bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract 107: Accelerated Intramuscular Epinephrine and Survival in Adult, Non-Traumatic Out-of-Hospital Cardiac Arrest: A Before-After Study
Authors: Palatinus Helen N , Johnson Michael , Wang Henry E , Youngquist Scott T
Published: December 2023

Introduction:
Survival after out-of-hospital cardiac arrest is poor. Treatment with early epinephrine is associated with improved survival but delays in vascular access may impact its timely delivery. Outcomes may be improved by novel methods to administer epinephrine prior to vascular access. We previously established that intramuscular epinephrine reduced time from 911 call to drug administration.

Aim:
To determine whether accelerated intramuscular epinephrine (IM-Epi) is associated with improved OHCA survival compared with standard IV/IO epinephrine.

Methods:
We conducted a before-after analysis of the implementation of an IM-Epi EMS protocol. We included adult OHCAs treated by the Salt Lake City Fire Department. Interventions were: pre-IM Epi (Jan 2010-Nov 2019), standard care IV or IO epinephrine; post-IM Epi (Dec 2019-Mar 2023), a single dose of 5 mg IM epinephrine prior to the initiation of IV/IO access. All other care followed standard ACLS, including additional dosing of epinephrine via IV/IO. Using multivariable logistic regression, we determined the association between IM-Epi and hospital survival, ROSC, and good neurologic function adjusted for Utstein variables.

Results:
Among 1,283 OHCAs, 307 (23.9%) received IM-Epi and 976 (76.1%) received usual care. Groups had similar sex, witnessed arrest, arrest location, initial rhythm, and response time, but younger age (57.3 vs. 59.5 years old; p=0.05) and higher bystander CPR (68.3% vs. 56.0%; <0.001) in the IM-Epi group. Time to epinephrine administration was faster for the IM-Epi group (12.0 vs. 15.3 min; <0.001). IM-Epi was associated with improved hospital survival (adjusted OR, 1.87; 95% CI, 1.12-3.10) and good neurologic outcome at discharge (adjusted OR, 1.76; 95% CI 1.02-3.01). IM-Epi first was not associated with differential rates of ROSC (adjusted OR, 1.02; 95% CI, 0.78-1.35) when compared to standard IV/IO first administration.

Conclusion:
In this before-and-after analysis, IM-Epi was associated with increased survival to hospital discharge and favorable neurologic function compared to standard care IV and IO epinephrine. Prospective randomized trials are needed to determine whether the observed effects of IM-Epi in OHCA improves outcomes.
Abstract 109: Nitric Oxide Added to the ECMO Circuit Improves Neuroprotection and Cardiac Function After Cardiac Arrest
Authors: Linardi Daniele , Mani Romel , Martinazzi Sara , Di Nicola Venanzio , Dolci Sissi , Mannino Loris , Decimo Ilaria , Gottin Leonardo , Luciani Giovanni Battista , Rungatscher Alessio
Published: December 2023

Background:
Veno-arterial extracorporeal life support (ECLS) is increasingly used in patients during cardiac arrest. Nitric Oxide (NO) has shown potential for exerting a protective role in ischemia/reperfusion damage in different organs.

Aim:
This study aims to investigate the cardio and neuroprotective effects of NO administered in the extracorporeal membrane oxygenation (ECMO) circuit after cardiac arrest.

Methods:
Thirty male SD rats were subjected to 10 minutes of cardiac arrest. They were randomly assigned to receive ECMO or ECMO plus NO (20 ppm) administered in the oxygenator (ECMO+NO). After 1 hour, the animals were weaned from ECMO, hemodynamic analysis using pressure-volume miniaturized catheter, and cardiac and brain samples were collected after two hours.

Results:
Analysis of cardiac function showed improved systolic cardiac function in the ECMO+NO group compared to standard ECMO (stroke volume: 55 ± 8 vs. 26 ± 9 μl, cardiac index: 9.05 ± 1.41 vs. 4.70 ± 0.81 ml/min/100g, dP/dt
max
: 6870 ± 290 vs. 5124 ± 205 mmHg/s; p<0.01). The ECMO+NO group also exhibited reduced systemic resistance (total peripheral resistance: 2.14 ± 0.42 vs. 2.95 ± 0.35 mmHg/ml/min/100g; p<0.05) and improved ventricular-arterial coupling (Ees/Ea: 0.96 ± 0.15 vs. 0.53 ± 0.15; p<0.001). Neuroinflammation, assessed by the expression of Iba1, a microglia activation marker, was attenuated in the ECMO+NO group (8.37 ± 0.41% vs. 12.58 ± 0.48%; p < 0.001). The extent of hypoxic brain areas, analyzed by thiol oxidation, was lower in the ECMO+NO group (4.07 ± 0.45% vs. 11.72 ± 1.03%; p<0.01).

Conclusions:
NO administration in the oxygenator during ECMO after cardiac arrest improves cardiac function and ventricular-arterial coupling and enhances neuroprotection decreasing neuroinflammation and hypoxic areas. NO administration in the ECMO circuit might be a promising therapeutic adjunct during ECLS.
Abstract 11315: Sex-Based Differences Following Catheter Ablation of Atrial Fibrillation: Patient Reported Outcomes and Quality of Life
Authors: Farwati Medhat , Arwa Younis , Tabaja Chadi , Amin Mustapha , Farwati Amr , Nakagawa Hiroshi , Saliba Walid I , Kanj Mohamed H , Bhargava Mandeep , Santangeli Pasquale , Taigen Tyler , Taigen Tyler , Tchou Patrick , Wazni Oussama M , Hussein Ayman
Published: December 2023

Introduction:
Catheter ablation for atrial fibrillation (AF) has been established as an effective intervention to improve quality of life (QoL). Data are scarce on sex-based differences in ablation outcomes.

Objective:
To examine clinical outcomes and QoL following AF ablation in females vs males from a large patient-reported outcomes (PRO) database.

Methods:
All patients undergoing AF ablation (2013-2021) at our center were assessed for outcomes using automated PRO surveys. The primary endpoint was AF recurrence based on PRO and electrocardiographic documentation. The atrial fibrillation symptom severity scale (AFSSS) was utilized to quantify QoL response. Baseline and 1-year patient surveys were used to estimate AFSSS as well as AF burden (mean of AF duration score and AF frequency score; scale 0: no AF to 10: continuous with 9 frequencies/durations in between).

Results:
A total of 7,166 patients were included (29.8% female). Compared to men, women were older (67 vs 64.2 years) and more likely to have paroxysmal AF (55% vs 45%). The rate of any post-procedural complications was low (<3%) and comparable between men and women. At 3 years, the cumulative incidence of AF recurrence was higher in women compared to men (32% vs 27%; p-value<0.05); Figure. In adjusted multivariable analysis, women had a 19.9% increased risk of AF recurrence compared to men during follow-up. Similar results were observed irrespective of AF type (paroxysmal vs persistent). QoL was significantly improved at 1 year in both groups; with a comparable reduction of mean AFSSS from 13.9 to 6.1 (56.3% decrease) in women and 10.88 to 4.29 (60.5% decrease) in men. Similarly, AF burden was significantly and comparably reduced in both men and women.

Conclusions:
Following catheter ablation for AF, women were found to be at increased risk for AF recurrence during follow-up. Nonetheless, both men and women had significant and comparable improvement in QoL and AF burden.
Abstract 11370: Comparing Coronary Artery Cross-Sectional Area Among Asymptomatic South Asian, White, and Black Participants: The Masala and Cardia Studies
Authors: Short Robert T , Carr Jeffrey , Nair Sangeeta , Terry James G , Lloyd-Jones Donald M , Kandula Namratha , Kanaya Alka M , Lin Feng
Published: December 2023

Introduction:
South Asian individuals have high risk of atherosclerotic cardiovascular disease (ASCVD). Some investigators suggest smaller coronary artery size may be partially responsible.

Hypothesis:
We hypothesized that South Asian participants would have smaller left anterior descending artery (LAD) cross sectional area (CSA) than Black and White participants, and that this association would be attenuated after adjusting for body size (BMI and height) and cardiovascular risk factors.

Methods:
We compared the LAD CSA (lumen and arterial wall) among South Asians in the Mediators of Atherosclerosis in South Asians Living in America study with White and Black participants in the Coronary Artery Risk Development in Young Adults study, adjusting for BMI, height, and other ASCVD risk factors. We used thin-slice non-contrast cardiac computed tomography to measure LAD CSA. We used linear regression models to explore differences by race/ethnicity in LAD CSA after adjusting for demographic, BMI, height, coronary artery calcium (CAC), and ASCVD risk factors.

Results:
We included 3,353 participants: 513 South Asian (44% women), 1286 Black (60% women), and 1554 White (54% women). After adjusting for age, BMI, height, there was no difference in LAD CSA between South Asian and White participants by sex. However, South Asian participants had smaller LAD CSA compared to Black participants by sex. After full adjustment for ASCVD risk factors, LAD CSA values were: South Asian women (19.9 mm
2
, 95% CI [18.8 - 20.9]) and men (22.3 mm
2
, 95% CI [21.4 - 23.2]; White women (20.0 mm
2
, 95% CI [19.4 - 20.5]) and men (23.6 mm
2
, 95% CI [23.0 - 24.2]); and Black women (21.6 mm
2
, 95% CI [21.0 - 22.2]) and men (26.0 mm
2
, 95% CI [25.3 - 26.7]) (
Figure 1
).

Conclusions:
After accounting for differences in body size, South Asian participants had smaller LAD CSA compared to Black participants, but similar to White participants. Future studies should determine whether LAD CSA is associated with future ASCVD events.
Abstract 11422: The Effect of Sodium-Glucose Cotransporter-2 Inhibitors on Stroke in Patients With Heart Failure With Preserved Ejection Fraction: A Meta-Analysis of Randomized Controlled Trials
Authors: KOMMU SHARATH
Published: December 2023

Background:
Randomized controlled trials on sodium-glucose cotransporter-2 (SGLT2) inhibitors in patients with heart failure with reduced ejection fraction (HFrEF) have shown them to be beneficial in improving cardiovascular outcomes, including improvement in heart failure parameters and reduced risk of major adverse cardiovascular events (MACE). Positive results are also noted in patients with heart failure with preserved ejection fraction (HFpEF). However, it is unclear if they have any additional benefit of decreased risk of stroke in this patient population of HFpEF.

Methods:
We performed MEDLINE (via PubMed) and ClinicalTrials.gov searches using the search words - SGLT2 inhibitors and heart failure. Among the reports identified, we screened for randomized controlled trials on HFpEF, that had stroke as one of their outcomes or side effects. We identified three studies that can be included in our meta-analysis.

Results:
12,553 (6279 in the treatment group and 6274 in the placebo group) are included in the meta-analysis. The baseline characteristics in both groups were similar. Among the patients treated for HFpEF, the total number of patients who had an ischemic stroke in the SGLT2 inhibitor group was 113 out of 6279 (1.8%), while in the placebo group, 101 out of 6274 (1.6%). We found that SGLT2 inhibitors did not significantly decrease the risk of ischemic stroke in patients treated for heart failure with preserved EF with a relative risk of 1.12 and 95% CI of 0.86 to 1.46.

Conclusion:
Our meta-analysis shows that in patients treated for HFpEF, SGLT2 inhibitors have a neutral effect on the risk of ischemic stroke.
Abstract 11433: Elevated Vascular Endothelial Growth Factor A is Associated With Disruption of Default Network Connectivity
Authors: Kapoor Arunima , Jang Jung Yun , Dutt Shubir , Alitin John Paul , Sible Isabel , Marshall Anisa , Shenasa Fatemah , Engstrom Allie , Gaubert Aimee , Nguyen Amy , Bradford David Robert , Rodgers Kathleen E , Han S. Duke , Nation Daniel
Published: December 2023

Introduction:
Vascular Endothelial Growth Factor A (VEGF-A) is an angiogenic signaling protein involved in the maintenance of the cerebral vasculature. VEGF-A may play a role in the pathogenesis of Alzheimer’s disease and vascular dementia; however, whether elevated VEGF-A levels indicate a pathophysiolocal response or protective mechanism remains unclear. No prior study has explored whether VEGF-A levels may be associated with changes in functional connectivity among brain regions prior to the development of cognitive decline.

Hypothesis:
Disruption of the default network often precedes the development of cognitive changes. In a sample of older adults, we hypothesized that VEGF-A levels may be associated with default network connectivity, indicating early involvement of VEGF-A in disease processes.

Methods:
Forty-six independently living older adults (mean age = 72.0 years; SD = 6.4; 34.8% male) free of dementia or clinical stroke underwent venipuncture and brain MRI. Plasma was assayed for VEGF-A. Using resting state functional MRI, blood-oxygen level dependent (BOLD) time series from all voxels in each region of interest (ROI) was averaged to determine mean ROI activity. Medial prefrontal cortex, lateral parietal cortex and precuneus cortex ROIs comprised the default network.

Results:
Accounting for age and sex, multiple linear regression analysis revealed a significant negative association between VEGF-A levels and default mode network connectivity (B =-.0007, 95% CI (-.0012, -.0002), p = .0096). This association persisted after adjusting for APOE4 carrier status and Framingham score. A significant association was present in both APOE4 carriers (p = .019) and non-carriers (p = .029).

Conclusions:
Prior studies evaluating the association between VEGF-A levels and cognition have been conflicted. This study is the first to examine whether VEGF-A may be linked to early changes in brain network connectivity which precede cognitive decline. These findings suggest that VEGF-A may be elevated early in the progression of neurocognitive disorders. Whether higher levels of VEGF-A contribute to the pathogenesis of neurocognitive disorders or play a protective role in persevering cognitive function warrants further investigation.
Abstract 11448: Secondary Quantitative Data Analysis of Active Commuting Infrastructure and Coronary Heart Disease in the United States
Authors: Makosiej Nick
Published: December 2023

Background:
It is established in modern scientific literature that physical inactivity is a significant risk factor for coronary heart disease. Implementing active commuting modalities like walking, cycling, and taking public transportation into daily living has been shown to increase physical activity. Prior research has shown the built environment influences the feasibility and likelihood of active commuting behavior. This begs the question of how the prevalence of coronary heart disease is impacted by available active commuting infrastructure.

Purpose:
Objective investigation of the relationship between active commuting infrastructure and age-adjusted prevalence of coronary heart disease, and associated cardiovascular risk factors in American cities.

Methods:
A quantitative secondary data analysis examining active commuting infrastructure via WalkScore, BikeScore, and TransitScore were correlated with and regressed against both risk factors for and age-adjusted prevalence of coronary heart disease. The sample included the top 150 most populated cities in the United States.

Results:
Better active commuting infrastructure has a strong inverse relationship with coronary heart disease prevalence and associated risk factors including hypertension, hyperlipidemia, and obesity. There are some limitations with conclusions that can be drawn from TransitScore and WalkScore due to lack of linearity in the data. Biking infrastructure has the most robust inverse correlation against coronary heart disease (R = -0.355, R
2
= 0.126, p = <0.001, B co-efficient = 6.995, CI = [6.425, 7.485]).

Conclusion:
Investing in active commuting infrastructure, particularly promoting cycling, could be a population level method of primary prevention to decrease the morbidity and mortality due to coronary heart disease in American cities.
Abstract 11548: An Examination of Differences in Ideal Cardiovascular Health Between Sexual Minority and Heterosexual Adults in the All of Us Research Program
Authors: Doan Danny , Ravindranath Rohith , Belloir Joseph , Nguyen Vince , Ensari Ipek , Sharma Yashika , Cook Stephanie , Caceres Billy A
Published: December 2023

Introduction:
Although cardiovascular health (CVH) disparities have been documented among sexual minority (e.g., gay/lesbian, bisexual) adults, research has been limited by a focus on sexual identity differences in individual, rather than composite, measures of CVH. Composite measures of CVH provide more comprehensive assessments of future cardiovascular disease risk.

Methods:
We analyzed data from the All of Us Research Program to examine sexual identity differences in CVH using the American Heart Association’s Life's Essential 8 measure of ideal CVH. Participants received a score from 0-100 for each CVH metric. We calculated an unweighted average to determine cumulative ideal CVH (range 0-100). Higher scores indicated a more favorable CVH profile. We used sex-stratified multiple linear regression models to estimate differences in individual CVH metrics and cumulative ideal CVH between sexual minority and heterosexual adults. All models were adjusted for age, race, ethnicity, household income, education, and insurance status

Results:
The sample included 6,597 participants with a mean age of 63.3 years (±13.89) of which 57% were female and 79% were Non-Hispanic White. Lesbian women (B = -7.43, 95% CI = -13.20, -1.65), gay men (B = -6.39, 95% CI = -10.17, -2.61), and bisexual men (B = -7.41, 95% CI = -14.71, -0.10) had less favorable nicotine exposure scores than their heterosexual counterparts of the same sex. Gay (B = -9.65, 95% CI = -16.60, -2.71) and bisexual men (B = -14.12, 95% CI = -27.53, -0.72) had less favorable physical activity scores than heterosexual men. Bisexual men also had lower cumulative ideal CVH scores than heterosexual men (B = -5.22, 95% CI = -9.16, -1.29). In contrast, gay men had more favorable body mass index scores (B = 6.23, 95% CI = 2.24, 10.22) than heterosexual men.

Conclusions:
This is the first study to examine ideal CVH in sexual minority adults in the All of Us Research Program. Findings have important implications for the development of interventions to promote optimal CVH among middle-aged and older sexual minority adults. Interventions to reduce nicotine exposure are needed for lesbian women and sexual minority men. Efforts to improve the CVH of sexual minority men should also focus on increasing physical activity.
Abstract 11617: Characterisation of Blood Biomarkers in Cardiac ATTR Amyloidosis
Authors: Ioannou Adam , Patel Rishi , Razvi Yousuf , Porcari Aldostefano , Rauf Muhammad , Martinez-Naharro Ana , Venneri Lucia , Lachmann Helen , Wechalekar Ashutosh , Whelan Carol , Hawkins Philip , Gillmore Julian D , Fontana Marianna
Published: December 2023

Introduction:
Transthyretin cardiac amyloidosis (ATTR-CA) is an increasingly recognised cause of heart failure. However, the role of cardiac and non-cardiac biomarkers in patients with ATTR-CA remains poorly understood. We sought to characterise a range of routinely measured blood biomarkers in ATTR-CA, and assess which biomarkers are independently associated with prognosis.

Methods:
Consecutive patients diagnosed with ATTR-CA between 2005 and 2023 were included.

Results:
We identified 2566 patients (wild-type ATTR = 1834, p.(V142I) = 425, non-p.(V142I) = 307). Anaemia (39%), uraemia (52%), hyperbilirubinemia (18%), raised alkaline phosphatase (ALP) (16%), raised c-reactive protein (CRP) (27%) and a troponin-T >56ng/L (52%) were common findings in the overall population, while hyponatraemia (6%) and hypoalbuminemia (2%) were less common. These abnormalities were most common in p.(V142I) patients, and became more prevalent as the severity of cardiac disease increased, as measured by New York Heart Association (NYHA) functional class (p<0.001 for all) and National Amyloidosis (NAC) disease stage (p<0.001 for all). Multivariable Cox regression analysis adjusting for age, NAC stage, and hereditary vs wild-type ATTR-CA demonstrated that anaemia (HR=1.19, 95%CI[1.04-1.37], P=0.013), uraemia (HR=1.23, 95%CI[1.04-1.45], P=0.011), hyperbilirubinemia (HR=1.32, 95%CI[1.13-1.57], P=0.001), raised ALP (HR=1.20, 95%CI[1.01-1.42], P=0.035), hyponatraemia (HR=1.65, 95%CI[1.28-2.11], P<0.001) and troponin-T >56ng/L (HR=1.72, 95%CI[1.46-2.03], P<0.001) were all independently associated with an increased risk of mortality.

Conclusions:
Blood biomarker abnormalities are common in ATTR-CA and are more prevalent in patients with advanced cardiac disease. ATTR-CA is a complex and multifaceted disease process with both cardiac and non-cardiac biomarkers being independently associated with prognosis.
Abstract 11621: Impact of Data Reporting on Outcome Analyses of Intra-Aortic Balloon Pump versus Impella Devices in Bridging Adult Heart Transplant Patients
Authors: Balch Jeremy , Bai Chen , Shickel Benjamin , Mardini Mamoun , Al-Ani Mohammad A
Published: December 2023

Introduction:
There is a paucity of evidence to guide temporary mechanic circulatory support (tMCS) as bridge to heart transplant (HTx).

Question:
Can matching techniques reveal device-related effects on peri-HTx outcomes between IABP (Intra-Aortic Balloon Pump) and Impella?

Methods:
Using the UNOS registry, this retrospective study selected adult patients listed as status 2 on IABP or Impella (V5.0 or V5.5) from 10/2018 to 1/2023. We assessed demographic, medical, hemodynamic, and biochemical data. Primary outcome was failure of status 2 listing strategy (composite of waitlist mortality, escalation of tMCS, and deactivation or delisting due to medical instability). Propensity scores were calculated using logistic regression and matching with a k-nearest neighbors classifier.

Results:
3505 IABP and 648 impella patients were identified based on missingness: (1) No missing data (n = 991, 23%), (2) missing hemodynamic data (n = 1606, 39%), (3) missing both hemodynamic and biochemical data(n = 1664, 40%), and (4) the completedataset (n = 4153). Prior to matching,, failure on status 2 occurred in 12.1% of all patients, 11% of IABP patients, and 17.7% of impella patients in group 4 (p < 0.01). After matching, only in group 4 did impella patients have a significantly higher rate of failure on status 2 (12.6 vs 18%, p < 0.01). Average treatment effect for impella on failure of status 2 was nonsignificant for group 1(ATE 0.06, 95%CI -0.016-0.166) and significant for group 2(ATE 0.06; 95% 0.001-0.125), group 3 (ATE 0.05, 95%CI 0.012-0.094), and group 4 (ATE 0.067, 95%CI 0.037-0.102) cohorts, favoring IABP. There was an increase in request for status 2 by exception in group 4 for impella patients (9.8% vs 8.6%, p=0.04).

Conclusion:
IABP versus Impella had minimal to no impact on failure on status 2 for matched cohorts. Differences appeared when either biochemical or hemodynamic data were omitted. Complete data availability is crucial for developing trustworthy and actionable models.
Abstract 11641: The Role of Inflammation in a Humanized Mouse Model of Transthyretin Cardiac Amyloidosis
Authors: Wu Xiaokang , Cai Nixuan , Evangelisti Alessandro , Jha Alokkumar , Woo Y Joe , Liao Ronglih , Alexander Kevin M
Published: December 2023

Transthyretin cardiac amyloidosis (ATTR) is an under-diagnosed, progressive form of cardiomyopathy, leading to heart failure and death. It is caused by the deposition of amyloid fibrils in the myocardium derived from the plasma protein transthyretin (TTR), but its pathogenesis is poorly understood. Informative in vivo models have proven elusive. Our research identifies inflammation as a potential exacerbating factor in ATTR, suggested by gene expression elevations in inflammatory markers from cardiac biopsies of ATTR-CM patients. To explore this, we created a murine TTR knockout model expressing the human V122I TTR variant. Significant elevations of human TTR were observed in the plasma post-injection (human TTR level (ng/ml) ATTR: 110 ± 10; Control: 28 ± 12; p=0.0008, N=3-5) with preserved cardiac function (FS% ATTR: 20 ± 6; Control: 23± 5; p=0.8162, N=3-5). Notably, the mouse model exhibited amyloid deposits in the heart, confirmed by immunofluorescence and Congo Red staining. Transmission electron microscopy revealed both immature and mature amyloid fibrils in the extracellular matrix (Figure1). RNA-sequencing of the ATTR mouse heart identified distinct transcriptomic patterns and conserved inflammation pathways similar to those seen in a cohort of human ATTR heart samples, such as TNF, T-cell, and B-cell receptor signaling. Up-regulation of inflammatory markers, including CXCL1/2/3 and CCL20, was also observed, and an increased level of CCL5 (MFI ATTR: 801 ± 105; Control: 426± 64; p=0.0061, N=3) was confirmed via luminance-based immunoassay. These chemokines are critical for directing leukocytes to inflammation sites. This study suggests that inflammation may play a role in ATTR pathogenesis. Further in vivo studies are needed to elucidate the mechanisms by which inflammation modulates ATTR amyloidosis.
Abstract 11645: Virutal Simulation-Based Continuing Medical Education Improves Diagnosis and Management of Atrial Fibrillation
Authors: Harris Margaret , Lacouture Michael , Guedj Philippe , Hakkarainen Jennifer
Published: December 2023

Introduction:
The ability of virtual patient simulation (VPS) case-based interventions to improve clinical decision making for patients with atrial fibrillation (AF) is unknown.

Methods:
Two patient cases were presented using a VPS platform where learners could order tests, make diagnoses, and order treatments in a manner matching the scope and depth of actual practice. Clinical decisions were analyzed, and learners received clinical guidance (CG) based on current evidence and expert recommendations. Learners could modify their decisions post-CG. Pre-(baseline) vs. post-CG decisions were compared using McNemar’s test. The intervention launched in August, 2022 and data were collected through December, 2022.

Results:
Overall, 1599 physicians participated. Physician specialties included cardiology (65%) and primary care physicians (35%). Significant improvements were seen for appropriate, timely diagnosis of AF and treatment selection in the overall learner population; treatment improvements were greatest for tailoring anti-arrhythmic drug (AAD) therapy in patients with recently diagnosed AF (
Table
). Improvements in selection of appropriate anti-arrhythmic drug (AAD) was observed for all specialties, although specialty-specific differences were apparent (
Table
). Significant improvements were also observed for selection of appropriate monitoring strategies to determine response to treatment and reaching treatment goals (
Table
).

Conclusion:
Case-based AF intervention employing VPS was associated with improvements in diagnostic and therapeutic decision-making among cardiologists and PCPs. Despite the observed improvements, gaps remain in diagnosing and selecting appropriate rhythm control management strategies for patients with AF.
Abstract 11656: Relation Between Method of Indexation for Normal Chamber Dimensions and Association With Functional Measures: The Multi-Ethnic Study of Atherosclerosis
Authors: Strom Jordan B , Mukherjee Monica , Nelson Lauren , Freed Benjamin H , Gardin Julius , Afilalo Jonathan , Shah Sanjiv J
Published: December 2023

Background:
Normalization of echocardiographic chamber measurements for body surface area (BSA) may result in biased estimation of dimensions in obese or sarcopenic individuals. While alternative scaling systems that circumvent this issue have been proposed, there remains a dearth of information on normal values indexed to scaling parameters other than BSA and whether they vary by sex or race/ethnicity.

Methods:
Of 3032 individuals who underwent echocardiography at Exam 6 in the Multi-Ethnic Study of Atherosclerosis (MESA), we identified 608 without apparent cardiopulmonary or cardiometabolic disease (69.5 ± 7.0 years, 46.2% male, 47.5% White). Normal values for left and right heart variables across a variety of ratiometric (BSA, body mass index [BMI], height) and allometric (height
1.6
, and height
2.7
) scaling systems were defined as the mean value ± 1.96 standard deviations and compared across sex and race/ethnicity categories. In the broader cohort (N = 3032), we evaluated the correlation of indexed parameters and functional measures (NT-proBNP, 6-minute walk distance (6MWD), and Kansas City Cardiomyopathy Questionnaire [KCCQ]).

Results:
Height
2.7
had the best overall mean correlation with functional measures (mean correlation -0.12 ± 0.04 with KCCQ; mean correlation -0.15 ± 0.08 with 6MWD) and was superior to BSA for KCCQ and 6MWD (both p < 0.001) but not NT-proBNP (both p > 0.05). Mean correlations for allometric scaling were greater than ratiometric scaling for KCCQ and 6MWD (both p < 0.001) but not NT-proBNP (both p > 0.05). For 6MWD, mean correlations for allometric scaling (p = 0.001) but not ratiometric scaling (p = 0.8) were more negative (suggestive of impaired function) than unindexed measures.

Conclusions:
In this a multi-ethnic cohort of community-dwelling older adults free from apparent cardiopulmonary or cardiometabolic diseases, we provide normative indexed values for commonly measured echocardiographic parameters across a variety of indexation methods and show that they differ across sex and race/ethnicity categories. Allometric height
2.7
correlated best with functional measures and was superior to BSA. Current chamber quantification guidelines should be updated to reflect normative data on scaled parameters.
Abstract 11695: Long-Term Clinical Outcomes of Minimally Invasive Aortic Valve Surgery in Patients With Aortic Valve Disease
Authors: Dokollari Aleksander , Torregrossa Gianluca , Cabrucci Francesco , Gemelli Marco , Rodriguez Roberto , Prifti Edvin , Pompeu Sa Michel , Bacchi Beatrice , Goldman Scott , Fatehi Hassanabad Ali , Sicouri Serge , Basel Ramlawi , Bonacchi Massimo
Published: December 2023

Introduction:
We aim to analyze multicenter long-term clinical outcomes of minimally invasive aortic valve replacement (MI-AVR) in patients with aortic valve disease.

Hypothesis:
We hypothesize that MI-AVR provides good long-term clinical outcomes in patients undergoing aortic valve surgery.

Methods:
All consecutive 1,972 patients undergoing MI-AVR with either ministernotomy (n= 986) or right anterior minithoracotomy (RAM, n=986) between 1999 and 2019, were included. Primary outcomes were all-cause mortality and cardiac death.

Results:
Preoperatively, mean age was 72.1 (±13.7) year-old, and mean STS-PROM risk score was 0.38%. Intraoperatively, mean operative time (min) was 213.97 (± 56.9), while 313 (15.9%) patients were converted to full sternotomy. Postoperatively, 69 (3.5%) patients had prolonged mechanical ventilation (< 24 hours), 59 (3%) patients had re-exploration for bleeding, 10 (0.5%) patients had paravalvular leak (moderate/severe), 22 (1.1%) patients had non-fatal stroke, and 28 (1.4%) patients had non-fatal myocardial infarction. Mean intensive care unit stay was 14.45 (± 10.15) hours, and mean hospital length of stay (LOS) was 7 (± 3.5) days. Thirty-day all-cause mortality occurred in 39 (2%) patients while 30-day cardiac-death occurred in 23 (1.2%) patients. Thirty-day predictors for all-cause mortality included age <75-years, post-operative LOS, peri-operative stroke, and RAM. Mean follow-up time was 10-years. At 20-year follow-up, all-cause death and CV-death incidence were 1156 (60%) and 170 (8.8%) patients, respectively. Valve-related deaths occurred in 33 (1.7%) patients. Long-term predictors for all-cause mortality included age <75-years, chronic kidney failure, mechanical ventilation <12 hours, RAM, and hospital LOS <10 days.

Conclusions:
MI-AVR is a safe, valid, and reproducible surgical procedure for patients with aortic valve disease. In addition, it provides good long-term outcomes.
Abstract 11716: Patent Foramen Ovale Closure vs Medical Therapy in Patients ≥ 60 Years of Age With Ischemic Stroke: A Retrospective Cohort Study
Authors: Cordova Sanchez Andres , Rawlley Bharat , Menezes Sherna , Morales Mejia Ana , Adames Ramos Kenneth , Chaudhuri Debanik
Published: December 2023

Background:
The benefit of patent foramen ovale (PFO) closure in patients aged ≥60 years with ischemic stroke is uncertain.

Purpose:
We conducted a retrospective cohort study to compare the outcomes of PFO closure vs medical therapy in this population.

Methods:
Using the TriNetX research database we identified patients ≥ 60 years with PFO who had an ischemic stroke from 2016 to 2021. Patients were divided into two groups: those undergoing PFO closure within 3 months of the stroke and those who received medical therapy only. Subgroup analyses was performed by age group (60 to 70 and ≥71). Propensity score matching was used to control for age, sex, hypertensive diseases, CKD, diabetes, dyslipidemias, ischemic heart disease, tobacco use, and neoplasms. Outcomes were measured from 1 month to 3 years after the index event and included all-cause mortality, new onset AF/flutter, arterial embolism, and services associated with stroke/embolism (thrombolysis, thrombectomy, administration of thrombolytics, and imaging of head and neck).

Results:
PFO closure was associated with lower number of services used in stroke/embolism (HR 0.57, 95%CI 0.42-0.78), a similar association was seen in those in the 60-70 age group (HR 0.539, 95%CI 0.373,0.78) but not in those ≥71 years. Arterial embolism was seen in 3.14% of the patients who received antiplatelets or anticoagulants only, but none of the patients who underwent PFO
(Table 1)
.

Conclusions:
PFO closure was associated with lower number of services used in stroke/embolism in patients aged ≥60 years with ischemic stroke. Our study could have been underpowered to find differences amongst those ≥71 years old. None of the patients who underwent PFO closure developed arterial embolism. PFO closure may be beneficial for older patients with ischemic stroke and warrant further investigation
Abstract 11740: Redefining Cardiac Involvement in Systemic Immunoglobulin Light Chain Amyloidosis and Treatment Implications
Authors: Porcari Aldostefano , Masi Ambra , Martinez-Naharro Ana , Razvi Yousuf , Patel Rishi , Ioannou Adam , Rauf Muhammad , Sinigiani Giulio , Wisniowski Brendan , Filisetti Stefano , CURRIE-CATHEY Jasmine , O'Beara Sophie , Kotecha Tushar , Knight Daniel , Moon James , sinagra Gianfranco , Virsinskaite Ruta , GILBERTSON Janet A , Venneri Lucia , Petrie Aviva , Lachmann Helen , Whelan Carol , Kellman Peter , Ravichandran Sriram , Cohen Oliver , Mahmood Shameem , Hawkins Philip N , Gillmore Julian D , Wechalekar Ashutosh , Fontana Marianna
Published: December 2023

Introduction:
Cardiac amyloidosis (CA) is the key determinant of survival in systemic AL amyloidosis.

Hypothesis:
To assess (i) the differences between serum biomarkers, echocardiography and CMR with ECV mapping in characterising cardiac involvement, (ii) their independent prognostic role, and (iii) the role of ECV mapping to guide treatment strategies.

Methods:
Consecutive patients newly diagnosed with systemic AL amyloidosis between 2015-2021 who underwent echocardiography, cardiac biomarkers, and CMR with ECV mapping at the time of diagnosis were included. Haematological response (HR) at 1 and 6 months was defined according to validated criteria. The primary outcome was mortality.

Results:
Five-hundred sixty AL patients were included. The different approaches produced different results in terms of presence and severity of cardiac infiltration (CA present from 48.2% to 93%). Over 40.5 months [IQR 9-58], only ECV was independently associated with mortality (p< 0.001). In the landmark analysis at 1 month, patients with ECV < 0.30 and with ECV 0.31-0.40 had an excellent long-term survival regardless of the achieved HR (p=0.92 and p=0.08, respectively), whilst in patients with ECV > 0.40 survival was dependent on the depth of the HR (p< 0.001). In the landmark analysis at 6 months, patients with ECV < 0.30 had excellent survival regardless of the achieved HR and patients with ECV 0.31-0.40 had excellent survival if achieving at least a PR (inter-group p=0.006 in NR vs PR). In ECV 0.41-0.50 and ECV > 0.50, long-term survival was excellent only among patients achieving CR (inter-group p< 0.05 in CR vs VGPR). Reaching a deep HR at 1 month vs 6 months was associated with better survival in ECV > 0.40 (p< 0.05), but not in ECV < 0.40.

Conclusions:
ECV mapping in systemic AL amyloidosis is the only independent predictor of prognosis. ECV mapping can define optimal depth and rapidity of the HR for each patient and inform treatment strategies.
Abstract 11820: Importance of Resting Heart Rate Assessment in Autonomic Dysfunction Evaluation in Congestive Heart Failure Patients
Authors: Tawfellos George , Gulko Daniel , Petrossian Gregory , Kenitz Jacqueline , Beegle Christina , Yoo Jeanwoo , Torosoff Mikhail
Published: December 2023

Background:
Novel treatments in congestive heart failure (CHF) aim at ameliorating autonomic dysfunction. Autonomic dysfunction typically manifests with resting tachycardia and blunted baroreceptor reflex response and been classically described in CHF with reduced LV ejection fraction (EF) but baroreflex function in CHF with preserved EF has not been well investigated.

Methods:
A single center prospective study was conducted by measuring resting and lowest heart rates (HR) during voluntary breath holding in 118 CHF patients, 68 ± 14 years old, 50 females (42.3%), BMI 30.1 ± 8.5 kg/m
2
, HTN in 97 (82.2%), CAD in 64 (54.2%), diabetes in 49 (41.5%), and chronic lung disease in 39 patients (33.1%). HFrEF less than 40% was found in 41 (34.7%) patients; for the purposes of analysis HRmrEF and HFpEF groups were combined. Beta-blockers were used in 92 (78%) and non-dihydropyridine calcium channel blockers were used in 7 (5.9%) patients.

Results:
The majority of HFpEF or HFmrEF patients had resting HR less than 80 bpm (55/77 patients, 71.4%), while the majority of HFrEF patients had resting HR more than 70 bpm (32/41 patients, 78%, p=0.015). Furthermore, HFpEF and HFmrEF patients had lower breath holding HR (69.7 ± 14.7 bpm in HFpEF and HFmrEF patients vs. 77.6 ± 13.9 bpm in HFrEF patients, p=0.005). There was a trend of increased resting HR in patients with Class IV CHF (p=0.179). Furthermore, class IV CHF patients manifested with increased breath holding HR (68.9 ± 15.3 bpm in combined NYHA class I-II, 69.9 ± 12.2 bpm in NYHA class III, 79.9 ± 16.1 bpm in NYHA class IV, p=0.02). Regardless of the CHF class (p=0.060) and/or LV EF (p=0.913), increased resting HR was associated with higher breath holding HR. Patients with baseline HR <60 bpm had breath holding HR of 54.6 ± 6.2 bpm, as compared to 94.9 ± 9.0 bpm in patients with baseline HR >90 bpm, p<0.001.

Conclusion:
In CHF patients, increased resting HR is a strong indicator of abnormal baroreceptor function. HRmrEF and HFpEF patients have lower resting and breath holding HR, suggesting less pronounced autonomic dysfunction, as compared to more pronounced autonomic dysfunction in HFrEF patients. Additional studies are needed to investigate whether autonomic modulation treatment is equally beneficial in patients across the LVEF spectrum.
Abstract 11829: Association of Adult Congenital Heart Disease and Serial Echocardiographic Parameters With Adverse Cardiac, Obstetric, and Neonatal Outcomes
Authors: Krishnamurthy Yamini , Lewis Matthew , Liu Lilly , Purisch Stephanie , Rosenbaum Marlon S
Published: December 2023

Background:
Risk factors for adverse cardiac, obstetric and neonatal outcomes in pregnant women with adult congenital heart disease (ACHD) are not well-defined.

Objective:
To assess the association of ACHD and serial echo parameters with adverse cardiac, obstetric and neonatal outcomes.

Methods:
ACHD patients with prenatal care and delivery at a tertiary care center from 2007-2022 were included. Serial echos during pregnancy and adverse cardiac outcomes (arrhythmia, heart failure, ICU admission) were reviewed. Adverse obstetric (pregnancy-induced hypertension, abruption, hemorrhage) and neonatal outcomes (small-for-gestational age, preterm delivery, NICU admission, fetal/neonatal demise) were compared between the ACHD cohort and an age- and gravidity-matched non-ACHD cohort. Logistic regression was used to calculate the odds ratio (OR) for adverse outcomes.

Results:
Of 188 ACHD patients (mean age 30.9 ± 5.9 years), 74.4% had moderate or greater anatomic complexity. 11.7% of ACHD patients had an adverse cardiac outcome. Adverse obstetric and neonatal outcomes were more common in ACHD patients (23.9% vs 10.4%, p < 0.001; 35.3% vs 17.0%, p < 0.001, respectively). Systemic ventricular dysfunction, systemic atrioventricular valve dysfunction, and decline in systemic ventricular function during pregnancy were associated with increased risk of adverse cardiac outcomes. ACHD was associated with increased risk of adverse obstetric and neonatal outcomes (OR 2.8, 95% Confidence Interval [CI] 1.7 - 4.8; OR 2.8, 95% CI 1.8 - 4.5, respectively). Echo predictors of adverse cardiac outcomes were not associated with increased risk of adverse obstetric or neonatal outcomes.

Conclusion:
ACHD is associated with adverse cardiac, obstetric and neonatal outcomes. Echo parameters are predictive of adverse cardiac, but not obstetric or neonatal outcomes. Large-scale studies are needed to identify drivers of adverse obstetric and neonatal outcomes in this population.
Abstract 11832: Carotid Sinus Massage Can Obviate the Need for Tilt Table Testing in Patients With Undiagnosed Vasodepressor Syncope
Authors: Truong Julie K , Adelakun Adeniyi , Prakash Atul
Published: December 2023

Introduction:
Head-up tilt table (HUTT) testing is typically utilized for patients with syncope where the diagnosis is unclear but suspicion of a vasovagal etiology. Carotid sinus massage (CSM) can be used to elicit a vasopressor response though typically used to diagnose carotid sinus hypersensitivity. The usual protocol of HUTT consists of baseline CSM, 30-mins of HUTT, a repeat of CSM, and drug infusion. This is time-consuming and tedious.

Hypothesis:
CSM has a high predictive value for a vasodepressor response and may prevent the need for the completion of the HUTT protocol.

Methods:
Consecutive patients with clinical suspicion of vasovagal syncope underwent HUTT. Protocol consisted of baseline CSM in the supine posture, 30-mins of HUTT at 60 degrees, repeat CSM, and infusion of isoproterenol infusion from 1 to 3 mcg/min. Beat-to-beat blood pressure (BP) monitoring was performed non-invasively and standard cuff BP monitoring every minute. Positive tilt was defined as a drop in BP by more than 20 mmHg with reproducible symptoms (correlation to clinical symptoms).

Results:
55 consecutive patients with a history of syncopal episode(s) underwent HUTT. 46 were females and 9 were male with a mean age of 54.4 ± 17.4 years old. They presented symptoms suggestive of a vasovagal etiology but were not diagnostic. 12 out of 55 (21.8%) patients had a positive reproducible response with supine CSM. 11 out of 12 of these patients subsequently had a positive result with protocol completion. This provided a positive predictive value (PPV) of 92%. 36 out of 55 (65.5%) patients had a negative response to CSM. All 36 had a negative result on completion of the HUTT protocol. This provided a negative predictive value (NPV) of 100%. 7 out of 55 (12.7%) patients had a “borderline” positive supine CSM. All 7 had a positive result with the completion of the HUTT protocol. Of note, these patients became positive only with isoproterenol infusion.

Conclusions:
CSM in the supine posture has a high PPV and NPV in eliciting a possible vasodepressor etiology. A full HUTT protocol may be only required in a patient who presents with a “borderline” CSM response in the supine posture. Therefore, CSM may easily be performed at the bedside with a monitor and a BP apparatus obviating the need for the full HUTT protocol.
Abstract 11841: Gene Therapy Improves Pathological Cardiac Remodeling in Human Hypertrophic Cardiomyopathy Gene Variant Knock-In Mice
Authors: Koitabashi Norimichi , Kawakami Ryo , Tokuyama Takeshi , Ahed Razan E , Torizal Fuad G , Anzai Tatsuya , Nagao Yasumitsu , Ishii Hideki , Uosaki Hideki
Published: December 2023

Introduction:
Some patients with hypertrophic cardiomyopathy (HCM) has been reported to develop ventricular systolic dysfunction, called the dilated phase of HCM (d-HCM). Although d-HCM is associated with increased morbidity and mortality, precise mechanism for the development of the pathological cardiac remodeling and gene-targeted therapy are still under investigation. It has been shown that cardiac myosin binding protein C (Mybpc3) missense mutation (R820Q) is associated with familial HCM and d-HCM.

Methods and Results:
We generated a knock-in mouse model, carrying the R820Q mutation of Mybpc3 (MyBP-KI mice). MyBP KI mice spontaneously developed cardiac hypertrophy and mild systolic dysfunction at 8 weeks of age, reproducing the d-HCM phenotype, while their littermate control mice showed normal cardiac mass and function. Transcriptome analysis by RNA-seq showed that, in addition to upregulation of heart failure-related fetal genes, mitochondria-related gene sets (oxidative phosphorylation and fatty acid metabolism) were suppressed in MyBP-KI mice compared to control mice. We examined adeno-associated virus (AAV)-mediated gene therapy on MyBP-KI mice. AAV vectors with wild type Mybpc3 controlled by the cardiac troponin T promoter were administered intravenously to MyBP-KI mice that began to develop hypertrophy at 8 weeks of age. Echocardiography and cardiac catheter examinations showed that the deterioration of cardiac function over time was significantly suppressed by AAV gene therapy. Overexpression of fetal genes of cardiomyocyte was significantly suppressed, mitochondrial gene abnormalities were also significantly attenuated, and histological myocardial fibrosis was also significantly suppressed by administration of AAV harboring wild type Mybpc3.

Conclusions:
Our MyBP-KI mice spontaneously recapitulated human d-HCM phenotype. Gene therapy with AAV, even when administered at a stage when cardiac remodeling has already begun to progress, successfully suppressed cardiac dysfunction at the genetic level and prevented the transition to d-HCM.