Predictors of complications related to venoarterial extracorporeal membrane oxygenation in adults: A multicenter retrospective cohort study

IntroductionVenoarterial extracorporeal membrane oxygenation (VA-ECMO) is a complex technology associated with risks and complications.ObjectiveTo identify predictors of complications related to VA-ECMO in adults.MethodsA retrospective cohort study, including 63 adult patients undergoing VA-ECMO, performed at two institutions in Brazil, from the time both centers implemented VA-ECMO (1999 in Institution A and 2012 in Institution B) treatment through March of 2018. The association between independent variables (institution, demographic, indications for ECMO, and pre-ECMO clinical characteristics) and the outcomes (neurological, renal, vascular, hemorrhagic, infectious, and mechanical complications) was investigated by means of multiple logistic regressions.ResultsPredictors of neurological complications were refractory cardiogenic shock following cardiotomy (OR = 0.10; 95% CI 0.00–1.01; p = 0.049) and following heart or lung transplant (OR = 0.04; 95% CI 0.00–0.42; p = 0.018). The use of inotropes/vasopressors was a predictor of vascular complications (OR = 7.72; 95% CI 1.83–39.87; p = 0.008). The levels of CK-MB were a predictor of renal complications (OR = 0.87; 95% CI 0.72–0.97; p = 0.046). Predictors of infectious complications were total bilirubin (OR = 0.02; 95% CI 0.00–0.26; p = 0.038) and body weight odds (OR = 1.24; 95% CI 1.08–1.61; p = 0.028). Class III heart failure was a predictor of mechanical complications (OR = 0.07; 95% CI 0.00–0.66; p = 0.034).ConclusionIdentifying predictors of complications may contribute to the indications for VA-ECMO.     

Efficacy of Mechanical Circulatory Support Used Before Versus After Primary Percutaneous Coronary Intervention in Patients with Cardiogenic Shock From ST-Elevation Myocardial Infarction: A Systematic Review and Meta-Analysis

BackgroundOptimal timing to initiate mechanical circulatory support (MCS) in patients with ST-elevation myocardial infarction (STEMI) complicated by cardiogenic shock (CS) remains unclear with studies showing conflicting results on whether to start before or after primary percutaneous coronary intervention (PPCI). This study aims to examine the association between mortality and MCS initiated before vs after PPCI in patients with STEMI complicated by CS.MethodsWe systematically searched PubMed, Embase, and Scopus for abstracts and full-text articles from inception to October 2021. Studies were included if they evaluated the association of mortality in patients who initiated MCS (specifically intra-aortic balloon pump (IABP), Impella, and venoarterial extracorporeal membrane oxygenation (VA-ECMO)) before PPCI versus after PPCI, specifically in patients with STEMI complicated by CS. Data were integrated using the random-effects models.ResultsTen studies involving 1,352 patients (956, 203, and 193 patients underwent IABP, Impella, and VA-ECMO respectively) with STEMI complicated by CS were included. There was no difference in mortality using IABP before or after PPCI ([OR] 1.77, 95% CI 0.77–1.61, I2 = 27%, p = 0.57). Nevertheless, Impella and VA-ECMO started before PPCI were significantly associated with a reduced risk of mortality compared to that started after PPCI ([OR] 0.49, 95% CI 0.26–0.92, I2 = 0%, p = 0.03 and [OR] 0.29, 95% CI 0.14–0.62, I2 = 0%, p = 0.001, respectively).ConclusionsIn patients with STEMI complicated by CS undergoing PPCI, the use of IMPELLA or VA-ECMO prior to PPCI significantly decreased mortality, in contrast to IABP, in which no difference in mortality was found between using it before or after PPCI. More rigorous studies are needed to clarify this association.     

Comparison of ECMO vs ECpella in Patients With Non-Post-Pericardiotomy Cardiogenic Shock: An Updated Meta-Analysis

IntroductionThe impact of Impella and ECMO (ECPELLA) in cardiogenic shock (CS) remains to be defined. The aim of this meta-analysis is to evaluate the benefit of ECPELLA compared to VA-ECMO in patients with non post-pericardiotomy CS.MethodsAll studies reporting short term outcomes of ECpella or VA ECMO in non post-pericardiotomy CS were included. The primary endpoint was 30-day mortality. Vascular and bleeding complications and LVAD implantation/heart transplant within 30-days were assessed as secondary outcomes.ResultsOf 407 studies identified, 13 observational studies (13,682 patients, 13,270 with ECMO and 412 with ECpella) were included in this analysis. 30-day mortality was 55.8% (51.6–59.9) in the VA-ECMO group and 58.3% (53.5–63.0) in the ECpella group. At meta-regression analysis the implantation of IABP did not affect mortality in the ECMO group. The rate of major bleeding in patients on VA-ECMO and ECpella support were 21.3% (16.9–26.5) and 33.1% (25.9–41.2) respectively, while the rates of the composite outcome of LVAD implantation and heart transplantation within 30-days in patients on VA-ECMO and ECpella support were 14.4% (9.0–22.2) and 10.8%. When directly compared in 3 studies, ECpella showed a positive effect on 30-day mortality compared to ECMO (OR: 1.81: 1.039–3.159).ConclusionOur data suggest that ECpella may reduce 30-day mortality and increase left ventricle recovery, despite increased of bleeding rates.     

Extracorporeal Membrane Oxygenation for Graft Dysfunction Early After Heart Transplantation: A Systematic Review and Meta-analysis

IntroductionVenoarterial extracorporeal membrane oxygenation (VA-ECMO) is a prevailing option for the management of severe early graft dysfunction. This systematic review and individual patient data (IPD) meta-analysis aims to evaluate (1) mortality, (2) rates of major complications, (3) prognostic factors, and (4) the effect of different VA-ECMO strategies on outcomes in adult heart transplant (HT) recipients supported with VA-ECMO.Methods and ResultsWe conducted a systematic search and included studies of adults (≥18 years) who received VA-ECMO during their index hospitalization after HT and reported on mortality at any timepoint. We pooled data using random effects models. To identify prognostic factors, we analysed IPD using mixed effects logistic regression. We assessed the certainty in the evidence using the GRADE framework. We included 49 observational studies of 1477 patients who received VA-ECMO after HT, of which 15 studies provided IPD for 448 patients. There were no differences in mortality estimates between IPD and non-IPD studies. The short-term (30-day/in-hospital) mortality estimate was 33% (moderate certainty, 95% confidence interval [CI] 28%–39%) and 1-year mortality estimate 50% (moderate certainty, 95% CI 43%–57%). Recipient age (odds ratio 1.02, 95% CI 1.01–1.04) and prior sternotomy (OR 1.57, 95% CI 0.99–2.49) are associated with increased short-term mortality. There is low certainty evidence that early intraoperative cannulation and peripheral cannulation reduce the risk of short-term death.ConclusionsOne-third of patients who receive VA-ECMO for early graft dysfunction do not survive 30 days or to hospital discharge, and one-half do not survive to 1 year after HT. Improving outcomes will require ongoing research focused on optimizing VA-ECMO strategies and care in the first year after HT.     

Interdependence of VA-ECMO output,pulmonary congestion and outcome after cardiac surgery

BackgroundVenoarterial-extracorporeal membrane oxygenation (VA-ECMO) is a life-saving method for patients with low-output failure after cardiac surgery. However, VA-ECMO therapy may increase left ventricular afterload due to retrograde blood flow in the aorta, which may lead to progression of pulmonary congestion. We examined the predictive value of pulmonary congestion in patients that need VA-ECMO support after cardiovascular surgery.MethodsWe enrolled a total of 266 adult patients undergoing VA-ECMO support following cardiovascular surgery at a university-affiliated tertiary care centre into our single-center registry. Pulmonary edema was assessed on bedside chest X rays at day 0, 3, 5 after VA-ECMO implantation.ResultsMedian age was 65 (57–72) years, 69% of patients were male and 30-day survival was 63%. At ICU-admission 20% of patients had mild, 54% had moderate and 26% showed severe pulmonary congestion. Pulmonary congestion at day 0 was not associated with outcome (adjusted HR 1.31; 95%-CI 0.89–1.93;P = 0.18), whereas pulmonary congestion at day 3 (adj. HR 2.81; 95%-CI 1.76–4.46;P<0.001) and day 5 (adj. HR 3.01;95%-CI 1.84–4.93;P<0.001) was significantly associated with survival. Linear regression revealed that out of left ventricular function, cardiac output, central venous saturation, maximum dobutamine and norepinephrine dose as well as fluid balance solely ECMO rotation was associated with the evolution of pulmonary congestion (P = 0.007).ConclusionsPulmonary edema three and five days after ECMO implantation are associated with poor survival. Interestingly, a high VA-ECMO output was the most important determinant of worsening pulmonary congestion within the first five days.     

Modelo de predicción de riesgo de mortalidad hospitalaria para pacientes con infarto de miocardio tratados con oxigenador extracorpóreo de membrana venoarterial

Introduction and objectivesThere are limited data to develop a risk prediction model of in-hospital mortality for acute myocardial infarction (AMI) patients treated with venoarterial (VA)-extracorporeal membrane oxygenation (ECMO). We aimed to develop a risk prediction model for in-hospital mortality in patients with AMI who were treated with VA-ECMO.MethodsA total of 145 patients with AMI who underwent VA-ECMO between May 2004 and April 2016 were included from the Samsung Medical Center ECMO registry. The primary outcome was in-hospital mortality. To develop a new predictive scoring system, named the AMI-ECMO score, backward stepwise elimination and β coefficient-based scoring were used based on logistic regression analyses. The leave-one-out cross-validation method was performed for internal validation.ResultsIn-hospital mortality occurred in 69 patients (47.6%). On multivariable logistic regression analysis, the AMI-ECMO score comprised 6 pre-ECMO or angiographic parameters: age > 65 years, body mass index > 25 kg/m², Glasgow coma score < 6, lactic acid > 8 mmol/L, anterior wall infarction, and no or failed revascularization. The C-statistic value of AMI-ECMO score for predicting in-hospital mortality was 0.880 (95%CI, 0.820-0.940). The incidence of in-hospital mortality after VA-ECMO insertion was 6.2%, 28.1%, 51.6%, and 93.8% for AMI-ECMO score quartiles (0 to 16, 17 to 19, 20 to 26, and > 26), respectively (P < .001 for trend). The AMI-ECMO scores were also significantly associated with the estimated rate of all-cause mortality during follow-up (per 1 increase, HR, 1.11; 95%CI, 1.08-1.14; P < .001).ConclusionsThe AMI-ECMO score can help predict early prognosis in AMI patients who undergo VA-ECMO.Full English text available from:www.revespcardiol.org/en     

The association between body mass index and in-hospital outcome among patients with acute myocardial infarction—Insights from China Acute Myocardial Infarction (CAMI) registry

BackgroundThe relationship between body mass index (BMI) and in-hospital mortality risk among patients with acute myocardial infarction (AMI) remains controversial.Methods and ResultsWe included 35,964 patients diagnosed with AMI in China Acute Myocardial Infarction registry between January 2013 and December 2016. Patients were categorized into 4 groups according to BMI level: BMI <18.5, 18.5–24.9, 25–30, and ≥30 kg/m² for underweight, normal, overweight, and obese groups, respectively. Clinical data were extracted for each patient, and multivariable logistic regression analysis was used to examine the association between BMI level and in-hospital mortality. Compared with normal-weight patients, obese patients were younger, more often current smokers, and more likely to have hypertension, hyperlipidemia, and diabetes. Multivariable regression analysis results demonstrated that compared with normal group, underweight group had significantly higher in-hospital mortality (odds ratio [OR]: 1.34; 95% confidence interval [CI]: 1.06–1.69; p = 0.016), while overweight group (OR: 0.86; 95% CI: 0.77–0.97; p = 0.011) and obese group (OR: 0.65; 95% CI: 0.46–0.91; p = 0.013) had lower mortality. All subgroups showed a trend toward lower in-hospital mortality risk as BMI increased.ConclusionsOur study provided robust evidence supporting “obesity paradox” in a contemporary large-scale cohort of patients with AMI and demonstrated that increased BMI was independently associated with lower in-hospital mortality.     

Real-World Safety and Efficacy of Transcatheter Mitral Valve Repair With MitraClip: Thirty-Day Results From the Italian Society of Interventional Cardiology (GIse) Registry Of Transcatheter Treatment of Mitral Valve RegurgitaTiOn (GIOTTO)

BackgroundAvailable scientific evidence of transcatheter mitral valve repair with the MitraClip comes from randomized controlled trials, which showed controversial results that hardly translate into real-world practice, and from registries of relatively small sample size.AimTo collect real-world data in a multicenter, prospective, country-level registry.Methods and resultThe Italian Society of Interventional Cardiology (GIse) Registry Of Transcatheter Treatment of Mitral Valve RegurgitaTiOn (GIOTTO) is an ongoing single-arm, multicenter, prospective registry that started enrollment in February 2016. Clinical end points were defined according to the Mitral Valve Academic Research Consortium (MVARC) criteria. From February 2016 to December 2018, 1189 patients (mean age 76 ± 9.1 years) were enrolled. The main MR etiology was functional (64.9%). MVARC technical success was 96.6%. At 30-day follow-up (n = 1131), MVARC device and procedural success were 92.5% and 87% respectively, and all-cause death was 3%. The majority of patients who died at 30-day had functional MR (69.7%). Mixed etiology (OR 0.94, 95% CI 0.02–0.61) and prolonged length of stay in ICU (OR 0.97, 95% CI 0.95–0.99) were found to be negative independent predictors of device success at 30-day. The EuroSCORE II (OR 0.96, 95% CI 0.93–0.99), LVEDV-I (OR 0.99, 95% CI 0.98–0.99) and prolonged length of stay in ICU (OR 0.98, 95% CI 0.97–0.99) were negative independent factors of MVARC procedural success at 30-day.ConclusionsThe GIOTTO registry is one of the largest prospective registries available on MitraClip and shows favorable acute and 30-day safety and efficacy.     

Outcomes With Drug-Coated Balloons vs. Drug-Eluting Stents in Small-Vessel Coronary Artery Disease

BackgroundThe use of drug-coated balloons (DCBs) in small-vessel coronary artery disease (SVD) remains controversial.MethodsWe performed a meta-analysis of all randomized controlled trials (RCTs) reporting the outcomes of DCB vs. DES in de-novo SVD. We included a total of 5 RCTs (1459 patients), with (DCB n = 734 and DES n = 725).ResultsOver a median follow-up duration of 6 months, DCB was associated with smaller late lumen loss (LLL) compared with DES (mean difference −0.12 mm) (95% confidence intervals (CI) [−0.21, −0.03 mm], p = 0.01). Over a median follow-up of 12 months, both modalities had similar risk of major adverse cardiovascular events (MACE) (8.7% vs. 10.2%; odds ratio (OR): 0.94, 95% CI [0.49–1.79], p = 084), all-cause mortality (1.17% vs. 2.38%; OR: 0.53, 95% CI [0.16–1.75], p = 0.30), target lesion revascularization (TLR) (7.9% vs. 3.9%; OR: 1.26, 95% CI [0.51–3.14], p = 0.62), and target vessel revascularization (TVR) (8.2% vs. 7.8%; OR: 1.06, 95% CI [0.40–2.82], p = 0.91). DCBs were associated with lower risk of myocardial infarction (MI) compared with DES (1.55% vs. 3.31%; OR: 0.48, 95% CI [0.23–1.00], p = 0.05, I2 = 0%).ConclusionPCI of SVD with DCBs is associated with smaller LLL, lower risk of MI, and similar risk of MACE, death, TLR, and TVR compared with DES over one year. DCB appears as an attractive alternative to DES in patients with de-novo SVD, but long-term clinical data are still needed.     

Cardiovascular Outcomes with Transcatheter vs. Surgical Aortic Valve Replacement in Low-Risk Patients: An Updated Meta-Analysis of Randomized Controlled Trials

BackgroundTAVR is an established treatment option in high and intermediate-risk patients with severe AS. There is less data regarding the efficacy of TAVR in low-risk patients. This meta-analysis evaluated efficacy and safety outcomes of transcatheter aortic valve replacement (TAVR) in comparison to surgical aortic valve replacement (SAVR) in low-risk patients with severe aortic stenosis (AS).MethodsDatabases were searched for randomized controlled trials (RCTs) that compared TAVR with SAVR for the treatment of low-risk patients with severe AS. We calculated pooled odds ratios (ORs) and 95% confidence intervals (CIs) using the random-effects model.ResultsThe final analysis included 2953 patients from 5 studies. Compared to SAVR, TAVR was associated with similar mid-term mortality [OR 0.67; 95% CI 0.37–1.21; p = 0.18], as well as similar short-term mortality [OR 0.51; 95% CI 0.24–1.11; p = 0.09]. Randomization to TAVR was associated with a reduced risk of developing acute kidney injury [OR 0.26; 95% CI 0.13–0.52; p < 0.001], short-term major bleeding [OR 0.27; 95% CI 0.12–0.60; p < 0.001] and new-onset atrial fibrillation [OR 0.17; 95% CI 0.14–0.21; p < 0.001]. However, TAVR was associated with a higher risk of requiring permanent pacemaker implantation [OR 4.25; 95% CI 1.86–9.73; p < 0.001]. There was no significant difference in the risk of myocardial infarction, stroke, endocarditis or aortic valve re-intervention between the two groups.ConclusionsOur meta-analysis showed that TAVR has similar clinical efficacy to SAVR, with a more favorable safety profile, in patients with severe AS who are at low-surgical risk.     

Aging and comorbidities influence the risk of hospitalization and mortality in diabetic patients experiencing severe hypoglycemia

Background and aimsTo assess the risk of hospitalization and mortality within 1 year of severe hypoglycaemia and theirs clinical predictors.Methods and resultsWe retrospectively examined 399 admissions for severe hypoglycemia in adults with DM at the Emergency Department (ED) of the University Hospital of Novara (Italy) between 2012–2017, and we compared the clinical differences between older (aged ≥65 years) and younger individuals (aged 18–64 years). A logistic regression model was used to explore predictors of hospitalization following ED access and 1-year later, according to cardiovascular (CV) or not (no-CV) reasons; 1-year all-cause mortality was also detected.The study cohort comprised 302 patients (median [IQR] age 75 [17] years, 50.3% females, 93.4% white, HbA_1c level 7.6% [1.0%]). Hospitalization following ED access occurred in 16.2% of patients and kidney failure (OR 0.50 [95% CI 1.29–5.03]) was the only predictor of no-CV specific hospitalization; 1-year hospitalization occurred in 24.5% of patients and obesity (OR 3.17 [95% CI 1.20–8.12]) and pre-existing heart disease (OR 3.20 [95% 1.20–9.39]) were associated with CV specific hospitalization; 1-year all-cause mortality occurred in 14.9% of patients and was associated with older age (OR 1.12 [95% CI 1.07–1.18]) and pre-existing heart disease (OR 2.63 [95% CI 1.19–6.14])ConclusionsSevere hypoglycemia is associated with risk of hospitalization and mortality mainly in elderly patients and it may be predictive of future cardiovascular events in diabetic patients with pre-existing heart disease and obesity.     

Clinical characteristics,outcomes, and factors associated with mortality in Nocardia pneumonia: 18 years' real-world data from a tertiary care hospital in Karachi,Pakistan

BackgroundPulmonary nocardiosis is a rare pulmonary infection with high morbidity and mortality. Limited real-world data on pulmonary nocardiosis patients are available from developing countries like Pakistan.MethodsThis retrospective observational study was conducted at the Aga Khan University Hospital, Karachi, Pakistan, from August 2003 to June 2020. Demographics, immune status, underlying diseases, laboratory data, treatment, and outcomes of all nocardiosis patients were recorded in predesigned proforma.ResultsSixty-six patients with smear/culture-proven pulmonary nocardiosis were identified. Most patients (83.3%) were treated with trimethoprim-sulfamethoxazole alone or in combination with other medicines. The overall mortality rate in our study was 33.3% (n = 22/66). Factors significantly associated with mortality were respiratory failure (p < 0.001), raised procalcitonin levels (p = 0.01), concomitant fungal infections (p = 0.01), concomitant TB (p = 0.03), and patients on combination therapy (p < 0.001).Respiratory failure (odds ratio [OR] 46.94 [95% confidence intervals [CI]: 5.01–439.03] p < 0.001), concomitant fungal infection (OR 17.09 [95% CI: 1.47–197.88] p- = 0.02) and patients on combination therapy (OR 6.90 [95% CI: 1.23–38.61] p = 0.02) were also identified as independent risk factors for mortality on multivariate analysis.ConclusionsThis study provides essential information on the clinical characteristics and risk factors, outcomes, and factors associated with mortality for pulmonary nocardial infections.     

Percutaneous Mitral Valve Repair Vs. Stand-Alone Medical Therapy in Patients with Functional Mitral Regurgitation and Heart Failure

BackgroundFunctional mitral regurgitation (FMR) is a common finding among patients with heart failure (HF) and it is related to adverse events. Outcomes in patients undergoing transcatheter mitral valve repair (TMVR) are still a matter of debate. We performed a meta-analysis to assess mid- and long-term outcomes of patients with FMR treated with MitraClip® compared to medical management.MethodsWe conducted an electronic database search of all published data PubMed Central, Embase, the Cochrane Central Register of Controlled Trials, ClinicalTrials.gov, and Google Scholar databases. The primary end-point was all-cause mortality. The secondary end-points were hospitalizations for HF, need for heart transplantation or left ventricular assist device, unplanned mitral valve surgery, myocardial infarction and stroke.ResultsFive studies (n = 1513 patients) were included in the analysis. The summary estimate including all the available studies showed a statistically significant reduction in all-cause mortality favoring MitraClip® (HR 0.56, CI 95% [0.38–0.84]) and HF hospitalizations (HR 0.65; CI 95% [0.46–0.92]). A significant reduction in the indication for advanced HF therapies (OR 0.48; CI 95% [0.25–0.90]) or the need for unplanned mitral valve surgery (OR 0.20; CI 95% [0.07–0.57]) was also found in the group of patients that underwent TMVR. No differences in the incidence of myocardial infarction or stroke were found between both groups of treatment. No publication bias was detected.ConclusionTMVR with MitraClip® system was related to a significant reduction in all-cause mortality, hospitalizations for HF and the need for HF transplant, left ventricular assist device or unplanned surgery beyond 1-year follow up.     

Prognostic factors of critical acute pancreatitis: A prospective cohort study

BackgroundPatients with critical acute pancreatitis (CAP) have the highest risk of mortality. However, there have been no studies specifically designed to evaluate the prognostic factors of CAP.Aims & methodsThis was a prospective observational cohort study involving patients with CAP. Three aspects including organ failure, (peri)pancreatic necrotic fluid cultures and surgical interventions were analyzed specifically to identify prognostic factors.ResultsOf the 102 consecutive patients with CAP, 83 patients (81.4%) received step-up surgical treatment, the mortality of the step-up group was 25.3% (21/83). 19 patients (18.6%) underwent step-down surgical treatment, the mortality of the step-down group was 57.9% (11/19). Overall mortality in the whole cohort was 31.4% (32/102). Multivariate analysis of death predictors indicated that multiple organ failure (MOF) (OR = 5.3; 95% CI, 1.5–18.2; p = 0.008), long duration (≥5 days) of organ failure (OR = 6.4; 95% CI, 1.2–54.3; p = 0.029), multidrug-resistant organisms (MDROs) infection (OR = 4.6; 95% CI, 1.3–15.8; p = 0.013), OPN (OR = 3.7; 95% CI, 1.5–8.8; p = 0.004) and step-down surgical treatment (OR = 3.5; 95% CI, 1.2–10.1; p = 0.019) were significant factors.ConclusionAmong patients with CAP, MOF, long duration (≥5 days) of organ failure, MDROs infection, OPN and step-down surgical treatment were identified as the predictors of mortality.     

The effect of gastrointestinal bleeding on outcomes of patients with acute pancreatitis: A national population-based study

ObjectivesTo investigate the adverse effect of gastrointestinal bleeding (GIB) in patients with acute pancreatitis (AP), accounting for the status of organ failure (OF).MethodsWe analyzed 107,349 patients with first-attack AP from the Taiwan National Health Insurance Research Database between 2000 and 2009. Patients were categorized into four groups according to the status of GIB and OF, the effect of which was assessed using multivariable analyses with generalized estimating equations models. Primary outcomes were 14-day and hospital mortality. Secondary outcomes were septic complication and prolonged hospital stay (>18 days).ResultsThe covariate-adjusted odds ratio for 14-day mortality, hospital mortality, septic complication, and prolonged stay all significantly increased at 4.63 (95% confidence interval [CI] 3.80–5.63), 4.22 (95% CI 3.66–4.87), 3.52 (95% CI 3.03–4.08), and 1.27 (95% CI 1.20–1.35), respectively for the patients with OF only (n = 88,561). The corresponding figures for the patients with GIB only (n = 5184) were lower but still significant at 1.44 (95% CI 1.09–1.91), 1.42 (95% CI 1.15–1.75), 1.54 (95% CI 1.19–2.00), and 1.38 (95% CI 1.28–1.48). The co-existence of GIB in patients with OF (n = 1663) showed little additional risk of all adverse outcomes. Results of sensitivity analyses (enrolling only patients with principal diagnosis of AP) showed similar findings except that septic complication was not seen for GIB only.ConclusionsOF poses greater adverse effects than GIB on outcomes of AP patients. Nevertheless, GIB still modestly increased the risks of prolonged stay and death in AP patients without OF.     

Sex-related differences in long-term mortality and heart failure in a contemporary cohort of patients with NSTEACS. The cardiochus-HSUJ registry

Introduction and objectivesThere is insufficient data regarding sex-related prognostic differences in patients with a non-ST elevation acute coronary syndrome (NSTEACS). We performed a sex-specific analysis of cardiovascular outcomes after NSTEACS using a large contemporary cohort of patients from two tertiary hospitals.MethodsThis work is a retrospective analysis from a prospective registry, that included 5,686 consecutive NSTEACS patients from two Spanish University hospitals between the years 2005 and 2017. We performed a propensity score matching to obtain a well-balanced subset of individuals with the same clinical characteristics, resulting in 3,120 patients. Cox regression models performed survival analyses once the proportional risk test was verified.ResultsAmong the study participants, 1,572 patients (27.6%) were women. The mean follow-up was 60.0 months (standard deviation of 32 months). Women had a higher risk of cardiovascular mortality compared with men (OR (Odds ratio) 1.27, CI (confidence interval) 95% 1.08-1.49), heart failure (HF) hospitalization (OR 1.39, CI 95% 1.18-1.63) and risk of all-cause mortality (OR 1.10, CI 95% 1.08-1.49). After a propensity score matching, female gender was associated with a significant reduction in the risk of total mortality (OR 0.77, CI 95% 0.65-0.90) with a similar risk of cardiovascular mortality (OR 0.86, CI 0.71-1.03) and HF hospitalization (OR 0.92, CI 95% 0.68-1.23). After baseline adjustment, the risk of all-cause mortality and cardiovascular mortality was lower in women, whereas the risk of HF remained similar among sexes.ConclusionsIn a contemporary cohort of patients with NSTEACS, women are at similar risk of developing early and late HF admissions, and have better survival compared with men, with a lower risk of all-cause mortality and cardiovascular mortality. The implementation of NSTEACS guideline recommendations in women, including early revascularization, seems to be accompanied by improved early and long-term prognosis.     

Synchronous resection of colorectal cancer primary and liver metastases: an outcomes analysis

BackgroundConcurrent resection of the primary cancer and synchronous colorectal cancer liver metastases (CRCLM) was evaluated for differences in outcomes following stratification of both the liver and colorectal resection.MethodsConsecutive cases of synchronous resection of both the CRC primary and CRCLM were reviewed retrospectively at a single, high-volume institution over a 17-year period (2000–2017).Results273 patients underwent simultaneous resection of CRCLM. The distribution of the primary lesion was similar between the colon (52.4%) and rectum (47.6%), while 46.9% of patients had bilobar liver disease. Major liver/major colorectal resection (n = 24) were significantly more likely to experience colorectal specific morbidity (OR 3.98, 95% CI 1.56–10.15, p = 0.004), liver specific morbidity (OR 7.4, 95% CI 2.22–24.71, p = 0.001), total morbidity (OR 2.91, 95% CI 1.18–7.18, p = 0.020) and 90-day mortality (OR 5.50, 95% CI 1.27–23.81, p = 0.023). Failure to receive adjuvant chemotherapy secondary to postoperative morbidity was associated with significantly worsened survival (HR for death 5.91, 95% CI 1.59–22.01, p = 0.008).ConclusionsPostoperative morbidity precluding the administration of adjuvant chemotherapy is associated with an increase in mortality. Combining a major liver with major colorectal resection is associated with a significant increase in major morbidity and 90-day mortality, and should be avoided.     

Venous lactate improves the prediction of in-hospital adverse outcomes in normotensive pulmonary embolism

BackgroundArterial lactate is an established risk marker in patients with pulmonary embolism (PE). However, its clinical applicability is limited by the need of an arterial puncture. In contrast, venous lactate can easily be measured from blood samples obtained via routine peripheral venepuncture.MethodsWe investigated the prognostic value of venous lactate with regard to in-hospital adverse outcomes and mortality in 419 consecutive PE patients enrolled in a single-center registry between 09/2008 and 09/2017.ResultsAn optimised venous lactate cut-off value of 3.3 mmol/l predicted both, in-hospital adverse outcome (OR 11.0 [95% CI 4.6–26.3]) and all-cause mortality (OR 3.8 [95%CI 1.3–11.3]). The established cut-off value for arterial lactate (2.0 mmol/l) and the upper limit of normal for venous lactate (2.3 mmol/l) had lower prognostic value for adverse outcomes (OR 3.6 [95% CI 1.5–8.7] and 5.7 [95% CI 2.4–13.6], respectively) and did not predict mortality. If added to the 2019 European Society of Cardiology (ESC) algorithm, venous lactate <2.3 mmol/l was associated with a high negative predictive value (0.99 [95% CI 0.97–1.00]) for adverse outcomes in intermediate-low-risk patients, whereas levels ≥3.3 mmol/l predicted adverse outcomes in the intermediate-high-risk group (OR 5.2 [95% CI 1.8–15.0]).ConclusionVenous lactate above the upper limit of normal was associated with increased risk for adverse outcomes and an optimised cut-off value of 3.3 mmol/l predicted adverse outcome and mortality. Adding venous lactate to the 2019 ESC algorithm may improve risk stratification. Importantly, the established cut-off value for arterial lactate has limited specificity in venous samples and should not be used.     

Worsening Renal Function in Patients With Acute Decompensated Heart Failure Treated With Ultrafiltration: Predictors and Outcomes

BackgroundUltrafiltration (UF) is used to treat patients with diuretic-resistant acute decompensated heart failure. The aim of this study was to identify predictors and the effect of worsening renal failure (WRF) on mortality in patients treated with UF.Methods and ResultsBased on changes in serum creatinine, 99 patients treated with UF were divided into WRF and control groups. Overall creatinine increased from 1.9 ± 9.7 to 2.2 ± 2.0 mg/dL (P < .001), and WRF developed in 41% of the subjects. The peak UF rate was higher in the WRF group in univariate analysis (174 ± 45 vs 144 ± 42 mL/h; P = .03). Based on multivariate analysis, aldosterone antagonist treatment (odds ratio [OR] 3.38, 95% confidence interval [CI] 1.17–13.46, P = .04), heart rate ≤65 beats/min (OR 6.03, 95% CI 1.48–48.42; P = .03), and E/E′ ≥15 (OR 3.78, 95% CI 1.26–17.55; P = .04) at hospital admission were associated with WRF. Patients with baseline glomerular filtration rate (GFR) ≤60 mg/dL who developed WRF during UF had a 75% 1-year mortality rate.ConclusionsWRF occurred frequently during UF. Increased LV filling pressures, lower heart rate, and treatment with aldosterone antagonist at hospital admission can identify patients at increased risk for WRF. Patients with baseline GFR ≤60 mg/dL and WRF during UF have an extremely high 1-year mortality rate.     

Minor vs. major leg amputation in adults with diabetes: Six-month readmissions,reamputations, and complications

AimsThe objective of this study was comparing medium-term outcomes between comparable minor and major amputations in adults with diabetes.MethodsWe used data from the 2016–2017 National Readmissions Database to construct a representative cohort of 15,581 adults with diabetes with lower extremity amputations. Patients were categorized by level of index amputation (major/minor), and propensity score matched to compare outcomes in candidates for either level of amputation. Readmission and reamputations were assessed at 1, 3, and 6 months following index amputation.ResultsIn the 6 months following index amputation, large proportions of patients were readmitted (n = 7597, 48.8%) or had reamputations (n = 1990, 12.8%). Patients with minor amputations had greater odds of readmission (OR = 1.25; 95% CI 1.18–1.31), reamputation (OR = 3.71; 95% CI 3.34–4.12), and more proximal reamputation (OR = 2.61; 95% 2.33–2.93) (all P < 0.001). Further, minor amputation patients had higher and lower odds of readmission for postoperative infection (OR = 4.45; 95% CI 3.27–6.05), or sepsis (OR = 0.79; 95% CI 0.68–0.93), respectively.ConclusionPatients desire to save as much limb as possible and should be counseled on higher risk for reamputation, readmission, and infection with minor amputations.