bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract 17534: Safety and Feasibility of Adenosine Stress CMR for CAV Detection in Orthotopic Heart Transplant Recipients
Authors: Bisaccia Giandomenico , Licordari Roberto , Leo Isabella , La Vecchia Giulia , Perotto Maria , Procopio Maria Cristina , Gallina Sabina , Wong Joyce , Bucciarelli-Ducci Chiara
Published: December 2023

Background:
Stress perfusion cardiac magnetic resonance (CMR) imaging is recommended in international guidelines in class I in patients with known or suspected CAD. Patients undergoing cardiac transplantation (OHT) are at risk of developing cardiac allograft vasculopathy (CAV). Adenosine is relatively contraindicated after transplantation because of a presumed risk of atrioventricular block in denervated hearts. We sought to evaluate the safety and feasibility of adenosine stress CMR in patients with OHT and suspected CAV.

Methods:
In an outpatient cohort study, we measured the incidence of adverse effects of adenosine stress CMR in consecutive OHT recipients undergoing quantitative stress perfusion CMR for suspected CAV. We additionally stratified patients based on presence of significant CAV (grades 2-3 versus 0-1) on either invasive or computed tomography coronary angiography to evaluate potential CMR biomarkers of significant coronary disease in this population.

Results:
We identified 50 adenosine stress CMR studies performed in 45 individual patients at a median of 19 years after transplantation (IQR 4.7-24.4); 9% of studies were conducted within the first year post-transplantation. No life-threatening adverse events, brief or prolonged atrioventricular block or other arrythmias occurred after adenosine infusion. Significant myocardial ischemia (≥ 1.5 segments) was reported in 17% of patients. When stratified by CAV severity, stress MBF index, but not inducible ischemia on visual inspection, was found to significantly differentiate patients with severe CAV from those without significant coronary disease (ANOVA p = 0.028).

Conclusion:
Adenosine stress perfusion CMR is safe and feasible in OHT recipients. Quantitative measurement of stress MBF index may represent a promising marker of coronary disease with incremental value over qualitative assessment of ischemia, and should be evaluated in future studies.
Abstract 17552: Pre-Existing Right Ventricular Lead Performance After Transcatheter Tricuspid Valve Replacements (TTVR)?
Authors: Ibrahim Rand , bhatia neal , Merchant Faisal M , El-Chami Mikhael F , Lloyd Michael S
Published: December 2023

Introduction:
Transcatheter tricuspid regurgitation (TTVR) is an investigational method for nonsurgical candidates with severe tricuspid regurgitation (TV). Many of these patients possess transvenous right ventricular (RV) leads, which can be a cause for TTVR. Outcomes regarding RV lead viability and functionality after TTVR have varied widely. We sought to describe the outcomes and management of RV leads after TTVR at our institution.

Hypothesis:
We expect transcatheter tricuspid valve replacement to negatively impact the performance of pre-existing right ventricular leads.

Methods:
This was a retrospective observational analysis of patients who received TTVR at our center independent of other clinical trials. Statistical analysis was performed using SPSS BMI Software.

Results:
A total of 30 patients underwent TTVR between 2021 and 2023. Nine patients had CIEDs, including one with SICD and one with transcatheter pacemaker. This resulted in 7 (23%) with an RV lead crossing the TV at the time of TTVR (3 Evoque valves, 5 S3 valves). The RV leads were connected to a pacemaker (PM) in five (71%) patients, an implantable cardiac defibrillator (ICD) in one and a CRT-D in another. On average, the patients underwent TTVR 5 years after cardiac implantable electronic device (CIED) implantation. All patients received RV lead testing at least once after TTVR and they were followed up for a median of 7 months after TTVR. 3 patients underwent pre-emptive lead extraction, which let to four (57%) patients with “jailed” RV leads. 3 of the four patients with jailed leads had lead dysfunction requiring system revision or reprogramming - including elevated lead threshold, clinical evidence of transient loss of capture, and non-jailed atrial lead undersensing post TTVR.

Conclusions:
We report a high incidence of lead malfunction due to RV jailing with TTVR and good outcomes of those undergoing preemptive extraction strategies. Approaches such as leadless systems and coronary sinus systems may be useful in this patient population.
Abstract 17559: Spontaneous Coronary Artery Dissection (SCAD) Under Immune Checkpoint-Inhibitor Therapy
Authors: Spannbauer Andreas , Skoro-Sajer Nika , Dona Carolina , Bartsch Rupert , Lamm Wolfgang , Gyongyosi Mariann , Lang Irene M , Bergler-Klein Jutta K
Published: December 2023

A 49-year-old female patient was admitted with symptoms of septic shock after her 8th cycle of neoadjuvant Carboplatin + Paclitaxel plus her 3rd cycle of Pembrolizumab for triple negative breast cancer in a curative setting. Despite empiric antibiotic therapy and fluid substitution the patient’s status continuously worsened necessitating a brief transfer to an ICU unit with catecholamine support. Levels of NT-proBNP (581pg/mL) and Troponin T (41ng/L) were measured on admission and massively increased to NT-proBNP 8038pg/mL and Troponin T 1044ng/L on the 2nd day. Sinus tachycardia, hypotension and lower extremity edema were apparent as signs of decompensated heart failure. Echocardiography showed moderate pericardial effusion, with preserved LV function and lack of wall motion abnormalities. Immune-checkpoint inhibitor (ICI) induced myocarditis was suspected. An MRI showed subendocardial late gadolinium enhancement (LGE) in the apex and midventricular wall, which was interpreted as either representing ischemic infarction or atypically distributed LGE due to ICI-associated myocarditis. An LVEF of 40%, as well as apical akinesia in the apex and midventricular sections consistent with apical ballooning as in Tako Tsubo syndrome were also observed. Angiography showed lesions consistent with spontaneous coronary artery dissection (SCAD) in the LAD and RCA. No PCI was performed. Over the next 2 weeks NT-proBNP and Troponin T continued to decline until discharge, and the patient stabilized with preserved ejection fraction. To summarize, this is a case of ICI myocarditis with concurrent SCAD and takotsubo-like left ventricular dysfunction.
Abstract 17562: Real-World Evidence for Comparative Effectiveness of Antihypertensive Therapeutic Intensification Strategies: Increasing Dose versus Adding a New Medication
Authors: Martin Ben , Sutherland Susan E , Rakotz Michael , Egan Brent M
Published: December 2023

Background:
Clinical efficacy research indicates a placebo-adjusted 7-11 mmHg reduction in SBP can be expected from adding an antihypertensive (AH) medication class compared to a 2-3 mmHg reduction from doubling the dose of a currently prescribed AH medication. Given the relative dearth of real-world data required for external validity and generalizability, we examined the comparative BP effects of AH class addition vs. dose escalation in electronic health records from adult ambulatory primary care clinics.

Methods:
Analysis was performed with observational data from five distinct health care organizations in 2020-2022. The BP-lowering effect in patients with existing AH medication (n=10,119) was compared for AH intensification (adding a class), versus a dose increase. One-to-one propensity-score (PS) matching was used to decrease the presence of bias and confounding in effect estimation.

Results:
After PS matching on 20 different clinical and demographic variables, 6,826 patients were included in the final model. Simple linear regression found a 1.31 mmHg greater SBP reduction (14.02 vs. 12.71 mmHg, p=0.0052) after adding a new medication compared to increasing dose. To control for regression to the mean, each group was compared to another group with no medication changes, and a 2.96 vs 1.50 mmHg difference was detected. Removing instances of class additions that resulted in known less than additive combinations of AH medications led to a more pronounced difference, with class additions having a 1.93 mmHg greater SBP reduction than dose increases (p=0.00003).

Conclusion:
This study provides quasi-experimental real-world evidence for a greater magnitude of SBP reduction after a new AH class is added than after increasing the dose of existing AH medication, although the magnitude of effect is much less than in efficacy studies. Further research to better understand the nuanced dynamics of dose escalation vs. class addition could improve the AH response to treatment intensification.
Abstract 17566: Prevalence of Lipoprotein(a) Testing Among Patients With CAD: A 10-year Retrospective Analysis at The University of Pennsylvania Health Systems
Authors: Parvathinathan Lakshmi , Risman Marjorie , Alsattari Ahmad , Rader Daniel J , Bajaj Archna
Published: December 2023

Background:
Lipoprotein(a) [Lp(a)] is a genetically driven independent risk factor for ASCVD.

Aims:
To determine the prevalence of Lp(a) testing in patients with CAD across the University of Pennsylvania Health Systems (UPHS) over the last 10 years.

Methods:
Electronic health record (EHR) data from 2012-2021 was queried to examine prevalence of Lp(a) testing in patients who presented with a diagnosis of CAD based on presence of corresponding ICD-9 or ICD-10 codes. Premature CAD was defined as CAD diagnosis in males age < 55 years or females age < 65 years. Race was self-reported.

Results:
Of the 173,966 patients with CAD, 2395 (1.4%) had an Lp(a) test result (mean 72.7 nmol/L), compared to 81,058 (46.6%) patients with at least one LDL-C result in the 10-year time period. About 94% of Lp(a) tests were ordered at outpatient visits, and 56.1% of the tests were ordered by Cardiology, 31.6% by Preventive Cardiology, 5.5% by Internal Medicine, and 1.2% by Neurology. Approximately 1.7% of males with CAD had an Lp(a) result (mean 65.9 nmol/L), 4.2% of males with premature CAD (mean 66.9 nmol/L), 1.6% of females with CAD (mean 84.1 nmol/L), and 3% of females with premature CAD (mean 80.9 nmol/L). The mean Lp(a) in Whites with CAD was 69.1 nmol/L compared to 104.3 nmol/L in Blacks and 54.8 nmol/L in Asians. The proportion of Whites with premature CAD who had an Lp(a) test was 3-fold higher than the proportion of Blacks with premature CAD.

Conclusions:
Although Lp(a) testing has increased over the past decade, it remains widely under-utilized in patients with CAD. Further, there is an apparent gap in the prevalence of testing in Black patients compared to Whites and Asians.
Abstract 17574: A Unique Incident Presentation of Cardiac Involvement in Mitochondrial Myopathy
Authors: Bhatia Unnati , Li Shuo , Demertzis Zachary , Williamson Brian
Published: December 2023

Case:
A 68 year old female with mitochondrial myopathy (MT-TK subset) and no significant cardiac history presented with shortness of breath and palpitations for 1 day. Initial vitals were HR 152, BP 174/102, RR 31, SpO2 83% on RA. Imaging showed pulmonary congestion, EKG showed new onset atrial flutter with RVR, and 2D echo showed a new drop in EF to 15% with global hypokinesis. BNP was elevated (861 pg/ml). Other labs including serial troponins were unremarkable. Patient was started on diuresis, nitroglycerin infusion, and anticoagulation. RVR persisted despite iv metoprolol, digoxin, and esmolol infusion. Cardioversion was planned but TEE revealed a LAA thrombus. Finally on day 3 of hospitalization, patient spontaneously converted to sinus rhythm. Amiodarone was added for rhythm control. Notably, a repeat 2DE showed improvement in EF to 35%, concerning for tachycardia induced cardiomyopathy. GDMT was started and patient was discharged in a stable condition. A month later patient successfully underwent cavotricuspid isthmus ablation and pulmonary vein isolation.

Discussion:
The heart is critically dependent on mitochondrial oxidative phosphorylation and is one of the most frequently affected organs in mitochondrial disorders (MIDs). Cardiac involvement (CI) can be structural (myocardium, coronary arteries, pericardium, aortic root), functional (impulse generation/ conduction, arrhythmias) or both. Since almost half of the cardiac ATP is used to maintain ion channel homeostasis, mitochondria is a key player in arrhythmogenesis. It is crucial to avoid conditions that may create a high metabolic demand (fever, stress) and drugs that may interfere with enzymes involved in mitochondrial metabolism (such as metformin, propofol, valproic acid, erythromycin). Antioxidants and respiratory chain cofactors are commonly used for supportive management, however benefits are inconsistent. Interventions targeted towards definite control, like ablation should be considered early. Additionally, a comprehensive cardiac evaluation is important at diagnosis considering the progressive nature of MIDs. At present, there is no targeted treatment and further studies are needed to explore mitochondria as a potential therapeutic target in arrhythmias.
Abstract 17584: Tricuspid Valve Infective Endocarditis: A Catastrophic Complication of Preterm Rupture of Membranes
Authors: Earthineni Geethika , Ghosh Somshukla , Verma Divya R , Harjai Kishore , Njoh Roland , Reddy Hanumanth K
Published: December 2023

Background:
Few cases of post-partum complication of Group B Streptococcus (GBS) tricuspid valve (TV) infective endocarditis (IE) after live vaginal birth have been reported. We present the same, further complicated by septic emboli tospleen through patent foramen ovale (PFO).

Case:
33-year-old 4 weeks post-partum female (G7P6) in septic shock was diagnosed with GBS TV IE with 41mm X 21mm vegetation(F1) with septic emboli to lungs and spleen. Echocardiogram showed PFO with right to left shunt. Ceftriaxone and Gentamycin were started. Her pregnancy was complicated with preterm premature rupture of membrane (PPROM); she had received no antenatal care. Vegetation was debulked with AngioVac procedure (AVP) while PFO was occluded with trans-septal compliant balloon(F2). After recovery from acute illness TV was replaced with bioprosthetic valve.

Decision-Making:
IE was most likely a post-partum complication in absence of IV drug use, intravascular device, right sided cardiac anomaly. Large size of vegetation with embolization warranted use of AVP to debulk the vegetation as a bridge to valve surgery. PFO occlusion with balloon during AVP prevented potential catastrophic embolization to the brain.

Conclusion:
Mothers colonized with GBS routinely get antibiotics to prevent transmission to the newborn; this case highlights the need for GBS screening and treatment to reduce maternal morbidity as well. Minimally invasive AVP can debulk vegetations thus decreasing infectious burden and risk of septic embolization before surgery.
Abstract 17596: Association of Racial-Ethnic Disparities and Frailty on Adverse Outcomes in Geriatric Patients Undergoing Elective Percutaneous Left Atrial Appendage Closure With Watchman Device
Authors: Patil Shivaraj , Atri Avica , Rojulpote Chaitanya , Tito Sahana , Bhattaru Abhijit , Atri Viha , Khraisha Ola
Published: December 2023

Introduction:
Use of left atrial appendage closure (LAAC) has become more widespread in the geriatric population. Frailty, a geriatric syndrome, is associated with significant morbidity and mortality.

Hypothesis:
Race/Ethnicity influences frailty status and may differentially impact adverse outcomes in elective LAAC procedure.

Methods:
Patients aged ≥65 years who underwent elective LAAC were identified using ICD-10 procedure code 02L73DK from 2016-2018 HCUP-NIS Database. Hospital Frailty Risk Score (HFRS) was calculated for each patient based on 109 ICD-10 diagnosis codes and classified into non-frail (HFRS < 5) and frail (HFRS score ≥ 5) groups. Charlson comorbidity index (CCI) was used to assess comorbidity burden. In-hospital major adverse event (MAE) was defined as the composite of mortality, stroke (ischemic or hemorrhagic) or TIA, bleeding or transfusion, vascular complications, myocardial infarction, systemic embolization, and pericardial effusion or tamponade requiring pericardiocentesis or surgery. Outcome was in-hospital MAE. Multivariate regression analysis was used to assess the association of race/ethnicity and frailty on MAE.

Results:
27,155 patients (Age = 77.3 ± 6.4 years; Female = 42.4%, White: 88%, Black: 3.4%, Hispanic:5.2%, Other: 3.4%) were included. Overall, the prevalence of frailty was 12.5% (White:12.4%, Black: 13.7%, Hispanic: 11.8%, Other: 13%). Overall, in-hospital MAE was 4.7%, with increased rates in frail patients (4% vs.9.6%; p<0.001). Rates of in-hospital MAE were frail-White: 9.3%, frail-Black: 8%, frail-Hispanic:20.6%, and frail-Other: 4.2% (p<0.001). On multivariate analysis, frail-White and frail-Hispanic patients were at increased risk of in-hospital MAE compared to non-frail patients (Figure).

Conclusion:
Further research is needed to highlight disparities by race/ethnicity and to identify potentially modifiable factors to mitigate adverse events in frail geriatric population undergoing LAAC.
Abstract 17600: The 10,000 Women Project: A Deeper Dive Into the Social Determinants of Cardiovascular Health of Black Women
Authors: Ibrahim Rand , Spikes Telisa , Jaskwhich Stacy , Lundberg Gina P
Published: December 2023

Introduction:
Factors influencing the severity of cardiovascular diseases (CVD) in women are not fully understood. Social determinants of health (level of education, income, insurance) play an important role in predicting CVD especially in the Black women community.

Hypothesis:
We hypothesize that having better social determinants of health will predict better behavioral changes after a 6-month follow up from a community screening effort.

Methods:
Between 2015 and 2018, CVD screening and education across the southeastern metropolitan region was provided as “The 10,000 Women Project”. Social determinants of health (insurance, level of education, income), comorbidities, CVD risk factors, activity, and dietary assessment were collected. Behavioral changes were assessed at a 6-month follow-up. Logistic regression analysis was used to assess for associations while adjusting for covariates.

Results:
A total of n=945 Black women were screened, 16% childbearing age (20-40yr). The majority had health insurance (93%) and at least college-level education (88%). The majority (49%) had a household income >$48,000. At least one CVD (HTN, DM, stroke, heart attack) was reported in 45% and smoking was reported in 11%. Only 28% met the AHA exercise recommendation (≥ 30minutes 3x/week) and 42% limited their salt intake. At 6-month follow-up, there was 60% odds of increased exercise (OR=1.6, p=0.034) among those with college-level education or higher. Also, they experienced 70% improvement in diet (1.7, p=0.024), a 60% weight loss (1.6, p=0.047), and 90% increase in regular BP measurement (1.9, p=0.016). Higher household incomes were associated with 50% higher odds of improving exercise (OR=1.5, p=0.008) and dietary habits (OR=1.5, p=0.01). Adjustments were made for age, demographics, CVD risk factors and comorbidities.

Conclusions:
We report greater positive changes in Black women with better baseline social determinants of health after a 6-month follow-up. Systemic changes are needed to address these underlying players of CVD diseases.
Abstract 17611: Acute Ischemic Stroke in Patients With LDL Less Than 70, What Next? Potential Role of TG/HDL Ratio for Treatment Optimization and Risk Stratification
Authors: Romero Garcia Alberto , Patel Pinal , Bhatija Rinku , Elmi Fadima , Alshdifat Esra'A , Wang Kai , Bhaskaran Aditya , GONZALES JEANIE , menon vidya , Shabarek Nehad , Lim Chee Yao
Published: December 2023

Introduction:
There are no established guidelines stratifying risk factors for patients who develop ischemic stroke after goal LDL is achieved. The effect of TG-HDL ratio on cerebrovascular accidents is still being studied. We aim to study the impact of TG-HDL ratio on the outcome of the patients with stroke and LDL less than 70 mg/dl and to determine if it can be used to prognosticate the cardiovascular/cerebrovascular outcome among these patients.

Methods:
This is a single center prospective observational study including patients admitted between January 2021 and March 2023 with stroke and LDL less than 70 mg/dl. Baseline data was collected by chart review. Patients were followed up at 6-month intervals. Logistic regression was used to determine which factors influenced mortality outcomes.

Results:
Among 801 patients admitted for acute stroke during the study period, 153 (22%) had an ischemic event and baseline LDL less than 70. Mean age was 68 SD13 .Total number of patients with TG:HDL ratio >2 was 91 vs 60 patients with ratio <2. The use of statins was comparable in both groups 58% vs 57% respectively. In patients with TG:HDL ratio >2, prevalence of DM was significantly higher than patients with ratio <2 (72% vs 41%). Mean NIHSS among patients with TG:HDL ratio >2 was 6.82 vs 5.95 in patients with ratio <2 (p=0.1). Mortality among patients with ratio >2 was 4.4% vs 17% in patients with ratio <2 (p=0.01) but when logistic regression was performed to control for confounders such as BMI, Age, sex, SBP on admission, statin use and comorbidities including CAD, CHF, A.fib and substance use. Patients with TG/HDL>2 had a higher risk of mortality (OR 7.3 IC95% 1.4-36.5, p=0.015). Total number of patients on follow up at 6 months were 32. Mortality at 6 months follow up was comparable between patient with TG:HDL ratio <2 and >2 (11.1% vs 14.3%, p=0.78).

Conclusions:
There is a potential role for TG-HDL ratio in determining cardio/cerebrovascular outcomes among patients who develop stroke with target LDL of ≤ 70 mgs/dl. Larger studies are needed to evaluate the role of the TG-HDL ratio as a biomarker to optimize risk stratification and improving outcomes in this population.
Abstract 17614: “Watchful Waiting” - Successful Medical Management of an Infected Watchman Device
Authors: Sachdeva Amitoj , Pant Kailash , Agarwal Yogesh K , Mehrotra Amit , Bhardwaj Chetan
Published: December 2023

Description of Case:
A 68-year-old male with a past medical history of alcoholic cirrhosis, ischemic cardiomyopathy, atrial fibrillation, ventricular tachycardia, and sick sinus syndrome presented with exertional dyspnea and lower extremity edema consistent with acutely decompensated systolic heart failure. He had multiple implantable cardiac devices including a watchman device. He was subsequently found to have methicillin-sensitive staphylococcus aureus (MSSA) bacteremia and developed sepsis. A transesophageal echocardiogram (TEE) was done to evaluate for infective endocarditis and a 1 cm mobile echodensity attached to the anterior aspect of the watchman device was found. Given active bacteremia, the echocardiographic appearance was felt to be most likely consistent with a vegetation. Due to significant medical and cardiac comorbidities, device extraction was deemed very high risk and deferred in favor of antibiotic therapy by a multi-disciplinary team. The patient was treated with intravenous cefazolin and oral rifampin. Clinical defervescence and clearance of bacteremia were achieved. A follow-up TEE in 6 weeks showed complete resolution of the watchman device vegetation.

Discussion:
Cardiac implantable devices provide significant morbidity and mortality benefits to patients but incur the potential risk of infection. Watchman device infection, though rare, has been reported. The current guidelines recommend the removal of all hardware in patients with established device infection. However, percutaneous, or surgical extraction of the watchman device bears significant risk and may not be feasible in all patients. Our case demonstrates the potential role of antimicrobial therapy alone with close surveillance in treating high-risk patients with watchman device infection.
Abstract 17622: CCN3 Deficiency in Myeloid Cells Exacerbates Aortic Dissection by Governing a Proinflammatory Program in Macrophages
Authors: Xu Qian , Zhou Xianming , Ferreira Neto Hildebrando C , Lin Zhiyong
Published: December 2023

Introduction:
Aortic dissection (AD) is a fatal disease. Macrophages are known central regulators of aortic inflammation and elastic fiber disruption, two major hallmarks of AD. Cellular communication network factor 3 (CCN3/NOV) is a matricellular protein associated with various biological cellular functions in cardiovascular disease and cancers. Emerging evidence strongly implicates a protective role of CCN3 against several types of vascular pathologies, however its role in AD remains unknown.

Hypothesis:
CCN3 deficiency in myeloid cells promotes AD development in murine models through the modulation of macrophage phenotype.

Aims:
We investigated the causal role of CCN3 loss in AD pathogenesis, focusing on its role in macrophages.

Methods:
3-4-week-old male myeloid-specific CCN3 knockout mice (CCN3F/F;LysMCre) and control mice (LysMCre) were given BAPN (β-aminopropionitrile monofumarate; 0.2%) in their drinking water for 4 weeks for AD modeling. Mouse survival rate and histological changes of the aorta were assessed. Single cell RNA sequencing analysis was performed to recapitulate cellular transcriptome profile changes. Finally, gain and loss of function studies in bone marrow-derived macrophages (BMDMs) were performed to decipher the underlying mechanism by which CCN3 controls macrophage plasticity.

Results:
Following BAPN administration, myeloid-specific CCN3 knockout mice had a higher mortality rate due to AD formation and aortic rupture. In accordance with this phenotype, vascular media thickness was markedly reduced, and elastic fiber fragmentation and macrophage infiltration were elevated in myeloid-specific CCN3 knockout mice. Using single-cell RNA-seq, we found that myeloid-deficiency of CCN3 was associated with a pathogenic pro-inflammatory phenotype of perivascular tissue-resident macrophages, which promoted deleterious aortic wall remodeling at early stages. Furthermore, CCN3 deficient BMDMs are prone to M1 macrophage polarization, an effect dependent on the activation of the JAK/STAT1 signaling pathway.

Conclusions:
Myeloid-deficiency of CCN3 drives vascular macrophages toward an M1-like, pathogenic phenotype and promotes dissecting aortic aneurysm.
Abstract 17626: Apolipoprotein A-IV-Associated Cardiac Amyloidosis: A Classic Presentation of a Rare Condition
Authors: Wopperer Samuel B , Aubry Marie Christine , Grogan Martha , Cullen Michael W
Published: December 2023

Introduction:
A 65-year-old male with type one diabetes mellitus underwent a pancreas and kidney transplant approximately seven years ago and has received chronic tacrolimus. He presented with subacute dyspnea on exertion, orthopnea, and edema. His background also includes ongoing chronic kidney disease stage 3A, orthostatic hypotension, and spinal stenosis. On exam, he had abdominal and lower extremity swelling. An echocardiogram showed preserved LVEF, concentric hypertrophy, hyperrefractile myocardium, reduced longitudinal strain with apical sparing, and a tiny pericardial effusion.

Hypothesis:
His echocardiogram indicated an infiltrative process such as amyloidosis or tacrolimus cardiotoxicity or possibly hypertrophic cardiomyopathy.

Methods:
Free light chains and protein studies with mass-fixation demonstrated no monoclonal gammopathy. PYP scan was negative for transthyretin amyloidosis. A cardiac MRI showed patchy subendocardial and midmyocardial delayed gadolinium enhancement, supporting the clinical suspicion for cardiac amyloidosis. With the need to exclude tacrolimus toxicity as well, subsequent endomyocardial biopsy revealed apolipoprotein A-IV-associated cardiac amyloidosis (Figure 1).

Results:
Apolipoprotein A-IV-associated cardiac amyloidosis occurs in about 0.6% of patients with cardiac amyloid and has classic manifestations of LV outflow obstruction, microvascular disease, and especially renal insufficiency. When these features occur in patients with clinical and imaging findings suggesting cardiac amyloidosis despite negative testing for more common types of amyloidosis, clinicians should proceed with endomyocardial biopsy to evaluate for less common forms.

Conclusions:
We report a rare case of apolipoprotein A-IV-associated cardiac amyloidosis. This case highlights the need for endomyocardial biopsy when clinical suspicion for cardiac amyloidosis persists despite negative testing.
Abstract 17638: Left Atrial Scar Burden Among Patients With Persistent Atrial Fibrillation Undergoing Catheter Ablation and Its Association With Patient Risk Factors and Risk of Recurrence
Authors: Pulaski Matthew , Thorne Christopher , Ling Ian , Varley Allyson , Nauffal Victor , Osorio Jose , Redouane Brahim , Sharma Esseim , Zadeh Andrew , Singleton Matthew J , Zei Paul , Ho Ivan C , Rajendra Anil , Zaman Junaid
Published: December 2023

Introduction:
Left atrial (LA) scar at time of catheter ablation (CA), assessed by bipolar voltage <0.5mV may indicate more advanced AF substrate. It is not known which risk factors are associated with scar burden and whether this is linked to worse clinical outcomes.

Hypothesis:
We hypothesized that patient demographics and comorbidities are associated with greater scar burden at time of CA and predispose to AF recurrence.

Methods:
The Real-AF registry is a prospective, observational, multicenter registry of patients undergoing CA with follow-up at 6 and 12 months. LA scar burden was calculated from CARTO as total % LA area < 0.50mV bipolar using the Pentaray catheter at first CA for persistent AF. We evaluated 1503 patients among this cohort using logistic regression modeling of age, sex, CHA2DS2-VASc and LVEF <= 35%, BMI and their association with LA scar burden categorized as 0 to 5% vs >= 6%. In 783 patients with 12-month clinical outcomes a Kaplan-Meier estimator was used to analyze risk of AF recurrence in these two cohorts.

Results:
Each additional year in age is associated with 1.07 greater odds (p<0.001, 95% CI=1.05, 1.08) of scar area >= 6%. Women had 2.08 greater odds (p<0.001, 95% CI=1.63, 2.65) of abnormal scar area compared to men, while patients with CHF had 1.67 greater odds (p<0.001, 95% CI=1.30, 2.16). Patients with LA scar burden >= 6% experienced significantly higher recurrence of AF compared to those with a lower scar burden (HR=1.8, p=0.0094) including after controlling for operator-specific effects (HR=1.9, p=0.0088), see figure 1.

Conclusions:
In a large multicenter registry of persistent AF patients undergoing CA, LA scar >=6% was associated with female sex, greater age, and CHF. An increased scar burden is associated with worse 12 month clinical outcomes from CA.
Abstract 17641: Frequency of Reported Euglycemic Ketoacidosis With Sodium-Glucose Cotransporter-2 Inhibitors is Not Increased in Patients With Heart Failure: Analysis of US Food and Drug Administration Adverse Event Reporting System (FAERS)
Authors: Yeung Samantha L , Wang Mengxi , Lou Mimi , Ng Tien M
Published: December 2023

Introduction:
Sodium-glucose cotransporter-2 inhibitors (SGLT2i) are first-line therapy for heart failure (HF) but have an associated risk for euglycemic ketoacidosis. Patients with HF exhibit many additional risk factors for euglycemic ketoacidosis. However, no data describes the incidence or risk of euglycemic ketoacidosis in HF.

Hypothesis:
Reported incidence of euglycemic ketoacidosis with empagliflozin and dapagliflozin is not higher in patients with HF compared to the general population.

Methods:
Cases of euglycemic ketoacidosis with empagliflozin and dapagliflozin (single or combination products) were identified in the Food and Drug Administration Adverse Event Reporting System (FAERS) from January 2022 to March 2023. HF was identified as those taking at least two of the listed medication categories (angiotensin converting enzyme inhibitor/angiotensin receptor blocker/angiotensin receptor neprilysin inhibitor, mineralocorticoid receptor antagonist, HF-approved beta blocker) with a loop diuretic or search terms related to cardiac failure from MedDRA. Cases with missing event date, age, gender, and reporter country were removed. Reporting rates of euglycemic ketoacidosis stratified by HF status were examined descriptively.

Results:
Out of 16,880 adverse event reports involving empagliflozin and dapagliflozin, a total of 432 (2.6%) cases of SGLT2 inhibitor-associated euglycemic ketoacidosis were identified (mean age 65±13 years, 55.6% male, and mean weight of 87±27 kg). Patients who developed euglycemic ketoacidosis were younger and of lower mean weight. The incidence of euglycemic ketoacidosis among patients without HF was 2.8% compared to 0.8% in patients with HF [OR 0.27, 95% CI (0.17, 0.44)]. Mortality or need for hospitalization was not increased in patients experiencing euglycemic ketoacidosis for both the HF cohort (mortality: 5.9% vs. 6.7%; hospitalization: 23.5% vs. 31.1%) and general population (mortality: 0.2% vs. 3.6%; hospitalization: 30.1% vs. 27.3%).

Conclusions:
Euglycemic ketoacidosis with empagliflozin and dapagliflozin was uncommon, does not appear to be more frequent in patients with HF compared to the general population, and does not appear to be associated with worse outcomes.
Abstract 17642: Takotsubo Cardiomyopathy After Guillian Barre Syndrome
Authors: Taj Shiza Saher , Ong Kenneth , Ahmed Zahoor
Published: December 2023

Introduction:
Guillian Barre Syndrome (GBS) has the potential to cause acute and long-term cardiac effects. Takotsubo Cardiomyopathy(TCM) is a life-threatening manifestation of dysautonomia in patients with GBS, although infrequently reported in the literature. We present a case of TCM in the setting of GBS.

Case Presentation:
A 54-year-old woman with no past history presented with progressive ascending bilateral lower limb weakness, numbness and paraesthesia following a recent chest infection. On exam, she had reduced motor power and absent deep tendon reflexes. MRI brain was normal. CSF analysis revealed albuminocytologic dissociation(1a). Nerve Conduction Studies(NCS) showed severe sensorimotor polyneuropathy with demyelinating features suggestive of GBS. She was treated with plasmapheresis. The next day, she developed respiratory failure and was hemodynamically unstable with persistent tachycardia and labile blood pressure. ECG showed sinus tachycardia with ST-segment depression(1b). Chest CT was normal. Echocardiogram showed moderate anterolateral hypokinesia with an ejection fraction(EF) of 30%. Coronary angiography showed no significant arterial stenosis, suggesting TCM with a diagnostic TCM score of 59 (1c,1d). She received steroids, furosemide and norepinephrine. Repeat ECG and echocardiogram on day 11 were normal with improved EF (52%).This was followed by a Cardiac MRI which was normal (1e).

Discussion:
The precise etiology of TCM in GBS is unknown and is believed to be related to a complex interplay of autonomic dysfunction, catecholamine release and inflammation. Although rare, TCM is a fatal complication of GBS, warranting urgent evaluation and management. Sudden onset hemodynamic instability and new onset ECG changes may raise the suspicion of TCM in GBS and must be ruled out. Early diagnosis and treatment can improve the patient’s prognosis.
Abstract 17645: Burden, Disparities, and Predictors of Major Adverse Cardiovascular and Cerebrovascular Events in Cancer Patients Hospitalized With COVID-19 in 2020
Authors: Krishnamurthy Shobana , Jitta Sahas Reddy R , Vatsavayi Priyanka , Tera Chenna reddy , Adla Jala Saisree Reddy , Maramreddy Supriya , Pasnoor Diksha Sanjana , Tripuraneni Sridevi , jammula kavya , Farooq Aisha , Dasari Utheja , Reddy Medha , Desai Rupak
Published: December 2023

BACKGROUND:
COVID-19 patients are at higher risk of major adverse cardiovascular and cerebrovascular events (MACCE). The underpinning effect of cancer in COVID-19 enhances this risk. Currently, we have limited nationwide data on MACCE events in cancer patients hospitalized with COVID-19. This study aims to identify demographic and clinical predictors of MACCE in this population.

METHODS:
We identified COVID-19-hospitalized cancer patients using the 2020 National Inpatient Sample. MACCE, inpatient mortality, and baseline demographics and comorbidities were assessed. Predictors of MACCE were calculated using multivariable regression analysis.

RESULTS:
Of 68,755 cancer patients hospitalized with COVID-19, 24% had MACCE, and 20.4% died in the hospital, with both outcomes being more significant among males, Asian or Pacific Islanders, and those in the fourth income quartile (all p<0.05). Comorbidities exhibited statistically significant associations for MACCE (all p<0.05). Higher adjusted odds of MACCE were found in age groups >65 (OR 4.17; 95% CI 2.94-5.91) and 45-64 (OR 1.77; 95% CI 1.26-2.48) than 18-44 years, self-paying patients (OR 2.15) than Medicare, urban non-teaching (OR 1.25) and urban teaching hospitalizations (OR 1.24) than rural, prior MI (OR 1.36; 95% CI 1.11-1.66), CKD (OR 1.37; 95% CI 1.22-1.54), severe sepsis (OR 2.75; 95% CI 2.42-2.13), respiratory failure (OR 2.67; 95% CI 2.41-2.96), and mechanical ventilation (OR 12.15; 95% CI 10.40-14.21). Compared to the Northeast, hospitals in the Midwest, West, and South had lower odds of MACCE. Obesity, tobacco use, hyperlipidemia, and prior chemotherapy also exhibited lower odds of MACCE (all p<0.05) (Table. 1).

CONCLUSION:
Our study using contemporary large-scale data found a concerning burden and higher risk of MACCE, particularly in the elderly, patients with CKD, prior MI, severe sepsis, respiratory failure, and mechanical ventilation.
Abstract 17653: Neighborhood Deprivation and Cardiovascular Health in US Adolescents, National Health and Nutrition Examination Survey 2007-2018
Authors: Baker-Smith Carissa M , Neally Sam , Falkner Bonita E , Akins Robert E , Powell-Wiley Tiffany M
Published: December 2023

Introduction:
AHA “Life’s Essential 8” scores cardiovascular health (CVH) as good, intermediate or poor based on diet, physical activity, sleep, tobacco exposure, cholesterol, blood pressure, blood glucose, and body mass index. CVH of the US population remains suboptimal, and the relationship between neighborhood deprivation and CVH in youth has not been fully explored.

Hypothesis:
We hypothesize that high neighborhood deprivation is associated with intermediate/poor CVH in adolescents.

Methods:
Using 2007-2018 National Health and Nutrition Examination Survey data, we examined the relationship between neighborhood deprivation index (NDI) and CVH status in adolescents. NDI was created from 2010 US Census data and reflects neighborhood level income, housing, education, and poverty status. Higher NDI indicates greater neighborhood deprivation. NDI values were divided into tertiles for analysis. We used proc survey logistic to assess the odds of poor/intermediate CVH status among youth living within high and intermediate compared to low deprivation communities. The model was adjusted for age, sex, ethnicity-race, household reference education and marital status, family poverty, rural vs urban residence and Citizenship status. All analyses were conducted using SAS 9.4,
p<0.05
.

Results:
We evaluated data from 3894 individuals, representative of 57,195,556 US adolescents 13 to 18 years of age. Most adolescents were non-Hispanic white (67%), male (51%), US Citizens (96%), mean age of 15 years, with an even distribution of youth living within low, intermediate and high deprivation neighborhoods (Table 1). We identified 31% greater odds of intermediate/poor CVH status among youth living within the most deprived communities (Table 2).

Conclusions:
Greater NDI associates with worse CVH in US adolescents. Public health initiatives should consider using NDI to tailor efforts in designing intervention strategies to preserve CVH status in US adolescents.
Abstract 17654: Sarpogrelate versus Clopidogrel for Arterial Interventions Systematic Review and Meta Analysis
Authors: Battikh Naim , Sawaf Bisher , Swed Sarya , Nasif Mohamad Nour , Alibrahim Hidar , Bohsas Haidara , Hassan Noheir Ashraf Ibrahem Fathy I , Abouainain Yasmeen , Khair Eldien jabban Yazan , Khan Ubaid , Hafez Wael
Published: December 2023

Background:
Sarpogrelate has been used to alleviate ischemic changes by preventing thrombosis, vasoconstriction, and vascular smoothmuscle proliferation. The worldwide use of Sarpogrelate is arguable due to the lack of reliable data regarding its efficacy and safety.Accordingly, our meta-analysis aims to compare the complications after receiving Sarpogrelate with Aspirin (S&A) vs. Clopidogrel withAspirin (C&A) as part of dual anti-platelet therapy in patients with endovascular intervention.

Methods:
Multiple electronic databases weresearched to identify relevant articles, including MEDLINE, Cochrane CENTRAL, Scopus, Google Scholar, Web of Science, and EMBASE. Allclinical studies that investigated the complication after performing Sarpogrelate versus clopidogrel with Aspirin for arterial interventionswere included in the meta-analysis. Reviews, case reports, conference abstracts, editorials, and animal studies were all excluded. Data wereanalyzed by using comprehensive meta-analysis studies. A complete quality assessment was performed using the Cochrane Risk of Bias toolversion 2 for randomized clinical trials (RCTs).

Results:
A total of 2588 studies were screened, with three studies included. Two multicenterRCTs and one retrospective cohort study including 527 patients (251 S&A and 276 C&A) were included. The overall quality was high in 2studies and fair in one. No statistically significant difference in restenosis, mortality, and bleeding risk as follows, respectively: (RR:0.81, 95%CI:0.52-1.2, P-value:0.36), (RR:0.37, 95% CI:0.06-2, P-value:0.25) and (RR:0.4, 95% CI:0.13-1.19, P-value:0.1).

Conclusion:
The antithromboticeffects of Aspirin with Sarpogrelate after vascular intervention are comparable to those of Aspirin plus Clopidogrel. Further large clinicalstudies are required to identify the actual difference in early and late complications after using Sarpogrelate versus clopidogrel.
Abstract 17666: Impact of Myocardial Fibrosis and Female Sex on Life-Threatening Arrhythmias and Sudden Cardiac Death in MVP Patients: A Prospective CMR Study With Over 2300 Patient-Years of Follow Up
Authors: Darwish Amr , Nguyen Duc , Kitkungvan Danai , El Tallawi Kinan Carlos , Bersali Akila , Saeed Mujtaba , Qamar Fatima , Valderrabano Miguel , Graviss Edward , Shah Dipan J
Published: December 2023

Background:
Mitral valve prolapse (MVP) is a common condition that exhibits a benign course. Conversely, a small subset of patients experiences life-threatening arrhythmias and sudden cardiac death (SCD). Multiple risk factors have been proposed for arrhythmia in MVP; however, few have been validated as independent predictors of hard arrhythmic events on longitudinal follow-up.

Methods:
A prospective cohort of 550 consecutive patients with MVP underwent comprehensive clinical assessment and late gadolinium enhancement (LGE) cardiac magnetic resonance. Patients were longitudinally followed for a composite outcome of SCD, aborted SCD, sustained or symptomatic ventricular tachycardia (VT) requiring implantable cardiac defibrillator (ICD) placement, or ventricular ablation. In a multivariable cox regression analysis, we adjusted for female sex, LGE, MVP leaflet involvement, mitral annular disjunction (MAD), and mitral regurgitation (MR) severity.

Results:
The cohort median age was 62 (IQR 51-71) years, comprising 50% women. Over a mean follow-up of 4.3 years, 44 patients (mean age 62.5 years ±10) met the composite outcome, of which n=33 (75%) were women. Myocardial fibrosis (LGE) was present in 61% of the outcome group (n=27). LGE (HR 3.52 [95%CI, 1.87-6.63],
P
<0.001) and female sex (HR 3.90 [95%CI, 1.92-7.95],
P
<0.001) were associated with worse outcomes in univariate analysis. Kaplan Meier statistics (Figure, A) indicated patients with LGE had a higher 5-year cumulative incidence of arrhythmic composite events than those without LGE (14.8% vs 4.4%,
P
<0.001). On multivariable analysis, female sex and myocardial fibrosis remained independent risk predictors across all models. (Figure, B).

Conclusion:
Female sex and myocardial fibrosis are independent predictors of life-threatening arrhythmic events and SCD in patients with MVP, suggesting that LGE should be an important component of risk stratification, especially in the female MVP population.
Abstract 17670: Double Trouble: Exploring the Rare Coexistence of Right and Left Atrial Thrombus After Left Atrial Appendage Ligation and Maze Procedure
Authors: Chigurupati Himaja Dutt , Waqas Muhammad , Neppala Sivaram , Patel Kinjal , Ahmad Asrar , suleiman Addi , Komer Claudia
Published: December 2023

Introduction:
Left atrial appendage (LAA) harbors around 90% of thrombus in patients with Atrial Fibrillation(AF) related strokes. Incomplete surgical ligation and LAA stump are independent risk factors for stroke and thromboembolism in AF patients. To our knowledge, we report the first case of biatrial thrombus occurring within 1 week of surgery.

Case Presentation:
A 76-year-old man with Paroxysmal AF and three-vessel coronary artery disease presented with 3-week exertional and resting shortness of breath and chest pain. Troponins were negative, and EKG revealed AF. Cardiothoracic surgery planned coronary bypass, MAZE procedure, and LAA clipping. Intra-operative transoesophageal echocardiogram(TEE) showed ejection fraction of 35% without LAA clot. Post-operatively, despite anticoagulation(AC) and beta blocker therapy, AF recurred within a week. Subsequent TEE prior to anticipated cardioversion(CV) revealed thrombus on the superior vena cava border of right atrium, anterolateral wall of left atrium and near the mitral valve annulus. CV was deferred, and he was sent to rehab with AC. We hypothesize that the thrombus may be attributed to a stunned atrium caused by ischemic myocardial injury. Our case underscores the need for heightened suspicion of thrombus in individual cases.

Discussion:
Left atrial appendage occlusion (LAAO) was implemented as stroke prophylaxis strategy in AF during surgical interventions like maze and coronary bypass. while the European Society of Cardiology advises continuing AC after LAAO, studies suggest discontinuing AC in high-risk bleeding patients after successful surgical AF ablation and LAAO if sinus rhythm is maintained for ≥3 months. LAAOS III study shows economic benefit of concomitant surgical LAAO during cardiac surgery in AF patients with CHA2DS2-VASc score ≥2 for stroke prevention. When used alongside AC, it offers incremental benefits. Safety of discontinuing AC after LAAO requires further investigation.