Risultati per: Circulation

Circulation, Volume 151, Issue 2, Page 125-125, January 14, 2025.

Circulation, Volume 151, Issue 2, Page 188-192, January 14, 2025.

Circulation, Volume 151, Issue 1, Page 1-3, January 7, 2025.

Introduction
Despite the implementation of mechanical thrombectomy, acute ischaemic stroke with large vessel occlusion (AIS-LVO) remains a significant health concern, characterised by substantial morbidity and mortality. Our trial aims to evaluate the efficacy and safety of minocycline in reducing infarct volume and improving functional outcomes in patients undergoing mechanical thrombectomy for anterior circulation AIS-LVO.

Methods and analysis
The MIST-A trial is a prospective, randomised, open-label, blinded-endpoint trial to be conducted across 12 medical centres. The study will enrol 180 adult patients who have experienced an anterior circulation AIS-LVO and have undergone mechanical thrombectomy. These patients will be randomly divided into two groups: one receiving minocycline in addition to standard care and the other receiving only standard care. The primary efficacy outcome is the change in infarct volume as measured by MRI, from baseline to day 5. The secondary efficacy outcomes include the incidence of intracerebral haemorrhage occurring within 24 hours and the clinical scores between the baseline and follow-up assessments. The primary outcome will be assessed using a mixed-effects model to determine the association between treatment and outcomes.

Ethics and dissemination
The study is approved by the Ethics Committee of Xijing Hospital (XJLL-KY20222186) and is registered at ClinicalTrials.gov (NCT05487417). This trial is estimated to end in the first quarter of 2025 and study findings are expected to be published in scientific journals that undergo peer review and also to be showcased at scientific conferences.

Trial registration number
NCT05487417.

Circulation, Volume 150, Issue 23, Page 1898-1903, December 3, 2024.

Circulation, Volume 150, Issue 21, Page 1732-1736, November 19, 2024.

Circulation, Volume 150, Issue Suppl_1, Page A4145857-A4145857, November 12, 2024. Objectives:Fontan patients have impaired exercise capacity. Exercise training has been shown to improve exercise performance. We aim to determine the effect of exercise training on SVH function, and its correlation with exercise capacity, body composition and self-reported QOL.Methods:31 paediatric Fontan patients were prospectively recruited to complete 3×30 minute homebased HIIT sessions per week for 20 weeks. Baseline physical activity levels, including structured sports participation, daily step-counts and active-zone-minutes (AZM) were recorded by accelerometer (Fitbit inspire3). Patients were considered active if they met 2 of the 3 criteria:1/Structured sports training ≥ 2 per week (moderate-vigorous intensity >30 minutes)2/Daily steps ≥ 10k3/AZM ≥60 minutes per dayBio-impedance-analysis, cardiopulmonary exercise tests, echocardiography including deformation imaging and PedQL questionnaires were performed at baseline and upon completion.Results:28 participants completed the programme. 86% had good compliance (completed >45/60 sessions). 17 male (60.7%), mean age 14.3±2.03 years, 14 LV-dominant, 14 non-LV dominant (9RV, 5BiV). No serious adverse events reported.The exercise duration improved from 7.56±2.6 to 9.16±2.5 minutes, p

Circulation, Volume 150, Issue Suppl_1, Page ASu605-ASu605, November 12, 2024. Introduction:Despite validated Termination of Resuscitation (TOR) rules for Out of Hospital Cardiac Arrest (OHCA) some OHCA patients are transported prior to Return of Spontaneous Circulation (ROSC), sometimes with long transport times. There are certain therapies unavailable in the prehospital setting which could make transport prior to ROSC beneficial for some OHCA patients.Hypothesis:We hypothesized that longer transport times for patients with ongoing Cardiopulmonary Resuscitation (CPR) would be associated with progressively lower probability of achieving ROSC.Aims:To determine if there is a transport time interval beyond which ROSC becomes so unlikely that transport time could be determinant factor for TOR.Methods:We performed a retrospective study of the 2020-2022 NEMSIS national prehospital dataset. We included adult OHCA patients that did not have ROSC prehospital, were transported to the hospital, and had outcome and timestamp data available. We calculated transport time for each encounter and stratified encounters into 5-minute transport time intervals. We defined our outcome as ROSC after transport. We used multivariable logistic regression evaluating the association between 5-minute increases in transport time and ROSC. We performed a secondary analysis of patients that met termination of resuscitation (TOR) criteria (unwitnessed OHCA with no CPR or AED placement prior to EMS arrival).Results:Of 1,409,692 OHCAs, we included 137,957 OHCAs that were transported without prehospital ROSC. The median transport time was 8.9 minutes (IQR 5.4-13.8), and 17,957 (13.1%) had ROSC after hospital arrival. In 5-minute intervals from 0-30 minutes, ROSC rates were 13.5%, 13.1%, 12.0%, 11.1%, 12.1%, and 13.9%. Odds of ROSC per 5-minute increase in transport time was 1.00 (95% CI 1.00-1.00). For patients that met field TOR criteria, rates of ROSC for each 5-minute interval from 0-30 minutes were 9.2%, 8.7%, 7.6%, 5.9%, 6.1%, 4.2%, 7.5%. Odds of ROSC per 5-minute increase in transport time was 0.93 (95% CI 0.88-0.98).Conclusion:In this dataset we were unable to identify a transport time interval up to 30 mins beyond which transport is futile, even in patients who were transported despite meeting the universal TOR rule. Decision to transport based on case-by-case OHCA characteristics could have influenced results. Further research is needed to identify the subset of patient in whom transport prior to ROSC may be beneficial.

Circulation, Volume 150, Issue Suppl_1, Page A4142198-A4142198, November 12, 2024. Background:Patients with single ventricle congenital heart disease palliated to Fontan circulation have increased all-cause mortality compared to age-matched controls. The reason for this increased mortality is not clear and cannot be fully explained by the underlying cardiac disease alone. We hypothesize that premature biologic aging contributes to this increased mortality.Methods:We collected demographic, clinical data and blood from patients with Fontan circulation and controls with structurally normal hearts. We assessed biologic age using telomere length (TL) measured by quantitative PCR from buffy coat DNA. Telomeres are repeating nucleoprotein structures at the end of chromosomes which shorten with age. Between group differences were assessed using t-test. Data was presented as mean±SD and p

Circulation, Volume 150, Issue Suppl_1, Page A4138960-A4138960, November 12, 2024. Introduction:More patients with Fontan circulation are surviving into adulthood and transitioning to adult congenital heart disease (ACHD) care. There are limited long-term outcome data in these patients.Research Questions:We sought to describe a cohort of adults with Fontan circulation and determine patient characteristics associated with long-term survival.Methods:A retrospective review of adults with Fontan circulation followed in our ACHD clinic between 2009 and 2023 was performed. The outcome of interest was transplant-free survival. Survival analysis was performed to explore association between patient factors and time from Fontan completion to patient death or transplant. Patients without events were censored at last follow-up date.Results:In our cohort of 429 patients, median age at first ACHD visit was 24 (IQR 22-29) years with median follow-up time of 3.9 (IQR 0.6-6.4) years. The most common underlying anatomies were tricuspid atresia (26.5%) and hypoplastic left heart syndrome (25.4%). Fontan completion, most commonly lateral tunnel (59.1%), was performed at a median age of 29.7 months. Extracardiac comorbidities in our cohort included: cirrhosis (42.9%), cyanosis (25.9%), and protein losing enteropathy (PLE) (7.0%). Forty-one patients (9.6%) died, 17 (4.0%) had a heart-liver transplant, and 2 (0.5%) had a heart transplant. Transplant-free survival at 20, 30, and 40 years after Fontan completion was 99%, 87%, and 63%. In total, 10 patients died from end-stage heart failure, 8 from sudden cardiac arrest, and 5 from post-transplant complications (Figure). Morphologic right ventricle, cirrhosis, cyanosis, and PLE were associated with worse transplant-free survival (Table).Conclusions:Factors associated with decreased transplant-free survival in a cohort of adult patients with Fontan circulation were identified. These data highlight the importance of early identification and potential intervention for these comorbidities to improve long-term outcomes.

Circulation, Volume 150, Issue Suppl_1, Page ASa305-ASa305, November 12, 2024. Background:TEE is increasingly recognized as a valuable imaging modality during cardiac arrest (CA) resuscitation, particularly for assessing the area of maximal compression (AMC) during CPR. Small single center studies have shown that compression of the left ventricular outflow tract or the aortic root (AMC-LVOT/Ao) is common during CPR, and that when CPR is performed with the AMC over the LV, this results in higher ETCO2, and ROSC. This study aimed to investigate the AMC and its relationship to ETCO2, and ROSC, hypothesizing that patients experiencing AMC-LVOT/Ao have lower ETCO2 and are less likely to achieve ROSC.Methods:A prospective, multicenter cohort study of patients with out-of-hospital and in-hospital CA (OHCA/IHCA) in whom TEE was performed during CPR comparing AMC over the LV (AMC-LV) vs AMC-LVOT/Ao. The study was conducted through the Resuscitative TEE Collaborative Registry, an ongoing multicenter research network involving 37 hospitals (NCT04972526). Collected data included patient and procedure characteristics, hemodynamics, and outcomes according to Utstein-style guidelines. Primary outcome was ROSC, and the secondary outcome was ETCO2 at the time of AMC determination. We performed univariate analysis and multivariate regression evaluating variables known to impact resuscitation outcomes.Results:271 patients including 205 OHCA and 66 IHCA were included. Only 133 (49%) of the total cohort had AMC-LV, with AMC-LVOT/Ao in 47% of OHCA and 42.1% of IHCA. There was no significant difference in the location of the AMC when analyzed by demographic characteristics, height, weight, or comorbidities between patients who received manual vs mechanical CPR. In OHCA, there was no difference in ROSC between AMC-LV and AMC-LVOT/Ao, however the group of patients with AMC-LVOT/Ao had on average 10 units lower ETCO2 compared to AMC-LV (Beta -10; 95% CI -19 – 1.5; p = 0.023). In IHCA, after controlling for factors known to impact outcomes, patients with AMC-LVOT/Ao had significantly lower probability of ROSC (OR 0.25, 95% CI 0.06-0.88; p=0.038).Conclusion:Obstruction of the LVOT/Ao during CPR is a common finding in CA patients evaluated with TEE. This multicenter study extends previous animal and smaller clinical studies suggesting the mechanistic association between the AMC during CPR, with ETCO2 and ROSC, and the potential of TEE-guided resuscitation to improve the effectiveness of CPR.

Circulation, Volume 150, Issue Suppl_1, Page A4140280-A4140280, November 12, 2024. Background:The Child Opportunity Index (COI) is a validated, comprehensive measure of social context, comprised of 29 indicators of child neighborhood opportunity, split into three domains (education, health and environment, and socioeconomic). Our previous work showed that low COI is associated with a 10% lower percent of predicted peak VO2post-Fontan. Exercise intolerance is a known prognostic factor for this patient population. Previous studies have shown that health inequities in education, environment, and socioeconomics factor into worse exercise outcomes. Cardiac MRI (CMR) measured muscle mass is a novel practical technique to evaluate muscle mass. We hypothesized that lower muscle mass by CMR is associated with lower exercise capacity and lower COI z-scores.Methods:A retrospective, single-center study was performed, analyzing 75 post-Fontan patients who had CMR completed between 2010 and 2022. The anterior and paraspinal muscles were measured (Figure). COI z-scores were split into low and high levels, and univariate analyses were subsequently performed to determine associations between COI levels, exercise capacity and muscle mass.Results:The mean age of the population was 19.09 years ± 8.58 with the majority being male (65.3%). Most patients underwent an extracardiac conduit repair (65.3%) (Table). There was a positive correlation between anterior (r=0.36, p=0.007) and paraspinal (r=0.34, p=0.01) muscle mass to peak VO2. There was no significant difference in paraspinal (p=0.15) or anterior (p=0.72) muscle mass between COI groups. Similarly, there were no significant associations between muscle mass and specific COI domains.Conclusion:Muscle mass correlated with exercise capacity in our population and is easy to measure by CMR. There was no correlation between COI level and muscle mass in this study, suggesting that the COI impact on exercise capacity is not directly mediated by lower muscle mass and that other factors should continue to be explored.

Circulation, Volume 150, Issue Suppl_1, Page A4140997-A4140997, November 12, 2024. Aim:Right ventricle to pulmonary circulation (RV-Pc) uncoupling represents a mainstay in staging progression of heart failure (HF), being an independent predictor of mortality. In addition, N-terminal pro-B-type natriuretic peptide (NT-pro-BNP) is a well-established diagnostic and prognostic serum biomarker. In lack of clear clinical evidences on the relationship between exercise levels of NT-proBNP and RV-Pc uncoupling, this represents the aim of our investigation.Methods and Results:A cohort of 13 HF stable patients (mean age 71.6 ± 8.1; 48% female, mean left ventricular ejection fraction 57±13%) underwent maximal exercise stress echocardiographic and cardiopulmonary exercise testing (iCPET) with RV 3D-imaging analysis and were compared with a control population. Natriuretic peptides levels were obtained at rest and peak exercise. RV-Pc coupling was addressed by using the length-force relationship TAPSE/PASP ratio (tricuspid annular plane systolic/excursion pulmonary arterial systolic pressure). As expected, HF patients exhibited a higher level of NT-pro-BNP compared to controls (mean 831 ng/ml vs 131 ng/ml, at rest; mean 793.3 vs 138 ng/ml at peak). In HF, TAPSE/PAPS at peak exercise decreased compared to rest (0.73 ± 0.19 vs 0.47 ± 0.15 respectively) with an inverse correlation between NT-pro-BNP and TAPSE/PAPS exercise (r=0.60, p

Circulation, Volume 150, Issue Suppl_1, Page ASu301-ASu301, November 12, 2024. Background:Chest compressions are a cornerstone of cardiopulmonary resuscitation (CPR), and evidence shows that fewer interruptions and higher chest compression fractions improve outcomes in cardiac arrest. Interruptions in chest compression are important in patients with shockable rhythms to assess the need for defibrillation; however, in pulseless electrical activity (PEA) or asystole, a pause in chest compressions every 2 minutes may be detrimental, as it decreases chest compression fraction and reduces myocardial, cerebral, and systemic perfusion.Hypothesis:We hypothesize that patients with non-shockable rhythms on whom chest compression intervals were greater than 2 minutes have better odds of achieving return of spontaneous circulation (ROSC).Objective:Our primary objective is to determine if longer chest compression intervals are associated with improved subsequent ROSC in patients with initial PEA or asystole rhythms.Methods:We conducted a retrospective cohort study of video-recorded adult atraumatic cardiac arrest resuscitations in a quaternary care Emergency Department from 1/30/2018 to 2/20/2024. We only examined patients in PEA or asystole and determined the duration of all chest compression intervals for each patient. We grouped the chest compression interval durations into 3 groups (

Circulation, Volume 150, Issue Suppl_1, Page ASa902-ASa902, November 12, 2024. Introduction:Patients who regain return of spontaneous circulation (ROSC) after in-hospital cardiac arrest are often critically ill and at risk of re-arrest. However, re-arrest is insufficiently studied. Pre-hospital data indicate a re-arrest rate ranging from 3% to 39%. Our study aims to assess the immediate hazard of re-arrest after ROSC, depending on whether the patient’s last observed rhythm before ROSC was shockable or not.Methods:We analyzed defibrillator recordings and clinical data from 763 cardiac arrest episodes at four different hospitals. ROSC was defined as an organized ECG rhythm compatible with a pulse, accompanied by the absence of chest compressions for at least one minute. An organized rhythm with a QRS frequency ≥ 12 was categorized as pulseless electrical activity (PEA). Conversely, a QRS frequency < 12 or a flat line represented asystole. Ventricular fibrillation or tachycardia (VF/VT) was identified based on its distinct morphology. We further stratified ROSC based on whether the preceding rhythm was shockable or not. After comparing four different parametric time-to-event models, we chose the most useful one and estimated the immediate hazard of re-arrest along the timeline of resuscitation.Results:After the initial event of cardiac arrest, we observed 316 re-arrests. Among these, 68% relapsed to PEA, 25% relapsed to VF/VT, and 7% relapsed to asystole. Summarized in the figure, the initial hazard of re-arrest from ROSC after PEA or asystole to a non-shockable rhythm was 0.02 per minute. By the 9th minute, this hazard decreased to 0.01 per minute. Meanwhile, the hazard for re-arrest to a shockable rhythm remained constant at 0.01 per minute. For re-arrest from ROSC after VF/VT back to VF/VT, the hazard was 0.05 per minute initially, decreasing to 0.03 per minute by the 12th minute. The corresponding hazard for re-arrest to PEA or asystole remained at 0.01 per minute.Conclusion:The hazard of re-arrest after return of spontaneous circulation (ROSC) to either pulseless electrical activity (PEA), asystole, or ventricular fibrillation/tachycardia (VF/VT) varies by the last observed state before ROSC. Notably, re-arrest to VF/VT following ROSC after previous VF/VT poses the highest risk. This understanding can assist healthcare professionals in anticipating events during the critical minutes following successful resuscitation and adjusting treatment accordingly.

Circulation, Volume 150, Issue Suppl_1, Page ASa1001-ASa1001, November 12, 2024. Introduction:Epinephrine is the mainstay of drug treatment during cardiac arrest and it is firmly established that it promotes Return of Spontaneous Circulation (ROSC). In this study we aimed to describe the effect and occurrence of ROSC after administering epinephrine to hospitalized patients with primary pulseless electrical activity (PEA), i.e., administered during PEA as the first recorded arrest rhythm.Method:We investigated 78 episodes of primary PEA registered between Aug. 2018 and Oct. 2022 at St. Olav University Hospital (Trondheim, Norway). In 36 episodes, the first dose of epinephrine was administered during primary PEA and registered with minute precision. We created different time dependent covariate profiles for the effect of epinephrine, starting at 0 (time of administration), rising linearly to 1 (presumed maximum effect) and decreasing to 0 immediately thereafter. Time to presumed maximum effect started at 5 seconds (s) after administration and increased in steps of 5s until 300s. We entered each of these different covariate profiles into separate Cox regression models using time to ROSC as outcome obtaining in total 60 Hazard ratios (HR) from all the models.Results:Median time to epinephrine administration was 185s (range 80 to 310) after start of resuscitation. In total, 23 patients obtained ROSC after the administration of epinephrine and 15 patients obtained ROSC without epinephrine. The different hazard ratios (y-axis) were plotted against the location of the maximum point of the covariate profile (x-axis) in Fig. 1. HR peaked twice, at 70 and 155s, 11.4(p< 0.001) and 4.1(p= 0.013), respectively.Discussion:This study indicates a strong effect of epinephrine during primary PEA 1-2 min after administration. This information may provide the treating team with useful insight on what to expect after administering epinephrine. In addition, the actual effect may be even larger, as the sickest patients (expected to respond less well to epinephrine) are more often monitored and thus recieve epinephrine earlier.