bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract 15805: Elevated Lp(a) and Risk of Repeat Coronary Revascularization and Cardiovascular Events Among Patients With Prior CABG
Authors: Abdelrahman Khaled , Berman Adam , Besser Stephanie , Shiyovich Arthur , Biery David W , Oliver Walter , Hainer Jon , Laychak Shelby , Huck Daniel M , weber Brittany , Di Carli Marcelo F , Cannon Christopher P , Bhatt Deepak L , Blankstein Ron
Published: December 2023

Introduction:
Elevated Lp(a) is associated with atherosclerotic, thrombotic, and proinflammatory effects. In patients with prior coronary artery bypass grafting (CABG), graft failure and progression of native CAD are associated with adverse outcomes. We sought to evaluate the relationship between Lp(a) and adverse cardiovascular events in patients with prior CABG.

Methods:
We included all patients with prior CABG from a large, contemporary Lp(a) registry. Cox proportional hazard models were used to estimate the association between repeat coronary revascularization (CR) - defined as percutaneous coronary intervention (PCI) or repeat CABG - as well as incident MI or CV death, stratified by tertiles of Lp(a).

Results:
Among the 16,419 individuals in the cohort, 878 (5.3%) patients (23.4% women, median age 66) had CABG prior to their Lp(a) test date. Among those with prior CABG, 81.7% had hypertension, 87.9% had hyperlipidemia, and 42.1% had diabetes. Patients with prior CABG had higher Lp(a) levels (46.3 nmol/L [IQR 15.8-148]) than with those without prior CABG (35 nmol/L [IQR 13-111.7]). Over a median follow-up of 11.2 years, patients in the highest Lp(a) tertile [>= 95 nmol/L] were more likely to undergo repeat CR (HR 1.86 (95% CI, 1.18-2.94), p=0.008) with PCI (n=83), repeat CABG (n=5), or both CABG and PCI (n=12). This association persisted when adjusted for age, sex, race, diabetes, and hypertension (HR 1.67 (95% CI,1.05-2.67). Additionally, patients in the highest Lp(a) tertile were more likely to experience CV death or MI (HR 1.56 (95% CI, 1.17-2.08); this increased risk persisted in adjusted analyses (HR 1.59 (95% CI,1.19-2.14) (see
Figure 1
).

Conclusions:
Among patients with prior CABG, elevated Lp(a) is associated with a higher risk of repeat coronary revascularization and adverse CV events. Future studies should focus on the potential role of Lp(a) lowering therapies for maintaining graft patency and reducing CV events.
Abstract 15831: Characterization of Patient-Specific Care Pathways in Cardiogenic Shock
Authors: Saha Amit , Beaini Hadi , Godfrey Sarah , Hall Eric J , Truby Lauren K , Hendren Nicholas S , Thibodeau Jennifer T , Hardin Elizabeth A , Araj Faris G , Hall Hurst M , Grodin Justin L , Drazner Mark H , Farr Maryjane A
Published: December 2023

Background:
Heterogeneity in patient characteristics and clinical severity may affect treatment goals and associated management in cardiogenic shock (CS). We sought to better describe the development over time of specific care pathways and the associated patient phenotypes informing such decisions in CS.

Methods:
We consented and prospectively enrolled 60 patients presenting with CS from November 2022 to May 2023. Provider notes were reviewed for language describing 3 distinct care pathways: Advanced Group (AG): urgent evaluation for left ventricular assist device and/or heart transplantation; Recovery Group (RG): eligible for native myocardial recovery only; and Palliation Group (PG): unlikely to recover. Remaining patients were classified as No Decision (ND). Pathway decisions were assessed at days 3 and 7.

Results:
Median cohort age was 59 years (IQR 42-66), and 67% (n = 40) were men. Initial SCAI stages D and E comprised 63% (n = 38) of cases. By hospital days 3 and 7, care pathways were defined in 11 (18%) and 36 (60%) patients, respectively (
Figure
). There were no ND deaths before day 7. Patient characteristics were similar regardless of whether a pathway was specified by day 7. Across care pathways, recovery options decreased with increased age (AG 45, RG 53, PG 66 years; p = 0.037) and new dialysis requirement (AG 0%, RG 36% [n = 5], PG 56% [n = 5]; p = 0.007). Initial SCAI stage, CS etiology (AMI 20% [n = 12], HF 58% [n = 35]), rate of shock team activation (15% [n = 9]), and mechanical circulatory support use (43% [n = 26]) were numerically similar. Palliative care was involved in 78% (n = 47) of cases overall and in all PG cases. In-hospital mortality was 29% (n = 16) and was highest in PG (88.9% [n = 8], p <0.0001).

Conclusion:
Even after 7 days in an intensive care unit at an academic medical center, 40% of patients with CS did not have a care pathway defined. These data suggest that structured interventions to expedite such decision-making should be tested to improve care in patients with CS.
Abstract 15835: Inhibition of Soluble Epoxide Hydrolase Reduces Cognitive Impairment and Improves Cerebral Hemodynamics in AD/ADRD
Authors: Tang Chengyun , Zhang Huawei , Border Jane J , Hammock Bruce D , Roman Richard J , Fan Fan
Published: December 2023

Alzheimer's Disease and Alzheimer's Disease-Related Dementias (AD/ADRD) is an emerging global healthcare crisis. However, underlying mechanisms have not been understood well enough to translate into precision medicine. Recent human genetic evidence indicated that soluble hydrolase (sEH) is linked to AD/ADRD. Inhibition of sEH has been reported to improve cognition in AD mice due to its anti-inflammatory and neuronal protective effects. Here, we examined whether inhibition of sEH with TPPU could reduce cognitive impairments by improving cerebral hemodynamics in 18-month-old diabetes (DM)-related ADRD rats and 6 months of TgF344-AD rats. The myogenic responses of the middle cerebral artery (MCA) were impaired in both AD and ADRD rats and were normalized with TPPU. The inner diameters of MCA increased by 49.16 ± 17.02 % in DM rats but decreased by 16.06 ± 2.46% and 11.24 ± 0.05% in age-matched control and TPPU-treated DM rats when pressure was elevated from 40 to 180 mmHg. Similarly, TPPU-treated AD rats significantly enhanced the MCA constriction by 25%. Forced dilatation occurred at pressures > 140 mmHg in MCAs in both rats and was rescued with TPPU treatment. Endothelial denuded MCAs from TPPU-treated DM rats constricted to 75.15 ± 4.25 % at a perfusion pressure of 140 mmHg and further constricted to 74.66 ± 4.01 % at 180 mmHg, compared to dilation of 155.48 ± 17.35 % and 172.78 ± 13.36 % in DM rats at the same pressures. The percentage of time spent with the novel object was 43.32 ± 8.04% and 83.23 ± 8.70% in DM and TPPU-treated DM rats, versus 75.68 ± 3.33% in non-DM rats. Impaired learning and short and long-term memory function examined with an 8-arm water maze in both DM and AD rats were rescued with TPPU treatment. These results provide the first evidence demonstrating that inhibition of sEH reverses cerebrovascular dysfunction and cognitive impairments in AD/ADRD.
Abstract 15843: Biatrial and Recurrent Cardiac Myxoma in a Rare Case of Carney Complex
Authors: Saha Bibek , Danielson Alex P , Kalinoski-Dubose Victoria R , Klarich Kyle W , Chareonthaitawee Panithaya
Published: December 2023

Primary cardiac tumors (CTs) are exceptionally rare, and are predominantly benign masses. Myxomas make up more than 60% of these lesions and most frequently develop in the left atrium (LA), followed by the right atrium (RA). Carney complex (CNC) is a rare, typically autosomal dominant, multiple endocrine neoplasia characterized by cutaneous findings, myxomas, endocrine and/or nonendocrine neoplasms. We report a rare case of CNC involving biatrial and recurrent myxomas.

A 36-year-old female presented to Cardiology Clinic at our center for management of CNC. Three years prior, she was evaluated at a local hospital for acute stroke where TTE showed a myxoma (2 x 2 x 2.5cm) attached to the left atrial septum, prompting resection. On followup TTE 2 years later, she had a mass in the LA, prolapsing through the mitral valve into the left ventricle. She underwent resection of the myxoma (2.9 x 3.9 cm) and left atrial appendage, which was complicated by recurrent stroke. She was found to have a PRKAR1A gene mutation (c.97 deletion) suggestive of CNC and was referred to our center. At Cardiology Clinic, she denied chest pain, dyspnea, presyncope, and syncope. Her father and children did not have the gene mutation. Exam revealed lentigines on her lower lip and pigmentation of an inner canthus. She was diagnosed with primary pigmented nodular adrenal disease by Endocrinology. On TEE, she was found to have a recurrent LA mass (1 x 1 x 0.8 cm) attached to the interatrial septum, but no right-to-left atrial shunt. This prompted surgery consultation. Numerous intracardiac myxomas were removed during surgery; one in the LA attached to the septum, 3-4 smaller ones, and one 2 cm myxoma located in the RA. The interatrial septum was also resected given recurrent myxoma in this region. She underwent cryoablation to prevent recurrence and did well post-surgery.

CTs, which includes primary CTs and secondary metastatic disease, are uncommon where the former has an incidence of 0.001-0.3%. We presented a case of recurrent and biatrial cardiac myxomas in the setting of CNC, which is seldomly reported in the literature. Taken together, given the rarity of primary CTs, genetic predispositions or syndromes should be considered especially in the setting of recurrence and/or multiple masses.
Abstract 15859: Cardiopulmonary Exercise Function in Methamphetamine-Associated Heart Failure
Authors: Xiao Sophia Y , Cedarbaum Emily R , Li Danny , WU YUANER , Wang Teresa , Durstenfeld Matthew S , Hsue Priscilla
Published: December 2023

Introduction:
The role of methamphetamine (meth) cessation in the functional recovery of methamphetamine-associated HF (meth-HF) is unknown.

Objective
To evaluate the role of active meth use on cardiopulmonary function in participants with meth-HF.

Methods:
We recruited participants from a longitudinal cohort study of meth-HF and used cardiopulmonary exercise testing (CPET) with maximal effort upright cycle ergometer to assess exercise cardiorespiratory function. Descriptive analysis was used to study associations between cardiopulmonary function and 1) active use and 2) ejection fraction (EF) recovery.

Results:
Of those assessed for eligibility (n = 55), 11 were deceased and 30 could not be contacted/declined participation. Ten studies were completed of the 14 scheduled, with three no-shows and one termination due to pre-test PVCs. Of those who completed studies, 90% were male, median age was 52 years [40, 54] and duration of HF was 33 months [16, 58]. Five were active users, and five had a recovered EF. All were on quad-guideline-directed medical therapy (GDMT) for a median duration of 15 months [9.1, 29]. Baseline EF was 28% [21, 42], and EF closest to CPET date was 50% [42, 59]. Peak VO
2
(% predicted) in prior vs. active use was 73 [66, 75] and 60 [48, 66]; in persistently low vs. recovered EF, it was 75 [66, 75] and 63 [60, 66] (
Figure 1A
). Adjusted heart rate reserve (aHRR, %) in prior vs. active use was 42 [37, 43] and 46 [44, 58]; in persistently low vs. recovered EF, it was 58 [44, 62] and 37 [35, 43] (
Figure 1B
). In prior vs. active use, VO
2
pulse (VO
2
/HR, mL/beat) was 16 [15, 17] and 13 [12, 15]. One participant died of sudden cardiac death between CPET and time of analysis.

Conclusions:
To our knowledge, this is the first study looking at cardiorespiratory fitness in the setting of meth use and HF. Our preliminary findings suggest that peak VO
2
and aHRR remain low, which suggests the presence of persistent cardiac effects of meth use despite cessation of use and/or recovery of EF.
Abstract 15881: Progression of Significant Functional Mitral Regurgitation in Medically Managed High Surgical Risk Patients
Authors: Al Ghadban Zeina S , Alajmi Hasan , Elganainy Mohamed , Abudaqa Loai , Alenezi Fawaz
Published: December 2023

Background:
Functional mitral valve regurgitation (FMR) remains a clinical challenge in patients with high operative risk. Medical therapy alone in FMR is associated with poor outcomes but data regarding MR and left ventricular (LV) systolic function changes over time are limited.

Objective:
Study the progression of MR severity and LV function in medically managed MR patients with high surgical risk who survived at least 6 months.

Methods:
Between Jan 1st, 2000 and Aug 31st, 2010, we identified patients with medically managed moderate to severe MR that fulfilled the EVEREST II High Risk Registry (HRR) criteria. All patients were selected based on optimal propensity matching and were required to have a follow up echocardiogram >6 months from the index study. Demographic, clinical and echocardiographic data was compared between baseline and follow up. Paired measurements of global longitudinal strain (GLS) were obtained in a subset of patients with suitable image quality.

Results:
159 patients (mean age 73.5, female 45%) fulfilled the study criteria. 130 patients(81%) had moderate and severe MR. Median STS score was 8.9 (IQR: 5.2-14.8) and betablockers as well as ACEI/ARB was used by 71% and 73% respectively. During a median follow-up of 441 days (IQR: 272-780), MR decreased in severity in 82 patients (51.6%) and remained unchanged or worsened in 77 patients (49.4%) Among patients with moderate MR at baseline, improvement was seen in 62 (47.5%), worsening in 6 (5%), and unchanged severity in 62 (47.5%).Among patients with severe MR at baseline, improvement was seen in 17 (58.5%) and 12 (41.5%) remained unchanged. Median LVEF did not change from baseline to follow-up (45%; IQR: 30-55 vs. 45%, IQR: 30-55, p=0.51). Among 43 patients with evaluable paired GLS measurements, GLS did not significantly change over time (-11.8 to -12.6; p=0.36)

Conclusions:
Despite the high mortality in medically managed MR patients, a substantial number of survivors improve their MR grade at follow-up.
Abstract 16000: β-arrestins Mediate Cardiac Infiltration of Cytotoxic CD8+ T Cells and Macrophages in Acute CVB3 Viral Myocarditis
Authors: Lucero Garcia Rojas Emilio Y. , Jiang Haoran , D'Anniballe Vincent , Galtes Daniella , Grogan Alyssa , Han Soonbo D , Rockman Howard A
Published: December 2023

Introduction:
In response to Coxsackievirus B3 (CVB3) infection, immune cells infiltrate the heart affecting viral clearance, tissue damage, and cardiac remodeling. However, the molecular mechanisms regulating the immune response during acute CVB3-induced myocarditis are not well understood. β arrestins (βarrs), scaffolding proteins that mediate G protein-coupled receptor internalization, desensitization, and signaling are known to regulate immune responses.

Hypothesis:
We hypothesized that the immune populations infiltrating the heart during acute CVB3 infection are dependent on βarrs.

Methods:
To test our hypothesis, 5- to 7-week-old mice lacking βarr1 (βarr1 KO; n=8), βarr2 (βarr2 KO; n=4), or C57BL/6 controls (WT; n=7) were injected intraperitoneally with 1x10
4
plaque forming units (PFU) of CVB3 or saline and immune cell populations were measured in the heart at 7 days post infection (dpi) using flow cytometry.

Results:
At 7 dpi, there was a marked increase in cytotoxic CD8+ T cells in hearts of WT mice that positively correlated with the level of viral infection as assessed by heart tissue PFU (slope= 1.34, Y-intercept= -3.77). In contrast, the degree of infiltration of CD8+ T cells was significantly blunted in βarr KO hearts over a broad range of heart PFU (βarr1 KO: Slope=-0.3, Y-intercept=1.65; p=0.03 vs WT; βarr2 KO: Slope=-0.32, Y-intercept= 1.3; p=0.003 vs WT). Helper CD4+ T cell populations remained unaltered at 7 dpi among all groups. Macrophages at 7 dpi were significantly reduced in βarr KO hearts over a range of PFU (WT: Slope= 18.6, Y-intercept -52.32; βarr1 KO: Slope= -5, Y-intercept=32; βarr2 KO: Slope=3.46, Y-intercept=-8.4; p=0.04 vs WT). To assess cardiac injury, we measured the level of apoptosis by TUNEL staining and found that CVB3 infected βarr KO hearts showed significantly fewer TUNEL positive cells than WT CVB3 infected controls (WT 8.7%± 2.74; βarr1 KO 1.7%±0.51; βarr2 KO 1.7%±0.37; p=0.04 vs. WT).

Conclusions:
These data indicate that βarrs participate in the cardiac infiltration of CD8+ T cells and macrophages in response to CVB3 infection and that blocking the action of βarrs may diminish the cardiotoxicity with the acute phase of CVB3-induced myocarditis.
Abstract 16047: Quantifying the Cardiovascular Burden of Extreme Heat: A Meta-Analysis of Over 400 Laboratory-Based Heat Exposure Studies
Authors: Meade Robert D , Akerman Ashley P , Notley Sean R , McGarr Gregory W , McCourt Emma R , Kirby Nathalie V , Costello Joseph T , Cotter James D , CRANDALL Craig G , Zanobetti Antonella , Kenny Glen P
Published: December 2023

Background:
Heat waves are associated with increased fatalities from cardiovascular events, which has been attributed to increased cardiac strain secondary to the effects of heat on cardiac function. However, our understanding of these adjustments has come primarily from laboratory research employing insulated/encapsulated heating modalities (hot water perfusion suits). We evaluated whether the cardiac responses seen in this work reflect those experienced in studies exposing participants to high ambient temperatures.

Methods:
We systematically reviewed studies published up to January 2023 examining cardiac outcomes in adults rendered hyperthermic with water perfusion suits or unencapsulated exposure in a climate chamber. Mixed effects meta-analyses were conducted to evaluate whether changes in each outcome with increasing core temperature were modified by heating modality. We also estimated associations (natural spline) between ambient heat index and thermal and cardiac responses in the climate chamber studies.

Results:
584 effect estimates of the heat-induced increase in heart rate (primary outcome) from 406 studies were included (~6800 participant exposures). Heart rate was 7 beats/min [95% CI: 3, 13] greater in the perfusion suit vs. climate chamber studies for similar increases in core temperature (P<0.001). Likewise, there were greater elevations in cardiac output (slope difference: 1.2 L/min/°C [0.1, 2.3]), systolic pressure (14 mm Hg/°C [3, 24]), and rate pressure product (2923 mm Hg·beats/min/°C [1027, 4808]) with rises in core temperature in the perfusion suit compared to climate chambers studies (P≤0.036). In the climate chamber studies, core temperature and heart rate increased as much as 1.0°C [0.8, 1.3] and 31 beats/min [16, 37] (P<0.001) in conditions reflective of deadly North American heat waves (heat index: 50-67°C).

Conclusions:
Our understanding of the effect of heat on cardiovascular responses primarily comes from encapsulated heating modalities, which we show overestimate heat-induced cardiac burden. To support public health research on extreme heat, we provide the first empirical estimates demonstrating considerable thermal and cardiac strain is experienced in conditions reflective of deadly heat waves.
Abstract 16052: Non-Canonical Mechanisms of BARKct-Mediated GRK2 Inhibition in Heart Failure Rescue
Authors: Cho Heidi , Chuprun Kurt , Gao Erhe , Koch Walter J
Published: December 2023

Introduction:
Significant GRK2 upregulation during HF results in desensitization of βARs. βARKct is a peptide inhibitor of GRK2 comprised of the last carboxyl terminal region of GRK2, and prevents GRK2 binding and βAR desensitization. βARKct overexpression attenuates HF and improves outcomes in animal models. Following oxidative stress, MAPKs phosphorylate the Ser670 (S670) residue of GRK2, which induces GRK2 binding to Hsp90 and localization to mitochondria, initiating pro-death pathways. As S670 is also found in βARKct, it may prevent endogenous GRK2 accumulation in the mitochondria.

Hypothesis:
βARKct-mediated cardioprotection in HF is due primarily to mitochondrial GRK2 blockade by βARKct.

Methods:
We generated cardiac-specific mutant βARKct-S670A transgenic mice harboring a Ser-to-Ala mutation at the S670 residue to prevent Hsp90 binding and allow for endogenous GRK2 to continue to translocate to the mitochondria upon ischemic injury, while retaining βARKct in the cytosol to act on βAR signaling pathways. Additionally, we have generated AAV vectors to deliver WT βARKct, βARKct-S670A, and phosphomimetic βARKct-S670D peptides in mice. We performed
in vivo
hemodynamic analysis to assess cardiac function in βARKct and βARKct-S670A transgenic mice. Additionally, intracellular cAMP levels in AC16 cardiomyocytes transfected with βARKct or βARKct-S670A, and βARKct-S670D plasmids were quantified in response to increasing doses of isoproterenol.

Results:
Hemodynamic analysis of the βARKct-S670A mice has demonstrated increased baseline contractility in βARKct-S670A mice compared to NLC mice, indicating comparable cardioprotective effects to βARKct mice lacking the point mutation, which are mediated by canonical pathways. In vitro cAMP quantification revealed AC16s transfected with βARKct, βARKct-S670A, and βARKct-S670D plasmids increased cAMP accumulation in response to increasing doses of isoproterenol compared to control.

Conclusions:
Studies characterizing the mitochondrial pathways involved in HF rescue following ischemic injury are ongoing. These findings will identify new mechanistic information of GRK2 inhibition for HF, and elucidate a new method for attenuating mitochondrial dysfunction during HF.
Abstract 16053: Mitral Valveception: The Promising Technique of Mitral Valve-in-Valve Replacement for Bioprosthetic Valve Dysfunction
Authors: Mehta Samir P , Naveed Shahmir , Campbell Jenna , Shakir Muhammad A , Qureshi Wasif
Published: December 2023

Introduction:
Degeneration of bioprosthetic mitral valves often presents as regurgitation or stenosis. The gold standard is surgical repair; however, many patients are considered too high risk for repair and therefore transcatheter mitral valve replacement (TMVR) can be considered in appropriately selected patients. We present a Mitral Valve in Valve (ViV) replacement as a rescue option for severe bioprosthetic mitral stenosis.

Case:
A 45-year-old male with a history of IV drug use, ischemic cardiomyopathy with placement of ICD and severe mitral regurgitation s/p bioprosthetic MVR (27mm Edwards) 7 years ago presented with dyspnea. He was found to have decompensated heart failure with evidence of cardiogenic shock. He required inotropes and admission to the Cardiac ICU. Echocardiogram demonstrated biventricular dysfunction with an EF of 15%, and a well-seated malfunctioning bioprosthetic valve with fixed posterior leaflets and severe degenerative stenosis (3D planimetry valve area 0.85cm2). His cardiogenic shock was felt to be in the setting of severe mitral stenosis on the background of underlying cardiomyopathy. He was deemed a poor surgical candidate by multidisciplinary team with an STS mortality and morbidity risk of 39% and 85%. He hence underwent a mitral ViV with successful placement of a 29mm Edwards SAPIEN 3 transcatheter valve with impella protection. Patient improved and was discharged off inotropes.

Discussion:
Surgical mitral valve replacement remains the standard of care currently for degenerated bioprosthetic mitral valves. Patients at heightened risk may require ViV procedure instead. In ViV, the ring of the bioprosthetic valve can serve as an anchoring point for the new valve. This avoids a major limitation with TMVR in the native mitral annulus. Severity of acute illness proved to be the determining factor heightening the need for ViV replacement as a rescue option in our patient.

Conclusion:
Management of failing surgical mitral bioprosthesis remains a challenge. ViV-TMVR is an evolving approach that can be used as an alternative in patients who are not surgical candidates. Low rates of periprocedural morbidity and mortality reported in literature strengthen the argument for TMVR, although more data is needed to guide management.
Abstract 16054: Comparing the Efficacy and Safety of Endovascular Therapy versus Surgical Revascularization for Critical Limb-Threatening Ischemia: A Systematic Review and Meta-Analysis
Authors: Abouzid Mohamed R , Anwar Junaid , Elshafei Shorouk , Naccour Shereen , Eldahtoury Samar , Nwaukwa Chima
Published: December 2023

Introduction:
The purpose of this meta-analysis is to examine the current evidence and compare the clinical outcomes of endovascular therapy and surgical revascularization for the treatment of critical limb-threatening ischemia CLTI.

Methods:
We conducted a systematic search of electronic databases for studies comparing the outcomes of endovascular therapy versus surgery in patients with CLTI. The primary outcomes were major adverse limb events (MALE) and major adverse cardiovascular events (MACE), while secondary outcomes included risk of bleeding, wound complications, readmission, unplanned reoperation, acute renal failure, and length of hospital stay.

Results:
A total of 14 observational studies (57,494 patients) were included. The overall effect favors surgery over endovascular intervention in terms of MALE [RR 1.13, 95 % CI (1.01-1.28), P = 0.04]. Endovascular therapy is associated with lower MACE rates compared to surgery [RR 0.62, 95 % CI (0.51-0.76), P < 0.00001]. Furthermore, the risk of bleeding, wound complications, readmission, unplanned reoperation, acute renal failure as well as the length of hospital stay were lower with endovascular intervention.

Conclusion:
Surgery may be preferred for CLTI patients to endovascular therapy as it has reduced MALE risk. Endovascular treatment may reduce the incidence of MACE, bleeding, readmission, unplanned reoperation, acute renal failure, and the length of hospital stay. Novel endovascular techniques may enhance results, particularly for patients with severe illness or limited surgical choices. The treatment decision should be based on several factors like individual patient characteristics and anatomical considerations.
Abstract 16059: Real-World Exploration of Low Density Lipoprotein Cholesterol Management in Patients With Atherosclerotic Cardiovascular Disease
Authors: Shah Nishant P , Mulder Hillary , Lydon Betsy , Chiswell Karen , Lampron Zachary , Cohen Lauren , Hernandez Adrian F , Patel Manesh R , Taubes Susan , Song Wenliang , Mulukutla Suresh R , Saeed Anum , Morin Daniel P , Bradley Steven M , Hu Xingdi , Pagidipati Neha J
Published: December 2023

Introduction:
Although guidelines recommend low-density lipoprotein cholesterol (LDL-C) to bel <70mg/dL in patients with atherosclerotic cardiovascular disease (ASCVD), implementation of these recommendations remains low.

Research Question:
To understand LDL-C management nationally and identify gaps or disparities in guideline directed care.

Methods:
A retrospective cohort study utilizing electronic medical record data from five health systems participating in the CardioHealth Alliance and PCORnet® was performed on patients with a LDL-C measurement in 2021 and prior ASCVD. Multivariable regression modeling was used to determine the relationship of clinical factors with guideline directed LDL-C targets.

Results:
Among 216,074 ASCVD participants, only 86,188 (40%) had LDL-C <70 mg/dL. Compared with participants with uncontrolled LDL-C (≥70mg/dL), those with LDL-C <70 mg/dL tended to be male (64.9% vs 49.1%), White (87.3% vs 83.9%), had coronary artery disease (83.5% vs 73.0%), heart failure (29.1% vs 21.3%), diabetes (48.2% vs 34.1%), and atrial fibrillation (26.1% vs 19.3%). Among those with LDL-C ≥70 mg/dL not on lipid lowering therapy (LLT) at baseline (n=53,957 [41%]), only 20% were initiated on any LLT within 6 months of the elevated LDL-C value. Several factors were associated with not achieving LDL-C <70 mg/dL (Figure) including female sex (RR 1.13 [95% CI 1.12-1.14] p <0.001), Black race (1.15 [1.14-1.16] p <0.001), and Hispanic ethnicity (1.04 [1.01-1.06] p=0.007). Additionally, prior Lp(a) testing was associated with reaching LDL-C target (0.87 [0.82-0.92], p<0.001).

Conclusions:
Within five large U.S. health systems, only 40% of ASCVD patients achieved target LDL-C of <70 mg/dL. Patients who were female, Black, and/or Hispanic were particularly unlikely to achieve target, highlighting significant disparities. Multidisciplinary and inclusive approaches from health system to community may be needed to improve LDL-C care nationally.
Abstract 16070: Prognostic Value of H2FPEF Score Among Symptomatic Patients Referred for Exercise Echocardiography
Authors: Kim Ga Hee , Konje Swiri , Munoz Alba , Gandhi Kruti , Moras Errol C , Perez Lizardo Christopher , Elias Joseph , Kaur Arpanjeet , Omar Alaa M , Argulian Edgar
Published: December 2023

Introduction:
The H2FPEF score is a recommended tool for estimating the likelihood of heart failure with preserved ejection fraction (HFpEF) in cases of unexplained dyspnea. Limited data is available regarding its prognostic ability. This restrospective study aimed to assess the prognostic value of the H2FPEF score for adverse cardiovascular outcomes.

Methods:
532 patients [age 69±6 years, 57% female, and ejection fraction 61±5% (all >50%)] with suspected symptoms of heart failure (HF) referred for exercise echocardiography were included. H2FPEF score was calculated based on: BMI >30 kg/m2 (2 points), atrial fibrillation (3 points), age >60 years (1 point), use of ≥2 hypertension drugs (1 point), E/e’ ratio >9 (1 point), and pulmonary systolic pressure >35 mmHg (1 point). Comparisons were made for death and HF hospitalization.

Results:
During a median follow-up of 3.8 years, 13 patients died, 35 had HF hospitalizations, and 48 experienced the composite outcome. The score distribution was as follows: 0-1 in 69 (13%) patients, 2-5 in 430 (81%) patients, and ≥6 in 33 (6%) patients. The H2FPEF score averaged 3.2±1.5 and showed a progressive increase in the risk of adverse outcomes. A score of 0-1 was associated with the lowest risk, ≥6 with the highest risk, and 2-5 with an intermediate risk (Figure 1A-C). Compared to a score of 0-1, increased risk for combined outcomes occurred with a score of 2-5 (HR: 3.4, 95% CI: 1.5-8) and ≥6 (HR: 9.6, 95% CI: 3.6-26). Similar risk patterns were observed for death and HF hospitalization. Importantly, during exercise echocardiography, new wall motion abnormalities occurred in 105 (20%) patients and did not differ significantly among the different H2FPEF score groups (p=0.403). A H2FPEF score >1 was associated with an increased risk regardless of the presence or absence of myocardial ischemia (Figure 1D).

Conclusions:
H2FPEF score is a useful prognostic tool in suspected HFpEF, regardless of echocardiographic presence or absence of ischemia.
Abstract 16107: Post-Cardioversion Device-Related Thrombus in a Patient With Left Atrial Appendage Occlusion Device on Apixaban
Authors: Ahmed Hasaan , Ismayl Mahmoud , Palicherla Anirudh , Heppler Miranda , Petraskova Terezia , Kousa Omar , Van De Graaff Eric
Published: December 2023

Introduction and Importance:
Current guidelines recommend against pre-procedural transesophageal echocardiogram (TEE) prior to cardioversion in atrial fibrillation patients compliant with oral anticoagulants for at least 3 weeks. The relevance of these guidelines remain unclear in those undergoing repeat cardioversion.

Case Presentation:
66-year-old male with a history of atrial fibrillation and an implanted left atrial appendage occlusion device(LAAO), compliant with apixaban, presented with dyspnea and lightheadedness. He was cardioverted into sinus rhythm 10 days prior to symptom onset with TEE unremarkable for thrombus. Vitals were remarkable for tachycardia and electrocardiogram revealed that the patient converted back into atrial fibrillation. Patient was then scheduled for cardioversion. At the patient’s request, a TEE was obtained which revealed a new thrombus in the left atrium located on his WATCHMAN device. Cardioversion was canceled and patient was admitted for coumadin initiation with lovenox bridge along with neurological monitoring due to increased stroke risk.

Clinical Discussion:
Restoration of sinus rhythm after cardioversion can lead to thrombus formation due to atrial stunning, a transitory dysfunction of the atrial appendage and atrium.Atrial stunning occurs immediately after cardioversion and can persist for several weeks. Time-span of preceding atrial fibrillation, presence of structural cardiovascular disease, and atrial size impact severity of atrial stunning and duration of anticoagulation needed.While anticoagulation decreases the risk of thrombus formation, it does not completely eliminate it, especially in those with increased stroke risk factors.

Conclusion:
Atrial fibrillation patients are susceptible to thrombus formation after cardioversion.Further studies should be done to assess the need for routine TEE after cardioversion in those with increased risk for stroke on anticoagulants or who have LAAO.
Abstract 16128: The Winslow Pathway and Internal Mammary Artery Harvesting in Patients With Aortoiliac Occlusive Disease
Authors: Shakir Muhammad Hassan , Abdul Basit Salman , Saleem Muhammad Sabih , hameed nasir , Pir Muhammad S
Published: December 2023

Introduction
We present a case where the left Internal Mammary Artery (IMA) was not a straightforward choice as the grafted vessel in a patient undergoing Coronary Artery Bypass Grafting (CABG).

Case Presentation
Patient was a 66 years old female with Hypertension, Hyperlipidemia, hypothyroidism, and tobacco use disorder. Evaluation for a motor vehicle accident secondary to a syncopal episode, and intermittent chest tightness over the past few months, showed ST depressions on ambulatory electrocardiographic monitoring, reversible ischemia in the anterior and apical walls on Exercise Stress Test and severe multivessel coronary artery disease involving the distal main left coronary artery and its branches on Coronary Angiography. CABG was advised. Preoperative peripheral angiogram showed bilateral common iliac artery occlusion, precluding IABP placement. Selective angiography of the left IMA showed the left IMA to be the major vessel supplying collateral circulation to the left iliac system. Patient subsequently underwent CABG with bilateral Saphenous Vein Harvest.

Discussion
IMA harvesting in patients with Aortoiliac Occlusive Disease (AOD) with prominent collaterals through the subclavian-IMA-inferior epigastric-external iliac pathway, AKA the Winslow Pathway (WP), can result in limb threatening ischemia, and elective IMA angiography and/or doppler flow evaluation before CABG can help identify this important collateral pathway. Alternative approaches in patients with AOD include simultaneous coronary and peripheral revascularization, completely avoiding IMA harvesting or in some cases, angioplasty, although there is no consensus thus far.
Abstract 16157: Impaired Branched Chain Amino Acid Metabolism in Porcine Right Atrial Dysfunction
Authors: Sternbach Jacob
Published: December 2023

Background:
Right atrial (RA) dysfunction is prevalent and an early predictor of mortality in pulmonary arterial hypertension (PAH). At present, the underlying pathobiology of RA dysfunction is not well defined, and thus approaches are needed to delineate potential therapeutic pathways to hopefully improve outcomes in PAH.

Methods:
Surgical pulmonary artery banding induced right ventricular and right atrial dysfunction in male piglets. 6 weeks post-banding, cardiovascular magnetic resonance imaging quantified cardiac structure/function. Right atrial and ventricular tissue was subjected to quantitative proteomics and targeted metabolomics.

Results:
PAB piglets had decreased RA ejection fraction (RAEF) and increased RA end-systolic volume. Pathway analysis revealed proteins responsible for branched chain amino acid (BCAA) degradation, including MCEE (Methylmalonyl CoA Epimerase), DLD (Dihydrolipoamide Dehydrogenase), HIBADH (3-hydroxyisobutyrate Dehydrogenase), ACAT1 (Acetyl-CoA Acetyltransferase 1), and IVD (Isovaleryl-CoA Dehydrogenase), were reduced in PAB RAs, which was not observed in RV tissue. Targeted metabolomics analysis demonstrated BCAAs were elevated in the RA of PAB piglets and BCAA levels were strongly and inversely associated with RAEF.

Conclusions:
Deranged BCAA metabolism is uniquely observed in the dysfunctional RA, which offers a new therapeutic target for this important clinical problem.
Abstract 16163: Low Dose Alteplase for Treatment of Pacemaker Lead Associated Thrombosis
Authors: hasan Aamir , mocanu marian
Published: December 2023

Multiple previously published case reports highlighted the thromboembolic risks associated with permanent transvenous pacemaker leads. Even though mostly clinically silent, pacemaker lead associated thrombosis has been linked to fatal outcomes via pulmonary or paradoxical embolism in the case of large mobile RA or RV thrombi formation. There is a lack of consensus on the optimal strategy for managing this condition. Oral and IV anticoagulation, thrombolysis, surgical and percutaneous thrombectomy have been attempted previously with mixed results.

A 72 year old gentleman with a history of CAD requiring PCI, paroxysmal atrial fibrillation, and AV node ablation with subsequent biventricular pacemaker implant was admitted to our hospital with a few weeks of worsening dyspnea, now present at rest. Surface echocardiogram showed multiple mobile echo densities in the right ventricle and right atrium, attached to the pacemaker leads, confirmed by TEE, most likely thrombi. The venous duplex was positive for right lower extremity DVT. Bilateral pulmonary emboli with mild right-sided heart strain were noted on CTA chest. The patient was initially treated with IV unfractionated heparin. We subsequently decided to start low-dose tPA infusion for 24 hrs, similar to current off-label protocols for mechanical prosthetic valves or bioprosthetic valve thrombosis. After an initial IV bolus of 5 mg, 1 mg/hour of alteplase was continued for 24 hours. Our team has decided to use percutaneous thrombectomy as a last resort.Follow-up ECHO immediately post tPA infusion showed complete thrombi resolution. The patient was asymptomatic at this point. He was discharged the following day on Lovenox and Coumadin.

To our knowledge, this is the first case demonstrating complete resolution of pacemaker lead-associated thrombi by using a 24 hr low dose tPA infusion in addition to IV anticoagulation. This can be entertained as a simple conservative initial strategy in stable patients with pacemaker lead/catheter-associated intracardiac thrombi.
Abstract 16234: Higher 30-Day Mortality Following Diagnostic Coronary Angiographies Performed at Community versus VA Hospitals Despite Similar Pre-Procedure Mortality Risk
Authors: Hynes Denise M , Govier Diana J , Hickok Alex , Gordon Howard S , Kobayashi Tai
Published: December 2023

Introduction:
Polices to improve access increased referrals to VA community care (VACC), including diagnostic coronary angiography (DCA). Yet, studies showing higher mortality rates following percutaneous coronary intervention at VACC vs VA facilities (VAF), raise concern about VACC quality.

Hypothesis:
30-day mortality following DCA would be greater at VACC vs VAF.

Methods:
We identified outpatient DCAs at VAF and VACC from October 2014-June 2019 (N=75,950) and were matched to balance DCAs on eight characteristics including baseline mortality risk. DCAs with same-day PCI, missing covariates or without a good match were excluded (n=33,060). Primary exposure was DCA at VACC (vs. VAF). We examined weighted characteristics of DCAs and 30-day mortality by VACC status; used weighted logistic regression, adjusting for Veterans’ age, race, rurality, insurance, distance to VAF, Elixhauser mortality risk score and presence of ischemic heart disease, to compare 30-day mortality following DCA at VACC vs VAF. We used instrumental variables analysis to explore any confounders.

Results:
Among 42,890 DCAs, 27% were at VACC. Weighted characteristics of DCAs were similar by VACC status; were predominantly among male, white race, older aged patients. VACC vs VAF patients had similar mean pre-DCA mortality risk scores (4.7 [SD 9.2]) vs 4.8 [SD 9.2]), respectively (SMD=-0.01). Overall, 30-day mortality was 0.9%; 2.5% at VACC and 0.4% at VAF (SMD=0.18). Overall, predicted probabilities of 30-day mortality were greater in VACC vs VAF (Figure 1).In weighted regression analysis, odds of 30-day mortality were greater in VACC vs VAF (aOR 7.07, 95% CI=4.88, 10.24, p lt0.001). Instrument variable analysis suggested selection on unobserved factors contributed to VACC assignment and mortality.

Conclusions:
Risk of 30-day mortality was greater following DCAs performed at VACC vs VAF, despite comparable baseline mortality risk. Further research is needed to explain this difference.
Abstract 16254: Short and Long-Term Outcomes of Patients With Cardiac Amyloidosis Presenting in Cardiogenic Shock
Authors: Nair Raunak M , Agrawal Ankit , Chawla Sanchit , Shekhar Shashank , Higgins Andrew , Lee Ran , Jaber Wael A , Rampersad Penelope , Cremer Paul C , Menon Venu
Published: December 2023

Background:
The characteristics and outcomes of patients with cardiac amyloidosis who present in cardiogenic shock (CS) remains poorly defined.

Methods:
All patients admitted to Cleveland Clinic Cardiac Intensive Care Unit (CICU) between Jan 1
st
, 2010, to Dec 31
st
, 2021, with a diagnosis of cardiogenic shock (CS) were retrospectively identified through electronic medical records and confirmed via physician chart review. Patients were further categorized into those with CS with cardiac amyloidosis (C-Amyloid) and CS without cardiac amyloidosis. 30-day and 1-year all-cause mortality was compared between the two groups with Kaplan-Meier (KM) estimates.

Results:
During the study period, a total of 2775 were patients were admitted to our CICU with CS of which, 29 patients (1%) had confirmed cardiac amyloidosis (C-amyloid). Amongst patients with CS and c-amyloid, 18 patients (62%) had TTR amyloid, 8 (28%) had AL amyloid and 3 were undefined. Compared to patients with other forms of CS, patients with C-amyloid were significantly older (median age of 70 vs 65, p=0.024), had lower prevalence of prior myocardial infarction (21% vs 42%, p=0.037) or coronary artery bypass grafting, and a higher prevalence of chronic kidney disease (69% vs 39%, p=0.002). There were no significant differences in the utilization of right heart catheterization, mechanical circulatory support or mechanical ventilation between the two groups. Comparison of survival probabilities revealed that CS patients with amyloid had similar 30-day (17% vs 21%, p=0.56) and 1-year all-cause mortality (38% vs 31%, p=0.6).

Conclusion:
Amyloid cardiomyopathy is a rare but unique etiology of CS in the CICU. Observed mortality rates are similar to patients with other forms of CS. Given breakthroughs in therapeutics for this condition, the proportion of patients with this clinical entity is expected to rise.
Abstract 16282: Incident Heart Failure With Preserved Ejection Fraction in a Cohort of Patients With Biopsy-Proven Non-Alcoholic Fatty Liver Disease
Authors: Wegermann Kara , Ahlers Carolyn , Karachaliou Georgia Sofia , Au Sandra , Miller Kaela , Chouairi Fouad , Diehl Anna Mae , Abdelmalek Manal , Moylan Cynthia , Fudim Marat
Published: December 2023

Introduction:
Non-alcoholic fatty liver disease (NAFLD) is associated with heart failure with preserved ejection fraction (HFpEF), independent of shared risk factors. The aim of this study was to determine the prevalence, clinical, and echocardiographic (TTE) features of HFpEF in patients with biopsy-proven NAFLD.

Methods:
We performed a retrospective single-center cohort study of patients with biopsy-proven NAFLD in the Duke NAFLD Biorepository and Clinical Database. Study entry was at the time of liver biopsy and patients were followed until death or 5/1/2023. Clinical and echocardiographic data were abstracted via manual chart review. HFpEF was defined as: at least one TTE characteristic (left atrial volume index ≥ 29 ml/m
2
, septal wall thickness ≥ 1 cm, or evidence of diastolic dysfunction) and signs or symptoms of heart failure (diagnosis of heart failure on problem list, hospitalization for heart failure, elevated NT pro-BNP level, jugular venous distention, use of loop diuretics, pulmonary or peripheral edema, fatigue, or exertional symptoms). Descriptive statistics were evaluated.

Results:
A total of 742 patients were included in the study. The mean age of the cohort was 50 +/- 12 years, and 83% were White. 95 (13%) had TTE both prior to study entry and during follow up, while 279 patients (38%) had TTE only during follow up. A total of 185 patients met criteria for HFpEF during follow up. After removing patients with TTE evidence of HFpEF prior to study entry, there were 132 cases of incident HFpEF over a mean follow up of 9.1 years, representing 47% of those with TTE after liver biopsy, and 18% of the overall cohort. Considering only TTE criteria, 142 patients had incident HFpEF. During follow up, 12 patients were hospitalized for heart failure.

Conclusions:
HFpEF is common in patients with NAFLD and a small percentage of patients do not have a chart diagnosis despite meeting echocardiographic criteria, suggesting that HFpEF may be under-recognized. Screening for HFpEF and/or formal care pathways to address early heart failure will be important to prevent morbidity and mortality in this population.
Abstract 16289: Functional Status Improves Following Heart Transplantation for Most Patients and Functional Status at One Year Predicts Five-Year Survival
Authors: Wittenberg Rachel E , Mostofsky Elizabeth , Mittleman Murray A
Published: December 2023

Introduction:
Heart transplantation is a critical treatment for end-stage heart disease, with the goal of improving both length and quality of life. We investigated predictors of functional status improvement following transplant and the impact of functional status at 1 year on survival.

Methods:
We used data from the Scientific Registry of Transplant Recipients on 34,649 U.S. adults who received a heart transplant from Jan. 2006 - Jul. 2020. Functional status was measured using the Karnofsky Performance Scale (KPS; 0-100%). Linear regression with stepwise selection was used to identify predictors of change in KPS from listing to transplant, and from transplant to 1 and 5 years post-transplant. Kaplan Meier curves with log-rank testing was used to compare 5-year survival between patients with poor (≤50%) versus non-poor (>50%) KPS at 1 year.

Results:
Mean KPS was low at listing (47.9%, SD 22.4%) and discharge following transplant (45.6%, SD 24.1%). At 1-year post-transplant, the mean KPS increased to 85.8% (SD 17.7%), which was stable at 5 years (Figure). There was a small difference in KPS at 1 and 5 years based upon KPS at listing (p<0.0001). After adjusting for KPS at transplant and transplant center, predictors of the magnitude of KPS change from transplant to 1 year included insurance type, diabetes, hypertension, prior cardiac surgery, smoking, “1A” waitlist priority, and hospitalization status. Predictors of KPS change from transplant to 5 years included insurance type, diabetes, ventricular assist device use, prior cardiac surgery, sex, and age. Only 5.5% of patients had poor KPS (≤50%) at 1 year. Of these patients, 5-year survival was significantly lower at 72.9% compared to 88.3% among patients with KPS>50% at 1 year (p<0.0001).

Conclusions:
Functional status is an important outcome following heart transplant and impacts survival. Most patients alive at 1 year have excellent KPS but clinical and social interventions may help optimize KPS among at-risk patients.