tbuckley/cabot-search huggingface dataset:
Abstract Sa305: Association Between Area of Maximal Compression During CPR Determined by Transesophageal Echocardiography, ETCO2, and Return of Spontaneous Circulation: An International Multicenter Study
Authors: Felipe Teran, Clark Owyang, Trenton Wray, Justine Lessard, William Bedard Michel, John Hipskind, Pedro Salinas, Vladyslav Dieiev, Jonathan Nogueira, Daniel Doynow, Eleonora de villa, Michael Woo, Rajiv Thavanathan, Katharine Burns, Ross Prager, Robert Arntfield, Frank Myslik, Evan Robinson, Lawrence Haines, Brian Buchanan, Zan Jafry, Nathaniel Sands, Aarthi Kaviyarasu, Benjamin Abella
Journal: Circulation (2024)

Background: TEE is increasingly recognized as a valuable imaging modality during cardiac arrest (CA) resuscitation, particularly for assessing the area of maximal compression (AMC) during CPR. Small single center studies have shown that compression of the left ventricular outflow tract or the aortic root (AMC-LVOT/Ao) is common during CPR, and that when CPR is performed with the AMC over the LV, this results in higher ETCO2, and ROSC. This study aimed to investigate the AMC and its relationship to ETCO2, and ROSC, hypothesizing that patients experiencing AMC-LVOT/Ao have lower ETCO2 and are less likely to achieve ROSC. Methods: A prospective, multicenter cohort study of patients with out-of-hospital and in-hospital CA (OHCA/IHCA) in whom TEE was performed during CPR comparing AMC over the LV (AMC-LV) vs AMC-LVOT/Ao. The study was conducted through the Resuscitative TEE Collaborative Registry, an ongoing multicenter research network involving 37 hospitals (NCT04972526). Collected data included patient and procedure characteristics, hemodynamics, and outcomes according to Utstein-style guidelines. Primary outcome was ROSC, and the secondary outcome was ETCO2 at the time of AMC determination. We performed univariate analysis and multivariate regression evaluating variables known to impact resuscitation outcomes. Results: 271 patients including 205 OHCA and 66 IHCA were included. Only 133 (49%) of the total cohort had AMC-LV, with AMC-LVOT/Ao in 47% of OHCA and 42.1% of IHCA. There was no significant difference in the location of the AMC when analyzed by demographic characteristics, height, weight, or comorbidities between patients who received manual vs mechanical CPR. In OHCA, there was no difference in ROSC between AMC-LV and AMC-LVOT/Ao, however the group of patients with AMC-LVOT/Ao had on average 10 units lower ETCO2 compared to AMC-LV (Beta -10; 95% CI -19 - 1.5; p = 0.023). In IHCA, after controlling for factors known to impact outcomes, patients with AMC-LVOT/Ao had significantly lower probability of ROSC (OR 0.25, 95% CI 0.06-0.88; p=0.038). Conclusion: Obstruction of the LVOT/Ao during CPR is a common finding in CA patients evaluated with TEE. This multicenter study extends previous animal and smaller clinical studies suggesting the mechanistic association between the AMC during CPR, with ETCO2 and ROSC, and the potential of TEE-guided resuscitation to improve the effectiveness of CPR.
Abstract 4147936: Comparative Analysis of the 30-Year Survival after Primary Transplant Versus Reconstructive Surgery for Hypoplastic Left Heart Syndrome
Authors: Caroline Shi, Yanxu Yang, Lazaros Kochilas
Journal: Circulation (2024)

Background: Reconstructive surgery for hypoplastic left heart syndrome (HLHS) starts with the Norwood procedure in early infancy. Primary transplant is an alternative strategy that has shown superior outcomes to reconstructive surgery in some patients with left heart obstructive lesions. This study compares the 30-year survival of HLHS following primary transplant vs. reconstructive surgery. Methods: Using data from the Pediatric Cardiac Care Consortium (PCCC), a large US-based registry for congenital heart surgeries, we included patients operated at &lt;6 mos old performing both Norwood and primary transplant for HLHS between 1987 and 2003. Deaths were tracked through 2022 by the US National Death Index. Kaplan-Meier curves and extended Cox regression models were used for survival comparison after adjusting for sex, race and birth era. We also performed subgroup analysis by birth era (early: 1987-1996 vs. late: 1997-2003). Results: Of 573 patients (males 61%) from 13 PCCC centers, 97 (17%) had a primary transplant. Patients with reconstructive surgery were younger at operation, less likely to be White, and more likely born in the late era. In-hospital survival was higher for primary transplant (79 % vs. 56%, p&lt;0.01) with the advantage remaining significant after adjustment (aOR 0.36; 95%CI: 0.21-0.62, p&lt;0.01). Over a median follow-up of 21.1 years (IQR 1.5, 25.3), 149 deaths occurred post-discharge. No significant difference was found between primary transplant vs. reconstructive surgery in the 30-year post-discharge survival (58.6% vs. 48.7%, p=0.07), although there was a trend towards significance after adjustment (aHR 0.68, 95% CI 0.45-1.05, p=0.08). During early era, primary transplant had 60% decreased hazard of death (aHR 0.40, 95%CI 0.23-0.72, p&lt;0.01) compared to reconstructive surgery, while no difference was found in the late era (aHR 0.99, 95% CI 0.50-1.97, p=0.98) (Figure). Conclusion: Primary transplant for HLHS was associated with improved 30-year survival. However, this improvement reached significance only in the early era suggesting improved outcomes with reconstructive procedures in recent years. Further analysis beyond survival is needed to elucidate the relative outcomes of these two strategies.
Abstract 4148058: Coordination Index Guides Synchronous Non-Blood Contacting Support of the Failing Heart
Authors: Benjamin Schmitt, Mark Anstadt
Journal: Circulation (2024)

Introduction: Direct mechanical ventricular actuation (DMVA) is a non-blood contacting biventricular support device that uniquely augments diastolic pump function and promotes early recovery of the failing heart. Investigations demonstrate DMVA improves intraventricular dyssynchrony while supporting the failing heart suggesting an effect similar to that of cardiac resynchronization therapy. Optimizing intraventricular synchrony may be dependent on timing device augmentation with the underlying heart rhythm. Hypothesis: The purpose of this study was to test the hypothesis that a coordination index can be used to optimize synchronous DMVA support of the failing heart. Methods: Canine (n=9) were instrumented and subjected to repeated periods of ventricular fibrillation (VF) to achieve progressive worsening of ischemic heart failure (HF). DMVA returned the circulation during VF and provided support during HF. DMVA support was initiated using pre-determined pressure/flow profiles based on heart size. DMVA pneumatic drive were tailored to optimize LV pump function using intra-cardiac ECHO imaging. DMVA cycle rates were adjusted between 110-130 bpm to most closely match the underlying native heart rate determined during periodic device removal. Hemodynamics and drive pneumatics were simultaneously recorded using 10 s data acquisitions. The coordination index (CI), a metric for synchrony of peaks was used to analyze the results (see table). Aortic flow waveforms were evaluated for the number of peaks during each DMVA compression. Failure to elicit a pressure or flow response (skipped cycles) was also identified. The CI indices were divided into 5 equal quantiles to characterize synchrony from best (Group 1) thru worst (Group 5). One-way ANOVA with post-hoc Tukey’s HSD was used to assess statistical differences (p&lt;0.05) for all comparisons. Results: Five groups of equally distributed CI quantiles were grouped from superior to inferior synchrony (Table). Periods of ventricular pacing was suggested evidenced by near-zero CI computations during DMVA support. Improved synchrony correlated with peak systolic and +dP/dt drive drive pneumatics. Lower CI was also linked to absence of skipped cycles. CI during VF support was consistently near-zero. Conclusions: CI can guide optimal synchronous DMVA support of the failing heart. Future studies will determine if optimizing synchronous support improves intraventricular synchrony and facilitates cardiac recovery.
Abstract 4147833: Parachute to the Rescue: The Mysterious Right Heart Mass
Authors: Rishi Trivedi, Prateek Madaan, bashaer gheyath, Oren Friedman, Siddharth Singh
Journal: Circulation (2024)

Case Presentation: A 27-year-old female with a history of Crohn’s disease and prior pulmonary nocardiosis presented with fever of unknown origin (FUO) and lung infiltrate. CT pulmonary angiogram revealed a segmental pulmonary embolism and a sessile mass with mobile components in the right atrium (RA). A band-like mass extending from the interventricular septum to the body of the right ventricle (RV) was also noted. Transthoracic echocardiogram confirmed these findings and showed moderate to severe tricuspid regurgitation. Lab testing was notable for white blood cell count elevation and positive lupus anticoagulant with unremarkable antibody panel. Based on initial testing, the differential diagnosis included RV thrombus, malignancy, or endocarditis. The patient was started on antibiotics, anticoagulation, and transferred to our hospital. Decision Making: The patient underwent a transesophageal echocardiogram that demonstrated a layered RA thrombus with mobile components, patent foramen ovale, and a congenitally dysplastic ‘parachute’ tricuspid valve (TV) with apical displacement of septal leaflet (Figure 1). It was noted that TV chordae tendinae attached to a single papillary muscle which was contiguous with the moderator band. Cardiac MRI confirmed these findings and that the RA mass was a thrombus. Despite anticoagulation and antibiotics, the patient continued to have intermittent fevers. PET CT demonstrated hypermetabolism of the RA thrombus and therefore suction thrombectomy was performed. Pathology revealed thrombus with purulent debris; however, no organisms were identified. With antibiotics and anticoagulation, the patient improved clinically and was discharged with plans for outpatient follow up. Discussion: Parachute deformity of the atrioventricular valves is characterized by unifocal attachment of chordae tendinae to a single papillary muscle. Parachute deformity of the TV has been very rarely reported (&lt;20 published cases) and it is associated with other congenital anomalies. This case of parachute TV deformity with FUO highlights the importance of multi-modality imaging in the workup of structural heart abnormalities and the importance of pattern recognition in diagnosing rare cardiac abnormalities.
Abstract Sa802: Why Physicians Use Sodium Bicarbonate During Cardiac Arrest: A Mixed Methods Survey of Adult and Pediatric Clinicians
Authors: Catherine Ross, Jill Sorcher, Ryan Gardner, Ameeka Pannu, Monica Kleinman, Michael Donnino, Amy Sullivan, Margaret Hayes
Journal: Circulation (2024)

Background: Despite national recommendations against the routine use of sodium bicarbonate (SB) during cardiac arrest, SB is used in about 50% of both pediatric and adult IHCA, making it the second most used drug, after epinephrine. Aims: To explore clinician practices and beliefs surrounding intra-arrest SB administration. Hypothesis: We hypothesized that SB use would vary by specialty, and that indications for intra-arrest SB not endorsed by AHA guidelines would be common. Methods: We performed a mixed methods electronic survey amongst adult and pediatric intensive care unit (ICU), emergency medicine (EM) and anesthesia attendings at two local institutions in Boston, MA from October 3 rd to December 15 th , 2023. Likert scale responses for likelihood of giving SB in 2 cardiac arrest scenarios were compared using a Chi-squared test. These responses were dichotomized to reflect those who would “probably” or “definitely” give SB versus those who would not, and respondent characteristics were compared. For the open-ended items, we performed qualitative thematic analysis. Results: Of 356 physicians invited, 224 (63%) responded. The likelihood of giving SB in Scenario 1 (10-minute asystolic arrest) and Scenario 2 (20-minute asystolic arrest) differed (Figure 1), with 54/224 (24%) respondents indicating they would give SB in Scenario 1 and 110 (49%) for Scenario 2. Additionally, likelihood of giving SB in Scenario 1 varied based on practice location (p = 0.025) with the lowest rates in pediatric and adult EM (8% and 10%, respectively) and the highest amongst those in adult ICUs (38%). These differences persisted for Scenario 2 (p = 0.001). SB use in Scenario 1 also decreased with increasing years of experience (p = 0.032). The most reported indications for SB were: hyperkalemia (78%); metabolic acidosis (76%) with a median reported threshold pH of 7.1 (IQR: 7, 7.2); tricyclic anti-depressant overdose (71%); and arrest duration (64%) with a median reported threshold of 15 minutes (IQR: 10, 20). In the qualitative analysis, additional themes emerged for reasons respondents give SB, including specific diagnoses, arrest rhythms, team dynamics and beliefs about the physiological effects of SB. Conclusions: Physicians reported significant practice variations surrounding cardiac arrest management with SB, including several indications for SB which are not supported by national cardiac arrest guidelines.
Abstract 4147858: ECG correlates of chronic right ventricular pacing: QT interval predicts pacing-induced cardiomyopathy while QRS duration predicts cardiac resynchronization therapy response
Authors: Amulya Gupta, Ahmed Shahab, Christopher Harvey, Seth Sheldon, Madhu Reddy, Amit Noheria
Journal: Circulation (2024)

Background: Some patients with chronic right ventricular (RV) pacing develop pacing-induced cardiomyopathy (PICM) and benefit from upgrade to cardiac resynchronization therapy (CRT). However, there are no established ECG screening criteria for PICM. Aim: We sought to evaluate ECG correlates of (i) PICM and (ii) CRT response. Methods: We retrospectively identified all CRT upgrades (biventricular pacing) for PICM (LVEF &lt;50%) at our center 2014-2018 and gauged CRT response (LVEF increase &gt;5% on echocardiogram 3-12 months post CRT). Patients with ≥5 ECGs all demonstrating RV pacing over ≥2 years and all echocardiographic LVEF ≥50% served as controls. Root-mean-squared (3D) ECG was obtained from reconstructed orthogonal X, Y, Z leads. We used logistic regressions to predict PICM and CRT response from ECG intervals and voltage-time-integrals (VTI). Results: 108 patients [74±11 years, 28% female, LVEF 29±8%, QRS duration (QRSd) 167±25 ms, QTc 515±39 ms] with CRT upgrade for PICM were compared to 186 controls (77±14 years, 53% female, LVEF 57±5%, QRSd 144±21 ms, QTc 473±33 ms). Discrimination of PICM was highest with QTc (AUC 0.80) followed by QRSd (0.77) and VTI QRS-3D (0.75, Table 1, Figure 1 ). QTc &gt;480 ms detected PICM with sensitivity 84% and specificity 74%. With CRT upgrade , LVEF improved by 14±11%. CRT response (ΔLVEF &gt;5%) occurred in 77/108 (71%). Lack of CRT response was best predicted by QRSd (AUC 0.65) followed by ΔVTI QRS-3D (0.61, Table 2 ). Lack of CRT response was noted in 52% with QRSd &gt;180 ms, while 78% with QRS duration ≤180 ms showed CRT response. Conclusions: In patients with chronic RV pacing, QTc &gt;480 ms identifies those susceptible to PICM, and QRSd &gt;180 ms identifies those who may not respond to CRT.
Abstract Sa106: Effect of Prehospital Advanced Airway Management on Arterial Blood Gases in the Pragmatic Airway Resuscitation Trial
Authors: Grace Sullivan, Henry Wang, Christopher Gage, Jonathan Powell, ELISABETE ARAMENDI, Xabier Jaureguibeitia, Andoni Elola, Ahamed Idris, Mohamud Daya, Shannon Stephens, Jestin Carlson, Graham Nichol, Tom Aufderheide, Ashish Panchal, Michelle Nassal
Journal: Circulation (2024)

Background: While prehospital advanced airway devices are commonly used in out-of-hospital cardiac arrest (OHCA), whether gas exchange differs between devices is unknown. Objective: To characterize arterial blood gas (ABG) differences between patients receiving laryngeal tube (LT) or endotracheal intubation (ETI) in the Pragmatic Airway Resuscitation Trial (PART). Methods: We included adult OHCA enrolled in PART with first ABG collected ≤ 90 minutes after emergency department (ED) arrival. We identified 1) last prehospital airway technique used (LT vs. ETI), 2) average end-tidal capnography (EtCO 2 ) values for the last 5 minutes of prehospital care, 3) return of spontaneous circulation (ROSC) in the ED, and 4) ED ABG measurements (pH, PaO 2 , PaCO 2 ). We compared ABG values between LT and ETI using the Mann-Whitney test, stratifying by ROSC vs. non-ROSC. We also determined the correlation between last 5-minute mean prehospital EtCO 2 and PaCO 2 using Pearson’s correlation. We also compared absolute difference between EtCO 2 and PaCO 2 (PaCO 2 - EtCO 2 ) using the Mann-Whitney test. All blood gas and EtCO 2 values are reported in mmHg. Results: Of 3004 patients enrolled in the parent trial, 483 had an ABG ≤ 90 minutes after ED arrival; 276 LT, 129 ETI, 76 no advanced airway, and 2 unknown. Among patients with ROSC in the ED, pH did not differ between LT and ETI (7.1 vs. 7.2, p=0.10), PaO 2 showed a tendency toward lower values in LT than ETI (142 vs. 170, p=0.07), and PaCO 2 was significantly higher in LT compared to ETI (59 vs. 50, p=0.002). Among patients without ROSC, pH did not differ between LT and ETI (7.0 vs. 7.0, p=0.55), PaO 2 was significantly lower in LT than ETI (85 vs. 123, p=0.03), and PaCO 2 did not differ between LT and ETI (64 vs. 60.5, p=0.58). EtCO 2 did not correlate with PaCO 2 in any airway device/ROSC combination: [LT+ROSC] r=0.02, [ETI+ROSC] r=0.14, [LT+non-ROSC] r=-0.11, [ETI+non-ROSC] r=0.51. PaCO 2 - EtCO 2 was significantly wider in non-ROSC than ROSC cases (27 vs. 18, p=0.03) but did not differ by airway device. Conclusions: ABG values may vary by prehospital advanced airway management methods. The correlation between EtCO 2 and PaCO 2 in patients with OHCA remains unclear.
Abstract Sa311: Abdominal Counter-Constriction Versus Abdominal Binding as Hemodynamic Adjuncts to Circumferential Thoracic Cardiopulmonary Resuscitation
Authors: Aidan Paradis, David Gaddy, Karen Moodie, Timothy Mader, Alexandre Dufresne, Christine Couturier, Simon Dufresne, Daniel Davis, Christopher Sims, Norman Paradis
Journal: Circulation (2024)

Introduction: Previously, some investigators have reported that static abdominal binding ( AB ) is adjunctive to sternal piston-based CPR. Others have found that it is not. Circumferential thoracic CPR ( CT-CPR ) is an alternative pump mechanism and may have enhanced hemodynamics and safety. We have previously reported that addition of pulsatile abdominal counter-constriction ( ACC ) further improves the hemodynamics of CT-CPR. Simple AB requires less energy than ACC, however the efficacy of AB as an adjunct to CT-CPR has not been studied. Hypothesis: One of the CTA-CPR abdominal adjuncts, ACC or AB, may be associated with greater indicators of hemodynamics. Methods: Ventricular fibrillation was induced in female Yorkshire swine (n = 3, 30 kg). CPR was provided by a pneumatic CT-CPR prototype and circumferential pneumatic bands. Forty-five-second epochs of CT-CPR with ACC or AB were performed. Aortic ( Ao ) and right atrial ( RA ) pressures were measured using micromanometer catheters and coronary perfusion pressure ( CPP ) was calculated. The change in CPP ( Delta-CPP ) from the beginning to the end of each treatment epoch was the principal indicator of hemodynamics. Results from all experiments were grouped by treatment type and subjected to a paired t-test. Results: The delta perfusion pressures are shown in the Figure. Final aortic pressures averaged 62 and 37mmHg for static AB and pulsatile ACC respectively. Final right atrial pressures averaged 45 and 8mmHg for static AB and ACC respectively. These yielded final CPPs of 17 and 29mmHg for static AB and pulsatile ACC respectively. Pulsatile counter-constriction was associated with much higher final CPP in every treatment pair. Conclusion: CT-CPR with adjunctive abdominal binding consistently increased both Ao and RA pressures. However, compared to AC, AB showed a much greater RA pressure increase, resulting in lower CPPs and Delta-CPPs. Abdominal counter-constriction may be superior to abdominal binding as an adjunctive modality in circumferential thoracic CPR. These results are similar to those reported by JT Niemann and JM Criley in 1984 using piston-based CPR. They observed that it appeared to raise vascular pressures but lower CPP.
Abstract 4147885: Aortic Growth Mapping to Examine Genotype-Phenotype Correlations in Heritable Thoracic Aortic Disease and Variants of Unknown Significance
Authors: Carlos Alberto Campello, Vedika Ramesh, Prabhvir Marway, Marion Hofmann Bowman, Rajani Aatre, Nicholas Burris
Journal: Circulation (2024)

Introduction: Methods to define genotype-phenotype correlations are needed to advance precision medicine in heritable thoracic aortic disease (HTAD), particularly for variants of unknown significance (VUS), where evidence is sparse. Vascular deformation mapping (VDM) - an image analysis tool - provides accurate, three-dimensional (3D) aortic growth mapping, to better define disease severity and phenotypes. Research Question: Does the extent of 3D aortic growth mapping vary among patients evaluated for HTAD according to their genetic test results? Methods: We included adults undergoing genetic testing for HTAD with at least 2 CT angiograms spanning ≥2 year interval. VDM quantified the 3D thoracic aortic growth over the longest interval. Results: We analyzed 122 patients (imaging follow-up 5.0 years ± 3.2), a median age of 62.5 years (range: 26-87), 33.6% females, 50% with a history of aneurysm and/or dissection in first-degree relatives, 32% with prior ascending aortic replacement (AAR). Genetic testing results were pathogenic/likely pathogenic (P/LP) in 17%, negative or benign/likely benign (B/LB) in 59%, and VUS in 46%. Among those with negative genetic testing, 80% had no growth by VDM. Among P/LP patients, 65% had at least one affected segment (6% showing growth without AAR; 24% with prior AAR; 35% with growth beyond AAR). Among VUS patients, 44% exhibited no aortic growth and 56% demonstrated aortic growth by VDM (30% with growth and native aorta; 26% with growth beyond the prior AAR). During follow-up, 10 VUS mutations were re-classified as B/LB or P/LP and VDM growth severity assessments were concordant with the re-classified category in 6 (60%). Among those with growth of the native aorta distal to AAR, 50% showed growth at non-dilated (&lt;30 mm) diameters. Conclusion: HTAD presents with variable aortic enlargement patterns that are effectively characterized by VDM, providing an avenue for patient-specific risk assessment and decision-making, especially for VUS cases.