] vs 0.815 [95 % CI 0.779-0.849], diagnostic accuracy 70.42 % vs 70.93 %, KS-statistic 0.513 vs 0.494 and brier score loss 0.295 vs 0.291). The random forest algorithm significantly outperformed logistic regression in predicting in-hospital stroke with respect to all performance metrics: F1 score 0.225 vs 0.095, AUC 0.767 [0.662-0.858] vs 0.637 [0.499-0.754], brier score loss [0.399 vs 0.407], and KS-statistic [0.465 vs 0.254].

CONCLUSIONS

The good discrimination of machine learning models reveal the potential of artificial intelligence to improve patient risk stratification for BAV.

Machine learning models predict total charges and drivers of cost for transcatheter aortic valve replacement

Background

Given the increasing healthcare costs, there is an interest in developing machine learning (ML) prediction models for estimating hospitalization charges. We use ML algorithms to predict hospitalization charges for patients undergoing transfemoral transcatheter aortic valve replacement (TF-TAVR) utilizing the National Inpatient Sample (NIS) database.

Methods

Patients who underwent TF-TAVR from 2012 to 2016 were included in the study. The primary outcome was total hospitalization charges. Study dataset was divided into 80% training and 20% testing sets. We used following ML regression algorithms: random forest, gradient boosting, k-nearest neighbors (KNN), multi-layer perceptron and linear regression. ML algorithms were built for for 3 stages: Stage 1, including variables that were known pre-procedurally (prior to TF-TAVR); Stage 2, including variables that were known post-procedurally; Stage 3, including length of stay (LOS) in addition to the stage 2 variables.

Results

A total of 18,793 hospitalization for TF-TAVR were analyzed. The mean and median adjusted hospitalization charges were $220,725.2 ($137,675.1) and $187,212.0 ($137,971.0-264,824.8) respectively. Random forest regression algorithm outperformed other ML algorithms at all stages with higher R² score and lower mean absolute error (MAE), root mean squared area (RMSE) and root mean squared logarithmic error (RMSLE) (Stage 1: MAE 79,979.11, R² 0.157; Stage 2: MAE 76,200.09, R² 0.256; Stage 3: MAE 69,350.09, R² 0.453). LOS was the most important predictor of hospitalization charges.

Conclusions

We built ML algorithms that predict hospitalization charges with good accuracy in patients undergoing TF-TAVR at different stages of hospitalization and that can be used by healthcare providers to better understand the drivers of charges.

Temporal Trends in the Utilization and Outcomes of Balloon Aortic Valvuloplasty in the Pre-Transcatheter Aortic Valve Implantation (TAVI) and TAVI Eras

We used a nationwide cohort to (1) compare characteristics and outcomes of patients who underwent balloon aortic valvuloplasty (BAV) in pre-transcatheter aortic valve transplantation (TAVI) and TAVI eras, (2) examine trends in utilization and outcomes of BAV from 2005 to 2017, (3) assess the association of BAV procedural volume with hospital-based TAVI volume, and (4) understand trends and outcomes of BAV in TAVI and non-TAVI centers in the TAVI era. Pre-TAVI era included hospitalizations from 2005 to 2011, and TAVI era included hospitalizations from 2012 to 2017. In the TAVI era, hospitals were classified into quartiles based on the number of TAVI procedures performed. Trends in volume of BAV procedures from 2012 to 2017 were assessed in non-TAVI and TAVI centers (based on TAVI volume). Between 2005 and 2017, a total of 6,962 hospitalizations for BAV were identified. There were no significant differences in in-hospital mortality or stroke between pre-TAVI and TAVI eras (mortality: pre-TAVI, 8.5% vs TAVI era, 9.3%, p = 0.354; stroke: pre-TAVI, 1.9% vs TAVI era, 1.3%, p = 0.083). However, acute kidney injury was more prevalent in the TAVI era and blood transfusion in the pre-TAVI era. Importantly, patients who underwent BAV in the TAVI era were more likely to have a greater number of co-morbidities and to undergo nonelective procedures. From 2005 to 2017, there was 10-fold increase in utilization of BAV. In the TAVI era, the maximum increase in number of BAV procedures was seen in hospitals with highest TAVI volume. In conclusion, although BAV procedural volume increased approximately 10-fold between 2005 and 2017, with concomitant expansion of TAVI, rates of mortality and stroke have remained stable. Despite this, the rate of BAV utilization continues to increase, thereby indicating a significant opportunity to improve outcomes in this patient population.

Autoimmune connective tissue diseases and aortic valve replacement outcomes: a population-based study

Aims

Patients with autoimmune connective tissue diseases (CTDs) have a high burden of valvular heart disease and are often thought of as high surgical risk patients.

Methods and results

Patients undergoing aortic valve replacement (AVR) were identified in the Nationwide Readmissions Database between January 2012 and December 2018. Patients with a history of systemic lupus erythematosus, rheumatoid arthritis, systemic sclerosis, mixed C, Sjögren syndrome, polymyositis, and dermatomyositis were included in the CTD cohort. Patients undergoing coronary artery bypass grafting concomitantly with AVR were excluded. A total of 569 600 hospitalizations were included, of which16 531 (2.9%) had CTD. CTD patients were more likely to be females, with higher rates of heart failure, pulmonary hypertension, and more likely to be insured by Medicare. CTD patients had lower mortality than non-CTD patients [odds ratio (OR) 0.66; 95% confidence interval (CI): 0.59–0.74] and stroke [OR 0.87; 95% (CI): 0.79–0.97]. CTD patients undergoing SAVR had lower mortality [OR 0.69; 95% (CI): 0.60–0.80] and stroke [OR 0.86; 95% (CI): 0.75–0.98). CTD patients undergoing TAVR had lower mortality outcomes [OR 0.67; 95% (CI): 0.56–0.80]; however, they had comparable stroke outcomes [OR 0.97; 95% (CI): 0.83–1.13, P = 0.69].

Conclusions

Outcomes for patients with CTD requiring AVR are not inferior to their non-CTD counterparts. A comprehensive heart team selection of patients undergoing AVR approaches should place CTD history under consideration; however, pre-existing CTD should not be prohibitive of AVR interventions.

Postdischarge-to-30-Day Mortality Among Patients Receiving MitraClip: A Systematic Review and Meta-Analysis

Background

MitraClip (MC) implantation is the recommended treatment for severe symptomatic mitral regurgitation in patients not responding to medical therapy and at prohibitive surgical risk. It is important to quantify immediate mortality during postdischarge-to-30-day period so as to improve the procedural outcomes. Hence, we aim to identify the incidence of postdischarge-to-30-day mortality and its associated predictors using the technique of meta-analysis.

Methods

We searched Medline, Embase, and Cochrane CENTRAL databases from inception until July 3, 2019 for studies reporting mortality prior to discharge, at 30 days and 1 year after MC implantation. The primary outcome was postdischarge-to-30-day all-cause mortality.

Results

Of 2394 references, 15 studies enrolling 7498 patients were included. Random effects analysis showed that all-cause cumulative inpatient, 30-day, and 1-year mortality was 2.40% (2.08, 2.77; I² = 0%), 4.31% (3.64, 5.09, I² = 41.9%), and 20.71% (18.32; 23.33, I² = 81.5%), respectively. The postdischarge-to-30-day mortality was 1.70% (95% confidence interval: 1.0, 2.70; I² = 84%). A total of 71.50% of deaths (95% confidence interval: 36.80-91.50, I² = 63%) in the postdischarge-to-30-day period were due to cardiac etiology. On meta-regression, pre-MC left ventricular ejection fraction (p = 0.003), Log.Euroscore (p = 0.047), Society of Thoracic Surgeons Predicted Risk of Mortality (p < 0.001), and prolonged ventilation >48 ​hours (p < 0.001) were found to be its significant predictors.

Conclusions

Our meta-analysis reports an additional mortality of ∼2% immediately after MC implantation during the postdischarge-to-30-day period. Majority of deaths occurred due to cardiac causes. Pre-MC left ventricular ejection fraction, Log.Euroscore, Society of Thoracic Surgeons Predicted Risk of Mortality score, and prolonged ventilation were found to be its significant predictors. Further studies are needed to better understand the causes of this early mortality to maximize benefits of this important therapy.