Orbital Atherectomy for Treatment of Severely Calcified Coronary Artery Bifurcation Lesions: A Multicenter Analysis

ObjectiveThis study evaluated the safety and efficacy of orbital atherectomy (OA) for the treatment of severely calcified coronary artery bifurcation lesions.BackgroundPercutaneous coronary intervention (PCI) of severely calcified coronary artery lesions is associated with lower procedural success and higher rates of target lesion failure compared to non-calcified lesions. OA is an effective treatment for calcified coronary artery lesions prior to stent implantation. However, there is little data regarding the safety and efficacy of OA in patients with coronary artery bifurcation lesions.MethodsData were obtained from analysis of patients with severe coronary artery calcification who underwent OA and coronary stent implantation at ten high-volume institutions. Data were pooled and analyzed to assess peri-procedural outcomes and 30-day major adverse cardiac events (MACE).ResultsA total of 1156 patients were treated with OA and PCI. 363 lesions were at a coronary artery bifurcation. There were no statistically significant differences in baseline characteristics between the bifurcation and non-bifurcation groups. In the bifurcation group, treatment involved the left anterior descending artery and its branches more frequently and right coronary artery less frequently. After propensity score matching, the 30-day freedom from MACE was not statistically significant between the two groups.ConclusionIn this multicenter cohort analysis, patients with severely calcified coronary bifurcation lesions had low rates of MACE and target vessel revascularization at 30 days at rates comparable to non-bifurcation lesions. This analysis demonstrates that OA is safe and effective for complex coronary lesions at both bifurcation and non-bifurcation locations.     

Percutaneous Coronary Intervention of Complex Calcific Coronary Lesions Utilizing Orbital Atherectomy Prior to Transcatheter Aortic Valve Replacement

BackgroundCoronary artery disease (CAD), often with severe calcification, is present in up to 75% of patients with severe aortic stenosis (AS) referred for transcatheter aortic valve replacement (TAVR). Management of CAD in such patients is challenging. Orbital atherectomy (OA) is an effective treatment of severely calcified coronary lesions prior to stent implantation. However, there is limited data on the use of OA for percutaneous coronary intervention (PCI) to treat calcific CAD patients prior to TAVR (OA PCI + TAVR).MethodsRetrospective analysis of patients with moderate/severe calcific CAD and moderate/severe AS who underwent staged OA PCI + TAVR at one high-volume institution. Data were analyzed to assess the 1-year major adverse cardiac events after index OA PCI [MACE: death, target lesion revascularization (TLR), and myocardial infarction (MI)].ResultsThere were 18 patients (mean age of 82) treated with staged OA PCI + TAVR, and of those, 10 (56%) were male, 7 (39%) Caucasian, and 11 (61%) Hispanic/Latino. The average left ventricular ejection fraction was 49% and congestive heart failure was present in 12 patients (67%). There were no angiographic complications (0%), stent thrombosis (0%), or stroke events (0%). The 30-day and 1-year MACE rates were 5.6% (0% death, 0% TLR, 5.6% MI) and 17% (0% death, 11% TLR, and 17% MI [all non-Q-wave MI]), respectively.ConclusionsIn this single-center observational cohort series, patients with heavily calcified coronary lesions treated with OA prior to TAVR had low rates of MACE at 30 days and 1 year. The results demonstrate the feasibility and safety of OA for the treatment of complex calcific coronary lesions prior to TAVR. An up-to-date literature review of atherectomy before, during, or after TAVR in patients with concomitant severe AS and calcific CAD is also provided.Table of contents summaryThere is limited data on the use of orbital atherectomy (OA) for percutaneous coronary intervention (PCI) to treat calcific coronary artery disease (CAD) patients prior to transcatheter aortic valve replacement (TAVR). Our primary aim was to evaluate the feasibility, safety, and 1-year outcome of OA PCI pre-TAVR in patients with complex CAD and severe aortic stenosis (AS). We also aimed to provide a brief up-to-date literature review of atherectomy before, during, or after TAVR in patients with concomitant severe AS and calcific CAD. This retrospective cohort study found that OA is feasible and safe for the treatment of severely calcified coronary lesions before TAVR, resulting in acceptable 30-day and 1-year outcomes.     

Same-day discharge after elective percutaneous coronary intervention: A single center experience

Introduction and objectivesElective percutaneous coronary intervention (PCI) has become an increasingly safe procedure. However, same day discharge (SDD) has yet to become standard practice. Our aim is to characterize the patients who underwent elective PCI and compare outcomes between the overnight stay (ONS) patient group and the group that was discharged on the same day at 24 hours and at 30 days.MethodsOne-year registry of patients who underwent an elective PCI. The possibility of SDD was established by the operator. Appropriate candidates were discharged at least four hours after the end of the intervention. The primary endpoints were defined as: Major adverse cardiac and cerebrovascular events (MACCE) — death, myocardial infarction (MI) stroke or transient ischemic attack (TIA), non-planned re-intervention — and vascular complications. Secondary endpoints were any unplanned hospital visit, readmission and re-catheterization.ResultsWe performed 155 elective PCIs. One patient was admitted to the coronary care unit; 111 patients stayed overnight (ONS Group); 43 patients were discharged the same day (SDD Group). Three patients had early (<4 hours) post procedure complications: two TIAs and one vascular access site complication. There were no MACCE between four and 24 hours, nor at 30 days. At 24 hours, two patients from the SDD group had unplanned visits. Between one and 30 days, more patients from the SDD group had unplanned visits (9.3% vs. 0.9%. p=0.02). One patient from the ONS group had a recatherization. There were no readmissions or reinterventions.ConclusionSame day discharge of selected patients who undergo elective PCIs is feasible and safe.     

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

BackgroundSeveral 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.MethodsThe 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.ResultsA 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)].ConclusionsOne-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.     

Trends,Predictors, and Outcomes Associated With 30-Day Hospital Readmissions After Percutaneous Coronary Intervention in a High-Volume Center Predominantly Using Radial Vascular Access

Background and aimPatients undergoing percutaneous coronary intervention (PCI) are at high-risk for hospital readmission. We examined the rate, factors associated with, and outcomes of 30-day readmissions for patients who underwent a PCI.MethodsWe reviewed medical records of all patients who underwent PCI between 2011 and 2014 at a central New England radial first, tertiary care center. Data was collected on occurrence and cause of readmission as well as patients' bleeding events and survival at one year. Logistic regression was used to examine factors associated with 30-day readmission as well as its association with bleeding and all-cause mortality.ResultsA total of 3858 patients were studied (mean age = 62.8 years with 26.1% women), among whom 348 (9.5%) patients were readmitted within 30-days. Cardiac causes of readmission represented 62% of all readmissions. In the multi-variable adjusted regression model, factors that were significantly associated with 30-day readmission included female gender, prior coronary bypass surgery, acute coronary syndrome, anemia, length of stay, and delay in initial presentation. Patients who were readmitted had more than twice the risk of bleeding and mortality at one year as compared to those who were not readmitted within 30 days.ConclusionsIn conclusion, our results suggest that early hospital readmission after undergoing PCI is common and has not changed in recent years. Efforts should be made to identify and closely monitor patients who are at risk for readmission after PCI.     

Outcomes After Coronary Orbital Atherectomy at Centers Without On-Site Surgical Backup: Diabetics Versus Non-Diabetics and Impact of Access Site

Background/purposeThere is limited data available on atherectomy usage in hospitals or centers without on-site surgical backup. The purpose of this retrospective analysis was to gain further knowledge by analyzing the in-hospital and 30-day outcomes of complex PCI patients (including diabetics) treated with coronary orbital atherectomy (OA) at centers without on-site surgical back-up.Methods/materialsAll comers treated with OA at two centers without on-site surgical backup were included. Baseline, procedure, and outcome data were compared in diabetic and non-diabetic patients. The impact of transfemoral (TFA) versus transradial (TRA) vascular access was also assessed.ResultsOf the 221 patients treated with OA, 43% were diabetics. The diabetes and no-diabetes groups had similar baseline demographic and lesion characteristics, except for the higher rate of chronic kidney disease seen in the diabetics. Overall, there was a high freedom from major adverse cardiac events (MACE; in-hospital: 99.5%; 30-day: 98.6%), as well as a high success in stent delivery (99.5%) and procedural success (97.3%). The rate of angiographic complications was low in both the diabetes and no-diabetes groups (3.1% vs. 1.6%, p = 0.450). TFA and TRA were used in 36% and 64% of the patients, respectively—resulting in low angiographic complications in both groups (3.8% vs. 1.4%, p = 0.263).ConclusionsDespite the complexity of patient co-morbidities and the presence of heavily calcified lesions, the results indicate that coronary OA can be used safely and effectively without on-site surgical back-up. OA treatment resulted in a high rate of successful stent delivery and procedural success, as well as low rates of angiographic complications and MACE, in diabetic and non-diabetic patients, regardless of access site.Table of contents summaryThere is limited data available on atherectomy usage in centers without on-site surgical backup. The purpose of this retrospective analysis was to gain further knowledge by analyzing the outcomes of complex PCI patients (including diabetics) treated with coronary orbital atherectomy (OA) at centers without on-site surgical back-up. The impact of transfemoral (TFA) versus transradial (TRA) vascular access was also assessed. Despite the complexity of patient co-morbidities and the presence of heavily calcified lesions, the results indicate that coronary OA can be used safely and effectively without on-site surgical back-up. OA treatment resulted in a high rate of successful stent delivery and procedural success, as well as low rates of angiographic complications and major adverse cardiac events, in diabetic and non-diabetic patients, regardless of access site (TFA or TRA).     

Same-Day Discharge After Outpatient PCI in a VA Hospital: Shared Decision Making and the VA MISSION Act

IntroductionThe VA Mission Act of 2018 sought to increase access to local care facilities for Veterans meeting certain eligibility criteria including a drive time of >60 min from a VA facility. As part of an ongoing review of our VA program's same day discharge (SDD) program following elective percutaneous coronary intervention (PCI), we investigated whether the distance criteria of the VA Mission Act had any impact on overall safety outcomes.MethodsWe performed a single center, retrospective study in patients who underwent outpatient PCI between 2013 and 2019. We stratified patients into an overnight observation (ON) and SDD group. We used Google Maps in order to calculate patient home distance to the Jesse Brown Veterans Affairs Hospital (JBVA).Primary endpoints included all-cause death andmajor adverse cardiac events (MACE; cardiovascular death, myocardial infarction, stroke, and/or target vessel revascularization). Secondary outcomes included total unplanned interactions with the healthcare system. Outcomes were analyzed at 30 days after PCI.ResultsThere were 76 patients in the SDD group. The SDD group had a median drive time of 80 min from the JBVA.Regarding primary outcomes, there were no cases of MACE in either group and there was no statistically significant difference in terms of all-cause mortality (ON: 1.3%, SDD: 0%, p = .5) 30 days following PCI. All secondary outcomes at 30 days did not demonstrate a statistically significant difference between either group.ConclusionSame day discharge following successful PCI procedures appears safe. In response to the VA Mission Act, drive time and distance travelled did not appear to impact outcomes.SummarySame day discharge in select patients at our VA hospital was both safe and feasible. Neither drive time nor distance travelled affected overall outcomes in response to the 2018 VA MISSION Act. As such, shared decision making between patients and physicians remains essential to ensure Veterans continue to receive high quality care that is in their best medical interest.     

Burden of 30-Day Readmissions After Percutaneous Coronary Intervention in 833,344 Patients in the United States: Predictors,Causes, and Cost: Insights From the Nationwide Readmission Database

Objectives

This study aimed to examine the 30-day unplanned readmissions rate, predictors of readmission, causes of readmissions, and clinical impact of readmissions after percutaneous coronary intervention (PCI).

Outcomes after Atherectomy Treatment of Severely Calcified Coronary Bifurcation Lesions: A Single Center Experience

BackgroundCoronary bifurcation and calcified lesions account for 15–20% and 6%–20% of percutaneous coronary interventions (PCI), respectively. Treatment of these lesions is associated with high periprocedural complication rates and unfavorable long-term clinical outcomes, including high rates of revascularization. This retrospective, single-center study evaluated the outcomes of atherectomy treatment for heavily calcified coronary bifurcation lesions.MethodsPatients who underwent a coronary atherectomy procedure to treat a heavily calcified lesion between January 2010 and March 2016 at Metropolitan Heart and Vascular Institute (Minneapolis, MN) were included in this retrospective study. Data were stratified to compare atherectomy treatment of coronary bifurcation lesions vs non-bifurcation lesions. Additionally, data were compared based on type of atherectomy utilized during the index procedure, either orbital (OAS) or rotational (RA) atherectomy. Major adverse cardiac events (MACE), defined as a composite of death, myocardial infarction (MI), and target vessel revascularization (TVR), were assessed at 30 days post-procedure.ResultsAmong the 177 patients treated with atherectomy, 72 patients had bifurcation lesions. Compared to patients with non-bifurcation lesions, patients with bifurcation lesions were more likely to have a history of prior PCI or coronary artery bypass grafting. Bifurcation lesions required a higher volume of contrast. There were similar low rates of slow flow/no-reflow (2.8% bifurcations vs 1.0% non-bifurcation; p = 0.355). The 30-day rates of death (1.4% vs 1.9%; p = 0.794), MI (0% vs 0%; p = NA), and TVR (0% vs 1.0%; p = 0.406) were similar in patients with bifurcation lesions versus those without, respectively. An atherectomy sub-analysis (OAS vs RA) of the patients with bifurcation lesions showed that OAS utilization was associated with shorter procedure time (81 min vs 109 min; p = 0.026) and fluoroscopy time (18 min vs 27 min; p = 0.007) compared to RA, respectively—no significant differences in baseline demographic or lesion characteristics were noted in the bifurcation atherectomy sub-groups, except for higher beta/calcium blocker use in RA bifurcation subjects.ConclusionsThe results of this study demonstrated that atherectomy treatment in patients with heavily calcified coronary bifurcation lesions is feasible, resulting in similar low 30-day MACE rates as compared to patients with non-bifurcation lesions. In addition, in this study OAS utilization versus RA in bifurcation lesions was associated with significantly shorter procedure and fluoroscopy time. Further studies are needed to assess the safety and efficacy of atherectomy in patients with severely calcified bifurcation lesions.Summary for annotated table of contentsThis retrospective, single-center study evaluated the outcomes of orbital and rotational atherectomy treatment for heavily calcified coronary bifurcation lesions as compared to non-bifurcation lesions. The results demonstrate that atherectomy treatment in patients with heavily calcified coronary bifurcation lesions is feasible, resulting in similarly low 30-day MACE rates as compared to patients with non-bifurcation lesions. In addition, in this study OAS utilization versus RA in bifurcation lesions was associated with significantly shorter procedure and fluoroscopy time.     

Index Admission and Thirty-Day Readmission Outcomes of Patients With Cancer Presenting With STEMI

BackgroundNational-level data of cancer patients' readmissions after ST-segment elevation myocardial infarction (STEMI) are lacking.ObjectivesThe primary aim of this study was to compare the rates and causes of 30-day readmissions in patients with and without cancer.MethodsAmong patients admitted with STEMI in the United States National Readmission Database (NRD) from October 2015–December 2017, we identified patients with the diagnosis of active breast, colorectal, lung, or prostate cancer. The primary endpoint was the 30-day unplanned readmission rate. Secondary endpoints included in-hospital outcomes during the index admission and causes of readmissions. A propensity score model was used to compare the outcomes of patients with and without cancer.ResultsA total of 385,522 patients were included in the analysis: 5956 with cancer and 379,566 without cancer. After propensity score matching, 23,880 patients were compared (Cancer = 5949, No Cancer = 17,931). Patients with cancer had higher 30-day readmission rates (19% vs. 14%, p < 0.01). The most common causes for readmission among patients with cancer were cardiac (31%), infectious (21%), oncologic (17%), respiratory (4%), stroke (4%), and renal (3%). During the first readmission, patients with cancer had higher adjusted rates of in-hospital mortality (15% vs. 7%; p < 0.01) and bleeding complications (31% vs. 21%; p < 0.01), compared to the non-cancer group. In addition, cancer (OR 1.5, 95% CI 1.2–1.6, p < 0.01) was an independent predictor for 30-day readmission.ConclusionsAbout one in five cancer patients presenting with STEMI will be readmitted within 30 days. Cardiac causes predominated the reason for 30-day readmissions in patients with cancer.     

Unplanned 30-Day Readmission after Coronary Artery Bypass in Patients with Acute Myocardial Infarction

Background/purposeThe Centers for Medicare and Medicaid services penalizes hospitals with higher than expected readmissions for coronary artery bypass graft surgery (CABG). Little information exists regarding outcomes in patients who sustain an acute myocardial infarction (MI) and undergo CABG as the primary revascularization strategy. Our goal was to determine the unplanned 30-day readmission rate in this high-risk population and predictors of readmission.Materials/methodsAn institutional database was queried to identify patients from 2011 to 2017 who were admitted with an acute MI and underwent CABG within 30 days. Chart review was performed to collect demographics, medical comorbidities and clinical information related to hospital course and readmission status.ResultsA total of 150 patients were included. The 30-day unplanned readmission rate was 23%, and the majority (80%) were non-cardiac related. Predictors of unplanned readmission included female sex (OR 2.61, 95% CI 1.042–6.549, p = 0.041), CABG performed <7 days following MI (OR 2.82, 95% CI 1.21–6.59, p = 0.017), and post-operative atrial fibrillation (OR 3.25, 95% CI 1.07–9.87, p = 0.038). Complications were identified in 32% of clinic visits in patients who did not require readmission.ConclusionsPatients who undergo CABG following MI are a high-risk population with nearly one-quarter readmitted within 30 days. Female sex, <7 days between the index MI and CABG, and post-operative atrial fibrillation are strong predictors for readmission. Early outpatient follow-up may be an effective intervention to reduce hospital readmissions by reassuring patients that non-cardiac symptoms are in line with anticipated post-operative pain and healing.     

Feasibility and Safety of Same-Day Discharge Following Transfemoral Transcatheter Aortic Valve Replacement

ObjectivesThis study evaluated the feasibility and safety of same-day discharge (SDD) following transfemoral transcatheter aortic valve replacement (TF-TAVR) compared with next-day discharge (NDD).BackgroundReducing hospital length of stay is an important goal for patients and hospitals. Cleveland Clinic implemented a post-TAVR SDD pathway beginning in March 2020.MethodsThe study retrospectively analyzed patients who underwent “minimalist” outpatient TF-TAVR in 2019 to 2020. SDD was applied to patients who met the predefined criteria. Outcomes included in-hospital and 30-day events and were compared between SDD and NDD (during and prior to availability of the SDD pathway).ResultsIn 2020, SDD and NDD accounted for 22.1% (n = 114 of 516) and 63.8% (n = 329 of 516) of outpatient TF-TAVR, respectively. SDD patients in 2020, compared with NDD patients in 2019 (n = 481), were younger, were more often male, and had a lower surgical risk. There were no significant differences in in-hospital events and 30-day readmissions (cardiovascular readmission: 3.5% vs 6.2%; P = 0.37; noncardiovascular readmission: 2.6% vs 4.0%; P = 0.78), and there were no deaths after SDD. These outcomes remained consistent after propensity score matching. Only 1 (0.9%) patient required pacemaker implantation after SDD (post-TAVR day 25). As expected based on SDD criteria, multivariable logistic regression analysis identified procedure end-time as the strongest predictor of SDD (adjusted OR: 7.74; 95% CI: 4.39-13.63), while male sex and baseline hemoglobin level were also associated with SDD.ConclusionsSDD after TF-TAVR was feasible in this early experience without impairing post-discharge safety. Our SDD pathway may serve as a useful strategy to improve bed utilization and reduce hospital stay for TAVR recipients.     

心肌梗死伴多支血管病变患者非梗死相关动脉处理时机的探讨

目的总结和分析因急性心肌梗死（acute myocardial infarction,AMI）伴多支血管病变行急诊经皮冠状动脉介入（percutaneous coronary intervention,PCI）治疗患者非梗死相关动脉处理情况,探讨非梗死相关动脉的处理时机。方法选择成功行急诊PCI治疗的合并多支血管病变AMI患者252例,其中未处理非梗死相关动脉用药物治疗51例,行冠状动脉动脉旁路移植术5例;而需处理非梗死相关动脉患者196例,其中7d内处理非梗死相关动脉（排除急诊PCI治疗当时同时处理非梗死相关动脉的患者）19例,7—14d内处理的患者81例,28-35d处理的患者96例。回顾性分析各组的一般临床资料,冠状动脉病变情况,观察的重点为各组3个月及6个月内主要心血管事件及再住院率。结果与其他组相比,28—35d干预组6个月内主要不良心血管事件（9．38％）、因心源性疾病二次入院率最低（10．4％）（P〈0．05）。结论在心肌梗死后第28—35天干预AMI患者非梗死相关动脉可能更有利于改善患者的预后。     

Profile of and risk factors for early unplanned readmissions in patients with acute necrotizing pancreatitis

IntroductionAcute necrotizing pancreatitis (ANP) complicates up to 15% of acute pancreatitis cases. ANP has historically been associated with a significant risk for readmission, but there are currently no studies exploring factors that associate with risk for unplanned, early (<30-day) readmissions in this patient population.MethodsWe performed a retrospective review of all consecutive patients presenting to hospitals in the Indiana University (IU) Health system with pancreatic necrosis between December 2016 and June 2020. Patients younger than 18 years of age, without confirmed pancreatic necrosis and those that suffered in-hospital mortality were excluded. Logistic regression was performed to identify potential predictors of early readmission in this group of patients.ResultsOne hundred and sixty-two patients met study criteria. 27.7% of the cohort was readmitted within 30-days of index discharge. The median time to readmission was 10 days (IQR 5–17 days). The most frequent reason for readmission was abdominal pain (75.6%), followed by nausea and vomiting in (35.6%). Discharge to home was associated with 93% lower odds of readmission. We found no additional clinical factors that predicted early readmission.ConclusionPatients with ANP have a significant risk for early (<30 days) readmission. Direct discharge to home, rather than short or long-term rehabilitation facilities, is associated with lower odds of early readmission. Analysis was otherwise negative for independent, clinical predictors of early unplanned readmissions in ANP.     

Association of Post-discharge Service Types and Timing with 30-Day Readmissions,Length of Stay,and Costs

BackgroundAlthough early follow-up after discharge from an index admission (IA) has been postulated to reduce 30-day readmission, some researchers have questioned its efficacy, which may depend upon the likelihood of readmission at a given time and the health conditions contributing to readmissions.ObjectiveTo investigate the relationship between post-discharge services utilization of different types and at different timepoints and unplanned 30-day readmission, length of stay (LOS), and inpatient costs.Design, Setting, and ParticipantsThe study sample included 583,199 all-cause IAs among 2014 Medicare fee-for-service beneficiaries that met IA inclusion criteria.Main MeasuresThe outcomes were probability of 30-day readmission, average readmission LOS per IA discharge, and average readmission inpatient cost per IA discharge. The primary independent variables were 7 post-discharge health services (institutional outpatient, primary care physician, specialist, non-physician provider, emergency department (ED), home health care, skilled nursing facility) utilized within 7 days, 14 days, and 30 days of IA discharge. To examine the association with post-discharge services utilization, we employed multivariable logistic regressions for 30-day readmissions and two-part models for LOS and inpatient costs.Key ResultsAmong all IA discharges, the probability of unplanned 30-day readmission was 0.1176, the average readmission LOS per discharge was 0.67 days, and the average inpatient cost per discharge was $5648. Institutional outpatient, home health care, and primary care physician visits at all timepoints were associated with decreased readmission and resource utilization. Conversely, 7-day and 14-day specialist visits were positively associated with all three outcomes, while 30-day visits were negatively associated. ED visits were strongly associated with increases in all three outcomes at all timepoints.ConclusionPost-discharge services of different types and at different timepoints have varying impacts on 30-day readmission, LOS, and costs. These impacts should be considered when coordinating post-discharge follow-up, and their drivers should be further explored to reduce readmission throughout the health care system.Supplementary InformationThe online version contains supplementary material available at 10.1007/s11606-021-06708-6.KEY WORDS: all-cause index admission, unplanned 30-day readmission, post-discharge services utilization, service types, Hospital Readmission Reduction Program     

Sex differences in 30-day readmission rates,etiology, and predictors after transcatheter aortic valve replacement

BackgroundThe aim of this study is to analyze sex-specific readmission rates, etiology, and predictors of readmission after transcatheter aortic valve replacement (TAVR). Readmissions after TAVR are common, contributing to increased health care utilization and costs. Many factors have been discovered as predictors of readmission; however, sex-specific disparities in readmission rates are limited.MethodsBetween January 2012 and September 2015, adult patients after TAVR were identified using appropriate international classifications of diseases, ninth revision, clinical modification from the National Readmission Database. Incidence of unplanned 30-days readmission rate was the primary outcome of this study. In addition, this study includes sex-specific etiology and predictors of readmissions. Multivariate logistic regression was performed to analyze adjusted readmission rates. Hierarchical 2-level logistic models were used to evaluate predictors of readmission.ResultsReadmission rate at 30 days was 17.3%, with slightly higher readmission rates in women (OR 1.09; CI: 1.01–1.19, p < 0.001) after multivariate adjusted analysis. Noncardiac causes were responsible for most readmissions in both genders. Etiologies for readmissions such as arrhythmias, pulmonary complications, and infections were slightly higher in women, whereas heart failure and bleeding complications were higher in men. History of heart failure, atrial fibrillation, prior pacemaker, and renal failure significantly strongly predicted readmissions in both genders.ConclusionWomen undergoing TAVR have slightly higher 30-day all-cause readmission rates. These results indicate that women require more attention compared to men to prevent 30-day readmission. In addition, risk stratification for men and women based on predictors will help identify high-risk men and women for readmissions.     

Discharge Against Medical Advice in Acute Ischemic Stroke: the Risk of 30-Day Unplanned Readmission

BackgroundDischarge against medical advice may be associated with more readmissions.ObjectiveTo evaluate DAMA in patients with acute ischemic stroke (AIS) and identify the relationship between DAMA and 30-day unplanned readmissions.DesignA retrospective cohort study.ParticipantsThe National Readmission Database was used to identify inpatients with a primary diagnosis of AIS who were either discharged home or DAMA between 2010 and 2017 in the USA.MeasuresDemographic features, hospital type, comorbidities, stroke risk factors, severity indices, and treatments were compared between patients discharged routinely and DAMA. Multivariable logistic regression was used to evaluate predictors of DAMA, and a double robust inverse probability of treatment weighting method was used to assess the association between DAMA and 30-day unplanned readmissions.Key ResultsOverall, 1,335,484 patients with AIS were included, of whom 2.09% (n = 27,892) were DAMA. The prevalence of DAMA in AIS patients increased from 1.65 in 2010 to 2.57% in 2017. The rates of 30-day unplanned readmissions for DAMA and non-DAMA patients were 16.81% and 7.78%, respectively. Patients with drug abuse, alcohol abuse, smoking, prior stroke, psychoses, and intravenous thrombolysis had greater odds of DAMA. DAMA was associated with all-cause readmissions (OR, 2.04; 95% CI, 2.01–2.07) and remained a strong predictor for transient ischemic attack/stroke-specific and cardiac-specific causes of readmissions.ConclusionsAlthough the DAMA rate is low in AIS patients, DAMA is a risk factor for all-cause and recurrent stroke-specific readmissions. Future studies are needed to address issues around compliance and engagement with health care to reduce DAMA.Supplementary InformationThe online version contains supplementary material available at 10.1007/s11606-020-06366-0.KEY WORDS: discharge against medical advice, readmission, acute ischemic stroke, risk factor     

Incidence,Causes, and Predictors of Early (≤30 Days) and Late Unplanned Hospital Readmissions After Transcatheter Aortic Valve Replacement

ObjectivesThe aim of this study was to determine the incidence, causes, and predictors of unplanned hospital readmissions after transcatheter aortic valve replacement (TAVR).BackgroundData regarding unplanned hospital readmissions after TAVR in a real-world all-comers population are scarce.MethodsA total of 720 consecutive patients undergoing TAVR at 2 centers who survived the procedure, were included. Median follow-up was 23 months (interquartile range [IQR]: 12 to 39 months), available in 99.9% of the initial population. The occurrence, timing, and causes of hospital readmission within the first year post-TAVR were obtained in all cases. Early and late readmissions were defined as those occurring ≤30 days and >30 days to 1 year post-TAVR, respectively.ResultsThere were 506 unplanned readmissions in 316 patients (43.9%) within the first year post-TAVR (median time: 63 days; IQR: 19 to 158 days post-discharge). Of these, early readmission occurred in 105 patients (14.6%), and 118 patients (16.4%) had multiple (≥2) readmissions. Readmissions were due to noncardiac and cardiac causes in 59% and 41% of cases, respectively. Noncardiac readmissions included, in order of decreasing frequency, respiratory, infection, and bleeding events as the main causes, whereas heart failure and arrhythmias accounted for most cardiac readmissions. The predictors of early readmission were periprocedural major bleeding complications (p = 0.001), anemia (p = 0.019), lower left ventricular ejection fraction (p = 0.042), and the combined presence of antiplatelet and anticoagulation therapy at hospital discharge (p = 0.014). The predictors of late readmission were chronic obstructive pulmonary disease (p = 0.001), peripheral vascular disease (p = 0.023), chronic renal failure (p = 0.013), and atrial fibrillation (p = 0.012). Early readmission was an independent predictor of mortality during the follow-up period (hazard ratio: 1.56, 95% confidence interval: 1.02 to 2.39, p = 0.043).ConclusionsThe readmission burden after TAVR in an all-comers population was high. Nearly one-fifth of the patients were readmitted early after hospital discharge, increasing the risk of mortality at follow-up. Reasons for readmission were split between noncardiac and cardiac causes, with respiratory causes and heart failure as the main diagnoses in each group, respectively. Whereas early readmissions were mainly related to periprocedural bleeding events, most late readmissions were secondary to baseline patient comorbidities. These results underscore the importance of and provide the basis for implementing specific preventive measures to reduce readmission rates after TAVR.     

Direct Stenting in Patients Treated with Orbital Atherectomy: An ORBIT II Subanalysis

BackgroundDirect stenting offers many potential advantages in appropriately selected lesions. Coronary artery calcification increases the complexity and risk of adverse events associated with percutaneous coronary intervention. This study aimed to examine the feasibility of direct stenting after treatment with orbital atherectomy (OA).MethodsORBIT II was a single-arm trial enrolling 443 subjects with de novo severely calcified coronary lesions treated with OA; direct stenting was utilized in 59.0% of cases. Procedural outcomes and 3-year major adverse cardiac event (MACE) rates were compared in subjects treated with pre-stent balloon dilatation versus direct stenting after OA.ResultsProcedural success (84.2% vs. 93.3%; p = 0.004) was significantly higher in the direct stenting cohort. 3-year MACE occurred less frequently in the direct stenting cohort (29.9% vs. 19.1%; p = 0.006), driven by lower rates of myocardial infarction and target lesion revascularization. In a propensity matched analysis, procedural success and 3-year MACE rates were similar in the pre-stent balloon dilatation and direct stenting groups (85.0% vs. 91.8%; p = 0.122 and 28.2% vs. 19.6%; p = 0.078, respectively).ConclusionsOrbital atherectomy facilitates direct stenting and is associated with high procedural success and favorable 3-year outcomes in carefully selected patients. Randomized studies are needed to assess the optimal strategy after lesion preparation with OA.     

Safety and Feasibility of Same Day Discharge Strategy for Primary Percutaneous Coronary Intervention

Background:The strategy for early discharge after primary percutaneous coronary intervention (PCI) could have substantial financial benefits, especially in low-middle income countries. However, there is a lack of local evidence on feasibility and safety of the strategy for early discharge. Therefore, the aim of this study was to assess the safety of early discharge after primary PCI in selected low-risk patients in the population of Karachi, Pakistan.Methods:In this study 600 consecutive low-risk patients who were discharged within 48 hours of primary PCI were put under observation for major adverse cardiac events (MACE) after 7 and 30 days of discharge respectively. Patients were further stratified into discharge groups of very early (≤ 24 hours) and early (24 to 48 hours).Results:The sample consisted of 81.8% (491) male patients with mean age of 54.89 ± 11.08 years. Killip class was I in 90% (540) of the patients. The majority of patients (84%) were discharged within 24 hours of the procedure. Loss to follow-up after rate at 7 and 30 days was 4% (24) and 4.3% (26) respectively. Cumulative MACE rate after 7 and 30 days was observed in 3.5% and 4.9%, all-cause mortality in 1.4% and 2.3%, cerebrovascular events in 0.9% and 1.4%, unplanned revascularization in 0.9% and 1.2%, re-infarction in 0.3% and 0.5%, unplanned re-hospitalization in 0.5% and 0.5%, and bleeding events in 0.5% and 0.5% of the patients respectively.Conclusion:It was observed that very early (≤ 24 hours) discharge after primary PCI for low-risk patients is a safe strategy subjected to careful pre-discharge risk assessment with minimal rate of MACE after 7-days as well as 30-days.