Repeat Coronary Bypass Surgery or Percutaneous Coronary Intervention After Previous Surgical Revascularization

ObjectiveTo assess long-term survival with repeat coronary artery bypass grafting (RCABG) or percutaneous coronary intervention (PCI) in patients with previous CABG.MethodsFrom January 1, 2000, through December 31, 2013, 1612 Mayo Clinic patients underwent RCABG (n=215) or PCI (n=1397) after previous CABG. The RCABG cohort was grouped by use of saphenous vein grafts only (n=75), or with additional arterial grafts (n=140); the PCI cohort by, bare metal stents (BMS; n=628), or drug-eluting stents (DES; n=769), and by the treated target into native coronary artery (n=943), bypass grafts only (n=338), or both (n=116). Multivariable regression and propensity score analysis (n=280 matched patients) were used.ResultsIn multivariable analysis, the 30-day mortality was increased in RCABG versus PCI patients (hazard ratio [HR], 5.32; 95%CI, 2.34-12.08; P<.001), but overall survival after 30 days improved with RCABG (HR, 0.72; 95% CI, 0.55-0.94; P=.01). Internal mammary arteries were used in 61% (129 of 215) of previous CABG patients and improved survival (HR, 0.82; 95% CI, 0.69-0.98; P=.03). Patients treated with drug-eluting stent had better 10-year survival (HR, 0.74; 95% CI, 0.59-0.91; P=.001) than those with bare metal stent alone. In matched patients, RCABG had improved late survival over PCI: 48% vs 33% (HR, 0.57; 95% CI, 0.35-0.91; P=.02). Compared with RCABG, patients with PCI involving bypass grafts (n=60) had increased late mortality (HR, 1.62; 95% CI, 1.10-2.37; P=.01), whereas those having PCI of native coronary arteries (n=80) did not (HR, 1.09; 95% CI, 0.75-1.59; P=.65).ConclusionRCABG is associated with improved long-term survival after previous CABG, especially compared with PCI involving bypass grafts.     

Impact of Pulmonary Hypertension on In-Hospital Outcomes and 30-Day Readmissions Following Percutaneous Coronary Interventions

ObjectiveTo evaluate the impact of pulmonary hypertension (PH) on percutaneous coronary intervention (PCI) outcomes and 30-day all-cause readmissions by analyzing a national database.MethodsWe queried the 2014 National Readmissions Database to identify patients undergoing PCI using International Classification of Diseases, Ninth Revision, Clinical Modification codes. These patients were then subcategorized based on the coded presence or absence of PH and further analyzed to determine the impact of PH on clinical outcomes, health care use, and 30-day readmissions.ResultsAmong 599,490 patients hospitalized for a PCI in 2014, 19,348 (3.2%) had concomitant PH. At baseline, these patients were older with a higher burden of comorbidities. Patients with PH had longer initial hospitalizations and higher 30-day readmission rates and mortality than their non-PH counterparts. This was largely driven by cardiac causes, most commonly heart failure (20.3% vs 9.0%, P<.001) and non–ST-segment elevation myocardial infarction. Recurrent coronary events (17.5% vs 9.5%, P<.05) including ST-segment elevation myocardial infarction predominated in the non-PH group.ConclusionPatients with PH undergoing PCI are a high-risk group in terms of mortality and 30-day readmission rates. Percutaneous coronary intervention in patients with PH is associated with higher rates of recurrent heart failure and non–ST-segment elevation myocardial infarction, rather than recurrent coronary events or ST-segment elevation myocardial infarction. This perhaps indicates a predominance of demand ischemia and heart failure syndromes rather than overt atherothrombosis in the etiology of chest pain in these patients.     

Skin Cancer in Solid Organ Transplant Recipients: A Review for the Nondermatologist

Solid organ transplant recipients (SOTRs) are at increased risk for the development of skin cancer compared with the general population, which requires consistent monitoring and management from a multidisciplinary team. The aim of this review is to provide a comprehensive overview for nondermatologist clinicians, outlining skin cancer diagnosis, treatment pearls, and skin cancer prevention strategies as they relate to SOTRs. A comprehensive search of the literature was conducted through the MEDLINE database with search terms including organ transplantation, transplant recipient, skin cancer, cutaneous neoplasms, management, and therapies. The search was limited to the English language and dates ranging from January 1, 2011, to December 28, 2021. All studies were reviewed for inclusion. Skin cancer will develop in more than half of SOTRs at some point in their life, most often nonmelanoma skin cancer such as basal cell carcinoma or squamous cell carcinoma. Melanoma and rarer cutaneous malignant neoplasms, such as Merkel cell carcinoma and Kaposi sarcoma, are also more frequent among SOTRs. A multidisciplinary effort at skin cancer screening and patient education is invaluable to prevent skin cancer–related morbidity and mortality in this population of patients. Reduction in immunosuppressive medications and surgical intervention are effective therapeutic approaches, and more novel systemic therapies including G protein–coupled receptor inhibitors and immune checkpoint inhibitors are possible options when traditional treatment approaches are not feasible. Checkpoint inhibitor therapy, however, comes with the risk of allograft rejection. With a growing and aging SOTR population, it is essential that SOTRs have support from dermatologists and nondermatologists alike in skin cancer prevention and treatment.     

Left Internal Mammary Artery as an Endocrine Organ: Insights Into Graft Biology and Long-term Impact Following Coronary Artery Bypass Grafting

The left internal mammary artery (LIMA) is considered the criterion standard vessel for use in coronary artery bypass grafting. In recent decades, countless studies have documented its superiority over other arterial and venous coronary artery bypass grafting conduits, although the full mechanisms for this superiority remain unknown. A growing body of literature has unveiled the importance of extracellular vesicles known as exosomes in cardiovascular signaling and various pathologic states. In this review, we briefly compare the clinical longevity of the LIMA relative to other conduits, explore the effects of varying grafting techniques on clinical and angiographic outcomes, and provide physiologic insights into graft function on a cellular and molecular level. Finally, we explore exosome signaling as it pertains to atherosclerosis in support of the LIMA as an “endocrine organ.”     

Acute Myocardial Infarction in Autoimmune Rheumatologic Disease: A Nationwide Analysis of Clinical Outcomes and Predictors of Management Strategy

ObjectivesTo examine national-level differences in management strategies and outcomes in patients with autoimmune rheumatic disease (AIRD) with acute myocardial infarction (AMI) from 2004 through 2014.MethodsAll AMI hospitalizations were analyzed from the National Inpatient Sample, stratified according to AIRD diagnosis into 4 groups: no AIRD, rheumatoid arthritis (RA), systemic lupus erythematosus (SLE), and systemic sclerosis (SSC). The associations between AIRD subtypes and (1) receipt of coronary angiography and percutaneous coronary intervention (PCI) and (2) clinical outcomes were examined compared with patients without AIRD.ResultsOf 6,747,797 AMI hospitalizations, 109,983 patients (1.6%) had an AIRD diagnosis (RA: 1.3%, SLE: 0.3%, and SSC: 0.1%). The prevalence of RA rose from 1.0% (2004) to 1.5% (2014), and SLE and SSC remained stable. Patients with SLE were less likely to receive invasive management (odds ratio [OR] [95% CI]: coronary angiography—0.87; 0.84 to 0.91; PCI—0.93; 0.90 to 0.96), whereas no statistically significant differences were found in the RA and SSC groups. Subsequently, the ORs (95% CIs) of mortality (1.15; 1.07 to 1.23) and bleeding (1.24; 1.16 to 1.31) were increased in patients with SLE; SSC was associated with increased ORs (95% CIs) of major adverse cardiovascular and cerebrovascular events (1.52; 1.38 to 1.68) and mortality (1.81; 1.62 to 2.02) but not bleeding or stroke; the RA group was at no increased risk for any complication.ConclusionIn a nationwide cohort of AMI hospitalizations we found lower use of invasive management in patients with SLE and worse outcomes after AMI in patients with SLE and SSC compared with those without AIRD.     

Clinical Characteristics,Management Strategies and Outcomes of Acute Myocardial Infarction Patients With Prior Coronary Artery Bypass Grafting

ObjectiveTo investigate the management strategies, temporal trends, and clinical outcomes of patients with a history of coronary artery bypass graft (CABG) surgery and presenting with acute myocardial infarction (MI).Patients and MethodsWe undertook a retrospective cohort study using the National Inpatient Sample database from the United States (January 2004–September 2015), identified all inpatient MI admissions (7,250,768 records) and stratified according to history of CABG (group 1, CABG-naive [94%]; group 2, prior CABG [6%]).ResultsPatients in group 2 were older, less likely to be female, had more comorbidities, and were more likely to present with non-ST-elevation myocardial infarction compared with group 1. More patients underwent coronary angiography (68% vs 48%) and percutaneous coronary intervention (PCI) (44% vs 26%) in group 1 compared with group 2. Following multivariable logistic regression analyses, the adjusted odd ratio (OR) of in-hospital major adverse cardiovascular and cerebrovascular events (OR, 0.98; 95% CI, 0.95 to 1.005; P=.11), all-cause mortality (OR, 1; 95% CI, 0.98 to 1.04; P=.6) and major bleeding (OR, 0.99; 95% CI, 0.94 to 1.03; P=.54) were similar to group 1. Lower adjusted odds of in-hospital major adverse cardiovascular and cerebrovascular events (OR, 0.64; 95% CI, 0.57 to 0.72; P<.001), all-cause mortality (OR, 0.45; 95% CI, 0.38 to 0.53; P<.001), and acute ischemic stroke (OR, 0.71; 95% CI, 0.59 to 0.86; P<.001) were observed in group 2 patients who underwent PCI compared with those managed medically without any increased risk of major bleeding (OR, 1.08; 95% CI, 0.94 to 1.23; P=.26).ConclusionsIn this national cohort, MI patients with prior-CABG had a higher risk profile, but similar in-hospital adverse outcomes compared with CABG-naive patients. Prior-CABG patients who received PCI had better in-hospital clinical outcomes compared to those who received medical management.     

Renal Neoplasia in Tuberous Sclerosis: A Study of 41 Patients

ObjectiveTo study the clinical features and identify unique renal neoplasia subtypes and their prognostic implications in individuals with tuberous sclerosis complex (TSC).Patients and MethodsThe Mayo Clinic nephrectomy registry included 37 patients with TSC diagnosed between 1970 and 2018. Four additional patients were identified from the pathology consultation and autopsy files. All available renal tumors were further characterized using immunohistochemistry and fluorescence in situ hybridization. Clinicopathologic features and follow-up were obtained from the medical record. The American Association for Cancer Research Project GENIE registry was accessed using cBioPortal for molecular profiling of angiomyolipoma (AML).ResultsA total of 276 renal tumors from 41 patients were analyzed. Renal tumors were classified into 9 distinct morphological subtypes, with AML predominating (238 [86%]). Interestingly, all these tumors acted in a benign fashion except one renal cell carcinoma with clear cells and fibromyomatous stroma and one epithelioid AML that metastasized. Molecular profiling studies revealed that epithelioid AMLs were enriched for alterations of TP53, RB1, and ATRX. Eight patients died of direct complications of TSC, including 3 of end-stage renal disease. To date, none have died of a renal epithelial neoplasm.ConclusionThe identification of unique renal neoplasia subtypes may provide important clues to establish a diagnosis of TSC, and in the somatic setting, this finding has important implications for accurate prognostication. These tumors tend to be indolent, and only 2 of 276 tumors in our study exhibited metastatic behavior. Our results support multidisciplinary management with a focus on preservation of renal function.     

Continuous Renal Replacement Therapy Liberation and Outcomes of Critically Ill Patients With Acute Kidney Injury

ObjectiveTo examine the association between continuous renal replacement therapy (CRRT) liberation and clinical outcomes among patients with acute kidney injury (AKI) requiring CRRT.MethodsThis single-center, retrospective cohort study included adult patients admitted to intensive care units with AKI and treated with CRRT from January 1, 2007, to May 4, 2018. Based on the survival and renal replacement therapy (RRT) status at 72 hours after the first CRRT liberation, we classified patients into liberated, reinstituted, and those who died. We observed patients for 90 days after CRRT initiation to compare the major adverse kidney events (MAKE₉₀).ResultsOf 1135 patients with AKI, 228 (20%), 437 (39%), and 470 (41%) were assigned to liberated, reinstituted, and nonsurvival groups, respectively. The MAKE₉₀, mortality, and RRT independence rates of the cohort were 62% (707 cases), 59% (674 cases), and 40% (453 cases), respectively. Compared with reinstituted patients, the liberated group had a lower MAKE₉₀ (29% vs 39%; P=.009) and higher RRT independence rate (73% vs 65%; P=.04) on day 90, but without significant difference in 90-day mortality (26% vs 33%; P=.05). After adjustments for confounders, successful CRRT liberation was not associated with lower MAKE₉₀ (odds ratio, 0.71; 95% CI, 0.48 to 1.04; P=.08) but was independently associated with improved kidney recovery at 90-day follow-up (hazard ratio, 1.81; 95% CI, 1.41 to 2.32; P<.001).ConclusionOur study demonstrated a high occurrence of CRRT liberation failure and poor 90-day outcomes in a cohort of AKI patients treated with CRRT.     

Coronary Artery Bypass Grafting in Octogenarians—Risks,Outcomes, and Trends in 1283 Consecutive Patients

ObjectiveTo describe the risks, outcomes, and trends in patients older than 80 years undergoing coronary artery bypass grafting (CABG).MethodsWe retrospectively studied 1283 consecutive patients who were older than 80 years and underwent primary isolated CABG from January 1, 1993, to October 31, 2019, in our clinic. Kaplan-Meier survival probability and quartile estimates were used to analyze patients’ survival. Logistic regression models were used for analyzing temporal trends in CABG cases and outcomes. A multivariable Cox proportional hazards regression model was developed to study risk factors for mortality.ResultsOperative mortality was overall 4% (n=51) but showed a significant decrease during the study period (P=.015). Median follow-up was 16.7 (interquartile range, 10.3-21.1) years, and Kaplan-Meier estimated survival rates at 1 year, 5 years, 10 years, and 15 years were 90.2%, 67.9%, 31.1%, and 8.2%, respectively. Median survival time was 7.6 years compared with 6.0 years for age- and sex-matched octogenarians in the general US population (P<.001). Multivariable Cox regression analysis identified older age (P<.001), recent atrial fibrillation or flutter (P<.001), diabetes mellitus (P<.001), smoking history (P=.006), cerebrovascular disease (P=.04), immunosuppressive status (P=.01), extreme levels of creatinine (P<.001), chronic lung disease (P=.02), peripheral vascular disease (P=.02), decreased ejection fraction (P=.03) and increased Society of Thoracic Surgeons predicted risk score (P=.01) as significant risk factors of mortality.ConclusionAlthough CABG in octogenarians carries a higher surgical risk, it may be associated with favorable outcomes and increase in long-term survival. Further studies are warranted to define subgroups benefiting more from surgical revascularization.     

Sex Differences in Outcomes Following Left Atrial Appendage Closure

ObjectiveTo evaluate the effects of female sex on in-hospital outcomes and to provide estimates for sex-specific prediction models of adverse outcomes following left atrial appendage closure (LAAC).Patients and MethodsCohort-based observational study querying the National Inpatient Sample database between October 1, 2015, and December 31, 2017. Demographics, baseline characteristics, and comorbidities were assessed with the Charlson Comorbidity Index (CCI), Elixhauser Comorbidity Index score (ECS), and CHA₂DS₂-VASc score. The primary outcome was in-hospital major adverse events (MAEs) defined as the composite of bleeding, vascular, cardiac complications, post-procedural stroke, and acute kidney injury. The associations of the CCI, ECS, and CHA₂DS₂-VASc score with in-hospital MAE were examined using logistic regression models for women and men, respectively.ResultsA total of 3294 hospitalizations were identified, of which 1313 (40%) involved women and 1981 (60%) involved men. Women were older (76.3±7.7 vs 75.2±8.4 years, P<.001), had a higher CHA₂DS₂-VASc score (4.9±1.4 vs 3.9±1.4, P<.001) but showed lower CCI and ECS compared with men (2.1±1.9 vs 2.3±1.9, P=.01; and 9.3±5.9 vs 9.9±5.7, P=.002, respectively). The primary composite outcome occurred in 4.6% of patients and was higher in women compared with men (women 5.6% vs men 4.0%, P=.04), and this was mainly driven by the occurrence of cardiac complications (2.4% vs 1.2%, P=.01). In women, older age, higher median income, and higher CCI (adjusted odds ratio [aOR], 1.32; 95% confidence interval [CI], 1.21 to 1.44; P<.001), ECS (aOR, 1.04; 95% CI, 1.02 to 1.07; P=.002), and CHA₂DS₂-VASc score (aOR, 1.24; 95% CI, 1.10 to 1.39; P<.001) were associated with increased risk of in-hospital MAE. In men, non-White race/ethnicity, lower median income, and higher ECS (aOR, 1.06; 95% CI, 1.04 to 1.09; P<.001) were associated with increased risk of in-hospital MAE.ConclusionWomen had higher rates of in-hospital adverse events following LAAC than men did. Women with older age and higher median income, CCI, ECS, and CHA₂DS₂-VASc scores were associated with in-hospital adverse events, whereas men with non-White race/ethnicity, lower median income, and higher ECS were more likely to experience adverse events. Further research is warranted to identify sex-specific, racial/ethnic, and socioeconomic pathways during the patient selection process to minimize complications in patients undergoing LAAC.     

Pituitary Adenoma Incidence,Management Trends,and Long-term Outcomes: A 30-Year Population-Based Analysis

ObjectiveTo perform a population-based study of pituitary adenoma epidemiology, including longitudinal trends in disease incidence, treatment patterns, and outcomes.Patients and MethodsIn this study of incident pituitary adenomas in Olmsted County, Minnesota, from January 1, 1989, through December 31, 2019, we identified 785 patients who underwent primary screening, 435 of whom were confirmed as harboring incident pituitary adenomas and were included. Primary outcomes of interest included demographic characteristics, presenting features, and disease outcomes (tumor control, biochemical control, and complications).ResultsAmong our 435 study patients, 438 unique pituitary adenomas were diagnosed at a median patient age of 39 years (interquartile range [IQR], 27 to 58 years). Adenomas were incidentally identified in 164 of the 438 tumors (37%). Common symptomatic presentations included hyperprolactinemia (188 of 438 [43%]) and visual field deficit (47 of 438 [11%]). Laboratory tests confirmed pituitary hormone hypersecretion in 238 of the 435 patients (55%), which was symptomatic in 222. The median tumor diameter was 8 mm (IQR, 5 to 17 mm). Primary management strategies were observation (156 of 438 tumors [36%]), medication (162 of 438 tumors [37%]), and transsphenoidal resection (120 of 438 tumors [27%]). Tumor and biochemical control were achieved in 398 (95%) and 216 (91%) secreting tumors, respectively. New posttreatment pituitary or visual deficits were noted in 43 (11%) and 8 (2%); apoplexy occurred in 28 (6%). Median clinical follow-up was 98 months (IQR, 47 to 189 months). Standardized incidence rates were 3.77 to 16.87 per 100,000 population, demonstrating linear expansion over time (R²=0.67). The mean overall standardized incidence rate was 10.1 per 100,000 population; final point prevalence was 175.1 per 100,000 population.ConclusionPituitary adenoma is a highly incident disease, with prolactin-secreting and incidental lesions representing the majority of tumors. Incidence rates and asymptomatic detection appear to be increasing over time. Presenting symptoms and treatment pathways are variable; however, most patients achieve favorable outcomes with observation or a single treatment modality.     

Sex Differences in Management and Outcomes Among Patients With High-Risk Pulmonary Embolism: A Nationwide Analysis

ObjectiveTo examine the sex differences in management and outcomes among patients with high-risk acute pulmonary embolism (PE).Patients and MethodsThe Nationwide Readmissions Database was used to identify hospitalizations with high-risk PE from January 1, 2016, to December 31, 2018. Differences in use of advanced therapies, in-hospital mortality, and bleeding events were compared between men and women.ResultsA total of 125,901 weighted hospitalizations with high-risk PE were identified during the study period; 46.3% were women (n=58,253). Women were older and had a higher prevalence of several comorbidities and risk factors of PE such as morbid obesity, diabetes mellitus, chronic pulmonary disease, heart failure, and metastatic cancer. Systemic thrombolysis and catheter-directed interventions were more commonly used among women; however, mechanical circulatory support was less frequently used. In-hospital mortality was higher among women in the unadjusted analysis (30.7% vs 27.8%, P<.001) and after propensity score matching (odds ratio [OR], 1.16; 95% confidence interval [CI], 1.08 to 1.25; P<.001), whereas the rates of intracranial hemorrhage and non–intracranial hemorrhage were not different. On multivariate regression analysis, female sex (OR, 1.18; 95% CI, 1.15 to 1.21; P<.001) was independently associated with increased odds of in-hospital mortality.ConclusionIn this contemporary observational cohort of patients admitted with high-risk PE, women had higher rates of in-hospital mortality despite receiving advanced therapies more frequently, whereas the rate of major bleeding events was not different from men. Efforts are needed to minimize the excess mortality observed among women.     

Clinical Outcomes of Adults With Bicuspid Aortic Valve: A European Perspective

ObjectiveTo describe the clinical history of patients with a wide age range diagnosed with bicuspid aortic valve (BAV) and no surgical indication and to evaluate the long-term outcome of patients with BAV referred for elective surgery.Patients and MethodsBetween 2005 and 2017, 350 consecutive patients with no surgical indication (surveillance group, mean age 53±16, 71% men) and 191 with a surgical indication (surgical group, mean age 59±13, 71% men) were prospectively included. Median follow-up was 80 (32 to 115) months.ResultsIn the surveillance group, the 5-year and 10-year survival rates were 93±1% and 89±2%, respectively, with a relative survival of patients with BAV compared with an age- and sex-matched control population of 98.7%. During follow-up, the cumulative 10-year incidence of aortic valve and aorta surgery was high; of 35±4%, the incidence of native valve infective endocarditis (IE) of 0.2% per patient-year, and no cases of aortic dissection were observed. In the surgical group, the 5-year and 10-year survival rates were 97±1% and 89±3%, respectively, with a relative survival of 99.4% compared with the general population. The incidence of IE was 0.4% per patient-year, and no cases of aortic dissection were observed.ConclusionThis regional cohort shows that the 10-year survival rates of patients with BAV and a wide age range, but mostly middle-aged adults, were similar to those of the general population with a very low rate of complications. Adherence to prophylactic surgical indications and younger age might have contributed to this lack of difference.