Risultati per: Circulation

Circulation, Volume 146, Issue Suppl_1, Page A151-A151, November 8, 2022. Background:Survival with favorable neurological outcomes is one of the goals in patients with out-of-hospital cardiac arrest (OHCA). Although previous studies have shown that a chance of neurologically intact survival was significantly lower at nighttime than at daytime in patients with OHCA, details are uncertain. The aim of this study was to evaluate the effect of time from collapse to prehospital return of spontaneous circulation (ROSC) on neurologically favorable survival in patients with OHCA at nighttime versus daytime.Methods:Using a nationwide OHCA registry database from 2005 to 2020 in Japan, a cohort of 1,902,986 patients with OHCA were retrospectively screened. In the present study, a total of 128,180 patients with witnessed OHCA who achieved prehospital ROSC were included. Nighttime was defined as 6:00 pm through 5:59 am. Neurologically favorable survival was defined as cerebral performance category score of 1 or 2 at 1 month.Results:Patients with witnessed OHCA at nighttime were likely to be younger (70.3±16.0 vs. 72.7±15.3 years, p

Circulation, Volume 146, Issue Suppl_1, Page A221-A221, November 8, 2022. Introduction:Several factors are known to influence return of spontaneous circulation (ROSC) following out-of-hospital (OHCA) and in-hospital cardiac arrest (IHCA). Machine learning (ML) methods are capable of analyzing large datasets to elucidate the clinical and prognostic value of specific variables. In cardiac arrest, ML may help identify predictors of ROSC in OCHA and ICHA.Purpose:The present systematic review summarizes the literature on ML algorithms used to predict ROSC in OHCA and IHCA.Methods:PubMed, EMBASE, Web of Science, and Cochrane were searched to identify articles. Studies on human subjects with OHCA or IHCA which used ML methods to predict ROSC were included.Results:A total of 4,094 studies were identified through a literature search. Ten were included in the final analysis with a total sample size of 240,798 patients (240,798 (93%) male). Studies used logistic regression (n=7), random forest models (n=2), or deep learning (n=1). Sociodemographic variables beyond age (n=8) and sex (n=5) were not used. Variables used for predicting ROSC included age (n=8), type of rhythm (n=7), witnessed arrest (n=5), and time to emergency services arrival (n=5). Most models were built using data from OHCA patients (n=7), with only three focused on IHCA. Studies utilized a variety of parameters for reporting the prognostic value of their models, including predictive accuracy (69%-99%), area under the receiver operating characteristic curve (0.71-0.83), sensitivity (50.2%-76.0%), and specificity (61.0%-92.9%).Conclusion:Despite the prevalence of cardiac arrest and advances in AI, only ten studies examined ML in the prognostication of ROSC. Logistic regression was predominantly used in the included studies, and there is a paucity of data on the efficacy of deep learning models. Furthermore, heterogeneity in the predictive efficacy of studied ML models merits additional work and the need for large-scale trials comparing ML to conventional methods and clinician judgment. Critically, there is also a need for greater data inclusivity in model development, understanding that marginalized populations are less likely to receive CPR.

Circulation, Volume 146, Issue Suppl_1, Page A219-A219, November 8, 2022. Purpose:Effectiveness of cardiopulmonary resuscitation (CPR) is associated to return of spontaneous circulation (ROSC), but the alignment of the characteristics of compressions (rate and depth) to AHA recommendations has not been proven to improve outcome. In this study the power of the near infrared spectroscopy to discriminate productive CPR, i.e. chest compression sequences leading to ROSC, was evaluated.Material and methods:The cerebral oxygen saturation (rSO2) measured in both cerebral lobules was recorded with the Nonin SenSmart 100X oximeter by Emergentziak-Osakidetza, the emergency service of the Basque Country, in the out-of-hospital cardiac arrest (OHCA). Concurrently, the ECG and bioimpedance were recorded by the Lifepak 15 desfibrillator. Chest compressions were delivered by Lucas 2 & Lucas 3 devices. Sequences of compressions longer than 30 s were extracted, and changes in the left (rSO2,L) and right (rSO2,R) lobes were automatically computed by signal processing. The increase of rSO2, measured every 4 s during the CPR-sequence, was adjusted with linear regression and compared for ROSC/no-ROSC patients as registered in the emergency department (ED).Results:Chest compression intervals were identified in the bioimpedance, and 403 CPR-segments were extracted from 115 patients (80 from 43 patients with ED-ROSC) with a mean(std) duration of 2.46(1.07) min. The median(IQR) increase of brain saturation per patient, rSO2,Land rSO2,R, were 2.1(1.1-5.5) and 1.9(0.9-3.8) points. The figure shows the linear adjustment of the evolutions for both ROSC/no-ROSC groups, with slopes of: 1.81 vs 1.23 min-1for ΔrSO2,L(p >0.05), 1.78 vs 0.95 min-1(p

Circulation, Volume 146, Issue Suppl_1, Page A11115-A11115, November 8, 2022. Introduction:The ventricular fibrillation (VF) often occurs in acute heart failure patients with Impella support, percutaneous transvalvular left ventricular assist device. Although Impella can preserve blood pressure in some VF patients, the hemodynamic mechanism of Impella during VF remains unclear.Aim:In this study, we examined the impact of Impella on hemodynamics and cerebral and coronary blood flows in a goat model of VF. We also addressed the optimal blood volume status to maintain the Impella circulation during VF.Methods:In six goats, we inserted Impella CP via the left carotid artery. We simultaneously recorded right (RAP) and left atrial pressure (LAP), central blood pressure at ascending aorta (CBP), and the blood flows of pulmonary artery (PA), left coronary circumflex artery (LCX), and right carotid artery (CA). The VF was induced by direct current. We compared the impact of Impella support level (P0, P4 and P8) on hemodynamics and each blood flow. Under P8-Impella supported VF condition, we withdrew blood continuously and observed the left ventricular (LV) suction point at which a frequent negative LV pressure occurred.Results:As shown in Fig. 1 and 2, Impella maintained hemodynamics flow-dependently, indicating the establishment of acute Fontan circulation. In P8-Impella support, systemic (PA flow), LCX and CA blood flows were preserved by 50.1±27.7, 50.7±12.5 and 67.3±5.6%. from baseline, respectively. The blood volume reduction induced the suction of Impella (Fig. 3) at RAP below 9.9±1.9 mmHg.Conclusions:Impella establishes the acute Fontan circulation and preserves hemodynamics including coronary and cerebral blood flows during VF. The optimal blood volume status should be considered to maintain the Impella operation during VF.

Circulation, Volume 146, Issue Suppl_1, Page A13028-A13028, November 8, 2022. Introduction:Adolescents and adults with a Fontan circulation demonstrate broad cognitive dysfunction. Neurological alterations and risk factors associated with worse outcomes are poorly characterized. Persisting hypoxemia and reduced exercise tolerance are also common and are associated with long-term morbidity and mortality. This study investigated white matter (WM) microstructure in adolescents and adults with a Fontan circulation and associations with CPET data and cognitive functioning.Methods:Ninety-two participants with a Fontan circulation (aged 13-49 years) underwent diffusion brain MRI. Diffusion tensor imaging MRI metrics were computed for 34 WM tracts of interest; Lower FA and higher MD and RD typically infers WM axonal injury and/or demyelination. RestingSaO2,peak exercise SaO2, and % predicted peak VO2(%pred VO2) were measured during CPET. Processing speed and executive function were assessed using Cogstate.Results:Mean resting and peak SaO2were 93.1% (± 3.81) and 90.1% (± 4.71) respectively and mean %pred VO2was 62.7% (± 18.5); all were significantly lower for participants with a patent fenestration compared to those without (p < 0.05). Mean processing speed and executive function z-scores were -0.72 (± 1.44) and -0.43 (± 1.09), respectively. Significant associations were identified between i) resting SaO2and the left corticospinal tract (CST) and bilateral superior longitudinal fasciculus I (SLF-I) ii) peak SaO2and bilateral CST, frontopontine tract, and SLF-I and -II, and the right SLF-III, and iii) %pred VO2and the right cingulum and left uncinate fasciculus (p < 0.05), whereby lower resting and peak SaO2and %pred VO2were associated with lower FA and/or higher MD and RD. Paradoxical associations were identified between processing speed and executive function and WM tract metrics (p < 0.05).Conclusion:Persisting hypoxemia and exercise intolerance may have long-term detrimental impact on WM microstructure in people with a Fontan circulation. Paradoxical associations between cognitive functioning and DTI-based metrics could be suggestive of compensatory WM remodeling. Longitudinal investigations are required to investigate the mechanisms and trajectory of altered WM microstructure in this cohort.

Circulation, Volume 146, Issue Suppl_1, Page A10572-A10572, November 8, 2022. Introduction:Diversity and inclusion remain a concern in the field of cardiology. Female cardiologists have less opportunity to chair sessions in scientific meetings than men. However, cardiologists’ awareness and perspectives on feasibility of chairing sessions is poorly understood.Methods:A web-based survey on awareness regarding the commitment of chairing sessions was sent to 14,798 certificated cardiologists registered with the Japanese Circulation Society (JCS).Results:A total of 3,412 valid responses were obtained, including 523 women and 2,889 men. Female cardiologists exhibited less interest in serving as chairpersons in Japanese and English sessions (71% women vs. 82% men, P

Circulation, Volume 146, Issue Suppl_1, Page A15584-A15584, November 8, 2022. Introduction:Patients born with a range of cardiac defects, not amenable to biventricular repair are palliated with establishment of Fontan circulation. Although majority of patients with Fontan circulation survive childhood, eventually they experience multi-system dysfunction, mainly frailty, impaired exercise capacity, blunted exercise-augmented hemodynamics, progressive liver fibrosis, and shortened survival. Fontan circulation associated biochemical abnormalities have not been well described.Materials and Methods:Twenty adult patients with Fontan circulation and 20 age- and sex-matched healthy subjects underwent a non-targeted metabolomics assessment using an LC-QTOF-MS system to detect potential Fontan-related biomarkers. These study participants were also investigated for markers of frailty, cardiopulmonary exercise testing, and resting as well as exercise-augmented hemodynamic evaluation.Results:A total of 1679 known plasma metabolites were detected in electrospray positive and negative modes among which 37 metabolites were significantly different (T-Test Unpaired (p

Circulation, Volume 146, Issue Suppl_1, Page A157-A157, November 8, 2022. Background:Out-of-hospital cardiac arrest (OHCA) patients with acute coronary syndrome (ACS) needs emergent coronary angiography and subsequent percutaneous coronary intervention to improve their outcomes. ‘STEMI equivalents’ in electrocardiogram (ECG) are known to help the diagnosis of ACS. However, these findings have not been sufficiently evaluated among OHCA patients. This study aimed to evaluate the diagnostic test accuracy (DTA) of ‘STEMI equivalents’ to identify ACS among OHCA patients without ST-segment elevation.Methods/Results:Nine emergency medical departments among the Comprehensive Registry of In-Hospital Intensive Care for OHCA Survival (CRITICAL) study in Osaka, Japan collected the patients’ first 12 leads ECGs after return of spontaneous circulation (ROSC) from 2012 to 2017. Patients with non-traumatic OHCA aged >=18 years old with ventricular fibrillation / pulseless ventricular tachycardia as first documented rhythm or rhythm at hospital arrival were included. Of them, patients without ST-segment elevation nor complete left bundle branch block were extracted. The DTAs; sensitivity, specificity, positive likelihood ratio (LR+), and negative and likelihood ratio (LR-) of STEMI equivalents (i.e., Isolated T-wave inversion, Wellens signs) for the diagnosis of the ACS were evaluated. ACS was diagnosed by the physicians in each hospital based on the coronary angiography.Results:A total of 143 cases were included in the analysis and 79 patients were diagnosed as ACS. Isolated T-wave inversion was found in 7 (3.2%) patients in the ACS group and 3 (8.8%) in the non-ACS group. The Wellens signs was present in 5 (6.3%) and 5 (7.8%) patients, respectively. The isolated T-wave inversion and the Wellens signs had high specificity with 0.95 (95% CI: 0.87-0.99) and 0.92 (95% CI: 0.82-0.97), whereas these findings had low LR+ with wide range of 95% CI with 1.89 (95% CI: 0.51-7.02), and 0.81 (95% CI: 0.25-2.68), respectively.Conclusion:In this study, the DTA of STEMI equivalents of single 12 leads ECG alone were not sufficient for the diagnosis of ACS after ROSC among OHCA patients without ST-segment elevation. Further investigation of the DTA evaluation considering the measurement timing and the change of the ECG is needed.

Circulation, Volume 146, Issue Suppl_1, Page A320-A320, November 8, 2022. Introduction:Literature on neuroprognostication suggests that gray-white matter ratio (GWR) measured from head computed tomography (CT) within two hours after return of spontaneous circulation (ROSC) can’t adequately predict neurological outcomes in out-of-hospital cardiac arrest (OHCA) patients. However, severe cerebral edema may predict poor outcomes within two hours after ROSC.Hypothesis:We evaluated if GWR measurements obtained early after OHCA (≤ 2 hours) indicated poor neurological outcomes in patients with severe cerebral edema.Methods:We conducted a multicenter, retrospective cohort study using data from five hospitals collected between 2007 and 2019 in Japan. Inclusion criteria: adult comatose OHCA survivors with head CT within two hours after ROSC. Exclusion criteria was trauma, stroke, or pre-existing neurological disorders. Primary outcome was poor neurological outcome, defined as Cerebral Performance Category (CPC) score ≥ 3 at one month after admission. GWR was measured at the levels of the basal ganglia (BG), corpus callosum (CC), and posterior internal capsule (PIC). The prognostic value of GWR for predicting poor outcome was assessed using a receiver operating characteristic (ROC) curve analysis, area under the curve (AUC) with sensitivity/specificity.Results:A total of 377 patients were included. Of those, 281 (74.6%) exhibited poor neurological outcome at one month after admission. GWR values did not alter by the time of obtaining head CT: 1.22 (0-30 min: n=194); 1.22 (31-60 min: n=127); 1.22 (61-120 min: n=56). Using a cut-off GWR value of

Circulation, Volume 146, Issue Suppl_1, Page A15324-A15324, November 8, 2022. Introduction:Single ventricle congenital heart disease such as hypoplastic left heart syndrome (HLHS) with a Fontan circulation accounts for the largest group of children hospitalized with circulation failure, with an in-hospital mortality of 20-50%. We sought to (i) evaluate the mechanisms underlying circulation failure and (ii) identify novel therapeutic targets.Methods:Blood was collected from patients with HLHS s/p Fontan and from controls with normal cardiac anatomy and function (N=5/group). Plasma microvesicles (MV) were isolated and proteomics assessed using data independent acquisition mass spectroscopy. Dysregulated proteins with a fold change >1.5 or < -1.5, p

Circulation, Volume 146, Issue Suppl_1, Page A13035-A13035, November 8, 2022. Mechanical circulatory support (MCS) is rarely used in adults with congenital heart disease and even more uncommon among those with single ventricle (e.g. Fontan) circulation. As survivorship among Fontan patients increases, evaluation for MCS is warranted. This systematic review’s objective is to study the outcomes of adult Fontan patients supported by MCS. METHODS We searched the literature in English in PubMed and Google Scholar in May 21 & 2, 2022 using MeSH terms: “VAD,” “Fontan,” and “circulatory assist device.” The search yielded 2785 results. After screening for title, abstract, patient age ( >18 y/o), and extractable individual patient data, 23 reports met the criteria. Ultimately, 15 full texts were reviewed and included in this report. RESULTS We identified 18 patients on MCS, including 7 on short-term devices (Impella), 4 on paracorporeal pulsatile devices (PPDs), and 7 on durable continuous flow ventricular assist devices (VADs). Short-term pumps were used for cardiogenic shock (5, with 3 survivors) or support of high-risk ablation procedures. PPDs were used as a bridge to transplantation, mean patient age of 23.5±3.4 years old; all survived after a mean time on MCS of 172±158 days.In the VAD cohort (7 patients, 85.7% males, age 25.1±4.0), 5 received Heartmate 3, one received Heartmate II, and one Heartware (Table 1). Indications for VAD included cardiogenic shock (4 patients, 2 on VA ECMO) or heart failure. VADs dramatically increased cardiac index from 1.6±0.14 to 3.6±0.1 L/min/m2, p=0.0003, and decreased Fontan pressure from 21.4±3.3 to 13.0±1.4 mmHg, p=0.02. Heartmate 3 mean speed was 6460±568.3 rpm. All patients survived, with mean time on VAD lasting 459.5±452.2 days. CONCLUSIONS Implanted mostly for catastrophic indications, adult Fontan patients demonstrated improved hemodynamics and excellent survival following MCS use. These improvements are promising, and earlier implantation prior to catastrophic events may lead to better outcomes.

Introduction
Advances in the care of patients with single-ventricle congenital heart disease have led to a new generation of individuals living with a Fontan circulation. For people with Fontan physiology, physical, psychological and neurodevelopmental challenges are common. The objective of this study is to describe and develop a deeper understanding of the factors that contribute to quality of life (QOL) among children, adolescents and adults living with a Fontan circulation across Australia and New Zealand, their parents and siblings.

Methods and Analysis
This article presents the protocol for the Australian and New Zealand Fontan Registry (ANZFR) QOL Study, a cross-sectional, population-based study designed to examine QOL among people of all ages with a Fontan circulation, their parents and siblings. Study eligibility criteria includes (1) individuals with a Fontan circulation aged ≥6 years, at least 12 months post-Fontan procedure and enrolled in the ANZFR; (2) parents of individuals enrolled in the ANZFR; and (3) siblings aged ≥6 years of an individual enrolled in the ANZFR. A novel, online research platform is used to distribute personalised assessments tailored to participant age and developmental stage. A suite of validated psychometric self-report and parent-proxy report instruments capture potential correlates and predictors of QOL, including symptoms of psychological distress, personality attributes, coping and cognitive appraisals, family functioning, healthcare experiences and costs, access to emotional support and socioeconomic factors. Clinical characteristics are captured via self-report and parent-proxy report, as well as the ANZFR. Descriptive analyses and multilevel models will be used to examine QOL across groups and to investigate potential explanatory variables.

Ethics and Dissemination
Approval has been obtained from all relevant Human Research Ethics Committees (HRECs), including the Sydney Children’s Hospitals Network and the Royal Children’s Hospital Melbourne HRECs. Study findings will be published in peer-reviewed journals and presented at national and international meetings and seminars.

Objectives
Rapid changes in glucocorticoid (GC) levels and adrenal insufficiency are related to the development of post-cardiac arrest (CA) syndrome. However, GC receptor (GR) expression changes have not been studied. Hence, this study aimed to investigate the association of early changes in GR expression and prognosis and immune response in patients who experienced CA.

Design
Prospective observational study.

Setting
Emergency department.

Participants
Patients (85) in the early period of return of spontaneous circulation (ROSC) after CA were admitted between October 2018 and October 2019. After a physical examination, age-matched and sex-matched healthy individuals (40) were recruited for the control group.

Primary and secondary outcome measures
GR expression and cell counts of circulatory T and B lymphocytes, natural killer cells and regulatory T (Treg) cells were assessed. Plasma total cortisol and adrenocorticotrophic hormone (ACTH) levels were also tested.

Results
All cell counts were lower, and plasma total cortisol levels were higher (p

Stroke, Ahead of Print. Clinical outcomes of patients with acute ischemic stroke depend in part on the extent of their collateral circulation. A good collateral circulation has also been associated with greater benefit of intravenous thrombolysis and endovascular treatment. Treatment decisions for these reperfusion therapies are increasingly guided by a combination of clinical and imaging parameters, particularly in later time windows. Computed tomography and magnetic resonance imaging enable a rapid assessment of both the collateral extent and cerebral perfusion. Yet, the role of the collateral circulation in clinical decision-making is currently limited and may be underappreciated due to the use of rather coarse and rater-dependent grading methods. In this review, we discuss determinants of the collateral circulation in patients with acute ischemic stroke, report on commonly used and emerging neuroimaging techniques for assessing the collateral circulation, and discuss the therapeutic and prognostic implications of the collateral circulation in relation to reperfusion therapies for acute ischemic stroke.

Stroke, Ahead of Print.

Stroke, Ahead of Print. Background:In patients with large vessel occlusion stroke of the anterior circulation, underlying cause is a determinant of outcome. Whether this is the case for posterior circulation large vessel occlusion stroke has yet to be determined. We aimed to report on cause in patients with posterior circulation stroke treated with endovascular thrombectomy and to analyze the association with functional outcome.Methods:We used data of patients with posterior circulation stroke included in the MR CLEAN (Multicenter Randomized Controlled Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands) registry, a prospective multicenter observational study, between 2014 and 2018. Stroke cause was categorized into large artery atherosclerosis (LAA), cardioembolism, arterial dissection, embolic stroke of undetermined source (ESUS), other determined cause, or undetermined cause. For primary analysis on the association between cause and outcome, we used multivariable ordinal logistic regression analysis to estimate the adjusted common odds ratio for a shift towards a better functional outcome on the modified Rankin Scale at 90 days with LAA as a reference group. Secondary outcomes included favorable functional outcome (modified Rankin Scale score 0–3), National Institutes of Health Stroke Scale score at 24 to 48 hours, reperfusion on digital subtraction angiography, and stroke progression.Results:Of 264 patients with posterior circulation stroke, 84 (32%) had LAA, 48 (18%) cardioembolism, 31 (12%) dissection, and 14 (5%) ESUS. Patients with a dissection were younger (48 [interquartile range, 43–60] years) and had a lower National Institutes of Health Stroke Scale at baseline (12 [interquartile range, 6–31]) than patients with other cause. Functional outcome was better for patients with cardioembolism and ESUS compared to LAA (modified Rankin Scale adjusted common odds ratio, 2.4 [95% CI, 1.1–5.2], respectively adjusted common odds ratio, 3.1 [95% CI, 1.0–9.3]). Patients with a dissection had a lower chance of successful reperfusion compared with LAA (adjusted odds ratio, 0.20 [95% CI, 0.06–0.70]).Conclusions:Unlike the anterior circulation, most frequent cause in our posterior large vessel occlusion stroke cohort is LAA followed by cardioembolism, dissection, and ESUS. Patients with cardioembolism and ESUS have a better prognosis for functional outcome after endovascular thrombectomy than patients with LAA.