tbuckley/cabot-search huggingface dataset:
Abstract 17520: Dynamic Intrapulmonary Shunting in the Setting of Amphetamine Use
Authors: Sara Samaan, Sivakumar Ardhanari
Journal: Circulation (2023)

Description of Case: A 35-year-old female non-smoker with ADHD on amphetamine for the past 3 months and family history of hereditary hemorrhagic telangiectasia (HHT) presented with significant exertional dyspnea for 1 week. She was hypoxic to 82% while walking, with normal oxygen saturation at rest. Transthoracic echocardiogram with agitated saline revealed extracardiac right-to-left shunting with exercise and Valsalva. This was confirmed by dobutamine stress echocardiogram with agitated saline (Figure 1A). Transesophageal echocardiogram with agitated saline (Figure 1B) revealed no shunt through the foramen ovale, but it demonstrated bubbles entering from the left upper pulmonary vein, suggestive of an extracardiac shunt from a pulmonary arteriovenous malformation (AVM). Right heart catheterization and pulmonary angiogram revealed normal pressures, and no pulmonary abnormalities with normal pulmonary venous return. Supine right heart catheterization with exercise revealed normal pressures, although the initial pulmonary artery (PA) saturation was 28%; repeat PA saturation one minute later was 48%. Arterial saturation was 95%. Pulmonary function testing, ventilation perfusion scan, high-resolution CT chest, and coronary CT angiogram were unremarkable. The patient was instructed to avoid all stimulants, and to take a non-hormonal contraceptive. At her 3-month follow-up, she reported significant improvement in her symptoms. She underwent a 6-minute walk test, and her lowest oxygen saturation was 88%. Discussion: This patient presented with exertional hypoxia, normal saturations at rest, evidence of an extracardiac shunt only with exertion and absence of clear sources of the shunt on imaging. With her family history of HHT, this is suggestive of a small pulmonary AVM that opened by elevated PA pressures, likely triggered by amphetamine use, and its discontinuation led to symptom resolution.
Abstract 13660: Endovascular Ultrasound Renal Denervation for Resistant Hypertension: A Systematic Review and Meta-Analysis of Randomized Sham-Controlled Trials
Authors: Nicole Felix, Marcelo Antonio Pinheiro Braga, Alleh Nogueira, Joao Gabriel Vallperde, Sofia de Assis Oliveira, Thomaz A Costa, Luis Claudio Pinto, Elizabeth Silaid Muxfeldt
Journal: Circulation (2023)

Background: Radiofrequency renal denervation (RDN) is used as a treatment for resistant hypertension, although its efficacy is still under evaluation. Similarly, ultrasound RDN, a less invasive technique, has yielded inconsistent results in this population. Hypothesis: Ultrasound RDN may lower blood pressure in patients with resistant hypertension. Aims: To compare the efficacy of ultrasound RDN versus a sham procedure in treating resistant hypertension. Methods: We systematically searched PubMed, Cochrane Library, and Embase in May 2023 to include randomized sham-controlled trials assessing the efficacy of ultrasound RDN. Statistical analyses were performed using Review Manager 5.4.1 using generic inverse variance weighting to pool mean ± standard deviation and least square mean ± standard error. Results: We included three studies comprising 323 patients with resistant hypertension on ≥ three antihypertensive medications, of whom 51.7% were randomized to RDN. Follow-up at analysis ranged from 8 to 24 weeks. There were no significant differences between groups in terms of change from baseline in 24-hour ambulatory systolic blood pressure (SBP; MD -2.15 mmHg; 95% -5.07, 0.76; p=0.15; Fig. 1A), 24-hour ambulatory diastolic blood pressure (DBP; MD -1.19 mmHg; 95% CI -2.91, 0.53; p=0.18; Fig. 1B) or office SBP (MD -1.71 mmHg; 95% CI -9.62, 6.20; p=0.67; Fig. 1C). Conclusion: In this meta-analysis, ultrasound RDN did not significantly reduce blood pressure in patients with resistant hypertension as compared with a sham procedure.
Abstract 13301: TRIM29 Causes Pathogenesis of Viral Myocarditis by Inducing PERK-Mediated Endoplasmic Reticulum Stress and Reactive Oxygen Species Responses
Authors: Wenting Lu, Junying Wang, Jerry Zhang, Yong Du, Mingli Fang, Ao Zhang, Gabriel Sungcad, Samantha Chon, Junji Xing
Journal: Circulation (2023)

Introduction: Viral myocarditis is an inflammatory disease of the myocardium which contributes to a significant fraction of sudden death in children and young adults. The ongoing coronavirus disease 19 pandemic emphasizes the need for understanding the pathogenesis mechanisms and potential treatment strategies for viral myocarditis. Methods: To understand the role of the novel E3 ligase TRIM29 in controlling viral myocarditis, wild-type and TRIM29 knockout mice were infected with coxsackievirus B3 (CVB3) for inducing viral myocarditis. Mice survival and heart function were monitored by transthoracic echocardiography, and hearts were harvested for histology and immunohistochemistry analysis. Real-time PCR, western blotting, co-immunoprecipitation, enzyme-linked immunoassay, flow cytometry, over-expression and knockdown techniques were used to understand the pathogenic mechanisms of TRIM29 in regulating endoplasmic reticulum stress response after virus infection in this study. Results: We found that TRIM29 was highly induced by cardiotropic viruses, including CVB3 and encephalomyocarditis (EMCV), and promoted protein kinase RNA-like endoplasmic reticulum kinase (PERK) mediated endoplasmic reticulum (ER) stress, apoptosis, and reactive oxygen species (ROS) responses that restrict viral replication in cardiomyocytes in vitro . TRIM29 deficiency protected mice from viral myocarditis by promoting cardiac antiviral functions and reducing PERK-mediated inflammation and immunosuppressive cells in vivo . Mechanistically, TRIM29 interacted with PERK to catalyze SUMOylation of PERK for maintaining its stability, thereby promoting PERK-mediated signaling pathways. Conclusions: Our data provide the first evidence that TRIM29-mediated PERK signaling pathways cause pathogenesis of viral myocarditis and identify the TRIM29-PERK axis as a potential therapeutic target for treating viral induced cardiovascular diseases.
Abstract 18759: Reliability and Accuracy of Non-Invasive versus Invasive Blood Pressure Monitoring During Atrial Fibrillation Ablation
Authors: Mohammed AlSadawi, Andreas P Kalogeropoulos, Daniel Mattimore, Abhijeet Singh, Jonathon Schwartz
Journal: Circulation (2023)

Introduction Patients with atrial fibrillation (AF) have multiple confounders that could affect the reliability of non-invasive blood pressure (NIBP). We sought to investigate if AF and paced rhythms (PR) modify the reliability of NIBP and accuracy against an invasive blood pressure (IBP) reference, as compared to sinus rhythm (SR), and impact NIBP validity for procedural monitoring. Hypothesis Changes in heart rhythm between AF, SR and PR, within a patient would not alter the reliability and accuracy of NIBP. Methods We conducted an observational study in patients undergoing an AF ablation procedure under general anesthesia with paired IBP, NIBP, and heart rhythm measurements available. Results We evaluated 91 patients ( Table 1 ) with 1,179 usable NIBP vs. IBP pairs; 547 (46.4%) during SR, 376 during AF (31.9%), and 256 (21.7%) during PR. In the entire sample, the average difference (standard error) between systolic NIBP and IBP was 2.9 (1.8) mmHg (P=0.10 against H0=0) with a within-subject standard deviation (SD) for the difference of 11.6 mmHg and intraclass correlation coefficient of 0.76 ( Fig. 1 ). Systolic NIBP was higher on average vs. IBP when in SR (6.2 [1.1] mmHg; P&lt;0.001), but not when in AF (1.5 [2.6] mmHg; P=0.55) or in PR (-2.0 [3.3] mmHg; P=0.54). However, the within-patient SD of the difference was high in SR, AF, and PR (SD 10.5, 12.9, and 11.9 mmHg, respectively). Results were similar for diastolic and mean NIBP vs. IBP. Conclusion AF or PR, as compared to SR, did not materially change the reliability and accuracy of NIBP vs. IBP. However, the high within-patient variation in systolic NIBP versus IBP raises concerns on the validity of NIBP for systolic blood pressure monitoring.
Abstract 14321: High Sensitivity C-Reactive Protein is Associated With Plaque Vulnerability and Increased Incidence of Adverse Events in Patients With Stable Coronary Disease
Authors: Masahiro Katamine, Yoshiyasu Minami, Takako Nagata, Kiyoshi Asakura, Yusuke Muramatsu, Daisuke Kinoshita, Kazuhiro Fujiyoshi, Junya Ako
Journal: Circulation (2023)

Introduction: Higher level of high sensitivity C-reactive protein (hsCRP) is associated with an increased risk of cardiovascular events in patients with coronary artery disease (CAD). However, the pathogenesis of the worse clinical outcomes in CAD patients with high hsCRP remains to be elucidated. Hypothesis: Higher hsCRP is associated with a higher prevalence of vulnerable characteristics in coronary plaques and an increased incidence of adverse events in patients with CAD. Methods: A total of 793 consecutive patients with stable CAD, who underwent intra coronary optical coherence tomography (OCT) imaging of the culprit vessel during percutaneous coronary intervention were included. Patients were classified into the higher hsCRP group (hsCRP ≥ 0.2 mg/dL, n=247) or the lower hsCRP group (hsCRP &lt; 0.2 mg/dL, n=546). OCT characteristics and clinical outcomes were investigated according to the level of hsCRP. Results: The prevalence of thin-cap fibroatheroma (TCFA) (32.0% vs. 20.9%, p &lt;0.001) and plaque with macrophage (53.9% vs. 46.2%, p =0.045) was significantly higher in the higher hsCRP group than in the lower hsCRP group (Panel A). The incidence of myocardial infarction was significantly higher in the higher hsCRP group than in the lower hsCRP group (log-rank p =0.006) during a median 938 days follow-up (Panel B) although the incidence of the composite of major adverse cardiac events was comparable (log-rank p =0.282). Among the four groups classified by the hsCRP level and the presence of TCFA, the incidence of myocardial infarction was the highest in the group with higher hsCRP and TCFA (log-rank p =0.017). Conclusions: Higher level of hsCRP was associated with a higher prevalence of vulnerable characteristics in coronary plaques and worse clinical outcomes in patients with stable CAD. The risk of recurrent myocardial infarction in patients with high hsCRP levels was further increased by the presence of TCFA.
Abstract 17002: Platelet-Derived Purified Exosome Product to Treat In-Stent Restenosis Porcine Model
Authors: Skylar A Rizzo, Swaiman Singh, Tyra A Witt, Mary Nagel, Paul Stalboerger, Atta Behfar
Journal: Circulation (2023)

Introduction: Patients with coronary artery disease (CAD) not amenable to revascularization are reported to have a 3-year mortality &gt;14%. Advances in treatment modalities including medical management, rotational atherectomy, balloon lithotripsy, and drug-eluting stents work for focal disease but poorly treat diffuse CAD. In a porcine model of in-stent restenosis, we here evaluated whether a pro-angiogenic platelet-derived exosome product (PEP) could be delivered into the perivascular space to foster collateral vessel formation. Methods/Results: Cobalt chromium stents were placed and were oversized by 1 mm in the left anterior descending (LAD) and posterior descending arteries (PDA) of sus scrofa domesticus pigs. In-stent restenosis was angiographically visualized at the 2-month timepoint, with hemodynamic significance documented with fractional flow reserve (FFR) of &lt;0.8. To document feasibility of PEP delivery into the perivascular space, exosomes were labeled with a far-red fluorescent tag and delivered into the perivascular bed. Here, the Bullfrog® micro-infusion catheter was positioned either in the great cardiac vein or the middle cardiac vein and PEP was delivered with the microneedle pointed towards the LAD or the PDA. Biodistribution demonstrated exosome retention and uptake around cardiac veins. Using the Bullfrog® technique, PEP was delivered in the perivascular space adjacent to areas of significant coronary stenosis. Initial results 1-month post-treatment demonstrated improved FFR of treated stenotic vessels (from 0.68 to 0.85), while untreated vessels demonstrate no change from previous FFR measurement (from 0.79 to 0.78). Conclusions: Here, exosome-mediated angiogenesis in the perivascular space improved coronary blood flow, distal to areas of stenosis. In patients with diffuse CAD, delivery of biotherapy in cardiac veins running anatomically parallel to stenosed epicardial arteries provides a novel therapeutic opportunity to supplement the existing armamentarium of therapies available for in-stent restenosis.
Abstract 17172: Paradoxical QRS Narrowing After Transcatheter Aortic Valve Replacement Concealing New Left Bundle Branch Block
Authors: Matthew A Kolansky, Daniel M Kolansky, Jeffrey J Smietana, Isaac R Whitman
Journal: Circulation (2023)

Introduction: Left bundle branch block (LBBB) after transcatheter aortic valve replacement (TAVR) is common and is a risk factor for high-grade atrioventricular (AV) block. We report a case of paradoxical QRS narrowing after TAVR in a patient with pre-existing incomplete right bundle branch block (iRBBB). Such QRS narrowing, masquerading as improved AV conduction, may conceal the development of new LBBB. Case Presentation: An 81-year-old man with severe aortic stenosis underwent TAVR with a 29mm Medtronic Evolut transcatheter self-expanding bioprosthetic valve. Post-operative TEE showed a well-seated valve without paravalvular leak. Preoperative ECG demonstrated sinus rhythm, 1 st degree AV delay (230 ms), and iRBBB (QRS 110 ms) (Fig. 1A). Immediately after TAVR, ECG showed a narrowed QRS (90 ms) with normal morphology (Fig. 1B). A narrowed QRS was sustained on post-operative day 2, with prolongation of the PR interval (260 ms; Fig. 1C). Electrophysiology study (EPS) showed a prolonged HV interval (65 ms) but no inducible block (Fig. 1D), and an implantable loop recorder (ILR) was placed. Discussion: Damage to the infranodal cardiac conduction system after TAVR is common, and approximately 15% of post-TAVR patients require pacemaker, with a higher occurrence in self-expanding valves as compared to balloon-expandable valves. Pre-existing RBBB as well as new-onset LBBB after TAVR increase the risk for heart block. Here, QRS normalization of an iRBBB concealed the development of new LBBB, by way of balanced delay in both the right and left bundles. This balanced delay is evident in the slightly longer PR interval post-operatively. Such a finding may be falsely reassuring and requires increased scrutiny (such as EPS and ILR placement). Conclusion: This case illustrates that paradoxical normalization of AV conduction following TAVR may belie an increased risk of high-grade AV block. Structural heart teams should be aware of this potential post-operative complication.
Abstract 18975: First Reported Case of SLE Associated Recurrent Pericarditis Treated With Rilonacept
Authors: Jaideep Singh Bhalla, Ushasi Saraswati, Rehan Karmali, Muhammad Majid, Aro Daniela Arockiam, Alveena Syed, Allan L Klein
Journal: Circulation (2023)

Description of case: A 42 year old female presented with a 1 month history of exertional dyspnea and intermittent pleuritic chest pain. She had a 12-year history of systemic lupus erythematosus (SLE) and non-specific interstitial pneumonitis being managed with mycophenolate mofetil. Labs showed an ESR of 76 mm/hr and CRP of 5.5 mg/dL. CT chest ruled out pulmonary embolism but showed a moderate pericardial effusion, also seen on an echocardiogram. A cardiac MRI (cMRI) showed moderate diffuse circumferential pericardial enhancement. She was diagnosed with lupus pericarditis and initially treated with ibuprofen, colchicine, prednisone, and hydroxychloroquine; however, continued to have persistent symptoms over the next few months. Repeat cMRI showed a transition to effusive constrictive physiology. She was offered pericardiectomy but following shared decision making and multi-disciplinary discussion, she was started on Rilonacept. She experienced significant and sustained relief in symptoms, improvement in inflammatory markers and reduction of pericardial enhancement on cMRI. Discussion To the best of our knowledge, this is the first case of Rilonacept used to successfully treat recurrent pericarditis from SLE. Recurrence in chronic idiopathic pericarditis is thought to be driven by the innate immune system and Interleukin-1 (IL-1), while in autoimmune diseases, it is mediated by the adaptive immune system and Type 1 Interferon, which is associated with a poorer prognosis. The RHAPSODY and AIRTRIP trials demonstrating efficacy of IL-1 blockers in recurrent pericarditis excluded patients with autoimmune diseases. Use of IL-1 blockers to treat Lupus pericarditis has only been reported in 2 cases using Anakinra. Our patient’s positive response to Rilonacept suggests the presence of additional target pathways in autoimmune diseases that may mediate pericarditis recurrence. Future prospective studies are needed to elucidate this further.
Abstract 14536: Pulmonary Vein Thrombosis: Illuminating the Risk Factors and Sequelae of a Rare and Often Incidentally Diagnosed Pathology
Authors: Daniel Sykora, Robert Churchill, David Hodge, Steven Callori, Damon Houghton, Robert D McBane, Waldemar E Wysokinski
Journal: Circulation (2023)

Introduction: Pulmonary vein thrombosis (PVT) is often diagnosed incidentally but data on its management and outcomes are sparse. Methods: We queried our institutional health record to identify patients ≥18 years of age diagnosed with PVT. Demographics, medications, risk factors, diagnostics, treatment, and sequelae were collected by manual chart review. Suspected tumor thrombus cases were excluded. Results: Seventy-two patients with PVT were identified (median age 62 years, 50% male). The cohort was mostly white (85%), overweight (BMI 26 kg/m), with frequent comorbidities including hypertension (44%), hyperlipidemia (38%), atrial fibrillation/flutter (29%), and history of venous thromboembolism (21%). The most common PVT risk factors were active malignancy (54%), lobectomy (21%), surgery within 30 days (19%), and extrinsic vein compression (15%). Most PVT were diagnosed by CT (86%) and affected a single vein (86%), mostly commonly the left upper PV (32%). Laboratory studies revealed median platelet count 243 х 10 9 cells/L (n=58) and D-dimer elevated in 6 patients when measured (67%, n=9). About one-third of patients were on therapeutic anticoagulation (37%) at PVT diagnosis. Most patients were started on new anticoagulation (78%, n=56), with unfractionated heparin as the most common initial therapy (68%). Of those anticoagulated, few were treated with a limited duration (20%, n=11, median 54 d, IQR 95) while most received indefinite anticoagulation (80%, n=45), primarily warfarin (45%), apixaban (24%), or enoxaparin (21%). Serial imaging was obtained in 69% (n=50, median 65 d, IQR 116) and demonstrated resolution of PVT in 32 (64%) patients. Common PVT complications noted were as follows: 4 year risk of LA thrombus (26%, 12/16 anticoagulated), mechanical ventilation (13%), pneumonia (9%), and ischemic stroke (9%, 5/6 anticoagulated). Conclusions: PVT is often associated with active malignancy, lobectomy, recent surgery, and extrinsic vein compression. Most PVT resolve on serial imaging. Clinicians should be aware of potential high-risk sequelae including LA thrombus and stroke as well as high anticoagulation failure rates when managing PVT.
Abstract 13983: Reproductive Health Counseling and Experiences Among Females With Congenital Heart Defects: Results From the Congenital Heart Survey to Recognize Outcomes, Needs, and Well-Being
Authors: Maureen K Galindo, Scott E Klewer, Karrie F Downing, Chelsea L Takamatsu, Michael D Seckeler, Matthew E Oster, R. Thomas Collins, Wendy N Nembhard, Elijah H Bolin, Sherry L Farr
Journal: Circulation (2023)

Introduction: The American Heart Association (AHA) recommends clinicians discuss reproductive health with women with congenital heart defects (CHD) beginning in adolescence due to their unique pregnancy and contraceptive needs. Therefore, we assessed reproductive health counseling and experiences among women with CHD, and differences by CHD severity. Methods: Women with CHD ages 19 to 38 years, identified in active, population-based birth defects registries from Arkansas, Arizona, and Atlanta, GA, completed the Congenital Heart Survey To Recognize Outcomes, Needs, and well-beinG (CH STRONG) from 2016 to 2019, including questions about reproductive health counseling, concerns and experiences. Prevalence estimates standardized to all CH STRONG-eligible women and adjusted prevalence ratios (aPR), calculated with multivariable Poisson regression, assessed differences by CHD severity. Results: Of 765 female respondents, 40.7% were 19-24 years, 66.7% were non-Hispanic white, and 67.7% had &gt; high school education. Overall, 21.3% received CHD-specific contraceptive counseling, 28.3% pregnancy counseling, and 12.8% advice to avoid pregnancy (Fig). Women with severe, compared to non-severe CHD, were more likely to receive clinician counseling about safe contraception (aPR=3.0, 95% confidence interval [CI]: 2.2-4.0), pregnancy (aPR=3.5, 95% CI: 2.7-4.6), and advice to avoid pregnancy (aPR=4.3, 95% CI: 2.9-6.5), and they were more likely to be concerned about their ability to have children (aPR=1.4, 95% CI: 1.1-1.8) and delay/avoid pregnancy (aPR=2.2, 95% CI: 1.5-3.2). No differences were seen in ever being pregnant (aPR=0.83, 95% CI: 0.6-1.1). Conclusions: Results suggest most women with CHD are not receiving AHA-recommended reproductive health counseling. Almost one in three women with severe CHD received clinician advice to avoid pregnancy, although AHA guidelines state pregnancy is contraindicated for few women with CHD.
Abstract 18070: Amyloid Ambush: A Shocking Encounter With AL Cardiac Amyloidosis
Authors: Amjad Basheer, Ayesha Azmeen, Chad Hovseth, Ronald Zolty
Journal: Circulation (2023)

Introduction: We present a case of a 44-year-old female with multiple comorbidities with a catastrophic course of cardiac AL amyloidosis. Case Presentation: The patient initially presented with symptoms, including epigastric pain, nausea, vomiting, and chest discomfort. Notably, she had a previous diagnosis of carpal tunnel syndrome. Soon after, she developed cardiogenic shock, sustained ventricular tachycardia, and was transferred to our center. Diagnostic Workup: The echocardiogram showed mildly reduced LVEF and moderately depressed RVSF. Initial RHC revealed significantly elevated right and left filling pressures and a low cardiac index. Cardiac MRI exhibited abnormal gadolinium kinetics and parametric mapping consistent with cardiac amyloidosis. Endomyocardial biopsy with light chain mass spectrometry confirmed the presence of AL amyloidosis. The kappa/lambda ratio was 60, and a bone marrow biopsy showed 30% plasma cells. Treatment and Outcome: The patient's cardiogenic shock worsened despite intensive support with an intra-aortic balloon pump and multiple iono-pressors. Unfortunately, her deteriorating condition rendered her ineligible for chemotherapy, transplantation, and left ventricular assist device (LVAD) placement. Conclusion: This case unveils the elusive nature of AL cardiac amyloidosis, where cardiogenic shock can be the initial presentation. Clinicians must remain vigilant, recognizing LV hypertrophy coupled with a low-voltage EKG and a preceding history of carpal tunnel syndrome. We underscore the rapid progression and limited treatment options.