Research Spotlight

Tajti, P., M. N. Burke, D. Karmpaliotis, K. Alaswad, F. A. Jaffer, R. W. Yeh, M. Patel, E. Mahmud, J. W. Choi, A. H. Doing, P. Datilo, C. Toma, A. J. C. Smith, B. Uretsky, E. Holper, S. Garcia, O. Krestyaninov, D. Khelimskii, M. Koutouzis, I. Tsiafoutis, J. W. Moses, N. J. Lembo, M. Parikh, A. J. Kirtane, Z. A. Ali, D. Doshi, W. Jaber, H. Samady, B. V. Rangan, I. Xenogiannis, I. Ungi, S. Banerjee and E. S. Brilakis (2018). “Prevalence and Outcomes of Percutaneous Coronary Interventions for Ostial Chronic Total Occlusions: Insights From a Multicenter Chronic Total Occlusion Registry.” Can J Cardiol 34(10): 1264-1274.

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BACKGROUND: Ostial chronic total occlusions (CTOs) can be challenging to recanalize. METHODS: We sought to examine the prevalence, angiographic presentation, and procedural outcomes of ostial (side-branch ostial and aorto-ostial) CTOs among 1000 CTO percutaneous coronary interventions (PCIs) performed in 971 patients between 2015 and 2017 at 14 centres in the US, Europe, and Russia. RESULTS: Ostial CTOs represented 16.9% of all CTO PCIs: 9.6% were aorto-ostial, and 7.3% were side-branch ostial occlusions. Compared with nonostial CTOs, ostial CTOs were longer (44 +/- 33 vs 29 +/- 19 mm, P < 0.001) and more likely to have proximal-cap ambiguity (55% vs 33%, P < 0.001), moderate/severe calcification (67% vs 45%, P < 0.001), a diffusely diseased distal vessel (41% vs 26%, P < 0.001), interventional collaterals (64% vs 53%, P = 0.012), and previous coronary artery bypass graft surgery (CABG) (51% vs 27%, P < 0.001). The retrograde approach was used more often in ostial CTOs (54% vs 29%, P < 0.001) and was more often the final successful crossing strategy (30% vs 18%, P = 0.003). Technical (81% vs 84%, P = 0.280), and procedural (77% vs 83%, P = 0.112) success rates and the incidence of in-hospital major complication were similar (4.8% vs 2.2%, P = 0.108), yet in-hospital mortality (3.0% vs 0.5%, P = 0.010) and stroke (1.2% vs 0.0%, P = 0.030) were higher in the ostial CTO PCI group. In multivariable analysis, ostial CTO location was not independently associated with higher risk for in-hospital major complications (adjusted odds ratio 1.27, 95% confidence intervals 0.37 to 4.51, P = 0.694). CONCLUSIONS: Ostial CTOs can be recanalized with similar rates of success as nonostial CTOs but are more complex, more likely to require retrograde crossing and may be associated with numerically higher risk for major in-hospital complications.

Sikka, S., L. Callender, S. Driver, M. Bennett, M. Reynolds, R. Hamilton, A. M. Warren and L. Petrey (2018). “Healthcare utilization following spinal cord injury: Objective findings from a regional hospital registry.” J Spinal Cord Med Oct 2: 1-7. [Epub ahead of print].

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OBJECTIVE: The purpose was to describe the prevalence and characteristics of healthcare utilization among individuals with spinal cord injury (SCI) from a Level I trauma center. DESIGN: Retrospective data analysis utilizing a local acute trauma registry for initial hospitalization and merged with the Dallas-Fort Worth Hospital Council registry to obtain subsequent health care utilization in the first post-injury year. SETTING: Dallas, TX, USA. PARTICIPANTS: Six hundred and sixty four patients were admitted with an acute traumatic SCI from January 2003 through June 2014 to a Level I trauma center. Fifty five patients that expired during initial hospitalization and 18 patients with unspecified SCI (defined by ICD-9 with no etiology or level of injury specified) were not included in the analysis, leaving a final sample of 591. OUTCOME MEASURES: Data included demographic and clinical characteristics, charges, and healthcare utilization. RESULTS: Mean age was 46.1 years (+/-18.9 years), the majority of patients were male (74%), and Caucasian (58%). Of the 591 patients, 345 (58%) had additional inpatient or emergency healthcare utilization accounting for 769 additional visits (median of 3 visits per person). Of the 769 encounters, 534 (69%) were inpatient and 235 (31%) were emergency visits not resulting in an admission. The most prevalent ICD-9 codes listed were pressure ulcer, neurogenic bowel, neurogenic bladder, urinary tract infection, fluid electrolyte imbalance, hypertension, and tobacco use. CONCLUSION: Individuals with SCI experience high levels of healthcare utilization which are costly and may be preventable. Increasing our understanding of the prevalence and causes for healthcare utilization after acute SCI is important to target preventive strategies.

Shibuya, N., C. Graney, H. Patel and D. C. Jupiter (2018). “Predictors for Surgery-Related Emergency Department Visits within 30 Days of Foot and Ankle Surgeries.” J Foot Ankle Surg Sep 6. [Epub ahead of print].

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Presentation to an emergency department (ED) after foot and ankle surgeries not only causes inconvenience to patients but also increases healthcare costs. To minimize this, many major institutions have tracked these data as a part of quality improvement measures. Our previous study showed that factors associated with any (surgery-related and unrelated) postoperative ED visits were not easily modifiable by surgeons. Therefore, in the current study, we focused on factors associated specifically with surgery-related postoperative ED visits, because this may provide some insights for surgeons rather than just administrators. We examined 513 foot and ankle surgeries, of which 114 resulted in 30-day postoperative ED visits for surgery-related reasons. Demographic, medical, and surgical factors were evaluated, and risk factors were identified after adjusting for potential clinically relevant covariates. Both inpatient and outpatient surgical settings and outpatient surgical settings alone were analyzed separately. Regardless of the setting, we found that shorter surgery was protective against postoperative ED visits, as was having a previous ED visit within 6 months before surgery. In the outpatient setting, younger age and having no insurance were also proxies for a postoperative ED visit, in addition to the above factors.

Saef, J., S. Sodhi, K. M. Tecson, V. Al Rashida, J. Mi Ko, K. S. White, P. A. Ludbrook and A. M. Cedars (2018). “Contributors to disease-specific health knowledge in adults with congenital heart disease: A correlational study.” Congenit Heart Dis Sep 27. [Epub ahead of print].

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OBJECTIVE: Growth in the adults with congenital heart disease (ACHD) population represents a challenge to the health care infrastructure. As patients with chronic disease are increasingly held accountable for their own care, contributors to disease-specific health knowledge, which are known to correlate with patients’ participation in care, merit investigation to design patient-focused interventions. DESIGN: We conducted a single-site, cross-sectional study of ACHD patients. Investigators retrospectively gathered clinical data as well as psychometric and health status assessments completed at the time of enrollment. OUTCOME MEASURES: We investigated the impact of clinical and psychological variables on Leuven Knowledge Questionnaire for Congenital Heart Diseases health knowledge composite scores (HKCS). Variables with significant associations were considered in a stepwise multivariable regression model to determine which combination of variables jointly explained variability in HKCS. RESULTS: Overall HKCS was associated with the number of prior cardiac surgeries (r = 0.273; 95% CI: 0.050-0.467; P = .016), perceived stress (r = 0.260; 95% CI: 0.033-0.458; P = .024), SF-36 emotional well-being (r = -0.251; 95% CI: -0.451, -0.024; P = .030), history of noncardiac surgery (P = .037), cirrhosis (P = .048), and presence of implantable cardioverter-defibrillator (P = .028). On multivariable modeling, only the number of cardiac surgeries was found to correlate with HKCS. CONCLUSIONS: While univariate correlations were found between HCKS and several other clinical and psychological variables, only number of prior cardiac surgeries independently correlated with disease-specific health knowledge in ACHD patients. These results suggest that clinical and psychological variables are not impediments to disease-specific health knowledge.

Roberts, W. C., N. Kondapalli and S. A. Hall (2018). “Usefulness of Total 12-Lead QRS Voltage for Diagnosis of Arrhythmogenic Right Ventricular Cardiomyopathy in Patients With Heart Failure Severe Enough to Warrant Orthotopic Heart Transplantation and Morphologic Illustration of Its Cardiac Diversity.” Am J Cardiol 122(6): 1051-1061.

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Although several electrocardiographic features of arrhythmogenic right ventricular cardiomyopathy (ARVC) (also called dysplasia) have been described, total 12-lead QRS voltage is not one of them. This report describes total 12-lead QRS voltage in 11 patients with ARVC who underwent orthotopic heart transplantation (OHT) because of progressively severe heart failure. Additionally, it illustrates the varied morphologic features of ARVC. The total 12-lead nonpaced QRS voltages before OHT ranged from 28 to 118 mm (mean 74 +/- 32), and those in the paced tracings, from 33 to 129 mm (62 +/- 32). The voltages are the lowest we have encountered among 12 previously reported cardiovascular conditions. The heart weights among the 11 ARVC patients ranged from 285 to 670 g (mean 448 +/- 125). Very low 12-lead QRS voltage is characteristic of patients with ARVC with heart failure severe enough to warrant OHT, and thus may serve as a clue to its diagnosis.