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Continuous Flow LVAD(CF-LVAD) are widely used as BTT among patients with Advance Heart Failure. The current study aimed to determine the impact of device related complications on waitlist mortality or delisting due to worsening clinical... more
Continuous Flow LVAD(CF-LVAD) are widely used as BTT among patients with Advance Heart Failure. The current study aimed to determine the impact of device related complications on waitlist mortality or delisting due to worsening clinical conditions. Methods: Patients who were bridged to heart transplant with a continuous flow LVAD (CF-LVAD) between April 2008 and September 2015 were identified from the UNOS heart transplant registry. They were then categorized by the presence or absence of CF-LVAD complications while on the wait list. Cox proportional hazards and Kaplan Meier survival curves were used for time-to-event analysis for the primary outcome. Results: Out of 7070 patients who were bridged to heart transplant, 4434(63%) got transplanted and 2510(36%) developed device related complications while on the waiting list. The primary outcome was present in 1631(23%) patients. Independent predictors of primary outcome were Age (HR/increasing unit: 1.01, 95% CI: 1.01-1.02, p value: <0.0001.), ABO blood group(O vs. A HR: 1.20, 95% CI: 1.20-1.36, p value: 0.003), Etiology of cardiomyopathy (Congenital vs. Ischemic HR: 3.46, 95% CI: 3.46(2.15-5.27, p value: <0.0001, Restrictive vs. Non-ischemic HR: 2.66, 95% CI: 1.67-3.99, p value: 0.0001), history of diabetes mellitus(HR: 1.18, 95% CI: 1.05-1.34, p value: 0.006). Developing one device-related complication was associated with a HR of 2.59 of having the primary outcome, (p<0.0001). The hazard risk however increased to 3.45 when ≥ 2 of the defined complications occurred. Conclusion: In conclusion, findings from the current study add to the existing literature: the incidence of morbidity and mortality in the current BTT era. While the development of any device-related adverse event is significantly associated with waitlist mortality or delisting, the occurrence of ≥ 2 almost doubles the risk. Improvement in clinical management strategies is needed to ensure optimal benefit of CF-LVADs for BTT therapy.
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Bariatric surgery may have a role in the management of morbidly obese patients with end-stage heart failure through increasing eligibility and improving outcomes of destination therapies. We conducted a nationally-representative,... more
Bariatric surgery may have a role in the management of morbidly obese patients with end-stage heart failure through increasing eligibility and improving outcomes of destination therapies. We conducted a nationally-representative, retrospective cohort study of patients with previous bariatric surgery undergoing either heart transplantation or left ventricular assist device implantation. Of 200 patients, < 6% experienced in-hospital mortality after destination therapy, comparable to that reported in the general heart recipient population. Risk-adjusted outcomes minimally differed from obese patients undergoing destination therapy without previous bariatric surgery. This study provides important safety benchmarking data and demonstrates the feasibility of bariatric surgery as a potential 'bridge' left ventricular assist device or transplantation in obese patients with end-stage heart failure.
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Introduction: Spontaneous Coronary Artery Dissection (SCAD) is reported to occur predominantly in young women. Gender differences in the clinical presentation and outcomes of patients with SCAD have not been studied on a population level.... more
Introduction: Spontaneous Coronary Artery Dissection (SCAD) is reported to occur predominantly in young women. Gender differences in the clinical presentation and outcomes of patients with SCAD have not been studied on a population level. We sought to compare the in-hospital outcomes of men and women presenting with acute myocardial infarction (AMI) and SCAD. Methods: We identified patients from the National Inpatient Sample (NIS) between 2005 and 2015 who presented with primary diagnoses of AMI and SCAD. We identified SCAD with ICD-9 code 414.12. A 1:1 propensity-matched cohort was created to examine the outcomes between men and women. Primary endpoint was in-hospital mortality. Secondary endpoints included in-hospital cardiac and non-cardiac complications. Results: Of the 6617 (32017 weighted national estimates) patients with SCAD over the study period, majority were males 3667 (55.4%). Males were younger than females (60.32 yr vs. 61.59 yr) and presented more often with ST-elevation myocardial infarction (STEMI) (53.0% vs. 45.9% P=&amp;lt;0.001). Propensity matching yielded 2366 males and 2366 females. In the matched group, there was no significant difference in in-hospital mortality between males and females (OR 1.20 95% CI -0.93-1.54). With regards to in-hospital complications, ventricular tachycardia (V-Tach) was significantly less frequent in females as compared to males (8.0% vs. 10.1% OR 0.76 p-value 0.003). There was no significant difference between females and males in the frequency of other complications, including intracranial hemorrhage (0.2% vs 0.2% OR 1.45 p-value 0.50), GI bleed (1.8% vs 1.3% OR 1.35 p-value 0.13), cardiogenic shock (9.8% vs 9.7% OR 1.01 p-value 0.86), acute heart failure (3% vs 2.6% OR 1.18 p-value 0.26), ventricular fibrillation(vfib) (5.6% vs 6.0% OR 0.928 p-value 0.48) or stroke ( 1.5% vs 1.0% OR 1.535 p-value 0.06) Conclusion: In our large population-based analysis, compared to females, males were more likely to present with STEMI as compared to females. With the except of V-Tach, which was higher in males, there were no significant gender differences in hospital outcomes namely inpatient mortality, cardiogenic, Vfib or acute heart failure.
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This study compares the postoperative outcomes, 30‐day readmission rates, and incidence of sternal wound infection‐related readmissions between patients receiving bilateral internal mammary arteries (BIMA) and single internal mammary... more
This study compares the postoperative outcomes, 30‐day readmission rates, and incidence of sternal wound infection‐related readmissions between patients receiving bilateral internal mammary arteries (BIMA) and single internal mammary artery (SIMA) grafting during coronary artery bypass graft (CABG) surgery.
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Research Interests: Frailty, Medicine, Humans, Internal Medicine, Female, and 15 moreMale, New Jersey, Health Status, Proportional hazards model, Retrospective Studies, Geriatric Assessment, Risk Factors, Aortic Valve, Postoperative Period, Grip strength, Frail elderly, Aortic valve stenosis, Multidetector Computed Tomography, Cardiovascular medicine and haematology, and hazard ratio
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Cardiovascular (CV) outcomes can be improved with commonality between provider and patient regarding gender and race/ethnicity. Slow growth in CV care provider diversity is an obstacle for women and underrepresented groups. The hope for... more
Cardiovascular (CV) outcomes can be improved with commonality between provider and patient regarding gender and race/ethnicity. Slow growth in CV care provider diversity is an obstacle for women and underrepresented groups. The hope for more equitable outcomes is unlikely to be realized unless trends change in selection of CV fellows and program directors (PDs). We investigate longitudinal trends of gender and racial/ethnic composition of CV FITs. De-identified demographic data were compiled in a descriptive cross-sectional study from AAMC of internal medicine (IM) residents and CV FITs from 2011 through 2021 to evaluate gender and race/ethnicity trends among CV trainees. Trends of CV fellows who later became program directors were analyzed. In the US between 2011 and 2021, 53% of IM residents were male while 40% female (7% unreported). Among CV FITs, 78% were male and 21% female. Races/ethnicities among CV FITs consisted of 36% non-Hispanic white, 28% non-Hispanic Asian, 5% Hispanic, 4%Black, and 25% were classified within other race/ethnicity categories. The proportion who became CV program directors followed similarly: 79% of PDs were male and 21% female. Demographic profiles for CV FITs have not significantly changed over the past decade despite increased diversity among IM residents. Efforts to improve diversity of CV FITs and PDs need to be analyzed. Slow growth of diversity in CV FITs is outpaced by rising patient diversity, leading to disparities in care and poorer CV outcomes for women and underrepresented minorities. Recruiting, training, and retaining diverse CV FITs is necessary.
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Background: The “July effect” is a well-described phenomenon in academic medicine, relating to the annual influx of new trainees. We examined whether the “July effect” impacts inpatient outcomes of admissions for heart failure (HF).... more
Background: The “July effect” is a well-described phenomenon in academic medicine, relating to the annual influx of new trainees. We examined whether the “July effect” impacts inpatient outcomes of admissions for heart failure (HF). Methods: Between 2012 and 2014, we included adult patients (≥18 years) with a primary diagnosis of HF, defined using ICD-9 codes, from the National Inpatient Sample. We excluded non-teaching hospitals. Primary endpoint was in-hospital mortality. Secondary endpoints included hospital length of stay (LOS) and total cost adjusted for inflation. Logistic regression and adjusted odds ratio (OR) were used to adjust for confounders. Based on academic calendar, we classified admissions into 4 quarters (Q1-4). Q1 and Q4 were designated to assess the effect of novice (July effect) vs. seasoned trainees, respectively. Results: We identified 699,675 HF admissions during Q1 and Q4 over the study period. Mean age was 71 years and 48% were females. There were 20,270 in-hospital deaths (Q1 9,695 vs. Q4 10,575). After adjusting for confounders, there was no mortality difference between Q1 and Q4 admissions; adjusted OR 0.96, p = 0.23 (Figure). Similarly, there was no difference in hospital LOS or total cost; 5.8 vs. 5.8 days, p = 0.66 and $13,755 vs. $13,586, p = 0.46, in Q1 and Q4, respectively. Conclusion: In the largest study to date, there was no evidence of a “July effect” on inpatient HF outcomes. This may be credited to the well-defined guidelines which facilitate safe patient care in these patients.
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Background: The study aim was to investigate the relationship between postoperative morbidity after transcatheter aortic valve replacement (TAVR) and short-term patient-reported health status, using the Kansas City Cardiomyopathy... more
Background: The study aim was to investigate the relationship between postoperative morbidity after transcatheter aortic valve replacement (TAVR) and short-term patient-reported health status, using the Kansas City Cardiomyopathy Questionnaire (KCCQ). Methods: The association between 30-day post-procedure changes in patient-reported heath status and post-TAVR outcomes was examined. Patients were stratified into three groups based on observed changes in KCCQ-Overall scores (OS): Group A, increase in KCCQ-OS ≥10 points; Group B, KCCQ-OS scores <10 points; and Group C, decline in KCCQ-OS ≥10 points. Variation components of KCCQ scores were determined using paired t-tests. Postoperative morbidity was investigated. Multivariable logistic regression was used to identify pre-procedural factors associated with an increase or decline in KCCQ-OS at 30 days. Results: A total of 223 patients with complete baseline and postoperative 30-day KCCQ responses was studied. At the 30-day follow up there was a significant change in baseline mean KCCQ-OS for all patients (mean difference 14.1; p <0.0001). Improvement in KCCQ-OS ≥10 was observed in 130 patients (58%), 64 patients (29%) had no change, and 29 patients (13%) had a decline in KCCQ-OS ≥10. The incidence of acute kidney injury (AKI), permanent pacemaker (PPM) placement and new-onset arrhythmia (NOA) was higher in group C than in groups A and B: AKI, 11%, 0%, 0%; p <0.001; PPM, 21%, 4%, 6%; p = 0.004; and NOA, 21%, 5%, 8%, p = 0.026. Independent predictors of decline in KCCQ scores after TAVR were PPM requirement (estimate: 0.76 CI 0.22, 1.29; p = 0.005) and NYHA functional class (III/IV) (estimate: -0.41 CI -0.71, 0.10; p = 0.009). Conclusions: TAVR patients experienced an improvement in health status after the procedure, but for a smaller proportion their health status worsened. Patients who experience perioperative complications may have a decline in their health status after the procedure in the short term.
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Background: The current study aims to identify predictors of extended postoperative length of stay (PLOS) after uncomplicated transcatheter aortic valve replacement (TAVR). Methods: Patients who underwent TAVR at a single center between... more
Background: The current study aims to identify predictors of extended postoperative length of stay (PLOS) after uncomplicated transcatheter aortic valve replacement (TAVR). Methods: Patients who underwent TAVR at a single center between June 2012 and June 2016 were analyzed. Patients were stratified by time into an early cohort (EC; 2012-2014) and current cohort (CC; 2015-2016). Those who had complications post procedure were excluded. The CC group was dichotomized based on its median PLOS. Factors associated with a longer PLOS were investigated by using multivariable logistic regression analysis. Results: Mean age of the 686 patients (299 in the EC group and 387 in the CC group) was 82 ± 8 years. PLOS in the CC group was significantly lower than in the EC group (4 days vs 6 days, respectively; P<.001). Median PLOS in the CC group was 2 days. Dichotomizing the CC group by median PLOS resulted in 148 patients (54%) ≤2 days vs 128 patients (46%) >2 days. Of these, PLOS was 1 day in 71 patients (26%) and 2 days in 61 patients (28%). Independent predictors of PLOS >2 days were non-transfemoral approach, non-elective admission, female sex, low mean transaortic gradient, presence of chronic renal failure, and pulmonary hypertension. Conclusion: Experience coupled with improvements in TAVR technology over the past few years have led to a significant decrease in PLOS after TAVR. In the current TAVR era, 1 out of every 2 patients stays for a day or two in the absence of perioperative adverse events.
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BACKGROUND We investigated patient outcomes in relation to their postoperative length of stay after minimally invasive valve surgery. METHODS All adults who survived elective, uncomplicated minimally invasive aortic or mitral valve... more
BACKGROUND We investigated patient outcomes in relation to their postoperative length of stay after minimally invasive valve surgery. METHODS All adults who survived elective, uncomplicated minimally invasive aortic or mitral valve surgery at a single center between 2012 and 2019 were classified by postoperative length of stay: early discharge (≤ 3 days) or late discharge (> 3 days). The trend in early discharge was investigated over the study period, predictors of early discharge were identified using multivariable logistic regression modeling, and one-to-one propensity score matching was used to determine which patients in the late-discharge cohort of similar health to patients discharged early. Adjusted outcomes of 30-day mortality, readmission, and direct costs were analyzed. RESULTS Among 1,262 consecutive minimally invasive valve patients, 618 were elective and uncomplicated, 25% (n=162) of whom were discharged early. The proportion of early-discharge patients increased over time (p for trend <0.05). A history of congestive heart failure, stroke, or smoking and higher Society of Thoracic Surgeons predictive risk of mortality score negatively predicted early discharge (p<0.05). Propensity score matching identified 101 (22%) late-discharge patients comparable to early-discharge counterparts. Adjusted 30-day mortality and readmission rates were comparable between cohorts. The median direct costs per patient ($20,046 vs. $22,124; p<0.05) were significantly lower in the early-discharge cohort. CONCLUSIONS In well-selected patients, early discharge after minimally invasive valve surgery was associated with lower costs but comparable postoperative outcomes. About one fifth of patients who remain in the hospital beyond postoperative day 3 may be candidates for earlier discharge.
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Recent advances in technology and the need to decrease surgical morbidity have led a rapid progress in laparoscopic adrenalectomy (LA) over the past decade. Robotics is attractive to the surgeon owing to the 3-dimensional image quality,... more
Recent advances in technology and the need to decrease surgical morbidity have led a rapid progress in laparoscopic adrenalectomy (LA) over the past decade. Robotics is attractive to the surgeon owing to the 3-dimensional image quality, articulating instruments, and stable surgical platform. The safety and efficacy of robotic adrenalectomy (RA) have been demonstrated by several reports. In addition, RA has been shown to provide similar outcomes compared to LA. Development of adrenal surgery has involved the description of several surgical approaches including the anterior transperitoneal, lateral transperitoneal (LT) and posterior retroperitoneal (PR). Among these, the most frequently preferred technique is LT adrenalectomy, primarily due to the surgeon's familiarity of the operative field, wider working space and visibility. The LT technique is suitable for the resection of larger, unilateral tumors and in scenarios where conversion to an open transperitoneal approach is warranted, it offers a lesser burden. Also, the larger view of the entire abdominal cavity and excellent exposure of both adrenal glands and surrounding structures provided by the LT technique render it safe and feasible in pediatric and pregnant individuals.
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Introduction: Patients living in neighborhoods with lower socioeconomic status have a greater risk for incident heart failure (HF), more severe symptoms, and increased risk of adverse clinical outcomes. We used high resolution... more
Introduction: Patients living in neighborhoods with lower socioeconomic status have a greater risk for incident heart failure (HF), more severe symptoms, and increased risk of adverse clinical outcomes. We used high resolution metabolomics profiling to identify novel biomarkers associated with neighborhood socioeconomic status (nSES) in patients with HFrEF. Methods: The Area Deprivation Index (ADI) was used to characterize nSES in a discovery (n=170) and a validation (n=166) cohort of patients with HFrEF. Targeted and untargeted high-resolution plasma metabolomics profiling coupled with partial least-squares discriminant analysis (PLS-DA) was used to identify metabolites and metabolic pathways uniquely perturbed in patients in the highest tertile of the ADI (indicating lower nSES). Metabolites with a variable importance in projection (VIP) &gt; 1 entered pathway enrichment analysis. Results: Compared to patients in the lower and middle ADI tertiles, patients with HFrEF living in the highest ADI tertile were more likely to be Black, and had higher body mass index and lower ejection fraction (all P &lt; 0.01). PLS-DA confirmed metabolites that may be associated with worse diet quality in patients in both the discovery and validation cohorts who lived in neighborhoods in the highest ADI tertile, including amino acids and their metabolic products (carnitine, methionine, tryptophan, phenylalanine, valine, phenethylamine, indole), and urate. Moreover, metabolites associated with the human exposome (5-valerolactone, 1-naphthylamine) were also identified. Pathway enrichment analysis revealed branched-chain amino acid metabolism, fatty acid metabolism, and purine metabolism as part of this distinct metabolic signature ( Figure ). Conclusions: Patients with HFrEF living in neighborhoods with lower SES have a distinct metabolic signature that may, in part, be related to worse diet quality and more severe HF.
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Background: Disparities in heart failure (HF) outcomes exist in the United States, in part, due to social determinants of health. Individuals from racial and ethnic minority groups report the highest rates of cost-related delays in care... more
Background: Disparities in heart failure (HF) outcomes exist in the United States, in part, due to social determinants of health. Individuals from racial and ethnic minority groups report the highest rates of cost-related delays in care and worse access to high-quality medical therapy. We have previously demonstrated that individuals residing in more deprived neighborhoods experience higher readmissions, and Black patients are more likely to reside in deprived neighborhoods than White patients. Here, we engaged patients from the most deprived neighborhoods to understand drivers of excess readmission from the patient perspective. Methods: We conducted semi-structured in-depth interviews with 25 patients (mean age 61 ± 9 years, 96% Black, 40% female) readmitted with HF at Emory Healthcare hospitals, and living in a neighborhood in the top 10% of the Social Deprivation Index. Qualitative descriptive analysis of the interviews was performed using a multilevel coding strategy. Results: Patients in this cohort had a mean EF 39 ± 19%, and experienced 3.2 ± 2.5 readmissions in the preceding 12 months. Most patients (84%) highlighted lack of access to medications as a driver of hospital readmission. Representative quotes from individual patients are highlighted in the Table. Patients reported the etiology of their lack of medication access included medication costs (64%), only having access to re-fills through the emergency room or hospitalization (36%), low health literacy (12%), and limited access to transportation (8%). Conclusion: Lack of access to medications for patients with HF who live in socioeconomically deprived neighborhoods poses a challenge to reducing the burden of HF. Providing cost-effective and sustainable access to medications for patients with HF from low resource settings is a potential solution to decrease the number of HF hospitalization and readmissions in this vulnerable patient population.
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Primary cardiac tumors (PCT) are rare, and their contemporary outcomes are not well characterized in the literature. We assessed temporal trends in patient characteristics and management of admissions for PCT in US hospitals.
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Transfemoral (TF) access for transcatheter aortic valve implantation (TAVI) is the most commonly used site, however its use may be limited by prohibitive peripheral arterial disease. Although a number of alternative access techniques have... more
Transfemoral (TF) access for transcatheter aortic valve implantation (TAVI) is the most commonly used site, however its use may be limited by prohibitive peripheral arterial disease. Although a number of alternative access techniques have been well described, each has been shown to be associated with increased risks when compared to a TF approach. Recently, planned treatment of iliofemoral artery disease using intravascular lithotripsy (IVL) has emerged as a means of preserving TF access. Ipsilateral or contralateral femoral artery access has been routinely used to perform IVL but its use may be limited in certain conditions. Here we describe the novel technique of using percutaneous axillary artery access to perform IVL of iliofemoral artery to facilitate its use for large bore access. We present a 78-year-old high surgical risk female with severe aortic stenosis who was found to have a prior stent in the contralateral iliac artery protruding into the aorta which limited a traditional 'up and over' approach, and thus axillary artery access was used to perform IVL. This is the first case in literature to describe the use of percutaneous axillary access to perform IVL of the iliac and common femoral artery to facilitate TF TAVI. Based on our previous experience we feel this technique holds promise for a routine use when use of other access sites is limited.
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BACKGROUND Surgical aortic valve replacement can be performed either through a minimally invasive (MI) or full sternotomy (FS) approach. The present study compared outcomes of MI versus FS for isolated surgery among patients enrolled in... more
BACKGROUND Surgical aortic valve replacement can be performed either through a minimally invasive (MI) or full sternotomy (FS) approach. The present study compared outcomes of MI versus FS for isolated surgery among patients enrolled in the PARTNER 3 low-risk trial. METHODS Patients with severe, symptomatic aortic stenosis at low surgical risk with anatomy suitable for transfemoral access were eligible for PARTNER 3 enrollment. The primary outcome was the composite endpoint of death, stroke, or rehospitalization (valve-, procedure-, or heart-failure-related) at 1 year. Secondary outcomes included the individual components of the primary endpoint as well as patient-reported health status at 30 days and 1 year. RESULTS In the PARTNER 3 study, 358 patients underwent isolated surgery at 68 centers through an MI (n=107) or FS (n=251) approach (8 patients were converted from MI to FS). Mean age and Society of Thoracic Surgeons score were similar between groups. The Kaplan-Meier estimate of the primary outcome was similar in the MI versus FS groups (16.9% versus 14.9%; hazard ratio [95% CI]: 1.15 [0.66 - 2.03]; P=0.618). There were no significant differences in the 1-year rates of all-cause death (2.8% versus 2.8%), all stroke (1.9% versus 3.6%), or rehospitalization (13.3% versus 10.6%, P > 0.05 for all). Quality of life as assessed by the Kansas City Cardiomyopathy Questionnaire score at 30 days or 1 year was comparable in both groups. CONCLUSIONS For patients at low risk for isolated surgery, MI and FS approaches were associated with similar in-hospital and 1-year outcomes.