bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract 15534: Pericardial Effusion in People With HIV in the Era of Antiretroviral Therapy
Authors: Inestroza Karla , Hurtado Vanessa , Larson Michaela , Severdija Ryan , Satish Sanjana , Alcaide Maria L , Hurwitz Barry E , Boulanger Catherine , Jayaweera Dushyantha , Powell Alexis , Martinez Claudia
Published: June 2023

Introduction:
Pericardial effusion was previously described as one of the most common forms of cardiovascular involvement in People with HIV (PWH). The presence of pericardial effusion was considered a marker of advanced HIV infection and associated with a low CD4 cell count. This study describes the incidence and association of pericardial disease with HIV-related factors in an era of wider availability of antiretroviral therapy (ART).

Methods:
A retrospective chart review was performed of patients who received HIV care at the University of Miami/Jackson Memorial Hospital between 2017-2019 with an available echocardiogram (n=396). We stratified patients according to the presence (n=51) or absence of pericardial effusion (n=345) and compared demographic, clinical, imaging, and laboratory data. A p-value <0.05 was considered statistically significant.

Results:
We found a prevalence of pericardial effusion in PWH of 4.5%. There was no statistically significant difference in age, gender, or race between groups. PWH with pericardial effusion had higher creatinine (2.1 mg/dL vs. 1.6 mg/dL, p=0.025) and pro-BNP (12,088 pg/mL vs. 6364 pg/mL, p=0.021) levels, were more likely to have chronic kidney disease (43.1% vs. 18%, p<0.001), tricuspid regurgitation (64.6% vs. 44.2%, p=0.009), and mitral regurgitation (60.8% vs. 35.9%, p<0.001) compared to PWH without pericardial effusion. There was no difference in CD4 count, CD8 count, viral load, length on ART, or history of tuberculosis between groups.

Conclusions:
We report a lower prevalence of pericardial effusion in PWH than previous results before the wide availability of ART (around 11%). In PWH with pericardial effusion, we found no association with HIV-related factors or length on ART. In this population, pericardial effusion was associated with comorbidities like chronic kidney disease and valvular abnormalities.
Abstract 15537: Complex Congenital Heart Patients: Education Program for Advanced Practice Providers
Authors: meliones christine D , Houston Raven Z , Ahmed Sheikh S , Numan mohammed T , Salazar Jorge D , Meliones Jon N , Corno Antonio F
Published: June 2023

Introduction:
With appropriate training and support, Advanced Practice Providers (APPs) offer value in specialty patient care in a congenital heart program (CHP) providing continuity, cost effective, and specialized care.

Hypothesis:
We hypothesized that APPs caring for patients in a CHP lack standard curriculum to quantify success and improvement. Developing a dedicated education program allows identification of knowledge gaps and improves focused learning. Integrating a shared model for education with pre/post-tests increases proficiency and professional development.

Methods:
20 APPs were included in our CHP education model including 63 focused learning modules in pediatric cardiology with complex congenital heart disease (CHD) and cardiac intensive care with aspects of post-operative management, multi-disciplinary, APP-specific teaching sessions, APP-led journal clubs, research/QI projects, interactive lectures, visuals, and key articles. Knowledge of the core CHP learning objectives were measured through 514 individual pre/post module tests by utilizing and strategically combining peer reviewed resources in CHD/critical care for each learning module. APPs satisfaction was evaluated using a 5-point scale (outstanding, good, acceptable, fair, unsatisfactory) for core education, faculty support, and translation to clinical practice.

Results:
Increase in knowledge was observed with pre/post test scores of 67.2% and 97.6%, respectively (P<0.0001). Fetal, chest radiography, and cardiac output were identified with lower pre-test scores < 50% allowing refocused education, resulting in post-test scores > 96% (P<0.0001). Core education program, faculty support, and translation to clinical practice were scored as outstanding (n=10, 50%) or good (n=10, 50%).

Conclusions:
In conclusion, our APPs and multi-disciplinary specialists have successfully integrated an education program, improving performance in a rapidly growing department. The success in identifying educational opportunities via pretests and adapting our educational focus has provided an infrastructure to improve patient care and safety. Our efforts and bidirectional feedback have resulted in satisfaction and ideally long-term APPs retention.
Abstract 15542: Immuno-Footprint of Myeloid Clusters in Human Abdominal Aortic Aneurysm
Authors: Silvestro Michele , Rivera Martinez Cristobal , Vlahos John , Pratama Muhammad Yogi , Kumari Puja , Sleiman Tellaoui Rayan , Maldonado Thomas , Ramkhelawon Bhama
Published: June 2023

Inflammation is a hallmark of abdominal aortic aneurysms (AAA) with central roles ascribed to myeloid lineage effector cells. However, the dynamics of circulating immune subsets, their interaction, and direct roles in AAA are not completely understood. Here, in human AAA and control blood, we used unbiased Cellular Indexing of Transcriptomes and Epitopes by Sequencing (CITEseq) to investigate the complex spectrum of the proteome and transcriptome of the immune population, with refined characterization of immune subtypes in the peripheral blood. We also performed matched CITEseq for AAA tissues, allowing to define the fate and immuno-footprint of distinct immune clusters from blood to tissue. Fresh aortic specimens and blood from patients undergoing open AAA repair (n=5) and from healthy donors (n=2) were processed for CITEseq with a panel of antibodies encompassing 15 biologically relevant immune cell surface markers. After alignment, demultiplexing and cell cluster identification, analysis of proteo/transcriptome was performed in peripheral blood and in paired aneurysmal tissue datasets. Unsupervised clustering of CITEseq datasets from peripheral blood revealed eleven distinct clusters, with a unique signature of
FCGR3A
/CD16
+
CD14
/CD14
lo
monocytic populations in AAA patients, showing characteristics of myeloid-derived suppressor cells. Interestingly, we also unveiled that a subset of pro-inflammatory monocytes coerced solidly with activated platelets in monocyte-platelet complexes (MPC). MPC were selectively accrued in the blood of AAA. Pairwise analysis of blood and aortic tissue revealed increased accumulation of
CD14
/CD14
+
but not
FCGR3A
/CD16
+
cells in AAA wall. In murine AAA modeled by angiotensin II infusion in ApoE
-/-
mice, we observed increased MPC in the circulation which correlated with increased inflammation in the aortic tissue. We further demonstrated that monocytes that bind to platelets are derived from the spleen. Splenectomy abrogated the formation of MPC and protected from AAA development in mice, similarly to targeted disruption of MPC. Here we show that interference with unbalanced circulating myeloid subsets and disruption of MPC are novel attractive avenues for therapeutic strategies in AAA.
Abstract 15572: Utility Trends and Outcomes of Fractional Flow Reserve (FFR) in Diagnostic Coronary Angiograms for Patients With Stable Angina: National Readmission Database (2016-2019)
Authors: Ghanem Fares , Alshami Mohammad , Aburumman Huthaifah , Jbara Manar H , Ramu Vijay K , Gajjar Bhavesh , Altibi Ahmed , Mkhaimer Yaman , Alhuneafat Laith , Patel Jeetendra B
Published: June 2023

Background:
In patients with intermediate severity stenosis in a coronary artery, FFR has become the gold standard to measure myocardial ischemia and facilitate the clinical decision regarding the need for revascularization. However, when compared to angiography, it is still underutilized in clinical practice to guide PCI. Our research investigates the difference in outcomes between angiography with versus without the measurement of FFR in real-world data.

Methods:
National readmission databases 2016-2019 were used to identify patients with CAD undergoing coronary angiogram with versus without FFR using ICD-10 codes. We excluded cases who had Acute Coronary Syndrome (ACS), revascularization by PCI or CABG in the index admission or was performed in the last 6 months of each year to allow time for follow-up. Primary outcomes of the study were 6-months ACS admissions, Secondary outcomes include 6-months revascularization by PCI or CABG and mortality. We matched both cohorts using propensity score matching (PSM) and performed logistic regression to compute the odds ratios (ORs) and corresponding 95% confidence intervals (CI).

Results:
Out of 1,039,508 angiography procedures done in the USA, 68,767 (6.6%) cases FFR were used, trends of FFR utilization are noted in figure 1. After propensity score matching, our cohort included 31,469 patients with angiography alone and 31,637 angiography with FFR. At six months of follow-up, there was no significant difference in readmission rates due to ACS, OR 0.84 (95%, 0.69-1.03, P=0.098) or revascularization by PCI/CABG, OR: 1.07 (95% CI, 0.92-1.23, P=0.39). However, there was a significant reduction in mortality in the FFR group compared to the angiography alone group OR 0.81 (95% CI, 0.69-0.94, P<0.01).

Conclusion:
In this nationally representative cohort, our study shows that angiography with FFR is associated with decreased mid-term mortality. In the USA, FFR utilization rate during Angiography remains minuscule (6.6%).
Abstract 15584: Metabolomic Signature of Fontan Circulation
Authors: Shah Ashish H , Ravandi Amir , Aliani Michel
Published: June 2023

Introduction:
Patients born with a range of cardiac defects, not amenable to biventricular repair are palliated with establishment of Fontan circulation. Although majority of patients with Fontan circulation survive childhood, eventually they experience multi-system dysfunction, mainly frailty, impaired exercise capacity, blunted exercise-augmented hemodynamics, progressive liver fibrosis, and shortened survival. Fontan circulation associated biochemical abnormalities have not been well described.

Materials and Methods:
Twenty adult patients with Fontan circulation and 20 age- and sex-matched healthy subjects underwent a non-targeted metabolomics assessment using an LC-QTOF-MS system to detect potential Fontan-related biomarkers. These study participants were also investigated for markers of frailty, cardiopulmonary exercise testing, and resting as well as exercise-augmented hemodynamic evaluation.

Results:
A total of 1679 known plasma metabolites were detected in electrospray positive and negative modes among which 37 metabolites were significantly different (T-Test Unpaired (p<0.05) followed by a multiple testing correction of p values (Benjamini-Hochberg)). These metabolites belonged to several classes of compounds including lipids, bile acids, amino acids, and derivatives. Several bile acids such as chenodeoxycholic acid glycine conjugate, glycoursodeoxycholic acid, and deoxycholic acid glycine conjugate were upregulated in patients with Fontan while 8-hydroxyguanine, N-arachidonoyl glycine, uracil, and cysteine were down-regulated in comparison to healthy subjects.

Conclusion:
In-depth plasma metabolomic analysis demonstrated metabolic pathways activation involved in bile acid formation, markers of oxidative stress, damage of DNA, whereas lower concentrations of several amino acids in patients with Fontan.
Abstract 15590: Smooth Muscle Specific Deletion of P90 Ribosomal S6 Kinase Alters the Vasomotor Response of Resistance Arteries
Authors: Ayon Ramon J , Wang Yves T , Kalra Jaspreet , Chen Yen-Lin , Kuppusamy Maniselvan , Markowska Zaneta , Daneva Zdravka , Sonkusare Swapnil K , Le Thu H , Somlyo Avril V
Published: June 2023

Background:
Smooth muscle (SM) contraction is triggered by Ca
2+
/calmodulin-dependent myosin light chain kinase (MLCK), which phosphorylates the regulatory light chain of myosin (RLC
20
). However, additional regulatory mechanisms exist. We found that global
Rsk2
KO mice had more dilated mesenteric arteries (MAs) with reduced myogenic tone and RLC
20
phosphorylation, and significantly lower blood pressure. Furthermore, RSK2-dependent activation of the Na
+
/H
+
exchanger resulted in an increase in pH
i
and increased Ca
2+
i
transients. However, it is unclear whether our observations were due to developmental abnormalities observed in
Rsk2
global KO mice.

Hypothesis:
RSK2 signaling in SM is a significant regulator of myogenic tone, arterial stiffness, and Ca
2+
signaling.

Methods:
To study the role of RSK2 signaling in vascular tone, we generated inducible SM-specific RSK2 KO mice. Detection of total and phospho proteins were determined by western blot. Pressure myography studies assessed vascular reactivity in 4
th
- and 5
th
-order MAs isolated from MYH11-Cre
+

Rsk2
fl/fl

(RSK2
SM
-/-
) and MYH11-Cre
-

Rsk2
fl/fl

(RSK2
SM
+/+
) mice. We examined SM-specific Ca
2+
events in pressurized MAs by confocal fluorescent microscopy.

Results:
Western blot confirms knock down of RSK2 expression (~70%) in MAs and aorta. Intraluminal pressure-induced constriction of MAs is attenuated in RSK2
SM
-/-
. RSK2
SM
-/-
MAs display a delay in development of myogenic tone at 40 mmHg and decreased vascular stiffness, compared to RSK2
SM
+/+
. Vasodilatory responses to Spermine NONOate (1-100 μM) in preconstricted (L-NNA; 10 μM) RSK2
SM
-/-
vessels were enhanced. RSK2
SM
-/-
MAs display fewer Ca
2+
events (97±19.6; n = 4) than RSK2
SM
+/+
(400±24.5; n = 4) at 80 mmHg (
p
= 0.0001). Additionally, Ca
2+
events are slower and longer-lasting in the RSK2
SM
-/-
. Decreased levels of p-RLC
20
are observed at 40 mmHg, but not 80 mmHg in RSK2
SM
-/-
vs. RSK2
SM
+/+
mice, consistent with impeding tone development.

Conclusion:
RSK2 signaling contributes to myogenic tone and vessel stiffness by regulating sensitivity to NO, increasing Ca
2+
events, and RLC
20
activity. RSK2 signaling pathway is a potential therapeutic target for hypertension.
Abstract 156: Clinical Significance Of Left Ventricular Systolic Dysfunction After Cardiac Arrest
Authors: Beekman Rachel , Kim Noah , Faridi Kamil , Aneni Ehimen , Chang Tiffany E , Arakaki Andrew , Kitlen Eva , Miller Elliott , Khosla Akhil , Wira Charles R , Greer David M , gilmore emily j
Published: June 2023

Introduction:
Post-resuscitative transthoracic echocardiography (TTE) in cardiac arrest survivors has led to increased identification of left ventricular systolic dysfunction (LVSD). We sought to evaluate the association between LVSD and in-hospital outcomes.

Methods:
This is a retrospective review of all cardiac arrest patients with TTE documenting left ventricular systolic function during admission to a single tertiary care center between 2015 and 2020. We used a multivariable logistic regression adjusted for age, sex, race, cardiac arrest location, witnessed arrest, initial rhythm, etiology, and Charlson Comorbidity Index to evaluate the association between LVSD and in-hospital outcomes. LVSD was defined as ejection fraction (EF) < 40% on TTE. Good neurologic outcome was defined as Cerebral Performance Categories 1-2. High vasopressor need was defined as peak norepinephrine-equivalent dose > 1mcg/kg/min within 72 hours of arrest. Use of antiarrhythmic was defined as any dose of amiodarone, esmolol, or lidocaine within 72 hours of arrest.

Results:
Of 477 cardiac arrest patients, 321 (67.3%) met inclusion and were included in the analysis. Mean age was 60.4 ± 16.9 years with most being male (n= 192, 59.8%) and Caucasian (n=203, 63.2%). The majority had out-of-hospital cardiac arrest (n=212, 66%) and presented with a non-shockable rhythm (n=220, 68.5%). LVSD was more common in patients with shockable rhythm (48.5% (n =49) vs 22.6% (n= 49), p<0.001). There was no difference in survival to hospital discharge, good neurologic outcome, or progression to brain death for patients with LVSD compared to those without (OR [95% CI] 1.04 [0.57-1.86], 0.87 [0.46-1.62], and 1.84 [0.70-4.79], respectively). LVSD was associated with increased use of antiarrhythmics (OR 2.85 [1.55-5.26]) and high vasopressor requirement (OR 1.81 [1.08-3.05]).

Conclusion:
LVSD was common in cardiac arrest patients, particularly those with shockable rhythm arrest, and was associated with increased vasopressor or antiarrhythmic use. There was no association between LVSD and survival to hospital discharge, functional neurologic outcome, or progression to brain death.
Abstract 15616: Single Cell Transcriptomic Profiling Identifies Ferroptosis and Oxidative Stress as Potential Drivers of Muscle Dysfunction in Pad
Authors: Tran Lillian , Ferrari Ricardo , Xie Bowen , Assaf Edwyn , Sachdev Ulka
Published: June 2023

Introduction:
Peripheral artery disease (PAD) affects >8 million people nationwide and is disabling. PAD-associated myopathy causes weakness yet is understudied. Unbiased transcriptomic profiling of muscle satellite cells (MuSC) which drive recovery may elucidate the etiology of ischemic myopathic change.

Hypothesis:
MuSC in PAD differentially express injury associated pathways that may be novel targets for intervention to reduce ischemic myopathy.

Methods:
Muscle tissue biopsies were obtained during lower extremity amputation or bypass in PAD/ischemic (N=4; ABI<0.6) and perfused conditions (N=4). CD56+ magnetic assisted cell sorting (MACS)-purified MuSCs were processed for single-cell RNA sequencing using the 10X Genomics platform. Unsupervised clustering and differential gene expression were performed. Western blot (WB) informed by transcriptomics confirmed pathway activation in perfused, ischemic and PAD(-) cells.

Results:
Among 25,298 analyzed ischemic and perfused cells, a unique cluster of MuSC transcriptionally programmed for apoptosis was detected under chronically ischemic PAD but not control conditions. Furthermore, quiescent cells with renewal capacity were lower in MuSC from ischemic muscle (17.8% vs. 26.3%, P =0.03) while pathologic myofibroblasts were almost exclusively seen in PAD (Fig.1A-B). Genes associated with iron metabolism (FTL, FTH), ferroptosis regulation (GSS), oxidative stress (HMOX) and the damage associated molecular pattern (DAMP) HMGB1 were upregulated in ischemic MuSC shown in violin plots (Fig.1C). By WB, CISD1 protein which regulates ferroptosis was elevated in PAD (p <0.03Fig.1C).

Conclusions:
The data implicate oxidative damage and iron-mediated programmed cell death as potential mechanisms driving muscle dysfunction from chronic ischemia. Targeting ferroptosis and oxidative stress represent novel ways to improve outcomes by reducing myopathy in PAD.
Abstract 15657: Risk Based Scheduling for Pediatric Cardiac Catheterization
Authors: Quinn Brian , Ibla Juan , Slater David , Thompson James , Ramirez Jessily , McAleney Paige , Ramsey Madison , Case Alexandria , Liu Haven , Jenkins Kathy J
Published: June 2023

Introduction:
Machine learning techniques can predict operational capacity needs and improve understanding of procedural risk in heterogeneous patient populations. Our goal is to combine machine learning and computer simulation to design scheduling formats for pediatric cardiac catheterization maximizing patient safety and system efficiency.

Methods:
Data for 13,115 pediatric cardiac catheterizations from 2010-19 were used to develop a simulation model including 3 catheterization interventional laboratories. Data on case time, patient and procedural complexity, and adverse events were used to determine statistical distributions on patient, procedure, and system factors for key components of the catheterization lab process. The simulation model was used to evaluate scheduling plans implemented for historical and synthetic populations of patients, comparing both system efficiency and total lab time spent where the system risk of an adverse event is high.

Results:
A simple scheduling heuristic model was developed where one lab worked cases from lowest to highest risk and another lab worked from highest to lowest risk. This scheduling heuristic was applied to all cases in 2018 and compared against the original schedule. Using thresholds of 10% and 20% probability of an adverse event to separate low, medium- and high-risk times. Implementing the sorting schedule resulted in the reduction of minutes spent at high-risk equivalent to 11.57 days per year.

Conclusions:
This study demonstrates that predictive analytics and simulation using simple scheduling heuristics results in reduced time at increased risk. Future work includes improving the fidelity of the model to include specific providers, case cancellations, and other system complexities.
Abstract 15797: Cardiovascular Outcomes of Bariatric Surgery and Anti-Obesity Medications in Patients With New Onset Heart Failure and Obesity
Authors: Mentias Amgad , Desai Milind Y , Aminian Ali , Cho Leslie , Jacob Miriam , Alvarez Paulino , Verma Subodh , Butler Javed , Nissen Steven E , Pandey Ambarish
Published: June 2023

Background:
Intentional weight loss with bariatric surgery is associated with better outcomes in younger patients with prevalent HF. However, temporal trends in use of bariatric surgery and anti-obesity medications (AOM) among older patients with new onset HF and obesity, and their effect on CV outcomes are not well studied.

Methods:
Medicare patients with obesity and new onset HF from 2013 to 2019 were identified using the 100% inpatient files. Patients who underwent bariatric surgery were matched to controls in a 1:2 ratio (matched on age, sex, race, BMI, and HF diagnosis year, and comorbidities). In a random 5% sample with available Part D data, HF patients with obesity who were prescribed AOM (Semaglutide, liraglutide, naltrexone or orlistat) were identified and matched to HF controls as above. Cox models were used to evaluate the association of weight loss therapies (modeled as a time-varying dependent variable) and risk of mortality, atrial fibrillation (AF), and HF readmission rate.

Results:
Overall, 1.5% (2684 of 174,196) patients with new onset HF and BMI ≥35 underwent bariatric surgery (46% men, age 55 y and BMI 52 Kg/m2). Bariatric surgery use increased from 0.3% in 2013 to 1.4% in 2019 (P <0.01). In propensity-matched analyses (surgery N=2144 vs. control N=3920, f/u of 4.2 y), bariatric surgery following incident HF was associated with a significantly lower risk of mortality and new-onset AF (Figure), and a lower rate of HF readmissions (pre- vs. post-surgery rate: 0.9 vs. 0.3/100 person-days). In the subset with Part D data (N=36603), use of AOM was low (3.7%). In propensity-matched analysis, (AOM N=611 vs. controls N=891, f/u of 1.8 y), use of AOM were associated with 30% lower risk of mortality and 35% lower risk of AF compared with controls.

Conclusions:
Bariatric surgery and AOM are associated with favorable CV outcomes among HF patients with obesity. However, their utilization remains extremely low highlighting an important gap in care of HF patients with obesity.
Abstract 15802: Chemogenetic Activation of Intracardiac Cholinergic Ganglia Neurons Reduces the Incidence of Arrhythmias After an Acute Myocardial Infarction
Authors: Alber Bridget R , Dyavanapalli Jhansi R , Gill Aman , Mendelowitz David , Kay Matthew W
Published: June 2023

Intracardiac cholinergic ganglia (ICG) neurons receive excitatory input from vagal pre-ganglionic fibers and are critical for the transmission of parasympathetic drive throughout the heart. During disease, electronic vagal stimulation improves cardiac function and reduces arrhythmias. However, vagal stimulation is not selective for efferent or cholinergic fibers and implanting an electronic device before unanticipated episodes of cardiac infarction is not clinically feasible. We addressed these limitations by testing the hypothesis that chemogenetic ICG activation immediately after an infarction would reduce arrhythmia incidence and improve ventricular function. Floxed DREADDs (AAV2-hSyn-DIOhM3D(Gq)-mcherry) were injected into the pericardial sac of neonatal rats that selectively express Cre recombinase in cholinergic neurons. At 8 weeks, hearts were excised for ex-vivo studies and excitatory hM3Dq DREADDs expressed in ICG cholinergic neurons were activated by clozapine-N-oxide (CNO). Heart rate (HR), LV developed pressure, and overall arrhythmia incidence were measured. In healthy hearts, CNO decreased HR for the duration of the experiment (247 ±10.56 to 189.35± 3.46 beats per minute, p<0.0001, n=5). To study ICG activation after infarction, hearts received CNO or saline after complete ligation of the left anterior descending coronary artery or partial obstruction of the left coronary artery. The ECG was analyzed to assess PR interval and arrhythmia incidence, including non-sustained and sustained VT and fibrillation. ICG activation increased PR interval from 39.13 ± 2.75 to 42.46 ± 3.07 ms (p=0.0097, n=5). ICG activation also reduced arrhythmia incidence after coronary artery ligation from 1.65 to 0.6467 arrhythmias per min (p=0.042, n=5), an outcome that is likely motivated by ICG neuron inhibition of adrenergic activity in addition to vasodilation and increased coronary flow. These studies demonstrate that cardiac cholinergic ICG activation following an MI quickly elevates cardiac parasympathetic drive, protecting against arrhythmias. Future studies will focus on measuring the inhibition of adrenergic activity by chemogenetic activation of cholinergic ICG neurons and local coronary flow increases.
Abstract 15843: Measures for Improving Health Equity in Pediatric Cardiology
Authors: Harmeling Anna , Leonard Michael , Kipps Alaina , Shin Andrew , Palmon Michal , Kameny Rebecca
Published: June 2023

Background:
Health inequity is an acknowledged clinical issue in pediatric cardiology with disparate outcomes for patients of difference races and ethic groups nationwide. Currently, there are no institutional real-time data dashboards to quantify local level inequities and target improvement projects.
Goals
Our aim was to determine metrics to measure patient outcomes and develop a health equity analysis tool to measure impact of future projects.

Methods:
This phase of the project was done in a three-step process. First, providers, administrators, and other stakeholders were surveyed to generate metric ideas. Next, PAC3 and PC4 Arbormetrix databases were utilized to note comparisons across institutions for these metrics. Finally, Lucile Packard Children's Hospital (LPCH) cardiac surgical data from 2017-2022 was used to determine metrics with statistical significance between groups of various demographic factors with standardization by procedure type, STAT category, and cardiopulmonary bypass time analysis.

Results:
Final metrics included postoperative length of stay (LOS), 30-day readmission rate, database discharge mortality, and hospital acquired complications. These were compared across race, ethnicity, Degauss scored socioeconomic status, and insurance type. For the most complex procedures (STAT category 5), LOS was nearly double for Hispanic vs. non-Hispanic patients (63 vs 34 days.) Additionally, Hispanic patients had a two-fold higher rate of 30-day readmission compared to non-Hispanic patients after pulmonary artery unifocalization surgery (8.0% vs. 4.0%) and 1.5-fold higher after VSD surgery (8.3% vs. 5.6%.)

Conclusions:
Utilizing these metrics, LPCH can efficiently note disparities in cardiac care and develop targeted solutions to mitigate them. Higher 30-day readmission rates, for example, may point to issues with health literacy or access. A final dashboard representing these metrics and analysis will be used by LCPH quality and improvement committees. Finally, further research and development will be done with partners at similar healthcare institutions regarding external validation and expansion.
Abstract 15880: Detection of an Acute Pulmonary Embolism in the Home Bed Using Adherence-Independent Home Monitoring
Authors: Torres Barba David , Harrington Nicholas , Agnihotri Parag , King Kevin
Published: June 2023

Acute pulmonary embolism classically presents with dyspnea, tachypnea, and hypoxia, but self-recognition of symptoms and clinical findings is often challenging. This is particularly true in elder patients or those with cognitive impairments. Digital health technologies offer opportunities to remotely detect pre-symptomatic illness. We present a prodrome of an acute pulmonary embolism as it emerges in the home during continuous respiratory monitoring using a non-contact adherence-independent home bed sensor. The patient is an 85-year-old woman who is morbidly obese, has limited mobility, and multiple comorbidities including a recent diagnosis of atrial fibrillation for which she was prescribed anticoagulation but has not yet initiated. As part of an observational study, nocturnal respiratory rates (NRR) were longitudinally monitored in her home bed using a non-contact, adherence-independent bed sensor. Eight days prior to admission, increasing NRR prompted a patient call to family who noted no acute symptomatic changes. During the call it was discovered she had not been started on apixaban. On subsequent days, persistently elevated NRR prompted a second phone call 4 days prior to admission (PTA), where again no acute symptoms were noted. Anticoagulation still had not been started at that time. NRR worsened further on days following the second call prompting a home visit by an RN who found the patient dyspneic, tachypneic in the high 20s, and hypoxic with oxygen saturations in the 80s, prompting a transfer to the emergency department for further evaluation. She was eventually diagnosed with an acute pulmonary embolism. After a week-long hospitalization, the patient was discharged on adequate anticoagulation therapy.This case suggests that adherence-independent home bed monitoring of nocturnal respiratory rate may enable early detection of chronic volume overload and acute pulmonary embolism, potentially facilitating early intervention.
Abstract 15889: Evaluation of a Novel CTA/DSA-Based Deep-Learning Cerebrovascular Segmentation Method for Cavernous Intracranial Aneurysms
Authors: Patel Aakash , Patel Tatsat Rajendra , Veeturi Sanyasi Sricharan , Waqas Muhammad , Monteiro Andre , Baig Ammad , Siddiqui Adnan H , Tutino Vincent M
Published: June 2023

Introduction:
CTA is a mainstay diagnostic imaging modality for screening and follow-up of intracranial aneurysms (IAs). One challenge facing neuroradiologists is detection and visualization of IAs on the cavernous internal carotid artery (ICA), which are often obstructed by bony tissue. Such IAs are either missed diagnosed, or must be re-imaged by high-resolution DSA. We sought to evaluate the performance of automated deep learning methods in segmenting cavernous ICA aneurysms from CTA.

Methods:
In 30 cases, we collected and registered CTA-DSA image pairs to train 2 deep-learning (DL) networks (namely, Brave-Net [BN], and DeepMedic [DM]) for brain vessel segmentation from CTA images of patients with IAs. Segmented DSA was used as the ground truth. Independent testing was performed on a separate cohort of 20 cases to compare network performances. The best-performing network was used for comparison against expert rater assessment in IA detection and segmentation. Quantitative evaluation of expert rater IA segmentation was also performed by comparing IA morphology quantified by parameters, such as size, aspect ratio, neck diameter, and undulation index, against DL predictions.

Results:
In the independent testing dataset, BN significantly outperformed DM in terms of Dice similarity coefficient DSC (0.875±0.0083 vs. 0.864±0.0075, p=0.004), while DM significantly outperformed BN in terms of precision (0.891±0.016 vs. 0.867±0.017, p<0.001). Qualitative assessment confirmed the superiority of DM in segmenting the IAs located on cavernous ICA. Compared to DM, expert raters missed 7 IAs located on cavernous ICA. Furthermore, DM segmentation provided better measurement of neck diameter (p=0.009), aspect ratio (p=0.029) and shape parameters as compared to the expert rater assessment.

Conclusions:
A deep learning approach using DM can provide a high-fidelity solution for CTA segmentation of vessels and IAs in the cavernous ICA region.
Abstract 173: Update And External Validation Of A Prognostic Model To Predict Neurological Outcomes At 90 Days In Out-of-hospital Patients With Cardiac Arrest
Authors: NISHIOKA NORIHIRO , Kiguchi Takeyuki , Kitamura Tetsuhisa , Iwami Taku ,   The CRITICAL Study Group Investigators
Published: June 2023

Introduction:
An accurate assessment of postcardiac syndrome (PCAS) is crucial for achieving good neurological outcomes. Herein, we modified and refitted the existing prognostic model in the updated derivation set and externally validated it.

Methods:
Data used to update the model included those from adult non-traumatic out-of-hospital cardiac arrest (OHCA) patients with return of spontaneous circulation (ROSC) between Jan. 2013 and Dec. 2019 from the CRITICAL study (a multicenter registry in Osaka, Japan). The outcome was the dichotomized 90-day Cerebral Performance Category. The model was updated by logistic regression with the least absolute shrinkage and selection operator regularization. External validation included OHCA patients with ROSC, between Jan. 2013 and Dec. 2019, from the JAAM-OHCA registry (a nationwide multicenter registry in Japan), which geographically differs from the derivation set. The model performance was assessed in the validation set.

Results:
We updated the model in the derivation set (n = 3391). In the validation set (n = 6185), compared to Model A’s (variables with prehospital or pre-ROSC) C-statistics of 0.941 (95% CI: 0.933-0.950), Model B’s (Model A + first in-hospital documented cardiac rhythm) and Model C’s (Model B + laboratory data available immediately post-ROSC) C-statistics increased to 0.948 (0.940-0.956) and 0.959 (0.953-0.965), respectively (Fig. 1). All models were well-calibrated to the observed outcome. Model C produced higher net benefits at all risk thresholds following decision curve analysis (Fig. 2). A web-based calculator can show the probability of a poor outcome (https://pcas-prediction.shinyapps.io/90d_lasso/).

Conclusion:
In the validation set, the updated model showed excellent performance in predicting neurological outcomes at 90 days in patients with postcardiac syndrome. Additional laboratory data can provide better prediction by removing ambiguous predictors from the model.
Abstract 177: Optimal Selection Of Predictors To Enhance Prognostic Performance In Post-resuscitation Care: A Single Center Experience
Authors: Lee Bong kyu , You Yeonho , Park Jung Soo , Min Jin Hong , In Yong Nam , Kang Changshin
Published: June 2023

Objectives:
The aim of this study was to investigate the optimal combinations that would enhance prognostic accuracy in post-resuscitation care after out-of-hospital cardiac arrest (OHCA).

Methods:
Prospectively registry data collected between May 2018 and January 2022 were analyzed. We analyzed the prognostic performance of all single predictors suggested from current guidelines: no ocular reflexes (OR) at 72 h, highly malignant pattern in electroencephalography at ≥ 24 h, neuron-specific enolase (NSE) at 72 h, and diffuse anoxic injury at 72 h on image studies of computed tomography (CT) and diffusion-weighted image (DWI). Gray-to-white matter ratio and high-signal intensity on CT and DWI, respectively, were used as a tool to estimate abnormal findings. We also analyzed the prognostic accuracy of combining strategies using 2 to 3 abnormal results from predictors. All prognostic accuracies were analyzed as sensitivities with false positive ratios (FPR) of < 2%. The primary outcome was poor neurological outcome after 3 months from OHCA.

Results:
We assessed 119 comatose adult survivors of OHCA, of whom 62 (52.1%) had poor neurological outcomes. The highest sensitivity among single prognostic modalities was found in abnormal DWI, with an FPR of < 2% (86.3%, 95% confidence interval [CI] 73.7 - 94.3). In multimodal assessments, combining NSE and DWI (87.8%, 95% CI 75.2 - 95.4) and combining NSE, OR, and DWI (87.8%, 95% CI 75.2 - 95.4) showed the highest sensitivities in dual and triple combining prognostic strategies, respectively. Combining strategies with image study at 72 h, regardless of whether CT or DWI, improved the sensitivities of every non-imaging study modality.

Conclusions:
This study emphasizes that combining prognostic strategies for multimodal assessment can enhance prognostic reliability. In particular, this combining strategy, along with the image study at 72 h, can be valuable to ensure the reliability of prognostication in post-resusciation care.

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Abstract 188: Resuscitative Endovascular Occlusion Of The Aorta (REBOA) As A Mechanical Method For Increasing The Coronary Perfusion Pressure In Non-traumatic Out-of-hospital Cardiac Arrest Patients
Authors: Kim Hee Eun , Park Seung Min , Han Ki Chan
Published: June 2023

Goal:
Resuscitative endovascular balloon occlusion of the aorta (REBOA), originally designed to block blood flow to the distal part of the aorta by placing a balloon in trauma patients, has recently been shown to increase coronary perfusion in cardiac arrest patients. This study evaluated REBOA in increasing the aortic pressure and coronary perfusion pressure (CPP) in non-traumatic out-of-hospital cardiac arrest (OHCA) patients.

Methods:
Adult OHCA patients with cerebral performance category 1 or 2 prior to cardiac arrest, and without evidence of aortic disease, were enrolled from Jan. to Dec. 2021. Aortic pressure and right atrial pressure were measured before and after balloon occlusion. CPP was calculated using the measured aortic and right atrial pressures, and the values before and after the balloon occlusion were compared.

Results:
Fifteen non-traumatic OHCA patients were enrolled in the study. The median call to balloon time was 46.0 (IQR, 38.0-54.5) min. The median CPP before and after balloon occlusion was 13.5 (IQR, 5.8-25.0) and 25.2 (IQR, 12.0-44.6) mmHg, respectively (P=0.001). The median increase in the estimated CPP after balloon occlusion was 86.7%.

Conclusion:
The results of this study suggest that REBOA may increase the CPP during cardiopulmonary resuscitation (CPR) in patients with non-traumatic OHCA.
Abstract 194: The Effect Of Recombinant Erythropoietin On Very Long-term Outcome After Moderate To Severe Traumatic Brain Injury
Authors: Skrifvars Markus B , Luethi Nora , Bailey Michael , French Craig , Nichol Alistair , Trapani Tony , McArthur Colin , Arabi Yaseen , Bendel Stepani , Cooper Jamie , Bellomo Rinaldo
Published: June 2023

Objectives:
Recombinant erythropoietin (EPO) administered during intensive care is one possible treatment method for patients with traumatic brain injury that may increase short-term survival. Its effect on long-term outcome including functional outcome is unknown.

Methods:
We conducted a long-term follow up of patients included in the multi-center erythropoietin in traumatic brain injury (TBI) trial (Clinical Trials.gov NCT00987454) conducted between 2010 and 2014. We invited patients treated in all countries except France to participate in a follow-up and evaluated survival and functional outcome with the Glasgow outcome scale extended (GOSE) with categories 5 to 8 defined as good outcome. We categorized TBI severity with the International Mission for Prognosis and Analysis of Clinical Trials in TBI (IMPACT-TBI) model and calculated adjusted odds ratios (OR) and 95% confidence intervals (CI).

Results:
Of 603 patients included in the original trial, 371 were included in the follow-up at a median of six years from injury (interquartile range 3-8 years). Out of 185 patients treated with EPO, 140 (76%) were alive and 110 (60%) had good outcome. The corresponding numbers for the 180 placebo patients were 136 (73%) and 100 (53%) (p=0.57, p=0.27). A multivariable model adjusting for the IMPACT severity provided comparable results the effect of EPO for survival (OR 1.3 95% CI 0.8-2.2, p=0.31)) and good outcome (OR 1.5 95% 0.9-2.4, p=0.09).

Conclusions:
EPO did not decrease mortality or improve outcome but the limited sample size does not rule out clinically meaningful effects suggesting the need for a larger study.
Abstract 207: Performance Of The Universal Tor Rule For Out-of-hospital Cardiac Arrest Cases Not Witnessed By Ems Providers In The Pan Asian Resuscitation Outcomes Study
Authors: Onoe Atsunori , Kajino Kentaro , Ng Wei Ming , Hidhearu Tanaka , Tagami Takashi , RYU HYUNHO , Lin Chih-Hao , Ong Marcus , Kuwagata Yasuyuki
Published: June 2023

Introduction:
In order to make effective use of limited medical resources in an aging society, ILCOR emphasizes the importance of considering the Termination of Resuscitation (TOR) rule in the prehospital setting. In Europe and the United States, the Universal TOR rule (no prehospital cardiac resumption, no witnessed by EMS, no shock at the scene) is utilized in the field. We used the Pan-Asian Resuscitation Outcomes (PAROS) data to examine cases of out-of-hospital cardiac arrest not witnessed by EMS providers in Singapore, Japan, Korea, and Taiwan. We also examined the validity of Universal TOR rule.

Methods:
This was a retrospective cohort study examining data from January 1, 2009 to June 31, 2018 of the Pan Asian Resuscitation Outcomes Study. We included patients with OHCA who were non-traumatic cardiac arrest and not witnessed by EMS providers. We examined the background of the patients, activities and response times of EMS, and survival outcomes. Then, we calculated the specificity, positive predictive value, etc. of cases that met the Universal TOR rule for poor neurological outcomes (CPC ≥ 3) .

Results:
The breakdown of cases was as follows: Singapore (10,976)/ Japan (117,814)/ Korea (17,926)/ Taiwan (17,063). Of these, Singapore 440 (4.0%)/ Japan 6,845 (5.8%)/ Korea 1,522 (8.5%)/ Taiwan 1,190 (7.0%) were discharged alive, and Singapore 263 (2.4%)/ Japan 3,791 (3.2%)/ Korea 679 (3.8%)/ Taiwan 457 (2.7%) were discharged alive for CPC 1 and 2. For CPC≥3 cases, the specificity of the universal TOR rule was Singapore 0.970/ Japan 0.912/ Korea 0.887/ Taiwan 0.742, and the positive predictive value was Singapore 0.999/ Japan 0.997/ Korea 0.995/ Taiwan 0.992.

Conclusions:
The positive predictive value for poor neurological prognosis at 1 month, among Universal TOR rule-compliant cases in the four countries was more than 99%. However, there were differences in the specificity of poor neurological outcome between countries.
Abstract 218: Sinus Rhythm Predicts Return Of Spontaneous Circulation In Pulseless Electrical Activity
Authors: Tanem Mardal Karianne , Skogvoll Eirik , Loennechen Jan P , Norvik Anders
Published: June 2023

Background:
Pulseless electrical activity (PEA) is a heterogeneous clinical state and increasingly observed during resuscitation from cardiac arrest. The aim of this study was to investigate whether the presence or emergence of sinus rhythm in patients with PEA influenced the likelihood of return of spontaneous circulation (ROSC).

Methods:
Single-lead ECGs were registered during resuscitation from in-hospital cardiac arrests (IHCAs) with PEA. We analyzed evidence of atrial/sinus rhythm as the presence or emergence of P-waves; expressed along the resuscitation timeline as a prevalence (between 0 and 1) during the preceding minute. This information was entered along with QRS-duration as a continuous, time-dependent covariate in an exponential multistate time-to-event model. We employed the software R version 4.1 for the statistical analyses.

Results:
99 episodes of CA from 90 patients were analyzed. We identified 189 segments of PEA without sinus rhythm and 52 segments with sinus rhythm. Almost none had sinus rhythm initially; usually it emerged as a response to resuscitation. Among segments with sinus rhythm, 22 transitioned to ROSC (42 %) while 55 without sinus rhythm transitioned to ROSC (29 %).According to the exponential model, a one-unit increase in the prevalence of sinus rhythm increased the chance of developing ROSC by a factor of 2.5 (95% CI 1.33-4.72).

Conclusion:
The emergence of sinus rhythm during treatment of PEA increases the probability of gaining ROSC. Sinus rhythm seems to be an intermediate stage in the development from PEA to ROSC. Sinus rhythm is easy to identify during cardiac arrest and may serve as a marker of treatment response. Occurrence of PEA with atrial rhythm during CA should encourage continuation of resuscitation.

Figure:
Left column displays rhythms before PEA with SR and right column displays rhythms following PEA with SR.Green: ROSC. Orange: PEA with sinus rhythm. Yellow: PEA. Red: VT/VF. Grey: ASY. Dark grey: Death.
Abstract 233: Chest Compression Release Velocity In Pediatric In Hospital Cardiac Arrest: A Descriptive Study
Authors: Hayes Jennifer E , Rappold Tommy , Duval-Arnould Jordan , Niles Dana , Sutton Robert M , Silver Annemarie E , Berg Marc , Lauridsen Kasper G , Nadkarni Vinay M ,   PediRES-Q Investigators
Published: June 2023

Introduction:
Chest compression release velocity (CCRV) during chest compression (CC) recoil is understudied in pediatrics. Our objective was to characterize CCRV during pediatric in hospital cardiac arrest (IHCA).

Methods:
Using the PediRES-Q multicenter prospective observational cohort from 2015 to 2021, we analyzed patients <18 years who received ≥ 20 minutes of CPR with quantitative CPR metrics (ZOLL R Series) across 30 sites. Median and Interquartile Range (IQR) CCRV, measured by pad integrated accelerometers, was defined as maximum velocity during CC recoil. CCRV was calculated for each CC and compared between 3 age groups. Initial (min 0-3), early (min 5-8), and late (min 15-20) periods of CPR were compared when metrics were available for all stages. Wilcoxon rank sum was used for comparisons.

Results:
Of 308 events with CC metric data and ≥ 20 min duration there were 106 (34%) <1 yo, 114 (37%) 1<8 yo, and 88 (29%) 8<18 yo. Median [IQR] duration was 43 [31, 58] min. Median CCRV for <1 yo: 152 [125, 179] mm/s; 1<8 yo: 213 [177, 261] mm/s; and 8<18 yo: 397 [294, 388] mm/s. Difference in CCRV between age groups was significant (p<0.0001) with CCRV increasing as age increased. 185 events had complete CC metric data during initial (min 0-3), early (min 5-8), and late (min 15-20) periods of CPR. There was no significant difference in CCRV over time: initial 222 [159, 329] mm/sec; early 218 [154, 322] mm/sec; late 219 [163, 321] mm/sec. Similar lack of difference over time was demonstrated between the 3 age groups: <1 yo initial 151 [113, 191] mm/sec; early 149 [119, 191] mm/sec; late 160 [127, 213] mm/sec; 1<8 yo initial 222 [177, 277] mm/sec; early 237 [186, 276] mm/sec; late: 220 [185, 256] mm/sec; and 8<18 yo initial 376 [270, 524] mm/sec; early 395 [277, 441] mm/sec; late 381 [280, 468] mm/sec.

Conclusions:
We characterized CCRV during pediatric IHCA as a metric of CPR performance related to chest recoil. CCRV was significantly slower for <1 yo, faster for 1 to <8 yo, and fastest for 8 to <18 yo. Surprisingly, CCRV was not different over time (initial, early, late CPR periods). These findings suggest differences in CCRV related to patient age but do not demonstrate changes in CCRV over time in the first 20 minutes of CPR.