Secondary mitral regurgitation is one of the most common valve diseases. The disease is a result of left atrial or left ventricular dysfunction. It is generally classified into stages based on its severity. While surgical intervention does not confer improved survival in this subset of mitral disease, recent advances in transcatheter interventions have resulted in improved survival and symptomatology in carefully selected patients. In this review, the multimodality imaging evaluation of the mitral valve and secondary mitral regurgitation is discussed. Commercially available and investigational transcatheter interventions for secondary mitral regurgitation management are also reviewed.

•Individual cases of Watchman FLX DAT are scarce in literature.•The Watchman FLX has shown lower rates of DAT than the Watchman 2.0.•Thrombus formation is still possible in rare instances with the Watchman FLX.

BACKGROUND: Preoperative cardiovascular risk stratification before noncardiac surgery is a common clinical challenge. Coronary artery calcium scores from ECG-gated chest computed tomography (CT) imaging are associated with perioperative events. At the time of preoperative evaluation, many patients will not have had ECG-gated CT imaging, but will have had nongated chest CT studies performed for a variety of noncardiac indications. We evaluated relationships between coronary calcium severity estimated from previous nongated chest CT imaging and perioperative major clinical events (MCE) after noncardiac surgery. METHODS: We retrospectively identified consecutive adults age ≥45 years who underwent in-hospital, major noncardiac surgery from 2016 to 2020 at a large academic health system composed of 4 acute care centers. All patients had nongated (contrast or noncontrast) chest CT imaging performed within 1 year before surgery. Coronary calcium in each vessel was retrospectively graded from absent to severe using a 0 to 3 scale (absent, mild, moderate, severe) by physicians blinded to clinical data. The estimated coronary calcium burden (ECCB) was computed as the sum of scores for each coronary artery (0 to 9 scale). A Revised Cardiac Risk Index was calculated for each patient. Perioperative MCE was defined as all-cause death or myocardial infarction within 30 days of surgery. RESULTS: A total of 2554 patients (median age, 68 years; 49.7% women; median Revised Cardiac Risk Index, 1) were included. The median time interval from nongated chest CT imaging to noncardiac surgery was 15 days (interquartile range, 3–106 days). The median ECCB was 1 (interquartile range, 0–3). Perioperative MCE occurred in 136 (5.2%) patients. Higher ECCB values were associated with stepwise increases in perioperative MCE (0: 2.9%, 1–2: 3.7%, 3–5: 8.0%; 6–9: 12.6%, P <0.001). Addition of ECCB to a model with the Revised Cardiac Risk Index improved the C-statistic for MCE (from 0.675 to 0.712, P =0.018), with a net reclassification improvement of 0.428 (95% CI, 0.254–0.601, P <0.0001). An ECCB ≥3 was associated with 2-fold higher adjusted odds of MCE versus an ECCB <3 (adjusted odds ratio, 2.11 [95% CI, 1.42–3.12]). CONCLUSIONS: Prevalence and severity of coronary calcium obtained from existing nongated chest CT imaging improve preoperative clinical risk stratification before noncardiac surgery.

Introduction: Perioperative risk estimation prior to non-cardiac surgery is a common clinical challenge. Coronary artery calcification (CAC) is more common in men and older individuals. We sought to determine if an index of coronary calcium derived from pre-operative non-gated chest computed tomography (CT) is associated with conventional estimates of peri-operative risk in subgroups by age and sex. Methods: We retrospectively identified men and women age ≥45 years who had undergone non-cardiac surgery at a large urban health system between 2016 and 2020 and had a non-gated chest CT within 1 year prior to surgery. Coronary calcium in each coronary artery (LAD, LCX, RCA) was graded as absent, mild, moderate, or severe with a corresponding numeric score (range: 0-3). A novel coronary calcium index (CCI) was determined as the sum of these scores. Correlations between the CCI and Revised Cardiac Risk Index (RCRI), a conventional measure of perioperative risk, were assessed in subgroups by age and sex using Spearman's correlation coefficient (𝜌;). Results: Among 2,560 patients, 49.8% (1,273) were female and 60.0% (1,538) were ≥65 years old. The CCI exhibited a correlation with RCRI in men (𝜌;: 0.204, p<0.001) and women (𝜌;: 0.200, p<0.001), with no differences by sex (p=0.95). Correlations between the CCI and RCRI were also observed in younger (age 45-64 years; 𝜌;: 0.180, p<0.001) and older (age ≥65 years; 𝜌;: 0.204, p<0.001) adults, with no differences by age group (p=0.53) Conclusion: An index of coronary calcium derived from non-gated chest CT imaging prior to surgery correlated with RCRI among all subgroups by age and sex. Coronary calcium from non-gated imaging represents a potentially promising approach to pre-operative risk evaluation.

Introduction: Cardiovascular events are feared complications of non-cardiac surgery. Prior studies demonstrate associations between coronary artery calcium (CAC) from ECG-gated computed tomography (CT) imaging and perioperative major adverse cardiac events. We sought to evaluate correlations between an index of CAC severity from preoperative non-gated CT imaging and traditional estimates of perioperative risk. Methods We identified consecutive adults age ≥45 years who underwent in-hospital, major non-cardiac surgery across a large urban health system between 2016 and 2020 and had non-gated (contrast or non-contrast) chest CT imaging performed within 1 year prior to surgery. Patients with prior coronary revascularization or heart valve surgery were excluded. CAC severity in each coronary artery was assessed and graded from absent to severe using a 0-3 scale by physicians blinded to clinical data. An index of CAC was computed as the sum of the scores for each coronary artery. The Revised Cardiac Risk Index (RCRI) was determined for each patient. Correlations between the CAC index and RCRI were assessed using Spearman Correlation Coefficient (𝜌;). Results A total of 2,560 patients met inclusion criteria - mean age 68.1 ± 12.3 years, 49.8% female, 60% white (Figure 1A). The median pre-operative RCRI score was 1 [IQR 0-1, range 0-6] (Figure 1B). A majority of patients (64.3%) had non-contrast chest CT imaging. The median CAC index was 1 [IQR 0-3, range 0-9] (Figure 1C). A correlation between the CAC index and RCRI (Coefficient (𝜌;): 0.209, p<0.001) was observed, with stepwise increases in the CAC index when stratified by pre-operative RCRI (Figure 1D). Conclusions A pragmatic, novel index of CAC derived from existing non-gated chest CT imaging correlates with pre-operative RCRI. As the RCRI is a validated preoperative risk stratification tool, this finding demonstrates the potential to leverage pre-existing, non-gated CT imaging to inform preoperative risk assessment.

Introduction: The clinical course of patients with prior CABG presenting with non-ST elevation myocardial infarction (NSTEMI) is not well defined. We aim to compare the management and outcomes of patients with and without prior CABG who present with an NSTEMI. Methods: Patients hospitalized with an NSTEMI between 2002-2018 were identified from the National Inpatient Sample (NIS). Baseline characteristics and outcomes of patients with prior CABG were compared to patients without. Outcomes included the rates of invasive management (defined as coronary angiography, PCI or CABG), and its individual components, as well as mortality, length of stay, and in-hospital charges. Results: A total of 1,445,545 cases of NSTEMI were identified of which 133,691 (9.3%) had a prior CABG. Patients with prior CABG were older (72.4 vs 68.6 years, p <0.001), more likely to be men (68.8% vs 56.9%, p <0.001), and of white race (79.7% vs 74.8%, p <0.001). The prior CABG cohort had lower rates of invasive management (50.4% vs 65.6%, p <0.001), PCI (23.7% vs 32.0%, p <0.001), or CABG (1.2% vs. 10.6%; p<0.001) in the unmatched analysis. Results were consistent in the propensity score matching analysis with the prior CABG group less likely to receive any invasive intervention (OR: 0.48, 95% CI 0.47 - 0.49) including PCI (OR: 0.66, 95% CI 0.64 - 0.67) or CABG (OR: 0.11, 95% CI 0.10 - 0.12) when compared to the no prior CABG group (Figure 1). Moreover, the risk of in-hospital mortality was higher in the prior CABG group (OR:1.15, 95% CI 1.10 - 1.21). Conclusions: Patients with prior CABG who present with NSTEMI have lower rates of invasive management and revascularization with associated higher in-hospital mortality when compared with patients without prior CABG.

Introduction: Post-operative patients are at increased risk for venous thromboembolism (VTE). Given the morbidity and mortality associated with VTE, risk stratification calculators have been developed based on pre-operative patient characteristics. Most risk calculators rely on logistic regression (LR) analysis. However, automated machine learning (AutoML) programs consistently outperform standard LR models in non-medical contexts. This study aims to investigate the utility of novel methods in developing a model for post-operative VTE after non-cardiac and cardiac surgeries. Hypothesis: We hypothesized that AutoML models would be superior to logistic regression models in predicting post-operative VTE. Methods: We used an AutoML system developed and released by Amazon in 2020, AutoGluon v0.3.1, to predict post-operative VTE using the 2016-2018 ACS NSQIP database. A total of 3,049,617 patients and 79 pre-operative variables were included. Post-operative VTE was defined as a deep venous thrombosis (DVT) or a pulmonary embolism (PE) within 30 days of the surgery. Models were trained for four hours to optimize performance on the Brier score, with lower being better. Validation of all performance metrics was done using the 2019 ACS NSQIP database. Results: 0.79% of the patients (n = 23,974) developed post-operative VTE. Brier scores were calculated for each model with the top performing model being an ensembled neural net model having a Brier score of 0.00758 on the validation set. The corresponding AUROC and AUC-PR was 0.784 and 0.035 respectively (Figure). Conclusions: The models generated via AutoML to predict post-operative VTE had similar discriminatory characteristics to those reported in the literature. Future post-operative VTE models may benefit from AutoML analysis.

Introduction: Coronary artery calcium (CAC) is strongly associated with cardiovascular risk. CAC burden can be qualitatively estimated from non-gated chest computed tomography (CT) imaging and may be used to predict future cardiovascular outcomes. We evaluated whether resident physician trainees can reliably estimate CAC burden from existing non-gated chest CTs using a semi-quantitative scoring method. Methods: A group of 4 resident physicians without formal training in CT image interpretation underwent a training session to qualitatively estimate CAC burden from non-gated, contrast and non-contrast CT scans. CAC was estimated for each coronary artery as absent, mild (1-24% vessel length), moderate (25-49% vessel length) and severe (>50% vessel length). All Chest CTs were reviewed by two physicians, each blinded to the interpretations of the other reviewer, to assess (a) the presence or absence of CAC, (b) the presence or absence of moderate-severe CAC, and (c) a semi-quantitative CAC index, at a per-patient level and by vessel. Inter-reader reliability (IRR) was assessed by percent agreement, Cohen's kappa coefficient, and the intraclass correlation coefficient (ICC). Results: Using a semi-quantitative scoring system to estimate an index of overall CAC burden, the ICC was 0.96 (CI 0.94-0.98). The percent agreement for the presence of any CAC was 74% (kappa 0.82) and 89% for moderate-to-severe CAC (kappa 0.85). The IRR stratified for each coronary vessel is shown in Table 1. CAC estimated from both contrast and non-contrast scans was associated with substantial agreement between readers ( Table 1 ). Conclusions: With a single training session, resident physicians can quickly and reliably estimate CAC burden from non-gated chest CT imaging. This may facilitate cardiovascular risk stratification in patients without dedicated cardiac testing. 1b

Objectives: Tonsillectomy is one of the most common otolaryngologic procedures. Hemorrhage after tonsillectomy is one of the most feared complications by surgeons and patients alike. The objective of this study was to analyze the risk factors associated with an increase in post-tonsillectomy hemorrhage in the pediatric population using a large national database. Methods: The Kids’ Inpatient Database (KID) from 2000 to 2012 was queried for patients between the ages of 1 to 17 years with post-tonsillectomy hemorrhage. Univariate and multivariate analyses were performed to obtain trends in patient demographics, comorbidities, and hospital information. Results: Overall 45 940 pediatric cases of tonsillectomy were identified of which 5470 (11.9%) resulted in postoperative hemorrhage. Patients with postoperative hemorrhage were significantly older with mean age of 8.62 (±4.75) compared to all patients. Females were found to have higher rates of hemorrhage when compared to males 14.6% versus 11.5% (P < .001). The rate of white patients who had hemorrhage was 16.3% (P < .001). The most common comorbidities significantly associated with hemorrhage were fluid and electrolyte disorders (6.6% P < .001), deficiency anemia (3.8%; P < .001), and coagulopathy (2.7%; P < .001). Urban nonteaching hospitals had higher rates of hemorrhage (19.6%; P < .001) and the Northeast was the most common region (15.2%; P < .001). On multivariate analysis, older patients and white ethnicity showed a significantly increased risk of hemorrhage. Patients with pre-existing comorbidities such as coagulopathy, deficiency anemia, and fluid and electrolyte disorders circulation were also found to have higher odds ratios of bleeding. Conclusion: Postoperative hemorrhage is a common complication following tonsillectomy with a rate of 11.9% in this study. A higher rate of hemorrhage was seen with increasing age, white race, and males overall, as well as patients with fluid and electrolyte disorders. Urban non-teaching hospitals and the Northeast region also saw increased rates of hemorrhage.

The study investigates the incidence of change in renal function and its impact on survival in renal dysfunction patients who were bridged to heart transplantation with a left ventricular assist device (BTT-LVAD). BTT-LVAD patients with greater than or equal to moderately reduced renal function (estimated glomerular filtration rate [eGFR] <= 60 ml/min/1.73 m(2)) at the time of listing between 2008 and 2018 were identified from a prospectively maintained database of the United Network for Organ Sharing. Patients with a baseline eGFR less than or equal to 15 ml/min/1.73 m(2) or on dialysis were excluded. Patients were divided into three groups based on percent change ([Pretransplant eGFR - listing eGFR/listing glomerular filtration rate (GFR)] x 100) in eGFR: Improvement greater than or equal to 10%, no change, decline greater than or equal to 10%, and their operative outcomes were compared. Posttransplant survival was estimated and compared among the three groups with the Kaplan-Meier survival curves and the log-rank test. Cox proportional hazards modeling was used to identify predictors of posttransplant survival. Out of 14,395 LVAD patients, 1,622 (11%) met the inclusion criteria. At the time of transplant, 900 (55%) had reported an improvement in eGFR greater than or equal to 10%, 436 (27%) had no change, and 286 (18%) experienced a decline greater than or equal to 10%. Postoperatively, the incidence of dialysis was higher in the decline than in the unchanged or improved groups (22% vs. 12% vs. 12%; p = 0.002). After a median follow-up of 5 years, there was no difference in posttransplant survival among the stratified groups (improved eGFR: 24.8%, unchanged eGFR: 23.2%, declined eGFR: 20.3%; p = 0.680). On Cox proportional hazard modeling, independent predictors of worse survival were: [hazard ratio: 95% CI; p] history of diabetes (1.43 [1.13-1.81]; p = 0.002) or tobacco use (1.40 [1.11-1.79]; p = 0.005) and ischemic time greater than 4 hours (1.36 [1.03-1.76]; p = 0.027). More than half of the patients with compromised renal function who undergo BTT-LVAD demonstrate an improvement in renal function at the time of transplant. A 10% change in GFR while listed was not associated with worse posttransplant survival.

Objective The current study aims to report trends of early discharges and identify associated direct costs using a nationally representative database of real-world data experience. Methods We used nationally weighted data on all patients who had transfemoral transcatheter aortic valve replacement (TAVR) from 2012 to 2017 and discharged alive from the National Inpatient Sample. Patients were divided into early (discharge ≤3 days of admission) and late discharge. Demographics and clinical characteristics were compared. Trends in early discharge and costs associated with admissions were analyzed over the study period. Results Of the 125,188 patients identified, 59,424 (46.9%) were discharged early. The proportion of early discharge increased from 15% in early 2012 to 68% in late 2017 ( P < 0.001), with the largest increase occurring from 2014 to 2015. Overall, the average cost of TAVR decreased from $58,408 in 2012 to $49,875 in 2017 ( P < 0.001). Compared to late discharge, patients discharged early reported costs savings of ≥$20,000 over the study period. Among the early discharge group, no significant differences in costs were observed for patients discharged on 0 to 1, 2, or 3 days after the procedure. Conclusions Postoperative length of stay after TAVR has decreased dramatically within the last decade with an observed reduction in procedural costs. While discharge within 3 days appeared cost effective, no differences in costs were noted among patients discharged ≤3 days.

Thank you very much for your comments, with which we agree. The National Inpatient Sample is a limited database that captures only the events of each admission, coded using International Classification of Diseases, 9th and 10th revisions. Consequently, the use of chemotherapy and postsurgical complications are unable to be accurately determined. This information would be relevant, in combination with tumor pathology, to better delineate best practices. Furthermore, this limited dataset cannot determine the particular factors affecting the relationship between atrial fibrillation and surgery. Previous studies have shown that atrial fibrillation may be associated with particular tumor types. As noted in the manuscript, primary cardiac tumors characteristics may benefit from analysis in other datasets. Longitudinal studies will also be of benefit to the treatment of primary cardiac tumors.

Many cases of cat and dog bites are associated with Pasteurella spp. infections. Antimicrobial therapy usually entails a β-lactam-β-lactamase inhibitor combination such as amoxicillin-clavulanic acid. Drug resistance in human Pasteurella spp. infections has rarely been reported in literature. In this report, we introduce the first documented case of a human Pasteurella spp. infection with resistance to amoxicillin-clavulanic acid. The potential emergence of drug-resistant Pasteurella spp may alter our therapeutic approach to animal bites in the future. This case highlights the need for further epidemiologic studies on Pasteurella spp antibiotic susceptibility patterns in both humans and cats.

OBJECTIVE:We investigated health and healthcare disparities in the treatment of aortic stenosis with transcatheter aortic valve replacement (TAVR) and how they affect resource utilization and costs.METHODS:We retrospectively reviewed all patients who were discharged alive after TAVR between 2012 and 2017 from the National Inpatient Sample. Patients were stratified by race and outcomes investigated were in-hospital complications, total procedural costs, and resource utilization. High resource utilization (HRU) was defined as length of stay (LOS) ≥7 days or discharge to a nonhome location. Multivariable regression models were used to identify predictors of HRU.RESULTS:TAVR patients (N = 29,464) were stratified into Caucasians (n = 25,691), others (n = 1,274), Hispanics (n = 1,267), and African Americans (AA, n = 1,232). More AA and Hispanics had TAVR at urban teaching centers (P = 0.003) and were less likely to be Medicare beneficiaries (P < 0.001). Distribution of TAVR patients in the lowest income quartile showed AA (50%) versus Caucasian (20%) versus Hispanic (33%, P < 0.001). In-hospital complications were higher among Hispanics and AA than Caucasians with prolonged LOS, procedural costs, and HRU. On multivariable analysis, independent predictors of HRU were TAVR year (P < 0.001), advanced age (P < 0.001), female sex (P < 0.001), non-Caucasian race (P = 0.038), history of coronary artery bypass grafting (P < 0.001), smoking (P < 0.001), chronic lung disease (P = 0.003), stroke (P < 0.001), and lowest income quartile (P = 0.002).CONCLUSIONS:There exist significant healthcare and health disparities among patients undergoing TAVR in the United States. Consequently, this unequal access to care and determinants of heath translate into higher resource utilization and costs.

Objectives: Tympanostomy tubes can prevent sequelae of otitis media that adversely affect long term hearing and language development in children. These negative outcomes compound the existing difficulties faced by children who are already diagnosed with developmental disorders. This study aims to characterize this subset of children with developmental disorders undergoing myringotomy and tympanostomy tube insertion. Methods: A retrospective review using the Kids' Inpatient Database (KID) was conducted, with codes from International Classification of Diseases, Ninth Revision used to query data from the years 2003 to 2012 to determine a study group of children with a diagnosis of a developmental disorder undergoing myringotomy and tympanostomy insertion. This group was compared statistically to patients undergoing these procedures who did not have a diagnosed developmental disorder. Results: In total, 21 945 cases of patients with myringotomy with or without tympanostomy tube insertion were identified, of which 1200 (5.5%) had a diagnosis of a developmental disorder. Children with developmental disorders had a higher mean age (3.3 years vs 2.9 years, P = .002) and higher mean hospital charges ($43 704.77 vs $32 764.22, P = .003). This cohort also had higher proportions of black (17.6% vs 12.3%, P < .001) and Hispanic (23.9% vs 20.6%, P = .014) patients, and had lower rates of private insurance coverage (39.6% vs 49%, P < .001). Conclusion: The population of children with developmental disorders undergoing myringotomy or tympanostomy tube placement has a different demographic composition than the general population and faces distinct financial and insurance coverage burdens. Further study should be done to assess if these differences impact long term outcomes.

INTRODUCTION: Psychiatric disorders are increasingly diagnosed in pediatric patients with inflammatory bowel disease (IBD) however the impact on hospital outcomes and resource utilization is relatively unknown. This study aimed to characterize trends of three most prevalent psychiatric conditions in pediatric patients hospitalized with IBD, as well as the impact of these conditions on hospital resource utilization. METHODS: Patients with IBD were identified in the Kids Inpatient Database using International Classification for Disease 9th and 10th revision codes from 2003, 2006, 2012, and 2016. Patient and hospital characteristics, disease severity, receipt of endoscopy, intestinal surgery, and parenteral nutrition were assessed. Psychiatric conditions were defined as major depressive, anxiety, and adjustment disorder. Multivariate regression was used to determine factors impacting hospital charges and length of stay. RESULTS: A weighted total of 92,290 patients with pediatric IBD were included. Median age was 17 and 50.2% were female; 63.2% had Crohn’s disease and 37.8% had ulcerative colitis. Overall, 7.9% of patients had any psychiatric condition; 2.8% had depression, 4.9% had anxiety, and 1.5% had adjustment disorder. Patients with psychiatric conditions had significantly higher proportion of females, white race, stoma presence, and malnutrition on univariate tests (P < .001) (Table 1). Incidence of each psychiatric condition increased significantly during the study period (Figure 1). In multivariate models, presence of any and each psychiatric disorder was associated with elevated length of stay and hospital charges overall as well as for Crohn’s disease and ulcerative colitis individually (Table 2). Each additional psychiatric condition similarly increased cost and length of stay. CONCLUSION: This study demonstrates a rising incidence of comorbid psychiatric disorders in hospitalized pediatric IBD patients. We additionally found that presence of psychiatric disorders was independently associated with increased length of stay and hospital charges despite having variable odds of receiving surgery and endoscopy. Given the potentially traumatic effects of surgery and hospitalization on pediatric IBD patients, development of strategies to improve mental health support are needed to reduce the psychosocial and finacial burden of these conditions.Table 1.: Baseline patient and hospital characteristics of hospitalized pediatric inflammatory bowel disease patients. EGD = esophagogastroduodenoscopyTable 2.: Negative binomial regression assessing impact of psychiatric conditions on length of stay and cost. *Adjusted for patient age, race, sex, insurance status, hospital bed size, disease severity, stoma, perianal disease, malnutrition, anemia, receipt of surgery, and endoscopyFigure 1.: Estimated national frequency of major depressive disorder, anxiety disorder, and adjustment disorder in pediatric inflammatory bowel disease patients from 2003 to 2016.

BackgroundHypothermic oxygenated machine perfusion improves outcomes in Liver Transplantation, but application is limited as O2 is supplied by a stationary circuit. A novel technique of O2 “pre-charge” in a portable pump would broaden use and further mitigate ischemia damage from organ transport.MethodsPorcine DCD livers were randomized to static cold storage (SCS, n = 8) or hypothermic machine perfusion (HMP). HMP was stratified into HMP-O2 (n = 5), non-O2 open to air HMP-RA (n = 5), and non-O2 with sealed lids or no air HMP-NA (n = 5). HMP-O2 was “pre-charged” using 100% O2 delivered at 10 L/min over 15 min. Perfusate and tissue O2 tension (pO2), liver biopsies, and fluid chemistries were analyzed.Results“Pre-charge” achieves sustained tissue and perfusate pO2 vs others. HMP-O2 results in decreased markers of hepatocyte injury: ALT (p < 0.05) and LDH (p < 0.05), lower expression of CRP and higher expression of SOD1 vs SCS. This suggests decreased inflammation and improved ROS scavenging.Conclusions“Pre-charge” is an effective technique, which allows portability and transport without an O2 source and improves graft parameters.