Right ventricular and left ventricular diameters are independent predictors of death or cardiopulmonary resuscitation in intermediate and high-risk pulmonary embolisms

Background

Increased right ventricular (RV) dilation measured by the ratio of RV diameter (RVD) to left ventricular (LV) diameter (LVD) (RV:LV) is associated with pulmonary embolism (PE) severity and mortality. Data regarding the individual contributions of RVD and LVD are limited.

Purpose

To examine RVD and LVD as independent contributors to death or need for cardiopulmonary resuscitation (CPR) in intermediate- or high-risk PEs treated with surgical or catheter-based strategies

Methods

We measured basal RVD and LVD on presenting transthoracic echocardiograms (TTE) using the diastolic 4-chamber view on 127 PEs managed with surgical embolectomy (n=95, 75%), extracorporeal membrane oxygenation (n=23, 18%), or catheter-directed embolectomy (n=9, 7%) for intermediate- (64%) or high-risk (36%) PE (based on European Society of Cardiology criteria) between 2005 and 2022. The primary outcome was the composite of death (n=2) or survivors requiring CPR (n=10).

Results

A total of 127 patients were analyzed. Subjects were 57±14 years, 38% women, BMI 34±8. Mean RVD and LVD were 4.4±0.9 cm and 3.9±0.8 cm respectively. All presented with severe RV dysfunction on TTE and elevated cardiac biomarkers (Troponin-I or B-type natriuretic peptide). Mean RV:LV was 1.2±0.3 (range 0.7 to 2.8). Using logistic regression, higher RV:LV was associated with increased odds of death or CPR (odds ratio (OR) 15 [95% confidence interval (CI): 2.5, 82] per 1-unit increase, p=0.002. RV:LV >1.2 was the cutoff most associated with death or CPR, OR 7.2 [95% CI: 1.5, 34.5], p=0.01. Increasing RVD [OR 3.8 (95% CI: 1.1, 12.8), p=0.03] and decreasing LVD [OR 4.9 (95% CI: 1.3, 16.9), p=0.02] were independent predictors of death or CPR. RVD >5.0 cm (OR 5.9 [95% CI: 1,5, 23.2], p 0.01) and LVD <3.6 cm (OR 7.0 [95% CI: 1.7, 27.9], p=0.006) were the cutoff values most associated with the primary outcome. These cutoff values remained significant predictors even after adjustment for body surface area. Other parameters or RV size and function (diastolic area, systolic area and fractional area change) did not predict death or CPR. All of the subjects meeting the primary outcome had high-risk PE.

Discussion

In addition to RV:LV greater than 1.2, RVD and LVD were independently associated with death or CPR among high- or intermediate risk PEs. The independent contribution of declining LVD on PE mortality is a novel finding and highlights PE associatient LV pathophysiology (hyperdynamic and underfilled) antecedent to hemodynamic collapse. PE literature focuses on RV dilation as a predictor of PE mortality. LVD may represent a useful measure to risk stratify PE patients and predict hemodynamic decompensation.

Funding Acknowledgement

Type of funding sources: None.

Survival and renal outcomes of direct heart transplant from veno-arterial extracorporeal membrane oxygenation support

Backgrounds

Patients on veno-arterial extracorporeal membrane oxygenation (VA-ECMO) support are given the highest priority for cardiac transplantation (OHT) in the new UNOS heart allocation policy adopted in October 2018. Although patients may receive an organ quicker there may not be enough time to recover end-organ function. To date, little is known about survival and renal outcomes of direct OHT in patients that have been supported with VA-ECMO as a bridge to transplant due to limited experience in most transplant centers.

Purpose

The aim of this study was to investigate survival and renal outcomes of direct OHT in patients supported with VA-ECMO prior to transplant.

Methods

From January 2010 to February 2022, 23 patients who received single organ OHT alone directly from VA-ECMO support were retrospectively analyzed (16 patients after the new allocation policy). Kaplan-Meier analysis was used to estimate event-free survival.

Results

The median age of recipients was 48 years. The median length of pre-transplant VA-ECMO support was 5 days. Additional pre-transplant support with intra-aortic balloon pump or Impella was utilized in 15 patients (65.2%) and 2 patients (9%) respectively. There was a trend toward improvement of serum creatinine after initiation of VA-ECMO support (Pre-ECMO: 1.66±1.22 mg/dl vs. Pre-OHT: 1.20±0.74 mg/dl, P=0.084). Four patients required preoperative renal replacement therapy (RRT); three were on RRT at the time of OHT. The median ischemic time of donor hearts was 168 minutes. VA-ECMO support was continued in 10 patients (43.5%) after OHT.

Hospital mortality was 8.7% (2 patients). Post-transplant RRT was required in 9 patients (39.1%), and, of these, 5 patients were transitioned to permanent dialysis. Among the 14 patients who did not require post-transplant RRT, none required RRT during the follow-up period (median, 21.5 months). Kaplan-Meier survival analysis showed that estimated survival at 1 year and 3 years were 86.1%, and 77.5%, respectively (Figure 1A). The freedom from dialysis rate was 82.4% at 1 year, and 74.9% at 3 years (Figure 2A). Both survival (100% vs. 66.7%, P=0.008, Fig.1B) and dialysis free rate (100% vs. 55.6%, P=0.002, Figure 2B) at one-year were significantly worse in patients who required postoperative RRT.

Conclusions

To our knowledge this is the largest single center study of OHT in patients that were supported with VA-ECMO. VA-ECMO as a bridge to end-organ recovery and OHT resulted in excellent outcomes. Patients who required post-transplant RRT more likely to require long-term dialysis, while those that did not receive RRT showed favorable outcomes. Overall survival in this patient population is comparable to patients that were not on VA-ECMO prior to transplant.

Funding Acknowledgement

Type of funding sources: None.

Does cardiac transplant protect against broken hearts?

Background

Takotsubo cardiomyopathy (TC) is a reversible stress-induced myocardial dysfunction with increased sympathetic activity caused by excessive release of catecholamines playing a central role in its pathophysiology. The occurrence of TC in transplanted hearts is rare given the complete denervation done during transplantation. However, it has been demonstrated that 40% of transplant recipients undergo sympathetic re-innervation. There have only been case reports describing TC in post-transplant recipients.

Purpose

To evaluate the incidence, baseline characteristics and outcomes of TC occurring in heart transplant recipients using Healthcare Cost and Utilization Project (HCUP) National (nationwide) Inpatient Sample (NIS) in United States from 2009 to 2014.

Methods

Using NIS data, we identified patients who underwent cardiac transplantation using ICD9 procedure codes 37.5 and 33.6. Among these patients, we identified those admitted to the hospital with diagnosis of TC based on ICD-9-CM code 429.83. We presented categorical data as percentages and continuous data as mean or median as appropriate.

Results

We identified 257 hospitalizations for TC in heart transplant recipient patients. There was an approximately 9-fold increase in admissions from 11 in 2009 to 95 in 2014. Among patients with TC, the mean age was 65.3±1.8 years and majority were female (76.6%). A majority of patients were Caucasians (63%) followed by smaller proportion of African-Americans (13.2%).

In-patient mortality in patients admitted with TC following heart transplant was 11.3% (n=29). During the hospitalization, 4.8% of patients had cardiogenic shock and 2.8% required mechanical circulatory support. The average length of stay for patients with TC was 16.6±3.3 days. The mean cost of hospitalization for these patients when adjusted for inflation were 237248±55709 dollars.

Conclusion

TC can still occur in substantially in heart transplant recipients and should be considered one of the differential diagnosis in transplant patients presenting to the hospital.

Funding Acknowledgement

Type of funding source: None

A nationwide 16 year analysis of trends and impact of arrythmias in transplant recipients

Background

Orthotopic heart transplantation is the most effective long-term therapy for end-stage heart disease. Denervation of transplanted heart with the loss of autonomic modulation, vasculopathy, utilization of immunosuppressant drugs, and risk of allograft rejection may result in change in the prevalence of arrhythmias in transplanted hearts.

Purpose

To describe the trends, distribution and the clinical impact of arrhythmias in transplanted hearts in a large nationwide population.

Methods

We queried the National Inpatient Sample with administrative codes. Cardiac transplant patients were identified using procedure ICD-9-CM codes 37.5 and 33.6. Common arrhythmias were extracted using appropriate validated ICD-9-CM codes. Statistical Analysis System (SAS) version 9.4 was used for analysis of data.

Results

There was a total of 30,020 hospitalizations of heart transplant recipients between 1999 and 2014 in the United States and 16342 (54.4%) of these had arrhythmias. The prevalence of total arrhythmias increased from 53.6% (n=1,158) in 1999 to 67.3% (n=1,575) in 2014. The most common arrhythmia was atrial fibrillation (26.83%) followed by ventricular tachycardia (22.86%) and the prevalence of individual arrhythmias is as shown in Figure 1.

Cardiogenic shock was higher in transplanted hearts with arrhythmias when compared with patients without arrhythmias (25.96% vs 18.18%; p<0.001). Transplant recipients with arrhythmias were also associated with an increased use of mechanical circulatory device (18.22% vs 12.67%, p<0.001). The use of implantable cardiac defibrillators and permanent pacemaker was also higher in the arrhythmia group (2.19% vs 0.63% and 40.43% vs 30.24% respectively, p<0.0001). However, there was no significant difference in inpatient mortality between transplant recipients with arrhythmias and without arrhythmias (7.72% vs 6.90%, p=0.225). Further, there was no significant difference in frequency of strokes between the groups (4.98% vs 5.08%; p=0.857).

The total hospital cost when adjusted for inflation was significantly higher in the arrhythmic patients, with an average cost of about $570,415±9,590 vs $439,707±8362 in patients without arrhythmias (p<0.0001). The mean length of hospitalization was 44.2±0.8 days in patients with arrhythmias compared to 33.9±0.8 days in patients without arrhythmias (p<0.0001).

Conclusion

A significant proportion of patients with heart transplant have cardiac arrhythmias and are associated with worse in-hospital outcomes of cardiogenic shock, increased length of stay, and cost of hospitalization. However, they are not associated with worse inpatient mortality.

Funding Acknowledgement

Type of funding source: None

Impact of age on the obesity paradox in acute coronary syndrome: a nationwide analysis

Background

The obesity paradox – indicating improved short term mortality in obese individuals has been widely explored in a number of cardiovascular conditions. However, its validity in an elderly population and the possible physiological impact of aging on this phenomenon in Acute Coronary syndrome (ACS) remain unclear. In this study, we aim to determine the relationship between obesity and in-hospital mortality, morbidity, and health care resource utilization in this cohort of patients.

Methods

A retrospective study was conducted using the AHRQ-HCUP National Inpatient Sample for the year 2014. Elderly adults (≥65 years) with a principal diagnosis of ACS and a secondary diagnosis of obesity were identified using ICD-9 diagnosis codes as described in the literature. The primary outcome of in-hospital mortality and secondary outcomes like length of hospital stay (LOS), and total hospitalization costs were analyzed. Propensity score (PS) using the next neighbor method without replacement with 1:1 matching was utilized to adjust for confounders. Independent risk factors for mortality were identified using a multivariate logistic regression model.

Results

In total, 1,137,108 hospital admissions with a primary diagnosis of ACS were identified, of which 7.46% were obese. In-hospital morality during the index admission was lower among obese patients with ACS compared to non-obese patients (4.62 vs 6.87%, p<0.001) with significantly lower 30-day readmission rates as well (p<0.001). However, in-hospital mortality rates during readmission were statistically equivalent between the obese and non-obese groups (5.6 vs 8.3%, p=0.72). LOS during the index admission was longer for obese patients (6.39 vs 5.36 days, p=0.65) but equivalent to non-obese patients during subsequent readmissions (p=0.12). The total cost of these admissions was significantly more in the obese cohort as well (p<0.001).

Conclusion

In this study, obese elderly patients admitted with ACS were found to have significantly reduced in-hospital mortality and 30-day readmission rates when compared to non-obese patients - reinforcing the obesity paradox independent of patient age.

Funding Acknowledgement

Type of funding source: None

A nationwide 16-year study of the trends, burden and impact of atrial fibrillation in cardiac amyloidosis

Background

Cardiac amyloidosis (CA) remains an underdiagnosed entity. Atrial fibrillation (AF) is common in patients with CA, likely owing to direct amyloid deposition in the left atrium. However, the prevalence of AF in CA and its association with in-hospital outcomes has not been studied in large populations.

Purpose

Our aim was to study the trends, baseline characteristics, and clinical impact of AF in patients with CA in the United States using the Healthcare Cost and Utilization Project (HCUP) National) Inpatient Sample (NIS) from 1999 to 2014.

Methods

We queried the NIS and identified CA using ICD-9-CM codes 277.39 and 425.7. AF in CA patients was identified using the ICD-9-CM code of 427.31. Statistical Analysis System (SAS) 9.4 was used for analysis of data.

Results

There were a total of 145,920 CA hospitalizations between 1999 and 2014 in the United States, of which 37,070 (25.4%) had AF. The prevalence of AF remained consistent from 27.5% in 1999 to 27.4% in 2014.

The mean age of patients with AF was 72.9±28.2 years and for patients without AF was 67±31.9 years (p<0.0001). The majority of the patients with AF were male (60.3%) and the study group was predominantly white (62.8% in patients with AF and 56.4% in patients without AF). CA patients with AF suffered more from thyroid-related disease (22.5% vs 16.1%), heart failure (62.9% vs 36.5%) and renal failure (34.7% vs 30.5%) and less from hypertension (29.3% vs 34.0%) and diabetes mellitus (23.2% vs 25.2%) (p<0.0001). There was no significant difference in the Charlson comorbidity score between the groups.

Inpatient mortality was significantly higher in CA patients with AF (10.4% vs 6.5%, p<0.001). However, in-patient mortality has been decreasing over the years from 10.3% in 1999 to 7.6% in 2014. Furthermore, cardiogenic shock was significantly higher in CA patients with AF (2.1% vs 1.2%, p<0.001), yet the use of mechanical circulatory support was not significantly different between the groups (0.42% vs 0.35%, p=0.375). Pacemaker implantation was also noted to be higher in CA patients with AF compared to patients without AF (2.8% vs 1.2%, p<0.0001).

There was no significant difference between CA patients with and without AF in mean cost of hospitalization ($58222±10752 vs $57695±545, p=0.081) or length of stay (7.9±0.1 vs 7.7±0.1 days, p=0.7089).

Conclusion

CA with atrial fibrillation is a well-recognized entity, and our large scale retrospective analysis found significant association with worse in-hospital outcomes and cardiogenic shock. Interestingly, trend of in-patient mortality in CA has been decreasing over the years, likely owing to improved imaging modalities for diagnosis. Optimal management of AF in CA is imperative to improve outcomes in this population.

Funding Acknowledgement

Type of funding source: None

A nationwide analysis of 16 year trends in cardiac transplantation for cardiac sarcoidosis

Background

Orthotopic heart transplant (OHT) is indicated for end-stage heart failure due to cardiac sarcoidosis (CS). However, utilization of OHT for CS has been controversial due to concern for involvement of other organs by sarcoidosis affecting long term outcomes.

Purpose

Our objective was to study the trends in OHT in patients with CS in the United States using Healthcare Cost and Utilization Project (HCUP) National (nationwide) Inpatient Sample (NIS) from 1999 to 2014.

Methods

Using NIS data, we identified patients older than 18 years with cardiac sarcoidosis using codes ICD 9-CM codes of 135 and 425.8. Among these patients, we identified those who underwent cardiac transplantation using ICD 9-CM procedure codes 37.5 and 33.6. We presented categorical data as percentages and continuous data as mean or median as appropriate.

Results

A weighted total of 24231 hospitalizations for CS was extracted from 1999 to 2014 of which 248 (1.02%) CS patients underwent OHT. The trends in cardiac transplant for CS is as shown in Figure 1.

The mean age of CS patients undergoing OHT was 51.7±1.1 years and 60.4% (n=150) were males. 114 (45.9%) were Caucasians and 27.8% (n=25) were African-American. 100% of the transplants were performed at medium (n=5) or large sized (n=243) teaching hospitals and 97.9% of cardiac transplants were also done at teaching hospitals. Heart transplants were mostly done in the South (36.3%) followed by Midwest (26.2%), West (25%) and Northeast (12.5%). Private insurance was the major payor source which covered 149 (60.1%) patients followed by Medicare covering 65 (26.2%) patients.

A total of 10 (3.9%) cardiac sarcoidosis patients died during the same hospitalization for cardiac transplantation. Following OHT, 84.2% (n=209) were discharged home and 11.6% (n=29) to short term hospitalization. The mean cost of hospitalization for OHT in CS when adjusted for inflation was 535144±56060 dollars while the average length of stay for heart transplant for CS was 46.2±6.6 days.

Conclusions

Cardiac transplant trends in CS have not changed from 1999 to 2014 despite recent studies showing improved outcomes and are associated with substantial cost of hospitalization and length of stay. Majority of cardiac transplant was done in Caucasians despite cardiac sarcoidosis being more common in African-Americans.

Funding Acknowledgement

Type of funding source: None

Breast cancer patients have lower in-hospital mortality after acute coronary syndrome, a 5 year nationwide analysis

Background

Breast cancer and cardiovascular disease (CVD) share common risk factors, and breast cancer therapies are well known to cause cardiotoxicity. Prior studies highlighted the higher burden coronary artery disease and the importance to further assess its consequences on breast cancer patients.

Purpose

We sought to evaluate the revascularization rate and in-hospital short-term outcomes of breast cancer patients following acute coronary syndrome (ACS) compared to the general female population.

Methods

We reviewed the Nationwide Inpatient Sample from 2010 to 2014 to identify female patients with principal diagnosis of ACS (ST-elevation and non ST-elevation myocardial infarction, and unstable angina). Two subgroups were identified, women with a history of breast cancer and women without, and were propensity matched.

Multivariate regression analyses were performed to evaluate the impact of breast cancer on primary outcome (in-hospital mortality) and secondary outcomes: occurrence of shock, acute kidney injury (AKI), mechanical ventilation (MV), and length of stay (LOS). We also compared the rate of cardiac procedures. Statistical significance of odd ratios (OR) is defined with p-value<0.05 and reported 95% confidence intervals (CI).

Results

We identified a total of 245,563 female patients with primary diagnosis of ACS, among them 10,625 (4.3%) had a history of breast cancer. The comorbidity of breast cancer was associated with statistically significant lower rates of mortality (OR 0.83, CI 0.74–0.94), shock (OR 0.87, CI 0.77–0.99), AKI (OR 0.90, CI 0.82–0.98), MV (OR 0.81, CI 0.71–0.92) and relative 5.4% decrease in LOS (CI: −7.8%, −3.0%). The cardiac procedural rates were similar for left heart catheterization (OR 0.96, CI 0.90–1.02), for percutaneous coronary intervention (OR 0.95, CI 0.89–1.02) and for CABG (OR 0.88, CI 0.78–1.00) compared to control group.

Conclusion

Breast cancer patients received a comparable catheterization and revascularization procedure rate and exhibited a statistically significant lower morbidity and mortality rates during hospitalization after an ACS event compared to the general female population.

Funding Acknowledgement

Type of funding source: None

A nationwide analysis of 16 year trends in cardiac transplantation for acute myocarditis

Background

Orthotopic heart transplant (OHT) is indicated in 1–8% of patients with myocarditis. However, national trends in the utilization of transplantation and outcomes in myocarditis across the United States are not well established.

Purpose

Our objective was to study the trends and baseline characteristic of myocarditis patients undergoing heart transplant in the United States using Healthcare Cost and Utilization Project (HCUP) National (nationwide) Inpatient Sample (NIS) from 1999 to 2014.

Methods

Using NIS data, we identified patients older than 18 years with myocarditis using codes ICD9 codes of 422.0 and 422.9. Among these patients, we identified those who underwent cardiac transplantation using ICD9 procedure codes 37.5 and 33.6. We presented categorical data as percentages and continuous data as mean or median as appropriate.

Results

We identified a total of 62,264 hospitalizations for myocarditis from 1999–2014. 430 (0.69%) myocarditis patients underwent OHT which consisted of 0.82% of all 29990 cardiac transplants identified in the same period. The trends in OHT for myocarditis is as shown in Figure 1.

The mean age was 32.9±2.4 years and 51.1% (n=219) were females. 235 (54.6%) were Caucasians and 60 (13.9%) were Hispanic. Majority of the transplants were performed at medium (16%) and large sized hospitals (80.4%). Cardiac transplants were mainly done at teaching hospitals (98.9%). Further, with regards to the geographical distribution of transplant procedure, most were done in the West (37.2%) followed by South (25.3%), Northeast (21.4%) and Mid-west (16%) of the United States. Private insurance was the major payor source which covered 245 (58%) patients followed by Medicaid covering 112 (26%) patients.

A total of 26 (6%) myocarditis patients died during the same hospitalization for OHT. In terms of discharge following OHT in myocarditis 85.8% (n=369) were discharged home and 8.1% (n=35) to short term hospitalization. The average length of stay for OHT for myocarditis was 64.3±6.3 days. Also, the mean cost of hospitalization for heart transplant in myocarditis when adjusted for inflation was 789,566±93,108 dollars.

In-patient mortality following OHT was not significantly different in large sized hospital compared to small and medium sized hospitals (7.6% vs 5.7%, p=0.54). However, the cost of hospitalization was significantly lesser in small and medium sized hospitals (588,363±154,349 vs 826,864±106,110 dollars, p<0.0001).

Conclusions

Only a small percentage of OHT is done for myocarditis with high proportion done in female when compared to OHT for other etiologies. Further studies need to be done to compare long term outcomes of heart transplant in myocarditis.

Funding Acknowledgement

Type of funding source: None

P2851Transvenous lead placement in the setting of venous obstruction: outcomes of tunneling technique versus venoplasty

Background

Venous stenosis is a well-recognized complication of transvenous leads when patients require lead revisions or device upgrade. In these cases, balloon venoplasty or alternative venous access with subcutaneous tunneling can be performed.

Purpose

Compare the outcomes of venoplasty vs. tunneling in patients requiring additional transvenous lead implantation.

Methods

A single center retrospective cohort study of all patients undergoing lead implantation/revision requiring venoplasty or tunneling from 2005–2017. Chi-squared and Wilcoxon Rank-Sum tests were used to compare categorical and continuous variables.

Results

Ninety five patients met our inclusion criteria (60 venoplasty & 35 tunneling). There was no difference in procedure success rates (p-value=0.98). Tunneling was associated with less fluoroscopy time but higher incidence of acute complications (0% vs. 23%, p-value=0.002) most requiring invasive intervention and/or blood product transfusion. Long term outcomes were comparable and related to lead failure or infection.

Outcomes for tunneling vs. venoplasty Variable Tunneling (n=35) Venoplasty (n=60) p-value Age Y 67 (23–84) 70 (29–91) 0.25 Male (%) 24 (69%) 41 (68%) 0.98 Number of existing leads 2.1 (1–4) 2.4 (0–4) 0.1 Age of oldest lead 7.0 (0–21) 7.2 (0–33) 0.73 Number of new leads 1.2 (1–3) 1.4 (1–3) 0.26 Fluoroscopy time (SD) min 29.2 (21.3) 39.7 (21.5) 0.012 Procedure success (%) 35 (100%) 55 (92%) 0.9 Acute complications (%) 8 (23%)1 0 (0%) 0.0002   Pocket hematoma/bleed 4 (11%)2   Hemothorax 2 (6%)3   Pericarditis 1 (3%)   Lead compromise 1 (3%) Follow up M 18 (0–76) 28 (0–98) N/A Long term lead issues (%) 6 (17%) 10 (17%) 0.95 Long term complication requiring intervention 4 (11%) 8 (13%) N/A Procedure success: functional lead placed as a result of venoplasty or tunneling. 1Two patients required blood products. 2Two patients required invasive intervention. 3One patient required chest tube and the other ICU admission.

Conclusions

Balloon venoplasty is associated with similar rates of success and a less incidence of acute complications when compared subcutaneous tunneling.

Acknowledgement/Funding

NIH T32 Training Grant HL07111-40