Risultati per: Report aggiornato sulla qualità dell’aria in Europa (2015)

Circulation, Volume 146, Issue Suppl_1, Page A13272-A13272, November 8, 2022. A 49-year-old female presented with complaints of angina and dyspnea on exertion for last 4 months, which caused significant limitation of ordinary physical activity. She had poorly controlled diabetes mellitus type 2 with HbA1C of 10.3%. EKG showed complete LBBB with QRS duration of 180 milliseconds. Echocardiogram was consistent with dilated left ventricle and global hypokinesia of left ventricle with ejection fraction of 25-30%. There was marked reduction in GLS (GLPS average of -7.0%). She underwent coronary angiogram which revealed normal epicardial coronary arteries.99mTc-sestamibi SPECT myocardial perfusion imaging (MPI) at rest, demonstrated moderate to severe ischemia involving apical, antero-septal, adjacent anterior wall and adjacent basal 2/3rdof inferior wall segments of LV myocardium (involving approx.~73% of RCA territory and 57% of LAD territory at 50% uptake threshold). There was wall motion abnormality in above mentioned segments on ECG gated SPECT and estimated LVEF with QGS was ~29±5%. She has been started on anti-ischemic measures, guideline directed therapy for HFrEF and comprehensive diabetes care. Diabetic cardiomyopathy is myocardial dysfunction with normal epicardial coronary arteries and absence of other cardiovascular diseases. It is characterized by myocardial fibrosis and associated systolic dysfunction preceded by diastolic dysfunction. Cardiac insulin resistance leads to advanced glycation end products, microvascular dysfunction etc. Perfusion defects observed during MPI in patients with LBBB may be due to CAD, microvascular dysfunction, or artifacts. In the setting of LBBB, isolated anteroseptal defect has low probability of CAD but presence of perfusion defects in RCA territory and apical region increases probability of ischemic events.In this case, there was ischemia with systolic dysfunction in the absence of any overt clinical coronary artery disease and no other identifiable cause.

Circulation, Volume 146, Issue Suppl_1, Page A15038-A15038, November 8, 2022. Introduction:Myocardial ischemia in adult ALCAPA (Anomalous left coronary artery from the pulmonary artery) may lead to sudden death as the first clinical presentation. Cardiac blood supply from the right coronary artery alone is not sufficient for an adult ALCAPA. The aim of the present study was to describe a clinical case of severe myocardial ischemia in an adult female with ALCAPA supplied by the right coronary artery alone.Patient and Clinical data:45-year-old female patient admitted to our hospital due to recurrent palpitation with tachypnoea after physical exertion for 2 years. Resting ECG on admission with ST-T changes and frequent premature ventricular contractions (PVC) indicated significant myocardial ischemia. Transthoracic echocardiography (TTE) showed dilated left ventricle (LVDd 64mm) with regional systolic dysfunction anterolateral and posterolateral with EF of 44% and dilated right coronary artery. An ALCAPA was observed with dilated caliber of 9 mm at ostium (Panel A) which was confirmed by computed tomographic angiography of the coronary artery and coronary angiography. Well-developed collateral vessels between peripheral right posterior descending (RPD) and distal left anterior descending (LAD) were demonstrated (Panel F). No collateral vessel was found between bronchial artery and ALCAPA. The bronchial arteries were visualized in normal size. The left coronary ostium was not found in the aortic root at aortography. The patient underwent anatomical reconstruction of left main coronary artery by using autologous pulmonary flap and recovered well postoperatively.Results:Postoperative ECG showed that the preoperative ST-T changes and PVC disappeared completely. Cardiac magnetic resonance imaging and TTE one month and 6 months postoperatively demonstrated continuously improved LV systolic function and myocardial perfusion posterolaterally and anterolaterally.Conclusion:Collateral flow from the right coronary artery alone is not sufficient for adult ALCAPA and completely surgical correction is necessary.

Circulation, Volume 146, Issue Suppl_1, Page A13191-A13191, November 8, 2022. Case Presentation:Infective endocarditis (IE) can sometimes be a diagnostic challenge because its presentation in its early stages may coincide with that of several other disease processes. It has an incidence of ~7 per 100,000 annually yet has an in-hospital mortality of about 20-25%. We present a case of a 56-year-old immunocompetent male with a recent diagnosis of leukocytoclastic vasculitis (LCV) who was admitted for acute renal failure (ARF). With his history of LCV (Figure 1), renal vasculitis was thought to be contributing to his ARF. On admission, he was afebrile and had a creatinine of 5.25 (baseline of 0.8), hyponatremia, anemia, mild leukocytosis, and mildly elevated lactate. No other infectious sequelae were noted. Nephrology was consulted for workup of renal failure, and a renal biopsy was recommended. Before the biopsy was able to be performed, blood cultures returned positive for Enterococcus faecalis. Transesophageal echocardiogram revealed a large, mobile 1.3-centimeter vegetation attached to the left ventricular outflow tract side of the non-coronary cusp of the aortic valve. Parenteral antibiotics were initiated, and cardiothoracic surgery was consulted for surgical correction. The patient ultimately underwent aortic valve replacement successfully with renal recovery to baseline and resolution of his leukocytoclastic vasculitis soon thereafter.Discussion:LCV has been established as a rare, but well-reported sign of IE. Similarly, only a few cases of IE presenting as ARF have been reported. In patients presenting with both LCV and ARF, it is important to maintain a high index of suspicion for IE. Going down the pathway to work up renal vasculitis may unnecessarily expose patients to invasive procedures, incorrect treatment modalities, and other complications.

Circulation, Volume 146, Issue Suppl_1, Page A12670-A12670, November 8, 2022. Introduction:Although most pediatric VAD patients survive to transplantation, some die on device therapy. The end-of-life experience of pediatric VAD patients is not well characterized.Hypothesis:Invasive interventions are common in pediatric VAD patients at the end-of-life.Methods:Retrospective review of pediatric VAD patients in the ACTION registry who died on device therapy between 3/2012-9/2021. Demographic and clinical data, including invasive interventions used at the end-of-life and the location of death, were analyzed.Results:107/721 (15%) of patients died on device at a median age of 5 years (IQR:1, 16) at 43 days (IQR: 17, 91) post implant. Goals of VAD therapy were bridge to candidacy for 50 patients (51%), bridge to transplant for 44 (37.6%), destination therapy for 2 (1.7%). The most common cause of death was multi-organ failure (n=35, 30%), followed by infection (n=12, 10.3%). Eighty-five of 92 patients (92.4%) died with a functioning device in place. Most patients were receiving invasive interventions (mechanical ventilation, 75%; vasoactive infusions, 62%) at the end-of-life. (Table 1). Only 10 (9%) patients died at home. Utilizing these data, we identified and estimated the frequency of four common end-of-life trajectories for pediatric VAD patients. (Figure 1).Conclusions:Aggressive interventions are common at the end-of-life of pediatric patients with VADs. Dying at home is uncommon. Identification of common end-of-life patterns will serve as an outcome measure and inform future practices to promote informed patient and provider decision-making to reduce suffering in those who die on device support.

Circulation, Volume 146, Issue Suppl_1, Page A14471-A14471, November 8, 2022. Introduction:Sarcoidosis is a multi-system disorder of unknown etiology that is commonly associated with hilar lymphadenopathy and granulomas. Cardiac involvement is less common, however, sarcoidosis is a known cause of restrictive cardiomyopathy. It typically presents as new-onset arrhythmias or heart failure, although cases of sudden cardiac death have been reported.Case presentation:We present a case of a 56-year-old male with a known history of pulmonary sarcoidosis, not on any active treatment, who presented to the emergency department with one week of continuous hiccups every few seconds associated with non-exertional dyspnea. Initial CT scan of the chest showed multiple stellate-like ground-glass opacities and progression of bronchiectasis. Troponins were negative. On the initial EKG, he was found to be in atrial flutter and was admitted to the general medical floor. He was given baclofen and the hiccups resolved over the next 24 hours. Cardiology was consulted for suspected cardiac sarcoidosis and they recommended transferring the patient to the tertiary care center for further evaluation. Upon arrival, the patient underwent catheter ablation for atrial flutter and he returned to the sinus rhythm after the procedure. The initial nuclear scan with gallium was not suggestive of cardiac sarcoidosis, however, subsequent cardiac MRI showed cardiac involvement. Due to the high risk of arrhythmias, the patient was scheduled for implantable cardioverter defibrillator placement before discharge. Treatment with steroids was deferred until after the PET scan could be completed. The patient was discharged in stable condition and interrogation of the device found it to be well functioning and with no significant arrhythmias noted.Conclusions:Presentation of cardiac sarcoidosis can be variable and should be considered in any patient with a known history of sarcoidosis who presents with atypical symptoms at or above the level of the diaphragm, such as hiccups or with new-onset arrhythmias.

Circulation, Volume 146, Issue Suppl_1, Page A9436-A9436, November 8, 2022. Introduction:Left Atrial Septal pouch (LASP) is defined as an incomplete closure between the septum primum and septum secundum with an elongated septum secundum. This produces a crevice in the left atrium that functions as a source for static blood and atrial dissociation. This in turn could progress to the formation of thrombi within the left atrium that has the potential to embolize causing ischemic infarcts.Case Description:Here we present a 63 year old Hispanic female with a past medical history of paroxysmal atrial fibrillation on apixaban, recurrent strokes, dyslipidemia, and hypertension who presented with expressive aphasia, and prosopagnosia. Previously, the patient was reported of having two cardioembolic cerebral vascular accidents (CVA). Computed tomography of the brain demonstrated an old infarct of the left posterior parietal lobe. Patient was treated with intra-arterial tissue plasminogen activator of the left posterior cerebral artery and right middle cerebral artery. MRI demonstrated four acute punctate infarcts in the left frontal lobe consistent with embolic infarcts. TEE demonstrated a large patent foramen ovale (PFO), a prominent eustachian valve, and LASP. It was determined that her PFO and LASP were the culprit for her recurrent CVA despite appropriate AC. The PFO/LASP were successfully closed with an Amplatzer PFO occluder device. Patient was discharged home.Discussion:The LASP can function as a source of thrombus formation and atrial disassociation, which can cause embolic CVA. No guidelines exist on how to properly address a LASP. One option would be to use a PFO closure device to close LASP. Other options may include AC despite the absence of atrial fibrillation.Conclusions:In conclusion, further studies are necessary in order to establish the most appropriate management in patients with LASP.

Circulation, Volume 146, Issue Suppl_1, Page A14762-A14762, November 8, 2022. Introduction: Anti-neoplastic agents that target vascular endothelial growth factor (VEGF) are known to have cardiovascular toxicities, principally hypertension, with a reported incidence of 21-40% in first-time users. Anti-VEGF induced hypertension can be challenging to control, and significant enough to lead to a dose reduction or discontinuation of the VEGF-targeted therapy, preventing patients from completing their cancer therapy.Methods:A single center prospective cohort of patients with cancer starting anti-VEGF therapy was compared to a retrospective control cohort that was 1:1 matched on gender, race, ethnicity, cancer type, and anti-VEGF therapy. For the prospective cohort, antihypertensive medications were started per an anti-VEGF hypertension algorithm. Elevated blood pressure was defined as consecutive blood pressure readings above 140/90 mmHg and control of blood pressure defined as consecutive readings

Circulation, Volume 146, Issue Suppl_1, Page A14489-A14489, November 8, 2022. Clinical Case:A 37-year-old transgender (TG) woman off gender-affirming hormonal therapy (GAHT) presented with substernal chest pain radiating to the left arm, worse with exertion and relieved with res. She was hypertensive and tachycardic on admission. Initial bloodwork revealed an elevated troponin I of 0.57 ng/mL, which peaked at 1.48 ng/mL. EKG on admission showed hyperacute T waves in the anterior leads without ST elevation (see Figure 1). She was diagnosed with non-ST elevation myocardial infarction (NSTEMI) and taken for left heart catheterization (LHC).Decision-Making:TTE showed preserved LVEF and basal inferior, basal inferolateral, basal anterolateral and mid-anterolateral hypokinesis. LHC showed proximal-to-mid right coronary artery (RCA) occlusion. After failed aspiration thrombectomy indicating calcified plaque, two overlapping drug-eluting stents (DES) were successfully deployed with restoration of flow. She was discharged home on aspirin, ticagrelor, atorvastatin, and carvedilol.Discussion:Despite a recent push to increase awareness, research and healthcare equality specific to lesbian, gay, bisexual, transgender, and queer (LGBTQ+) patients, a significant gap persists. Specifically, stress, inflammation, dyslipidemia, and thromboembolism predispose this understudied population to increased coronary artery disease (CAD) and myocardial infarction (MI). Accordingly, greater effort needs to be taken to mitigate preventable cardiac morbidity and mortality in this patient population.Conclusion:CAD in LGBTQ+ adults is well studied. However, there are few published studies on CAD specifically among TG men and women. National cross-sectional data highlights this disproportionate risk of CAD and MI among TG men and women relative to their cisgender female and male peers, a healthcare disparity recently emphasized by the AHA. Consequently, care must be taken to eliminate these aforementioned inequalities.

Circulation, Volume 146, Issue Suppl_1, Page A15281-A15281, November 8, 2022. Introduction:Spontaneous coronary artery dissection (SCAD) is an important cause of acute coronary syndrome especially in young patients. Factors associated with delays in presentation and care delivery are not well understood.Methods:We used data from the iSCAD Registry which is a prospective multicenter US registry of patients with SCAD. Early vs. delayed hospital presentation (< 24 vs. ≥ 24 hours), and early vs. delayed coronary angiography (time from hospital presentation to coronary angiography < 24 vs. ≥ 24 hours) for SCAD patients with AMI were assessed. Patient characteristics, and in-hospital events were compared between the two groups. Factors associated with delayed presentation and angiography were explored using multivariable logistic regression.Results:A total of 346 SCAD (294 white, 52 non-white) patients presented with STEMI (34%) or NSTEMI; 57 had a delayed presentation to the hospital after symptoms onset. No significant factors were identified for delays in seeking care. However, white race was less likely to have delayed invasive coronary angiography (multivariable OR=0.38; 95% CI 0.19 to 0.76; p=0.0059). Patients undergoing delayed angiography were also more likely to be medically managed (91.7% vs. 69.8%, p=0.0008), but less likely to receive dual antiplatelet therapy (57.0% vs. 73.1%, p=0.007). In-hospital outcomes were similar between the two groups.Conclusion:In this study, no patient-related variables were identified that predicted a delay in presentation with AMI secondary to SCAD. On the other hand, non-white race was associated with delays in performing invasive coronary angiography. Further investigation is required to determine the factors contributing to this potential disparity.

Circulation, Volume 146, Issue Suppl_1, Page A11660-A11660, November 8, 2022. Introduction:Diagnosing a pulmonary embolism (PE) can be challenging, especially when it presents as another “can’t miss” diagnosis like acute coronary syndrome. Although electrocardiogram (EKG) abnormalities can be seen in many PE presentations, rarely are ST elevations noted. We describe a case report of PE presenting as STEMI.Case presentation:A 71-year-old woman with hypertension, hyperlipidemia, type 2 diabetes mellitus, and morbid obesity presented to the emergency department with chest pain radiating to the jaw along with shortness of breath. On initial presentation her heart rate was 110 bpm, respiratory rate 40, 84% SpO2 on room air, and blood pressure 150/84 mmHg. EKG showed ST elevation in anterior leads V1-V2 and reciprocal changes of ST depression in lateral leads I, aVL, V5-V6. Serial troponins were elevated and she underwent left heart catheterization which showed non-obstructive coronary artery disease and hyperdynamic left ventricular function. Right heart catheterization (RHC) showed an elevated mean pulmonary artery pressure of 49 mmHg, and pulmonary artery pulsatility index was 2.2, suggestive of right ventricular dysfunction which prompted an urgent CT pulmonary angiogram and transthoracic echocardiogram. The CT revealed extensive pulmonary embolism and echocardiogram demonstrated dilated right ventricle with hypokinesis and akinetic right ventricular free wall. A left lower extremity ultrasound revealed deep vein thrombosis.Discussion:This patient depicts an uncommon presentation of acute PE masquerading as acute coronary syndrome. Her case was diagnostically challenging as her EKG findings were not consistent with those typically seen in acute PE. Review of the literature reveals only a handful of case reports of a PE appearing to be a STEMI. Although rare, clinicians should entertain the idea of PE when presented with ST elevation and no culprit lesion and a careful RHC may be useful in establishing diagnosis.

Circulation, Volume 146, Issue Suppl_1, Page A14459-A14459, November 8, 2022. Introduction:Cardiobacterium hominis, part of the oropharyngeal flora, is a gram-negative bacteria reported to cause infection in less than 5% of patients with infective endocarditis (IE). In children, congenital heart disease (CHD) is a predominant risk factor for developing IE. Herein we describe an unusual presentation ofC. hominisbioprosthetic valve endocarditis.Case Presentation:A 23-year-old woman with bicuspid aortic valve and aortic valve stenosis underwent aortic bioprosthetic valve placement in 2017. In March 2022, she presented to an emergency room with left lower abdominal pain. A CT scan demonstrated occlusion of the left iliac artery. Medications at that time included oral contraceptive pills and baby aspirin. No echocardiogram was obtained at that visit. She presented for a routine cardiology follow-up in May 2022 at which time she was asymptomatic. Transthoracic echocardiogram demonstrated moderate to severe aortic insufficiency, though the mechanism could not be delineated. There was concomitant development of mild mitral valve and tricuspid valve insufficiency. She denied dyspnea, chest pain, or fevers. Laboratory investigation showed mild elevation of CRP and a normal ESR. A transesophageal echocardiogram demonstrated that the severe aortic regurgitation was through a paravalvar leak (figure 1). There was no evidence of vegetations. Three separate blood cultures grewC. hominis. The patient was admitted for IV antibiotic therapy prior to bioprosthetic replacement.Conclusions:C. hominisis an infrequent cause of endocarditis and most cases present with fever and elevated ESR. This patient had an unusual presentation with left iliac thrombus, which in retrospect was likely due to embolism of a vegetation. She also developed aortic bioprosthetic paravalvar leak. This case highlights the need for a high degree of suspicion for endocarditis in patients with CHD and bioprosthetic valves.

Circulation, Volume 146, Issue Suppl_1, Page A11377-A11377, November 8, 2022. Introduction:Association of takotsubo syndrome (TTS) with spontaneous coronary artery dissection (SCAD) has been described previously. Characteristics and in-hospital prognosis of SCAD patients with concomitant TTS remain unclear.Methods:Patients with angiography-confirmed SCAD were selected from the iSCAD Registry and underwent core lab adjudication of left ventriculography (LVG) and coronary angiography including assessment of SCAD lesion characteristics, TIMI Flow Grade (TFG), and TIMI Myocardial Perfusion Grade (TMPG). Classic TTS was defined as wall motion abnormality (WMA) presenting as apical ballooning. TTS variants were defined as non-apical WMA discordant to dissected coronary territory with apical sparing. In-hospital event was defined as composite of recurrent myocardial infarction (MI), cerebrovascular accident, heart failure requiring diuretics, or new arrhythmia.Results:On blinded review of LVG from 216 patients, TTS was identified in 38 (17.6%) patients (classic, midventricular, and focal pattern: 86.8%, 2.6%, and 10.5%, respectively). There was no significant difference in age, cardiovascular risk factors, history of anxiety or depression, recreational substance use, emotional or physical stressors, extracoronary vascular abnormalities, peak troponin levels, or TFG of dissected arteries between TTS and non-TTS groups. TTS patients were more likely to present with ST-segment elevation MI (47.4% vs 27.5%; p=0.02), left anterior descending artery (LAD) involvement (89.5% vs 59.0%; p=0.0004), and TMPG < 3 (68.4% vs 48.3%; p=0.02) compared to non-TTS patients. TTS patients had a greater risk of in-hospital events (32.4% vs 15.1%; p=0.01), mainly attributed to new arrhythmia (27.0% vs 6.5%; p=0.0009) and heart failure (11.4% vs 3.0%; p=0.03).Conclusion:Coexistence of TTS and SCAD was associated with ST-elevation MI, LAD involvement, impaired microvascular myocardial perfusion, and adverse in-hospital outcomes.

Circulation, Volume 146, Issue Suppl_1, Page A12536-A12536, November 8, 2022. Introduction:Aortic Dissection (AD) results from a tear between the layers of the aorta. This is often seen among older males or those with heritable connective tissue disorders, and it mostly presents as chest pain. Management involves surgical repair wherein post procedure complications are to be expected. Mediastinitis, or deep sternal wound infection, however, is likewise unusual.Case Presentation:We present a case of a 29-year-old Filipino male presenting with sudden diffuse abdominal pain; he had no comorbidities and had no significant history suggestive of connective tissue disorders. Physical examination was mostly unremarkable. CT Aortogram revealed presence of dissection from the proximal ascending aorta up to the common iliac arteries, with the entry tear measuring 8.5mm at the level of T5, with extension to the proximal branches of the aortic arch, both common carotid arteries, right renal, right internal and external iliac arteries. Echocardiogram also showed a normal aortic valve but with dilated sinus of Valsalva(4.5cm, z-score 5.13). The patient underwent a Modified Bentall Procedure with Cabrol Shunt, with delayed closure of operative site due to extensive bleeding. Cystic medial necrosis was not seen on biopsy. After developing persistent post-operative fever, repeat chest CT showed a fluid collection in the mediastinum encasing the ascending aorta and main pulmonary trunk; culture of abscess fluid was positive forCandida tropicalis. He was then given prolonged parenteral followed by oral antifungal therapy and subsequently discharged improved.Discussion:Vascular causes of abdominal pain should be considered in patients with scant history and physical findings. Major vascular surgery has expected complications such as bleeding and infection; the management of such complications should incorporate a multidisciplinary approach as in such cases, a trial of medical management may be safer than repeat surgery.

Circulation, Volume 146, Issue Suppl_1, Page A10768-A10768, November 8, 2022. Introduction:Ruptured mycotic aortic aneurysm is a relatively rare, life-threatening disease, which is associated with remarkable mortality. In East Asia, mortality caused by this disease is high and it is commonly caused by Salmonella species. Majority of cases of mycotic aneurysms caused by Salmonella were in the abdominal aorta wherein most of them presented with chills and fever while some presented with diarrhea from 2 days to 1 month before the aneurysm was diagnosed. Patients who present with diarrhea and abdominal pain are likely to be missed. It is therefore important that mycotic abdominal aneurysm be recognized early, and prompt treatment be initiated.Case:A 78-year-old American male, Philippine immigrant with history of ischemic stroke and chronic smoking presented with diarrhea and severe abdominal pain. Complete blood count showed leukocytosis with neutrophilic predominance. A computed tomography scan of whole abdomen exhibited a fusiform aneurysm of the infrarenal abdominal aorta with large periaortic hematoma indicating prior rupture. Open abdominal aortic aneurysm repair was successfully done and intravenous Meropenem and Ciprofloxacin were given. Blood, urine, thrombus, and aortic plaque cultures were obtained and all revealed Salmonella specie with same antibiogram. Intravenous Meropenem and Ciprofloxacin was transitioned to intravenous Ceftriaxone and was continued for 6 weeks post-operatively.Conclusion:Mycotic abdominal aortic aneurysm can be diagnosed with the combination of clinical symptoms, laboratory, radiological findings, and intraoperative findings. However, vague and non-specific symptoms do not rule out the diagnosis. High index of suspicion and low threshold for CT imaging is necessary in any patient age >60 years who present with abdominal pain and with previous history of gastroenteritis. Prompt initiation of antibiotic therapy and surgical intervention are the treatment of choice.

Circulation, Volume 146, Issue Suppl_1, Page A12256-A12256, November 8, 2022. Rivaroxaban is a direct oral anticoagulant that works by inhibiting factor Xa. Direct anticoagulants have largely replaced direct vitamin K inhibitors (VKAs) due to the increased risk of major hemorrhages and the need for regular monitoring and dose adjustments. However, there have been multiple reports of elevated international normalized ratio (INR) and incidents of bleeding in patients on rivaroxaban, which brings into question the potential need for monitoring. The purpose of this review is to differentiate the patients that may benefit from regular monitoring and to propose future directions for implementation of monitoring. Here we report a case of an INR of 4.8 in a patient who presented with a gastrointestinal bleed and a drop of five gm/dL in hemoglobin four days after starting rivaroxaban following right femoral popliteal bypass graft stenting. The patient had no liver or kidney abnormalities and was not taking any medication or consuming any foods that could introduce any significant drug interaction. Additionally, we conducted a systematic review of similar reports in the literature with the goal of identifying the factors that could influence rivaroxaban’s levels in the blood or its influence on the INR. We reviewed PubMed using keywords including; “rivaroxaban”, “anti-Xa”, “DOAC”, “elevated”, “INR”, “bleeding”, “hemorrhage”, “pharmacology”, and “pharmacokinetics”. The literature revealed reports of INRs up to 5.2. Reviewing the pharmacokinetics of rivaroxaban indicated possibly higher drug levels in Caucasians, patients with a low body mass index (BMI), and patients with polymorphisms in the genes coding for CYP3A4, CYP2J2, or p-glycoprotein, assuming no renal or liver disease and no significant drug-drug or drug-food interactions. INR can be falsely normal if the thromboplastin reagent used to monitor the INR on warfarin is not sensitive to the changes in INR due to rivaroxaban. We suggest finding a thromboplastin reagent that is sensitive to INR changes with rivaroxaban, which could yield clinically relevant INRs on rivaroxaban allowing for accurate monitoring. We then suggest conducting studies to evaluate the cost effectiveness of regular monitoring in at-risk patients.

Circulation, Volume 146, Issue Suppl_1, Page A13763-A13763, November 8, 2022. Introduction:Transcatheter edge-to-edge repair (TEER) of the mitral valve has become an established therapy for patients with severe mitral regurgitation; however, the impact of institutional variations in the number of edge-to-edge TEER for readmission rates with large-scale data is not well investigated.Objectives:Our study aimed to describe the institutional variations of TEER, and also the association between the institutional volume and readmission rates after the procedure across the US institutions.Methods:We conducted a retrospective cohort study of TEER performed in the US between 2019 using the Nationwide Readmission Database. We divided the patients according to the tertiles based on site-specific case of TEER (Q1 [lowest]-Q3 [highest]) and evaluated its association with 30-day readmission rates using Cox proportional hazard model.Results:Overall, 4,922 patients who underwent TEER (mean age 76.8 ± 11.5 years, and 54.5% male) at 250 institutions were included in the analyses. Patients in Q3 (highest tertile) were more likely to be older, and have comorbidities, albeit risk adjusted 30-day readmission rates were similar in each group (Q1: 13.5%; Q2: 13.6%; Q3: 13.7%). Rather than the volume of the procedure, institutional characteristics, such as teaching hospitals located in metropolitan area (hazard ratio [HR 1.92, confidence interval [CI] 1.41-2.61) and institutions with predominantly non-elective (e.g. urgent or emergent) TEER cases (HR 1.75 95% CI 1.39-2.22), or patient characteristics such as chronic heart failure (HR 1.91 95%CI 1.33-2.73), cancer (HR 1.87 95%CI 1.15-3.06), chronic kidney disease (HR 1.45 95% CI 1.20-1.75), chronic pulmonary disease (HR 1.40 95% CI 1.13-1.72), diabetes mellitus (HR 1.39 95% CI 1.12-1.72), and history of percutaneous coronary intervention (HR 1.37 95% CI 1.07-1.76) were associated with a higher incidence of 30-day readmission.Conclusions:Among patients undergoing TEER in a contemporary representative US cohort, procedure volume variation was not associated with the 30-day readmission rate.