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Cardiogenic shock (CS) is associated with high mortality and often requires involvement of a multidisciplinary provider team to deliver timely care. Care coordination is more difficult on weekends, which may lead to a delay in care. We sought to assess the effect of weekend admissions on outcomes in patients admitted with CS. Patients admitted with CS were identified from 2005 to 2014 in the National Inpatient Sample using ICD9 code 785.51. Baseline demographics, in-hospital procedures, and outcomes were obtained and compared by day of admission. A multivariable model was used to assess the impact of weekend admission on in-hospital mortality. A total of 875,054 CS admissions were identified (age 67.4 ± 15.1 years, 40.2% female, 72.1% Caucasian), with 23% of patients being admitted on weekends. Baseline co-morbidities were similar between groups. Weekend admissions were associated with higher in-hospital mortality (40.6% vs 37.5%) and cardiac arrest (20.3% vs 18.1%, p < 0.001 for both) consistently over the study period. Use of temporary and permanent mechanical support devices and heart transplantation were slightly less common for weekend admissions. In a multivariable model adjusting for relevant confounders, weekend admission was associated with a 10% increased mortality in patients with CS. In conclusion, patients with CS admitted on weekends had higher in-hospital mortality and were slightly less likely to receive mechanical support and advanced therapies compared with those admitted on weekdays. Future studies and health system initiatives should focus on rectifying these disparities with around-the-clock multidisciplinary coordinated care for CS.

Cardiogenic shock (CS) is associated with high morbidity and mortality despite recent advances in the temporary mechanical circulatory support (MCS) devices. The current utilization and outcomes of these MCS devices with or without vasopressors compared with conventional medical therapy (no-MCS) in CS remain poorly described. The study population was extracted from the 2014 Nationwide Readmissions Database using International Classification of Diseases, Ninth Revision, Clinical Modification codes for CS, temporary MCS devices, and vasopressor infusion. Study end points included in-hospital all-cause mortality, length of index hospital stay (LOS), the likelihood of receiving invasive treatment, postprocedural bleeding, vascular complications, total hospitalization charges, and discharge disposition. A total of 59,148 discharges with a diagnosis of CS were identified (age 67 years; 38.5% female). Temporary MCS devices were utilized in 22.7%. The use of these devices was associated with lower in-hospital all-cause mortality (33.0% vs 39.7%, p <0.01), increased likelihood of invasive therapy (75.7% vs 26.3%, p <0.01), and increased likelihood of being discharged home (24.8% vs 20.6%, p <0.01). However, the MCS group had longer LOS (16.9 vs 12.1 days, p <0.01), higher vascular complications (2.6% vs 1.4%, p <0.01), bleeding (31.2% vs 16.8%, p <0.01), and total hospitalization charges ($374,574 vs $182,045, p <0.01). In conclusion, the use of the temporary MCS devices for the treatment of CS was associated with lower mortality, increased the likelihood of receiving invasive treatment and the likelihood of being discharged home. However, it was associated with higher in-hospital complications, LOS, and hospitalization charges.

Safety-net hospitals (SNHs) are hospitals that serve a higher proportion of patients insured by Medicaid or uninsured and have been reported to have poor outcomes compared with non-SNHs. Procedural and clinical outcomes of ST-segment elevation myocardial infarction complicated by cardiogenic shock (STEMI-CS) at SNHs have not been well described. Nationwide Inpatient Sample from 2005 to 2011 was queried to identify STEMI-CS and age ≥18. SNHs were defined as hospitals with the highest number of inpatient stays that were paid by Medicaid or were uninsured (the top quartile). A total of 23,229 STEMI-CS of which 3,639 (15.7%) were treated at SNHs. Admissions to SNHs were younger (mean age 66.0 vs 67.2, p < 0.001), more likely men (64.0% vs 62.2%, p = 0.04), more frequently ethnic minorities (Black; 11.0% vs 6.0%, Hispanic 20.4% vs 5.8%, p < 0.001), and had higher Elixhauser ≥4 (25.8% vs 21.9%, respectively, p < 0.001). Percutaneous coronary interventions were less performed (60.4% vs 65.8%, p < 0.001) whereas administrations of thrombolysis (2.9% vs 2.1%, p = 0.001) were more frequent at SNHs. Coronary artery bypass and the use of mechanical circulatory support was similar. In-hospital mortality was significantly elevated at SNHs (36.6% vs 32.7%, adjusted odds ratio 1.24, 95% confidence interval 1.10 to 1.39) whereas new dialysis, stroke, and fatal arrhythmias were similar. The median length of stay was similar (6 vs 7 days, p = 0.58) but the median cost was higher (40,175 vs 38,012 US dollars, p = 0.01) at SNHs. SNHs had lower utilization of percutaneous coronary intervention and higher in-hospital mortality compared with non-SNHs in STEMI-CS. Further cause analysis is warranted to improve outcomes of STEMI-CS admitted at SNHs.

There are approximately 2,200 orthotopic heart transplant (OHT) surgeries performed annually in the United States.1 Most of the recipients are chronically ill with long-standing heart failure, and a prevalence of malnutrition ranging from 35% to 57%.2 The decision surrounding candidacy is based on a careful assessment of risk (including malnutrition) and benefits, and in many cases, OHT may proceed despite underlying malnutrition. After adjusting for all baseline co-morbidities, malnutrition was an independent predictor of all-cause in-hospital mortality (odds ratio [OR]: 1.74, 95% confidence interval [CI]: 1.08 to 2.80, p < 0.001). Malnourishment in advanced heart failure is frequent and may be multifactorial, secondary to an increased systemic inflammatory response, congestive gastropathy leading to a protein-losing enteropathy, and heightened levels of circulating catecholamines.

In patients who underwent TAVI and TEER during the same hospitalization, the inpatient mortality was significantly higher than those who underwent TAVI followed by TEER during the subsequent hospitalization ([<11 patients], p = 0.04). [...]patients who underwent combined procedure during the same hospitalization were more likely to have cardiogenic shock (19.5% vs <9% [<11 patients], p <0.01), acute kidney injury (37.5% vs 19.5%, p = 0.03), required mechanical circulatory support (p = 0.02), invasive mechanical ventilation (16.2% vs <9% [<11 patients), p = 0.01), and had higher mean length of stay (17 vs 6 days, p <0.001). [...]in the case of functional MR, TAVI followed by reassessment of symptoms and echocardiography for the need of TEER has been proposed.7 This has been suggested because of the positive left ventricle remolding after TAVI, which in turn leads to improvement in MR.1 In light of our study in addition to other limited observational studies available, we propose that TEER of MR after TAVI is a viable treatment option. Because our analysis showed higher morality in the cohort that underwent both procedures during the same hospitalization, perhaps a staged TEER after TAVI in the appropriate time window is better advised. [...]the database lacks data on long-term outcomes.Disclosures The authors have no conflicts of interest to declare.

Risk-averse behavior has been reported among physicians and facilities treating cardiogenic shock in states with public reporting. Our objective was to evaluate if public reporting leads to a lower use of mechanical circulatory support in cardiogenic shock. We conducted a retrospective study with the use of the National Inpatient Sample from 2005 to 2011. Hospitalizations of patients ≥18 years old with a diagnosis of cardiogenic shock were included. A regional comparison was performed to identify differences between reporting and nonreporting states. The main outcome of interest was the use of mechanical circulatory support. A total of 13043 hospitalizations for cardiogenic shock were identified of which 9664 occurred in reporting and 3379 in nonreporting states (age 69.9 ± 0.4 years, 56.8% men). Use of mechanical circulatory support was 32.8% in this high-risk population. Odds of receiving mechanical circulatory support were lower (OR 0.50; 95% CI 0.43–0.57; p<0.01) and in-hospital mortality higher (OR 1.19; 95% CI 1.06–1.34; p<0.01) in reporting states. Use of mechanical circulatory support was also lower in the subgroup of patients with acute myocardial infarction and cardiogenic shock in reporting states (OR 0.61; 95% CI 0.51–0.72; p<0.01). In conclusion, patients with cardiogenic shock in reporting states are less likely to receive mechanical circulatory support than patients in nonreporting states.

To quantify the effect of absorption changes in the deep tissue (cerebral) and shallow tissue (scalp, skin) layers on functional near-infrared spectroscopy (fNIRS) signals, a method using multi-distance (MD) optodes and independent component analysis (ICA), referred to as the MD-ICA method, is proposed. In previous studies, when the signal from the shallow tissue layer (shallow signal) needs to be eliminated, it was often assumed that the shallow signal had no correlation with the signal from the deep tissue layer (deep signal). In this study, no relationship between the waveforms of deep and shallow signals is assumed, and instead, it is assumed that both signals are linear combinations of multiple signal sources, which allows the inclusion of a “shared component” (such as systemic signals) that is contained in both layers. The method also assumes that the partial optical path length of the shallow layer does not change, whereas that of the deep layer linearly increases along with the increase of the source–detector (S–D) distance. Deep- and shallow-layer contribution ratios of each independent component (IC) are calculated using the dependence of the weight of each IC on the S–D distance. Reconstruction of deep- and shallow-layer signals are performed by the sum of ICs weighted by the deep and shallow contribution ratio. Experimental validation of the principle of this technique was conducted using a dynamic phantom with two absorbing layers. Results showed that our method is effective for evaluating deep-layer contributions even if there are high correlations between deep and shallow signals. Next, we applied the method to fNIRS signals obtained on a human head with 5-, 15-, and 30-mm S–D distances during a verbal fluency task, a verbal working memory task (prefrontal area), a finger tapping task (motor area), and a tetrametric visual checker-board task (occipital area) and then estimated the deep-layer contribution ratio. To evaluate the signal separation performance of our method, we used the correlation coefficients of a laser-Doppler flowmetry (LDF) signal and a nearest 5-mm S–D distance channel signal with the shallow signal. We demonstrated that the shallow signals have a higher temporal correlation with the LDF signals and with the 5-mm S–D distance channel than the deep signals. These results show the MD-ICA method can discriminate between deep and shallow signals. [Display omitted] ► Method for evaluating deep/shallow-tissue contribution to fNIRS signal is proposed. ► We assume both deep and shallow signals are linear combinations of multiple sources. ► Multi-distance optodes and ICA are combined for the proposed method (MD-ICA). ► The method is demonstrated with a dynamic phantom and human brain measurements. ► MD-ICA can be applied to data that is highly correlated between deep/shallow signals.

Arterial spin labeling (ASL) has undergone significant development since its inception, with a focus on improving standardization and reproducibility of its acquisition and quantification. In a community-wide effort towards robust and reproducible clinical ASL image processing, we developed the software package ExploreASL, allowing standardized analyses across centers and scanners. The procedures used in ExploreASL capitalize on published image processing advancements and address the challenges of multi-center datasets with scanner-specific processing and artifact reduction to limit patient exclusion. ExploreASL is self-contained, written in MATLAB and based on Statistical Parameter Mapping (SPM) and runs on multiple operating systems. To facilitate collaboration and data-exchange, the toolbox follows several standards and recommendations for data structure, provenance, and best analysis practice. ExploreASL was iteratively refined and tested in the analysis of >10,000 ASL scans using different pulse-sequences in a variety of clinical populations, resulting in four processing modules: Import, Structural, ASL, and Population that perform tasks, respectively, for data curation, structural and ASL image processing and quality control, and finally preparing the results for statistical analyses on both single-subject and group level. We illustrate ExploreASL processing results from three cohorts: perinatally HIV-infected children, healthy adults, and elderly at risk for neurodegenerative disease. We show the reproducibility for each cohort when processed at different centers with different operating systems and MATLAB versions, and its effects on the quantification of gray matter cerebral blood flow. ExploreASL facilitates the standardization of image processing and quality control, allowing the pooling of cohorts which may increase statistical power and discover between-group perfusion differences. Ultimately, this workflow may advance ASL for wider adoption in clinical studies, trials, and practice.

Aerobic exercise in young adults can induce vascular plasticity in the hippocampus, a critical region for recall and recognition memory. In a mechanistic proof-of-concept intervention over 3 months, we investigated whether healthy older adults (60–77 years) also show such plasticity. Regional cerebral blood flow (rCBF) and volume (rCBV) were measured with gadolinium-based perfusion imaging (3 Tesla magnetic resonance image (MRI)). Hippocampal volumes were assessed by high-resolution 7 Tesla MRI. Fitness improvement correlated with changes in hippocampal perfusion and hippocampal head volume. Perfusion tended to increase in younger, but to decrease in older individuals. The changes in fitness, hippocampal perfusion and volume were positively related to changes in recognition memory and early recall for complex spatial objects. Path analyses indicated that fitness-related changes in complex object recognition were modulated by hippocampal perfusion. These findings indicate a preserved capacity of the aging human hippocampus for functionally relevant vascular plasticity, which decreases with progressing age.