bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract 14317: The Prevalence of Motile Ciliary Gene Variants in Children With Transposition of the Great Arteries and Tetralogy of Fallot
Authors: Howell Alison J , Pisesky Andrea , Wee Wallace , Runeckles Kyle , Yao Roderick , Bouwmeester Jade , Min Sandar , Mital Seema , Dell Sharon , Nield Lynne E
Published: June 2023

Introduction:
Motile ciliary dysfunction plays a central role in the pathogenesis of respiratory abnormalities and congenital heart disease (CHD). The role of ciliary gene variants in the non-heterotaxic CHD population is not well characterised.

Methods:
This single-centre retrospective cohort study aimed to determine the prevalence of Primary Ciliary Dyskinesia (PCD) gene variants in children with isolated Transposition of the Great Arteries (TGA) and Tetralogy of Fallot (TOF). Patients with whole genome sequencing between 2008-2018 were included. We identified pathogenic (P) or likely pathogenic (LP) single-nucleotide variants (SNVs) and short insertion/deletions (indels) in coding regions of 45 genes known to cause PCD. Patient characteristics and associated respiratory outcomes were evaluated from chart reviews.

Results:
PCD gene variants were found in 2.9% (5/172) TGA and 3.8% (10/264) TOF patients. Thirteen probands were heterozygous for P/LP SNVs/ indels; CCDC40 N=6, DNAH11 N=2, SPAG1 N=2 and one each of DNAH8/DNAAF1/ARMC4. Two were compound heterozygotes for variants in DNAH11 and DNAH8.

At last follow-up, mean age was 14.5 years (SD 6.8, 57.9% male) and 7 deaths had occurred. Asthma was diagnosed in 10.5% TGAs and 8.1% TOFs with 3.9% and 7.3% respectively requiring hospitalisation for primary respiratory illness.

In the variant positive subgroup, 5/15 had respiratory abnormalities - bronchiectasis (N = 1), asthma (N = 2), neonatal cough (N = 1), ventilator-associated pneumonia (N = 2). Additional cardiac anomalies occurred in 53% (8/15) - abnormal systemic veins (N = 3), situs inversus, dextrocardia (N = 1), right arch (N = 5), hypoplastic right ventricle (N = 1). An abnormal coronary pattern was seen in 4/5 TGAs. Vaginal and renal agenesis each occurred in 1 patient.

Conclusions:
Our findings suggest a high prevalence and potential association of ciliary gene variants with respiratory outcomes and situs anomalies in non-heterotaxy CHD.
Abstract 14318: The Effect of Time-Restricted Eating on Physical Activity: Results From the Time-Restricted Intake of Meals (Trim) Randomized Trial
Authors: Turkson-Ocran Ruth-Alma N , Dougherty Ryan J , Duan Daisy , Pilla Scott J , Schrack Jennifer A , Clark Jeanne M , Maruthur Nisa M
Published: June 2023

Introduction:
Time-restricted eating (TRE) is a dietary pattern that may promote weight loss by limiting caloric intake, but evidence for its effects on physical activity are limited.

Objective:
To determine the effect of a TRE pattern compared to a usual eating pattern (UEP) on physical activity.

Methods:
We examined physical activity data from 41 adults with prediabetes or untreated diabetes (HbA1c 5.7-6.9%) and obesity (BMI 30-50 kg/m
2
) randomized to consume 80% of their total calories before 1 pm (TRE) or ≥50% of their calories after 5 pm (UEP) with identical macronutrient content. Participants were fitted with a wrist-worn GT9X accelerometer (Actigraph; Pensacola FL) to measure free-living physical activity behaviors for one week at baseline and 12 weeks. Outcomes were mean total activity counts (measure of activity volume and intensity) and time spent active (measure of activity volume) per day. We used linear mixed effects regression models with participant-specific random intercepts to examine the difference in outcomes between the two groups from baseline to 12 weeks; the intervention-by-time interaction was the term of interest (β
int
).

Results:
Thirty-nine adults (mean age 59.5 years; 92% female; 92% African American) completed actigraphy assessments. We observed a significant decrease in all physical activity measures from baseline to 12 weeks in TRE, but not in UEP (
Table
). Total activity counts (p for β
int
=0.005), but not time spent active (p for β
int
=0.094) declined significantly in TRE compared to UEP.

Conclusion:
In this randomized feeding study, TRE was associated with reduced physical activity intensity while overall physical activity volume was unaffected, compared to a UEP. This unexpected compensatory decrease in physical activity intensity may limit the efficacy of TRE for achieving weight loss. Future studies are needed to understand the mechanisms behind this effect, and to optimize TRE interventions to maintain physical activity levels.
Abstract 14320: Regionalization of Non-Pulmonary Vein Triggers for Atrial Fibrillation Using Non-Invasive Electrocardiographic Imaging
Authors: Thind Munveer , Arceluz Martin , Lou Qing , Ciaverelli Sara , Lucena Padros Irene , Kubala Maciej , Dhakal Bishnu P , Bode Weeranun D , Cerantola Maxime , Mirwais Maiwand , Bush Kelvin , Zado Erica S , Guandalini Gustavo , Hyman Matthew C , Lin David , Deo Rajat , Nazarian Saman , Tschabrunn Cory M , Schaller Robert D , Epstein Andrew E , Supple Gregory E , Frankel David S , Santangeli Pasquale , Callans David J , Marchlinski Francis E
Published: June 2023

Introduction

Ablation of non-pulmonary vein triggers (NPVTs) after pulmonary vein isolation (PVI) reduces atrial fibrillation (AF) recurrence, but localizing NPVTs can be challenging. We evaluated the potential for noninvasive electrocardiographic imaging (ECGi) to regionalize NPVTs and expedite more focused catheter-based mapping. ECGi combines measured body surface potentials with heart-torso geometry acquired from computed tomography (CT), to generate an activation map from a single recorded beat.

Methods

In 12 patients with AF undergoing first time AF ablation, the ECGi vest was fitted for preprocedural CT scan and then worn during procedure. Following completion of PVI, we paced from 15 atrial sites where NPVTs commonly arise (Figure 1), and evaluated the epicardial activation map generated by ECGi during steady state pacing at cycle length of 700-800 ms allowing an unobscured P wave. Merging of invasive anatomic map with CT-based ECGi map allowed comparison of ECGi activation map with true pacing location (Figure 2).

Results

From 180 pacing sites in our patient cohort (67% male, 58% persistent AF, 67% left atrial dilation), median distance between earliest activation site on ECGi map and pacing location was 16 mm (interquartile range, 11-22 mm), with 95% of sites within 30 mm (Figure 2). Septal pacing sites were measured to the epicardial aspect of the interatrial septum.

Conclusions

ECGi is able to consistently approximate the origin of paced beats from common NPVT sites and suggests the potential for rapid regionalization of NPVTs. The identified region can then be the focus of more detailed catheter-based mapping techniques to facilitate successful ablation of NPVTs.
Abstract 14331: Impact of Three-Dimensional Mitral Valve Geometry on Hemodynamic Severity in Rheumatic Mitral Stenosis
Authors: Giffoni Rodrigo T , Hung Judy , Medrado Neto João R , Pinto Airandes S , Padua Lucas B , ESTEVES WILLIAM , Tan Timothy C , Levine Robert , Nunes Maria D
Published: June 2023

Introduction:
Pathologic derangements of rheumatic mitral stenosis (MS) change valve shape which may determine the hemodynamic severity of the obstruction. This study was designed to assess the role of mitral valve shape on transvalvar pressure gradients in patients with MS.

Methods:
A total of 186 patients with MS, area of 1.1 ± 0.3 cm
2
, who underwent three-dimensional (3D) transesophageal echocardiographic study, were enrolled. A set of morphological variables to assess the mitral valve (MV) geometry, including diameter, area, height, volume and aortic-mitral angle was obtained using dedicated software. 3D doming index, the proposed index to differentiate between conical and dome shapes, was calculated by dividing the valvar volume (tenting volume) by the valvar height (tenting height). The resulting "average area" was divided by the minimum area of ​​the 3D annulus (Figure 1). Determinants of mean pressure gradient were assessed using linear regression models.

Results:
The 3D doming index was significantly correlated with transmitral gradient in the multivariate model (p = 0.007), adjusted for age, sex, heart rate, pulmonary artery systolic pressure, net atrioventricular compliance (C
n
), and left atrial volume. Specifically, the inclusion of 3D doming index in a model with other factors that influence gradients resulted in improvement in model performance evaluated by R
2
which increased from 0.57 to 0.60. In the 152 patients who underwent successful percutaneous valvuloplasty, there was a significant correlation between the percentage of increase in the valve area and 3D doming index (r = 0.2; p <0.026), after adjustment for the echo score revisited.

Conclusions:
In rheumatic MV stenosis, 3D geometric shape was associated with transmitral pressure gradient, independent of other parameters. 3D Doming index correlated with the percentage increase in MV area in a subgroup undergoing valvuloplasty.
Abstract 14351: Prognostic Impact of a Novel Objective Assessment System for Frailty in Patients Who Undergo Transcatheter Aortic Valve Implantation
Authors: Suzuyama Hiroto , horio eiji , Taguchi Eiji , Horibata Yoko , Yamada Masahiro , Konami Yutaka , Sassa Toshiharu , Ideta Ichiro , Sakamoto Tomohiro
Published: June 2023

Background:
Preprocedural assessment of frailty is often used to predict prognosis following transcatheter aortic valve implantation (TAVI). We introduced a novel scoring system, the Saiseikai Frailty Score (SFS), which contains objective indices of physical and mental ability, vitality, nutrition status and comorbidity.
Methods and Results
Consecutive 431 patients who underwent TAVI were prospectively enrolled. The SFS consists of 7 items; gait speed, grip strength, physical activity, body weight, fatigability, cognitive function and serum albumin levels, and the sum of abnormal items is presented as the SFS. SFS 0-1 are defined as low frailty (LF), 2-3 as intermediate frailty (IF) and 4-7 as high frailty (HF). Prognosis up to 1 year after the procedure and landmark analysis after 1yr were prospectively evaluated according to the frailty (median follow-up period 951 days). Of the 431 patients (age 85.0±4.9yrs [mean±SD], male 29.5%), 116 patients (26.9%) were categorized as LF, 197 (45.7%) as IF and 118 (27.4%) as HF. The cumulative 1-year mortality was significantly higher in the HF group than the other 2 groups (p=0.0038, log-rank test). Post 1-year landmark analysis revealed that only the LF had better prognosis than the other 2 groups (p=0.0013). The modified SFS with information of malignancy, lung and kidney function (LF 0-1, IF 2-3 and HF 4-11) clearly stratify the 3 groups in both the short- and long-term mortality (p=0.0006 and p<0.0001).

Conclusions:
The SFS enabled sophisticated and objective stratification of prognosis after TAVI. This novel frailty assessment system will be useful to determine the precise indication for TAVI.
Abstract 14354: Prognostic Impact of Low Serum Chloride Level in Elderly Patients With Heart Failure
Authors: Shirotani Shota , Jujo Kentaro , Kishihara Makoto , Watanabe Shonosuke , Takada Takuma , Abe Takuro , Yamaguchi Junichi
Published: June 2023

Background:
Patients with heart failure (HF) are known to be stratified the risk of mortality by serum chloride level. However, since large-scaled studies to date have not included the elderly patients, it is still unclear whether serum chloride level well predicts the prognosis of the elderly patients with HF, whose clinical profiles are different from young adult patients. We aimed to test the hypothesis that hypochloremia gave different prognostic impacts in non-elderly and elderly patients with HF.

Methods:
This observational study included 1,326 elderly patients (
>
65 year-old) without regular hemodialysis who were hospitalized for worsening of HF and discharged alive. They were divided into two subgroups depending on serum chloride levels at admission (Low-chloride group (
<
97 mEq/L, n=244); Normal-chloride group (
>
98 mEq/L, n=1518)), referred to prior reports. Propensity scores were developed and patients in Normal-chloride group were matched with those in Low-chloride group in a 1:1 ratio. The endpoint of this study was death from any cause.

Results:
Among 1,326 unmatched patients, Low-chloride group included significantly more male patients, and those with higher BUN, CRP, bilirubin levels, dose of furosemide and atrial fibrillation, and prescriptions of oral anticoagulant, and lower BMI, blood pressure, hemoglobin, prescription of mineral corticoid receptor antagonist, thiazide and statins. Following propensity score matching by diverse baseline parameters, 106 pairs in both groups were included in the matched population. During 413 days of median observational period, 62 patients (28.8%) died. Kaplan-Meier analysis showed that patients in the Low-chloride group had a significantly higher mortality rate (p=0.011,
Figure
).

Conclusion:
In this observational study, baseline hypochloremia was associated with an increased mortality in elderly patients hospitalized with heart failure.
Abstract 14366: Young, Healthy Female With Myocarditis and Cardiogenic Shock After Mild COVID-19 Infection
Authors: Kaur Sukhpreet , Montana Paul , Martillo Miguel , Grazette Luanda
Published: June 2023

Background:
We present a case of a young female with no pre-existent conditions, who presented to the hospital one month after a mild COVID-19 infection with severe myocarditis complicated by cardiogenic shock.

Case:
A 40-year-old female with no prior medical history and a regular, vigorous exercise program developed a mild COVID-19 infection with symptoms of mild fatigue, myalgias, chills, fever, and loss of taste, which resolved within a week. A month later, she presented to the hospital with exertional dyspnea, weakness, chest pressure, abdominal pain, and fatigue. A transthoracic echocardiogram revealed a left ventricular ejection fraction of 15% with a severely dilated left ventricle, global hypokinesis and severe mitral regurgitation. Right heart catheterization demonstrated cardiogenic shock with a cardiac index of 1.4 liters per minute by Fick equation, and she was admitted to the cardiac intensive care unit. Cardiac magnetic resonance revealed subepicardial delayed enhancement along the lateral and inferolateral walls and elevated T1 mapping consistent with myocarditis. A right ventricle biopsy revealed myocyte hypertrophy and patchy interstitial fibrosis without evidence of inflammatory tissue. She was diuresed, supported with inotropic therapy, and empirically treated with high doses of glucocorticoids. She clinically improved with weaning of inotropes and was discharged in stable condition on goal-directed medical therapy after 2.5 weeks.

Conclusion:
This patient represents a case of severe cardiogenic shock, after initial infection and in the absence of previously identified risk factors for development of COVID myocarditis. The absence of inflammatory tissue on pathology raises questions regarding the centrality of inflammatory processes in COVID-19-related myocardial injury leading to “long COVID” syndrome. These findings indicate the need for ongoing investigation of the long-term cardiovascular consequences of COVID-19.
Abstract 14367: Residual Cardiovascular Risk Despite Secondary Prevention: Data From Contemporary Cardiovascular Outcomes Trials Spanning 2010 - 2021
Authors: Korjian Serge , Daaboul Yazan , Bhatt Deepak L , Ridker Paul M , Yeh Robert W , Mehran Roxana , Baron Suzanne J , Libby Peter , Chi Gerald , Kalayci Arzu , Nara Paul , Shaunik Alka , Gibson C. Michael
Published: June 2023

Introduction:
Despite aggressive secondary prevention, a persistent risk of cardiovascular (CV) events exists among patients with coronary artery disease (CAD). In addition to traditional risk factors, this residual risk results, at least in part, from persistent pro-inflammatory and metabolic contributors. This study evaluated the incidence of recurrent CV events in contemporary CV outcome trials between 2010-2021.

Methods:
A total of 45 randomised, controlled trials were included. Studies were categorized based on patient population and enrollment strategy into 3 groups: 1) Early post-ACS (enrolled within 72h of event), 2) late post-ACS (enrolled after 72h of event), and 3) chronic CAD or risk equivalent (type 2 diabetes or 2 or more CV risk factors). Due to a wide range of follow-up durations, data were normalized to events per 100 patient-years.

Results:
Follow-up duration ranged from 30 to 2957 days. Overall, recurrent CV events varied between 2% and 10%. Trials that enrolled patients within 72h of ACS demonstrated the highest risk for recurrent events with a median of 21.8 events per 100 patient-years (IQR 11.3-66.0). Patients enrolled >72h after ACS had significantly lower risk with a median of 3.4 events per 100 patient-years (IQR 2.9-4.1), likely due to a survival bias in those enrolled later after their index event. The rate of recurrent events was comparable between trials that enrolled patients 72h post-ACS and trials that enrolled patients with chronic CAD. There was no correlation between trial year and event rate.

Conclusions:
Despite standard of care therapy, there is a persistent residual risk of recurrent events especially early after ACS. Our study demonstrates a residual risk ranging from 3 to as high as 22 events per 100 patient-years. This risk is likely higher in a non-trial setting where medication adherence and follow-up are not strictly controlled. Novel strategies for secondary prevention comprise a major unmet need to further decrease this risk.
Abstract 14375: Guideline Directed Medical Therapy After Peripheral Vascular Intervention and Association With Long-Term Outcomes at an Academic Health System
Authors: Hu Jiun-Ruey , Smolderen Kim G , Provance Jeremy A , Romain Gaelle , Baumbach Andreas , Velazquez Eric J , Lorusso Francine , Churchwell Keith , Schulz Wade L , Scierka Lindsey , Mena-Hurtado Carlos
Published: June 2023

Introduction:
Guideline-recommended medical therapy (GDMT) for cardiovascular risk reduction remains sub-optimally prescribed in patients with peripheral artery disease (PAD). To begin addressing this issue, it is key as a health system to be able to monitor electronic health record (EHR)-based real-world data to assess GDMT usage rates and its association with long-term mortality and amputation.

Methods:
We included all patients with PAD who underwent peripheral vascular interventions (PVI) across the Yale New Haven Health System in 2016-2022. GDMT at PVI discharge was defined as having all 3 of: angiotensin converting enzyme inhibitor/angiotensin receptor blocker (if hypertensive), antiplatelet, and statin. Propensity scores were calculated based on age, sex, race, ethnicity, and Elixhauser comorbidities. Inverse probability weighted Cox regression models with a random effect for site and provider were constructed to evaluate the relationship between GDMT and 2-year mortality and major amputation.

Results:
A total of 3,741 patients with PAD underwent PVI. The average age was 72.3 (± 12.9) years, and 39% were female. GDMT rates at PVI discharge ranged from 24% to 40% during the study period. Lack of GDMT at discharge had a statistically insignificant association 2-year mortality risk (hazard ratio [HR]: 1.21, 95% confidence interval [CI]: 0.98-1.50, p=0.07; figure top) and a significant positive association with 2-year major amputation risk (HR: 2.73, 95% CI:1.51-4.94, p<0.001; figure bottom).

Conclusions:
This study leveraged system-wide EHR data to study GDMT use and its association with mortality and major amputation, which may serve as a metric for quality of PAD care.
Abstract 14398: Novel Cardiac Electrical Activation Parameter Associated With CRT Response
Authors: Bilchick Kenneth C , Bivona Derek , Morales Frances , Sharma Puneet , Darby Andrew , Malhotra Rohit , Monfredi Oliver , Mason Pamela K , Mangrum J M , Oomen Pim
Published: June 2023

Introduction:
Simultaneous assessment of cardiac electrical activation and left ventricular (LV) function could identify optimal cardiac resynchronization therapy (CRT) pacing strategies, leading to improved CRT response and outcomes.

Hypothesis:
Changes in three-dimensional (3D) cardiac electrical activation timing correlate with LV function.

Methods:
3D cardiac electrical activation maps from the CardioInsight 252-electrode mapping vest (Medtronic) and cardiac ultrasound images were acquired during and 6 months after CRT defibrillator implantation. Maps were acquired for intrinsic electrical activation and three CRT pacing configurations: synchronized LV pacing, right ventricular (RV) pacing, and biventricular (BIV) pacing. Three novel electrical activation parameters were calculated: LV80, RV80, and BIV80, defined as the time at which 80% of the LV, RV, or both ventricles, respectively, were electrically activated.

Results:
In 30 CRT patients (65.6 ± 11.3 years old, 36.7% female, 43.3% with LV scar, 57% with left bundle branch block [LBBB], and 43% with right bundle branch block [RBBB]), simultaneous measurements of electrical activation and LV function were obtained. Figure panels A and B show representative plots of the proportion of the LV and RV activated versus time within the QRS for a patient with LBBB. In this patient, BIV pacing improved the LV80 but worsened the RV80 compared with the intrinsic rhythm, consistent with a discordant effect on ventricular function. Panel C shows that synchronized LV pacing has a more unfavorable effect on RV activation than BIV pacing in this patient. In the entire cohort, the BIV80 was significantly associated with the change in LVESVI six months after CRT (p<0.05) (panel D).

Conclusion:
A novel measurement of 3D cardiac electrical activation demonstrates the effects of different CRT pacing strategies on LV and RV function and predicts LV functional improvement after CRT.
Abstract 14400: Predicting In-Hospital Mortality Among Patients Admitted With Heart Failure: A Machine Learning Approach
Authors: He Rosemary , Jawadi Zina , Srivastava Pratyaksh , Khalil Suzan , Eskin Eleazar , Chiang Jeffrey , Nsair Ali
Published: June 2023

Introduction:
Patients hospitalized with heart failure (HF) experience high in-hospital mortality. Machine learning predictive models have the potential to identify heart failure patients at risk of adverse outcomes.

Methods:
Using the electronic medical record (EMR) at a large academic medical center, we identified 49,457 patients who were admitted with heart failure from 2011 to 2022. 71% were admitted with HF with reduced ejection fraction (HFrEF, EF≤40%) and 29% with HF with mildly reduced or preserved ejection fraction (HFmrEF/HFpEF, EF >40%). Using patient demographics, comorbidities, admission medications, labs, and vitals throughout the hospitalization, we constructed random forest machine learning models to predict in-hospital mortality. We compared model performance to that of logistic regression utilizing the same variables.

Results:
The median age (25th-75th percentile) of the cohort was 72 (59-83) years, and 45% of the group was female. 71% patients were admitted with HFrEF and 29% patients were admitted with HFmrEF/HFpEF. For the overall cohort, our machine learning model was able to predict in-hospital mortality with a sensitivity (SN) of 91%, a specificity (SP) of 85%, and an area under the curve (AUC) of 0.95 (Figure 1). For those with HFrEF, our model demonstrated a SN of 91%, SP of 87% and AUC of 0.95, and for those with HFmrEF/HFpEF, a SN of 87%, a SP of 89%, and an AUC of 0.94. For all three cohorts, our models outperformed logistic regression. The top predictors of in-hospital mortality were BNP, BUN, and Systolic BP for those admitted with HFrEF, and sex, creatinine, and diastolic BP for those with HFmrEF/HFpEF.

Conclusions:
Machine learning models built from EMR data have the ability to accurately predict in-hospital mortality among patients admitted for HF. Such prediction tools, when used in the appropriate context, may help flag hospitalized heart failure patients at high risk for in-hospital mortality.
Abstract 14409: Deep Learning Approach for Analyzing Chest X-rays to Predict Cardiac Events in Heart Failure
Authors: Kusunose Kenya , Hirata Yukina , Tsuji Takumasa , Kotoku Jun'ichi , Sata Masataka
Published: June 2023

Introduction:
A deep learning (DL) model based on a chest X-ray (CXR) was reported to predict elevated pulmonary artery wedge pressure (PAWP) as congestive heart failure (HF).

Hypothesis:
We hypothesize that a previously developed application of a CXR-based DL algorithm could also be used to predict re-hospitalized HF in patients with HF. This study aimed to 1) investigate the role of probability of elevated PAWP to predict clinical outcomes in association with other parameters, and 2) to evaluate whether probability of elevated PAWP based on DL added prognostic information to other conventional clinical prognostic factors in HF.

Methods:
We evaluated 192 patients hospitalized with HF. We used a previously developed AI model to predict HF and calculated probability of elevated PAWP in the study cohort. The primary endpoint was readmission following HF and cardiac death.

Results:
Probability of elevated PAWP was associated with echocardiographic parameters including left atrial size, filling pressure, and pulmonary artery pressure.

During a median follow-up period of 58 months, 57 patients were either readmitted or died. Probability of elevated PAWP appeared to be associated with worse clinical outcomes. After adjustment for readmission score and laboratory data in a Cox proportional-hazards model, probability of elevated PAWP at pre-discharge (per 1SD) was associated with event free survival, independent of elevated left atrial pressure (LAP) by echocardiography (hazard ratio:1.39, 95%CI:1.17-1.65, p<0.001). In sequential Cox models, a model based on clinical data (χ2, 16.8) was improved by elevated LAP (χ2,24.4;
p
=0.005), and increased further by probability of elevated PAWP (χ2,41.1;
p
<0.001).

Conclusions:
This study suggests that probability of elevated PAWP provides important incremental prognostic value for predicting readmission and cardiac mortality risk assessment in patients with HF.
Abstract 14411: Transcatheter Closure of Residual Leak Using Gore Cardioform Occluder After Failed Surgical Ligation of Left Atrial Appendage
Authors: Mandava Sri , Gade Akhil , Salagundla Nethuja , Thambidorai Senthil
Published: June 2023

Introduction:
In non-valvular atrial fibrillation, the left atrial appendage (LAA) is the most common site for thromboembolic formation. The current recommendation is that patients with afib and a CHA2DS2-VASC risk score >2 who undergo cardiac surgery should simultaneously have surgical left atrial appendage closure (Grade 1b). A rare complication that can occur includes incomplete LAA surgical closure with the residual leak, leading to an increased risk of stroke or thromboembolic events. We present two cases with residual leaks on follow-up after surgical ligation of LAA.

Methods:
Two patients aged 75 to 80 years old with a history of paroxysmal atrial fibrillation, surgical mitral valve repair, and surgical left atrial appendage ligation underwent a transesophageal echocardiogram (TEE) to evaluate the LAA. The CHA2DS2-VASC risk score was 3 for both patients. There was evidence of a residual leak greater than 5 mm between the left atrium and left atrial appendage.

Results:
Given the residual leak and risk scores, both patients had an increased risk of stroke. Therefore both patients underwent successful transcatheter closure of the left atrial appendage using a 20 mm Gore CARDIOFORM occluder. TEE was used to confirm no residual color flow and confirmed complete closure of the defects. Patients were continued on oral anticoagulation (DOAC) for six weeks with the plan to switch to antiplatelets.

Conclusions:
Studies have shown that surgical ligation of LAA can result in a residual leak which can increase the risk of systemic embolization. Following failed surgical ligation of LAA, transcatheter closure of residual leak with Gore CARDIOFORM occluder may be a safe and effective strategy for management. Further studies are needed to evaluate the safety, efficacy, and outcomes of utilizing a septal occluder device in patients with residual leaks due to failed surgical ligation of LAA.
Abstract 14421: Avoid Pericardiectomy in Transient Constrictive Pericarditis
Authors: Yaker Zachary S , Majid Muhammad , Linchangco Richard , Syed Alveena , Klein Allan L
Published: June 2023

Case Presentation:
A male in his 40s presented for chest pain, dyspnea and bilateral leg edema. He has a history of hypertrophic cardiomyopathy treated with septal myectomy complicated by constrictive pericarditis (CP) that was treated with right-sided pericardiectomy, NSAIDs, colchicine, and steroids. Echo showed LVEF of 55% with thickening of the pericardium, abnormal septal bounce, tethering of the right atrium, respiratory variation in flow across the mitral and tricuspid valves and IVC plethora. Cardiac MRI showed diffuse mild thickening of residual left-sided pericardium, mild diffuse circumferential pericardial enhancement, mild diastolic septal bounce, diastolic restraint, exaggerated inspiratory flattening and conical deformity of the ventricles without evidence of myocardial inflammation or scarring. Right heart catheterization showed near equalization of RV and LV pressures, RV and LV respiratory concordance, aortic pulsus paradoxus with an inspiratory decrease of 15 mmHg, and Kussmaul’s sign with an inspiratory increase in RA pressure of 68 mmHg. Left heart catheterization showed normal coronaries. The patient was diagnosed with CP and underwent repeat pericardiectomy and was treated with NSAIDs and diuretics. On follow-up, patient had symptomatic improvement but still had evidence of residual constriction on echocardiogram.

Discussion:
Pericardiectomy is the definitive treatment for CP, however it carries high morbidity and mortality rates. Recurrence of constrictive pericarditis requiring repeat pericardiectomy is very rare and risk factors for recurrence are not well-defined. His initial pericardiectomy was complicated with evidence of active visceral epicarditis with epicardial constriction. This case suggests that active inflammation at the time of pericardiectomy is a potential risk factor for recurrent CP requiring repeat pericardiectomy, and surgery should be deferred until the active inflammation has subsided.
Abstract 14424: Comparative Evaluation of Various Risk Scores in Non-ST-Segment Elevation Myocardial Infarction
Authors: Kunal Shekhar , Pathak Vijay , Pathak Pooja
Published: June 2023

Introduction:
Risk stratification is an integral component of the management strategy in patients with non-ST-elevation myocardial infarction (NSTEMI). Multiple risk scores have been proposed however, these have not been validated in developing countries such as India.

Hypothesis:
This study aims to determine the various prognostic factors in patients with NSTEMI as well as to compare and validate the performance of different risk stratification scores in these subjects.

Methods:
This was a single center prospective observational study wherein diagnosed with NSTEMI were enrolled. A detailed clinical history including symptomatology, presence of risk factors and family history were recorded. In all enrolled patients based on the prospectively collected data, five risk scores i.e. TIMI, GRACE version 2.0, PURSUIT, HEART and CAMI-NSTEMI were computed. Outcome data in terms of both in-patient as well as at 14 days, six months and one year major adverse cardiovascular events (MACE) were obtained.

Results:
A total of 1102 patients were enrolled with a mean age of 59.6
±
11.2 years. MACE occurred in 140/1102 subjects (12.7%) with mortality in 89 (8.1%) patients. Patients with MACE were elderly, had higher frequency of smoking, hypertension, diabetes and stroke. Multivariate logistic regression analysis revealed that angina in last 48 hours, diabetes, smoking, cardiac arrest on presentation and fragmented QRS on ECG were independent predictors of MACE. All risk scores were able to predict MACE events equally well however, for in-hospital MACE, TIMI risk score had the highest predictive ability. However, for 14-day, 6 month and one year MACE, GRACE scores had highest predictive ability.

Conclusions:
Our study showed that all risk scores had a good predictive ability for both short term as well as intermediate-term MACE events.
Abstract 14433: Rates of Serious Adverse Events During Home-Based Exercise in Lower Extremity Peripheral Artery Disease: Results From Three Randomized Clinical Trials
Authors: Nayak Pooja , Tian Lu , Zhao Lihui , Xu Shujun , McDermott Mary M
Published: June 2023

Background:
Home-based exercise is recommended by guidelines for people with lower extremity peripheral artery disease (PAD) to improve walking performance. This post-hoc analysis of three randomized clinical trials studied the association of home-based exercise, compared to control, on rates of serious adverse events in people with PAD.

Methods
Data were combined from three randomized clinical trials that compared home-based walking exercise to a control group that did not exercise. In all three trials, people with an abnormal baseline exercise stress test were excluded. Participants randomized to home-based exercise worked with a coach, who used behavioral methods to help them adhere to home-based walking exercise, consisting of walking for exercise five times per week for up to 50 minutes/session. The control groups received educational sessions instead of exercise. Participants were questioned each month about occurrence of serious adverse events, defined as hospitalizations, deaths, or events causing persistent disability.

Results
651 people with PAD from three randomized trials were included (mean age 70, 49% women, 53% Black). People randomized to exercise had higher rates of cardiovascular events than control (Table). Among those randomized to exercise, people with history of myocardial infarction (p=0.0002), angina (p=0.0004), stroke (p=0.03), pulmonary disease (p=0.02), and poorer baseline six-minute walk distance (280.29 vs 338.15 meters, p=0.0002) had higher rates of cardiovascular events.

Conclusion
In these post-hoc analyses, people with PAD randomized to a home-based walking exercise intervention had higher rates of cardiovascular events, compared to a control group during the trial. Further study is needed to determine whether this association represents a causal effect. People with PAD who have lower six-minute walk distance or a history of cardiovascular disease may require closer monitoring during a home-based exercise program.
Abstract 14439: Using Augmented Mean Arterial Pressure to Assess Post-Transcatheter Aortic Valve Replacement Mortality
Authors: Chao Chiehju , Agasthi Pradyumna , Seri Amith Reddy , Barry Timothy , Shanbhag Anusha , Wang Yuxiang , Eleid Mackram F , Fortuin Floyd D , Sweeney John , Pollak Peter , El Sabbagh Abdallah , Lester Steven , freeman william , Naqvi Tasneem Z , Holmes David R , Appleton Chris P , Arsanjani Reza
Published: June 2023

Introduction:
Post-transcatheter aortic valve replacement (TAVR) outcome of patients is an important research topic. To accurately assess post-TAVR mortality, we examined a family of new echo-parameters (augmented systolic blood pressure (AugSBP) and arterial mean pressure parameters (AugMAP)) derived from blood pressure and aortic valve gradient (
Figure 1
).

Methods:
Patients in the Mayo Clinic National Cardiovascular Diseases Registry-TAVR database who underwent TAVR between January 1, 2012, and June 30, 2017, were identified to retrieve baseline clinical, echocardiographic, and mortality data. The median of AugSBP and AugMAP were used to stratify patients in Kaplan-Meier analysis.

Results:
The final cohort contained 974 patients with a mean age of 81.4±8.3 years old, and 56.6% were male. The mean Society of Thoracic Surgeons risk score was 8.2±5.2. The median follow-up duration was 354 days, and the one-year all-cause mortality rate was 14.2%. Detailed characteristics are summarized in
Table 1.
AugMAP1 < 102.5 mmHg (median) was associated with a 3-fold risk of all-cause mortality post-TAVR at 1 year (hazard ratio 3.0, 95%confidence interval 2.0-4.5, p<0.0001)(
Figure 1
).

Conclusions:
Augmented mean arterial pressure provides clinicians with a simple but effective approach to quickly identify patients at risk and potentially improve post-TAVR prognosis.
Abstract 14440: Machine Learning-Based Approaches to Identify Diabetic Cardiomyopathy
Authors: Patel Kershaw , Segar Matthew , Vaduganathan Muthiah , Tang Wai Hong W , Willett Duwayne , Pandey Ambarish
Published: June 2023

Introduction:
Machine learning methodology can provide means for the identification of diabetic cardiomyopathy (DbCM), a severe and evolving complication of diabetes that leads to high morbidity and mortality. Phenotypic characterization of patient subgroups may support clinically relevant risk stratification in the population with DbCM.

Methods:
Among individuals with diabetes from the ARIC study cohort (training, n=953), unsupervised hierarchical clustering was performed with 24 candidate variables incorporating echocardiographic parameters, NT-proBNP, and hs-cTnT. The cluster with highest risk of HF was identified as DbCM. A deep learning (DL) classifier was developed to predict DbCM in the ARIC training cohort and validated in a pooled community-based cohort (ARIC testing plus CHS; n=1,050) and an electronic health record (EHR) cohort (n=3,139).

Results:
Clustering identified 3 phenogroups. Participants in group 3 (vs. 1 and 2) were more commonly men, had higher levels of creatinine, hs-cTnT, and NT-proBNP, higher LA size and LVMi, and increased prevalence of diastolic dysfunction and hypertension. The 5-year risk of HF was significantly higher in phenogroup 3 and thus identified DbCM (17.8% vs. 2.0% [phenogroup 2] vs. 3.5% [phenogroup 1]) (
Figure 1A
). The key predictors of DbCM were NTproBNP, LVMi, LA size, and diastolic dysfunction parameters (
Figure 1B
). The DL classifier demonstrated high model performance in identifying DbCM (AUROC = 0.96, accuracy = 0.93, and precision = 0.75). In the validation cohort (community-based), the DL classifier identified 16% of participants with DbCM with a two-fold higher risk of HF (HR [95% CI], 1.99 [1.47-2.67]; ref = no DbCM). A similar pattern of findings was observed in the EHR cohort (37% with DbCM; DbCM vs. no DbCM: HR [95% CI], 1.58 [1.17-2.12]).

Conclusion:
Machine learning-based techniques can be used to define and identify DbCM which is associated with higher risk of overt HF.
Abstract 14445: Patients With Peripheral Artery Disease Living in Food Deserts Are Associated With Worse Outcomes and Suboptimal Medical Therapy
Authors: El-Zein Rayan S , Nguyen Dan D , Fu Zhuxuan , Gosch Kensey , Bunte Matthew C
Published: June 2023

Introduction:
Major adverse cardiac events (MACE) represent important clinical outcomes for patients with PAD, while also disproportionally impacting minority populations. Guideline-directed optimal medial therapy (OMT) is known to reduce MACE events, but whether the OMT-adjusted rate of MACE events are influenced by social determinants of health, including living in a food desert (FD) has not been previously explored.

Methods:
Patients with PAD from a single-system registry were geocoded as living in a FD vs non-FD according to the US Department of Agriculture Food Access Research Atlas. FDs are characterized as census tracts with low income and poor food access (defined as proximity to a grocery store). MACE was defined as a composite of all-cause death, acute myocardial infarction, or stroke. OMT was defined as being prescribed antiplatelet, statin, renin-angiotensin inhibitors, and with tobacco abstention. Cox proportional hazards models examined the association of area characteristics (FD, poor access, low income) and MACE, adjusted for traditional factors. Multivariable logistic regression examined the association of demographic, clinical, and area characteristics with OMT.

Results:
From 2015 to 2021, 1,834 (15.4%) of 11,907 lived in FDs. Patients in FDs were more likely Black or Hispanic, residing in urban areas, had low vehicle access, and had a higher prevalence of hypertension, diabetes, and chronic kidney disease. Those living in FDs had a higher adjusted risk of MACE (HR 1.17 [1.04-1.31], p=0.008) driven by all-cause death (HR 1.19 [1.03-1.37], p=0.018). Female sex, malnutrition, COPD, CKD, and low area income were significantly associated with lower odds of achieving OMT.

Conclusions:
Living in food deserts is a major barrier to optimizing care and improving outcomes among patients with PAD. Future prospective studies should examine the impact of community and health policy interventions that mitigate poor food access.
Abstract 14453: Deep Learning Enabled Measurement of Cardiac Sphericity Predicts Disease Risk Among Subjects With Normal Left Ventricular Size and Function
Authors: Vukadinovic Milso , Kwan Alan C , Salerno Michael , Lee Daniel C , Albert Christine M , Cheng Susan , Li Debiao , Ouyang David , Clarke Shoa L
Published: June 2023

Introduction:
Cardiac imaging primarily focuses on measurements of chamber size and function. Quantitative assessment of morphology may provide additional prognostic information. Left ventricle (LV) sphericity has been proposed as one metric but has not been studied in large populations and is poorly characterized in patients with normal LVs. We aimed to assess the clinical relevance and genetic drivers of sphericity among individuals with normal LV size and systolic function using deep learning enabled phenotyping of cardiac MRIs.

Methods:
The study cohort consisted of UK Biobank participants with normal LV ejection fraction, LV end-systolic, and end-diastolic volumes by MRI. A fully convolutional neural network was used to perform image segmentation of cardiac chambers. The main exposure was the LV sphericity index, defined as the ratio of short-axis to long-axis lengths of the smallest rectangle encompassing the LV in a 4-chamber view. Risk for incident outcomes were measured using Cox analysis. Genome-wide association study (GWAS) was performed using HAIL software with standard quality-control. Genetic correlations were measured using linkage-disequilibrium score regression. Causal inference was performed using two-sample Mendelian randomization (MR).

Results:
We identified 38,897 subjects with normal LV volumes and ejection fraction. Mean age was 55 ± 8, and 54% were female. After adjusting for age, sex, BMI, hypertension, and pulse-rate, a 1 standard deviation increase in sphericity index was associated with increased risk of atrial fibrillation (HR 1.31, 95% CI 1.23-1.38, P <2x10
-16
) and cardiomyopathy (HR 1.62, 95% CI 1.29-2.02, P 2.4x10
-5
). GWAS of sphericity index identified 4 loci at genome-wide significance, with 3 candidate genes previously implicated in cardiac development and conduction. Sphericity index showed a genetic correlation with cardiomyopathy (
rg
0.42, P 0.01) but not with atrial fibrillation (
rg
0.04, P 0.5). Bidirectional MR analyses supported cardiomyopathy as being causal for sphericity but not the reverse.

Conclusion

LV sphericity in subjects with normal size and function is genetically mediated and may reflect subclinical manifestations of cardiomyopathic risk prior to LV remodeling by standard measures.
Abstract 14457: Cardiac MRI Results Following RFA and Cryoballoon Ablation: DECAAF II Subanalysis
Authors: Nelson Daniel , Dhore Aneesh , Mekhael Mario , Noujaim Charbel , El Hajjar Abdel Hadi , Marrouche Nassir
Published: June 2023

Introduction:
Radiofrequency (RFA) and cryoballon ablation are standard approaches for rhythm control of atrial fibrillation. Both strategies involve scar formation of the left atrial tissue. To date there have been no studies using post ablation cardiac magnetic resonance imaging (MRI) to assess residual fibrosis and scar created by standard radiofrequency and cryoballoon ablation.

Methods:
The current study is a sub analysis of the control group of the Delayed-Enhancement MRI Determinant of Successful Catheter Ablation of Atrial Fibrillation trial (DECAAF II). This was a multicenter, randomized, controlled, single blindedtrial that evaluated atrial arrhythmia recurrence (AAR) between PVI alone and PVI plus fibrosis guided ablation. Baseline MRI and 3-month post ablation MRI were obtained to assess lesion and scar formation.

Results:
Of the 843 patients randomized in the trial, 428 patients were in the control arm that received standard PVI alone. Of those 428 patients, 367 patients (85.7%) underwent RFA and 61 (14.3%) underwent cryoballoon ablation. Average procedure duration was 147 minutes for RFA and 107 minutes for cryoballoon (p = 0.001). The rate of AAR at 451 days was 42.0% in the RFA group and 45.9% in the cryoballoon group (p = 0.66). At the 3-month post MRI the RFA arm had significantly more left atrial scar formation compared to cryoballoon arm (8.8% vs. 6.4%, p = 0.001). Also, the RFA arm had more covered fibrosis (3.6% vs. 2.9%, p = 0.02) and less non-covered fibrosis (14.9% vs. 17.2%, p = 0.05) compared to the cryoballoon arm. The amount of scar formation did not predict AAR (p = 0.07).

Conclusions:
In this subanalysis of the DECAAF II trial, there was no significant difference in the rate of AAR between RFA and cryoballoon ablation. However, RFA caused significantly more left atrial scar compared to cryoballoon ablation on 3-month post MRI.
Abstract 14489: Non-ST-Elevation Myocardial Infarction in a Transgender Woman: A Case Report and Perspective Into an Emerging High-Risk Population
Authors: Hossain Afif , Wengrofsky Perry , Malangu Boniface , Kakar Parul , Saeed Qaisra Y , Gardin Julius
Published: June 2023

Clinical Case:
A 37-year-old transgender (TG) woman off gender-affirming hormonal therapy (GAHT) presented with substernal chest pain radiating to the left arm, worse with exertion and relieved with res. She was hypertensive and tachycardic on admission. Initial bloodwork revealed an elevated troponin I of 0.57 ng/mL, which peaked at 1.48 ng/mL. EKG on admission showed hyperacute T waves in the anterior leads without ST elevation (see Figure 1). She was diagnosed with non-ST elevation myocardial infarction (NSTEMI) and taken for left heart catheterization (LHC).

Decision-Making:
TTE showed preserved LVEF and basal inferior, basal inferolateral, basal anterolateral and mid-anterolateral hypokinesis. LHC showed proximal-to-mid right coronary artery (RCA) occlusion. After failed aspiration thrombectomy indicating calcified plaque, two overlapping drug-eluting stents (DES) were successfully deployed with restoration of flow. She was discharged home on aspirin, ticagrelor, atorvastatin, and carvedilol.

Discussion:
Despite a recent push to increase awareness, research and healthcare equality specific to lesbian, gay, bisexual, transgender, and queer (LGBTQ+) patients, a significant gap persists. Specifically, stress, inflammation, dyslipidemia, and thromboembolism predispose this understudied population to increased coronary artery disease (CAD) and myocardial infarction (MI). Accordingly, greater effort needs to be taken to mitigate preventable cardiac morbidity and mortality in this patient population.

Conclusion:
CAD in LGBTQ+ adults is well studied. However, there are few published studies on CAD specifically among TG men and women. National cross-sectional data highlights this disproportionate risk of CAD and MI among TG men and women relative to their cisgender female and male peers, a healthcare disparity recently emphasized by the AHA. Consequently, care must be taken to eliminate these aforementioned inequalities.