tbuckley/cabot-search huggingface dataset:
Abstract 16245: Prevalence and Time Course of Adverse Events After a Biopsy Diagnosis of Antibody-Mediated Rejection in Pediatric Heart Transplant Recipients
Authors: Melanie D Everitt, Elfriede Pahl, Devin A Koehl, Ryan S Cantor, James K Kirklin, christine reed, Matthew D Zinn, Amanda D McCormick, Jessie Yester, Philip Thrush, Jenna Schauer, Donna Lee
Journal: Circulation (2023)

Background: Antibody-mediated rejection (AMR) is of great relevance when assessing therapies to improve survival for pediatric heart transplant (HT). Biopsy (EMB) is the most specific means for diagnosing AMR. This study explores the impact on survival and adverse events after treated rejection (TRej) in children with AMR on EMB (any pAMR 1h or i, 2, or 3) vs acute cellular rejection (ACR). Methods: Children in the Pediatric HT Study transplanted between 1/2015-6/2022 who survived ≥2 weeks and had at least 1 TRej with EMB data were included. Survival was compared after 1st TRej with any AMR to pure ACR. Secondary outcomes of infection, malignancy, and cardiac allograft vasculopathy (CAV) after 1st TRej were assessed. Risk factors for mortality after AMR were identified using Cox proportional hazard modeling. Results: Among 3172 HT recipients, 906 (29%) had at least 1 TRej. Of these, 697 (77%) had EMB data to determine the presence of AMR. At the 1st TRej episode, 261 (37%) children had features of AMR. Median time to 1st Trej was earlier in those with AMR vs ACR, 0.11 vs 0.29 yrs. p=0.001. Survival after 1st TRej with AMR was worse than ACR in the 1st yr post HT (A); however, survival was similar when 1st TRej occurred after year 1 (B) (Figure 1 A, B). The AMR group had higher panel reactive antibody at HT, more congenital heart disease (CHD), and more had ABO incompatible HT (all p&lt;0.05). There was no difference in time to 1st infection, malignancy, or CAV between those with treated AMR vs ACR. Multivariate predictors of graft loss after AMR were younger age, CHD, and ECMO at HT, and hemodynamic compromise at TRej (all p&lt;0.048). Neither AMR grade nor concomitant ACR was associated with graft loss after AMR. Conclusion: This is the largest analysis of contemporary outcomes of EMB-confirmed AMR in pediatric HT. Findings underscore the impact of early AMR on graft loss and the need for tailored therapies. Similar time to infection after AMR vs ACR is notable since immune targets of therapy often differ.
Abstract 16982: Baseline Diameter Does Not Predict Growth Rate in Ascending Thoracic Aortic Aneurysm
Authors: Prabhvir S Marway, Nic Tjahjadi, Carlos Alberto Campello Jorge, Heather A Knauer, Greg Spahlinger, Himanshu J Patel, Nicholas S Burris
Journal: Circulation (2023)

Introduction: Patients with ascending thoracic aortic aneurysm (aTAA) are recommended to undergo routine imaging surveillance. While maximal diameter is the primary metric of disease severity, recent AHA/ACC guidelines emphasize the importance of aortic growth in determining surgical candidacy and risk of complications. Increasing diameter is often assumed to confer higher aortic growth rate (GR) due to increased wall tension; however, this relationship is poorly studied. Goal: To investigate the relationship between aTAA diameter and GR using Vascular Deformation Mapping (VDM), a validated technique for 3D growth mapping with sub-millimeter accuracy. Methods: We identified 122 patients with ascending aortic dilation (≥4.0 cm) and serial gated CT angiograms (CTA) with an interval of ≥2 years. Ascending GR was defined as the 90th percentile of wall deformation (radial direction) by VDM, normalized by interval (mm/y). Maximal diameter measurements were taken from the baseline CTA report. Aortic height index (AHI, cm/m) and aortic cross-sectional area/height ratio (CSAH, cm^2/m) were calculated. Ascending aortic length (AL, mm) was measured from the annulus to the origin of the innominate artery. Results: 122 patients (60.7% male, mean age 62.8 ± 10.9 y, 0% connective tissue disease) showed a mean baseline diameter of 44.7 ± 3.7 mm and mean GR of 0.30 ± 0.44 mm/y. No correlation was noted between GR and baseline diameter (r= -0.02, p= 0.86), AHI (r= -0.06, p= 0.54), CSAH (r= -0.04, p= 0.70), or AL (r= 0.08, p= 0.41). Diameter was modestly correlated with GR (r = 0.65, CI 95%: 0.11-0.89, p = 0.02) among the small subgroup with diameter ≥50mm (n=12). GR was not significantly correlated to age (r= -0.13, p= 0.17) and did not differ by sex (p= 0.91) or hypertension (p= 0.51). No demographic or anatomic variables were predictive of GR on multivariable analysis. Conclusions: Maximal aortic diameter is not predictive of aortic GR, especially at sizes under surgical thresholds (&lt;50 mm).
Abstract 14137: Stress-Induced Cardiomyopathy After Uncomplicated Permanent Pacemaker Implantation
Authors: Jiyeon Seo
Journal: Circulation (2023)

Stress-induced cardiomyopathy (SCMP) after permanent pacemaker (PPM) implantation is rare. Here, we report an additional case which was initially misdiagnosed as another disease due to atypical symptoms after PPM implantation. Case presentation: A 79-year-old woman with dizziness and dyspnea for one month visited Cardiology Department. She had a history of hypertension, dyslipidemia, diabetes-mellitus and stage IV chronic kidney disease. We confirmed complete atrioventricular block. Left ventricular ejection fraction (LVEF) was normal. PPM implantation was successfully performed without complications. The next day she felt very well with no symptoms. On the second day, she suddenly developed a fever and complained severe left neck pain. She had cough, sputum and general weakness without chest pain. C-reactive protein level increased and systolic blood pressure was decreased. We started antibiotics considering infection. We also checked implantation site, but there were no signs of infection. On the third day, echocardiography showed decreased LVEF (30%), akinesia of apical and medium segments of LV wall with preserved kinetics of basal segments without pericardial effusion (Figure 1). There was no significant stenosis on coronary angiography and we confirmed SCMP. After few days, her blood pressure and symptoms were improved. We prescribed sacubitril-valsartan, bisoprolol and furosemide. At 10 days after implantation, she was discharged with improved symptoms. Conclusion: Our case emphasizes that even successful implantation of PPM without complications can be a potential risk of SCMP. In the absence of typical cardiac symptoms after PPM implantation, a poor general condition may also be considered as a sign of SCMP. Therefore, it is necessary to monitor the patient for at least three more days after PPM implantation.
Abstract 18643: An Index to Measure Inequity-Health Equity Index for Guideline Directed Medical Therapy Among HFrEF
Authors: Xiaowei Yan, Zijun Shen, Rashon Lane, Kristen Azar
Journal: Circulation (2023)

Background: Heart failure affects 6.2 million adults in the US with 50% five-year mortality. Effectiveness of guideline-directed medical therapy (GDMT), composed by four different medications, has been established to reduce morbidity and mortality for heart failure with reduction ejection fraction (HFrEF), and with strong incremental impact of number of GDMT medications. Despite immense positive evidence, &lt; 5% of patients with HFrEF are on the appropriate target doses of all 4 GDMTs, and there is substantial disparity of GDMT use among race/ethnic groups or socio-economical levels. However, the study to quantify the inequity of GDMT prescription is lacking. Hypothesis: Significant inequity exists in the GDMT prescription among HFrEF. Aims: We derived a health equity index (HEI) for GDMT prescription for HFrEF patients to provide administrators with an assessment tool for evaluating disparity of GDMT use at a large healthcare system covering diverse geographic areas and population in northern California. Methods: HEI for GDMT (3+ GDMT medications) is estimated by ratio of observed-to-expected values. The number of expected patients with 3+ GDMT medication level was derived from a weighted average of subpopulation distribution of the 3+ GDMT prescription for each race/ethnicity and medium income race/medium income level within the population catchment area. Observed 3+ GDMT use was captured from the medication order data in the EHR. HEI &gt; 1.0 represents existence of health inequity. We applied this method to the whole HFrEF population, and then to each of geographic area where the race/ethnicity and medium income level vary significantly. Results: Among 45,222 HFrEF patients 24.6% had 3+ GDMTs, varying from 19% to 29% in 6 geographic areas. The HEI for the whole HFrEF population was 1.33. Further analysis revealed that highest disparity occurred at East Bay area (Oakland area) (1.67), serving large proportion of non-Hispanic Black patient population, and lowest at Palo Alto area (1.27). Conclusion: HEI for GDMT reflects disparity in receiving adequate care for HFrEF population. Substantial disparity was observed in different geographic areas, implying the priority of delivering equitable care to HFrEF should start with the area with highest disparity.
Abstract 16434: 104-Week Safety and Effectiveness of Low-Density Lipoprotein Cholesterol-Lowering Therapy With Evolocumab in Patients With Familial Hypercholesterolemia/Hypercholesterolemia in Japan: Results of Post-Marketing Surveillance
Authors: Koutaro Yokote, Junya Ako, Kazuo Kitagawa, Nobuhiro Osada, feng sheng, Masae Sonoda, Tadamichi Kubo, Tamio Teramoto
Journal: Circulation (2023)

Introduction: Evolocumab is the first monoclonal antibody against proprotein convertase subtilisin/kexin type 9 approved in Japan for familial hypercholesterolemia (FH) and hypercholesterolemia (HC). Aims: This study assessed the 104-week safety and effectiveness of low-density lipoprotein cholesterol (LDL-C)-lowering therapy with evolocumab in patients with FH (homo/heterozygous) and HC in a real-world setting in Japan. Methods: Overall, 3721 and 2792 patients (108 and 91 homozygous FH, 2007 and 1613 heterozygous FH, 1606 and 1088 HC) from 668 clinical sites comprised the safety and effectiveness analysis sets, respectively. Primary safety endpoints: incidence (%) and number of patients with adverse drug reactions and serious adverse events. Effectiveness endpoints: % change in LDL-C from baseline at Week 12 (n=2386, primary endpoint) and Weeks 4-104 (secondary endpoint). Results: Mean age: 63.2 years; female: 33.8%. The mean±SD follow-up duration was 545.5±218.8 days. Adverse drug reaction subject incidence was 5.2%. Serious adverse event subject incidence was 8.9% (330/3721). The adverse event incidences of myocardial infarction and stroke were 0.6% (n=23/3721) and 0.6% (n=21/3721; 0.3% ischemic stroke [n=12]/0.2% hemorrhagic stroke [n=9]), respectively. Table 1 shows adverse events by lowest achieved LDL-C levels. The mean±SD % change in LDL-C from baseline to Weeks 12 and 104 were –45.7%±28.2% (n=84) and –50.9±21.1% (n=48) in homozygous FH patients ( P &lt;0.001 vs baseline; two-sided paired t -test), –56.0%±28.9% (n=1440) and –54.5±28.3% (n=905) in heterozygous FH patients ( P &lt;0.001), and –63.3%±23.7% (n=862) and –60.8±28.1% (n=352) in HC patients ( P &lt;0.001), respectively. Conclusions: There were no trends between the lowest achieved LDL-C levels and adverse events in Japanese patients. Evolocumab was well tolerated and sustained LDL-C reduction in patients with FH and HC in a real-world clinical setting in Japan.
Abstract 17199: A Case of Ventricular Fibrillation Arrest After Immune Checkpoint Inhibitor Therapy
Authors: Kelly R McKay, Mohammad Hashim H Jilani, Alex Moseley
Journal: Circulation (2023)

Description of Case: Our patient is a 65-year-old male who suffered sudden cardiac arrest due to ventricular fibrillation while receiving his second cycle of therapy for non-small cell lung cancer, which consisted of carboplatin, pemetrexed, nivolumab, and ipilimumab. Initial symptoms included sudden onset chest pain and dyspnea during infusion, which then rapidly progressed to ventricular fibrillation, and he was successfully defibrillated with ROSC. Subsequent coronary angiogram revealed patent coronary arteries, and cardiac MRI (CMR) was consistent with acute myopericarditis. Our patient was treated with high dose steroids and colchicine. Discussion: Immune checkpoint inhibitors (ICI) are a novel drug class with an emerging role in treatment of various tumors, including lung cancer. ICIs prevent the interaction between host checkpoint proteins and tumor partner proteins, allowing the immune system to appropriately attack tumor cells. Two such ICI include nivolumab and ipilimumab, which are frequently administered together. ICI therapy is linked with very rare but potentially life-threatening cardiac side effects including malignant arrhythmias, such as ventricular fibrillation and polymorphic ventricular tachycardia, along with risk of myocarditis and pericarditis. The risk is highest in the first 30 days; patients who received nivolumab and ipilimumab in combination and those treated for non-small cell lung cancer were found to have a higher risk of cardiac side effects. The timeline of events in our patient with subsequent CMR findings make the diagnosis of sudden cardiac arrest secondary to ICI therapy the most likely cause. Patients receiving ICI therapy should be monitored appropriately with algorithms in place for prompt detection and triaging of such patients who develop these side effects.
Abstract 17389: Sex Differences in Aortic Dissection Outcomes in the Houston Aortic Collaborative Experience
Authors: Harleen K Sandhu, Charles C Miller, Scott A Lemaire, Ourania Preventza, Siddharth K Prakash, Firas Mussa, Gustavo Oderich, Joseph Coselli, Hazim J Safi, Anthony L Estrera, Rana O Afifi
Journal: Circulation (2023)

Background: Data on sex-related differences in presentation, management, and clinical outcome in acute aortic dissection (AAD) are sparse, especially for acute type A (AAAD) and acute type B (ABAD) subtypes. Aims: To determine the effect of sex on AAD presentation, management and outcomes in a large cohort of patients from two major aortic surgery centers. Methods: We retrospectively reviewed the two-institution clinical data of all consecutive patients treated for AAD from 2000 to 2022. Data were analyzed by univariate and multivariable methods for short- and long-term data using SAS 9.4. Cox multivariable analyses were restricted to 3 years’ follow-up to avoid violating the proportional-hazards assumption. Results: Overall, 1,855 patients treated for AADs with 1,109 AAAD and 746 ABAD. Median age was 60 years (IQR:50-70); 620 (33%) were women. Women were older (64 vs 58 yrs; P&lt;.001), had lower baseline renal function (36% vs 26%, p&lt;.001) and more genetically triggered aortic disease (11% vs 7%, P=.002). Clinical presentation is shown in Table. Women had fewer renal (17% vs 24%; P=.001), bleeding (10% vs 14%; P=.01), and GI (22% vs 26%; P=.048) in-hospital complications. 30-day mortality was not different between groups (12% vs 14%; P=.271). There was no significant difference in mid or long-term survival by sex overall, however, stratified analysis showed lower survival for women with AAAD, notably in the first 3 years (Figure). Among AAAD cases, absolute risk difference attributable to COPD in stratified analysis was 17% in women (p&lt;.01), but numbers are small (n=63). Multivariable risk factors for 3 year mortality were female (HR 1.3, p&lt;.016), GFR&lt;60 (HR 1.4, p&lt;.003), rupture (HR 2.0, p&lt;.001), CAD (HR 1.8, p&lt;.001), mesenteric MPS (HR 2.1, p&lt;.001). Conclusions: Women with AAD presented at an older age with poor baseline renal function and had higher prevalence of genetic disease and ABAD. 3-year adjusted survival for women with AAAD was worse than men; COPD may modify risk by sex.
Abstract 17123: Opioid Withdrawal Causing a Broken Heart!
Authors: Karan Chhabra, Swapna Gudipati, Richard Bloomingdale
Journal: Circulation (2023)

Introduction: Takotsubo syndrome is a condition characterized by transient acute left ventricular systolic dysfunction. Although it was previously thought of as a benign self-limiting condition, it is now known to be associated with significant morbidity and mortality. Case: A 26-year-old male patient with past medical history of Fentanyl abuse now on methadone, presented with features of opioid withdrawal. ECG on arrival was normal sinus rhythm with QTc 488 ms. with a troponin of 2.63. Due to excessive agitation and vomiting, he was given IV haloperidol and ondansetron. The patient then became unresponsive and sustained a cardiac arrest. He was found to be in polymorphic ventricular tachycardia and was able to be resuscitated. ECG after resuscitation demonstrated new yamaguchi T waves with a QTc 597 ms and troponin of 6.60. Transthoracic echocardiography subsequently revealed a reduced ejection fraction of 35% with apical hypokinesis, and he was referred for an ischemic evaluation with CTA coronary that showed normal coronary arteries. He was diagnosed with takotsubo cardiomyopathy and was initiated on dapagliflozin, metoprolol succinate and losartan. For opioid dependence, he was prescribed buprenorphine/naloxone being mindful of his QTc and was provided a wearable cardioverter defibrillator on discharge. Final ECG demonstrated QTc of 465 ms. Discussion: Opioid withdrawal is known to cause a high adrenergic state and this catecholamine excess can result in cardiac stunning, creating transient left ventricular dysfunction along with wall motion abnormalities. Patients with takotsubo cardiomyopathy typically have normal coronary arteries. Approximately 4.5% of these patients can die during their hospitalization and 4% can die within 30 days of discharge. So, clinicians must keep a high index of suspicion for this syndrome in patients with history of substance use disorder, especially in the setting of troponin elevation.
Abstract 19084: The Deadly Squeeze - Coronary Vasospasm Complicated by Myocardial Infarction and Cardiac Arrest
Authors: Maliha Butt, Maxine Nelson, Vyshnavi Ishwarawaka, Dilanthy Annappah, Varun Victor, Sara Godil, Abdallah Masri, Prabhakaran Gopalakrishnan
Journal: Circulation (2023)

Introduction: Acute coronary syndrome (ACS) typically results from atherosclerotic plaque rupture. However, about 6% of ST elevation Myocardial Infarction (STEMI) patients have no obstructive disease. We present a case of STEMI, diagnosed with coronary vasospasm. Hypothesis: Methods: A 54-year-old female with alcohol abuse, smoking and uncontrolled hypertension presented after an out of hospital ventricular fibrillation cardiac arrest. EKG showed anterolateral ST elevation (STE). Left heart catheterization (LHC) showed moderate to severe multi-vessel disease without a definitive culprit lesion. STE resolved. Heart team approach for revascularization was contemplated. Echocardiogram showed systolic dysfunction with ejection fraction (EF) of 25%. Patient had another cardiac arrest and EKG showed recurrent anterolateral STE. Repeat LHC showed severe vasospasm of Left anterior descending (LAD) artery and diagonal branch, which improved with intracoronary (IC) nitroglycerin. Vasospasm was attributed to smoking and catecholamine excess from alcohol withdrawal. She was started on intravenous nitroglycerin and amlodipine. Her hospital course was complicated by high degree AV block requiring temporary pacer. She was eventually extubated with good neurological recovery and recovered systolic function (EF 60%). She was counselled on smoking and alcohol cessation and discharged home on isosorbide dinitrate and Amlodipine with planned surgical revascularization. Results: Coronary vasospasm (CVS) can occur both in normal and diseased coronaries. Risk factors include smoking, alcohol use and withdrawal, cocaine, mental stress, etc. Vasospasm may present as Prinzmetal’s angina, myocardial infarction, AV block, or fatal arrhythmias. IC nitroglycerine during LHC aids in diagnosis of CVS in setting of ACS. IVUS (Intravascular ultrasound) may help diagnose presence or absence of concomitant atherosclerotic disease. Provocative testing with IC ergonovine and acetylcholine may be considered in non-ACS setting. Conclusions: This case emphasizes the need to have a high index of suspicion for vasospasm to prevent associated complications and establish an accurate diagnosis and guide proper management of this potentially fatal disease.
Abstract 13502: Obesity Paradox in Severe Rheumatic Mitral Stenosis: A Prospective Analysis Using a Machine Learning-Based Approach
Authors: Alexandre Negrao Pantaleao, Antonio Mutarelli, Thiago Petrilli Maffei Dardis, Guillaume GOUDOT, Renata Matheus Faccioli, Mauri Brandão de Medeiros Neto, Ghazal Sanadgol, Koushiar Moshe Yaghoubian, Eula Neves, Marina Marangoni Roschel, Maria C Nunes
Journal: Circulation (2023)

Background: The obesity paradox posits that obese patients have better prognosis in cardiovascular diseases. Scarce data exists on the obesity paradox in rheumatic mitral stenosis (RMS) Hypothesis: Obesity is associated with a favorable prognosis in severe RMS Methods: Patients with severe RMS referred to a tertiary center from 2011 to 2022 were prospectively included. Patients with previous valve interventions were excluded; clinical and echocardiographic data were collected at baseline. Severe RMS was defined as a mitral valve area ≤ 1.5 cm2 by planimetry and patients were divided into 2 groups: (1) BMI ≥ 30 kg/m 2 ; (2) BMI &lt; 30 kg/m 2 . A combined outcome of percutaneous mitral valvuloplasty, mitral replacement and cardiovascular death was set. Logistic regression adjusted for confounders and gradient boosted decision-tree analysis were used Results: A total of 315 patients (82.2% female, mean age 53.3 years) were included. Over a median follow up of 30 months, 87% of patients had the outcome. MVA was higher in group 1 (p&lt;0.001) while left atrial volume index (LAVi) and net atrioventricular compliance were lower (p=0.008 both). Overall, BMI was not a good independent predictor of outcome (OR 0.98, 95% CI: 0.91-1.06, p=0.50) and occurrence of outcome was similar between groups (p=0.481). In both groups, mean importance of BMI in determining the outcome was similar (17.7 ± 6.1% and 17.0 ± 2.6% respectively) Conclusion: Obese patients had higher MVA and lower LAVi. However, our data suggests that BMI was not a significant independent predictor of poorer prognosis and its importance was not different between the groups. These findings challenge the obesity paradox in severe RMS