tbuckley/cabot-search huggingface dataset:
Abstract Or108: Optimizing Post-resuscitation Care after Resuscitative Endovascular Balloon Occlusion of the Aorta and Automated Head-up Position Cardiopulmonary Resuscitation.
Authors: Nicolas Segond, Pouria Pourzand, Johanna Moore, Anja Metzger, Bayert Salverda, Mithun Suresh, kerry bachista, Guillaume Debaty, Keith Lurie
Journal: Circulation (2024)

Background: Addition of resuscitative endovascular balloon occlusion of the aorta (REBOA) to automated head-up position (AHUP) cardiopulmonary resuscitation (CPR), the combination of active compression decompression CPR, an impedance threshold device, and controlled gradual elevation of the head and thorax, increases cerebral perfusion pressure. Optimal management of REBOA deflation after prolonged AHUP-CPR and ROSC is unknown. Hypothesis: We hypothesized that partial deflation of REBOA, rather than full deflation after ROSC, would result in better hemodynamic parameters. Aims: To compare hemodynamic parameters 1 minute before and 1 minute after complete (100%) versus partial (50%) REBOA deflation after prolonged AHUP-CPR and ROSC. Methods: Yorkshire pigs weighing ∼40 kg were anesthetized and ventilated. After 10 minutes of untreated ventricular fibrillation, AHUP-CPR was started and continued for a median time of 44 minutes. After ROSC, REBOA deflation was initiated in two ways: complete (100%) or partial (50%) deflation over 5 seconds. The following hemodynamic parameters were measured 1 minute before and 1 minute after deflation: mean aortic pressure (MAP), cerebral perfusion pressure (CerPP), and coronary perfusion pressure (CorPP). Data, in mmHg, are presented as mean ± SD, and compared using a paired t-test. Results: 13 pigs were included, with 8 pigs in the 100% deflation group and 5 in the 50% deflation group. After ROSC in the 100% deflation group, MAP was 81.5±36.0 before deflation vs. 43.0±14.4 after (p=0.01), whereas in the 50% deflation group, MAP was 90.5±33.0 vs. 83.4±33.3 (p=0.02). CerPP was 72.3±34.4 before deflation vs. 35.9±14.6 (p=0.01) in the 100% deflation group, and 84.6±31.2 vs. 77.6±31.8 (p=0.02) with 50% deflation. Similarly, CorPP was 74.1±37.3 before deflation vs. 36.1±15.8 (p=0.01) after in the 100% deflation group, and 83.0±32.7 vs. 76.1±33.0 (p=0.02) in the 50% deflation group. The differences from before to after deflation were markedly less in the 50% deflation group versus the 100% deflation group: MAP (7.0±4.3 vs. 38.5±25.7, p=0.02), CerPP (7.1±4.4 vs. 36.3±24.4, p=0.02), and CorPP (6.0±4.2 vs. 39.8±25.2, p=0.02), respectively. Conclusion: In this porcine model of prolonged cardiac arrest, partial deflation of the REBOA balloon post ROSC resulted in strikingly higher hemodynamics compared with complete deflation. These findings highlight the need to develop a post-ROSC REBOA deflation strategy when used during AHUP-CPR.
Abstract 4147676: Outcomes Of Chronic Total Occlusion Of Coronary Artery Compared Between Urban And Rural Hospitals In The United States
Authors: yasar sattar, Adishwar Rao, Salman Abdul Basit, Muhammad Abdullah Naveed, Mohammed Saifuddin, Hafeez Hassan
Journal: Circulation (2024)

Background: Chronic total occlusion (CTO) of the coronary artery is a complex condition necessitating special care, and the prognosis may vary due to differences in technical and human resources between urban and rural hospitals. Aim: To evaluate differences in mortality and cardiovascular outcomes in hospitalizations for CTO at urban centers compared to rural centers. Methods: We queried the National Inpatient Sample (NIS) database from 2016-2021 for hospitalizations related to CTO using the ICD-10 CM code I2582. We compared baseline characteristics and outcomes between urban and rural hospitals using Pearson Chi-Square test and two-sample t-test or Wilcoxon Rank Sum test. We also computed adjusted odds ratios (aORs) using multivariate logistic regression models and conducted a sensitivity analysis using 1:1 propensity score matching. Results: Out of 562,880 weighted hospitalizations for CTO, patients admitted to urban centers were younger (mean age 67.78 y vs 68.40 y, p&lt;0.001), more likely to be Black American (10.2% vs 6.4%, p&lt;0.001) or Hispanic (10.2% vs 6.4%, p&lt;0.001), had a longer duration of hospital stay (median 4 d vs 3 d, p&lt;0.001), and witnessed higher total charges (median $89,408 vs $55,559, p&lt;0.001) and total cost (median $21,384 vs $17,279, p&lt;0.001) than those in rural hospitals. Multivariate analyses revealed that patients in urban hospitals had higher odds of mortality (aOR 1.28, p=0.010), cardiogenic shock (aOR 1.55, p&lt;0.001), cardiac arrest (aOR 1.31, p&lt;0.001), requiring mechanical circulatory support (aOR 1.52, p&lt;0.001), and acute kidney injury (aOR 1.24, p&lt;0.001) compared to those at rural hospitals. Urban hospitals were also associated with lower odds of myocardial infarction (aOR 0.79, p&lt;0.001) and major adverse cardiovascular and cerebrovascular events (aOR 0.85, p&lt;0.001). Conclusion: Urban hospitals were associated with increased odds of mortality, cardiogenic shock, cardiac arrest, need for mechanical circulatory support, and acute kidney injury compared to rural hospitals. Despite ample resources at urban hospitals, differential baseline comorbidity burdens may have contributed to these differences thus underscoring the need to conduct prospective studies to better understand the factors responsible for these disparities.
Abstract Sa207: Early Nebulized Inhaled Nitroglycerin Enhances Carotid Blood Flow Without Compromising Coronary Perfusion Pressure During CPR in a Swine Cardiac Arrest Model
Authors: Scott Youngquist, Christopher Kelly, Helen Palatinus, Nicole Ewer, Guillaume Hoareau, Michael Johnson
Journal: Circulation (2024)

Introduction/Background: Pulmonary vasodilators reduce pulmonary vascular resistance and may improve blood flow during CPR. However, most are not available outside of an ICU setting. Nitroglycerin is an inexpensive pulmonary vasodilator that EMS widely uses to treat chest pain. Research Questions/Hypothesis: We hypothesized that nebulized, inhaled nitroglycerin (NIN) would improve carotid blood flow (CBF) without reducing coronary perfusion (CPP) or arterial pressures. Goals/Aims: The principal aim of this investigation was to assess the hemodynamic effects of NIN administered during CPR in a swine model of cardiac arrest. Methods/Approach: N=17 Mixed breed Yorkshire swine (54 + 5 kg) were sedated, intubated, and placed under isoflurane general anesthesia. Following instrumentation with arterial and right atrial pressure catheters as well as a carotid flow probe, the fraction of inspired oxygen (FiO 2 ) was titrated to achieve a PaO 2 of 80-100 mmHg. Ventricular fibrillation (VF) was then induced with a pacing catheter, and the ventilator turned off. After 7 minutes of untreated VF, mechanical chest compressions with a LUCAS device were initiated. Three minutes later, mechanical ventilation was resumed at prearrest settings with 100% FiO 2 . Two minutes later, 5 mL of either nebulized normal saline (NNS controls, n=9) or 10 mg of nitroglycerin (NIN treatment, n=8) was delivered through a nebulizer placed in line with the endotracheal tube, by random allocation. After 4 minutes of nebulized treatment, IV epinephrine (0.15 mg/kg) was administered, followed 2 minutes later by defibrillation. NIN or nebulized NS was continued until the volume was fully delivered, while standard ALS resuscitation proceeded until ROSC or 40 min of arrest had elapsed. Data were analyzed using mixed effects models. Results/Data: Prearrest hemodynamic and blood gas variables were similar between groups. There were no statistically significant differences in systolic or diastolic arterial pressures or CPP. However, there was a statistically significant increase in CBF following NIN (Figure). After 4 minutes of treatment, CBF in NIN-treated animals was approximately double that of NNS controls: 85 mL/min (95% CI 63-108 mL/min) vs 41 mL/min (95% CI 21-61 mL/min), respectively. ROSC was achieved in 3/9 (33%) NNS controls and in 5/8 (63%) of NIN-treated animals (p=0.23). Conclusions: In this small study, early NIN treatment resulted in superior CBF without decreasing arterial pressures or CPP.
Abstract Sa902: Re-arrest Immediately after Return of Spontaneous Circulation
Authors: Eirik Unneland, Anders Norvik, Daniel Bergum, David Buckler, Abhishek Bhardwaj, Trygve Eftestol, ELISABETE ARAMENDI, Trond Nordseth, Benjamin Abella, Jan Terje Kvaloy, Eirik Skogvoll
Journal: Circulation (2024)

Introduction: Patients who regain return of spontaneous circulation (ROSC) after in-hospital cardiac arrest are often critically ill and at risk of re-arrest. However, re-arrest is insufficiently studied. Pre-hospital data indicate a re-arrest rate ranging from 3% to 39%. Our study aims to assess the immediate hazard of re-arrest after ROSC, depending on whether the patient’s last observed rhythm before ROSC was shockable or not. Methods: We analyzed defibrillator recordings and clinical data from 763 cardiac arrest episodes at four different hospitals. ROSC was defined as an organized ECG rhythm compatible with a pulse, accompanied by the absence of chest compressions for at least one minute. An organized rhythm with a QRS frequency ≥ 12 was categorized as pulseless electrical activity (PEA). Conversely, a QRS frequency &lt; 12 or a flat line represented asystole. Ventricular fibrillation or tachycardia (VF/VT) was identified based on its distinct morphology. We further stratified ROSC based on whether the preceding rhythm was shockable or not. After comparing four different parametric time-to-event models, we chose the most useful one and estimated the immediate hazard of re-arrest along the timeline of resuscitation. Results: After the initial event of cardiac arrest, we observed 316 re-arrests. Among these, 68% relapsed to PEA, 25% relapsed to VF/VT, and 7% relapsed to asystole. Summarized in the figure, the initial hazard of re-arrest from ROSC after PEA or asystole to a non-shockable rhythm was 0.02 per minute. By the 9th minute, this hazard decreased to 0.01 per minute. Meanwhile, the hazard for re-arrest to a shockable rhythm remained constant at 0.01 per minute. For re-arrest from ROSC after VF/VT back to VF/VT, the hazard was 0.05 per minute initially, decreasing to 0.03 per minute by the 12th minute. The corresponding hazard for re-arrest to PEA or asystole remained at 0.01 per minute. Conclusion: The hazard of re-arrest after return of spontaneous circulation (ROSC) to either pulseless electrical activity (PEA), asystole, or ventricular fibrillation/tachycardia (VF/VT) varies by the last observed state before ROSC. Notably, re-arrest to VF/VT following ROSC after previous VF/VT poses the highest risk. This understanding can assist healthcare professionals in anticipating events during the critical minutes following successful resuscitation and adjusting treatment accordingly.
Abstract Sa309: The Effect of Active Thoracic Deconstriction on Circumferential Constriction 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: Active thoracic deconstriction ( ATD ) is an impactful addition to standard closed-chest CPR, thought to increase perfusion pressure (CPP) by augmenting venous return. Most studies of ATD, however, have been conducted using piston-based sternal compression CPR ( PBSC-CPR ), which can cause significant thoracic skeletal trauma. In contrast, circumferential constriction CPR ( CC-CPR ) does not cause significant structural damage, possibly preserving the thoracic-recoil-based venous return mechanism. If that is the case, CC-CPR would not benefit from ATD. Hypothesis: ATD has no effect on CC-CPR hemodynamic parameters. Methods: Ventricular fibrillation was induced in Yorkshire swine (n = 3 , ~30 kg). CPR was provided by a custom pneumatic CC-CPR system. ATD during CC-CPR was achieved by active deflation against a hard outer shell, called a cuirass, using Velcro interfaces between the animal, the belt, and the cuirass. CC-CPR was alternated in 45-second epochs between active pneumatic deflation with and without a rigid cuirass. Aortic ( Ao ) and right atrial ( RA ) pressures were measured, and coronary perfusion pressure ( CPP ) derived. ETCO2 and carotid flow were also measured. Results from all experiments were grouped by treatment type and subjected to Analysis of Variance. Results: 39 epochs in three studies were included. There were no statistically significant differences (P &lt; 0.1) in CPP, ETCO2, or carotid flows between treatment types (Table). Conclusion: Because of its much larger contact surface area, the total possible decompression force during CC-CPR is greater than during PBSC-CPR. Despite this, the presence or absence of the rigid cuirass—and thus active deconstriction—appeared to have no impact on hemodynamic parameters. This finding suggests that the benefit of ATD during PBSC may derive from compensating for the damaged thoracic recoil mechanism, not enhancement of an extant mechanism. If the skeletal trauma of PBSC-CPR devices is avoided, the apparent benefit of ATD might be lessened. Further study to test this potentially important hypothesis is indicated.
Abstract Or115: Execution of Transesophageal Echocardiography in Cardiopulmonary Resuscitation for Patients with Out-of-hospital Cardiac Arrest (EXECT-CPR): A Clustered Randomized Clinical Trial
Authors: Sheng-En Chu, Jen-Tang Sun, Chiao-Yin Cheng, Matthew Ma, Wen-Chu Chiang
Journal: Circulation (2024)

Background: Current cardiopulmonary resuscitation (CPR) guidelines recommend chest compressions at "the center of the chest." However, studies have shown that over half of patients with out-of-hospital cardiac arrest (OHCA) experience aortic valve (AV) compression following this recommendation, which may worsen outcomes. We hypothesized that using transesophageal echocardiography (TEE) to guide chest compressions in adult OHCA patients, avoiding AV compression and targeting the left ventricle (LV), would improve outcomes compared to the conventional site. Methods: The EXECT-CPR trial was a single-center cluster randomized clinical trial enrolling adults (≥20 years old) with non-traumatic OHCA presenting to the emergency department (ED). Exclusion criteria included return of spontaneous circulation (ROSC) before ED arrival, extracorporeal CPR, pre-existing contraindications for TEE, do-not-resuscitate orders, or obvious signs of death. Patients were assigned to the TEE-guided or conventional group using biweekly cluster randomization. Both groups received standard advanced life support, except the intervention group's compression site, which was initially conventional then rapidly adjusted by TEE. The primary outcome was sustained ROSC (≥20 mins). Secondary outcomes included survival to ICU and discharge with favorable neurological outcomes. The sample size was estimated at 66/group. Analyses were performed on intention-to-treat (ITT) and per-protocol (PP) basis. Results: From June 26 to November 15, 2023, a total of 262 OHCA patients were sent to the ED, and 132 were enrolled in the final analysis (mean age 65 years, 66% male), with 66 in each group. In the TEE-guided group, TEE was successfully imaged in 53 patients (5.3 mins after arrival at the ED). Due to clinical situations, only 46 patients completed the assigned TEE-guided interventions. Of these, 35 patients, who were initially not compressed at the LV, had their compression sites successfully adjusted (9.2 mins after arrival at ED). In ITT analysis, the primary outcome was 29/66(43.9%) in the TEE-guided group and 26/66(39.4%) in the conventional group (odds ratio[OR] 1.21, P=0.60), while in PP analysis it was 20/46(43.5%) and 26/66(39.4%) (OR 1.18, P=0.67; adjusted OR 1.63, P=0.28). Secondary outcomes showed no significant differences. Conclusion: Among adults with non-traumatic OHCA, TEE-guided CPR with an adjusted compression site in the ED did not result in different outcomes compared to conventional CPR.
Abstract Sa1206: Chicago improves its Out-of-Hospital Cardiac Arrest Survival
Authors: Shaveta Khosla, Courtney Schwerin O'Reilly, Pavitra Kotini-Shah, Elizabeth Froelich, Eddie Markul, Katie Tataris, Teri Campbell, Marina Del Rios, Joseph Weber, Terry Vanden Hoek
Journal: Circulation (2024)

Background: Illinois Heart Rescue began monitoring out-of-hospital cardiac arrest (OHCA) data in 2013, and since then the program has expanded from one Emergency Medical Services (EMS) agency to 110 agencies and 118 hospitals in Illinois that report to Cardiac Arrest Registry to Enhance Survival (CARES). In Chicago, apart from community bystander cardiopulmonary resuscitation trainings and resuscitation academy trainings, the program provides audits and feedback for 911 calls, and critical insights to the hospitals. Aim: Our aim was to assess OHCA survival rates in Chicago for 2023 and compare those to prior years. Methods: We included non-traumatic adult OHCA served by Chicago EMS and reported to CARES between 2013 to 2023. Cases that occurred in a healthcare facility or a nursing home were excluded. Rates were generated; percentage changes and trends were assessed. Results: Of the 23,688 cases from 2013-2023 in Chicago, 2470 cases occurred in 2023. The highest rates of survival to hospital admission (STHA, 30.6%), survival to hospital discharge (STHD, 10.6%), favorable neurologic survival (6.6%) and Utstein survival to hospital discharge (37.8%) since 2013 were recorded in 2023, and particularly since 2020 the survival rates increased consistently. From 2020 to 2023, the STHA increased by 44% (p for trend=0.048), STHD by 76% (p=0.03), favorable neurologic survival by 91% (p=0.03), and Utstein survival by 93% (p=0.02). Overall survival rates were similarly increased in both men and women for the most part. STHD increased in men by 95%, and in women by 48% from 2020 to 2023, with the survival rate becoming comparable in the two genders in 2023 (10.8% in men vs. 10.2% in women). Similarly, the rate of favorable neurologic survival increased in both, but the increase was steeper in men with a higher survival rate in men (7.2% vs. 5.7% in women) in 2023. Utstein survival also improved significantly in men and reached 40% in 2023 (with an increase of 152% from 2020 to 2023, p=0.004). By race and ethnicity, STHD and favorable neurologic survival increased consistently in Hispanic and Black cases from 2020 to 2023. Conclusion: Chicago experienced a significant increase in OHCA survival. This is a result of concerted efforts of Chicago Fire Department/EMS, hospitals and community with the support of Illinois Heart Rescue. As a result of these efforts, the survival rates in Chicago are now comparable to or exceed the national rates.
Abstract 4147384: P66ShcK81-sumoylation mediates hyperlipidemia-induced endothelial dysfunction in mice
Authors: Shravan Kumar Uppulapu, JITENDRA KUMAR, Sujata Kumari, Kanika Sharma, William Paradee, Ravi Prakash Yadav, Vikas Kumar, Santosh Kumar
Journal: Circulation (2024)

Introduction: Hyperlipidemia promotes atherosclerosis, a leading cause of myocardial infarction and stroke. Atherosclerosis is commonly associated with endothelial dysfunction. Elevated levels of p66Shc and sumoylated proteins have been implicated in hyperlipidemia-induced endothelial dysfunction. Recently, we discovered that SUMO2 modifies p66Shc at lysine-81, regulating its function. However, the role of endogenous p66ShcK81 sumoylation remains unclear. Methods: We used LDLr-/- mice and p66ShcK81R knock-in mice on an LDLr-/- background (p66ShcK81R-KI x LDLr-/-). Hyperlipidemia was induced by feeding the mice a high-fat diet for 4 weeks. We monitored body weight gain and measured serum total cholesterol levels. Endothelial function, oxidative stress, and sumoylation were assessed in the aortas. Additionally, we performed global mass spectrometry to identify the molecular signaling pathways regulated by p66ShcK81-SUMO2ylation in endothelial cells. Results and Discussion: To determine the contribution of SUMO2 to this sumoylated pool of proteins, we treated human umbilical vein endothelial cells with oxidized LDL and knocked down SUMO2 with siRNA. The majority of the sumoylated proteins were found to be SUMO2-conjugated, suggesting that SUMO2 is primarily affected in hyperlipidemia. In LDLr-/- mice on a high-fat diet, we observed increased expression of SUMO2/3-conjugated proteins compared to controls. Feeding a high-fat diet induced a similar increase in serum cholesterol levels as well as weight gain in both LDLr-/- and p66ShcK81R-KI x LDLr-/- mice. Vascular reactivity revealed significant impairment of endothelium-dependent vasorelaxation of aortic rings in LDLr-/- mice. However, aortic rings from p66ShcK81R-KI x LDLr-/- mice displayed vasorelaxation similar to control p66ShcK81R-KI mice. We also noted increased oxidative stress (8-OHdG levels) in LDLr-/- mice, which was significantly reduced in p66ShcK81R-KI x LDLr-/- mice. Lastly, mass spectrometry data indicated that p66ShcK81-SUMO2ylation promotes mitochondrial dysfunction and impairs Rho-GTPase signaling in endothelial cells. Conclusion: Our findings demonstrate that p66ShcK81 mediates hyperlipidemia-induced endothelial dysfunction and oxidative stress. Investigating the role of specific molecules regulated by p66ShcK81-SUMO2ylation may lead to the discovery of novel tools to manage endothelial dysfunction caused by hyperlipidemia.
Abstract 4147545: Adverse Events with Pulsed Field Ablation - A Review of the Food and Drug Administration’s Manufacturer and User Facility Device Experience Database
Authors: Julie Cooper, William Zagrodzky, Jason Zagrodzky, Samuel Omotoye, Mayank Sardana, Andrew Kaplan, Mark Link, Thomas Bunch, James Daniels
Journal: Circulation (2024)

Introduction: Pulsed field ablation (PFA) is an adaptation of direct current ablation first used for catheter ablation in the 1980s. Expectations of a reduced risk profile led to the current resurgence in investment and interest in the technology as a potential alternative energy source for ablations to treat atrial fibrillation (AF). However, reports of adverse events, including new risks, are increasing. Research Question: How many adverse effects are reported with the use of newly available PFA systems? Aims: Quantify and describe the adverse events from PFA reported to date in the Food and Drug Administration’s (FDA) Manufacturer and User Facility Device Experience (MAUDE) database. Methods: We searched the U.S. FDA’s MAUDE database for all reports filed with the code “QZI”, which is the product code for PFA systems created with the first FDA approvals in February 2024. All reports from inception through April 2024 (a total of 3 months) were included in this review. Per manufacturer presentation in May 2024, approximately 1000 cases utilizing PFA had been captured in a post-market registry of the predominant commercially used technology, but the exact number of cases can not be determined from MAUDE data. Results: A total of 217 adverse events were reported over the first 3 months of US approval, with 91 of these considered patient injuries. These injuries included 10 cases of cardiac tamponade, 7 reports of postoperative arrhythmia, 6 instances of device-related tissue entrapment, 5 cases of hemolysis with impaired renal function, 5 cases of stroke or TIA, including both embolic and hemorrhagic, 3 cases of intraoperative heart block, 2 coronary spasms, and 2 cases of intraoperative ST elevation. (Figure) Of the 91 reported patient safety events, 46 required hospitalization, 13 cases required temporary pacing, 11 required pericardiocentesis, 4 required dialysis, 4 required cardiothoracic surgery, and 2 required cardioversion. Conclusions: A number of adverse events have been reported to the MAUDE database in the first 3 months of FDA approval of PFA. The cardiac electrophysiology community should remain vigilant to ensure that the benefit-risk profile remains acceptable for patient safety.