bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract 13248: The Impact of Instructions for Covering the Mouth and the Nose on Dispatch-Assisted Cardiopulmonary Resuscitation
Authors: Fukushima Hidetada , Asai Hideki , Yamamoto Koji , Kawai Yasuyuki
Published: December 2021

Introduction:
Under the SARS-CoV-2 pandemic, rescuers are recommended to cover their mouth and nose with a facemask or a cloth as well as victim’s mouth and nose when performing cardiopulmonary resuscitation (CPR). However, its impact on dispatch-assisted CPR (DACPR) has not been investigated well.

Hypothesis:
DACPR including the instruction for covering the rescuer’s and the victim’s mouth and nose can significantly delay the start of the first chest compression.

Methods:
We retrospectively analyzed DACPR records of the Nara Wide Area Fire Department, covering population of 853,000/3361km
2
, in Japan. We investigated the key time intervals of 505 DACPR records between May 2020 and March 2021. We also compared the results to that of the same period in 2019 (535 records).

Results:
Dispatchers failed to provide mask instruction in 322 cases (63.8%). The median time interval from the emergency call and the start of CPR instruction was longer in 2020 (197 seconds vs 190 seconds, p=0.641). The time to the first chest compression was also delayed in 2020 (264 seconds vs 246 seconds, p=0.015). Among the cases that dispatchers successfully provided mask instruction (183 cases, 36.2%), median time intervals to the start of instruction and the first chest compression were relatively faster than cases without mask instruction (177 seconds vs 211 seconds and 254 seconds vs 269.5 seconds, respectively).

Conclusions:
Dispatchers failed to provide mask instruction in the majority of CA cases. However, our study results indicate that the impact of mask instruction on DACPR can be minor in terms of immediate CPR provision.
Abstract 13298: Density, Coverage and Usage of Automated External Defibrillators in Out-of-Hospital Cardiac Arrest Across Europe
Authors: Kjoelbye Julie , Andelius Linn , Baldi Enrico , Auricchio Angelo , Blom Marieke , Jonsson Martin , Jørgensen Anne Juul , Hansen Carolina Malta , Folke Fredrik
Published: December 2021

Introduction:
Though deployment of Automated External Defibrillators (AEDs) is increasing rapidly, AEDs are often deployed in an un-strategic manner. Consequently, little is known about the association between AED density, AED coverage of out-of-hospital cardiac arrest (OHCA), and bystander defibrillation across different countries. This study aimed to investigate the differences in AED densities (AEDS/100,000 inhabitants/1,000 km2), the AED coverage of OHCAs, and bystander defibrillation across Europe.

Hypothesis:
AED density is directly associated with degree of bystander defibrillation across Europe.

Methods:
The study is a European Sudden Cardiac Arrest network towards Prevention, Education, New Effective Treatment (ESCAPE-NET) project. We included data from Ticino (Switzerland), Lombardy (Italy), and The Capital Region (Denmark) from 2019, covering over 3.7 million inhabitants. AED accessibility was defined as the AED being accessible 24/7 or not and AED coverage was defined as the OHCA being covered by an AED within 100, 250 and 500 meters. AED coverages were calculated the same way by all participants using a free software program (QGIS).

Results:
AED densities were: 87.3 for Ticino, 15.2 for Lombardy, and 139.4 for The Capital Region. The percentages of OHCAs covered by any AED and by 24/7 accessible AEDs are shown in Figure 1. The calculated AED density per 1% bystander defibrillation (for the percentage of OHCAs bystander defibrillated within 100, 250 and 500m of an AED) were 34.9, 17.5 and 15.6 for Ticino, 76.0, 50.7 and 38.0 for Lombardy and 19.4, 12.6 and 11.2 for The Capital Region.

Conclusion:
We found great variation in both AED coverage and 24/7 AED accessibility across regions, as well as marked differences in bystander defibrillation according to local AED density. Other factors like geographical differences in the regions, optimal AED placement and citizen responder programs for AED use might explain the observed differences.
Abstract 13347: Oxygen Metabolism After Cardiac Arrest: Patterns and Association With Survival
Authors: Berg Katherine M , Balaji Lakshman , Issa Mahmoud S , Donnino Michael W , Grossestreuer Anne V
Published: December 2021

Introduction:
How mitochondrial damage from cardiac arrest (CA) and resuscitation affects oxygen metabolism, and whether changes in metabolism are associated with outcome, is not well understood. We previously reported an association between higher oxygen consumption (VO2) in the first 12 hours after return of spontaneous circulation (ROSC) and survival in 17 post-arrest (PA) patients. The present study was conducted to investigate the association of VO2, VCO2 and RQ with survival in a larger PA cohort.

Methods:
From adult patients enrolled in several CA trials at our center, we selected those receiving targeted temperature management with ≥60 minutes of post-ROSC metabolic data collected in the first 24 hours after ROSC, using a gas exchange monitor that measures continuous VO2, VCO2 and RQ.The area under the curve (AUC) for VO2, VCO2 and RQ was calculated using all available values in the first 12 and 24 hours after ROSC. For both time periods, logistic regression was used to describe the relationship between survival and each AUC. We adjusted for temperature, sedation, and vasopressor
s.
Hourly medians were plotted by survival.

Results:
Of 64 patients included, 32 (50%) survived. There was no significant association between survival and AUC-VO2 or AUC-VCO2 in the first 12 (n=43) or 24 (n=64) hours after ROSC. 21 (49%) had a median RQ <0.7 in the first 12 hours, and there was an association between survival and AUC-RQ in this time period (see table).

Conclusion:
There were no significant associations between VO2, VCO2 and survival in the first 12 and 24 hours after ROSC. RQ was abnormally low in many patients, and higher RQ in the first 12 hours after ROSC was associated with survival.
Abstract 13393: Liraglutide Improves Myocardial Redox State in Humans by Regulating the Adipose Tissue-Derived Long-Chain Ceramides
Authors: Akawi Nadia , Checa Antonio , Akoumianakis Ioannis , Farid Shakil , Srivastava Vivek , Krasopoulos George , Channon Keith M , Wheelock Craig , Torekov Signe S , antoniades Charalambos
Published: December 2021

Introduction:
A notable reduction in major adverse cardiovascular events and cardiovascular mortality was observed in several cardiovascular studies via treatment with liraglutide, which have been suggested to be mediated through several mechanisms including inhibition of oxidative stress.

Hypothesis:
We hypothesised that treatment with liraglutide reduces oxidative stress via modulating circulating levels of long-chain ceramides.

Methods:
We measured vascular superoxide production using lucigenin-enhanced chemiluminescence and levels of circulating ceramides using LC-MS/MS in 633 participants of the Oxford Heart Vessels and Fat (OxHVF) cohort. We also measured 33 sphingolipid species (SPL) in plasma from 32 obese individuals (average BMI 33.5±2.5kg/m
2
at inclusion) participating in a randomized clinical trial (RCT) of low calorie diet and liraglutide.

Results:
We found a significant association between superoxide production by internal mammary arteries (IMA) and circulating levels of long-chain ceramides (C16:0, C17:0, C18:0, C18:1)
(A-D)
. In the RCT, all participants adhered to an 8-week low-calorie diet (800 kcal/day)
(E)
, during which they lost 9.9±6.0 kg of body weight exhibiting a significant reduction in BMI (
p
<0.0001), which was paralleled by significant effects on the circulating levels of SPL
(F)
. Following this initial phase, the patients were randomised to liraglutide treatment (1.2 mg daily) or no treatment, for a period of 52 weeks. Liraglutide treatment differentially affected several SPL species compared to the control group despite no significant changes in BMI in any of the two groups
(G-J)
.

Conclusions:
In this study, we observed for the first time in human a regulatory effect of liraglutide on the circulating levels of long-chain ceramides that are shown to be associated with vascular oxidative stress suggesting a promising mechanistic link that justifies further exploration.
Abstract 13623: Predicting Acute Kidney Injury Using Biomarkers of Renal Injury Following Cardiac Arrest
Authors: Pawar Rahul D , Roessler Lara L , Issa Mahmoud S , Grossestreuer Anne V , Holmberg Mathias Johan J , Cole Andrew , Liu Xiaowen , Donnino Michael , Moskowitz Ari
Published: December 2021

Aim:
Acute kidney injury (AKI) after cardiac arrest (CA) is common and associated with worse outcomes. We aimed to evaluate the performance of kidney specific biomarkers including kidney injury molecule-1 (KIM-1), neutrophil gelatinase-associated lipocalin (NGAL) and cystatin-C in predicting AKI post-CA as compared to serum creatinine.

Methods:
Patients with kidney specific biomarkers collected as part of randomized trials conducted in adult post-CA populations (NCT02260258, NCT01319110) were included. Patients with Kidney Disease Improving Global Outcome (KDIGO) stage III AKI immediately after enrollment and patients not enrolled at the coordinating center were excluded. Creatinine, KIM-1, NGAL and cystatin-C were measured immediately before enrollment. The primary outcome measure was KDIGO stage III AKI in the first 7-days after enrollment. We determined the association and discrimination of renal biomarkers with relation to KDIGO stage III AKI.

Results:
Of 63 patients included, 12 (19.1%) developed stage III AKI and 40 (63.5%) died prior to hospital discharge. As compared to patients who did not develop stage III AKI, those who developed stage III AKI had higher baseline serum creatinine (1.75 [IQR:1.3, 2.75] vs 1.3 [1.1, 1.7], p=0.04), higher NGAL (879 [IQR: 442,1194] vs 234 [IQR: 163, 482], p<0.001) and higher cystatin-C (2567 [IQR: 1222,3835] vs 1248 [IQR: 808,1691], p=0.01). There was no difference in KIM-1 (-1.70 [IQR: -2.79, -0.40] vs -1.87 [IQR: -2.70, -1.27], p=0.57). Of the various biomarkers, NGAL measured early after return of spontaneous circulation had the highest discrimination for the future development of stage III AKI [AUROC 0.81 (95%CI:0.69-0.93)] as compared to creatinine [AUROC 0.69 (95%CI: 0.51-0.87)], and cystatin-C [AUROC 0.74 (95%CI:0.57-0.90)] though the difference in AUROC was not significant (p>0.05 for all comparisons). KIM-1 had lowest discrimination [AUROC 0.55 (95%CI:0.34-0.76)].

Conclusion:
In post-CA patients enrolled in the two clinical trials, NGAL measured early after CA had the highest discrimination for the development of stage III AKI though the discrimination was not significant compared to creatinine possibly due to small sample size.
Abstract 13686: Variation in Time in Therapeutic Range for Cooling for Out-of-Hospital Cardiac Arrest
Authors: Wheelock Kevin M , Chen Lian , Girotra Saket , Chan Paul S , Khera Rohan
Published: December 2021

Introduction:
For comatose survivors of out-of-hospital cardiac arrest (OHCA), targeted temperature management (TTM) is strongly recommended with a goal temperature of 32-36C for a period of at least 24 hours. However, adherence to this target in clinical practice remains unknown. We developed time-in-therapeutic range (TTR) as a treatment metric for patients receiving TTM and evaluated patient- and site-level variation in TTR.

Methods:
We used data from the Resuscitation Outcomes Consortium-CCC trial which included patients with OHCA across 10 North American sites during 2011-2015. We identified patients who underwent TTM for >12 hours. Serial temperature measures were evaluated between hypothermia start and end times with temperatures between consecutive measures imputed using a linear interpolation method. TTR was defined as percent of time between 32C and 36C during TTM (Fig A). Site was defined based on trial clusters, which represented hospitals served by the same EMS agency. Site-level variation in TTR<90% was evaluated in hierarchical logistic regression using median odds ratio (OR), after adjustment for patient-level factors.

Results:
A total of 2,695 patients across 49 clusters were included with a median of 45 (IQR: 34 - 52) patients per cluster. The median duration of hypothermia was 23 (IQR: 21 - 24) hours with a median time outside therapeutic range of 0.9 (IQR: 0.0 - 4.2) hours. The median TTR was 96.1% but 1,654 (61%) patients had at least one temperature outside the therapeutic range and 991 (37%) patients had a TTR <90%. There was large variation across sites in the proportion of patients with TTR<90%, ranging from 10% to 68%, with a median OR of 1.74 (Fig B).

Conclusions:
Within a large randomized controlled trial, more than 1 in 3 OHCA patients treated with TTM had a TTR <90%, with large variation in TTR across sites. These findings highlight an urgent need to focus on improving quality of TTM in clinical practice.
Abstract 13747: Targeting Urokinase-Type Plasminogen Activator (uPA) and the uPA Receptor, Reduces Vascular Inflammation and Lung Hemorrhage in Systemic Lupus and SARS CoV2 Infection in Mouse Models of Respiratory Distress Syndromes
Authors: Zhang Liqiang , Yaron Jordan R , Schutz Lauren , Aliskevich Emily , Browder Kyle , Saldevar Nicholas , Zanetti Isabela R , Elmadbouly Nora , Glenn Honor , Li Yize , Kibler Karen , Hogue Brenda , McFadden Grant , Lucas Alexandra R
Published: December 2021

Introduction:
Acute respiratory distress syndromes with vascular inflammation and alveolar hemorrhage have high mortality and limited treatment. Autoimmune disease and severe viral infection cause vascular inflammation and hemorrhage. Serine protease coagulation pathways increase inflammatory cell activation and damage. Viruses have evolved highly effective immune modulating
ser
ine
p
roteinase
in
hibitors,
serpins
. Myxomavirus Serp-1 improves survival and reduces inflammation, vasculitis and lung hemorrhage in MHV68 gamma herpes infections (P < 0.01). Serp-1 also reduces Lupus alveolar hemorrhage (DAH) and proved safe and effective in a randomized, blinded, dose escalating trial in patients with coronary stent implant.

Hypothesis:
We hypothesize that treatment with PEGylated Serp-1 (PEGSerp-1) will reduce hemorrhage and inflammatory vasculitis in autoimmune and infectious lung disease.

Methods:
Pristane induced DAH and SARS-CoV-2 virus infections were treated with PEGSerp-1 in mouse models.

Results:
Serp-1 and PEGSerp-1 given daily IP for 14 days significantly reduced pristane induced DAH (N = 30 C57Bl/6 mice; P < 0.05) at 14 days follow up. PEGSerp-1 also reduced lung hemorrhage given for 7days treatment (N = 6 mice; P <0.01) or when given 7 days after pristane induction of DAH (N = 6 mice; P < 0.01). Macrophage invasion (P < 0.01), Prussian blue staining for hemosiderosis, C5b-9 complex deposition and soluble uPAR (suPAR) were significantly reduced with PEGSerp-1 treatment. PEGSerp-1 given daily after SARS-CoV-2 infection (48hrs, BALB/c mice, N = 16) also significantly reduced lung inflammation; decreased F4/80+ and iNOS+ macrophage staining (P < 0.02). Virus titer was also reduced in TMPRS2+ Vero cells (10μg/mL), and in SARS infected lungs. PEG Serp-1 homes to areas of pristane lung damage, but not normal lungs, indicating targeting of protease activation. No adverse effects were detected.

Conclusion:
Treatment for vascular inflammation and hemorrhage in severe autoimmune and virus induced respiratory distress syndromes is very limited. Targeting thrombolytic and inflammatory serine protease uPA/ uPAR complex activation provides a new therapeutic approach to severe respiratory distress in autoimmune disease and viral infection.
Abstract 14171: Prehospital Outcomes and Patient Characteristics Associated With PulsePoint Dispatches for Out-of-Hospital Cardiac Arrest in Pittsburgh, Pennsylvania
Authors: Salcido David , Martin-Gill Christian , WEISS LEONARD , Salcido David D
Published: December 2021

Background:
Mobile phone-based dispatch of volunteers to out-of-hospital cardiac arrest (OHCA) has been shown to increase the likelihood of early chest compressions and AED application. In the United States, limited characterization of patients encountered as a result of such systems exists, including PulsePoint Respond, a smartphone-based volunteer dispatch system.

Objective:
Examine prehospital case characteristics and outcomes from a multi-year deployment of PulsePoint in Pittsburgh, Pennsylvania.

Methods:
Case data, including PulsePoint determinant triggers and timing, prehospital electronic health records (EHRs), and computer aided dispatch records were obtained for suspected EMS-treated OHCA cases that did and did not generate PulsePoint alerts within the service area of Pittsburgh EMS for the period July 2016 to October 2020. EHRs were reviewed to determine true OHCA status, and OHCA case characteristics were extracted according to the Utstein template. Key characteristics and the outcome of prehospital return of spontaneous circulation (ROSC) were summarized and compared between cases with and without PulsePoint dispatches. Chi-squared tests were used to determine statistical significance of relationships.

Results:
There were 1229 OHCA cases overall in the capture period, with an estimated 29.6% occurring in public. Of 840 total PulsePoint dispatches, 68 (8.1%) were for true OHCA. Forty-five (66.2%) of these were witnessed, 43 (63.2%) received bystander CPR, and 17 (25%) had an AED applied prior to first responder arrival. Twenty-seven (39.7%) had an initial shockable rhythm, and 34 (50%) achieved ROSC in the field. Compared to non-PulsePoint dispatch generating OHCA, PulsePoint alert-associated patients were significantly more likely to be male (p=0.024), have bystander CPR/AED application performed (p<0.001), have an initial shockable rhythm (p<0.001), and achieve ROSC (p<0.001). EMS response time, age, ALS response time, and witnessed status were not significantly different.

Conclusions:
A minority of PulsePoint dispatches in Pittsburgh were triggered by true OHCA. Among cases that did generate a PulsePoint dispatch, case characteristics were prognostically favorable.
Abstract 14258: Modulation of Kynurenine Pathway to Prevent Brain Injury After Cardiac Arrest and Cardiopulmonary Resuscitation in Mice
Authors: Magliocca Aurora , Perego Carlo , Motta Francesca , Merigo Giulia , Fumagalli Francesca M , Micotti Edoardo , Latini Roberto , Ristagno Giuseppe
Published: December 2021

Introduction:
Kynurenine pathway (KP) is emerging as one of the potential components affecting cardiac arrest (CA) outcomes. The aim of this study is to evaluate the effects of KP inhibition through genetic deletion of the rate-limiting enzyme of the KP, indoleamine-2,3-dyoxygenase (IDO) on survival and neurological outcome after CA.

Methods and Results:
Sixteen adult male wild-type (WT) and IDO-deleted (IDO
-/-
) mice were subjected to 8 min untreated CA followed by resuscitation. At baseline heart rate and mean arterial pressure (MAP) did not differ among groups. At the time of return of spontaneous circulation, 30 and 60 min later, MAP was higher in the IDO
-/-
group compared to the WT one (p=0.0005). IDO
-/-
mice showed higher survival compared to WT at 7 days after CA (68.5% in IDO
-/-
vs 37.5% in WT; log rank p=0.036). Neurological function was higher in IDO
-/-
than in WT mice during the 7 days following CA (p=0.0124). IDO
-/-
mice also showed an improved locomotor function compared to WT mice (p=0.037). Brain magnetic resonance imaging (MRI) with diffusion tensor imaging (DTI) sequences showed a reduction in fractional anisotropy in the external capsule of the corpus callosum in WT mice compared to IDO
-/-
mice at 7 days after resuscitation (p=0.015). We then treated additional IDO
-/-
mice with L-kyn 15 min before CA, to revert the IDO
-/-
phenotype. Brain MRI with diffusion-weighted imaging (DWI) sequences and histological analysis were performed 24h after CA in WT, IDO
-/-
, and IDO
-/-
+L-Kyn mice. Brain MRI revealed restriction of water diffusivity 24h after CA in WT mice. IDO-deletion reduced water diffusion abnormalities while the beneficial effect was reverted in the L-kyn group (p=0.01). Degenerating neurons in the frontal cortex, represented as Fluoro-Jade B positive cells, were more numerous in WT compared to IDO
-/-
mice; L-kyn halted this IDO deletion-induced reduction in degenerating cells (p=0.05).

Conclusion:
KP inhibition improves survival and neurological outcome after CA. The neuroprotective effect of IDO-deletion was associated with preservation of brain white matter microintegrity and with reduction of cerebral cytotoxic edema. Reversal of these beneficial effects by L-kyn administration in IDO
-/-
mice further confirm the KP role in CA outcome.
Abstract 14264: National Comparison of Hospital Market Share for Out-of-Hospital Cardiac Arrest and Elective Cardiac Surgery
Authors: Buckler David G , Abbott Ethan , Abella Benjamin , Carr Brendan G , Wiebe Douglas , zebrowski alexis
Published: December 2021

Introduction:
Competition in the healthcare market is a theoretical driver of innovation, cost-savings, and improved quality. When patients are treated for certain emergent conditions, such as out-of-hospital cardiac arrest (OHCA), individuals have less choice in their treating hospital. For patients undergoing elective cardiac valve replacement surgery (EVRS), hospital choice may reflect distinct referral patterns and preferences. Our objective was to compare hospital market share for different cardiac services, thus allowing for better understanding of the care landscape and target interventions to improve outcomes.

Methods:
Using age-eligible Medicare fee-for-service institutional claims, an emergency department (ED) treated OHCA cohort was identified via ICD-9/10 diagnosis codes and ED charges. EVRS, an inpatient referral procedure, were identified from in-patient summary claims using procedure codes. Market shares were built for each hospital by sequential addition of ZIP-code areas and calculating the hospital’s cumulative market share. Geographic market share areas were defined for each hospital at 90%, 25% and 10% cut-offs if present. Correlation between corresponding market shares and patient counts were assessed using Pearson’s r.

Results:
Between 1/2013 and 12/2015, we identified 206,162 EVRS claims and 222,018 OHCA claims. Median age was similar (77 vs 78 yrs), as was percent of female patient (43% vs 44%). Very few beneficiaries (0.38%) appeared in both cohorts. Many more hospitals cared for OHCA than EVRS (4482 vs 1170). More OHCA treating hospitals achieved a 25% market share (68% vs 57%) however, EVRS hospital with a 25% market share covered more population (420,294 vs 66,394) and had a greater client radius (21 vs 15 miles). Among the hospitals providing care to both cohorts, the cumulative market share and patient counts were positively correlated (r = 0.49 and 0.46 respectively, p<0.001 for both).

Conclusion:
Despite many more hospitals providing care for OHCA, the market share for EVRS and OHCA trend together. This market trend, combined with the association of better outcomes with higher OHCA volume suggests that OHCA should be regionalized within markets to facilities that provide elective cardiac surgical procedures.
Abstract 14468: Machine-Learning Identifies Out-of-Hospital Cardiac Arrest Patients With Higher Probability of Survival While Undergoing Extracorporeal Cardiopulmonary Resuscitation
Authors: Crespo Ruben , Wastvedt Solvejg , Wolfson Julian A , Yannopolous Demitris , Bartos Jason
Published: December 2021

Introduction:
Neurologically favorable survival following OHCA depends on many factors including patient age, presenting rhythm, bystander CPR, CPR duration, and return of spontaneous circulation (ROSC). This study aims to utilize machine learning to construct predictive models of neurologically favorable survival in OHCA patients receiving standard ACLS and extracorporeal cardiopulmonary resuscitation (ECPR).

Methods:
3011 patients from the Amiodarone, Lidocaine, Placebo Study (ALPS) were analyzed using supervised and unsupervised machine learning approaches based on several variables available at the time of hospital presentation after OHCA. Machine learning platforms were developed to create real world predictive models of resuscitation. The model was then refined for 180 patients from the UMN-ECPR study with refractory VF/VT cardiac arrest who underwent ECPR. Resuscitative variables were selected and ranked on the likelihood ratio of predicting survival.

Results:
Machine learning analysis of the ALPS cohort yielded a model of survival with an area under the receiver-operating characteristic curve (AUC) of 0.92. ROSC, CPR duration and age were the highest determinants of neurologically favorable survival. The model was tested on the UMN-ECPR cohort, showing an AUC of 0.74 with a sensitivity and negative predictive value for survival of 12% and 60%, respectively. Machine learning was again used to render a model tailored for the UMN-ECPR group. The ECPR predictive algorithm had an AUC of 0.83, sensitivity and negative predictive value for survival of 70% and 80%, respectively, in which presenting rhythm to the cath lab, ROSC and CPR duration were the main determinants of neurologically favorable survival.

Conclusion:
Simple and effective predictive algorithms can predict the outcomes of cardiac arrest using only cardiac arrest characteristics. Use of ECPR changes the predictive determinants substantially. While this information is helpful in the appropriate context, the specificity required to withdraw care or halt resuscitation will require further data points and refinement.
Abstract 14505: Determinants of Stabilization for Out-of-Hospital Cardiac Arrest Patients Undergoing Extracorporeal Cardiopulmonary Resuscitation
Authors: Crespo Ruben , Kosmopoulos Marinos , Yannopolous Demitris , Bartos Jason
Published: December 2021

Introduction:
Sudden cardiac arrest causes approximately 400,000 deaths in the United States per year. Extracorporeal membrane oxygenation (ECMO), in conjunction with coronary interventions, was shown to improve survival for patients with refractory shockable rhythms in the ARREST trial. However, it remains unclear which parts of the protocol are critical for hemodynamic stabilization in these patients. Therefore, this study aims to assess patient status through each step of the ARREST trial protocol.

Methods:
Retrospective assessment was performed in 185 adults with refractory ventricular fibrillation/ventricular tachycardia out-of-hospital cardiac arrest transported for ECPR. Continuous variables were compared using parametric or non-parametric testing when normality was not met. Chi-square was used to compare categorical values and linear regression models to compare associations between survival and angiographic characteristics.

Results:
Distribution data showed 32% of patients achieved ROSC prior to extracorporeal membrane oxygenation or coronary intervention, though they had ongoing cardiogenic shock. ECMO provided hemodynamic stabilization with an organized cardiac rhythm in 31% of patients prior to coronary intervention. ECMO and coronary revascularization was required for hemodynamic stabilization and development of an organized cardiac rhythm in 30% of patients. The remaining 7% of patients failed to achieve ROSC despite ECMO, revascularization, and medical therapy. The angiographic profile from each of these groups was evaluated and showed that 63% of all patients had obstructive CAD including 48% of patients that arrived with ROSC and cardiogenic shock, 71% of patients that stabilized with ECMO alone, and 100% of patients that achieved ROSC after coronary interventions (p<0.01).

Conclusions:
Coronary revascularization is not required for stabilization of most patients. However, the impact of coronary artery disease on recovery potential is not known.
Abstract 16803: Cabozantinib Induced Cardiomyopathy; Second Reported Case Of A Rare Adverse Effect
Authors: Tanveer Ud Din Mian , Asawa Palash , Joseph Namita , Radhakrishnan Anita
Published: December 2021

Case Presentation:
A 27-year-old female with no prior medical history was diagnosed with metastatic paraganglioma in 2016. She was started on Cyclophosphamide, Vincristine and Dacarbazine and eventually transitioned to Pembrolizumab for 2 years. Due to progression of disease, she was started on compassionate 40 mg daily Cabozantinib in 2019. Echocardiogram at that time revealed normal ventricular function. One month later, she presented with new onset hypoxic respiratory failure. ProBNP was elevated to 7854 pg/nl. TTE showed moderate pericardial effusion with cardiac tamponade physiology and LVEF of 30%. Cabozantinib was discontinued due to elevated LFT. Repeat TTE after 1 month showed recovery of LVEF to 55% and only trace pericardial effusion. Due to her aggressive malignancy Cabozantinib was reinitiated at 20mg daily. Her LVEF remained stable on multiple serial TTE for 1 year so an attempt at Cabozantinib 40 mg was made once again. One month later, she had worsening dyspnea and TTE showed LVEF drop to 35%. Cardiac MRI revealed LVEF 37% with a moderate pericardial effusion along with gadolinium uptake consistent with perimyocarditis. Cabozanitib was discontinued and Colchicine 0.6 mg daily started. Eventually, LVEF normalized and pericardial effusion resolved. Patient was restarted on Cabozanitib 20mg and has remained stable from a cardiovascular standpoint

Discussion:
In the past decade the rise of tyrosine kinase inhibitors, like Cabozantinib, have transformed the scope of medical oncology. In 2019 Al hussein et al described the first case of Cabozantinib induced cardiomyopathy. We present, to our knowledge, the second reported case. This case identifies a strong temporal relationship between Cabozantinib, LV systolic dysfunction and perimyocarditis with higher doses. Interestingly, our patient received Pembrolizumab for 2 years, but had heart failure symptoms only 1 month after Cabozanitib initiation. Although theoretically possible, it is unlikely Pembrolizumab was the cause, given normal TTE 2 years after initiation and strong temporal relationship to Cabozantinib. Further studies are required to establish the cardiotoxic side effects of Cabozantinib and inform guidance on cardiac monitoring.
Abstract 16925: Covid-19 Vaccine Associated Acute Myocarditis
Authors: Goel Mishita , Jerome Aldin , Khanam Verisha , Chawla Raashi , Choksi Nishit
Published: December 2021

Case Presentation:
A 19 year old male presented with sudden onset chest pain radiating to back. He was a smoker and denied using cocaine since his last hospitalization for cocaine-induced myocardial infarction 2 years ago. UDS was negative. EKG showed normal sinus rhythm with no ST-T wave changes. Initial troponin was 0.850. Potassium levels were low at 2.9 mmol/L but other labs were normal. Chest CT angiography ruled out aortic dissection. He was started on heparin drip. Stat Echocardiogram showed LVEF of 55-60% with no wall motion abnormalities. Repeat potassium levels normalized after replacement, however, his troponins were trending up from 3.9 and 11.5. He continued to complain of severe chest pain, so underwent cardiac catheterization which showed normal coronary arteries and LVEF 55-60%. Heparin drip was discontinued and NSAIDs and colchicine were started. Cardiac MRI
(see Figure)
was done that showed patchy mid-wall and epicardial delayed gadolinium enhancement involving the basal inferolateral wall, with mild hyperintense signal on the triple IR sequence, suggestive of myocarditis. On further probing, he reported receiving a second dose of Moderna COVID vaccine 3 days prior to presentation.

Discussion:
In December 2019, a novel RNA virus causing COVID-19 infection was reported, which quickly reached a pandemic level. COVID-19 vaccines were granted emergency use authorization by FDA. With millions of people receiving COVID-19 vaccinations worldwide, rare adverse effects are now being reported. The benefits of vaccination undoubtedly outweigh any minor side effects. However major adverse effects like this are potentially fatal. This case report warrants further investigation into the association of myocarditis with COVID-19 vaccinations and further recommendations regarding vaccination in younger adults.
Abstract 16926: Outside The Box But All Squeezed In: A 23-year-old Man With Progressive Dyspnea After Overseas Travel
Authors: Glynn Peter A , Hughes Zachary , Ghafourian Kambiz , Beahan Maribeth , Mikati Issam A , Cohn Susan , Bachta Kelly , Malsin Elizabeth , Rustad Andrea , Zhou Xiaolong (Alan) , Khan Sadiya
Published: December 2021

Case Presentation:
A 23-year-old previously healthy man presented with progressive dyspnea. Physical examination revealed jugular venous distension and lower extremity edema. Laboratory testing demonstrated elevated B-type natriuretic peptide (193 pg/mL) and normal high sensitivity troponin. Echocardiogram revealed small pericardial effusion, respiratory variation in diastolic flow across the mitral valve, diastolic septal bounce, and annulus reversus (
Figure
). The differential diagnosis for constrictive pericarditis was broadly considered in the context of a recent febrile illness and frequent travel to Hawaii and Vietnam; we included infectious, autoimmune, and malignant etiologies. Cardiac magnetic resonance imaging revealed thickening and diffuse enhancement in the pericardium as well as ventricular interdependence. Chest CT identified hilar and anterior mediastinal lymphadenopathy. Laboratory testing was positive for QuantiFERON gold and negative for COVID-19, HIV, and ANA. Transbronchial biopsy demonstrated non-necrotizing granulomas with negative acid-fast bacilli smear, culture, and polymerase chain reaction for mycobacterial DNA. Re-examination identified a red-brown plaque on the patient’s thigh; biopsy showed granulomatous inflammation and rod-shaped organism with positive FITE staining. A presumed unifying diagnosis was made of extrapulmonary tuberculosis (TB) complicated by constrictive pericarditis.

Discussion:
Despite being a primarily pulmonary disease, systemic involvement can occur with TB with the heart being one of the most common extrapulmonary sites. This case highlights 1) the utility of extra-cardiac diagnostic testing (e.g., dermatologic biopsy) in the diagnosis of constrictive pericarditis, and 2) the diagnostic challenge associated with extrapulmonary TB, particularly paucibacillary disease that requires a detailed social history with “out-of-the-box” thinking.
Abstract 16928: Amiodarone For Atrial Fibrillation In The Setting Of Cardiogenic Shock And Thyroid Storm
Authors: Patel Ashish , Jang Sae , Saba Samir
Published: December 2021

Case Presentation:
A 29-year-old man with a history of hyperthyroidism presented to an outside hospital with altered mentation and palpitations in the setting of non-adherence to thyroid medications. He was found to be in atrial fibrillation with rapid ventricular response. Initial vital signs included a heart rate of 165 beats/min, respiratory rate of 43 breaths/min, blood pressure of 134/115 mmHg, and O2 saturation of 94% on 2L of oxygen. Point of care ultrasound showed an EF of 10% and a dilated IVC. Labs showed a creatinine of 0.7 mg/dL, total bilirubin of 3.9 mg/dL, ALT of 39 IU/L, AST of 62 IU/L, ALP of 181 IU/L, lactate of 7.6 mMol/L, TSH of < 0.01 uIU/mL, free T4 of > 5.00 ng/dL, and a T3 of > 30.00 pg/mL. He was treated with methimazole and then switched to propylthiouracil (PTU). Esmolol and diltiazem resulted in worsening cardiogenic shock and PEA arrest twice requiring VA ECMO cannulation. Upon transfer to our facility, he was started on potassium iodide (SSKI). He had electrical cardioversion twice with reversion back to atrial fibrillation. He was then started on amiodarone and digoxin. He remained in atrial fibrillation but achieved rate control with heart rates in the 100s.

Discussion:
Amiodarone is typically avoided in atrial fibrillation in the setting of thyrotoxicosis due to its high iodine content which can precipitate further thyroid hormone synthesis. However, in the setting of cardiogenic shock, treatment options are limited. We learned from our endocrinology colleagues that amiodarone can be beneficial when patients are treated with PTU and SSKI as amiodarone blocks the conversion of T4 to T3. Amiodarone should be started after PTU as PTU prevents thyroid hormone synthesis and blunts the effect of the iodine load of amiodarone. In conclusion, amiodarone can be considered earlier for the treatment of atrial fibrillation in the setting of thyrotoxicosis especially if treatment options are limited by cardiac dysfunction granted the patient has been started on PTU.
Abstract 16932: Primary Hyperaldosteronism And Resistant Hypertension In Pregnancy
Authors: Koczo Agnes , Countouris Malamo E , Hauspurg Alisse , Berlacher Kathryn
Published: December 2021

Case Presentation:
A 42-year-old woman with history of primary hyperaldosteronism (PA), IDDM and chronic kidney disease stage 3b (baseline Cr 2.5 mg/dl) presented at 10 weeks gestation with uncontrolled hypertension during pregnancy. Given prior difficulties conceiving and lack of discussions surrounding pregnancy risks, preconception counseling had not been done. She was taking carvedilol, spironolactone, and furosemide at pregnancy diagnosis. Given unclear safety profile in pregnancy, her spironolactone was discontinued. Her regimen was uptitrated to nifedipine 90 mmHg, carvedilol 50mg BID, hydralazine 50mg TID and furosemide 80mg BID. At 18 weeks gestation, she was readmitted with severe range hypertension and fluid overload unresponsive to escalating diuretic dosing. Due to poor urine output and creatinine to 5.5 mg/dl, she was initiated on dialysis. Her fetus was diagnosed with severe intrauterine growth restriction (IUGR) and umbilical doppler noted reversal of umbilical artery end-diastolic flow indicating severely elevated arterial resistance (Figure). During admission, she developed resistant hypertension requiring nicardipine and esmolol drips and severe headache, concerning for superimposed preeclampsia (SIPE). At 25 weeks gestation, she was taken for urgent c-section. Given extreme prematurity and growth restriction, her newborn baby passed away shortly after delivery.

Discussion:
This case highlights complications which arise from PA and antepartum persistent hypertension including progression of kidney disease, heart failure, IUGR, SIPE, and preterm delivery. It further highlights unique challenges using targeted therapies of mineralocorticoid receptor antagonists in PA in pregnancy. This information is crucial as PA is an increasingly recognized cause of resistant hypertension in young adults. Both PA and preeclampsia involve pathophysiologic mechanisms in the RAAS pathway and deserve further attention and research.
Abstract 17047: Nintedanib And Cardiomyopathy: A Vascular Failure?
Authors: Lu Alexander J , Lai Li , Ali Hyeon-Ju R , Ashrith Guha , Cooke John P
Published: December 2021

Description of the Case:
Patient 1 is a 61-year-old woman with a history of rheumatoid arthritis-related interstitial lung disease (ILD). Six months after initiation of nintedanib, she was diagnosed with new-onset heart failure. Cardiac magnetic resonance imaging (CMR) was consistent with nonischemic cardiomyopathy (NICM) with ejection fraction (EF) of 15-25%. EKG showed new bifascicular block (right bundle branch block and left anterior fascicular block). Nintedanib was discontinued, and four months later, echocardiogram showed recovered EF (50-54%). EKG abnormalities resolved with biventricular pacing. Patient 2 is a 57-year-old-man with a history of scleroderma-related ILD and stable diastolic heart failure (EF = 55-60%). Six months after initiation of nintedanib, he was admitted for heart failure exacerbation. CMR showed NICM with EF = 35%, and EKG showed prolonged QRS (130 ms). Given the rapid progression of cardiomyopathy, nintedanib was discontinued.

Discussion:
We report two patients with underlying connective tissue disease who developed significant nonischemic cardiomyopathy in temporal association with initiation of nintedanib. Nintedanib is a tyrosine kinase inhibitor, antagonizing three angiogenic signaling pathways mediated by vascular endothelial growth factor receptor (VEGFR), fibroblast growth factor receptor (FGFR), and platelet derived growth factor receptor (PDGFR). The nintedanib-treated cohorts of the TOMORROW and INPULSIS trials for idiopathic pulmonary fibrosis showed a high incidence of myocardial infarction (MI). With the recent SCENSIS trial, nintedanib was approved in 2019 for ILD associated with systemic sclerosis. There are likely multifactorial effects of this triple angiokinase inhibitor, seeing that it inhibits multiple growth factors essential for vascular homeostasis, the balance between mesenchymal and endothelial cell fates. Thus, there may be multiple pathways for cardiomyopathy due to “vascular failure,” including MI and importantly, cardiac fibrosis. Based on our observations, we urge other clinicians to report their experience with nintedanib use in patients with underlying connective tissue disease and to carefully monitor these patients for adverse cardiovascular effects.
Abstract 17056: Report Of An Adult Living With Undiagnosed Total Anomalous Pulmonary Venous Return
Authors: Beam Kent , Alegria Jorge , Schwartz Matthew
Published: December 2021

Case Presentation:
25-year-old male presented with cellulitis and abscess of the lower extremity. He was an immigrant from Guatemala. He worked in landscaping and played soccer with limited exertion. His exam was notable for cyanosis and clubbing of all digits. A II/VI systolic ejection murmur at the left upper sternal border and a mildly accentuated P2 was auscultated. ECG was notable for right axis deviation and right ventricle hypertrophy. Chest x-ray showed a widened mediastinum with perihilar vascular prominence. CT chest with contrast demonstrated all pulmonary veins forming a large, coalescing venous structure draining into the left innominate vein. Transthoracic echocardiogram confirmed total pulmonary venous return by way of a large vertical vein draining into a dilated innominate vein and a 2.7 cm ostium secundum ASD.

Discussion:
Total anomalous pulmonary venous return (TAPVR) is a rare, often deadly condition. Most patients die in infancy. In the rare adult patient with unrepaired TAPVR, exercise intolerance, cyanosis, clubbing of the digits, and growth retardation is often noted. A right ventricular heave with auscultation of a fixed, split second heart sound with a loud pulmonic component is common. On chest x-ray, the classic “snowman” appearance is seen with vertical vein connections as in our patient. Right heart enlargement represents the base, and an enlarged connecting vertical vein and SVC make up the upper portion. Echocardiography can demonstrate the anomalous pulmonary venous conduit coursing behind the left atrium. CT angiography can also reveal TAPVR and the patient’s specific anatomy. Amongst the few surviving adult TAPVR patients, similar characteristics include large ASDs, short anomalous veins, and absence of pulmonary venous obstruction. A large interatrial connection provides adequate systemic flow. The latter two factors reduce pulmonary vascular resistance, hence improving pulmonary flow and systemic oxygen concentrations.
Abstract 17085: An Anomalous Outcome Of Renal Transplant
Authors: Prasad Pooja , Enestvedt Kristian , Shehzad Rehman , Golwala Harsh
Published: December 2021

Case Presentation:
A 65 year old man with diabetic renal disease developed acute dyspnea at rest on the first post-operative day after an uncomplicated deceased donor renal transplant. He was hypertensive, tachycardic, and hypoxemic. His electrocardiogram showed anterior ST elevations with reciprocal inferior ST depressions and his chest x-ray revealed pulmonary edema. He was given anti-platelet therapy, nitroglycerin, beta blocker and taken emergently for angiography. He had a thrombotic occlusion of a co-dominant anomalous left circumflex artery arising from the ostium of a moderate caliber right coronary artery. He underwent successful percutaneous coronary intervention. His post-revascularization echocardiogram showed a hypokinetic to akinetic inferior wall with preserved global left ventricular systolic function. Coronary CT for further assessment of the course of the anomalous artery was not pursued given minimal benefit and the risk of worsening graft function. He was discharged on dual anti-platelet therapy, beta blocker and a statin.

Discussion:
There is no consensus about risk stratification before renal transplant. Our patient’s pre-operative exercise treadmill test (ETT) showed reduced functional capacity at 5.6 metabolic equivalents, failure to reach target heart rate, with 1.0 mm down sloping ST depression in infero-lateral leads with no ischemic symptoms. While our patient had an equivocal ETT, his lack of angina argued against further work-up. Post-operatively, a pro-inflammatory state, increased shear stress, acquired thrombophilia and immunosuppressive medications can all contribute to plaque rupture with thrombus formation. Atherosclerosis due to diabetes and renal disease coupled with mechanical factors such as passive compression at the intraarterial course, acute angle take-off or valve-like closure of the slit orifice may have subjected our patient with an anomalous left circumflex artery to an acute ST-elevation MI.
Abstract 17133: Complete Inferior Vena Cava Thrombosis In A Sickle Cell Patient With Suspected May Thurner Syndrome
Authors: Finn Matthew T , Rosenzweig Erika , Turner Mariel , Kirtane Ajay J , Parikh Sahil , Sethi Sanjum S
Published: December 2021

Case Presentation:
19 year old woman with sickle cell anemia and nephrotic syndrome presented with leg and back pain. While treated for vaso-occlusive crisis, patient developed dyspnea and chest pain. She underwent CT chest which revealed a right lower lobe pulmonary embolism. The patient was started on anticoagulation. Her transthoracic echocardiography revealed normal right heart function but nearly occlusive inferior vena cava (IVC) thrombus just distal to the right atrium. Subsequently a CT venogram demonstrated extensive thrombus from the left external iliac vein to the right atrium as well as compression of the left common iliac vein. Multidisciplinary discussion was performed to discuss options including medical therapy, surgical removal, or catheter-based removal. Given concern for further pulmonary embolization, patient underwent catheter based thrombus removal. A 26 french access was obtained in the right internal jugular vein and a 17 french access was obtained in the right femoral vein. Using the Angiovac system, mechanical thrombectomy was performed in the IVC. The angiovac system is a 24 french suction catheter with filtration and reperfusion through the right femoral vein. Limited thrombus removal was achieved. Next,14 french left femoral vein access was obtained and the Inari Clottriever device was used to mechanically score and remove a significant amount of thrombus (Figure 1). Post removal angiography revealed a patent IVC with minimal residual thrombus.

Discussion:
IVC thrombosis is a rare presentation of venous thromboembolism (VTE). This patient had multiple reasons for VTE including nephrotic syndrome and likely May Thurner Syndrome (MTS). MTS is an underdiagnosed entity resulting in mechanical compression of the left iliac vein in upto 50% of patients presenting with left lower extremity VTE. While proximal extension of thrombus is rare as seen in this case, high clinical suspicion is warranted for accurate diagnosis and treatment.