Impact of COVID-19 pandemic on the volume, cost, and outcomes of cardiac electrophysiology procedures in the United States

BACKGROUND

During the COVID-19 pandemic, professional societies recommended deferral of elective procedures for optimal resource utilization.

OBJECTIVE

We sought to assess changes in procedural trends and outcomes of electrophysiology (EP) procedures during the pandemic.

METHODS

National Inpatient Sample databases were used to identify all EP procedures performed in the United States (2016-2020) by International Classification of Diseases, Tenth Revision codes. We evaluated trends in utilization, cost/revenue, and outcomes from EP procedures performed.

RESULTS

An estimated 1.35 million EP procedures (82% devices and 18% catheter ablations) were performed (2016-2020) with significant yearly uptrend. During the pandemic, there was a substantial decline in EP procedure utilization from a 5-year peak of 298 cases/million population in the second quarter of 2019 to a nadir of 220 cases in the second quarter of 2020. In 2020, the pandemic was associated with the loss of 50,233 projected EP procedures (39,337 devices and 10,896 ablations) with subsequent revenue loss of $7.06 billion. This deficit was driven by revenue deficit from dual-chamber permanent pacemaker (PPM) utilization ($2.88 billion, 49.3% of lost cases), ablation procedures ($1.84 billion, 21.7% of lost cases), and implantable cardioverter-defibrillator implantation ($1.36 billion, 12.0% of lost cases). To the contrary, there was a 9.4% increase in the utilization of leadless PPM. EP device implantation during the pandemic was associated with higher adverse in-hospital events (9.4% vs 8.0%; P < .001).

CONCLUSION

In the United States, the significant decline in EP procedures during the pandemic was primarily driven by the reduction in dual-chamber PPM utilization, followed by arrhythmia ablation and implantable cardioverter-defibrillator implantation. There was a substantial increase in leadless PPM utilization during the pandemic.

Higher body mass index is strongly linked to poor outcomes in adult COVID-19 hospitalizations: A National Inpatient Sample Study

Aims

The coronavirus disease 2019 (COVID-19) pandemic has resulted in more than 6 million deaths worldwide. Studies on the impact of obesity on patients hospitalized with COVID-19 pneumonia have been conflicting, with some studies describing worse outcomes in patients with obesity, while other studies reporting no difference in outcomes. Previous studies on obesity and critical illness have described improved outcomes in patients with obesity, termed the "obesity paradox." The study assessed the impact of obesity on the outcomes of COVID-19 hospitalizations, using a nationally representative database.

Materials and Methods

ICD-10 code U071 was used to identify all hospitalizations with the principal diagnosis of COVID-19 infection in the National Inpatient Database 2020. ICD-10 codes were used to identify outcomes and comorbidities. Hospitalizations were grouped based on body mass index (BMI). Multivariable logistic regression was used to adjust for demographic characteristics and comorbidities.

Results

A total of 56,033 hospitalizations were identified. 48% were male, 49% were white and 22% were black. Patients hospitalized with COVID-19 pneumonia in the setting of obesity and clinically severe obesity were often younger. Adjusted for differences in comorbidities, there was a significant increase in mortality, incidence of mechanical ventilation, shock, and sepsis with increased BMI. The mortality was highest among hospitalizations with BMI ≥60, with an adjusted odds ratio of 2.66 (95% Confidence interval 2.18-3.24) compared to hospitalizations with normal BMI. There were increased odds of mechanical ventilation across all BMI groups above normal, with the odds of mechanical ventilation increasing with increasing BMI.

Conclusion

The results show that obesity is independently associated with worse patient outcomes in COVID-19 hospitalizations and is associated with higher in-patient mortality and higher rates of mechanical ventilation. The underlying mechanism of this is unclear, and further studies are needed to investigate the cause of this.

Feasibility and Safety of Intracardiac Echocardiography Guidance in Mitral Transcatheter Edge-to-Edge Repair: Analysis of the National Inpatient Sample Data From 2015 to 2020

Data on the use of intracardiac echocardiography (ICE) guidance in mitral transcatheter edge-to-edge repair (mTEER) procedure is limited to case reports and small case series. Our study aims to assess the feasibility, safety, utilization patterns, and clinical outcomes of mTEER procedure with ICE guidance using a nationally representative real-world cohort of patients. This study used the National Inpatient Sample database from quarter 4 of 2015 to 2020. We used a propensity-matched analysis and adjusted odds ratios for in-hospital outcomes/complications. A P value of < 0.05 was considered significant. A total of 38,770 weighted cases of mTEER were identified. Of the included patients 665 patients underwent ICE-guided mTEER while 38,105 had TEE-guided mTEER. There were no differences in the in-hospital mortality between both groups (2.5% vs 3.0%, P = 0.58). Adjusted odds of in-hospital mortality (aOR 0.83, 95%CI [0.42-1.64]) were not significantly different. There were no differences in periprocedural complications including cardiac (aOR 0.85, 95%CI [0.54-1.35]), bleeding (aOR 1.45, 95%CI [0.93-2.33]), respiratory (aOR 0.88, 95%CI [0.61-1.25]), and renal (aOR 0.89, 95%CI [0.66-1.20]) complications between patients undergoing ICE-guided vs TEE-guided mTEER. There was no difference in GI complications between both groups (aOR 1.11, 95%CI [0.46-2.70]). The adjusted length of stay was less among ICE-guided mTEER (median: 1 vs 2, P < 0.01) with lower inflation-adjusted costs of hospitalization ($35,513 vs $47,067, P < 0.01). ICE-guided mTEER is safe when compared with TEE guided mTEER with no significant differences in in-hospital mortality, cardiac, bleeding, respiratory, and renal complications.

COVID-19 Infection Is Associated With Increased In-Hospital Mortality and Complications in Patients With Acute Heart Failure: Insight From National Inpatient Sample (2020)

Introduction: Patients with acute heart failure (AHF) exacerbation are susceptible to complications in the setting of COVID-19 infection. Data regarding the clinical outcomes of COVID-19 in patients admitted with AHF is limited. Methods: We used the national inpatient sample database by utilizing ICD-10 codes to identify all hospitalizations with a diagnosis of AHF in 2020. We classified the sample into AHF with COVID-19 infection versus those without COVID-19. Primary outcome was in-hospital mortality. Secondary outcomes were acute myocardial infarction, need for pressors, mechanical cardiac support, cardiogenic shock, and cardiac arrest. Also, we evaluated for acute pulmonary embolism (PE), bacterial pneumonia, need for a ventilator, and acute kidney injury (AKI). Results: We identified a total of 694,920 of AHF hospitalizations, 660,463 (95.04%) patients without COVID-19 and 34,457 (4.96%) with COVID-19 infection. For baseline comorbidities, diabetes mellitus, chronic heart failure, ESRD, and coagulopathy were significantly higher among AHF patients with COVID-19 (P < .01). While CAD, prior MI, percutaneous coronary intervention, and coronary artery bypass graft, atrial fibrillation, chronic obstructive pulmonary disease, and peripheral vascular disease were higher among those without COVID-19. After adjustment for baseline comorbidities, in-hospital mortality (aOR 5.08 [4.81 to 5.36]), septic shock (aOR 2.54 [2.40 to 2.70]), PE (aOR 1.75 [1.57 to 1.94]), and AKI (aOR 1.33 [1.30 to 1.37]) were significantly higher among AHF with COVID-19 patients. The mean length of stay (5 vs 7 days, P < .01) and costs of hospitalization ($42,143 vs $60,251, P < .01) were higher among AHF patients with COVID-19 infection. Conclusion: COVID-19 infection in patients with AHF is associated with significantly higher in-hospital mortality, need for mechanical ventilation, septic shock, and AKI along with higher resource utilization. Predictors for mortality in AHF patients during the COVID-19 pandemic, COVID-19 infection, patients with end-stage heart failure, and atrial fibrillation. Studies on the impact of vaccination against COVID-19 in AHF patients are needed.

Utility of rapid atrial pacing before and after TAVR with balloon-expandable valve in predicting permanent pacemaker implantation

BACKGROUND

High-grade or complete atrioventricular block (AVB) requiring permanent pacemaker (PPM) implantation is a known complication of transcatheter aortic valve replacement (TAVR). Wenckebach AVB induced by rapid atrial pacing (RAP) after TAVR was previously demonstrated in an observational analysis to be an independent predictor for PPM. We sought to investigate the utility of both pre- and post-TAVR RAP in predicting PPM implantation.

METHODS

In a single-center, prospective study, 421 patients underwent TAVR with balloon-expandable valves (BEV) between April 2020 and August 2021. Intraprocedural RAP was performed in patients without a pre-existing pacemaker, atrial fibrillation/flutter, or intraprocedural complete AVB to assess for RAP-induced Wenckebach AVB. The primary outcome was PPM within 30 days after TAVR.

RESULTS

RAP was performed in 253 patients, of whom 91.3% underwent post-TAVR RAP and 61.2% underwent pre-TAVR RAP. The overall PPM implantation rate at 30 days was 9.9%. Although there was a numerically higher rate of PPM at 30 days in patients with RAP-induced Wenckebach AVB, it did not reach statistical significance (13.3% vs. 8.4%, p = 0.23). In a multivariable analysis, RAP-induced Wenckebach was not an independent predictor for PPM implantation at 30 days after TAVR. PPM rates at 30 days were comparable in patients with or without pre-TAVR pacing-induced Wenckebach AVB (11.8% vs. 8.2%, p = 0.51) and post-TAVR pacing-induced Wenckebach AVB (10.2% vs. 5.8%, p = 0.25).

CONCLUSION

In patients who underwent TAVR with BEV, there were no statistically significant differences in PPM implantation rates at 30 days regardless of the presence or absence of RAP-induced Wenckebach AVB. Due to conflicting results between the present study and the prior observational analysis, future studies with larger sample sizes are warranted to determine the role of RAP during TAVR as a risk-stratification tool for significant AVB requiring PPM after TAVR.

Outcomes of Percutaneous Atrial Septal Defect Closure With Mitral Transcatheter Edge-to-Edge Repair and Transseptal Mitral Valve Replacement (2015 to 2020)

Patients who underwent transcatheter edge-to-edge repair (TEER) or transcatheter mitral valve replacement (TMVR) have a transeptal access created by an iatrogenic atrial septal defect (ASD) which leads to significant complications requiring closure. Given limited data, we used the National Inpatient Sample between 2015 and 2020 to evaluate the clinical outcomes of percutaneous closure of ASD (PC-ASD) in TEER/TMVR hospitalizations. A total of 44,065 eligible weighted hospitalizations with either TEER (n = 39,625, 89.9%) or TMVR (n = 4,440, 10.1%) with a higher rate of PC-ASD in the TMVR group (10.7% vs 2.0%, p <0.01). The TEER with PC-ASD group were more likely to experience acute heart failure and right ventricular failure and had longer hospital stays but there was no difference in in-hospital mortality compared with the no PC-ASD group. In the TMVR group, there was no difference in the odds of acute heart failure, right ventricular failure, cardiogenic shock, or acute hypoxic respiratory failure, but the odds of mechanical circulatory support, in-hospital mortality, and length of stay were significantly higher in patients with PC-ASD in the TMVR group. In conclusion, rates of percutaneous closure of ASD after TEER were lower than after TMVR and associated with worse in-hospital mortality in TMVR but not in TEER. Further prospective clinical trials are needed to identify patients who would benefit from the closure of iatrogenic ASD.

Epidemiology, characteristics, and outcomes of adult haemophagocytic lymphohistiocytosis in the USA, 2006-19: a national, retrospective cohort study

Background

Haemophagocytic lymphohistiocytosis (HLH) is a rare and life-threatening syndrome characterized by an excessive inflammatory response. Limited data exist on adult HLH.

Methods

In this national, retrospective cohort study, we analysed data from the US National Inpatient Sample database collected between October 1, 2006 and December 31, 2019. Using the International Classification of Diseases (ICD) codes, we identified all adult patients who were admitted non-electively with the diagnosis of HLH. We described demographic characteristics, triggers, and associated conditions. Trends of diagnosis, treatment, and in-hospital mortality were analysed using joinpoint models. In-hospital mortality rates were compared using multivariable logistic regression models that adjusted for demographic characteristics and associated conditions. Finally, we described resource utilization outcomes including cost of hospitalization and length of stay.

Findings

We identified 16,136 non-elective adult HLH admissions. The population pyramid showed a bimodal distribution, with peaks in young adults (16-30 years) and older adults (56-70 years). Joinpoint regression analysis revealed a significant increase in HLH incidence per 100,000 admissions over the study period (Average Annual Percent Change [APC] = 25.3%, p < 0.0001), and no significant change in rates of in-hospital mortality (slope = -0.01; p = 0.95) or administration of in-hospital HLH treatment (slope = 0.46, p = 0.20). The most common associated conditions were malignancy (4953 admissions [30.7%]), infections (3913 admissions [24.3%]), autoimmune conditions (3362 admissions [20.8%]), organ transplant status (639 admissions [4%]), and congenital immunodeficiency syndromes (399 admissions [2.5%]). In-hospital mortality was higher in older adults and males. Furthermore, Congenital immunodeficiency syndromes had the worst in-hospital mortality rate (mortality rate 31.1%, adjusted OR 2.36 [1.56-3.59]), followed by malignancies (mortality rate 28.4%, adjusted OR 1.80 [1.46-2.22]), infections (mortality rate 21.4%, adjusted OR 1.33 [1.10-1.62]), other/no trigger (mortality rate 13.6%, adjusted OR 0.73 [0.58-0.92]), autoimmune (mortality rate 13%, adjusted OR 0.72 [0.57-0.92]), and post-organ transplant status (mortality rate 14.1%, adjusted OR 0.64 [0.43-0.97]). The overall mean length of stay was 14.3 ± 13.9 days, and the mean cost of hospitalization was $54,900 ± 59,800.

Interpretation

We provide insight into the burden of adult HLH in the USA. The incidence has been increasing and the outcomes remain dismal. This signifies the growing need for the development of updated diagnosis and treatment protocols that are specific to adult HLH.

Funding

None.

Bullous herpes zoster masquerading as a bullous pemphigoid flare: A case report

Herpes zoster (HZ) results from the reactivation of dormant varicella zoster virus (VZV) in the posterior dorsal root ganglia manifesting as painful vesicles along the dermatomal distribution as shingles. The risk of reactivation is higher in immunocompromised patients. Herpes zoster lesions can have varied presentations including bullous forms, may induce BP flare, may co-exist in the same lesions, and should be included in the list of differentials for BP flares not responding to the standard of care. Here, we describe a case of a 74-year-old female with a history of recurrent bullous pemphigoid (BP) flares, who was on mycophenolate mofetil, and presented with skin lesions on her right thigh which were typical for her BP flares. Unlike prior flares, the lesions did not respond to prednisone therapy. Her hospitalization course was complicated by encephalopathy. Intravenous acyclovir was started empirically. Viral cultures and polymerase chain reaction from the lesions came back positive for VZV, but the patient succumbed to her illness shortly afterward.

Outcomes of therapeutic plasma exchange in severe autoimmune hemolytic anemia hospitalizations: An analysis of the National Inpatient Sample

BACKGROUND

Autoimmune hemolytic anemia (AIHA) is characterized by humoral and/or cellular immune-mediated hemolysis of red blood cells. The role of therapeutic plasma exchange (TPE) in AIHA is unclear.

STUDY DESIGN AND METHODS

We queried the National Inpatient Sample (NIS) for 2002-2019 to identify hospitalizations with the primary diagnosis of AIHA. We included hospitalizations with the highest severity subclass identified by All Patient Refined Disease Related Group (APR-DRG). We used multivariate regression analysis to compare in-hospital mortality and other relevant in-hospital outcomes between hospitalizations that received TPE and those that did not.

RESULTS

We identified 255 weighted hospitalizations in the TPE group and 4973 in the control group. Those in the control group were older (median age 67 vs. 48 years, p < .001) and had a higher prevalence of most comorbidities. The TPE group had higher odds of all-cause in-hospital mortality (odds ratio [OR], 1.59; 95% confidence interval [CI], 1.19-2.11). They also had higher rates of many secondary outcomes, including requiring mechanical ventilation, developing circulatory shock, acute stroke, urinary tract infections, intracranial hemorrhage, acute kidney injury, and requiring new hemodialysis. No significant differences were noted in the rates of acute myocardial infarctions, bacterial pneumonia, sepsis/septicemia, thromboembolic events, and other bleeding events. Furthermore, the TPE group had a higher median length of hospital stay (19 vs. 9 days, p < .001).

CONCLUSION

Hospitalizations with severe AIHA that received TPE had higher rates of adverse in-hospital outcomes.

Delayed vs early cardioversion in patients with paroxysmal atrial fibrillation: a population-based study (2015-2020)

Aim: There is limited data on clinical outcomes of delayed cardioversion (DCV) compared with early cardioversion (ECV) in paroxysmal atrial fibrillation (AF) patients. Methods: We utilized data from National Inpatient Sample (2015-2020) and propensity-score matched analysis to determine adjusted odds ratio (aOR) of major clinical outcomes, including 17,879 AF cases: 9725 and 8154 underwent ECV and DCV, respectively. Results: Compared with ECV, DCV was associated with higher odds of acute heart failure (AHF; aOR 1.79 [1.67-1.92]; p < 0.01), median length of stay (4 vs 2 days; p < 0.01) and cost of hospitalization ($33,410 vs $21,738; p < 0.01) with no significant difference in inpatient mortality and other cardiovascular and neurological outcomes. Conclusion: Compared with ECV, DCV was associated with more AHF and resource utilization.

Gastrointestinal Bleeding in Patients Supported with Left Ventricular Assist Devices: The Journey from Bridging to Destination

End-stage heart failure is a prevalent and fatal cardiovascular disease. Almost 1 in 4 cases of mortality in the United States is attributed to heart failure. Left ventricular assist devices (LVADs) have emerged as a safe destination therapy or bridge to transplant. Despite remarkable results, LVAD is associated with significant adverse events, such as gastrointestinal bleeding (GIB). In this review, we aimed to understand the incidence and prevalence, pathophysiologic mechanisms, predictors, diagnostic mechanisms, management, and preventative measures of GIB in patients with an LVAD. GIB is a common adverse event in patients with an LVAD with an incidence of 15% to 25%. The exact pathogenesis of GIB is poorly understood. However, different mechanisms of bleeding have been described, such as arteriovenous malformations, acquired von Willebrand syndrome, coagulopathy, and treatment with antithrombotic therapy. Upper GIB is the most common site of GIB in patients with an LVAD. The management of GIB in patients with LVAD includes ensuring hemodynamic stability, holding or reversing antithrombotic therapy, and investigating and controlling the source of GIB through diagnostic and interventional endoscopic and radiologic means. Prophylactic medication use (e.g., danazol, octreotide, and bevacizumab) can decrease the risk of GIB in patients with an LVAD by decreasing arteriovenous malformations. Despite that the overall risk of GIB has decreased with new advancements in LVAD technology, further studies are needed regarding predictors, risk stratification, and optimal antithrombotic therapy to minimize the morbidity and mortality in patients with an LVAD. In conclusion, prompt diagnosis and management in a multidisciplinary team approach are crucial and lifesaving in such a life-threatening condition.

Trends and Outcomes of Transcatheter Tricuspid Valve Repair and Surgical Tricuspid Valve Repair in Patients With Tricuspid Valve Regurgitation; A Population Based Study

Data on clinical outcomes of transcatheter tricuspid valve repair (TTVR) compared with surgical tricuspid valve repair (STVR) in patients with tricuspid valve regurgitation (TVR) remains limited. Data from the national inpatient sample (2016-2020) and propensity-score matched (PSM) analysis was utilized to determine adjusted odds ratio (aOR) of inpatient mortality and major clinical outcomes of TTVR compated with STVR in patients with TVR. A total of 37,115 patients with TVR were included: 1830 (4.9%) and 35,285 (95.1%) underwent TTVR and STVR, respectively. After PSM, there was no statistically significant difference in baseline characteristics and medical comorbidities between both groups. Compared with STVR, TTVR was associated with lower inpatient mortality (aOR 0.43 [0.31-0.59], P < 0.01), cardiovascular complications (aOR 0.47 [0.3-0.45], P < 0.01), hemodynamic complications (aOR 0.47 [0.4-0.55], P < 0.01), infectious complications (aOR 0.44 [0.34-0.57], P < 0.01), renal complications (aOR 0.56 [0.45-0.64], P < 0.01), and need for blood transfusion. There was no statistically significant difference in odds of major bleeding events (aOR 0.92 [0.64-1.45], P 0.84). Also, TTVR was associated with less mean length of stay (7 days vs 15 days, P < 0.01) and less cost of hospitalization ($59,921 vs $89,618) compared with STVR. There was an increase in the utility of TTVR associated with a decrease in the utility of STVR from 2016 to 2020 (P < 0.01). Our study showed that compared with STVR, TTVR was associated with lower inpatient mortality and clinical events. Nevertheless, further studies are needed to investigate the difference in outcomes between both procedures.

Atypical Peutz-Jeghers Syndrome Presenting With a Huge Jejunojejunal Intussusception in a Young Male: A Case Report

Intussusception is considered one of the rare causes of intestinal obstruction in adults compared to pediatric patients. It usually presents with non-specific clinical manifestations ranging from mild recurrent abdominal pain to severe acute abdominal pain. The non-specificity of its symptoms makes it difficult to diagnose preoperatively. As 90% of adult intussusceptions are due to a pathological lead point, this prompts the underlying medical condition to be identified. We herein report a rare case of a 21-year-old male with atypical clinical features of Peutz-Jegher syndrome (PJS), presenting with jejunojejunal intussusception as a result of a hamartomatous intestinal polyp. A preliminary diagnosis of intussusception was made after an abdominal computed tomography (CT) scan and was confirmed intraoperatively. Postoperatively, the patient's condition improved steadily, and he was discharged with a referral to the gastroenterologist for further assessment.

Cardiac Arrest Secondary to Inferior ST-Segment-Elevation Myocardial Infarction in Patient with Paroxysmal Nocturnal Hemoglobinuria and COVID-19 Infection

Patients with paroxysmal nocturnal hemoglobinuria (PNH) have transient attacks of complement-mediated hemolysis and thrombosis that can be spontaneous or secondary to precipitating factors such as infections. We present a case of a 63-year-old male patient with a medical history of PNH who presented with typical chest pain, fever, cough, jaundice, and dark-colored urine. On examination, he was hemodynamically stable but had conjunctival icterus. A few minutes after presentation, the patient suffered a ventricular fibrillation cardiac arrest and then achieved a return of spontaneous circulation after receiving two defibrillator shocks. EKG showed inferior wall ST-segment elevation myocardial infarction. Labs showed hemoglobin of 6.4 g/dl, elevated cardiac markers, serum lactate dehydrogenase, and indirect bilirubin. Serum haptoglobin was < 1 mg/dl. His COVID-19 polymerase chain reaction test was positive. Immediately, the patient received 2 units of packed RBCs and underwent a coronary angiogram (CA), which revealed total proximal occlusion of the right coronary artery. He underwent successful percutaneous coronary intervention (PCI), and two drug-eluting stents were placed. His peripheral blood immunophenotyping and flow cytometry showed loss of glycosylphosphatidylinositol-linked antigens and decreased expression of CD 59/14/24. He was started on ravulizumab, a humanized monoclonal antibody complement five inhibitor. Both PNH and COVID-19 increase the risk of thrombosis. Endothelial injury and cytokine storm increase the risk of thrombosis in COVID-19 patients, whereas the activation of the coagulation system and the impairment of the fibrinolytic system by complement cascade leads to thrombosis in PNH patients. Regardless of which pathway leads to coronary artery thrombosis, CA and PCI can be life-saving.

Predictors of Mortality in Patients With Refractory Cardiac Arrest Supported With VA-ECMO: A Systematic Review and a Meta-Analysis

Cardiac arrest (CA) is associated with high mortality rate, ranging between 75% and 93%. Given its significance, venoarterial extracorporeal membrane oxygenation (VA-ECMO) has been used for end-organs perfusion and to maintain adequate oxygenation as a life-saving option in refractory CA. The predictors for the success of VA-ECMO in this setting have not been established yet. In this meta-analysis, we aim to identify the variables associated with increased mortality in patients with CA supported with VA-ECMO. We conducted a systematic review and meta-analysis to evaluate mortality-predicting factors in patients with CA supported with VA-ECMO that were published between January 2000 and July 2022. To identify relevant articles, the MEDLINE (Pubmed, Ovid) and Cochrane Databases were queried with various combinations of our prespecified keywords, including VA-ECMO, CA, and mortality predictors. We performed a meta-analysis using a random-effects model to calculate the odds ratio (OR). We retrieved a total of 4476 records, out of which we included 10 observational studies in our study. A total of 931 patients were included in our study with the age range of 47-68 years, predominantly males (63.9%). The overall mortality was 69.4%. The predictors for mortality were age >65 (OR 4.61, 95% CI 1.63-13.03, P < 0.01), history of chronic kidney disease (OR 2.42, 95% CI 1.37-4.28, P < 0.01), cardiopulmonary resuscitation duration prior to ECMO > 40 minutes (OR 6.62 [95% CI 1.39, 9.02], P < 0.01), having an initial nonshockable rhythm (OR 2.62 [95% CI 1.85, 3.70], P < 0.01) and sequential organ failure assessment score >14 (OR 12.29, 95% CI 2.71-55.74, P <0.01). Regarding blood work, an increase in lactate by 5 mmol/L increased the odds of mortality by 121% (2 studies; OR 2.21 [95% CI 1.26, 3.86], P < 0.01; I2 = 0%) while the increase in lactate by 1 mmol/L increases odd of mortality by 15% (2 studies, OR 1.15 [95% CI 1.02, 1.31], P = 0.03, I = 0%), and an increase in creatinine by 1 mg/dL increased the odds of mortality by 225% (1 study; OR 3.25 [95% CI 1.22, 8.7], P = 0.02). Albumin was protective as for each 1 g/dL increase, the odds of mortality decreased by 68% (1 study; OR 0.32 [95% CI 0.14, 0.74], P < 0.01). Refractory CA requiring VA-ECMO has a high mortality. Predictors of mortality include age >65, history of chronic kidney disease, cardiopulmonary resuscitation duration prior to ECMO > 40 minutes, initial rhythm being non-shockable and Sequential Organ Failure Assessment score >14.

Trends and Outcomes of Left Atrial Appendage Occlusion in Renal and Liver Transplant Recipients: Insights From the United States National Inpatient and Readmission Database

Left atrial appendage occlusion using the Watchman device has emerged as an alternative treatment strategy for preventing strokes in patients with atrial fibrillation. However, there is no data on its safety and clinical outcomes in prior renal or liver transplant recipients. We included a total of 61,995 patients from the National Inpatient Sample (NIS, in-hospital outcomes) and 55,048 patients from the National Readmission Database (NRD, 30-day outcomes) who underwent percutaneous left atrial appendage occlusion (LAAO). From this group, 0.65% (n=405) and 0.62% (n=339) were renal and liver transplant recipients in NIS and NRD respectively. Transplant recipients were younger compared with non-transplant recipients (mean age 69 vs 77 years, P=<0.01). There was little difference in terms of in-hospital mortality (0% vs 0.2%, P=0.43), major complications (6.2% vs 5.6%, P=0.61), cardiovascular complications (2.5% vs 2.8%, P=0.73), neurological complications (1.2% vs 0.7%, P=0.21) or bleeding complications (1.2% vs 0.7%, P=0.99) between transplant vs. non-transplant patients. Based on the NRD database, 30-day readmission rate was not meaningfully different for transplant recipients undergoing LAAO (9.44%) when compared to non-transplant patients (8.12%, [log-rank, P=0.56]). There was no difference between 30-day major or cardiovascular complications, however vascular complication rates were significantly higher for transplant recipients (OR 2.56, 95% CI [(1.66-3.47]). Our study findings suggest that LAAO may be safe for patients with a prior renal or liver transplant in terms of major complications, cardiovascular complications, and all-cause readmission rates. However vascular complications may be higher in transplant recipients. Further large-scale studies are needed to confirm these findings.

Same-Day Discharge after Percutaneous Left Atrial Appendage Closure: Insights from the Nationwide Readmission Database 2015-2019

Data on the feasibility of same-day discharge (SDD) following percutaneous left atrial appendage closure (LAAC) remain limited. We analyzed the US Nationwide Readmission Database from quarter four of 2015 to 2019 to study the safety and feasibility of SDD after LAAC. After excluding non-elective cases and in-hospital deaths, a total of 54,880 cases of LAAC were performed during the study period. Following LAAC, 2% (n=1077) of patients underwent SDD, 88% (n=48,428) underwent next-day discharge (NDD), 5.2% (n=2881) were discharged on the second day (ScD), and 4.5% of patients (n = 2494) were discharged 3 or more days after LAAC. There was no difference in 30-day readmission rates between SDD and NDD (7.3% [n=79] vs 7.4% [n=3585], P=0.94). The hospitalization costs were significantly lower for SDD compared with NDD ($22,963 vs $27,079, P≤0.01). SDD discharge following percutaneous LAAC appears to be safe and is associated with lower hospitalization costs. Further prospective studies are needed to determine the safety and feasibility of SDD with percutaneous LAAC.

Cardiovascular Complications During Delivery Admissions Associated With Assisted Reproductive Technology (from a National Inpatient Sample Analysis 2008 to 2019)

Women who conceive through assisted reproductive technology (ART) have a known increased risk of obstetric complications. However, whether ART is also associated with higher risk of developing cardiovascular complications during delivery admissions has not been well established. We used data from the National Inpatient Sample (2008 to 2019) and used the International Classification of Diseases codes to identify delivery hospitalizations and ART procedures. A total of 45,867,086 weighted delivery cases were identified, of which 0.24% were among women who conceived through ART (n = 108,542). Women with an ART history were older at the time of delivery (median 35 vs 28 years, p <0.01) and had a higher prevalence of hypertension, gestational diabetes, and dyslipidemia (all, p <0.01). After adjustment for age, race/ethnicity, co-morbidities, multiple gestation, insurance, and income, ART remained an independent predictor of peripartum cardiovascular complications, including pre-eclampsia/eclampsia (adjusted odds ratio [aOR] 1.48, 95% confidence interval [CI] 1.45 to 1.51), heart failure (aOR 1.94, 95% CI 1.10 to 3.40), and cardiac arrhythmias (aOR 1.39, 95% CI 1.30 to 1.48), compared with natural conception. Likewise, the risk of acute kidney injury (aOR 2.57, 95% CI 2.25 to 2.92), ischemic stroke (aOR 1.73, 95% CI 1.24 to 2.43), hemorrhagic stroke (aOR 1.63, 95% CI 1.27 to 2.11), pulmonary edema (aOR 2.29, 95% CI 2.02 to 2.61), and venous thromboembolism (aOR 1.92, 95% CI 1.63 to 2.25) were higher with ART. However, odds of developing peripartum cardiomyopathy or acute coronary syndrome were not associated with ART. Length of stay (3 vs 2 days, p <0.01) and cost of hospitalization ($5,903 vs $3,922, p <0.01) were higher for deliveries among women with a history of ART. In conclusion, women who conceived with ART had higher risk of pre-eclampsia, heart failure, arrhythmias, stroke, and other complications during their delivery hospitalizations. This may, in part, contribute to their increased resource utilization seen.

Trends, Predictors, and Outcomes of Cardiovascular Complications at Delivery Associated With Gestational Diabetes: A National Inpatient Sample Analysis (2004-2019)

Background Gestational diabetes (GD) is associated with increased risk of long-term cardiovascular complications. However, data on acute peripartum cardiovascular complications are not well established. Hence, we aimed to investigate the association of GD with acute cardiovascular outcomes at the time of delivery admission. Methods and Results We used data from the National Inpatient Sample (2004-2019). International Classification of Diseases, Ninth Revision (ICD-9) or Tenth Revision (ICD-10) codes were used to identify delivery hospitalizations and GD diagnosis. A total of 63 115 002 weighted hospitalizations for deliveries were identified, of which 3.9% were among individuals with GD (n=2 435 301). The prevalence of both GD and obesity increased during the study period (P trends<0.01). Individuals with GD versus those without GD had a higher prevalence of obesity, hypertension, and dyslipidemia. After adjustment for age, race or ethnicity, comorbidities, insurance, and income, GD remained independently associated with cardiovascular complications including preeclampsia (adjusted odds ratio [aOR], 1.97 [95% CI, 1.96-1.98]), peripartum cardiomyopathy (aOR, 1.15 [1.08-1.22]), acute kidney injury (aOR, 1.16 [1.11-1.21]), stroke (aOR, 1.15 [1.09-1.23]), and arrhythmias (aOR, 1.48 [1.46-1.50]), compared with no GD. Moreover, delivery hospitalizations among individuals with GD were associated with increased length (3 versus 2 days, P<0.01) and cost of hospitalization ($4909 versus $3682, P<0.01). Even in the absence of preeclampsia, GD was associated with elevated cardiovascular risk. Conclusions Individuals with GD had a higher risk of preeclampsia, peripartum cardiomyopathy, acute kidney injury, stroke, and arrhythmias during delivery hospitalizations. As rates of GD are increasing globally, efforts to improve preconception cardiometabolic health and prevent GD may represent important strategies to improve peripartum maternal outcomes and mitigate long-term cardiovascular risk.

Effects of Heterozygous Variants in the Leptin-Melanocortin Pathway on Roux-en-Y Gastric Bypass Outcomes: a 15-Year Case-Control Study

INTRODUCTION

Heterozygous variants in the leptin-melanocortin pathway are associated with obesity. However, their effect on the long-term outcomes after Roux-en-Y gastric bypass (RYGB) is still unknown.

METHODS

In this matched case-control study, 701 participants from the Mayo Clinic Biobank with a history of RYGB were genotyped. Sixty-three patients had a heterozygous variant in the leptin-melanocortin pathway. After excluding patients with potential confounders, carriers were randomly matched (on sex, age, body mass index [BMI], and years since surgery) with two non-carrier controls. The electronic medical record of carriers and matched non-carriers was reviewed for up to 15 years after RYGB.

RESULTS

A total of 50 carriers and 100 matched non-carriers with a history of RYGB were included in the study. Seven different genes (LEPR, PCSK1, POMC, SH2B1, SRC1, MC4R, and SIM1) in the leptin-melanocortin pathway were identified. At the time of surgery, the mean age was 50.8 ± 10.6 years, BMI 45.6 ± 7.3 kg/m², and 79% women. There were no differences in postoperative years of follow-up, Roux limb length, or gastric pouch size between groups. Fifteen years after RYGB, the percentage of total body weight loss (%TBWL) in carriers was - 16.6 ± 10.7 compared with - 28.7 ± 12.9 in non-carriers (diff = 12.1%; 95% CI, 4.8 to 19.3) and the percentage of weight regain after maximum weight loss was 52.7 ± 29.7 in carriers compared with 29.8 ± 20.7 in non-carriers (diff = 22.9%; 95% CI, 5.3 to 40.5). The nadir %TBWL was lower - 32.1 ± 8.1 in carriers compared with - 36.8 ± 10.4 in non-carriers (diff = 4.8%; 95% CI 1.8 to 7.8).

CONCLUSIONS

Carriers of a heterozygous variant in the leptin-melanocortin pathway have a progressive and significant weight regain in the mid- and long-term after RYGB. Genotyping patients experiencing significant weight regain after RYGB could help implement multidisciplinary and individualized weight loss interventions to improve weight maintenance after surgery.

Management of Obesity and Nonalcoholic Fatty Liver Disease: A Literature Review

With the recent urbanization and globalization, the adult obesity rate has been increasing, which was paralleled with a dramatic surge in the incidence and prevalence of nonalcoholic fatty liver disease (NAFLD). NAFLD poses a growing threat to human health as it represents the most common cause of chronic liver disease in developed countries. It encompasses a wide spectrum of conditions starting from a build-up of fat in hepatocytes (steatosis), to developing inflammation (steatohepatitis), and reaching up to cirrhosis. It is also associated with higher rates of cardiovascular mortalities. Therefore, proper timely treatment is essential and weight loss remains the cornerstone in the treatment of obesity-related liver diseases. When diet, exercise, and lifestyle changes are not successful, the current recommendation for weight loss includes antiobesity medications and bariatric endoscopic and surgical interventions. These interventions have shown to result in significant weight loss and improve liver steatosis and fibrosis. In the current literature review, we highlight the expected outcomes and side effects of the currently existing options to have a weight-centric NAFLD approach.

Impact of Baseline BMI and Adherence to Follow-Up on the Outcome of Sleeve Gastrectomy in Treatment of Adolescent Obesity

BACKGROUND

Adolescent obesity is considered a public health challenge. Sleeve gastrectomy (SG) may be considered a safe option for treatment of adolescent obesity. This study aimed to assess the outcomes of SG in treatment of severe obesity in adolescents, with emphasis on the impact of baseline body mass index (BMI) and adherence to follow-up.

METHODS

This was a single-center retrospective cohort study on adolescents with severe obesity who underwent SG at a tertiary referral bariatric center. The main outcome measures were weight loss, improvement in comorbidities at 12 months postoperatively, and complications.

RESULTS

A total of 72 adolescent patients (47 female) of a mean BMI of 47.9 ± 7.1 kg/푚² were enrolled in the study. The mean %TWL was 34.94 ± 9.35 and the mean %EWL was 73.47 ± 22.12. Complete remission was recorded in all patients with type 2 diabetes mellitus (DM), pre-DM, and sleep apnea, in 80% of patients with hypertension, and 57% of patients with hypothyroidism. The long-term complication rate after SG was 18%. Patients with higher preoperative BMI had significantly (p = 0.018) lower %EWL at 1 year.

CONCLUSION

SG is an effective and safe surgical procedure for adolescents with severe obesity. It was associated with a significant weight loss, high comorbidity remission rates, and no mortality or serious complications. Lower baseline BMI and better adherence to follow-up were associated with better outcome of SG.

Adsorption of Pb(II) ions from contaminated water by 1,2,3,4-butanetetracarboxylic acid-modified microcrystalline cellulose: Isotherms, kinetics, and thermodynamic studies

Microcrystalline cellulose (MCC) has been utilized as an adsorbent material for the removal of Pb(II) ions from aqueous solution after treatment with 1,2,3,4-butanetetracarboxylic acid (BTCA) at elevated temperature to obtain MMCC. The resulting adsorbent was characterized for point of zero point charge (pHZPC), estimation of carboxyl content, Fourier transform infrared spectroscopy (FT-IR), scan electron microscopy (SEM), and textural properties, including surface area, and subsequently utilized for the removal of Pb(II) ions from aqueous solution. The adsorption process was probed by investigating the effect of adsorbent dose, pH of solution, temperature, agitation time, and Pb(II) ion concentration. The results showed successful functionalization of MCC using BTCA, significantly improved the binding properties of the adsorbent towards Pb(II) ions. Isothermal adsorption data was analyzed using Langmuir, Freundlich and Temkin models, evaluated via nonlinear regression analysis. The maximum adsorption capacity was found to be 1155 mg/g (at pH 5 and 30 °C) from Langmuir theory, and appears independent of surface area. The Freundlich model was found to provide the best fit and the constant n was determined to be 2.69, indicating that adsorption of Pb(II) ions onto MMCC is favorable. Kinetic modelling showed good agreement for the pseudo-second order kinetic model, supporting the theory that chemisorption is involved in the adsorption process, which is promoted by a high density of active sites. Thermodynamic analysis showed that the adsorption of Pb(II) ions onto MMCC was endothermic and nonspontaneous; hence, MMCC offers an effective method of Pb(II) ion removal from aqueous solutions, with potential for water remediation processes.

Clinical genomics expands the morbid genome of intellectual disability and offers a high diagnostic yield

Intellectual disability (ID) is a measurable phenotypic consequence of genetic and environmental factors. In this study, we prospectively assessed the diagnostic yield of genomic tools (molecular karyotyping, multi-gene panel and exome sequencing) in a cohort of 337 ID subjects as a first-tier test and compared it with a standard clinical evaluation performed in parallel. Standard clinical evaluation suggested a diagnosis in 16% of cases (54/337) but only 70% of these (38/54) were subsequently confirmed. On the other hand, the genomic approach revealed a likely diagnosis in 58% (n=196). These included copy number variants in 14% (n=54, 15% are novel), and point mutations revealed by multi-gene panel and exome sequencing in the remaining 43% (1% were found to have Fragile-X). The identified point mutations were mostly recessive (n=117, 81%), consistent with the high consanguinity of the study cohort, but also X-linked (n=8, 6%) and de novo dominant (n=19, 13%). When applied directly on all cases with negative molecular karyotyping, the diagnostic yield of exome sequencing was 60% (77/129). Exome sequencing also identified likely pathogenic variants in three novel candidate genes (DENND5A, NEMF and DNHD1) each of which harbored independent homozygous mutations in patients with overlapping phenotypes. In addition, exome sequencing revealed de novo and recessive variants in 32 genes (MAMDC2, TUBAL3, CPNE6, KLHL24, USP2, PIP5K1A, UBE4A, TP53TG5, ATOH1, C16ORF90, SLC39A14, TRERF1, RGL1, CDH11, SYDE2, HIRA, FEZF2, PROCA1, PIANP, PLK2, QRFPR, AP3B2, NUDT2, UFC1, BTN3A2, TADA1, ARFGEF3, FAM160B1, ZMYM5, SLC45A1, ARHGAP33 and CAPS2), which we highlight as potential candidates on the basis of several lines of evidence, and one of these genes (SLC39A14) was biallelically inactivated in a potentially treatable form of hypermanganesemia and neurodegeneration. Finally, likely causal variants in previously published candidate genes were identified (ASTN1, HELZ, THOC6, WDR45B, ADRA2B and CLIP1), thus supporting their involvement in ID pathogenesis. Our results expand the morbid genome of ID and support the adoption of genomics as a first-tier test for individuals with ID.

Enhancement of the Adsorption of Co(II) and Ni(II) Ions onto Peanut Hulls through Esterification Using Citric Acid

Peanut hulls were modified chemically by esterification with citric acid under conditions which yielded hulls rich in carboxyl content. The esterified products thus obtained were used in the removal of Co(II) and Ni(II) ions from aqueous solutions. The factors affecting the esterification reaction and the adsorption of the metal cations onto the peanut hulls before and after esterification were thoroughly investigated. The results obtained highlighted the following conclusions. The optimum conditions for esterification involve the treatment of peanut hulls (1 g) with 12.4 mmol citric acid in the presence of a very small amount of water for 2 h at 140°C. Similarly, the optimum pH for the adsorption of cobalt(II) ions onto the peanut hulls citrate was 7.0. The adsorption capacity, qe (mg/g), of Co(II) ions onto the peanut hulls citrate increased on increasing the extent of esterification, expressed as mequiv. —COOH/100 g sample. The maximum values for the adsorption capacity, qmax, were 28.7 mg/g and 270.3 mg/g on native and peanut hulls citrate, respectively. The qmax values for of Ni(II) ion adsorption were 5 mg/g and 175.4 mg/g on native and peanut hulls citrate, respectively. The equilibrium data were well fitted by the Langmuir and Freundlich adsorption models and showed the large capacity of peanut hulls citrate in the removal of Co(II) and Ni(II) ions from aqueous solutions.