Guy Rozen

Background: Analysis of the National Inpatient Sample database for the safety of procedures that are primarily outpatient in nature can be biased due to the selective hospitalization of patients who have complications during these procedures. Methods: This is a retrospective cross‐sectional analysis of hospitalized patients in the National Inpatient Sample data set who underwent an atrial fibrillation catheter ablation between 2016 and 2022. Patients were divided into 2 groups based on the day of hospitalization on which the ablation was performed: day 1 of admission or before (group 1), versus day 2 of admission or later (group 2). Patient baseline characteristics and procedural complication rates were compared. Results: The analysis included 47 925 weighted hospitalizations of patients who underwent atrial fibrillation catheter ablation. Group 1 had significantly fewer octagenerians (6.9% versus 10.4%), lower rates of renal disease (12.6% versus 20.0%), heart failure (28.3% versus 45.8%), and ischemic heart disease (16.0% versus 20.5%), P P P <0.001). Conclusions: Patients undergoing procedures on the day of admission or before were younger and had fewer comorbidities. Despite this, these patients had a significantly higher rate of procedural complications. The likely explanation for these results is selection bias, where patients undergoing outpatient procedures who are at higher risk or develop complications are admitted as inpatients, thus falsely inflating the complication rate of patients in the National Inpatient Sample data set.

BACKGROUND: Intracardiac echocardiography (ICE) is increasingly used to guide left atrial appendage occlusion as an alternative to transesophageal echocardiography (TEE), particularly in elderly patients for whom general anesthesia may pose additional risks. Real-world comparative safety data in older adults remain limited, with prior studies including only small ICE cohorts. We aimed to compare short- and long-term outcomes of ICE- versus TEE-guided left atrial appendage occlusion in adults aged ≥80 years. METHODS: We queried the TriNetX US Collaborative Network to identify patients aged ≥80 years with atrial fibrillation who underwent percutaneous left atrial appendage occlusion from 2015 to 2025. Patients were stratified by imaging modality: ICE- versus TEE-guided approach. Propensity score matching (1:1) was performed across demographics and comorbidities, yielding 2913 patients per group. Outcomes were assessed from the index procedure through 7 days, 90 days, and 1 year using Cox proportional hazards models to generate hazard ratios with 95% CIs. Outcomes included mortality, stroke, device thrombosis, pericardial effusion, pericardiocentesis, tamponade, and device leak. RESULTS: Baseline characteristics were well balanced after matching, with a mean age of 83 years and 44% women. At 90 days, ICE and TEE demonstrated no significant differences in mortality (hazard ratio, 1.18 [95% CI, 0.81–1.73]), stroke, device thrombosis, pericardial effusion, pericardiocentesis, tamponade, or device leak. At 1-year follow-up, mortality (hazard ratio, 0.93 [95% CI, 0.76–1.13]), stroke, and device thrombosis remained similar between groups. However, ICE was associated with a higher incidence of device leak compared with TEE (hazard ratio, 1.81 [95% CI, 1.11–2.97]). CONCLUSIONS: In this large propensity-matched cohort of very elderly patients undergoing left atrial appendage occlusion, ICE and TEE demonstrated comparable rates of mortality, stroke, and device thrombosis at 90 days and 1 year. ICE was associated with a higher rate of device leak at 1 year, warranting careful procedural technique and follow-up surveillance. Prospective studies are needed to define optimal intraprocedural imaging strategies in this high-risk population.

Background: Rheumatic diseases (RDs) are associated with increased cardiovascular morbidity, including a 40% higher risk of atrial fibrillation (AF). While ablation has become the cornerstone of rhythm control, its safety in patients with rheumatic diseases remains poorly defined. Methods: Adults with a primary admission diagnosis of AF catheter ablation from 2016 to 2022 were identified using the National Inpatient Sample. We excluded patients with other forms of supraventricular tachycardia, pacemaker/defibrillator procedures, and atrioventricular junction ablations. Sociodemographic, clinical characteristics, and outcomes were compared between groups. Multivariate logistic regression adjusted for age, race, sex, and potential comorbid confounders was used to assess for independent associations. Results: A weighted total of 48,855 patients were included, 2.5% of which had RD. These patients were predominantly female, older, and had higher rates of renal dysfunction, hypertension, heart failure, history of stroke, ischemic heart disease, heart failure, and obstructive sleep apnea (all p < 0.001). Patients with RD had higher complication rates (12.9% vs. 8.8%, p < 0.001); specifically, bleeding (p < 0.001), infection (p = 0.008), pericardial (p = 0.003), and respiratory complications (p < 0.001). RDs were not found to be an independent predictor of complications, though there was a trend towards more complications (odds ratio 1.43, 95% confidence interval 0.97–2.11, p = 0.070). Conclusions: Patients with RD undergoing AF ablation were older, female, and had higher rates of comorbidities. This translated to higher unadjusted periprocedural complications in patients with rheumatic diseases. While RDs were not independently associated with adverse outcomes, a trend towards increased complications was observed.

Background/Objectives: Sudden cardiac arrest (SCA) accounts for ~50% of cardiovascular mortality in the U.S. Cardiovascular complications are common in acute and post-acute COVID-19 infection. We aimed to examine nationwide trends in SCA-related hospitalizations in the United States before and during the COVID-19 outbreak. Methods: Using data from the National Inpatient Sample, we conducted a retrospective analysis of hospitalizations for SCA in the U.S. between 2016 and 2020. Sociodemographic and clinical characteristics and in-hospital mortality were compared between the pre-COVID (2016–2019) and COVID (2020) eras. Multivariable analysis was performed to identify factors associated with mortality. Results: Among a weighted total of 153,100 SCA hospitalizations between 2016 and 2020, the median age was 65 years, 62.7% were male, and 66.6% were white. There was a trend towards fewer hospitalizations in 2020 compared to prior years (n = 28,585 vs. n_average = 32,129, p = 0.07). In-hospital mortality remained unchanged between the pre-COVID and COVID eras (47.7% vs. 47.3%, p = 0.66). Increased mortality was associated with female sex (OR: 1.21; 95% CI: 1.15–1.28; p < 0.001), non-white race (OR: 1.24; 95% CI: 1.15–1.28; p < 0.001), history of renal failure (OR: 1.08; 95% CI: 1.02–1.15; p = 0.007), and diabetes (OR: 1.32; 95% CI: 1.25–1.39; p < 0.001). In 2020, 1.5% of the study population was diagnosed with COVID-19 infection, which was found to be independently associated with increased in-hospital mortality (OR: 1.57; 95% CI: 1.27–1.95; p < 0.001). Conclusions: In 2020, there was a trend towards a decrease in hospitalizations for SCA, while COVID-19 infection was independently associated with higher in-hospital mortality among patients admitted with SCA.

Importance Analysis of the National Inpatient Sample (NIS) database for the procedural safety of interventions that are primarily outpatient in nature can be inherently biased due to the selective hospitalization of patients who suffer complications during their outpatient procedures. Objective Using atrial fibrillation (AF) ablation as an example of a procedure typically performed in the outpatient setting, we will test the hypothesis that the population of patients who had their procedure prior to, or on the day of hospital admission (some being outpatient cases, eventually admitted to hospital) will show a significantly higher rate of procedural complications, compared to patients who had a true inpatient ablation, from day 2 of hospital stay and later. Design This study is a retrospective analysis of hospitalizations in the NIS dataset, including patients aged 18 and older, who underwent an AF ablation between 2016-2022. Patients were divided into two groups based on the day of hospitalization on which the ablation was performed – day 1 of admission or prior (group 1), vs. day 2 of admission or later (group 2). Patient baseline characteristics and procedural complication rates were compared. Setting Hospitals that performed AF ablations in the United States between January 1, 2016, and December 31, 2022. Participants A weighted selection of patients aged 18 years and older who underwent an in-patient AF ablation, as identified by the NIS database (N = 47,925). Exposures Catheter ablation for AF. Main Outcome(s) and Measure(s) In-hospital procedural complications, length of stay and mortality Results The analysis included 47,925 weighted hospitalizations in patients that underwent AF ablation. Most patients (n= 33,925, 70.8%) underwent catheter ablation (CA) on the day of admission or the days before (group 1). Group 1 was younger, with fewer octogenarians, 6.9% vs. 10.4% (pConclusions and Relevance Patients undergoing their procedure on the day of admission or prior were younger and had significantly fewer comorbidities, consistent with a population that includes outpatient profile characteristics. Despite the younger and healthier population, these patients suffered from a significantly higher rate of procedural complications. The most plausible explanation to these results is a selection bias, where patients undergoing an outpatient procedure who are at higher risk, or develop complications are admitted as inpatients, thus falsely inflating the complication rate among the patients in the NIS database. The NIS database in its current form, has important limitations when used to assess procedures that are primarily outpatient in nature, requiring careful interpretation of the complication rates arising from such analyses.

Background/Objectives: Atrial fibrillation (AF) and flutter (AFL) are the most common cardiac arrhythmias worldwide. Cardiovascular complications are a common manifestation of acute and post-acute COVID-19 infection. We aimed to analyze the nationwide trends in clinical characteristics and outcomes of patients hospitalized for AF/AFL before and during the COVID-19 outbreak in the U.S. Methods: This study is a retrospective analysis of patients, aged 18 and older, hospitalized for AF/AFL in the U.S. between 2016 and 2020. We drew data from the National Inpatient Sample (NIS) database. Baseline sociodemographic and clinical data, as well as outcomes including stroke, acute coronary syndrome (ACS), and mortality, were analyzed. Multivariable analysis was performed to identify independent associations between the different clinical and demographic characteristics and the composite endpoint of Mortality/ACS/Stroke. Results: An estimated total of 2,163,699 hospitalizations for AF/AFL were identified. The hospitalization volume between 2016 and 2019 was stable, averaging 465,176 a year, followed by a significant drop to 302,995 in 2020. Patients’ median age was 72 years (IQR 62–80), 50.9% were male, and 81.5% were white. The composite endpoint steadily increased from 6.5% in 2016 to 11.8% in 2020 (P_trend < 0.001). In a multivariable regression analysis, age > 75 (OR: 1.35; 95% CI 1.304–1.399, p < 0.001), ischemic heart disease (OR: 1.466; 95% CI: 1.451–1.481; p < 0.001), and chronic kidney disease (OR: 1.635; 95% CI: 1.616–1.653; p < 0.001) were associated with the composite endpoint. COVID-19 was associated with the composite endpoint outcome in the year 2020 (OR: 1.147; 95% CI: 1.037–1.265; p = 0.007). Conclusions: Hospitalization for AF/AFL dropped significantly during the first year of the COVID-19 pandemic outbreak, possibly due to patients’ avoidance of hospital visits. The composite endpoint of Mortality/ACS/Stroke uptrended significantly during the study period. COVID-19 was shown to be independently associated with the adverse composite outcome Mortality/ACS/Stroke.

Background: Routine addition of an atrial lead during an implantable cardioverter‐defibrillator (ICD) implantation for primary prevention of sudden cardiac death, in patients without pacing indications, was not shown beneficial in contemporary studies. We aimed to investigate the use and safety of single‐ versus dual‐chamber ICD implantations in these patients. Methods and Results: Using the National Inpatient Sample database, we identified patients with no pacing indications who underwent primary‐prevention ICD implantation in the United States between 2015 and 2019. Sociodemographic and clinical characteristics, as well as in‐hospital complications, were analyzed. Multivariable logistic regression was used to identify predictors of in‐hospital complications. An estimated total of 15 940 patients, underwent ICD implantation for primary prevention of sudden cardiac death during the study period, 8860 (55.6%) received a dual‐chamber ICD. The mean age was 64 years, and 66% were men. In‐hospital complication rates in the dual‐chamber ICD and single‐chamber ICD group were 12.8% and 10.7%, respectively ( P P P <0.001) in the dual‐chamber ICD group. Multivariable analyses confirmed atrial lead addition as an independent predictor for “any complications” (odds ratio [OR], 1.1 [95% CI, 1.0–1.2]), for pneumo/hemothorax (odds ratio, 1.1 [95% CI, 1.0–1.4]), and for lead dislodgement (odds ratio, 1.3 [95% CI, 1.1–1.6]). Conclusions: Despite lack of evidence for clinical benefit, dual‐chamber ICDs are implanted for primary prevention of sudden cardiac death in a majority of patients who do not have pacing indication. This practice is associated with increased risk of periprocedural complications. Avoidance of routine implantation of atrial leads will likely improve safety outcomes.

Background Information regarding the prevalence and etiologies of complete atrioventricular block (CAVB) in younger patients is scarce. We aimed to investigate the potential causes for non-iatrogenic CAVB, the prevalence of CAVB without an identified etiology, the utilization of guidelines-recommended advanced imaging modalities in adults presenting with an early-onset CAVB of unidentified etiology, as well as to identify the predictors for cardiac implantable electronic device (CIED) insertion. Methods Using the National Inpatient Sample (NIS) database, we identified patients aged 18-60 hospitalized with non-iatrogenic CAVB in the US between 2015 (last quarter)-2019. Baseline demographics, clinical characteristics, potential etiologies for CAVB, advanced imaging utilization as well as outcomes including the need for temporary cardiac pacing (TCP) and CIED implantation were analyzed. Multivariable logistic regression models were used to identify predictors of CIED implantation. Results An estimated total of 14,495 patients aged 18-60 with non-iatrogenic CAVB were identified. The mean age was 51 years, 60% were males and 3,050 (21%) had documentation of a prior conduction disorder. Eleven percent of the patients had a diagnosis of syncope and 6% suffered from a cardiac arrest. Two third of the patients (9,735, 67%) had no identified etiology for CAVB, of whom 8,205 (84%) were implanted with a permanent pacemaker (PPM), 180 patients (2%) with an implantable cardioverter-defibrillator (ICD), and 295 patients (3%) with a cardiac resynchronization therapy device. Only 40 patients (0.3%) underwent advanced imaging during their hospitalization. In multivariate analyses, older age [adjusted OR 1.046 (1.04-1.05), pConclusion The majority of patients, hospitalized in the US for non-iatrogenic early-onset CAVB, had no identified etiology for their conduction disease. Despite the current US and European guidelines recommendation, advanced imaging prior to CIED implantation was under-utilized in this patient population.