Frequency of Complications Including Death from Coronary Artery Bypass Grafting in Patients With Hepatic Cirrhosis

Advanced liver disease is a risk factor for cardiac surgery. However, liver dysfunction is not included in cardiac risk assessment models. We sought to identify trends in utilization, complications, and outcomes of patients with cirrhosis who underwent coronary artery bypass graft surgery (CABG). Using the National Inpatient Sample database, we identified patients with cirrhosis who underwent CABG from 2002 to 2014. Propensity-score matching was used to identify differences in in-hospital mortality and postoperative complications in cirrhosis and noncirrhosis patients. We identified a total of 698,799 CABG admissions of which 2,231 (0.3%) had cirrhosis (mean age 63.6 ± 9.6 years, 74% men, 63% white, mean Charlson co-morbidity index 3.3 ± 1.8). Cardiopulmonary bypass was used in 71% of patients. Mean length of stay was 13.7 ± 11.4 days and hospitalization cost $67,744.6 ± 58,320.4. One or more complications occurred in 44% of cases. After propensity-score matching, patients with cirrhosis had a higher rate of complications (43.9% vs 38.93%; p < 0.001) and in-hospital mortality (7.2% vs 4.07%; p < 0.001) than noncirrhosis patients. On multivariate analysis, cirrhosis and ascites were associated with increased in-hospital mortality (odds ratio 2.87; 95% confidence intervals 2.37 to 3.48) and postoperative complications (odds ratio 5.11; 95% confidence intervals 3.88 to 6.72). In conclusion, patients with cirrhosis constitute a small portion of patients who underwent CABG in the United States but have a higher rate of complications and in-hospital mortality compared with noncirrhosis patients. In-hospital mortality remains high for this subset of patients but has decreased in recent years.

Coronary revascularization for acute myocardial infarction in the HIV population

OBJECTIVE

To analyze trends in management and outcomes of patients infected with the human immunodeficiency virus (HIV) undergoing percutaneous coronary intervention (PCI) for an acute myocardial infarction (AMI) in the United States.

BACKGROUND

Infection with HIV is an independent risk factor for accelerated atherosclerosis associated with higher rates of AMI. Current trends and outcomes of HIV-infected individuals presenting with AMI in the United States remain unknown.

METHODS

Using the Healthcare Cost and Utilization Project National Inpatient Sample database we identified HIV-infected individuals who underwent PCI for an AMI from 2002 to 2013. Multivariable logistic regression and propensity-score matching were performed to analyze outcomes.

RESULTS

We identified a total of 59 194 patients of which 7841 underwent PCI during index hospitalization (13.3%). Most patients were men (71%), ≥50 years of age (82%), and white (74%). ST-elevation myocardial infarction was present in 21% of cases. Charlson comorbidity index (CCI) was 5.67 ± 0.4. Predictors of post-procedural complications included female sex, black race, higher CCI, and placement of a bare metal stent, whereas predictors of mortality included occurrence of a complication, ST-elevation myocardial infarction, age ≥70 years, and higher CCI. Conversely, placement of a drug-eluting stent was associated with a reduced risk of complications and mortality. After propensity-score matching, HIV-infected individuals were less likely to undergo PCI and receive a drug-eluting stent, while having longer length of stay, higher hospitalization costs, and higher in-hospital mortality when compared to non-infected individuals.

CONCLUSION

Significant disparities continue to affect HIV-infected individuals undergoing PCI for AMI in the United States.

Transcatheter Mitral Valve Repair With MitraClip for Symptomatic Functional Mitral Valve Regurgitation

Transcatheter edge-to-edge mitral valve repair (TMVr) with MitraClip has proved to be safe and effective for high-risk surgical patients with severe symptomatic degenerative mitral regurgitation. There is paucity of data regarding its use in functional mitral regurgitation (FMR). The objective of this study was to evaluate the use of MitraClip in patients with symptomatic moderate or severe FMR and a high surgical risk. Medical libraries were systematically searched for studies assessing the use of MitraClip for patients with symptomatic moderate or severe FMR and a high surgical risk. Studies reporting safety and efficacy outcomes at 12 months were included in the analysis. A total of 12 studies including 1,695 patients (age 73 [interquartile range [IQR] 70.5 to 74], 69.8% men, left ventricular ejection fraction 32.5% [IQR 29.5 to 36], New York Heart Association class II to IV) who underwent TMVr with MitraClip were included in the analysis. Acute procedural success was 89% (IQR 85.5 to 92). Ischemic cardiomyopathy was the most common cause of left ventricular dysfunction. Over 2/3 of patients had known coronary artery disease, 35% a previous myocardial infarction, and 38.5% had a previous cardiac surgery. Survival to hospital discharge was 98% (IQR 97 to 100) and 30-day survival 97% (IQR 96 to 98). Overall survival at 12 months was 82% (IQR 77 to 87). Mitral valve re-intervention at 12 months was infrequent (3%; IQR 2 to 6.5). In conclusion, our pooled analysis suggests that TMVr with MitraClip is feasible, safe, and carries a low rate of mitral valve re-intervention at 12 months in patients with symptomatic moderate or severe FMR and a high surgical risk.

Outcomes of hemodynamic support with Impella in very high-risk patients undergoing balloon aortic valvuloplasty: Results from the Global cVAD Registry

BACKGROUND

Reports on the role of hemodynamic support devices in patients with severe aortic stenosis (AS) and left ventricular (LV) dysfunction undergoing balloon aortic valvuloplasty (BAV) are limited.

METHODS

Patients were identified from the cVAD registry, an ongoing multicenter voluntary registry at selected sites in North America that have used Impella in >10 patients.

RESULTS

A total of 116 patients with AS who underwent BAV with Impella support were identified. Mean age was 80.41±9.03years and most patients were male. Mean STS score was 18.77%±18.32, LVEF was 27.14%±16.07, and 42% underwent concomitant PCI. In most cases Impella was placed electively prior to BAV, whereas 26.7% were placed as an emergency. The two groups had similar baseline characteristics except for higher prevalence of CAD and lower LVEF in the elective group, and higher STS score in the emergency group. Elective strategy was associated higher 1-year survival compared to emergency placement (56% vs. 29.2%, p=0.003). One-year survival was higher when BAV was used as a bridge to definitive therapy as opposed to palliative treatment (90% vs. 28%, p<0.001). On multivariate analysis, STS score and aim of BAV (bridge to definitive therapy vs. palliative indication) were independent predictors of mortality.

CONCLUSION

In this large cohort of patients with AS and severe LV dysfunction undergoing BAV, our results demonstrates feasibility and promising long-term outcomes using elective Impella support with the intention to bridge to a definitive therapy.

Use of Aminocaproic Acid in Combination With Extracorporeal Membrane Oxygenation in a Case of Leptospirosis Pulmonary Hemorrhage Syndrome

A 32-year-old man presented with a 10-day history of fever, chills, nausea, vomiting, myalgia, nonproductive cough, and worsening dyspnea after freshwater swimming in the Caribbean 1 week prior to presentation. Shortly after arrival at the hospital, the patient developed severe respiratory distress with massive hemoptysis. Based on serologic workup, he was diagnosed with leptospirosis pulmonary hemorrhage syndrome leading to diffuse alveolar hemorrhage, severe hypoxemic respiratory failure, and multiorgan failure. He received appropriate antibiotic coverage along with hemodynamic support with norepinephrine and vasopressin, mechanical ventilation, and renal replacement therapy in an intensive care unit. Introduction of extracorporeal membrane oxygenation was initiated to provide lung-protective ventilation supporting the recovery of his pulmonary function. Aminocaproic acid was used to stop and prevent further alveolar hemorrhage. He fully recovered thereafter; however, it is uncertain whether it was the use of aminocaproic acid that led to the resolution of his disease.

[Percutaneous transluminal angioplasty with a balloon catheter in native aortic coarctation: long-term experience]

Between August 1988 and October 1993, 19 patients with native aortic coarctation were subjected to transluminal percutaneous balloon angioplasty, 12 of which were men (63.1%) and 7 were women (36.9%), with an average age of 22 +/- 7.7 years (r- 16 to 52), all of whom suffered from arterial hypertension at the time of the procedure, and a systolic pressure of 190 +/- 32.2 mmHg (r- 160 to 240). The gradient of the systolic pressure (GPS) was 77 +/- 0.9 mm, the average diameter of the balloon catheters that were used was 18.3 +/- 1.7 mm (r- 15 to 20). For all the patients, the procedure was carried out under local anesthesia and the usual Seldinger technique. After carrying out the procedure, the GPS as well as the blood pressure dropped to 5.0 +/- 4.1 mmHg and 130 +/- 20.6 mmHg, respectively. In similar manner, the enlargement of the ring displayed an increase of 4.2 +/- 0.9 to 14.1 +/- 1.6 mm. There were no complications in any of the procedures. During the follow-up, 11 patients were catheterized again in a period of 24.7 +/- 12.6 months (r- 10 to 48) with GPS of 5 +/- 2 mmHg. Besides, an increase of 15.4 +/- 1.2 mm in the ring's diameter was observed. In these patients, there was no evidence of the aneurysms at the dilatation site. Of the rest of the patients under control, 17 of whom have been able to maintain normal blood pressure without medical treatment, and only two required low dosages of antihypertensive treatment.(ABSTRACT TRUNCATED AT 250 WORDS)

[Mitral insufficiency after mitral balloon-catheter valvuloplasty: its incidence, predictive factors and prognosis]

From October 1991 to October 1993, a total of 205 patients with rheumatic mitral stenosis (178 female, 27 male, mean age 38 years, range 17-72) underwent percutaneous transvenous mitral commissurotomy (PTMC), 138 with the Inoue balloon and 67 with double balloon-catheter techniques. Mitral regurgitation (MR) was detected in 10% of the cases prior to the procedure, and 37% after PTMC (p < 0.05), grade I in 45 patients (22%), grade II in 24 (12%), grade III in 4 (2%), and grade IV in 3 (1.5%) cases (p = 0.003, 0.002, N.S. and N.S., respectively. In 40% of the total group (83/205) there was no new or worsening MR; in 26.8% of the cases (55/205) new MR appeared (p = 0.004); in 23% (47/205) MR increased one grade (p = 0.002) and in 9.7% (20/205) two or more grades. The comparative incidence of MR was 40.5% (56/138) with the Inoue balloon, and 16.4% (11/67) with the double balloon technique (p = 0.03); the severity of MR was grade I in 27% vs 9% (p = 0.001), grade II in 9.4% vs 6% (p = 0.05), grade III in 2.1% vs 1.5% (N.S.), and grade IV in 2.1% vs 0% (N.S.). Only the presence of commissural calcification and echo-score > 8 points were found as independent predictors of severe MR. In conclusion, mild and moderate MR occur frequently after PTMC, with significantly greater incidence using the Inoue technique. Severe MR following PTMC is much less frequent, and the comparative incidence is somewhat greater with the Inoue balloon, though the difference is not significant.

[The treatment of severe mitral stenosis by percutaneous transvenous commissurotomy]

In 110 adult selected patients, 87.1% female (average age 38.2 years, range 16-72) with symptomatic, severe mitral stenosis eligible for surgery, we performed balloon catheter transvenous mitral commissurotomy (BCTMC) as alternative treatment. Inoue's catheter was utilized in 80 cases (72.7%), and the double-balloon technique in 30 (27.3%). The procedure was successful in 102 patients (92.7%, 2nd attempt in 5 cases), with optimal results in 96 (87.3%); and it was unsuccessful in one patient for a technical difficulty. Complications occurred in 3 cases due to perforation of a cardiac chamber (2.7%); and 4/106 patients developed severe mitral insufficiency (3.8%). The mitral valve area increased from 1.09 +/- 0.27 to 2.6 +/- 0.87 cm2 (p < 0.0001); the diastolic mitral gradient decreased from 18.9 +/- 5.9 to 3.6 +/- 2.8 mmHg (p < 0.0001); similar reduction was obtained in mean left atrial pressure from 26.2 +/- 6.5 to 12.5 +/- 4.2 mmHg (p < 0.0001), and mean pulmonary artery pressure from 38 +/- 17 to 26.2 +/- 10.4 mmHg (p < 0.005). New mitral insufficiency appeared or increased in more of one grade in 12/106 patients (11.3%), and it was not detectable in 86/106 patients. During long-term follow-up (average 10.4 months, range 5 to 24), all patients (100 cases) improved their functional class (83.1% asymptomatic), and maintained their 2D echocardiographic mitral valve area. In conclusion BCMTC is the treatment of choice for selected cases of acquired symptomatic mitral stenosis, with immediate and long term results comparable to surgical commissurotomy.

[Percutaneous transvenous mitral commissurotomy with a Medi-tech balloon catheter: the initial experience and midterm follow-up]

From Jan-21-91 to Jan-8-92 we performed percutaneous transvenous mitral commissurotomy (PTCM) with a Medi-tech balloon catheter (MBC) in 41 patients bearing mitral stenosis simple o predominant. We utilized an anterograde transseptal approach in order to access the mitral valve, the procedure failed in 5 patients, in 30 of them we used double MBC and single MBC were utilized in 6 patients. Both left ventriculogram and hemodynamic parameters were taken before and after PTCM. Posterior to PTCM an important decrease appeared in the mitral transvalvular gradient from 20.6 +/- 2.7 to 2.4 +/- 1.7 mmHg (p < 0.0001) and an average pressure of pulmonary artery of 46.2 +/- 9.8 to 23.9 +/- 6 mmHg (p < 0.0001), and also the pulmonary arterial resistance from 1178.1 to 557.1 dinas/cm-5/seg. There was an important concomitant increase in mitral valvular area from 0.84 +/- 0.11 to 2.38 +/- 0.08 cm2 (p < 0.0001) and in cardiac rate from 2.7 +/- 0.7 to 2.9 +/- 0.52 L/min (p < 0.001).

COMPLICATIONS

Two female patients developed cardiac tamponade, one of them the procedure was successful, and for the other it was decided to submit her to valvular replacement. Mitral insufficiency was present in three patients; GI/IV in two of them and GII/IV angiographic in one. Another patient presented cerebral thromboembolism with complete recovery within 15 days. Short left to right shunt was detected only in 8 patients being 1.2/1 in 6 of them, 1.3/1 in one and 1.4/1 in other patient. Thirty three uncomplicated were dismissed within a maximum of 48 hours after procedure.(ABSTRACT TRUNCATED AT 250 WORDS)