Implantable continuous-flow left ventricular assist devices (CF-LVADs) are used for long-term LV support in bridging patients to heart transplantation or as destination therapy. With prolonged support times, some patients will have repeat complications necessitating multiple device exchanges. To elucidate the safety and efficacy of repeat device exchange, we retrospectively reviewed data from 25 patients who underwent two or more CF-LVAD implantations between July 2005 and August 2017. Indications for exchange were thrombus/hemolysis (n = 8, 32%), electromechanical device malfunction (n = 14, 56%), and infection (n = 3, 12%). The implanted devices were the HeartMate II (n = 13, 52%), the HeartWare HVAD (n = 11, 44%), and the Jarvik 2000 (n = 1, 4%). Average hospital length of stay was 44 days (range 4–221 days), and 17 patients (68%) survived to discharge. Average duration of support after the most recent LVAD implantation was 802 days (range 1–3,229 days). Overall survival was 72% at 1 year and 60% at 2 years. Postoperative complications included respiratory failure in five patients (20%), device infection in five (20%), bleeding requiring reoperation in four (16%), neurologic dysfunction in four (16%), and acute renal failure in two (8%). Overall, our data suggest that repeat LVAD exchange is a feasible option for patients with recurrent device-related complications.

Objective Risk-scoring systems for surgical aortic valve replacement (AVR) were largely derived from sternotomy cases. We evaluated the accuracy of current risk scores in predicting outcomes after minimally invasive AVR (mini-AVR). Because transcatheter AVR (TAVR) is being considered for use in low-risk patients with aortic stenosis, accurate mini-AVR risk assessment is necessary. Methods We reviewed 1,018 consecutive isolated mini-AVR cases (2009 to 2015). After excluding patients with Society of Thoracic Surgeons Predicted Risk of Mortality (STS-PROM) scores ≥4, we calculated each patient’s European System for Cardiac Operative Risk Evaluation (EuroSCORE) II, TAVR Risk Score (TAVR-RS), and age, creatinine, and ejection fraction score (ACEF). We compared all 4 scores’ accuracy in predicting mini-AVR 30-day mortality by computing each score’s observed-to-expected mortality ratio (O:E). Area under the receiver operating characteristic (ROC) curves tested discrimination, and the Hosmer–Lemeshow goodness-of-fit tested calibration. Results Among 941 patients (mean age, 72 ± 12 years), 6 deaths occurred within 30 days (actual mortality rate, 0.6%). All 4 scoring systems overpredicted expected mortality after mini-AVR: ACEF (1.4%), EuroSCORE II (1.9%), STS-PROM (2.0%), and TAVR-RS (2.1%). STS-PROM best estimated risk for patients with STS-PROM scores 0 to <1 (0.6 O:E), ACEF for patients with STS-PROM scores 2 to <3 (0.6 O:E), and TAVR-RS for patients with STS-PROM scores 3 to <4 (0.7 O:E). ROC curves showed only fair discrimination and calibration across all risk scores. Conclusions In low-risk patients who underwent mini-AVR, current surgical scoring systems overpredicted mortality 2-to-3-fold. Alternative dedicated scoring systems for mini-AVR are needed for more accurate outcomes assessment.

BACKGROUND: Public reporting of cardiac surgery ratings has been advocated to inform patient selection of hospitals. Although Society of Thoracic Surgeons (STS) ratings are based on audited riskadjusted patient outcomes, other rating systems rely on administrative databases. In this study, we evaluate correlation among 4 widely used hospital rating systems for coronary artery bypass grafting (CABG) and aortic valve replacement (AVR). STUDY DESIGN: We identified an initial cohort of 602 hospitals from US News & World Report's (USN) listing of the 2016-2017 "Best Hospitals for Cardiology & Heart Surgery." From this cohort, current publicly available CABG and AVR ratings were collected from the STS, USN, Centers for Medicare & Medicaid Services, and Healthgrades. All 4 rating systems rated hospitals as high, average, or below average performers for each procedure. We then determined the match rate between rating systems for individual hospitals and assessed interrater reliability with Cohen's k. RESULTS: Rating systems had different distributions of high and low performing ratings assigned. USN rated hospitals as high performing for both CABG and AVR more frequently compared with STS, Healthgrades, and Centers for Medicare & Medicaid Services. For CABG, the match rate between systems varied from 50% to 85%, with the best match between STS and Centers for Medicare & Medicaid Services. Similarly for AVR, the match rate varied from 50% to 73%, with the best match between STS and Healthgrades. Interrater reliability was poor among the 4 rating systems (k < 0.2) and consistent with no agreement for CABG and AVR ratings. CONCLUSIONS: Publicly reported cardiac surgery ratings have significant discrepancy and poor correlation. This might confuse instead of clarify public perception of hospital quality for cardiac surgery.

BackgroundStudies have shown an influence of BMI on clinical outcomes in patients with RA treated by anti-TNF agents.1 The efficacy of abatacept does not seem to be impacted by weight; baseline weight was not identified as a predictive factor of efficacy (DAS28 [CRP] <2.6) in a post hoc analysis of the AVERT trial2 and, in real-world analyses, BMI did not impact the retention rate on drug or effectiveness.3,4 Clinical evaluation of RA in obese patients can be difficult, but power Doppler ultrasound (PDUS) is a method for evaluating joints that can differentiate joint effusion from synovitis and identify real disease activity due to RA. APPRAISE was the first prospective, multinational study to use the composite greyscale/PDUS synovitis score, developed by the OMERACT-EULAR Ultrasound Task Force, to measure early signs of response to treatment with IV abatacept plus MTX.5-7ObjectivesTo explore the effect of BMI on the efficacy of IV abatacept plus MTX using PDUS.MethodsPDUS was assessed over 6 months in underweight/normal (<25 kg/m2), overweight (25–<30 kg/m2) and obese (≥30 kg/m2) patients receiving IV abatacept plus MTX. Efficacy was assessed by the percentage of patients achieving DAS28 (CRP) <2.6, low disease activity (DAS28 [CRP] ≤3.2) or clinically meaningful improvement (change in DAS28 [CRP] of ≥1.2).ResultsOf the 96/104 patients evaluable for PDUS, 46 (47.9%) had a BMI <25 kg/m2, 28 (29.2%) were overweight and 22 (22.9%) were obese. Baseline demographics and disease characteristics were comparable between the BMI subgroups; however, differences were noted at baseline between global PDUS joint effusion scores within each BMI subgroup: mean (SD) score was 15.7 (15.2) for the underweight/normal group, 19.6 (16.1) for the overweight group and 23.0 (16.4) for the obese group. Mean changes from baseline in PDUS and DAS28 (CRP) scores over 6 months for each BMI subgroup are presented; no differences between the BMI subgroups were detected (Figure). Note that when using more stringent criteria such as the percentage of patients reaching DAS28 (CRP) <2.6 over time, a greater response within the first month was seen in the underweight/normal group versus overweight and obese groups, influenced mainly by high-sensitivity CRP and patient global assessment; responses were otherwise similar over 6 months.ConclusionsThis post hoc analysis of the APPRAISE study confirms that BMI does not affect clinical response to IV abatacept plus MTX nor does it influence the magnitude in changes of PDUS-detected inflammation over time.ReferencesGremese E, et al. Arthritis Care Res 2013;65:94–100.Emery P, et al. Arthritis Rheum 2014;66(Suppl 11):S1084. Poster 2485.Nüsslein H, et al. Arthritis Rheum 2014;66(Suppl 11):S1088. Poster 2492.Iannone F, et al. Ann Rheum Dis 2014;73(Suppl 2):498–9. Poster FRI0313.D'Agostino MA et al. Ann Rheum Dis 2012;71(Suppl 3):186. Poster THU0095.D'Agostino MA, et al. Arthritis Rheum 2012;64(Suppl 10):S352. Poster 810.D'Agostino MA, et al. Arthritis Rheum 2012;64(Suppl 10):S353. Poster 811.Disclosure of Int...