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Circulation, Volume 150, Issue Suppl_1, Page A4136330-A4136330, November 12, 2024. Introduction:Accurate assessment of pacing thresholds during permanent pacemaker implantation is critical to ensure device function and longevity. A few reports have described rate-related threshold variability during MicraTMleadless pacemaker (Medtronic Inc, Minneapolis, MN) procedures. Postulated mechanisms for this phenomenon include variable myocardial contact or micro-dislodgment, and inflammation-induced phase IV block. In this case series, we demonstrate the use of adenosine to induce transient heart block for accurate threshold assessment in patients with tachycardia during leadless pacemaker placement.Cases:A 69-year-old male with a history of atrial flutter presented with complete atrioventricular (AV) block requiring emergent transvenous pacing. A Micra placement was performed. During the procedure, the patient was tachycardic in rapid atrial flutter despite multiple doses of metoprolol. It was noted that with rapid pacing from the pacemaker at 120 pulses per minute (ppm) the threshold was ≤1V at 0.24 ms. An adequate “tug-test” was performed and at least 2 of 4 tines were noted to be fixated based on fluoroscopic motion. To confirm the capture threshold before final deployment, 12 mg of adenosine was given to induce heart block. However, at a rate of 60 ppm, there was no ventricular capture at 3V at 0.24ms. The device was repositioned and repeat threshold testing with adenosine at 60 ppm was 0.38V at 0.24ms. Pacing parameters were assessed the next day and remained stable.Similarly, a 75-year-old female with ischemic cardiomyopathy was admitted with new atrial fibrillation (AF). She then developed pauses prompting Micra placement. During initial threshold testing, she was in rapid AF despite receiving multiple doses of metoprolol. Heart block was induced with 12mg adenosine to assess the threshold at a lower pacing rate of 60 ppm. The capture threshold achieved was 0.5V at 0.24ms.Discussion:Nusbickel et al., Yoshiyama et al., and Sano et al. have reported rate dependent discrepancies in capture thresholds after Micra implantation. Our cases highlight the importance of capture threshold assessment at lower pacing rates during implantation. In patients who are tachycardic at the time of the procedure, adenosine may be useful to more reliably assess device capture threshold and determine the need for repositioning.

Circulation, Volume 150, Issue Suppl_1, Page A4140908-A4140908, November 12, 2024. Background:Coronary artery aneurysm seen in patients undergoing coronary angiography is an uncommon disorder with poorly understood pathophysiology. Patients have variable clinical presentations and often poor long-term outcomes. Management of these patients still pose a clinical dilemma given there are no standardized treatment guidelinesDescription of case and discussion:A 44-year-old male with a significant past medical history of hypertension, diabetes mellitus, and hyperlipidemia presented in the emergency room (ER) for acute onset chest pain. His pain was retro-sternal, non-radiating, and pressure-like in nature. Pain was initially rated as 2/10 intensity which progressed to 9/10 later in the day with associated diaphoresis. He took acetaminophen which provided no relief. His electrocardiogram (EKG) showed ST elevation in the inferior and lateral leads. Initial troponin was negative. The cardiac catheterization laboratory was activated and the patient was administered loading doses of Aspirin, ticagrelor and a bolus of intravenous (IV) heparin.An emergent left heart catheterization and coronary angiogram was performed which revealed a 100% thrombotic occlusion of the mid LAD as well as severe ectasia of the proximal vessel. There was mild ectasia of the left circumflex and right coronary arteries without any significant stenosis. There were no collaterals to the distal LAD consistent with an acute presentation. At the level of the occlusion (mid LAD), there was an aneurysm measuring up to 10 mm in diameter by angiography. Intravenous eptifibatide was administered with the continuation of IV heparin. The thrombotic occlusion was managed medically with a plan to repeat angiography in 24-48 hours. Transthoracic echocardiography revealed a preserved left ejection fraction at about 55-60% with mild hypokinesis of the apex. Repeated angiography in 48 hours revealed a mostly patent LAD with diffuse TIMI 2 flow and sub occluded distal LAD at the apex. He was discharged home with dual antiplatelet therapy, a statin, and a beta blocker. Two weeks later he was seen on outpatient setting and his medications were transitioned to Rivaroxaban and clopidogrelConclusion:Large LAD aneurysms are not common and they carry long term complications which includes thrombosis (as seen in our patient), fistula formation, and rupture. Management of this condition is still challenging as there are no standardized management guidelines.

Circulation, Volume 150, Issue Suppl_1, Page A4146542-A4146542, November 12, 2024. Background:Beta blockers have the potential to mitigate the damage caused by adrenergic overdrive in septic shock. However, there is limited data supporting their effectiveness in controlling heart rate in these patients. Recent meta-analyses have demonstrated that beta-blockers can lower mortality rates in patients with sepsis. To evaluate the efficacy of beta-blockers in sepsis and septic shock, we conducted a comprehensive systematic review and meta-analysis.Methods:We performed a systematic review and meta-analysis by thoroughly searching MEDLINE, Scopus, and the Cochrane Database of Systematic Reviews to evaluate the efficacy of beta-blockers in sepsis and septic shock. Random-effects models were utilized to pool effect sizes. The DerSimonian-Laird estimator calculated between-study variance, and the Jackson method was employed to determine a 95% confidence interval (CI).Results:Our analysis included 8 eligible studies with a total of 893 patients (446 in the beta-blocker group, with 64% being female, and 447 in the placebo group, with 59% being female) at 28 days of follow-up. In the beta-blocker cohort, there were 171 deaths (38.3%), whereas the control group had 212 deaths (47.4%) at 28 days of follow-up. The use of beta-blockers did not significantly improve overall 28-day mortality (pooled odds ratio, 0.59; 95% CI, 0.34-1.03; p = 0.07) (Figure).Conclusion:The findings of this systematic review and meta-analysis suggest that beta-blockers do not significantly enhance survival rates among patients with sepsis and septic shock.

Circulation, Volume 150, Issue Suppl_1, Page A4146198-A4146198, November 12, 2024. Introduction:Lung cancer is divided broadly into two main types: Small cell lung cancer (SCLC) and non-small cell lung cancer-NSCLC. Approximately 70% of SCLC cases have metastasized to other parts of the body including lymph nodes, bone, liver, adrenal glands, and brain [1]. SCLS metastasis to cardiac tissue is rare. Primary cardiac tumors are as rare with a reported prevalence of 0.028% [2]. Here we present a 59-year-old female (59F) with recurrent SCLC metastasis with evidence of a newly diagnosed primary cardiac tumor.Case Presentation:59F with a past medical history of SCLC status-post chemotherapy and radiation presented for evaluation of worsening left upper extremity pain, paresthesia, motor weakness, and neck pain. During the hospital admission, an echocardiogram demonstrated extensive thrombus from the Superior Vena Cava (SVC) into the right atrium (RA) and an irregular echogenic 37 mm x 26 mm mass partially attached to the posterior leaflet of the tricuspid valve. The RA mass was successfully removed by mechanical thrombectomy. Pathological results of the RA mass revealed significant malignant epithelioid and spindled neoplasm with myxoid stroma– concerning for myoepithelial disease.Discussion:Cardiac tumors, although uncommon, should be included in the list of possible diagnoses when observing any abnormal mass detected through cardiovascular or thoracic imaging techniques. Cardiac tumors are likely due to metastatic origins as metastatic cardiac tumors occur 20 times more frequently than primary cardiac tumors[3].When metastatic cardiac tumors are suspected, malignant melanoma and leukemia are the most frequent origins[4]. Rarely does SCLC metastasize to cardiac tissue. Primary cardiac tumors are typically benign (90%), with primary malignant tumors being very rare[5]. Patients may be asymptomatic, or present with nonspecific symptoms such as exertional dyspnea, fevers, arthralgias, or life-threatening cardiac tamponade[6]. For right atrial tumors, treatment strategies are usually dependent on symptomatology, in which removal via aspiration or surgical resection has demonstrated a favorable prognosis[7].Conclusion:Given the rarity of primary cardiac tumors in the setting of metastatic SCLC, there exist no evidence-based guidelines for optimal management of right atrial tumors. In our patient, mechanical aspiration was performed without complications and prevented potential adverse cardiopulmonary events from occurring.

Circulation, Volume 150, Issue Suppl_1, Page A4143727-A4143727, November 12, 2024. Efforts to ameliorate rural healthcare burnout stemming from overwork have taken many approaches, including the increased usage of Artificial Intelligence (AI) to aid in generating electronic medical records (EMR). This new application of AI technology demands characterization of the possible benefits and efficacy of its new use. Using a commercially available AI software (Freed AI) designed for EMR production, we conducted a study to determine the quality of EMR generated by AI.Methods:This trial analyzed 248 patient-provider interactions within a rural setting of Medicare’s Chronic Care Management (CCM program), recorded by Freed AI and a human scribe. Three blinded readers with a clinical background were given 2 notes from the same patient-encounter. One note was written by a provider and one was generated by Freed AI. Each reader performed a binary, independent assessment of each note compared with the note generated by the human control. Readers were trained on definitions of the categories clarity, accuracy, completeness, and relevance. The time required per encounter was also recorded and analyzed.Discussion:As seen in Table 1, AI performed better than a human-generated EMR in the fields of clarity and relevance, suggesting effective formatting and a well calibrated understanding of what information is medically relevant. No significant difference in completeness was observed, suggesting AI was able to record as much valuable information as traditional charting. AI performed below the human standard in the category of accuracy. For example, AI sometimes misspelled names or misunderstood complex situations being discussed because it was not able to infer certain information which a human, using outside knowledge and past experiences, could. The reduction in time spent while utalizing AI demonstrates a highly significant decrease in workload and allows providers freedom to allocate more time interacting with each patient and hopefully reducing physician burnout.

Circulation, Volume 150, Issue Suppl_1, Page A4144883-A4144883, November 12, 2024. Background:Iron deficiency (ID) is common amongst patients with heart failure (HF). The European Society of Cardiology (ESC) guidelines recommends intravenous (IV) Iron supplementation in symptomatic HF patients with reduced left ventricular ejection fraction (LVEF) and ID to alleviate HF symptoms and improve quality of life. The current study aims to assess adherence to the latest ESC guidelines in treatment of ID in HF patients admitted to non-cardiac (outlier) wards at St. George’s University Hospital (SGH), London. The results were compared to standard practice at a dedicated heart failure unit (HFU) at SGH.Methods:Retrospective data was collected on consecutive HF patients, admitted to SGH between September 2022 and September 2023. 386 patients met the inclusion criteria, defined as HF with LVEF < 50% and ID according to ESC guidelines. Of total population, 190/386 patients were admitted to the outlier wards and 196/386 to the HFU. Patients considered ineligible for administration of IV Iron therapy, were those not meeting the guideline thresholds for treatment of ID, patients with active cancer or bleeding and patients on oral Iron supplementation.Results:The mean age of patients admitted to HFU was 71 +/- 13 SD, 66% male. 72% (141/196) of the patients were tested for ID, of which 51% (72/141) had ID as per inclusion criteria. 57% (41/72) of those with ID were prescribed IV Iron, whilst 43% (31/72) were not treated. The reason for not treating patients identified as Iron deficient was presence of active infection (19/31) or bleeding (3/31). In 9/31 of untreated patients with ID, the reason for not being prescribed with IV Iron was not identifiable through review of medical notes. It is important to note that 28% (55/196) were not tested for ID during their hospitalisation and missed the opportunity for treatment.(Figure 1)In outlier wards, mean age was 77 +/- 14 SD, 66% male. 46% (87/190) patients were tested for ID, of which 16% (14/87) were identified as Iron deficient and were prescribed IV Iron. 4% (12/87) were not treated for no obvious reason and 18% (16/87) met the criteria for ID, but due to presence of contraindication did not receive IV Iron. Missed opportunity was 54% in outlier population.(Figure 2)Conclusion:This study demonstrated that patients admitted to HFU, were more likely to be tested for ID and receive IV Iron, compared to patients admitted to outlier wards but there is still room for considerable improvement in both settings.

Circulation, Volume 150, Issue Suppl_1, Page A4147178-A4147178, November 12, 2024. Background:Loeffler endocarditis is a rare and clinically challenging presentation of hypereosinophilic syndrome (HES). Early detection and treatment are critical for this disease that otherwise carries a high risk of morbidity and mortality. We present a complex case of a patient with HES and sequelae.Case:A 41-year-old male with history of asthma presented with cough, dyspnea on exertion, orthopnea, and right arm pain. He noted a 15-pound weight loss in the past few months. In addition to right upper superficial vein thrombus, he was initially diagnosed with pneumonia, but labs were concerning for significant leukocytosis (WBC 54.23 103/uL) and hypereosinophilia (45%), as well as anemia and thrombocytopenia. Cardiology was consulted for evidence of cardiac involvement with high sensitivity troponin 480 ng/L and BNP 399 pg/mL. Transthoracic echocardiography and cardiac MRI showed mild apical biventricular dilatation with moderate apical hypokinesis. There was nonenhancing T2 hypointense eccentric signal in both apices, suggestive of organized thrombus. Circumferential mid-cavity subendocardial delayed enhancement in the left ventricle and right ventricular apex was noted. Systolic function was preserved, but there were signs of pulmonary arterial hypertension. These findings were consistent with Loeffler endocarditis. He underwent bone marrow biopsy, which confirmed diagnosis of FIP1L1-PDGFRA+ HES.The presence of the FIP1L1-PDGFRA mutation is correlated with an increased risk of cardiac involvement in patients with HES and is also associated with worse prognosis. Following an interdisciplinary discussion between the hematology, rheumatology, and cardiology teams, he was started on imatinib, methylprednisolone followed by prednisone taper, and apixaban. His symptoms and blood counts have since drastically improved, and he is being monitored closely for resolution of the thrombi and for any signs of heart failure.Conclusion:HES complicated by Loeffler endocarditis is a unique presentation of infiltrative disease causing inflammatory, thrombotic, and fibrotic cardiac sequelae. It can portend deadly complications, including valvular involvement, thromboembolic events, and heart failure. A high clinical suspicion is required due to the multitude of possible symptom presentations. Multimodality imaging and interdisciplinary management with early accurate diagnosis and treatment are necessary to slow disease progression and reduce morbidity risk.

Circulation, Volume 150, Issue Suppl_1, Page A4139584-A4139584, November 12, 2024. Introduction:We present a case of hypertrophic obstructive cardiomyopathy (HOCM) with incidental wild-type transthyretin cardiac amyloidosis (ATTRwt-CA) discovered after septal myectomy.Case presentation:A 62-year-old male with a history of bilateral carpal tunnel syndrome as well as a family history of sudden cardiac death consistent with HOCM on autopsy (patient’s father) presented to the clinic with symptoms of exertional shortness of breath, hypotension, and pre-syncope. An external monitor revealed one episode of non-sustained supraventricular tachycardia, otherwise was unremarkable. He experienced worsening symptoms for which emergency department evaluation revealed anterior lead T-wave inversions on EKG. Cardiac catheterization revealed non-obstructive coronary artery disease. Shortly thereafter, a cardiac MRI was significant for probable HOCM based on septal hypertrophy, late gadolinium enhancement (LGE) with mid-wall fibrosis in the basal/mid inferolateral segments, and systolic anterior motion (SAM) of the mitral valve. Pre-stress echocardiogram revealed a sigmoid septum with septal wall thickness of 1.6 cm and no left ventricular outflow tract (LVOT) gradient. Post-stress echocardiogram revealed severe SAM with septal contact, LVOT gradient of 70 mmHg, as well as hypotension. Genetic testing was negative, and the patient underwent successful septal myectomy with papillary muscle reorientation and resection of secondary chordae. The pathology of the myocardium obtained during surgery resulted with histological features suggestive of HOCM in addition to confirmed ATTRwt-CA for which tafamidis was initiated.Discussion:Literature reporting HOCM and ATTRwt-CA within the same patient is rare. Both conditions cause increased myocardial thickness which can present phenotypically similar, making diagnosis difficult. Utilization of modern imaging modalities such as cardiac MRI and echocardiography should provide valuable information for differentiation, but as in our case, direct tissue visualization can be required for diagnosis. Each diagnosis has unique imaging characteristics that help define them such as asymmetric septal hypertrophy with dynamic LVOT obstruction, SAM of the mitral valve, and fibrotic areas on LGE in the setting of HOCM compared to diffuse and symmetric global subendocardial LGE and concentric hypertrophy with ATTRwt-CA.Conclusion:Our case reveals the importance of avoiding anchoring bias as concomitant diagnoses can present.

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