tbuckley/cabot-search huggingface dataset:
Abstract 16739: Tricuspid Regurgitation Following Conduction System Pacing Lead Entanglement in Chordae Tendineae
Authors: Chandra Chhetri, Shahan Haseeb, Umair A Ansari, Rajat Goyal
Journal: Circulation (2023)

Case Description: A 62-year-old male with symptomatic sinus bradycardia presented for pacemaker implantation. Conduction system pacing (CSP) was pursued using the Medtronic 3830 lead. The lead was advanced through a C315His sheath and positioned at the basal-mid ventricular septum. Passive pacing demonstrated V1 notching and aVR/aVL discordance. An attempt was made to fixate the lead but despite rapid clockwise turns at the proximal lead tip, no lead penetration was seen in the LAO projection. The lead was removed and the sheath was repositioned. A second attempt was made with similar results. When attempting to remove the lead however, the lead remained adherent to the tissue despite multiple counter-clockwise turns. Increasing traction was applied at the proximal lead tip which resulted in elongation of the fixation screw and eventual disengagement from the tissue. Upon examination of the lead tip, there was fibrinous tissue suggestive of either chordae tendineae or valve remnant. Further attempts at CSP were aborted and the patient underwent traditional RV septal lead placement. Transthoracic echocardiogram (TTE) performed following the procedure demonstrated mild-moderate eccentric tricuspid regurgitation, likely due to chordae injury. Discussion: Left bundle branch pacing (LBBP) is becoming an increasingly popular form of CSP and requires deep penetration of the septum to engage the left bundle branch. To our knowledge, this is only the second case describing tricuspid valve chordae tendineae entanglement as a result of a CSP attempt. Most often, tricuspid regurgitation due to LBBP is attributed to entrapment of the septal TV leaflet from a basal position of the pacing lead. In our case, we suspect tricuspid valve injury occurred as a direct result of entanglement of the screw into the chordae. Potential ways to mitigate this complication are to pursue a more distal implantation site or to confirm adequate passive injury current prior to fixation to ensure the screw tip engages the myocardial tissue. Most of all, it is important to recognize that when a lead is not advancing into the septum, one should abort the position early and try an alternative site to avoid complications.
Abstract 17944: Process Mapping Care of Patients With Lower Extremity Wounds Due to Chronic Limb Threatening Ischemia
Authors: Lauren Cralle, Misty Humphries
Journal: Circulation (2023)

Background: The care experience for patients with wounds due to chronic limb threatening ischemia (CLTI) is rarely understood. Quality improvement programs frequently fail to recognize the entire process involved in accessing care. We developed a process map for stakeholders to guide quality improvement for CLTI patients. Methods: We recruited a team of stakeholders, including nurses, providers, coordinators, and patients, and met through iterative meetings to create a process map. We categorized barriers, identified actors, and estimated wait times. Based on information gathered, targeted solutions to improve care were developed. Results: We mapped 2 pathways, inpatient hospitalization and outpatient evaluation, for CLTI patients seeking care. Within these 2 paths, we identified 25 action steps with 15 decision points. We identified a total of 105 barriers to patients accessing care in each pathway. These were mapped into 9 categories grouped into multiple patient factors, health systems resources, insurance, communications, and waiting. We also identified 40 actors whose role in the process could create barriers within the process, including family, translators, social services, insurance. Finally, we grouped solutions into 4 categories. Overall, the shortest time to treatment was mapped as 8 weeks with expedited care to over 1 year with care provided solely in clinic. Conclusion: Process mapping highlights the great lengths patients endure to get treatment as well as specific opportunities for improving care between systems, providers, patients, and families. This work should serve as the foundation for quality improvement programs for patients with CLTI.
Abstract 12699: Impact of Mode of Delivery on Maternal and Fetal Outcomes in Pregnant Patients With Heart Failure or Pulmonary Hypertension
Authors: Kunal N Patel, Monil Majmundar, Harshvardhan Zala, Tasveer Khawaja, Rajkumar P Doshi, Ankur Kalra, Mathew Lippmann, Martha Gulati
Journal: Circulation (2023)

Introduction: Despite the existing guidelines, data on maternal, fetal, and obstetric outcomes associated with various modes of delivery in pregnant patients with heart failure (HF) or severe pulmonary hypertension (pHTN) is limited. Methods: This retrospective population based cohort study used Nationwide Readmission Database to identify all hospitalized pregnant patients who were primarily admitted for vaginal or cesarean delivery from 2011 to 2019. Pregnant patients with HF or pHTN were identified. Primary outcomes were inhospital maternal and fetal mortality. Result: 23,359 hospitalized pregnant patients with HF or pHTN were identified. Cesarean deliveries were performed more than vaginal deliveries (66.2% vs. 33.8%). Patients undergoing cesarean delivery had lower odds of fetal mortality [OR: 0.18 (0.07-0.45), p&lt;0.001] and postpartum hemorrhage than vaginal delivery. However, the odds of in-hospital maternal mortality [OR: 2.0 (1.07-3.77), p=0.03], ACS, and puerperal sepsis were higher in cesarean group than in vaginal delivery group. There were no differences in the odds of in-hospital stroke and DVT/PE between two groups. We found that 167 pregnant women would have to undergo cesarean delivery to have one inhospital maternal mortality (NNH=167), and 164 pregnant women would have to undergo cesarean delivery to prevent one fetal mortality (NNT=164). There were increased odds of all-cause readmissions within 6 months in patients who had cesarean delivery compared with those who had vaginal deliveries. There was no difference in risk of acute exacerbation of HF, readmission mortality, ACS, stroke, and DVT/PE between two groups at 6 months. Conclusion: In this retrospective multicentric cohort study, cesarean delivery was associated with lower fetal mortality but higher inhospital maternal mortality. Thus, unique features of each patient case should be considered via a multidisciplinary discussion before determining a preferred delivery method.
Abstract 13338: Intravenous Iron for Patients With Iron Deficiency and Acute or Chronic Heart Failure, a Meta Analysis
Authors: Ahmed K. Awad, Mahmoud Shabaan Abdeljalil, Adel Mouffokes, Merihan A Elbadawy, Ayman K. Awad, Ambreen Nabeel, Syed Karam Gardezi, Rehmat Ullah Awan
Journal: Circulation (2023)

Iron deficiency is very common in heart failure (HF), both with preserved and reduced ejection fraction (HFp/rEF); and has significant impact on both symptoms and prognosis. This review highlights the effect of use of intravenous iron (IVI) therapy in patients with HFrEF Several databases were searched to identify RCTs that investigate the efficacy and safety of IVI therapy in patients with acute or chronic HF. A meta-analysis was performed using RevMan using random effect model. We used the odds ratio (OR) and mean difference (MD) for dichotomous and continuous outcomes, respectively presented with the corresponding 95% confidence interval (CI). A total of 18 studies were included with 3,436 patients with mean age of 68 years old. There was no statistically significant difference between IVI and placebo in terms of cardiovascular death or all-cause hospital admission. However, IVI was associated with statistically significant lower risk for hospitalization for any cardiovascular disorder and all cause death with OR 0.42 [95% CI 0.28, 0.64, p&lt;0.0001] and 0.61 [95% CI 0.39, 0.96, p=0.03], respectively. Additionally, there was statistically significant variation in serum ferritin and serum transferrin from baseline favoring intravenous iron with MD -189.62 [95%CI -236.55, -142.69, p=0.01], and -7.65 [95% CI -13.43, -1.87, p=0.009], respectively. Furthermore, IVI was associated with a significant improvement in HF patients’ functional status, evaluated by both Kansas City Cardiomyopathy Questionnaire (KCCQ), and changes from baseline in left ventricular ejection fraction (LVEF) with MD -7.14 [95% CI -10.52, -3.76, p&lt;0.0001], and 3.76 [95% CI 2.32, 5.21, p&lt;0.00001], respectively. Our meta-analysis demonstrated the capability of IVI to improve clinically meaningful outcomes as HF-related cardiovascular-related hospitalization as well as functional status; however, intravenous iron showed no difference in term of mortality.
Abstract 353: The Uncertainty Principle in Cardiac Arrest and Critical Care Trials
Authors: Jacob Vine, Lakshman Balaji, Katherine Berg, Franklin Li, Ari Moskowitz, Anne V Grossestreuer, Michael Donnino
Journal: Circulation (2023)

Introduction: A challenge with clinical trials is the capacity to identify a population that may potentially benefit from the intervention that is not “too well” (will recover) or “too sick” (will not survive) regardless of intervention. While inclusion criteria attempt to obtain this, populations enrolled in trials include pts in which bedside clinicians would be able to categorize in terms of likelihood of survival independent of study intervention. We further hypothesize that patients categorized as having an uncertain outcome would be most likely to benefit from the intervention. Methods: We present subgroup analyses of patients from the Thiamine as a Metabolic Resuscitator in Cardiac Arrest (THACA) trial in patients with out of hospital cardiac arrest and the Ascorbic Acid, Corticosteroids and Thiamine in Sepsis (ACTS) trial in patients with septic shock. The treating physician predicted at the time of enrollment whether the patient is “very likely”, “very unlikely”, or ”uncertain” to be alive at 30 days. Results: Among 31 pts in the THACA trial with physician predictions, 12/31 (39%) were predicted very unlikely to be alive on day 30, 3/31 (10%) very likely, and 16/31 (52%) uncertain. Among 200 pts in the ACTS trial, 13/200 (7%) of patients were predicted as very unlikely, 72/201 (36%) very likely and 115/201 (57%) uncertain. Predicted mortality was associated with observed mortality in both trials(p = 0.04, p&lt;0.001). When evaluating the primary outcome in the population categorized as uncertain, there was a non-significant shift in favor of the intervention in THACA (p = 0.69); and a difference favoring the intervention in ACTS (p = 0.03) as opposed to the overall cohort which did not reach statistical significance (p = 0.12). Conclusion: In two RCTs in patients with cardiac arrest and septic shock, physicians reliably predicted mortality. Restricting analyses to pts with an uncertain outcome, the primary outcome in one trial changed from trending toward favoring the intervention to a statistically significant difference. The second trial shifted in favor of the outcome but did not reach statistical significance. These findings suggest that physician prediction may be a potential method to target patients with the greatest chance to benefit from clinical trials.
Abstract 18715: A Cardiovascular Health Literacy Intervention Targeting Arab Women
Authors: Keren Greenberg, Aisha Saifi, Maha Nubani Husseini, Mayada Karjawally, Nisreen Agbaria, Donna Zwas
Journal: Circulation (2023)

Health Literacy (HL) is defined as an individual's motivation and ability to gain access to, understand and use information in ways which promote and maintain good health. Low health literacy is associated with increased cardiovascular risk factors. Arab women in Israel are at high cardiovascular risk with cardiovascular mortality that exceeds the mortality in Jewish women by 60%, and may have reduced health literacy. Objectives: To assess HL in Arab women in East Jerusalem and to design, implement and evaluate an interactive HL intervention in Arab women that will lead to an Increase in the percentage of women who utilize effective patient-doctor communication skills, increased self efficacy with regards to the patient-doctor interaction, improved comprehension of test results and increased cardiovascular knowledge. Methods: Tailored 3 session workshop. Questionnaires were administered before and 3 months after the intervention. Results: 267 women participated. 12.1% had inadequate health literacy and 24.2% had problematic health literacy. Of these women, there were matched pre/post questionnaires for 195 women. Matched participants reported increased preparatory behaviors before doctor visits including preparing symptom lists, question lists, medication lists, and medical documents (all p&lt;.001.) They reported increased scores on the Perceived Efficacy in Patient-Physician Interactions scale (7.25 to 7.95, p&lt;.001) , in particular in low efficacy participants who increased from 5.6 to 7.7, p&lt;.001. Health literacy as measured on the HLS-EU-16 increased from 12.6 to 14.33 (p&lt;.001), and 84.5% were in the sufficient range. Conclusions: A three session, tailored interactive HL workshop improved patients’ pre-visit preparation skills, self-efficacy and HL in a convenience sample of Arab women from East Jerusalem. HL can be improved with intervention and as such can be considered a modifiable risk factor for cardiovascular disease.
Abstract 16215: Reduced Left Atrial Strain and Risk of Ischemic Stroke in Patients With Normal Sinus Rhythm: A Systematic Review and Meta-Analysis
Authors: Maria Benitez Gonzalez, Rocio Barriga Guzman, Andre L Carvalho Ferreira, Ana Lima, Camila Guida
Journal: Circulation (2023)

Introduction: Abnormalities in the left atrium have been linked to a higher risk of ischemic cerebrovascular events. Left atrial (LA) strain analysis can identify LA dysfunction, even in patients with normal LA volumes. However, the precise association between LA strain and the occurrence of ischemic stroke in individuals who are in normal sinus rhythm (NSR) is not well established. Hypothesis: This systematic review and meta-analysis aimed to assess the relationship between reduced LA strain and the risk of ischemic stroke in patients with NSR. Methods: We searched PubMed, Embase, and Cochrane Central for studies that examined our clinical question. Two reviewers independently performed study selection, data extraction, and assessment of bias. Statistical analysis was performed using Review Manager 5.4.1. Heterogeneity was assessed with I2 statistics. We calculated pooled multivariable-adjusted hazard ratios (HR) with 95% confidence intervals (CI) under a random effects model. Results: We included 8,632 patients from 4 cohort studies, of which 3 were prospective. The mean follow-up ranged from 2.5 years to 10.9 years. The mean age ranged from 68.8 to 75.2 years. All results were obtained through multivariable-adjusted analysis, which includes adjusting for LA size and occurrence of new-onset atrial fibrillation during follow-up. The incidence of ischemic stroke was significantly increased in patients with reduced reservoir strain (HR 1.53; 95% CI 1.09-2.15; p=0.01; Figure 1) and conduit strain (HR 1.39; 95% CI 1.16-1.59; p &lt; 0.001). Reduced contractile strain was not predictive of stroke incidence (HR 1.94; 95% CI 0.96-3.93; p=0.07). Conclusions: Our findings indicate an independent association of reduced LA strain with an increased incidence of ischemic stroke in patients without a previous history of atrial fibrillation. Future studies are warranted to evaluate the role of LA strain as part of a comprehensive risk stratification for stroke.
Abstract 14753: Cigarette Smoking is Acutely Associated With Increased Cardiac Arrhythmias
Authors: Michelle Yang, Defne Yilmaz, Janet Tang, Kathleen Chang, Grace Wall, Gregory M Marcus
Journal: Circulation (2023)

Background: Chronic cigarette smoking is a known risk factor for the eventual development of atrial fibrillation (AF). However, the acute effects of cigarette smoking on arrhythmias in patients with AF have not been elucidated. Methods/Approaches: We conducted a prospective observational study enrolling consenting adults with a diagnosis of paroxysmal AF and who actively smoked. Participants were equipped with continuously recording ECG devices (iRhythm, San Francisco, CA) for up to 14 days and used a smart lighter (Quitbit, San Francisco, CA or Slighter, Cary, NC) or button presses on the ECG device to time-stamp cigarette smoking events in real-time. Outcomes included any AF, atrial flutter (AFL), supraventricular tachycardia (SVT), ventricular tachycardia (VT), atrial ectopic rhythms (EAR), and ventricular bigeminy and trigeminy. For this case-crossover study, we used a generalized linear mixed model with a Poisson distribution and accounted for the clustering of repeated measures for each participant to estimate the incidence rate ratio (IRR) between arrhythmias and smoking events. Results: We enrolled 29 participants (45% female, mean 55 ± 13 years old, 76% non-Hispanic white), where 22 used a smart lighter, and 7 relied on real-time button presses to document smoking events. Mean study duration was 12 ± 4 days. While wearing the monitor, 24 participants experienced ≥ 1 arrhythmia, including AF (n = 3), SVT (n = 19), VT (n= 5), EAR (n = 23), and ventricular bigeminy/trigeminy (n =12), and 9 participants had ≥ 1 sustained arrhythmia (arrhythmic events &gt;30 secs). Every additional cigarette smoked per day was associated with a 6% increase in arrhythmia events (IRR 1.06, 95% CI 1.05-1.07, P &lt; 0.001; Figure ). No statistically significant relationships were observed between smoking events and sustained arrhythmias per day. Conclusion: The data suggest smoking acutely increases the chance an arrhythmia will occur.
Abstract 13591: Utilization and Spending on Fixed-Dose Combination Treatment for Hypertension in Medicare and Medicaid, 2016-2020
Authors: Mohammed Essa, Joseph S Ross, Sanket Dhruva, Nihar R Desai, Erica S Spatz, Kamil Faridi
Journal: Circulation (2023)

Introduction: ACC/AHA hypertension guidelines recommend fixed-dose combination (FDC) medications for Stage 2 hypertension to improve adherence and blood pressure control. However, utilization, total spending, and generic availability of FDC antihypertensives among U.S. adults are unknown. Methods: We evaluated total claims in millions (M) and inflation-adjusted spending for all first-line single and FDC antihypertensive medications consisting of ACEi/ARBs, calcium channel blockers, and/or thiazide diuretics in Medicare Part D and Medicaid from 2016 to 2020. We also evaluated use of generic vs. brand-name first-line antihypertensives. Results: Though total antihypertensive claims increased from 2016 to 2020 in Medicare and Medicaid, use of FDC antihypertensives decreased from 20.6M to 16.9M claims in Medicare (12.6% to 9.4% of all first-line hypertension treatment claims), and from 4.6M to 3.4M claims in Medicaid (12.3% to 8.8%), respectively ( Figure ). Total spending on FDC antihypertensives decreased from $823.3M to $670.9M in Medicare and from $58.9M to $46.9M in Medicaid over this time period. Generically available medications constituted &gt;96% of all Medicare and Medicaid claims in 2016 and &gt;99% of all Medicare and Medicaid claims in 2020 for both single and FDC antihypertensives. Spending on FDC brand-name medications decreased by 87.6% in Medicare ($385.5M to $47.7M) and by 94.1% ($24.9M to $1.5M) in Medicaid. Conclusions: Though FDC medications are widely recommended for treatment of hypertension and almost exclusively generic, use of these agents in Medicare and Medicaid has decreased from 2016 to 2020. Further efforts are needed to understand the decrease in FDC use and to increase adoption of FDC antihypertensives in clinical practice.
Abstract 15152: One-Year Evolution of Patients With Pulmonary Embolism During the Highest Epidemic Peak of COVID-19: COVID-EP Study
Authors: Roger Rosario, Antoine ELIAS, Hélène Bouvaist, Julien Dreyfus, Saby Ludivine, Damien Fard, Justine Bonomini, Cecile BIELMANN, Rahamia Ahamada, Guillaume PENARANDA, laurent bonello, François-Xavier Lapébie, Aurélien Seemann, Thibault Perret, Gregoire Range, Nicolas Meneveau
Journal: Circulation (2023)

Introduction: During the first COVID peak, among patients admitted to intensive care unit, pulmonary embolism (PE) diagnosis frequency was high. In April 2020 (highest epidemic peak of COVID), no PE management guidelines were effective, and PE evolution in this context was uncertain. Although several studies had explored a potential link between COVID and PE, none had focused on PE evolution according to COVID status excepted for death and short-term complications. Hypothesis: Our aim was to investigate whether COVID status and/or treatments used at the time of PE could affect PE evolution in longer-term. Aims: The main objectives were: (1) To assess the occurrence at 6 and 12 months after PE diagnosis of one of the following complications of interest: interstitial pathology, recurrence of PE, pulmonary arterial hypertension (PAH) or death, (2) to investigate the impact of the treatment dispensed on PE evolution. Methods: A National multicenter prospective cohort study was conducted in patients diagnosed with PE in April 2020. Patients were divided into two groups according to their COVID viral status (COVID-positive and COVID-negative) and were followed up to 12 months. Results: A total of 87 patients were included into 12 centers. No difference in global complication rates was observed between the groups at 6 and 12 months (p=0.4682 and p=0.5045 respectively). However, we observed that COVID-Positive patients had more interstitial pathology at 3, 6 and 12 months than COVID-Negative patients (p=0.0075, p=0.0088 and p=0.0033 respectively). Furthermore, the PE complication rate was significantly higher in patients treated with heparin-alone in COVID-negative patients (p=0.0002). Conclusions: COVID status did not appear to influence PE evolution, in accordance with the literature. Interstitial pathology has recently been shown to be a complication of COVID, which may explain its higher incidence in the COVID-positive group. Because of the exceptional context of the COVID pandemic in which this study was conducted and the short duration of inclusion, it might be interesting to confirm these results with a study on a larger population and over a longer period, in order to possibly update the management of patients with PE.