tbuckley/cabot-search huggingface dataset:
Abstract 4143359: Troponin as a Predictor for Diagnosis and as a Prognostic Marker for Cardiovascular Outcomes in Immune Checkpoint Inhibitor (ICI) related Myocarditis.
Authors: Milagros Pereyra, JUAN FARINA, Ahmed K. Mahmoud, Isabel Scalia, Kamal Awad, Christopher Kanaan, Maria Cecilia Tagle-Cornell, Barbara Novais, Laura Koepke, Courtney Kenyon, Joerg Herrmann, Reza Arsanjani, Chadi Ayoub
Journal: Circulation (2024)

Background: ICI-related myocarditis is challenging to diagnose and associated with adverse cardiovascular events and mortality. ICI therapy has also been associated with acute coronary events. There is limited data regarding cardiac troponin T (cTnT) and its association with these cardiovascular outcomes. Methods: All patients treated with ICI at a tertiary institution from 2011 to 2022 were identified, and the charts of those with cTnT measurements were reviewed. In patients with cTnT elevation (cutoff of &gt;14 ng/L), if the Bonaca criteria for myocarditis were met, these patients were labeled as cTnT+/myocarditis+, otherwise as cTnT+/myocarditis-. Patients with non-elevated cTnT values were labeled cTnT-. Medical records were reviewed for baseline characteristics and long-term outcomes, including cardiac death, new heart failure (HF) diagnosis, and MACE (myocardial infarction, TIA/stroke, new HF diagnosis). Kaplan-Meier curves were created to plot the comparison between the three groups. Results: A total of 1669 cancer patients who received ICI therapy had post-ICI cTnT measurements. Mean age was 68.7±11.3, 58.3% were male, with follow-up at 1 year post ICI administration. Of these, 59 patients were cTnT+/myocarditis+, 1077 patients were cTnT+/myocarditis-, and 533 were cTnT-. Survival free of cardiac death, MACE and new HF diagnosis showed a graded response from worst in cTnT+/myocarditis+ patients and best in cTnT- patients; cTnT+/myocarditis- patients had a more favorable but still worse prognosis than cTnT- patients (Figure 1). A cTnT value of 95 ng/L was identified as the best cutoff for the diagnosis of ICI-related myocarditis (AUC 0.82, sensitivity 81.36%, specificity 81.62%). The optimal cTnT cutoff for cardiac death was 576 ng/L (0.70, sensitivity 72%, specificity of 61%) and for MACE 319 ng/L (AUC 0.61, sensitivity 70%, specificity of 52%). Conclusion: In cancer patients receiving ICI therapy cTnT elevations indicate a higher risk of MACE, HF, and cardiac mortality even in patients without myocarditis. Although worst outcomes are seen in those meeting diagnostic criteria for myocarditis.
Abstract 4143423: Pulmonary Valve Replacement-Related Change in Biventricular Global Function Index in Repaired Tetralogy Of Fallot
Authors: Shanique Sterling, Francesca Sperotto, Minmin Lu, Lynn Sleeper, Edward O'Leary, Anne Valente, Tal Geva
Journal: Circulation (2024)

Background: Reduced biventricular global function index (BVGFI)—a novel indicator of ventricular performance—is associated with adverse clinical outcomes in patients with repaired tetralogy of Fallot (rTOF). The impact of pulmonary valve replacement (PVR) on BVGFI has not been characterized. Research Question: What is the impact of PVR on BVGFI in rTOF? Objectives: To characterize the impact of PVR on BVGFI and identify pre-PVR determinants of depressed BVGFI after PVR in rTOF. Methods: This is a single-center retrospective cohort study of rTOF patients fulfilling the following criteria: 1) Cardiac magnetic resonance (CMR) prior to and after PVR, utilizing the most proximal CMR to PVR within 2 years before and 3 years after the procedure; and 2) No interval cardiac procedure other than PVR. Patients with rTOF were compared with a control group free of heart disease. Based on the distribution of BVGFI in the control group, BVGFI was categorized as normal (&gt;46), intermediate (40-46), or depressed (&lt;40). Associations between pre-PVR characteristics and post-PVR depressed BVGFI were explored. Results: Compared with controls (n=136), BVGFI was lower in rTOF (n=141) pre-PVR (46.6±7.6 vs 56.5±5.1, p&lt;0.001). In rTOF, right ventricular volumes, mass, and ejection fraction decreased after PVR while BVGFI did not differ (46.6±7.6 vs 45.5±6.8, p=0.051). Individual changes in BVGFI from pre- to post-PVR varied as shown in Figure 1. In multivariable analysis, pre-PVR factors independently associated with depressed post-PVR BVGFI were lower BVGFI (adjusted-OR 0.81, 95% CI 0.76-0.89; p&lt;0.001), male sex (OR 3.56, 95% CI 1.47, 8.66; p=0.005), ≥moderate pulmonary regurgitation (OR 7.01, 95% CI 1.33, 37.1; p=0.022), and left ventricular end-systolic volume index &gt;41 ml/m 2 vs &lt; 33 ml/m 2 (OR 2.8, 95% 1.33-7.31; p&lt;0.001). Conclusions: On average, pre-PVR BVGFI remained stable after PVR with notable variation among individual patients. Lower pre-PVR BVGFI, ≥moderate pre-PVR pulmonary regurgitation, male sex, and higher pre-PVR left ventricular end-systolic volume index are independently associated with depressed post-PVR BVGFI. Further research is warranted to elucidate the role of BVGFI in informing timing of PVR.
Abstract 4143311: Non-statin Medication Utilization under Medicare Part D Population
Authors: Shreyash Parajuli, Vidit Majmundar, Priya Pandey, Amir Joshi, Aishwarya Yamparala, Sourbha Dani
Journal: Circulation (2024)

Introduction: Statin intolerance is reported in 5–30% of patients and contributes to reduced statin adherence and persistence, as well as a higher risk for adverse cardiovascular outcomes. For patients with known or suspected statin intolerance and high ASCVD risk, non-statin therapy is currently a class IIa recommendation by the National Lipid Association (NLA). Method: We accessed publicly available datasets from the Centers for Medicare and Medicaid Services (CMS). The non-statin medications included in these studies are bempedoic acid, evolocumab, alirocumab, inclisiran, and evanicumab. Key variables, such as beneficiaries, claims, and total spending, were analyzed and presented below. We looked at the trend of medication from 2020 to 2022. All costs were adjusted for inflation and represented in 2022 US dollars. Results: We analyzed CMS Medicare Part D plans of Bempedoic Acid, Inclisiran, Alirocumab, Evolocumab and Evanicumab, covering 2020–2022. We noticed a 3- to 4-fold increase in total beneficiaries and claims for bempedoic acid, along with a sharp rise in total spending from 3.5 million dollars to 19.4 million dollars after adjusting for inflation rate using the consumer price index inflation calculator. The trends for other non-statin medications were similar. We also created comparative graphs for 2022 and noticed a total spending of 97.5% among proprotein convertase subtilisin/kexin type 9 (PCSK-9) in Medicare D CMS populations. Discussion We can see a rise in total Medicare spending among all the drugs. Amongst different lipid-lowering agents, proprotein convertase subtilisin/kexin type 9 (PCSK-9) inhibitors are the most commonly used, followed by bempedoic acid. Newer agents, like Evanicumab and Inclisiran are also available on the market, and their trend has not yet been determined. Inclisiran, however, has the highest average spending per beneficiary. How the Inflation Reduction Act of 2022 will affect drug utilization is yet to be seen. Limitation The pattern of data used may not be generalizable to other payer demographics. Policy changes can affect the comparability of data over different periods. Conclusion From 2020 to 2022, the number of claims, beneficiaries, and total spending on various lipid-lowering agents steadily increased.
Abstract 4143354: Novel Methods Improve Assessment of Virtual Reality’s Impact on Physician Mental Models During Pre-Surgical Planning
Authors: Eliot Bethke, Matthew Bramlet, Jennifer Amos, James Evans, Bradley Sutton
Journal: Circulation (2024)

Background: Virtual Reality (VR) has found numerous applications in healthcare, including 3D presentation of patient anatomy modeled from traditional medical imaging. While individual VR systems have been evaluated for their utility in pre-surgical planning, there remains a gap in understanding of the impact VR has on physicians’ mental models. VR is often assessed on performance criteria, omitting relevant perspectives of the physician’s experience. Research Questions: We sought to explore the following: 1) How does VR affect physicians’ perceptions of complex congenital heart cases, and 2) What strategies do physicians employ while exploring patient anatomy in VR. Goals and Aims: The aim of this study was to analyze how mental models change after reviewing anatomy in VR, and to describe common patterns of behavior in VR which provide deeper insight into the complex task of pre-surgical planning. Methods: We deployed a novel methodology of undirected think-aloud sessions in VR which we anchored to pre and post-session questionnaires based on the NASA Task Load Index. VR sessions were recorded in first-person view and were qualitatively analyzed by five independent coders using a grounded theory approach where codes emerged from the data. Iterative refinement of codes led to identification of multiple patterns of behavior which were summarized thematically. Pre and post-session surveys were analyzed statistically. Results: 10 VR sessions were captured from 3 physicians totaling 2.5 hours of recordings. Physician confidence in their understanding of the anatomy increased from a mean of 4/5 before VR to 5/5 after (p=0.012). Themes emerging from VR sessions included: 1) Exploration of the 3D environment led to confirmation of understanding and complex decision making, 2) Emotions expressed in VR reflected strengths and weaknesses of the VR tool, and 3) Confidence may mask complex decision making crucial to the surgical planning process. Reported mental, physical, and time demands of VR all remained low (&lt;3/10 median) with high accomplishment of goals (10/10 median). Conclusion: Eliciting rich descriptions of physician perspectives of patient anatomy in VR provides a more detailed glimpse at the decision making and exploration which helps to refine mental models during pre-surgical planning. The 3D VR environment helps enable exploration of the anatomy which in turn leads to complex decision making and refinement of understanding of the case before surgery.
Abstract 4143443: Characteristics of patients with left ventricular aneurysms undergoing ventricular tachycardia ablation
Authors: Srilakshmi Garikapati, Abhishek Maan, Kirtivardhan Vashistha, Sakshum Chadha, Seth Newman, Jacqueline Mirza, Eric Stanton, Marc Miller, jacob Koruth, Mohit Turagam, Joshua Lampert, William Whang, Srinivas Dukkipati, Vivek Reddy
Journal: Circulation (2024)

Background: Left ventricular aneurysms (LVAs) are associated with a higher risk of occurrence of ventricular tachycardia (VT). Although there have been smaller studies and case-reports published on the role of catheter ablation of VT in patients with LVAs, larger case-series with relatively longer follow up after VT ablation are limited. Purpose: We sought to assess procedural characteristics and clinical outcomes after VT ablation in patients with LVAs. Methods: We performed a retrospective review on consecutive sets of patients with LVAs who had undergone VT ablation between 01/2015 and 10/2023 at our center. The diagnosis and segmental location of LVAs was confirmed by two independent reviewers (AM and KV) upon review of images from either a transthoracic echocardiogram or cardiac magnetic resonance imaging (cMRI). Procedural reports of VT ablation were reviewed for the characteristics of electroanatomical mapping, number and morphological features of VTs induced and ablation parameters. Data on outcomes after VT ablation was collected by using a combination of clinical follow up and data from remote monitoring and in-person device interrogations. Results: A total of 33 patients with LVAs underwent VT ablation at our center between 2015 and 2023. The average age of patients in our study cohort was 65 +/- 15 years and 88% of them were males. The average left ventricular ejection fraction was 34 +/- 12% and the etiology of the LVAs was ischemic in 58% and non-ischemic in 42% of patients. In the non-ischemic subgroup, the most common etiology was hypertrophic cardiomyopathy (27%) followed by other causes such as mycotic aneurysm (3%), congenital aneurysm (3%), aneurysm secondary to dilated cardiomyopathy (3%) and causes that were unclear (6%). The most common segment involved in the LVAs was apical (85%) followed by basal (in 15%) of patients. The median number of distinct VTs induced and ablated during VT ablation procedure was 2 (IQR: 1-3). The average cycle length of the VTs induced was 353 + 85 ms and the predominant morphology was right bundloid (in 77% of VTs induced). Follow up Data: Upon a median follow up of 245 (IQR of 86-898) days, the overall success rate of VT ablation was 68%. Conclusions: Occurrence of VT is quite common in patients with LVAs in the setting of ischemic and non-ischemic etiologies. Our case-series describes the safety and feasibility of catheter ablation for VT in patients with LVAs.
Abstract 4143420: Additive Prognostic Significance of Vascular Disease in Patients Referred for Exercise Stress Echocardiography
Authors: Hannah Hart, Alaa Omar, Edgar Argulian
Journal: Circulation (2024)

Background: The presence of carotid plaque (CP) may serve as an indicator of panvascular atherosclerosis. However, the observed incongruity between carotid disease and the presence and severity of coronary artery disease (CAD) suggests differing mechanisms. We investigated the prognostic value of this incongruity, considering both known atherosclerosis and myocardial ischemia. Methods: In a retrospective analysis, we examined 111 patients (mean age: 64±12 years, 58% women) who underwent exercise stress echocardiography, with recent carotid artery and coronary evaluation. We computed a Vascular Disease (VasD) score, integrating the presence of carotid plaque (CP) on carotid ultrasound, known coronary artery disease (CAD), and myocardial ischemia (MyI). Subsequently, patients were followed for 5.5 years for mortality, coronary revascularization, and cardiac hospitalization. Results: During the follow-up period, 29 patients experienced the combined outcome (4 deaths, 10 revascularizations, and 22 hospitalizations). Among the cohort, 44 patients exhibited no vascular disease, while 67 displayed evidence of vascular disease, categorized as 42 with VasD of 1 (comprising 30 CP, 9 CAD, and 3 MyI), 14 with VasD of 2 (5 CP and CAD, 6 CP and MyI, 3 CAD and MyI), and 11 with VasD of 3. There were no significant differences between patients with and without VasD concerning sex, diabetes, renal function, atrial arrhythmia, baseline LVEF, and baseline diastolic function. However, patients with VasD were older, had higher H2FPEF scores, and lower exercise capacity, as well as elevated baseline and exercise-induced filling pressures. The incidence of the combined outcome showed a progressive increase with higher VasD scores (p&lt;0.001). Survival curves depicted a rising risk of the outcome corresponding to increasing VasD scores (Figure 1). Conclusions: The presence of vascular disease as quantified by known CAD, CP as detected by carotid ultrasound, and myocardial ischemia identified during exercise stress echocardiography demonstrates a substantial additive prognostic role in mid-term cardiovascular outcomes.
Abstract 4143330: Pediatric Paracorporeal VAD Antiplatelet Protocol
Authors: Ashish Garg, Rachel Bercovitz, Nora Hammond, Michael Monge, Philip Thrush, Anna Joong
Journal: Circulation (2024)

Background: Ischemic stroke remains a dreaded complication of paracorporeal (continuous-PC; pulsatile-PP) ventricular assist devices (VADs) in pediatric patients. Advancements in anticoagulation management have improved the stroke rate to 12-17%, however, the management of antiplatelet therapy varies across centers. This study examines the outcomes of an antiplatelet protocol for patients with paracorporeal VADs at our center. Methods: We developed an antiplatelet protocol (Fig. 1) with dose adjustments guided by platelet function assays, VAD fibrin burden, and bleeding risk. We retrospectively reviewed patients with a paracorporeal VAD between December 2018 to December 2023. Demographic variables, incidence of thrombotic and bleeding events, and outcomes were assessed using descriptive statistics. Results: The cohort comprised 44 patients (52% male), median age 19 months (1 month - 8 years), with 22 (50%), 9 (20.5%), and 13 (29.5%) patients supported on PP, PC, and multiple VAD types respectively. Median support duration was 131 (PP; IQR 87, 183), 31 (PC; IQR 16, 46), and 88 (multiple VADs; IQR 66, 196) days. Diagnoses included cardiomyopathy 38% (n=17), congenital heart disease 57% (n=25) and others 5% (n=2). Thrombotic complications included: ischemic stroke in 6.8% (n=3) (1.9 events/100 patient months compared to 6-11 events/100 months reported in recent multicenter registry data); 11% (n=5) patients underwent 6 pump exchanges for fibrin burden. Major bleeding rate was 29.5% (n=13), most commonly gastrointestinal bleed; there were no hemorrhagic strokes. Five (11.3%) patients had an asymptomatic subdural hematoma (n=4 tiny/small, n=1 moderate). A positive clinical outcome was achieved in 86%, with 77% (n=34) bridged to transplant, 5% (n=2) explanted for recovery, and 5% (n=2) alive on device. Overall mortality was 14% (2 died on device, 4 transitioned to ECMO and died). Conclusions: Our experience underscores the efficacy of a structured antiplatelet protocol in managing pediatric patients with paracorporeal VADs associated with a low stroke rate. Future studies are needed to assess the generalizability of these findings.
Abstract 4143355: Association of Elevated Serum Lipoprotein(a) with New-Onset Atrial Fibrillation: A Retrospective Study of 108930 Patients
Authors: Moaz Kamel, Kamal Awad, Ahmed K. Mahmoud, JUAN FARINA, Isabel Scalia, Milagros Pereyra, Mohammed Tiseer Abbas, Nima Baba, Chadi Ayoub, Reza Arsanjani
Journal: Circulation (2024)

Background: Atrial fibrillation (AF), the most common clinically managed cardiac arrhythmia, is known to increase the risk of heart failure, stroke, and mortality. Lipoprotein(a) [Lp(a)], a well-established risk factor for atherosclerotic cardiovascular disease (ASCVD), also plays a role in cardiovascular health. However, the influence of Lp(a) on the development of AF, independent of its association with ASCVD, remains unclear. Hypothesis: Elevated Lp(a) may be associated with increased risk of new-onset AF. Methods: A retrospective study was conducted on patients from the three Mayo Clinic sites who had their Lp(a) levels measured and had no prior history of AF. Patients were categorized into two groups based on their serum Lp(a) concentrations: high Lp(a) (≥50 mg/dL) and low Lp(a) (&lt;50 mg/dL). New AF diagnoses were identified during the follow-up period. Survival probabilities between the two Lp(a) groups were compared using the Kaplan–Meier curve and the Log-Rank test. Cox regression analyses, both univariable and multivariable, were performed to evaluate established risk factors and compare the risk of new-onset AF between the high and low Lp(a) groups. Results: A total of 108,930 patients were included (median age: 55 years, 58% males), with a follow-up duration for up to 10 years. Incident AF was detected in 8432 (7.7%) patients. Median serum levels of Lp(a) were significantly higher in patients with AF versus non-AF patients: 15 (IQR 43) vs. 12 (IQR 34) mg/dL, p&lt;0.001. The percentage of patients having elevated Lp(a) was significantly higher in the AF group versus non-AF group: 2119 (25%) vs 21151 (21%), p&lt;0.001. Survival probability for new-onset AF was significantly lower in patients with elevated Lp(a) compared with those with low Lp(a) (log rank p&lt;0.001, Figure 1). In the univariate analysis, high Lp(a) levels were associated with a 17% increase in the risk of AF (HR = 1.17, 95% CIs: 1.12 to 1.23). The multivariate analysis adjusted for well-established risk factors for AF showed a less strong but still significant association, with a 10% increase in AF risk (HR = 1.10, 95% CI: 1.05 to 1.15). Conclusion: Our study suggests that elevated Lp(a) (≥50 mg/dL) seems to be an independent risk factor for new-onset AF. Future prospective studies are still warranted to validate our results.
Abstract 4143300: Atrial Function Improves Stroke Prediction in Patients with Atrial Fibrillation
Authors: Ahmad Kassar, Nadia Chamoun, Yaacoub Chahine, Nazem Akoum
Journal: Circulation (2024)

Background: Stroke contributes to significant morbidity and mortality in atrial fibrillation (AF). Clinical risk scores lack predictive accuracy and mechanistic links to thrombo-embolization. Hypothesis Adding MRI-derived parameters to stroke risk calculators improves their predictive accuracy. Aims Demonstrate an association between left atrial emptying fraction (LAEF), long axis strain (LAS) and stroke in AF patients. Incorporating the above-mentioned LARF and LAS into the CHA 2 DVASc score improves its predictive accuracy. Methods: AF patients undergoing cardiac MRI were identified from the University of Washington Cardiac Arrhythmia Data Repository (CADRe). Pts with prior AF ablation were excluded from the study. LAEF and LAS were quantified using a semi-automated contouring of the LA wall was done through image processing software (CVI42®) (Panel A). Results: 417 pts (average age 66±13years; 64% males) were included. The average CHA 2 DVASc (stroke component removed) score was 2.1±1.4. LAEF was 46.18%±11.64%, and LA LAS was 24.28%±13.45%. Univariate analysis revealed a significant association between stroke/TIA and LAEF (OR= 0.962, p= 0.024); but not with LAS (OR=0.962, p=0.091) or CHA 2 DVASc (OR=1.084; p=0.553). LAEF remained significantly associated with stroke in multivariate analysis, adjusting for age, gender, congestive heart failure, hypertension, coronary artery disease, and diabetes, (OR= 0.963, p= 0.042). Three other models including composite CHA 2 DVASc with and without LAEF with their respective ROC curves and AUC are shown in Panel B. Adding LAEF improved the AUC of CHA 2 DVASc (AUC 0.564 vs 0.653; p=0.048) or its components (AUC 0.539 vs 0.632; p=0.043). Using a cut-off LAEF of 46.53% (AUC: 0.71 CI: 0.61,0.81; Sensitivity: 68%; Specificity: 74%) resulted in the reclassification of 47(11.3%) pts to a higher risk category and none (0%) to lower risk (Panel C). Conclusion: Left atrial emptying fraction is independently associated with stroke or TIA, and improves the predictive accuracy of clinical risk scores in AF pts.