Persistent and Recurrent Device-Related Thrombus After Left Atrial Appendage Closure: Incidence, Predictors, and Outcomes

BACKGROUND

Scarce data exist on the evolution of device-related thrombus (DRT) after left atrial appendage closure (LAAC).

OBJECTIVES

This study sought to assess the incidence, predictors, and clinical impact of persistent and recurrent DRT in LAAC recipients.

METHODS

Data were obtained from an international multicenter registry including 237 patients diagnosed with DRT after LAAC. Of these, 214 patients with a subsequent imaging examination after the initial diagnosis of DRT were included. Unfavorable evolution of DRT was defined as either persisting or recurrent DRT.

RESULTS

DRT resolved in 153 (71.5%) cases and persisted in 61 (28.5%) cases. Larger DRT size (OR per 1-mm increase: 1.08; 95% CI: 1.02-1.15; P = 0.009) and female (OR: 2.44; 95% CI: 1.12-5.26; P = 0.02) were independently associated with persistent DRT. After DRT resolution, 82 (53.6%) of 153 patients had repeated device imaging, with 14 (17.1%) cases diagnosed with recurrent DRT. Overall, 75 (35.0%) patients had unfavorable evolution of DRT, and the sole predictor was average thrombus size at initial diagnosis (OR per 1-mm increase: 1.09; 95% CI: 1.03-1.16; P = 0.003), with an optimal cutoff size of 7 mm (OR: 2.51; 95% CI: 1.39-4.52; P = 0.002). Unfavorable evolution of DRT was associated with a higher rate of thromboembolic events compared with resolved DRT (26.7% vs 15.1%; HR: 2.13; 95% CI: 1.15-3.94; P = 0.02).

CONCLUSIONS

About one-third of DRT events had an unfavorable evolution (either persisting or recurring), with a larger initial thrombus size (particularly >7 mm) portending an increased risk. Unfavorable evolution of DRT was associated with a 2-fold higher risk of thromboembolic events compared with resolved DRT.

Machine learning vs. conventional methods for prediction of 30-day readmission following percutaneous mitral edge-to-edge repair

BACKGROUND

Identifying predictors of readmissions after mitral valve transcatheter edge-to-edge repair (MV-TEER) is essential for risk stratification and optimization of clinical outcomes.

AIMS

We investigated the performance of machine learning [ML] algorithms vs. logistic regression in predicting readmissions after MV-TEER.

METHODS

We utilized the National-Readmission-Database to identify patients who underwent MV-TEER between 2015 and 2018. The database was randomly split into training (70 %) and testing (30 %) sets. Lasso regression was used to remove non-informative variables and rank informative ones. The top 50 informative predictors were tested using 4 ML models: ML-logistic regression [LR], Naive Bayes [NB], random forest [RF], and artificial neural network [ANN]/For comparison, we used a traditional statistical method (principal component analysis logistic regression PCA-LR).

RESULTS

A total of 9425 index hospitalizations for MV-TEER were included. Overall, the 30-day readmission rate was 14.6 %, and heart failure was the most common cause of readmission (32 %). The readmission cohort had a higher burden of comorbidities (median Elixhauser score 5 vs. 3) and frailty score (3.7 vs. 2.9), longer hospital stays (3 vs. 2 days), and higher rates of non-home discharges (17.4 % vs. 8.5 %). The traditional PCA-LR model yielded a modest predictive value (area under the curve [AUC] 0.615 [0.587-0.644]). Two ML algorithms demonstrated superior performance than the traditional PCA-LR model; ML-LR (AUC 0.692 [0.667-0.717]), and NB (AUC 0.724 [0.700-0.748]). RF (AUC 0.62 [0.592-0.677]) and ANN (0.65 [0.623-0.677]) had modest performance.

CONCLUSION

Machine learning algorithms may provide a useful tool for predicting readmissions after MV-TEER using administrative databases.

Outcomes of Transcatheter Aortic Valve Replacement With and Without Index Chronic Total Occlusion of Coronary Artery: A Propensity Matched Analysis

Transcatheter aortic valve replacement (TAVR) utilization is increasing, along with procedural success. Coronary angiography is frequently performed before the TAVR procedure for coronary artery disease workup. Chronic total occlusion (CTO) of the coronary artery shares common risk factors with aortic stenosis and could be challenging, especially in terms of procedural safety. The outcomes of TAVR among patients with concomitant CTO are not extensively studied. We analyzed the National Inpatient Sample database between October 2015 and December 2020 to evaluate the clinical characteristics, procedural safety, and outcomes among patients who underwent TAVR who had concomitant CTO lesions. A total of 304,330 TAVRs were performed between 2015 and 2020, 5,235 of which (1.72%) were in patients with TAVR-CTO and 299,095 (98.28%) in those with TAVR-no CTO. After propensity matching, there was no difference in the odds of in-hospital mortality (adjusted odds ratio [aOR] 1.28, 95% confidence interval [CI] 0.94 to 1.75, p = 0.11). However, TAVR-CTO was associated with an increased incidence of acute myocardial infarction (aOR 1.27, 95% CI 1.05 to 1.53, p = 0.01), cardiac arrest (aOR, 2.60, 95% CI 1.64 to 4.11, p <0.0001), and need for mechanical circulatory support (aOR 2.6, 95% CI 1.88 to 3.59, p <0.0001). There was no difference in the incidence of stroke, major bleeding, complete heart block, or requirement for permanent pacemaker between the 2 groups. However, the TAVR-CTO cohort had a slightly greater length of stay and total hospitalization cost. TAVR is a relatively safe procedure among those with concomitant CTO lesions; however, it is associated with a greater incidence of acute myocardial infarction, cardiac arrest, and requirement for mechanical circulatory support.

Lead Cap Use in Interventional Cardiology: Time to Protect Our Head in the Cardiac Catheterisation Laboratory?

Background: Radiation exposure is an occupational hazard for interventional cardiologists and cardiac catheterisation laboratory staff that can manifest with serious long-term health consequences. Personal protective equipment, including lead jackets and glasses, is common, but the use of radiation protective lead caps is inconsistent. Methods: A systematic review qualitative assessment of five observational studies using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines protocol was performed. Results: It was concluded that lead caps significantly reduce radiation exposure to the head, even when a ceiling-mounted lead shield was present. Conclusion: Although newer protective systems are being studied and introduced, tools, such as lead caps, need to be strongly considered and employed in the catheterisation laboratory as mainstay personal protective equipment.

Evaluating Gender-based Differences in Clinical Outcomes for Patients Undergoing Left Atrial Appendage Occlusion: A Single Centre Experience

There is emerging recent data that has shown women to be more prone to in-hospital major adverse events after trans catheter left atrial appendage occlusion. Institutional LAAO registry at West Virginia University (WVU) was reviewed from January 2016 to October 2021 to identify 271 women and 293 men who underwent successful LAAO device implantation. Patients were evaluated for gender-based differences in baseline characteristics, CHA₂DS₂-VASc Score, HAS-BLED score, procedural data, in-hospital, and follow-up outcomes. Compared to men, women had lower baseline comorbidities including coronary artery disease (135 (49.6%) vs 172 (58.7%), P = 0.03), myocardial infarction (MI) (56 (20.5%) vs 85 (29%), P = 0.02) and coronary artery bypass surgery (10 (3.6%) vs 27 (9.2%), P = 0.008). Women were noted to have a higher CHA₂DS₂-VASc Score (5.3 ± 1.4 vs 4.4 ± 1.4, P < 0.001), and left ventricular ejection fraction (57.9 ± 7.7 vs 52.7 ± 12.4, P < 0.001). Women were noted to have a significantly higher rate of in-hospital composite adverse events (74 (27.2%) vs 58 (19.8%), P = 0.03); bleeding events (38 (10.2%) vs 19 (6.4%), P = 0.003) and associated blood transfusion (6 vs 0, P = 0.001) compared with men. No statistically significant differences were noted between both genders regarding the follow-up outcome. Our single center study shows women to have higher in-hospital composite adverse events as well as higher bleeding events during the index hospital admission.

Cardiovascular outcomes of transradial versus transfemoral percutaneous coronary intervention in End-Stage renal Disease: A Regression-Based comparison

Background

Limited data is available on the comparison of outcomes of transradial (TR) and transfemoral (TF) access for percutaneous coronary intervention (PCI) in patients with end-stage stage renal disease (ESRD).

Methods

Online databases were queried to compare cardiovascular outcomes among TR. and TF in ESRD patients. The outcomes assessed included differences in mortality, cerebrovascular accidents (CVA), periprocedural myocardial infarction (MI), bleeding, transfusion, and periprocedural cardiogenic shock (CS). Unadjusted odds ratios (OR) were calculated using a random-effect effect model.

Results

A total of 6 studies including 7,607 patients (TR-PCI = 1,288; TF-PCI = 6,319) were included. The overall mean age was 67.7 years, while the mean age for TR-PCI and TF-PCI was 69.7 years and 67.9 years, respectively. TR-PCI was associated with lower incidence of mortality (OR 0.46 95 % CI 0.30–0.70, p < 0.05, I2 0.00 %), bleeding (OR 0.45 95 % CI 0.29, 0.68, p < 0.05, I2 3.48 %), and transfusion requirement (OR 0.52 95 % CI 0.40, 0.67, p < 0.05, I2 0.00 %) (Fig. 1). There were no differences among TR-PCI and TF-PCI for periprocedural MI, periprocedural CS, and CVA outcomes.

Conclusion

TR access was associated with lower mortality, bleeding, and transfusion requirement as compared to TF access in patients with ESRD undergoing PCI.

Snare and track (SNACK) technique: a novel approach for successful placement of an intracardiac echocardiogram catheter in the left atrium: a case report

Background

Placing an intracardiac echocardiogram (ICE) catheter in the left atrium allows for excellent visualization of the left atrial appendage to guide left atrial (LA) appendage occlusion (LAAO). Nonetheless, it requires a separate septal puncture or a unique set of skills to navigate the ICE through a previously prepared septal puncture, which can be challenging.

Case summary

This report describes a novel method to insert an ICE in the left atrium through a single septal puncture utilizing a snare technique. A 76-year-old male underwent LAAO by ICE guidance. After obtaining a standard atrial septal puncture, we were unable to advance the ICE into the left atrium. Therefore, we used a loop snare to grasp the ICE catheter-tip in the right atrium and direct it into the left atrium via the prepared septal puncture by tracking a pigtail wire that we routinely place as part of the procedure. Afterward, the left atrial appendage was successfully occluded with a Watchman device (Boston Scientific, Galway, Ireland), and the patient was discharged home without complications.

Discussion

The described technique could be a helpful tool for ICE placement to the left atrium in a controlled fashion, especially when challenging anatomy is encountered.

Meta-Analysis Comparing Distal Radial Versus Traditional Radial Percutaneous Coronary Intervention or Angiography

Data comparing outcomes of distal radial (DR) and traditional radial (TR) access of coronary angiography and percutaneous coronary intervention (PCI) are limited. Online databases including Medline and Cochrane Central databases were explored to identify studies that compared DR and TR access for PCI. The primary outcome was the rate of radial artery occlusion (RAO) and access failure. Secondary outcomes included access site hematoma, access site bleeding, access site pain, radial artery spasm, radial artery dissection, and crossover. Unadjusted odds ratios (ORs) with a random-effect model, 95% confidence interval (CI), and p <0.05 were used for statistical significance. Metaregression was performed for 16 studies with 9,973 (DR 4,750 and TR 5,523) patients were included. Compared with TR, DR was associated with lower risk of RAO (OR 0.51, 95% CI 0.29 to 0.90, I² = 42.6%, p = 0.02). RAO was lower in DR undergoing coronary angiography rather than PCI. Access failure rate (OR 1.77, 95% CI 0.69 to 4.55, I² 87.36%, p = 0.24), access site hematoma (OR 1.11, 95% CI 0.68 to 1.83, I² 0%, p = 0.68), access site pain (OR 2.22, 95% CI 0.28 to 17.38, I² 0%, p = 0.45), access site bleeding (OR 1.11, 95% CI 0.16 to 7.62, I² 85.11%, p = 0.91), radial artery spasm (OR 0.79, 95% CI 0.49 to 1.29, I² 0%, p = 0.35), radial artery dissection (OR 1.63, 95% CI 0.46 to 5.84, I² 0%, p = 0.45), and crossover (OR 1.54, 95% CI 0.64 to 3.70, I² 25.48%, p = 0.33) did not show any significant difference. DR was associated with lower incidence RAO when compared with TR, whereas other procedural-related complications were similar.

Leak closure following left atrial appendage exclusion procedures: A multicenter registry

BACKGROUND

Though infrequent, incomplete left atrial appendage closure (LAAC) may result from residual leaks. Percutaneous closure has been described though data is limited.

METHODS

We compiled a registry from four centers of patients undergoing percutaneous closure of residual leaks following LAAC via surgical means or with the Watchman device. Leak severity was classified as none (no leak), mild (1-2 mm), moderate (3-4 mm), or severe (≥5 mm). Procedural and clinical success was defined as the elimination of leak or mild residual leak at the conclusion of the procedure or follow-up, respectively.

RESULTS

Of 72 (age 72.2 ± 9.2 years; 67% male) patients, 53 had undergone prior LAAC using the Watchman device and 19 patients surgical LAAC. Mean CHADS₂ -VA₂ Sc score was 4.0 ± 1.8. The median leak size was 5 mm, range: 2-13). A total of 13 received Amplatzer Vascular Plug-II, 18 received Amplatzer Duct Occluder-II and 40 patients received coils. One underwent closure using a 21 mm-Watchman. Procedural success was 94%. Zero surgical and nine Watchman patients (13%) had a residual leak at procedural-end (five mild, three moderate, and one severe)-only one patient had no reduction in leak size. Overall leak size reduction was 94%. Two (3%) had intraoperative pericardial effusion. There were no device embolizations, device-related thrombi, or procedural deaths. Clinical success was maintained at 94%. Two had cerebrovascular accidents-at 2 days (transient ischemic attack) and 10 months postprocedure. Two had major bleeding outside the 30-day periprocedural window.

CONCLUSION

Percutaneous closure of residual leaks following left atrial appendage closure is feasible and associated with good outcomes. The procedural risk appears to be satisfactory.

Comparison of left atrial appendage parameters using computed tomography vs. transesophageal echocardiography for watchman device implantation: a systematic review & meta-analysis

BACKGROUND

Inaccurate sizing of left atrial appendage (LAA) occlusion devices is associated with increased stroke risk. We compared the LAA size to implant the Watchman device assessed by computed tomography (CT) to transesophageal echocardiography (TEE). We also compared procedural outcomes between the two modalities.

METHODS

Databases were searched to identify studies comparing LAA anatomical measurements and procedural outcomes across imaging modalities for the Watchman device implantation.

RESULTS

Seven studies were included in the analysis (242 patients on TEE, and 232 on CT). The LAA orifice was larger when sized with CT compared to TEE (CT mean vs TEE SMD 0.30mm, 95%CI 0.09-0.51mm, P<0.01; and CT max vs TEE SMD 0.69mm, 95%CI 0.51-0.87mm, P < 0.001). Additionally, CT, including CT-based 3-dimensional models, had higher odds of predicting correct device size compared to TEE (OR 1.64; 95%CI 1.05-2.56; P = 0.03). CT resulted in a lower fluoroscopy time vs TEE (SMD -0.78 min, 95% CI -1.39 to -0.18, P = 0.012). No significant differences were found in device clinical outcomes.

CONCLUSION

Compared to TEE, CT resulted in larger LAA orifice measurements, improved odds of predicting correct device size, and reduced fluoroscopy time in patients undergoing LAA occlusion with the Watchman device. There were no significant differences in other procedural outcomes.

Treatment Effect of Percutaneous Coronary Intervention in Dialysis Patients With ST-Elevation Myocardial Infarction

RATIONALE & OBJECTIVE

Patients receiving maintenance dialysis have higher mortality following primary percutaneous coronary intervention (pPCI) than patients not receiving dialysis. Whether pPCI confers a similar benefit to patients receiving dialysis remains unknown. We compared the effect of pPCI on in-hospital outcomes among patients hospitalized for STEMI and receiving maintenance dialysis to the effect among patients hospitalized for STEMI but not receiving dialysis.

STUDY DESIGN

Retrospective cohort study.

SETTING & PARTICIPANTS

We used the National-Inpatient-Sample (2016-2018) and included all adult hospitalizations with a primary diagnosis of STEMI.

PREDICTORS

Primary exposure was PCI. Confounders included dialysis status, demographics, insurance, household income, comorbidities, and the elective nature of the admission.

OUTCOMES

In-hospital mortality, stroke, AKI, new dialysis requirements, vascular complications, gastrointestinal bleeding, blood transfusion, mechanical ventilation, palliative care, and discharge destination.

ANALYTICAL APPROACH

The average treatment effect [ATE] of pPCI was estimated using propensity score matching within ESRD and non-ESRD groups independently to explore if the effect is modified by ESRD status. Additionally, the average marginal effect [AME] was calculated accounting for the clustering within hospitals.

RESULTS

4,220 (1.07%) out of 413,500 hospitalizations were for patients receiving dialysis. The dialysis cohort was older (65.2±12.2 vs. 63.4±13.1, p<0.001), had more females (42.4% vs. 30.6%, p<0.001) and more comorbidities, but fewer White patients (41.1% vs. 71.7%, p<0.001). Patients receiving dialysis underwent less angiography (73.1% vs. 85.4%, p<0.001) or pPCI (57.5% vs. 79.8%, p<0.001). pPCI was associated with lower mortality in patients receiving dialysis (15.7% vs. 27.1%, p<0.001) as well as in those who were not (5.0% vs. 17.4%, p<0.001). The ATE on mortality did not differ significantly between patients receiving dialysis (-8.6% [-15.6%, -1.6%], p=0.02) and those who were not (-8.2% [-8.8%, -7.5%], p<0.001 (p-interaction=0.9). The AME method showed similar results (-9.4% [-14.8%, -4.0%], p<0.001) among patients receiving dialysis and those who were not (-7.9% [-8.5%, -7.4%], p<0.001) (p-interaction=0.59). Both the ATE and AME were comparable for other in-hospital outcomes in both groups.

LIMITATIONS

Administrative data, lack of pharmacotherapy and long-term outcome data, and residual confounding.

CONCLUSION

Compared with conservative management, pPCI for STEMI was associated with comparable reductions in short-term mortality among patients irrespective of their receipt of maintenance dialysis.

Treatment Effect of Percutaneous Coronary Intervention in Men Versus Women With ST-Segment-Elevation Myocardial Infarction

Background Women are less likely to receive primary percutaneous coronary intervention (pPCI) than men. A potential reason is risk aversion because of the worse outcomes with pPCI among women. However, whether pPCI is associated with a comparable mortality benefit in men and women remains unknown. Methods and Results We selected patients admitted with a principal diagnosis of ST-segment-elevation myocardial infarction in the National Inpatient Sample (2016-2018). We used propensity-score matching to calculate average treatment effects of pPCI for in-hospital mortality, major complications, length of stay, and cost. As a sensitivity analysis, we used logit models followed by a marginal command to calculate the average marginal effect. We included 413 500 weighted hospitalizations (30.7% women, 69.3% men). Women had more comorbidities except smoking and prior sternotomy. Compared with men, women were less likely to undergo angiography (81.0% versus 87.0%; adjusted odds ratio [OR], 0.77; 95% CI, 0.74-0.81; P<0.001) or pPCI (74.0% versus 82.0%; adjusted OR, 0.76; 95% CI, 0.73-0.79; P<0.001). There were no significant differences in average treatment effects of pPCI on mortality between men (-8.4% [-9.3% to -7.6%], P<0.001), and women (-9.5% [-10.8% to -8.3%], P<0.001) (P interaction=0.16). This persisted in age-stratified analyses (≥85, 65-84, 45-64, <45 years) and sensitivity analysis, excluding emergent admissions. The average treatment effects of pPCI on major complications were comparable except for acute stroke, leaving against medical advice, and palliative encounter. There were no differences in the average treatment effects of pPCI on length of stay, but the proportional increase in cost with pPCI was higher in women. Conclusions pPCI results in a comparable reduction in in-hospital mortality in men and women. Nonetheless, risk-adjusted rates of pPCI remain lower in women in contemporary US practice.

Trends in outcomes, cost, and readmissions of transcatheter edge to edge repair in the United States (2014-2018)

INTRODUCTION

Despite the growth in transcatheter edge-to-edge repair (TEER) volume in the United States, data on the temporal changes in procedural outcomes are lacking.

METHODS

We utilized the National Readmission Database to assess the annual changes in patient's characteristics, in-hospital outcomes, cost, and readmissions for patients who underwent TEER between January 1, 2014 and December 31, 2018. Outcomes of interest included mortality, major adverse cardiovascular events (MACE) and any adverse event (AE). We also assessed length of stay and cost.

RESULTS

A total of 22,692 hospitalizations were included. The mean age increased from 75.2 ± 12.9 in 2014 to 78.1 ± 9.8 years in 2018. Changes in the prevalence of risk factors were heterogenous. The incidence of in-hospital mortality decreased from 4.0% in 2014 to 2.0% in 2018. Both MACE and any AE decreased significantly. Although the incidence of 30-day readmission remained stable, there was a trend towards a temporal increase in both 90-day and 180-day. The adjusted median length of stay of the index admission decreased by 50% and this trend was associated with a $2100 reduction in risk and inflation adjusted in-hospital cost, however, this reduction was offset by the increased total cost of readmissions within the first 6 months resulting in similar net-cost.

CONCLUSION

The volume of TEER has grown substantially between 2014 and 2018 coupled with a temporal improvement in in-hospital outcomes and reduction in cost and length of stay. Re-hospitalization rates after TEER remained steady at 30-day and trended towards worsening overtime at 90- and 180-days.

Predictors of Device-Related Thrombus Following Percutaneous Left Atrial Appendage Occlusion

BACKGROUND

Device-related thrombus (DRT) has been considered an Achilles' heel of left atrial appendage occlusion (LAAO). However, data on DRT prediction remain limited.

OBJECTIVES

This study constructed a DRT registry via a multicenter collaboration aimed to assess outcomes and predictors of DRT.

METHODS

Thirty-seven international centers contributed LAAO cases with and without DRT (device-matched and temporally related to the DRT cases). This study described the management patterns and mid-term outcomes of DRT and assessed patient and procedural predictors of DRT.

RESULTS

A total of 711 patients (237 with and 474 without DRT) were included. Follow-up duration was similar in the DRT and no-DRT groups, median 1.8 years (interquartile range: 0.9-3.0 years) versus 1.6 years (interquartile range: 1.0-2.9 years), respectively (P = 0.76). DRTs were detected between days 0 to 45, 45 to 180, 180 to 365, and >365 in 24.9%, 38.8%, 16.0%, and 20.3% of patients. DRT presence was associated with a higher risk of the composite endpoint of death, ischemic stroke, or systemic embolization (HR: 2.37; 95% CI, 1.58-3.56; P < 0.001) driven by ischemic stroke (HR: 3.49; 95% CI: 1.35-9.00; P = 0.01). At last known follow-up, 25.3% of patients had DRT. Discharge medications after LAAO did not have an impact on DRT. Multivariable analysis identified 5 DRT risk factors: hypercoagulability disorder (odds ratio [OR]: 17.50; 95% CI: 3.39-90.45), pericardial effusion (OR: 13.45; 95% CI: 1.46-123.52), renal insufficiency (OR: 4.02; 95% CI: 1.22-13.25), implantation depth >10 mm from the pulmonary vein limbus (OR: 2.41; 95% CI: 1.57-3.69), and non-paroxysmal atrial fibrillation (OR: 1.90; 95% CI: 1.22-2.97). Following conversion to risk factor points, patients with ≥2 risk points for DRT had a 2.1-fold increased risk of DRT compared with those without any risk factors.

CONCLUSIONS

DRT after LAAO is associated with ischemic events. Patient- and procedure-specific factors are associated with the risk of DRT and may aid in risk stratification of patients referred for LAAO.

Gender-based outcomes of coronary bifurcation stenting: A report from the National Readmission Database

BACKGROUND

There is a paucity of data focusing on women's outcomes after percutaneous coronary interventions (PCI) for coronary bifurcation lesions (CBLs).

METHODS

Patients who received PCI for CBLs in the context of acute coronary syndrome (ACS) during the period of 01 October 2015- 31 December 2017, were identified from the United States National Readmission Database. The primary endpoint of this study was in-hospital major adverse events (MAEs). The secondary endpoints were in-hospital mortality, vascular complications, major bleeding, post-procedural bleeding, need for blood transfusion, severe disability surrogates (non-home discharge and need for mechanical ventilation), resources utilization surrogates (length of stay and cost of hospitalization), and 30-day readmission rate. A 1:1 propensity score matching was used to compare the outcomes between women and men.

RESULTS

A total of 25,050 (women = 7,480; men = 17,570) patients were included in the current analysis. After propensity score matching, women had higher in-hospital MAEs (7 vs 5.2%, p < .01), major bleeding (1.8 vs 0.8%, p < .01), post-procedural bleeding (6.1 vs 3.4%, p < .01), need for blood transfusion (6.4 vs 4.2%, p < .01), non-home discharges (10.2 vs 7.1%; p < .01), longer length of hospital stay (3 days [IQR 2-6] vs. 3 days [IQR 2-5], p < .01) and higher 30-day readmission rate compared to men (14.2 vs. 11.5%, p < .01).

CONCLUSIONS

Among all-comers who received PCI for CBLs in the context of ACS, women suffered higher MAEs and 30-day readmission rates compared to their men' counterparts. The higher MAEs in the women were mainly driven by higher postprocedural bleeding rates and the need for blood transfusion.

Differences in the characteristics and outcomes of isolated tricuspid and mitral valve surgery for valvular regurgitation

BACKGROUND

Isolated tricuspid valve (TV) surgery is associated with markedly worse outcomes than isolated mitral valve (MV) surgery. We hypothesized that this is related to late referral of patients with isolated TV disease.

METHODS

Adult patients who underwent isolated TV or MV surgery in 2016-2017 were identified in the National-Readmission-Database. We compared the outcomes of isolated TV and MV surgery before and after adjustment for surrogates of late referral.

RESULTS

A total of 21,446 patients who had isolated MV (n = 19,933), or TV surgery (n = 1153) were included. Patients in the TV group were younger (55.7 ± 16.6 vs. 63.4 ± 12.3 years), had lower socioeconomic status, but higher prevalence of surrogates for late referral [acute HF 41.0% vs. 22.0%, advanced liver disease 16.8% vs. 2.6%, non-elective surgery status 44.3% vs. 23.5%, need for peri-operative mechanical circulatory support 27.7% vs. 4.7%, and unplanned admissions in the 90 days before surgery 31.0% vs. 18.8%, (P < 0.001 for all)]. Surgery was performed on day 0/1 of the admission in 80% of patients in the MV group and 52% in the TV group, P < 0.001. Repair rate was 63.5% in the TV group and 56.3% in the MV group (P < 0.001). In-hospital mortality was 3-folds higher after TV surgery (8.7% vs. 2.5%; OR = 3.41, 95%CI 2.73-4.25, p < 0.001). However, this difference became non-significant after adjusting for baseline characteristics including surrogates for late referral (OR = 1.24, 95%CI 0.85-1.82, p = 0.27).

CONCLUSION

The poor outcomes of isolated TV surgery compared with isolated MV surgery may be largely explained by the late referral for intervention in patients with isolated TR.

Association of Transcatheter Mitral Valve Repair Availability With Outcomes of Mitral Valve Surgery

Background

Transcatheter mitral valve repair (TMVr) is currently offered at selected centers that meet certain operator and institutional requirements. We sought to explore the hypothesis that the availability of TMVr is associated with improved outcomes of MV surgery.

Methods and Results

We used the Nationwide Readmissions Database to identify patients who underwent MV surgery at centers with or without TMVr capabilities between January 1 and December 31, 2017. The primary end point was in‐hospital mortality. Secondary end points were postoperative complications, resource use, and 30‐day readmissions. A total of 24 477 patients from 595 centers (446 TMVr, 149 non‐TMVr) were included. There were modest but statistically significant differences in the prevalence of comorbidities between the groups. Patients at non‐TMVr centers had higher unadjusted in‐hospital mortality than those at TMVr centers (5.6% versus 3.6%, P<0.001). They also had higher rates of postoperative complications, longer hospitalizations, higher cost, and fewer home discharges but similar 30‐day readmission rates. After propensity matching, mortality remained higher at non‐TMVr centers (5.5% versus 4.0%, P<0.001). Rates of postoperative complications, prolonged hospitalizations, and nonhome discharges also remained higher. Postoperative mortality was consistently higher at non‐TMVr centers in multiple risk‐adjustment analyses incrementally accounting for differences in risk factors, surgical volume, availability of surgical repair, and excluding concomitant procedures. In the most comprehensive model, surgery at non‐TMVr centers was associated with higher odds of death (odds ratio, 1.41; 95% CI, 1.14–1.73; P=0.002).

Conclusions

Mitral valve surgery at TMVr centers is associated with improved in‐hospital outcomes compared with non‐TMVr centers.

Determinants of Morbidity and Mortality Associated With Isolated Tricuspid Valve Surgery

Background

Whether the poor outcomes of isolated tricuspid valve surgery are related to the operation itself or to certain patient characteristics including late referral is unknown.

Methods and Results

Adult patients who underwent isolated tricuspid valve surgery were identified in the Nationwide Readmissions Database (2016–2017). Patients who had redo tricuspid valve surgery, endocarditis, or congenital heart disease were excluded. Multivariable logistic regression was performed to identify contributors to postoperative mortality. A total of 1513 patients were included (mean age 55.7±16.6 years, 49.6% women). Surrogates of late referral were frequent: 41% of patients were admitted with decompensated heart failure, 44.3% had a nonelective surgery status, 16.8% had advanced liver disease, and 31% had an unplanned hospitalization in the prior 90 days. The operation was performed on day 0 to 1 of the hospitalization in only 50% of patients, and beyond day 10 in 22% of patients. In‐hospital mortality occurred in 8.7% of patients. Median length of stay was 14 days (7–35 days), and median cost was $87 223 ($43 122–$200 872). In multivariable logistic regression analysis, surrogates for late referrals (acute heart failure decompensation, nonelective surgery status, or advanced liver disease) were the strongest predictors of in‐hospital mortality (odds ratio [OR], 4.75; 95% CI, 2.74–8.25 [P<0.001]). This was also consistent in a second model incorporating unplanned hospitalizations in the 90 days before surgery as a surrogate for late referral (OR, 5.50; 95% CI, 2.28–10.71 [P<0.001]).

Conclusions

The poor outcomes of isolated tricuspid valve surgery may be largely explained by the late referral for intervention. Studies are needed to determine the role of early intervention for severe isolated tricuspid regurgitation.

Temporal Trends in Resource Use, Cost, and Outcomes of Transcatheter Aortic Valve Replacement in the United States

OBJECTIVE

To evaluate the contemporary trends in outcomes and resource use associated with transcatheter aortic valve replacement (TAVR) in the United States.

METHODS

We identified patients who underwent TAVR between January 1, 2012, and December 31, 2017, in the National Readmission Database. We assessed temporal trends in clinical outcomes, length-of-stay, non-home discharges, and cost of the index TAVR hospitalization. We also evaluated the changes in the burden of hospitalizations before and after TAVR.

RESULTS

A total of 89,202 patients were included. In-hospital mortality decreased from 5.3% (188) in 2012 to 1.6% (484) in 2017 (adjusted odds ratio: 0.37, 95% CI: 0.30 to 0.46). Risk-adjusted incidences of new dialysis, vascular complications, blood transfusion, and mechanical ventilation decreased, but strokes and pacemaker implantations remained unchanged. Length of stay decreased from median of 7 (interquartile range [IQR]: 4 to 11) to 2 (IQR: 2 to 5) days (P<.001). Risk-adjusted non-home discharges decreased from 32.2% (1134) to 15.5% (386) (P<.001). Median cost of the TAVR hospitalization decreased from $56,022 (IQR: $43,690 to $75,174) to $46,101 (IQR: $36,083 to $59,752) (P<.001). Pre-TAVR admissions at 30, 90, and 180 days decreased from 21.6% (713), 39.5% (1160), and 50.5% (1009) in 2012 to 15.5% (4451), 30.2% (7186), and 36.8% (5928) in 2017, respectively (P<.001). Similarly, re-hospitalizations at 30, 90, and 180 days post-TAVR decreased from 17.5% (531), 27.9% (657), and 34.2% (521) to 12.4% (3486), 21.1% (4783), and 29.1% (4306), respectively (P<.001). The expenditure on index, pre-, and post-TAVR hospitalizations increased from $0.53 to $2.8 billion between 2012 and 2017.

CONCLUSION

This study reflects the changes in the characteristics and outcomes of TAVR in the United States between 2012 and 2017. It also shows the temporal decrease in resource use, cost, and burden of hospitalizations among patients undergoing TAVR in the United States, but an increase in the overall expenditure on TAVR-related hospitalizations.

The state of renal sympathetic denervation for the management of patients with hypertension: A systematic review and meta-analysis

BACKGROUND

Sympathetic nervous system plays a central role in the development and persistence of essential hypertension. In recent years renal sympathetic denervation (RSD) has emerged as a promising option for the treatment of patients with hypertension.

METHODS

We conducted a literature search of PubMed, EMBASE, Cochrane library and Clinicaltrials.gov from inception through April 20, 2020. Outcomes of interest were change in 24-hour ambulatory systolic (ASBP) or diastolic blood pressure (ADBP) and change in office systolic (OSBP) or diastolic blood pressure (ODBP). We pooled data from randomized controlled trials (RCTS) comparing RSD to sham procedures in the management of hypertension using the random effect model.

RESULTS

A total of 1,363 patients from eight studies were included in the current meta-analysis. The mean age of the included patients was 56 ± 2.6 years, 29% were women and the median duration of maximum follow up was 6-month (range 3-12 month). There was more reduction favoring RSD in ASBP (Weighted mean difference [WMD] -3.55; 95% CI -4.91 - -2.19, p < .001, I² = 0%), ADBP (WMD -1.87; 95% CI -3.07 - -0.66, p = .002, I² = 43%), OSBP (WMD -5.5; 95% CI -7.59 - -3.40, p < .001, I² = 7%) and ODBP (WMD -3.20; 95% CI -4.47 - -1.94, p < .001, I² = 14%).

CONCLUSION

The use of RSD for the management of hypertension resulted in effective reduction in the ambulatory and office blood pressure compared to sham procedure. Adequately powered RCTs of RSD are needed to confirm safety, reproducibility and assess the impact on clinical outcomes.

Gender-based outcomes of impeller pumps percutaneous ventricular assist devices

BACKGROUND

There is paucity of data focusing on females' outcomes after the use of impeller pumps percutaneous ventricular assist devices (IPVADs).

METHODS

Patients who received IPVADs during the period of October 1st, 2015-December 31, 2017, were identified from the United States National Readmission Database. A 1:1 propensity score matching was used to compare the outcomes between females and males.

RESULTS

A total of 19,278 (Female = 5,456; Male = 13,822) patients were included in the current analysis. After propensity score matching and among all-comers who were treated with IPVADs, females had higher in-hospital major adverse events (MAEs) (38 vs. 32.6%, p < .01), mortality (31 vs. 28%, p < .01), vascular complications (3.3 vs. 2.1%, p < .01), major bleeding (7.8 vs. 4.8%, p < .01), nonhome discharges (21.6 vs. 16.3%; p < .01), and longer length of stay (7 days [IQR 2-12] vs. 6 days [IQR 2-12], p = .02) with higher 30-day readmission rate compared to males (20.5 vs.16.4%, p < .01). Furthermore, among patients who received the IPVADs for high-risk percutaneous coronary intervention (HRPCI), females continued to have worse MAEs, which was driven by high rates of major bleeding. However, among patients who received IPVADs for cardiogenic shock (CS) the outcomes of females and males were comparable.

CONCLUSIONS

Among all-comers who received IPVADs, females suffered higher morbidity and mortality compared to males. Higher morbidity driven mainly by higher rates of major bleeding was seen among females who received IPVADs for the hemodynamic support during HRPCI and comparable outcomes were observed when the IPVADs were used for CS.

Sex-stratified analysis of the safety of percutaneous left atrial appendage occlusion

OBJECTIVES AND BACKGROUND

There is insufficient current evidence about whether sex impacts outcomes of percutaneous left atrial appendage occlusion (LAAO). The aim of this study was to investigate the association between sex and short-term outcomes of LAAO.

METHODS

Patients who were hospitalized and underwent LAAO from October 2015 to December 2017 in the National Readmission Database were queried. The primary endpoint of interest was major in-hospital adverse events. Secondary endpoints included, 30-day readmission rate, nonhome discharge, and cost of hospitalization. Propensity score matching (1:1) was performed to compare the outcomes among women and men.

RESULTS

A total of 9,281 patients were included in the current analysis [women = 3,659 (39%); men = 5,622 (61%)]. Comparing women to men, women had lower prevalence of diabetes mellitus (30.6% vs 35.7%, p < .01), heart failure (28.6% vs 30.8%, p = .03), vascular disease (55.5% vs 69.6%, p < .01) and renal failure (18.3% vs 21.2%, p < .01), and higher CHA₂ DS₂ VASc score (5 [IQR4-6] vs 4 [IQR3-6], p < .01). After propensity-score matching, women had higher rate of major in-hospital adverse events (2.8% vs 1.9%; p < .01), and nonhome discharges (11.4% vs 6.7%; p < .01). Additionally, 30-day readmission rate was higher among women (10% vs 8.6%, p = .03).

CONCLUSION

Among hospitalized patients undergoing LAAO, women carry higher risk for major in-hospital adverse events, nonhome discharge, and 30-day readmission rates.

Temporal Trends in the Incidence and Outcomes of Pacemaker Implantation After Transcatheter Aortic Valve Replacement in the United States (2012-2017)

Background

Nationwide studies documenting temporal trends in permanent pacemaker implantation (PPMI) following transcatheter aortic valve replacement (TAVR) are limited.

Methods and Results

We selected patients who underwent TAVR between 2012 and 2017 in the National Readmission Database. The primary end point was the 6‐year trend in post‐TAVR PPMI at index hospitalization and at 30, 90, and 180 days after discharge. The secondary end point was the association between PPMI and in‐hospital mortality, stroke, cost, length of stay, and disposition. Among the 89 202 patients who underwent TAVR, 77 405 (86.8%) with no prior pacemaker or defibrillator were included. Patients who required PPMI had a higher prevalence of atrial fibrillation (43.6% versus 38.7%, P<0.001) and conduction abnormalities (28.4% versus 15.3%, P<0.001). The incidence of PPMI during index admission increased from 8.7% in 2012 to 13.2% in 2015, and then decreased to 9.6% in 2017. The incidence of inpatient PPMI within 30 days after discharge increased from 0.5% in 2012 to 1.25% in 2017 (P_trend<0.001). Inpatient PPMI beyond 30 days remained rare (<0.5%) during the study period. After risk adjustment, PPMI was not associated with in‐hospital mortality or stroke but was associated with increased nonhome discharge, longer hospitalization, and higher cost. The incremental expenditure associated with post‐TAVR PPMI during index admission increased from $9.6 million to $72.2 million between 2012 and 2017.

Conclusions

After an upward trend, rates of PPMI after TAVR in the United States stabilized at ~10% in 2016 to 2017, but there was a notable increase in PPMI within 30 days after the index admission. PPMI was not associated with increased in‐hospital morbidity or mortality but led to longer hospitalization, higher cost, and more nonhome discharges.

Incidence and Outcomes of Acute Ischemic Stroke Following Percutaneous Coronary Interventions in Men Versus Women

Comparative data on the incidence and outcomes of stroke after percutaneous coronary interventions (PCI) between men and women are limited. We identified hospitalizations for PCI in the National-Inpatient-Sample between January 1, 2003 and December 31, 2016. We compared the incidence of post-PCI stroke and in-hospital complications, mortality, and cost of post-PCI strokes between men and women. Among 8,753,574 weighted hospitalizations for PCI, 49,097 (0.56%) were complicated with ischemic stroke. The incidence of post-PCI stroke was higher in women than men following PCI for ST-elevation myocardial infarction (STEMI) 1.4% versus 0.8% (odds ratio [OR] 1.69, 95% confidence interval [CI] 1.62 to 1.77, p <0.001), non-ST-elevation myocardial infarction (NSTEMI) 1.1% versus 0.7% (OR 1.59, 95% CI 1.52 to 1.63, p <0.001), and unstable angina/stable ischemic heart disease (US/SIHD) (0.5% vs 0.3%, OR 1.66, 95% CI 1.61 to 1.72, p <0.001). These differences remained significant after risk adjustment. Among patients with post-PCI stroke, women had worse on-hospital mortality, and major complications compared with men. However, after propensity score matching, post-PCI mortality was similar in men and women who suffered a stroke after STEMI (23.0% vs 25.7%, p = 0.34), and NSTEMI (9.9% vs 9.1%, p = 0.56), but higher in women who suffered a stroke after PCI for UA/SIHD (12.5% vs 10.4%, p = 0.042). Surrogates of disabling stroke, length of stay, and cost were similar in men and women. However, women had more vascular complications and blood transfusion across all indications. In conclusion, women are more likely to suffer post-PCI stroke than males regardless of the PCI indication. Among those with post-PCI strokes, women have higher adjusted rates of vascular complications and blood transfusion.

Thirty-Day Readmissions After Chronic Total Occlusion Percutaneous Coronary Intervention in the United States: Insights From the Nationwide Readmissions Database

BACKGROUND

Several studies have investigated early readmissions after percutaneous coronary interventions (PCIs). However, studies investigating 30-day readmission following PCI for chronic total occlusion (CTO) are lacking.

METHODS

The National-Readmission-Database (NRD) was queried to identify patients undergoing elective CTO PCI between January 1, 2016 and December 31, 2016. We assessed the incidence, predictors, and cost of 30-day readmissions.

RESULTS

A total of 30,579 CTO PCIs were identified in the NRD. After excluding patients who had acute myocardial infarction (n = 14,852), the final cohort included 15,907 patients. In this group of patients, 254 patients (1.5%) expired during their index admission and, 1600 patients (10%) had an unplanned readmission within 30 days. Cardiac causes constituted 54.2% of all causes of readmission. During the readmission, 15.8% of patients had coronary angiography, 8.4% underwent PCI, and 0.9% underwent bypass grafting. Independent predictors of 30-day readmission included baseline characteristics [age (OR 0.99, 95%CI 0.98-0.99), female (OR 1.14, 95%CI 1.01-1.28), lung disease (OR 1.36, 95%CI 1.20-1.55), heart failure (OR 1.42, 95%CI 1.24-1.62), anemia (OR 1.30, 95%CI 1.12-1.50), vascular disease (OR 1.18, 95%CI 1.03-1.35), history of stroke (OR 1.50, 95%CI 1.28-1.76) and the presence of a defibrillator (OR 1.68, 95%CI 1.39-2.03)], and procedural complications [acute kidney injury (OR 1.55, 95%CI 1.33-1.80) and gastrointestinal bleeding (OR 1.67, 95%CI 1.03-2.71)].

CONCLUSIONS

One-tenth of patients undergoing CTO PCI are readmitted within 30-days, mostly for cardiac causes. The majority undergo angiography but <10% receive revascularization. Certain patient and procedural characteristics independently predicted 30-day readmission.

Temporal trends in the utilization and outcomes of percutaneous coronary interventions in patients with liver cirrhosis

OBJECTIVES

We sought to assess the national trends in the utilization and outcomes of percutaneous coronary interventions (PCI) in patients with cirrhosis.

BACKGROUND

Contemporary data on PCI in patients with liver cirrhosis are limited.

METHODS

The National-Inpatient-Sample was used to identify patients who underwent PCI between 2003 and 2016. We examined the annual PCI rate, and compared the in-hospital morbidity, mortality, resource utilization, and cost following PCI in patients with and without cirrhosis.

RESULTS

A total of 8,860,178 PCI hospitalizations were identified, of those, 20,339 (0.2%) were performed in patients with cirrhosis. Annual PCI rates decreased overtime in patients without liver cirrhosis but increased in those with cirrhosis (P_trend < .001). Patients with cirrhosis had a characteristic clinical, demographic, and socioeconomic profile compared with those without cirrhosis. The use of bare-metal stents decreased from 69.1 to 11.4% in the noncirrhosis group, and from 81.9 to 21.3% in the cirrhosis group. Compared with propensity-matched patients without cirrhosis, PCI in cirrhotic patients was associated with higher in-hospital mortality across all indications (STEMI 19.1 vs. 11.5%, p = .002; NSTEMI 8.7 vs. 5.6%, p = .002; and UA/SIHD 7.7 vs. 4.3%, p < .001). Cirrhotic patients also had significantly higher rates of acute kidney injury, but similar rates of vascular complications and stroke. Additionally, cirrhotic patients had longer hospitalizations, were less likely to be discharged home, and accrued higher cost across all PCI indications.

CONCLUSIONS

Patients with cirrhosis who are deemed "suitable PCI candidates" in current practice remain at high-risk for worse short-term morbidity and mortality, and higher cost of care.

Iatrogenic Circumflex Artery Stenosis Following Mitral Valve Repair

Injury of the left circumflex coronary artery is a potentially serious complication of mitral valve surgery due to the proximity of the vessel to the posterior segment of the mitral annulus. Suture-related distortion of the artery with partial or subtotal occlusion is the most commonly implicated mechanism. Herein, we present a case of symptomatic iatrogenic circumflex coronary artery stenosis following mitral valve annuloplasty for degenerative mitral valve regurgitation.

A Case of Transient ST Elevation and Polymorphic Tachycardia without Angina Diagnosed by Holter Monitoring

We report the case of 52-year-old female with recurrent episodes of palpitations and dizziness. Holter monitoring revealed transient ST elevations followed by episodes of polymorphic ventricular tachycardia associated with episodes of palpitations and dizziness. Coronary angiography revealed mildly irregular right coronary artery with 90% stenosis. The patient underwent percutaneous coronary intervention with successful placement of a stent to the mid-right coronary artery. The patient has been followed closely over a period of 12 months. There haven't been any recorded episodes of tachycardia, and the patient has remained symptom-free.

Intracardiac versus transesophageal echocardiography to guide transcatheter closure of interatrial communications: Nationwide trend and comparative analysis

OBJECTIVES

This study aimed to assess current temporal trends in utilization of ICE versus TEE guided closure of interatrial communications, and to compare periprocedural complications and resource utilization between the two imaging modalities.

BACKGROUND

While transesophageal echocardiography (TEE) has historically been used to guide percutaneous structural heart interventions, intracardiac echocardiography (ICE) is being increasingly utilized to guide many of these procedures such as closure of interatrial communications.

METHODS

Using the Nationwide Inpatient Sample, all patients aged >18 years, who underwent ASD or PFO closure with either ICE or TEE guidance between 2003 and 2014 were included. Comparative analysis of outcomes and resource utilization was performed using a propensity score-matching model.

RESULTS

ICE guidance for interatrial communication closure increased from 9.7% in 2003 to 50.6% in 2014. In the matched model, the primary endpoint of major adverse cardiovascular events occurred less frequently in the ICE group versus the TEE group (11.1% vs 14.3%, respectively, P = 0.008), mainly driven by less vascular complications in the ICE group (0.5% vs 1.3%, P = 0.045). Length of stay was shorter in the ICE group (3 ± 4 vs 4 ± 4 days, P < 0.0001). Cost was similar in the two groups 18 454 ± 17 035$ in the TEE group vs 18 278 ± 15 780$ in the ICE group (P = 0.75).

CONCLUSIONS

Intracardiac echocardiogram utilization to guide closure of interatrial communications has plateaued after a rapid rise throughout the 2000s. When utilized to guide interatrial communication closure procedure, ICE is as safe as TEE and does not increase cost or prolonged hospitalizations.

Comparative Outcomes of Surgical and Transcatheter Aortic Valve Replacement for Aortic Stenosis in Nonagenarians

Transcatheter aortic valve replacement (TAVR) emerged as a promising alternative to surgical aortic valve replacement (SAVR) in extreme-aged patients with severe aortic stenosis (AS). Data on the outcomes of TAVR or SAVR in nonagenarians are limited. The Nationwide Inpatient Sample was used to identify patients aged 90 years or older who underwent TAVR or SAVR from 2004 to 2013. In-hospital morbidity and mortality were assessed. From 2004 to 2013, 9,066 (national estimate) nonagenarians underwent aortic valve replacement. After the introduction of TAVR, most nonagenarians were treated with TAVR (76%) compared with SAVR (24%). A total of 1,847 nonagenarians who underwent SAVR (n = 1,152) or TAVR (n = 695) were included in the analysis. In-hospital mortality was similar between patients who underwent SAVR (6.4%) compared with TAVR (6.5%; p = 0.29). Vascular complications were more common after TAVR (11.9% vs 6.3%, p <0.001), whereas blood transfusion (46.2% vs 33.7%, p <0.001), and acute kidney injury (25.8% vs 20.4%, p = 0.009) were more common after SAVR. Pacemaker implantation and stroke rates were similar between the 2 groups. In a propensity-matched analysis of 630 patients who underwent isolated TAVR (n = 315) or SAVR (n = 315), in-hospital mortality was similar for (6.0% for SAVR vs 7.9% for TAVR, p = 0.35). SAVR was associated with higher rates of acute kidney injury (24.1% vs 16.8%, p = 0.02) and blood transfusion (46.0% vs 35.2%, p = 0.001), whereas TAVR was associated with increased rates of vascular complications (10.2% vs 6.0%, p = 0.07). Stroke (4.1% vs 4.1%, p = 0.99) and pacemaker implantation rates were also similar (13.0% vs 9.2%, p = 0.12) between the TAVR and SAVR groups, respectively. In conclusion, in nonagenarians, both SAVR and TAVR can be performed with acceptable in-hospital outcomes. Referral for aortic valve replacement in these patients should not be precluded based on age alone.