bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract 11123: Outcomes After Percutaneous Coronary Intervention for Patients With Stable Coronary Disease and Left Ventricular Systolic Dysfunction
Authors: DeVore Adam D , Yow Eric , Krucoff Mitchell W , Shaw Linda K , Chiswell Karen , O’Connor Christopher M , Ohman E. Magnus , Velazquez Eric J
Published: July 2021

Background:
Clinical trial data suggest a modest improvement in outcomes when coronary bypass surgery (CABG) is added to medical therapy for patients with stable coronary artery disease (CAD) and left ventricular systolic dysfunction (LVSD). However, limited data are available to understand the impact of percutaneous coronary interventions (PCI) on mortality for patients with stable CAD and LVSD.

Methods:
We studied 901 patients in the Duke Databank for Cardiovascular Diseases. All patients underwent a coronary angiogram at Duke University for suspected CAD between 1995 and 2012. Patients included in the analysis all had CAD amenable to PCI (>50% stenosis) in at least 1 vessel, reduced LVEF (< 35%), and stable CAD. Patients with CCS class III or IV angina or CABG within 30 days were excluded. Of 901 patients, 259 were treated with PCI and 642 were treated with medical therapy. Propensity scores for PCI, created from 24 different variables (including age, LVEF, comorbid conditions, and medications), were used to assemble a matched cohort of 444 patients (222 pairs) receiving PCI or medical therapy alone. A survival curve was derived using the Kaplan-Meier method and the hazard ratio (HR) for mortality was estimated using Cox regression modeling.

Results:
In the matched cohort, the mean age was 63 years with 321 (72%) males. Three-vessel disease was present in 70 patients (16%). The mean EF was 27% and 153 (35%) reported NYHA Class III/IV symptoms; 392 (88%) were treated with beta-blockers and 378 (85%) with ACE-inhibitors or ARBs. Over 12 years of follow-up, patients in both groups had similar mortality (Figure), HR 0.87 (95% confidence interval 0.68-1.10).

Conclusion:
In this well-profiled, propensity-matched cohort, there was no significant difference in long-term mortality between patients treated with medical therapy alone or with medical therapy plus PCI. More studies are needed to understand the impact of PCI on other outcomes including symptoms and functional status.
Abstract 11133: The Incidence and Predicting Factors of Heart Failure After First Acute Myocardial Infarction: A Population[[Unable to Display Character: ‐]]Based Study in Taiwan
Authors: Lee Cheng-Han , Li Yi-Heng , Cheng Ching-Lan , Chen Jyh-Hong , Kao Yang Yea-Huei
Published: July 2021

Background:
Early coronary revascularization and medical therapy advancement improve the survival of patients (pts) with acute myocardial infarction (AMI). However, survivors of AMI are at heightened risk of developing heart failure (HF) and there is a paucity of information regarding this issue in Asian countries. This study described the temporal trends in the incidence of HF after the first AMI and the predicting factors of HF development in Taiwan.

Methods:
We conducted a nationwide population-based cohort study by using 1999 to 2009 National Health Insurance Research Database. Pts aged≧18 years, with no history of HF, who hospitalized with a first AMI between January 2002 and December 2008 were identified and followed up for one year. The primary outcome was HF. We evaluated the incidence of HF during the index hospitalization, 30 days, 6 months, and one year after the discharge. The predicting factors of HF were identified by Cox proportional hazard model.

Results:
Overall, 42,011 first AMI pts (mean age 64.4 ± 13.8 years; male 75.0%) from 2002 to 2008 were identified. The HF incidence during the index hospitalization was 14.8%. After exclusion of HF during the hospitalization, the overall HF prevalence at 30 days, 6 months, and 1 year was 9.6%, 14.2%, and 16.8%, respectively. The HF prevalence at 1 year declined from 17.9% to 14.9% (p<0.05) from 2002 to 2008. The independent predicting factors of HF after the first AMI were elder age (≧65 years) (adjusted HR 1.81, 95% CI 1.51-2.18), diabetes mellitus (adjusted HR 1.30, 95% CI 1.21-1.41), chronic kidney disease (adjusted HR 1.41, 95% CI 1.20-1.65), use of loop diuretics within 30 days after the discharge (adjusted HR 2.21, 95% CI 2.00-2.43), and recurrent AMI (adjusted HR 2.43, 2.16-2.74).

Conclusions:
Survivors of AMI without prior HF remain at risk of developing HF in Taiwan and most episodes occur within 6 months after AMI. Five important clinical factors of HF were identified that may help us for risk stratification.
Abstract 11148: Effects of Obstructive Sleep Apnea on In-Hospital Mortality in Patients With Myocardial Infarction
Authors: Khoshchehreh Mahdi , Malik Shaista
Published: July 2021

Introduction:
Obstructive sleep apnea (OSA) is a common chronic disorder characterized by repetitive episodes of apnea, resulting in intermittent asphyxia and arousal from sleep. OSA is associated with adverse medical outcomes, including amplified sympathetic activity and fluctuations in blood pressure and heart rate.

Studies have shown higher prevalence and incidence of hypertension among patients with OSA. Patients with OSA had a higher incidence of cardiovascular events included stroke and myocardial infarction (MI). OSA is also linked to higher cardiovascular disease morbidity.

Hypothesis:
This study investigated the impact of OSA on in-hospital mortality in patients with MI.

Methods:
We used the Nationwide Inpatient Sample, a publicly available database of inpatient care. We analyzed the mortality among MI victims with OSA compared to patients without OSA. Ultimately the care of over 840,000 patients with MI was analyzed for the primary endpoints. Analyses were adjusted for demographics, comorbid conditions, and hospital characteristics.

Results:
OSA patients constituted 3.47% of all patients with MI. OSA was more prevalent among patients with NSTEMI, compare to STEMI counterparts (3.84% vs 2.60% respectively). Logistic regression was used to estimate the overall probability of in-hospital death with adjustments for age, sex, race, Elixhauser comorbidities, primary payer, and hospital characteristics including location, teaching status, bed-size, and total admissions. The adjusted odd ratio of in-hospital death was 1.36 (95%CI: 1.17-1.59) and 1.03 (95%CI: 0.97-1.10) for STEMI and NSTEMI respectively. OSA was associated with longer hospital stay for both STEMI and NSTEMI. (Length of stay>3 days OR: 1.85 (95%CI: 1.70-2.01) and 1.44 (95%CI: 1.38-1.49) respectively)

Conclusions:
OSA is associated with higher mortality, and lengthier hospitalization among patients with MI. Targeted interventions may improve outcomes in this group.
Abstract 11174: A Novel Approach to Critical Congenital Heart Disease (CCHD) Screening at Moderate Altitude
Authors: Wright Jason T , Mark Duster , Russell Leilani B , Sontag Marci K , Eller Cindy , Rausch Christopher M
Published: July 2021

Introduction:
Prenatal studies and postnatal physical exam leave 13- 55% of neonates with CCHD undiagnosed leading to presentation in extremis or death. The AHA has endorsed newborn pulse oximetry screening to capture these infants prior to hospital discharge. Moderate altitude can impart higher screening failure rates. We therefore evaluated a modified CCHD screening protocol in an attempt to reduce false positive screenings at a moderate altitude of 6200 feet (1890 m).

Methods:
We prospectively enlisted well newborn infants greater than 35 weeks. Near 24 hours of life, trained nursing staff performed pulse oximetry on the right hand and either foot. Those with saturations ≤95% with
<
3% difference between hand and foot measurements passed. Infants with saturations <86% failed. Infants with saturations between 86-94% or >3% difference in saturations were placed in an oxygen hood with FiO2 designed to replicate sea level atmospheric oxygen tension for 20 minutes to accelerate neonatal transition. These infants were tested again up to 2 additional screens in room air with standard sea level protocol. Providers were notified and echocardiograms ordered for all infants deemed to have failed.

Results:
A total of 2005 infants completed the protocol. The failure rate was 0.3% (7/2005), which was not different from the sea level rate of 0.2%. Sea level CCHD screening criteria would have given a failure rate of 0.75%. An additional 2.1% (42/2005) had incomplete screening and were not passing at the time the test was stopped. We found 5/7 (71.4%) infants failed secondary to low saturations, 1/7 (14.3%) failed secondary differential saturations, and 1 infant failed for multiple reasons. Three of the seven infants with failing screens were discharged prior to echocardiogram. None of the infants receiving echocardiograms had critical congenital heart disease.

Conclusions:
We found a failure rate of 0.3% using an alternate algorithm adjusted for altitude. This failure rate approximates the overall screening failures reported at sea level and is significantly lower than prior reports at altitude. Additional research is needed specifically addressing sensitivity and positive predictive value for screening at moderate altitudes.
Abstract 11215: Exercise Influences Penetrance and Outcomes in Family Members of Arrhythmogenic Right Ventricular Dysplasia/Cardiomyopathy Patients Carrying a Pathogenic Desmosomal Mutation
Authors: Sawant Abhishek C , Murray Brittney , Tichnell Crystal , Bhonsale Aditya , te Riele Anneline S , Tandri Harikrishna , Tedford Ryan J , Judge Daniel P , Calkins Hugh , James Cynthia A
Published: July 2021

Background:
Endurance exercise is associated with adverse arrhythmic outcomes and development of heart failure in arrhythmogenic right ventricular dysplasia/cardiomyopathy (ARVD/C)-associated desmosomal mutation carriers. However studies comparing exercise participation in family members with desmosomal mutations are lacking.

Methods:
Structured exercise interviews were performed focusing on duration, intensity and timing among ten families with 37 patients (9 probands, 28 family members) carrying a pathogenic plakophilin (
PKP2
) mutation. Exercise was classified based on 36
th
Bethesda Conference into endurance/dynamic sports and static sports. Baseline characteristics, non-invasive and invasive clinical data, family history data and occurrence of ventricular tachycardia/appropriate defibrillator intervention (VT/VF) were collected.

Results:
Exercise duration (hours/year) at last follow up was highest among probands. Family members meeting 2010 Task Force Criteria [TFC] had significantly higher exercise duration (Figure 1-A), were more likely to be endurance athletes (77% vs. 33%, p=0.03), and had significantly higher participation in sports with high dynamic component (Median 416[IQR:123-864] vs. 214[IQR:48-408] hours/year; p=0.046) than family members not meeting TFC. Family members who were endurance athletes had worse arrhythmic course (Figure 1-B), were more likely to meet a major or minor 2010 TFC for depolarization/repolarization abnormalities (p=0.05), 2010 TFC for structural abnormalities (p=0.024) and had significantly lower right ventricular ejection fraction (48% vs. 57%; p=0.007).

Conclusion:
Mutation carrier family members of probands who are endurance athletes have increased penetrance, worse arrhythmic outcomes and greater structural changes compared with family members who are not endurance athletes and should be advised to restrict participation in exercise, especially with a high dynamic component.
Abstract 11267: LX4211, a Dual Inhibitor of Sodium-Glucose Cotransporters 1 and 2, Reduces Systolic Blood Pressure in Patients With Type 2 Diabetes Mellitus and Moderate to Severe Renal Impairment
Authors: Lapuerta Pablo , Strumph Paul , Banks Philip , Ogbaa Ikenna , Zambrowicz Brian , Sands Arthur
Published: July 2021

Introduction:
Selective sodium-glucose cotransporter 2 (SGLT2) inhibitors target only the kidney, and they have reduced efficacy when patients with type 2 diabetes mellitus (T2DM) have renal impairment (RI). LX4211 blocks sodium and glucose absorption in the gastrointestinal tract by inhibition of SGLT1, and it enhances urinary sodium and glucose excretion in the urine through inhibition of SGLT2. The dual SGLT1/2 action of LX4211 was anticipated to reduce systolic blood pressure (SBP) in addition to improving glucose control in the setting of RI.

Methods:
This analysis explored the effect of LX4211 on SBP in a clinical trial of patients with T2DM and moderate to severe RI. Patients (N=31) were randomly assigned to be treated with LX4211 (400 mg, N=16) or placebo (N=15) qd for 7 consecutive days. Postprandial glucose levels after a standard high glucose meal served as the primary measure of pharmacodynamic activity. Baseline and Day 8 trough SBP measures were each an average of 3 seated assessments.

Results:
Mean baseline characteristics included age 66.4 years, estimated glomerular filtration rate (eGFR) 43.4 mL/min/1.73 m
2
, and SBP 130.9 mmHg. Postprandial glucose area under the curve (sampled from pre-dose to 4 hours post meal) was reduced from Baseline to Day 7 by 169.3 mg*hr/dL on LX4211 compared to placebo (p=0.003). Day 8 SBP reductions were 11.4 mmHg on LX4211 and 0.0 mmHg on placebo (p=0.045 for difference between groups). Patients with greater RI (eGFR <45 mL/min/1.73 m2) treated with LX4211 (N=6) had a 10.5 mmHg SBP reduction compared to 0.3 mmHg on placebo (N=9). The difference between seated and standing SBP did not change with LX4211 (0.0 mmHg change, Day 8 vs. Baseline). There were no reports of hypotension, hypovolemia, no serious adverse events, and no patient discontinued due to an adverse event. Mild hypoglycemia was reported in 1 LX4211 patient compared to 2 placebo patients.

Conclusions:
LX4211 may reduce SBP and enhance glycemic control in T2DM patients with moderate to severe RI.
Abstract 11392: Chronic Low-Level Transcutaneous Electrical Stimulation of the Auricular Branch of the Vagus Nerve: A New Approach to Attenuate Neural Remodeling and Reduce Ventricular Arrhythmias in a Post-Infarction Canine Model
Authors: Wang Song y , Yu Li L , Lu Zhi B , Wang Zhuo , Huang Bing , Liao Kai , Saren Gao W , Yang Kang , Qu Yuan y , He Bo , He Wen B , Jiang Hong
Published: July 2021

Introduction:
Left stellate ganglion (LSG) and cardiac neural remodeling, which are associated with ventricular arrhythmias (VAs) in post-infarction model, can be attenuated by low-level vagus nerve stimulation. However, whether chronic low-level transcutaneous electrical stimulation at the tragus, where the auricular branch of vagus nerve innervate, can attenuate neural remodeling both in heart and LSG and then reduce VAs is unknown.

Hypothesis:
We hypothesized that chronic low-level tragus stimulation (LL-TS) would attenuate cardiac and LSG nerve remodeling and then reduce inducibility of VAs in a post-infarction model.

Methods:
Twenty beagles after ligating coronary artery were randomly divided into normal control (NC, n=4), MI treated with LL-TS (MI-TS n=8)and MI treated with shame LL-TS (MI-NTS, n=8)groups. LL-TS was performed at 80% below the threshold, at which sinus rate or atrioventricular conduction slowing can be initially induced, for 2 hours a day for 2 months. Left stellate ganglionic nerve activity (SGNA) and left thoracic vagal nerve activity (VNA) was recorded. Slope of ventricular restitution curves (Smax) and programmed ventricular stimulation were performed to evaluate VAs. Nerve sprouting, nerve synaptic density and associated protein expression both in LSG and hearts were evaluated by immunostaining or Western blotting.

Results:
Two months later, the increased SGNA induced by MI was attenuated by LL-TS. However, the increased VNA was strengthened.In the MI-TS group, the number of sympathetic nerves both in peri-infarct zone and LSG were reduced, while the parasympathetic nerve fibers were increased compared to MI-NTS group. Moreover, the expression of synaptophysin, NGF in peri-infarct as well as in LSG in the MI-TS group was significantly lower than the MI-NTS group, while the level of SK2 was much higher.Chronic LL-TS also significantly decreased the Smax, LF/HF ratio and arrhythmia score of programmed ventricular stimulation induced VAs.

Conclusions:
These findings suggested that chronic LL-TS augmented cardiac vagal and reduced sympathetic tone, attenuated cardiac and LSG nerve remodeling, regulated nerve associated protein expression and potentially contributed to reducing vulnerability to VAs.
Abstract 11420: Long-Term Mortality, MACE, and Angina Among Patients With Diabetes and Myocardial Infarction
Authors: Arnold Suzanne V , Spertus John A , McGuire Darren K , Lipska Kasia J , Li Yan , Xu Yaping , Stolker Joshua M , Goyal Abhinav , Kosiborod Mikhail
Published: July 2021

Background:
Patients with diabetes mellitus (DM) are at higher risk for adverse events after MI, including death and recurrent ischemia. As such, we sought to develop prediction models to identify DM patients at highest risk for these outcomes.

Methods:
We examined 3 adverse outcomes (3-year mortality, 1-year angina, 1-year MACE [mortality, MI, stroke, urgent revascularization]) among patients with DM discharged alive after MI from 24 US hospitals. Using Harrell’s backward selection, we developed hierarchical multivariable models with a parsimonious set of covariates for each outcome. The mortality and angina models were validated in a separate 19-site US MI registry.

Results:
Among 1626 DM patients, event rates were 19% for 3-year mortality, 11% for 1-year MACE, and 27% for 1-year angina. The models had good discrimination, with c-indices of 0.80, 0.72, and 0.73, respectively, and excellent calibration. The strongest predictors (in terms of F-value) were age, hemoglobin, and creatinine for mortality; depression, hemoglobin, and history of heart failure for MACE; and angina prior to MI, age, and prior CABG for angina (Table). The observed rates of outcomes in the lowest to highest decile of predicted risk ranged broadly for all 3 outcomes, with ranges of 1-58% for mortality, 1-38% for MACE, and 8-62% for angina. The mortality and angina models performed well in the validation cohort, although they tended to over-predict mortality at higher levels of risk and under-predict angina at lower levels of risk.

Conclusion:
Patients with DM and MI represent a particularly high-risk cohort, with increased mortality, MACE, and angina. However, patients with DM are not a homogenous group, as there is a broad range of risk levels for adverse outcomes within the DM population. We have developed and validated models so as to identify the highest-risk DM patients for whom closer follow-up and secondary prevention strategies can be targeted most aggressively.
Abstract 11455: Mechanism Underlying Increased eNOS Expression and Neuroprotection in Mice With Targeted Deletion of ROCK2
Authors: Hiroi Yukio , Noma Kensuke , Kim Hyung-Hwan , Li Yuxin , Okamoto Ryuji , Sun Jianxin , Michael A. Moskowitz Michael A , Liao James K
Published: July 2021

Background:
The Rho kinases (ROCK1 and ROCK2) are important regulators of the actin cytoskeleton. We have recently shown that ROCK activity is increased during the onset of ischemic stroke and that the ROCK inhibitor, fasudil, decreased the severity of focal cerebral ischemia, in part, through the upregulation of endothelial nitric oxide synthase (eNOS). However, the precise mechanism by which ROCK regulates eNOS expression is unknown.

Methods and Results:
Using RNA affinity chromatography with 3’UTR of eNOS mRNA followed by MALDI-TOF-MS analysis, we have identified eukaryotic elongation factor 1 alpha 1 (eEF1A1) as an actin-binding protein, which directly binds to eNOS mRNA and regulates eNOS mRNA stability. Overexpression of eEF1A1 decreased, and knock-down of eEF1A1 by siRNA increased, eNOS expression. Protein kinase assays using eEF1A1 with purified ROCK1 and ROCK2 showed that eEF1A1 is strongly phosphorylated by ROCK2, but not ROCK1, and that eEF1A1 phosphorylation by ROCK2 is required for binding to and destabilization of eNOS mRNA. Indeed, treatment of human endothelial cells (EC) with fasudil decreased eEF1A1 phosphorylation, but not expression. This was associated with increased eNOS mRNA stability and expression, and NO production. Furthermore, compared to that of WT and ROCK1+/- mice, eNOS mRNA stability and expression were increased in ECs from ROCK2+/- mice and endothelium-dependent relaxation was enhanced in both ROCK2+/- and EC-specific ROCK2 KO mice (EC-ROCK2-/-). These results correlated with decreased cerebral infarct size and neurological deficits in both ROCK2+/- and EC-ROCK2-/- mice subjected to transient focal cerebral ischemia. When ROCK2+/- mice were place on eNOS-/- background (double mutant ROCK2+/-/eNOS-/- mice), the neuroprotective effects observed in ROCK2+/- mice were abolished, indicating that eNOS mediates neuroprotective effects in ROCK2-deficient mice.

Conclusion:
ROCK2 negatively regulates eNOS expression by phosphorylating eEF1A1, which is required for eEF1A1 to bind to eNOS mRNA. The binding of eEF1A1 decreases eNOS mRNA stability and expression. These findings suggest a novel mechanism by which ROCK2 could impair endothelial function and worsen cerebral ischemia.
Abstract 11556: Association of Sleep Disordered Breathing and ECG R-Wave to Radial Artery Pulse Delay: The MESA Study
Authors: Kwon Younghoon , Jacobs David R , Lutsey Pamela L , Hannan Peter , Chirinos Julio A , Brumback Lyndia , Dean Dennis , Redline Susan , Duprez Daniel
Published: July 2021

Background:
Arterial stiffness is a well-recognized predictor of cardiovascular disease (CVD). ECG R-wave to Radial artery pulse delay (RRD) is a novel hemodynamic index in which arterial stiffness is an important component (shorter delay = Higher arterial stiffness) and is obtainable from a single tonometric measurement at the radial artery with simultaneous ECG. Sleep disordered breathing (SDB) has emerged as a risk factor for CVD. The aim of the study was to determine the association of SDB with RRD.

Methods:
Multi-Ethnic Study of Atherosclerosis participants in 2010-2012 without overt CVD who underwent a sleep study, radial artery tonometry and cardiac MRI were eligible for this cross-sectional analysis (N = 1173, Mean [SD] age: 67.8 ± 8.8, Women: 55.4%). Independent associations between SDB indices including apnea hypopnea index (AHI) and oxygen (O2) desaturation index (ODI: events with more than 4% O2 desaturation), and RRD (transit time in msec) were examined. Model was constructed to adjust for isovolumetric contraction time, another component of RRD, by including measures of contractility and preload (left ventricular ejection fraction (LVEF) and left ventricular end diastolic volume (LVEDV) respectively).

Results:
Median [IQR] of AHI and ODI were 7.9/hr [2.9- 18.0] and 7.5/hr [3.0- 17.5] respectively. Adjusting for transit path length, demographic factors, BMI and CVD risk factors, both AHI and ODI were inversely associated with RRD (β= -50.3 msec per SD, p = 0.09 and β= -0.60.2 msec per SD, p = 0.04 respectively). In gender stratified analyses given presence of significant interaction, measures of SDB were predictive of RRD only in men. No significant associations were found with key nocturnal hypoxemia indices including mean O2 saturation (SpO2), percent time with SpO2less than 90 % and minimum SpO2. Men, older age, Asian race, high blood pressure, LVEF and LVEDV were also inversely associated with RRD.

Conclusion:
SDB was associated with shorter RRD implying higher arterial stiffness in men only. These findings suggest the importance of apnea related dynamic change in SpO2 (intermittent hypoxia and reoxygenation) in its potential link to arterial stiffness and also highlights effect modification by gender in the association between the two.
Abstract 11582: Catheter Ablation of Supraventricular Tachycardia in Patients With Total Cavopulmonary Connection
Authors: Toyohara Keiko , Nishimura Tomomi , Shoda Morio , Nakanishi Toshio
Published: July 2021

Introduction:
Management of arrhythmias after the Fontan operation is difficult. Total cavopulmonary connection (TCPC), rather than atriopulmonary connection, is considered the optimal method to minimize the risk of arrhythmias, although they are sometimes still observed after TCPC. Catheter ablation (CA) for supraventricular tachycardia (SVT) is extremely difficult after TCPC because the systemic venous route is excluded from the atria. The purpose of this study was to evaluate the efficacy of CA in treating SVT after TCPC.

Results:
CA was attempted after TCPC in 14 patients aged 8-37 years (median: 23 years). TCPC was performed using the lateral tunnel approach in 5 patients, the intra-atrial conduit procedure in 2, and the extracardiac polytetrafluoroethylene conduit procedure in 7. During CA, the atrium was approached either by a transseptal puncture (12 patients), a fenestration in the patch (1 patient), or suture leakage (1 patient). Transseptal puncture was performed using a conventional Brockenbrough needle in all 12 patients. There were no clinically significant complications and only one unsuccessful puncture. SVT included atrial flutter in 4 patients, atrial tachycardia in 7, atrioventricular reentrant tachycardia (AVRT) via the accessory pathway in 1, and AVRT involving twin atrioventricular nodes in 2. Acute treatment of SVT with CA was achieved in 10 patients (71%), but tachycardia recurred in 3 during follow-up. Deterioration of cyanosis was not observed after transseptal puncture, and closure of the puncture site was confirmed in all 12 patients. Overall, SVT was successfully managed using CA in 7 out of 14 patients (50%), and with medication in the remaining patients.

Conclusions:
SVT may arise after the TCPC procedure. Puncture of the extracardiac conduit is feasible, and CA can be an effective treatment option for refractory SVT after TCPC.
Abstract 11584: Left Atrial Appendage Occlusion for Prevention of Stroke in Non-Valvular Atrial Fibrillation: A Meta-Analysis
Authors: Bode Weeranun D , Patel Nikhil , Gehi Anil K
Published: July 2021

Introduction:
Atrial fibrillation (AF) increases the risk of thromboembolic stroke. When anticoagulation for stroke prevention is contraindicated, left atrial appendage occlusion (LAAO) may be performed. Studies of LAAO have been limited by their small size, disparate patient populations, and lack of control group. To better understand the value of LAAO for prevention of stroke and systemic embolism, we performed a meta-analysis of studies evaluating the efficacy and safety of LAAO in non-valvular AF.

Methods:
A meta-analysis was performed of the safety and efficacy of LAAO in comparison with standard therapy for stroke prevention in non-valvular AF using random-effects modeling. Because only one trial had a control group comparing the efficacy of LAAO to standard therapy (warfarin), large outcomes data of stroke prevention were used to produce a hypothetical control group based on clinical variables in the individual studies (CHADS2 score). Results were stratified according to LAAO device type.

Results:
We identified 16 studies with a total of 1759 patients receiving LAAO. Summary estimates demonstrate LAAO reduced risk of stroke in comparison with no therapy or aspirin therapy (RR 0.34, 95% CI 0.25-0.46) and in comparison with warfarin therapy (RR 0.65, 95% CI 0.46-0.91, Figure). Summary estimates differed based on the study used to derive the hypothetical control group. Device deployment was unsuccessful in 6.1% of patients and overall complication rate was 7.1%. Efficacy and safety were similar across LAAO device type (Watchman, Plaato, Amplatzer cardiac plug, and Lariat). There was no significant heterogeneity between studies using the Cochrane Q statistic or the I2 index.

Conclusions:
Our data suggest that LAAO is a reasonable alternative to anticoagulation therapy. Data was limited with the use of most available devices. To better establish the risk and benefit of LAAO in comparison with standard therapy, more randomized controlled trials are necessary.
Abstract 11602: Impact of Pre-Operative Type-B Natriuretic Peptide Level on Survival After Aortic Valve Replacement for Aortic Stenosis
Authors: Clavel Marie-Annick , Tribouilloy Christophe , Malouf Joseph , Michelena Hector I , Suri Rakesh M , Rusinaru Dan , Jaffe Allan S , Enriquez-Sarano Maurice
Published: July 2021

Introduction:
Levels of type-B natriuretic peptide (BNP) adjusted for age and sex are a powerful predictor of mortality after the diagnosis of aortic stenosis (AS).

Objective:
To assess whether BNP activation (compared to normal values) affects mortality after aortic valve replacement (AVR).

Methods:
In 494 patients with AS, plasma level of BNP was measured pre-operatively at the time of Doppler-Echocardiography. BNP was normalized as BNPratio (BNP measured/BNP maximum normal value for age and sex) to evaluate the impact of BNP activation on post-operative outcomes.

Results:
Mean age was73±11 years and 300 (61%) patients were male. Mean aortic valve area was 0.82±0.20cm2, mean gradient 51±16mmHg, and mean Left Ventricular Ejection Fraction 59±15%. Incidence of hypertension was 65%, diabetes 27% and chronic kidney disease 22%. Median of BNP was 211 (interquartile: 87-508) and BNPratio 2.2 (1.0-5.2). After adjustment age, gender, body surface area, Charlson score index, presence of symptoms, creatinine, hemoglobin, systolic blood pressure, indexed aortic valve area and left ventricular ejection fraction, the BNPratio (log transformed) was a predictor of long-term mortality (p<0.0001) with an hazard ratio 1.34 (1.14-1.60). Moreover, stratification by BNPratio showed increasing long-term post-operative mortality with BNPratios>2 (Figure).

Conclusions:
BNP activation defined using BNPratios (normalized for age and sex) is a powerful independent predictor of long-term mortality after aortic valve replacement for AS. Furthermore, patients with a BNPratio>2 before aortic valve replacement incur excess mortality during follow-up in relation to the increasing BNPratio. These data support the use of the BNPratio to guide the timing of AVR.
Abstract 11658: Riser Pattern is Associated With Mild Cognitive Impairment in Heart Failure Patients
Authors: Komori Takahiro , Eguchi Kazuo , Saito Toshinobu , Nishimura Yoshioki , Hoshide Satoshi , Kario Kazuomi
Published: July 2021

Introduction:
The riser pattern, an abnormal blood pressure (BP) pattern in which sleep BP exceeds awake BP, is a predictor of adverse cardiovascular outcomes. Although the riser pattern is associated with various factors, its significance in heart failure (HF) patients has not been established. HF patients often suffer from cognitive impairment (CI), but the relationship between the riser pattern and CI is not clearly understood.

Hypothesis:
We tested the hypothesis that the riser pattern is associated with mild CI, a form of brain damage that could develop to dementia.

Methods:
We performed the Mini-Mental State Examination (MMSE), ambulatory BP monitoring, echocardiography, and blood tests in 444 HF patients just before they left the hospital. Mild CI, a measure of cognitive function, was defined as a score <26.

Results:
The mean age of the patients was 68±13 years; 61.5% were male; and 22.5% exhibited a riser pattern. The MMSE score was significantly lower in the Riser group than in the Non-riser group (23±5 vs 25±5, p<0.01). In multivariable logistic regression analysis, a riser pattern was significantly associated with mild CI (odds ratio 2.07, 95% confidence intervals 1.19-3.61, p<0.01) after adjusting for significant covariates.

Conclusions:
A riser pattern was associated with mild CI in HF patients. An abnormal circadian BP rhythm in HF patients is clinically significant as a potential indicator of subclinical brain damage.
Abstract 11685: Early Myocardial Gene Expression Profiling After Deep Hypothermic Circulatory Arrest Reveals Ontogenetic Adaptive Mechanisms Underlying Ischemia-Reperfusion Tolerance in the Swine
Authors: Yamada Miki , Sheikh Amir , Collins Kevin , Frederiksen James , Quick George , Lodge Andrew , Podgoreanu Mihai
Published: July 2021

Previous studies suggest that immature hearts are more tolerant to ischemia than adult myocardium; whether differences exist during ontogenic development in severity of global myocardial ischemia/reperfusion (I/R) injury associated with cardiac surgery remains unknown. We employed swine models of deep hypothermic circulatory arrest (DHCA) to test the hypothesis that early differential regulation of cardioprotective genes is associated with increased tolerance of neonatal myocardium to surgical I/R.

Male neonatal and adult pigs were randomized to DHCA or sham (N=5-14/group). DHCA animals underwent cardiopulmonary bypass (18°C), DHCA 60 min, and were recovered for 3h. Severity of perioperative myocardial injury was determined biochemically (Troponin I) and echocardiographically. Transcript levels were quantified in left ventricular myocardium using Affymetrix Porcine Genome arrays, followed by differential expression and pathway analysis.

A 2-fold increase in severity of perioperative myocardial injury was found in adult pigs (Fig.A). Of 596 transcripts differentially expressed in neonates (≥1.5-fold change, DHCA vs. sham, FDR<0.05), 53 were shared with adults (Fig.B). Among them, divergent expression patterns were found for oxysterol binding protein-like 6 (down-regulated in adults up-regulated in neonates) and bromodomain adjacent to zinc finger domain 2B (up-regulated in adults - down-regulated in neonates). Top transcripts uniquely upregulated in neonates but unchanged in adults were the apoptosis inhibitor baculoviral IAP repeat containing 2, and signal transducer and activator of transcription 3. mTOR signaling and p53 signaling were the top canonical pathways deregulated in adults and neonates, respectively.

A high resistance to surgical I/R injury in neonatal vs adult swine heart is correlated with robust differences in early transcriptional programs, suggesting the involvement of fundamental adaptive ontogenetic processes.
Abstract 11758: The Heart Team: Myth Vs. Reality
Authors: Geller Charles M , Bergmann Steven R , Tranbaugh Robert F
Published: July 2021

INTRODUCTION:
The management of patients with complex CAD has led to the development of a heart team strategy involving shared decision making by a multidisciplinary team. Both the 2010 ESC/EACTS Guidelines and the 2012 AHA/ACC Criteria consider a heart team evaluation to be a class 1 indication to determine the treatment of patients with LM and/or 3VD prior to PCI. This study assessed our single institution’s compliance with this strategy.

METHODS:
Since July, 2012 patients with LM and/or 3VD or multi-vessel restenosis following prior PCI were recommended to have a multidisciplinary heart team discussion prior to any treatment. From November 1, 2012 through April 30, 2014 the results and therapeutic outcomes of all diagnostic cardiac catheterizations were analyzed. The total number of patients meeting criteria for a heart team evaluation, those actually having such a discussion and the subsequent treatment pathways were assessed.

RESULTS:
During the 18 month study period, 5740 patients underwent diagnostic cardiac catheterization. Of these, 522 patients met criteria for a heart team evaluation. A total of 266 patients (51%) were discussed by the heart team prior to treatment. Of this group, 153 patients received CABG (58%), 101 patients received PCI (38%), and 12 patients received medical management (5%). A total of 256 patients (49%) were not submitted for evaluation by the heart team. Of this group, 3 patients received CABG (1%), 227 received PCI (89%) and 26 received medical management (10%). The total PCI:CABG ratio for all patients was 17:1 and the total PCI:CABG ratio for those 522 patients with LM and/or 3VD was 3:1. Of this group, for those undergoing a heart team evaluation, the PCI:CABG ratio was 0.7:1 and without an evaluation the PCI: CABG ratio was 76:1 (p<0.001).

CONCLUSIONS:
Despite established guidelines and a clinician consensus regarding the management strategy for complex CAD, half of eligible patients were not prospectively assessed by the heart team. When an evaluation was performed, the PCI:CABG ratio shifted from 76:1 to 0.7:1. Only through a collaborative process can optimal patient care be achieved.
Abstract 11769: Impact of Exercise to the Heterogeneity of Regional Left Ventricular Mechanics
Authors: Tsutsui Rayji S , Kusunose Kenya , Thomas James D , Popovic Zoran B
Published: July 2021

Background:
The segmental heterogeneity of strain and strain rate in speckle tracking echocardiography are pitfalls in the assessment of left ventricular (LV) mechanics in subjects without LV wall motion abnormality. We aimed to assess the segmental heterogeneity of strain and strain rate at rest and during exercise in healthy subjects.

Methods:
Twenty-three healthy young volunteers (38 ± 10 years, 13 female) underwent supine bicycle stress testing. Segmental circumferential (Scirc), radial (Srad) and longitudinal (Slong) end-systolic strains and corresponding peak systolic strain rates (SRcirc, SRrad, SRlong) were obtained by STE (EchoPac, GE Medical) for each of 16 LV segments at rest and during exercise. Global values of strain and strain rate components were obtained by averaging segmental values.

Results:
At rest, all three end-systolic strains showed significant segmental heterogeneity (p < 0.01 for all comparisons). In contrast, peak systolic SRcirc and SRrad had uniform values throughout segments, while SRlong had modest segmental heterogeneity (p = 0.02). During exercise, heart rate (67 ± 10 to 136 ± 19 bpm), systolic blood pressure (124 ± 13 to 170 ± 21mmHg), and biplane ejection fraction (58 ± 4 to 72 ± 5 %), increased significantly (p < 0.001 for all comparisons). At peak exercise, there was a small, but significant increase in global Slong (-19.9 to -23.9%, p < 0.001) and Scirc (-19.6 to -24.2%, p < 0.001) without the change in Srad (46.8 to 41.1%, p > 0.05). On the other hand, all global systolic strain rates almost doubled during exercise; SRcirc from -1.26 to -2.49 s
-1
, p < 0.0001; SRrad from 1.82 to 3.26 s
-1
, p < 0.0001; SRlong from -1.56 to -2.93 s
-1
, p < 0.0001. Importantly, segmental heterogeneity following exercise was not present for all strain and strain rate components (p > 0.05 for all comparisons).

Conclusions:
Segmental heterogeneity was less pronounced in peak systolic strain rates than in end-systolic strains at rest. Exercise abolished segmental heterogeneity for all strain and strain rate components. Overall, peak systolic strain rate is least affected by segmental heterogeneity and may be more useful in the assessment of LV mechanics than end-systolic strain.
Abstract 11771: Both Semi-Quantitative and Quantitative Assessment of Positron Emission Tomography Strongly Predicts Outcomes in Patients Being Evaluated for Cardiac Sarcoidosis
Authors: Bazylevska Vladyslava , Feringa Herman H , Venkata Samala , Russell Raymond R , Jacoby Daniel , Bellumkonda Lavanya
Published: July 2021

Background:
18F-FDG positron emission tomography (PET) along with 82Rubidium radiotracer imaging is a non-invasive semi-quantitative technique that aids in the diagnosis of cardiac sarcoidosis. More recently, quantitative analysis using standardized uptake values (SUV) has shown that higher SUV indicates greater degree of active inflammation. This study evaluated the prognostic value of positive PET results on clinical outcome and assessed SUV in relation to PET interpretation and its prognostic value.

Methods:
We retrospectively analyzed 83 patients with proven or suspected cardiac sarcoidosis, referred for PET imaging between 2009-2013. Baseline characteristics and follow-up events were obtained by medical chart review. Outcomes included death, SCD, heart transplant, drop in EF (>10%), new VT, and ICD discharge. Automated software was used to obtain pixel-based counts from which SUV was calculated.

Results:
During follow-up, composite endpoints occurred in 23 patients (28%). In multivariate analysis, semi-quantitative assessment of abnormal myocardial FDG uptake was a significant predictor of adverse clinical outcome (HR=3.01, 95% CI=1.06-8.59). This association remained significant in subgroup analysis of Japanese Ministry of Health and Welfare Criteria (JMHC) negative patients (HR=6.96, 95% CI=1.18-40.9). In quantitative assessment, SUV heterogeneity as expressed by the absolute difference in maximum and minimum myocardial SUV value of >0.56 most accurately represented abnormal myocardial FDG uptake (ROC area under the curve 0.82). This was also an independent significant predictor of adverse outcome (HR=3.77, 95% CI=1.15-12.4).

Conclusions:
Patients with abnormal FDG uptake are 3 times more likely to have adverse outcomes. Abnormal FDG uptake remains a very strong predictor of outcomes in those with negative JMHC. A difference between maximal and minimal SUV of >0.56 g/ml most accurately represents abnormal FDG uptake by semi-quantitative assessment and also predicts adverse outcome. Both semi-quantitative and quantitative assessment of myocardial FDG uptake can be important to clinicians to identify those patients at highest risk for adverse events.
Abstract 11787: Traumatic Acute Myocardial Infarction Following Blunt Chest Trauma
Authors: naderi nazila , Dao Timothy , Eng Marvin
Published: July 2021

Coronary artery dissection is a rare complication following blunt chest trauma, accounting for <2% of blunt cardiac injuries. The diagnosis is frequently missed likely due to intervening concomitant injuries or sudden death. We report a case of motorcycle collision causing multiple injuries including blunt chest trauma associated with new inferior injury pattern on ECG in 43-year-old previously healthy man. Initially the patient was hypertensive and tachycardic. Electrocardiogram showed inferior ST elevation, bedside echocardiogram revealed distal apical and inferoapical hypokinesis with normal ejection fraction without pericardial effusion. Given the mechanism of injury, CT angiography and TEE first excluded the initial working diagnosis of aortic dissection. Urgent angiography showed a distal dissection of a wrap around LAD. Attempted revascularization was unsuccessful due to the inability to find the true lumen. Concomitant multiple fractures, lung contusion and a small mediastinal hematoma prevented anticoagulation therapy and conservative management ensued. Follow-up echocardiogram confirmed a sustained infarction with distal anterior and apical akinesis but preserved ejection fraction. No arrhythmia or recurrent ischemia noted during hospital admission, however he was chosen to manage conservatively for his wrist fracture due to recent infarction. This case report underscores need for a high index of suspicion for cardiac injury and the need to maintain a broad differential following chest trauma. Additionally, presence of an injury pattern should prompt confirmatory angiography to differentiate coronary injury from cardiac contusion as they have different long-term outcome.
Abstract 11790: Echocardiography is Able to Detect Morphological and Functional Changes of the Right Heart in Sport Scuba Divers
Authors: Pudil Radek , Horakova Lucie , Rozloznik Miroslav , Balestra Constantino
Published: July 2021

Introduction:
Scuba diving represents stressful event for cardiovascular system. Breathing with compressed air, hyperbaric environment and microbubbles formation are the main factors are the most influencing factors for pulmonary circulation.

Hypothesis:
The aim of the study was to evaluate the change in morphology and function of the right heart after scuba dive with compressed air.

Methods:
Ten healthy sport divers (2 woman, 8 men, average age 42.1 ± 4.1 yrs., 21-52yrs) performed one scuba dive with compressed air (the depth was 20 meters, bottom tine 20 minutes, one safety stop at 3 m, water temperature 15°C). Echocardiography was performed just before and immediately after the dive, and every 60 minutes after surfacing with the aim to evaluate the presence of microbubbles (iVivid, GE).

Results:
After the dive, left atrium, right ventricle and inferior vena cava diameters significantly decreased (LA: 30.4±2.1 vs. 27.1±1.2 mm, p<0.05; RV: 27.8±2.1 vs. 25.2±1.1mm, p<0.05; IVC: 19.3±1.1 vs. 17.6±0.9 mm, p<0.05). LV ejection fraction, fractional shortening and myocardial performance index remained unchanged (LVEF: 65.7±7.1 vs. 62.2±10, p ns; FS: 40.9±6.1 vs.38.9±9.9, p ns; LV MPI: 0.50±0.15 vs. 0.48±0.14, p ns). We found significant decrease in mitral E/A (E/A 1.37±0.18 vs. 1.19±0.15 m/s, p<0.05). Right ventricle functional parameters decreased (TAPSE: 29.9±2.1 vs. 26.1±2.2 mm, p<0.05; RV MPI: 0.58±0.18 vs. 0.43±0.16mm, p<0.05). Analysis of the pulsed tissue Doppler velocities of the tricuspid annulus showed significant decrease in S’ parameter (S’lat 16.1±1.1 vs. 13.9±2.3, p<0.05). In 8 divers (80%), microbubbles were detected in right heart. They were detectable in pulmonary circulation for 3 hours. Due to this fact, the Doppler estimates of pulmonary artery pressure were not possible.

Conclusions:
Scuba dive with compressed air is associated with decrease of the both ventricle and atria diameters. It is associated with the decreased diastolic LV function and global RV function. These changes can be associated with the presence of microbubbles in lung circulation. This study showed echocardiography is able to detect changes of the circulation which are associated with the recreational dive.
Abstract 11802: Coronary Artery Calcification is the Strongest Predictor of Abnormal Duke Prognostic Coronary Artery Disease Index
Authors: Shah Aman M , Kelesidis Iosif , Hasan Naeema , Torrens Ainhoa , Fuster Valentin , Falk Erling , Muntendam Pieter , Sillesen Henrik , Boxt Lawrence , Wang Dan , Negassa Abdissa , Garcia Mario
Published: July 2021

Background:
Cardiac CT angiography (CCTA) is a useful non-invasive tool to assess coronary artery disease (CAD). The CCTA derived modified Duke prognostic CAD index (MDS) has been shown to predict coronary events in symptomatic patients. No prior study has investigated MDS in asymptomatic patients or the relationship of conventional biomarkers of CAD with MDS.

Objective:
We sought to determine the ability of clinical, serologic, and imaging biomarkers of CAD to predict abnormal MDS in asymptomatic patients.

Methods:
There were 374 asymptomatic patients in the High Risk Plaque Study who were evaluated by clinical, serologic, and imaging biomarkers of CAD that underwent CCTA. MDS was calculated from CCTA using a 16-segment convention for coronary tree (high MDS defined as ≥3). The association of MDS with clinical, serologic, and imaging biomarkers was assessed.

Results:
There were 58 patients identified with high MDS. These patients had lower HDL-C (44 v. 53, p<0.001) and higher CACS (899 v. 26, p<0.001), Framingham risk score (17.5 v. 11, p<0.001), carotid intima-media thickness (0.82 v. 0.74, p=0.001), and triglycerides (150 v. 136, p = 0.011). In multivariate analysis, only CACS≥400 (OR = 15.3, 95% CI: 7.4-31.5, p<0.001) and CACS overall (OR = 6.02, 95% CI: 3.58 - 10.09, p<0.001) independently predicted MDS. Receiver operating characteristic curve analysis revealed improved prediction of MDS with addition of CACS: from AUC = 0.7531 to 0.8951.

Conclusion:
In asymptomatic patients, CACS is the strongest independent predictor of MDS when compared to conventional biomarkers of CAD.