Risultati per: Short Acting Opioid

Circulation, Volume 146, Issue Suppl_1, Page A11768-A11768, November 8, 2022. Introduction:Despite early mitigation efforts, the opioid pandemic in the United States has persisted and affected many Americans. A public health emergency was declared regarding opioid prescriptions. Alternative approaches to postoperative pain control after transvenous cardiac device implants (TCDI) in adults have not been described.Methods:We report a single center retrospective analysis of 153 consecutive patients that underwent TCDI from January to August 2021 with ultrasound guided pectoral nerve block (PNB) using liposomal bupivacaine prior to implant for postoperative pain control. Pain scores (0-10) were recorded systematically during recovery, at discharge, and at wound check follow up. Opioid use in the postoperative period was recorded as well.Results:A total of 153 patients were evaluated, 50% female with a mean age of 71.2 years. All patients received PNB successfully with no device site infection or hematoma. The mean Visualized Analog Scale (VAS) pain scores at 1, 3, and 5 hours after the procedure, at discharge, and at follow up were 1.93, 1.22, 1.10, 1.05, and 0.125 respectively. No patients required opioids for pain control throughout the average postoperative period of 14 days.Conclusion:Pectoral nerve block with liposomal bupivacaine can be administered safely before TCDI and provides adequate pain control without need for opioid use postoperatively. Further research is needed to assess broad scale implications of this approach to larger patient populations.Figure 1: Ultrasound Guided PNB, pectoralis major (PM), pectoralis minor (Pm)Graph of the average postoperative pain score and opioid use during follow up visit over time

Circulation, Volume 146, Issue Suppl_1, Page A13282-A13282, November 8, 2022. Introduction:Opioids are commonly used to treat pain and agitation in the cardiac intensive care unit. However, responsiveness to opioids in pediatric patients is poorly understood, and few guidelines exist for personalized management of sedation. This leads to probable overprescription of opioids in the pediatric ICU, which can extend length of stay and have negative long-term health consequences. In this work, we build a decision support tool to predict a patient’s response to an opioid bolus measured by the state behavior scale (SBS), using available patient data at the time of administration.Methods:We built a dataset including all individual doses of morphine administered to patients admitted to the CICU between 2011-2020. Patients missing critical hemodynamic or SBS data were excluded from the analysis. The change in SBS score before and after morphine administration was converted to a binary outcome, where a decrease in SBS score was considered to be favorable (A). A LASSO regression model was trained to predict SBS response. The predictors utilized in the model included demographics, hemodynamic data, SBS score measurements before morphine, concomitant drug infusions/boluses and morphine response to prior doses. The model was trained on 80% of data and evaluated on 20%.Results:Of 197,242 intravenous boluses, 66,195 boluses administered to 6,021 patients (median age 7.2 mo) were included. The median change in SBS score was 0 (IQR -1 – 0) with 33% of administrations classified as favorable responses. The model coefficients are shown in (B). The model predicts 74% of unfavorable morphine responses with 95% confidence, AUC = 0.899 (C).Conclusions:Nearly three-quarters of ineffective responses to morphine can be predicted with 95% confidence using the prediction models developed. Such models could substantially reduce morphine over-administration for critically ill patients in the pediatric cardiac ICU.

Circulation, Volume 146, Issue Suppl_1, Page A15871-A15871, November 8, 2022. Introduction:Discrimination may contribute to sleep disparities, and subsequent adverse cardiovascular health. Despite the higher prevalence of insomnia among women, particularly historically minoritized women compared to men, limited studies examine the association between discrimination and insomnia and sleep duration.Methods:Among 26,616 women (Race/Ethnicity: Asian = 323; Black = 457; Hispanic= 258; White=25,287) in the Women’s Health Study stress follow-up cohort (Mean age =72.3+6.1 years), we investigated the relationship of discrimination with insomnia and sleep duration and tested education and income as effect modifiers. Insomnia was self-reported as trouble falling asleep OR waking after sleep onset 3+/week and daytime sleepiness 3+/week. Sleep duration was defined according to weekday and weekend bed and wake times, and categorized as short (7 and 9 hours). Everyday discrimination (e.g., treated with less courtesy or respect, received poorer service, etc.) frequency was divided into tertiles then dichotomized as high (upper tertile) and low (lower & middle tertile).Results:Insomnia, and short and long sleep duration were reported by 11%, 11%, and 15% of women, respectively, and high levels of discrimination were reported by 40% of women. There was a higher proportion of Asian and Black women who reported high discrimination compared to Hispanic and White women (53.2% and 57.3% vs 39.8% and 38.4%, respectively). Women reporting high vs. low discrimination were more likely to have insomnia and short sleep duration, but less likely to have long sleep [Insomnia Adjusted Prevalence Ratio (aPR): 1.33, 95% CI: 1.28-1.38; Short Sleep (aPR): 1.14, 95% CI:1.09-1.19; Long Sleep (aPR): 0.96, 95% CI: 0.95-0.97)]. Associations of discrimination with insomnia and short sleep duration were pronounced among Hispanic and White, but not Asian and Black women, and those of higher education ( >bachelors vs $50,000 vs

Circulation, Volume 146, Issue Suppl_1, Page A15084-A15084, November 8, 2022. Introduction:In patients at high bleeding risk (HBR), a short dual antiplatelet therapy (DAPT) duration after coronary stenting has been associated with fewer bleeding events and preserved ischemic protection. Whether these effects are maintained in diabetic patients is unclear.Purpose:To assess the safety and efficacy of 1- versus 3-month DAPT after percutaneous coronary intervention (PCI) with stent implantation among HBR patients with or without diabetes.Methods:We included patients from three prospective, international, single-arm studies (XIENCE Short DAPT Program), which enrolled HBR patients successfully treated with a fluoropolymer-based cobalt-chromium everolimus-eluting stent (XIENCE, Abbott). Subjects were eligible for DAPT discontinuation at 1 month (XIENCE 28 USA and Global) or at 3 months (XIENCE 90), if free from ischemic events and adherent to DAPT. The primary endpoint was the composite of all-cause death or any myocardial infarction (MI). The key secondary endpoint was Bleeding Academic Research Consortium (BARC) type 2 to 5 bleeding. Outcomes were assessed between 1 and 12 months after index PCI using propensity score adjustment.Results:Out of 3,352 patients, 1,299 (38.8%) had diabetes. The rate of death or MI at 12 months was higher in diabetic than in non-diabetic patients (10.1% vs 6.6%) while the rate of BARC 2-5 bleeding was similar (9.5% vs 9.2%). A one v. three months of DAPT duration resulted in a borderline reduction in death or MI (adj. HR 0.70, 95% CI 0.47-1.05) in diabetic but not in non-diabetic patients (adj. HR 1.24, 95% CI 0.86-1.79; p-interaction=0.016) and fewer BARC 2-5 bleeding in both groups (adj. HR 0.67, 95% CI 0.45-1.01 and adj. HR 0.77, 95% CI 0.56-1.06, respectively; p-interaction=0.950).Conclusions:Among HBR patients undergoing everolimus-eluting stent implantation, diabetic patients derive important benefit in reducing death and MI and bleeding events from a one month compared with three-month DAPT duration.

Circulation, Volume 146, Issue Suppl_1, Page A14446-A14446, November 8, 2022. Regulated cell death is an essential piece of normal development and maintenance of tissue homeostasis, wherein BCL2 like 1 (BCL2L1) protein is involved in key signaling pathways. Alternative splicing in exon 2 ofBcl2l1produces Bcl-x short (Bcl-xS) isoform. However, mutations in around 5’ splice site are classified as variants of uncertain significance in humans, and the isoform-specific role of endogenous Bcl-xS remains largely unexplored. Here we show the role of Bcl-xSin vivoby generating the mice with a mutation in 5’ splice site of theBcl2l1that inhibits Bcl-xS alternative splicing. Although loss of BCL2L1 leads to embryonic lethal with massive cell death, Bcl-xS knockout (KO) mice were born at a mendelian ratio and showed no overt abnormality until 3 months of age. Thereafter, the KO mice developed cardiac hypertrophy (heart weight/tibia length, 8.59+/-0.308 vs 11.61+/-0.631,p= 0.0005 and 2.13-fold increase in individual cardiomyocyte size,p= 0.0001) with contractile dysfunction (EF, 69.25+/-1.31 vs 56.57+/-3.07,p= 0.0028) and splenomegaly (spleen weight/tibia length, 5.32+/-0.25 vs 7.12+/-0.49,p= 0.0051) at 6 months of age. Despite that overexpression of Bcl-xS induced cell death in cardiomyocytes (2.497-fold compared to LacZ,p< 0.0001), there was unexpectedly no overt difference in the level of apoptosis in the KO heart (TUNEL, 0.033+/-0.003 vs 0.030+/-0.002 %,p= 0.359), but fibrosis was significantly increased in the KO heart (1.602+/-0.095 vs 2.340+/-0.145 %,p= 0.0017). Diabetes was not evident in the KO mice (blood glucose, 169.8+/-10.9 vs 153.3+/-8.46 mg/dl,p= 0.2595). Mechanistically, we found that the Akt/mTOR and JNK/cJun signaling are activated in the KO heart and the JNK/cJun signaling is activated with increased Bax expression in the KO spleen. These results suggest that Bcl-xS may be dispensable for development, but is essential for maintaining homeostasis of multiple organs, especially cardiosplenic network, in a tissue-dependent mechanism.

Circulation, Volume 146, Issue Suppl_1, Page A12107-A12107, November 8, 2022. Background:Short-term (

Circulation, Volume 146, Issue Suppl_1, Page A15102-A15102, November 8, 2022. Background:Non-ischemic cardiomyopathies (NICM) occur in the absence of contributory coronary artery disease or significant valvular heart disease. This study examined if VT recurrence post-scar-homogenization in NICM patients was due to progression of the disease after successful ablation or incomplete ablation during the index procedure.Methods:Consecutive NICM patients receiving redo procedure after their 1st VT ablation were included. All patients underwent bipolar substrate mapping with standard scar settings of normal tissue >1.5 mV and severe scar

Circulation, Volume 146, Issue Suppl_1, Page A9881-A9881, November 8, 2022. Background:Sleep-disordered breathing (SDB) and blood pressure (BP) variability are closely associated with cardiovascular diseases. We have recently reported that pulse-transit-time (PTT) has enabled to monitor the beat-to-beat BP, identifying a strong relationship between the severity of SDB and the extent to very short-term BP variability. Here, we investigated the effects of continuous positive airway pressure (CPAP) on very short-term BP variability.Methods:We studied 57 patients (mean age 61 years old, male 42) with SDB who underwent the full polysomnography on two consecutive days for diagnosis (baseline) and CPAP. PTT was continuously monitored together, and PTT-based BP values were measured on a beat-to-beat basis. PTT index was defined as the average number of acute transient rises in BP (≥12 mmHg) within 30 seconds per hour.Results:Apnea-hypopnea index (AHI) was decreased from 46.5±22.4 to 13.7±15.0 (P

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.

Circulation, Volume 146, Issue Suppl_1, Page A11138-A11138, November 8, 2022. Introduction:Patients with a ST-Elevation Myocardial Infarction (STEMI) and concomitant lung cancer are an understudied cohort. In this study, we explore the in-hospital outcomes of STEMI patients with and without lung cancer.Methods:We queried the National Inpatient Sample database (2016-2019) to identify patients admitted with a principal diagnosis of STEMI and secondary diagnosis of lung cancer. We conducted propensity score matching using a greedy nearest neighbor 1:1 model. Multivariable logistic regression was used to compare mortality.Results:7020 patients met our inclusion criteria. Patients with a STEMI and lung cancer had 1.84 times higher odds of suffering in-hospital mortality compared to STEMI patients without lung cancer (aOR 1.84, 95% CI: 1.55-2.17; p < 0.001). When separated by race, STEMI patients with lung cancer had a higher mortality rate amongst White (11.5% vs 6.5%, p < 0.001) and Black (11.9% vs 6.5%, p = 0.03, Figure 1) patients. STEMI patients with lung cancer were less likely to undergo percutaneous coronary intervention (22.3% vs 32.0%, p < 0.001). There was no difference in intraoperative and postoperative cardiac arrest, cerebral infarction and respiratory failure. Additionally, STEMI patients with lung cancer had longer hospital stays (4.9 days vs 4.4 days, p < 0.001, Table 1).Conclusions:Patients with a STEMI and lung cancer had higher odds of suffering in-hospital mortality compared to patients with a STEMI without lung cancer. Our findings emphasize the importance of risk-benefit analysis and collaborative discussion amongst the care team prior to choosing the appropriate treatment modality.

Circulation, Volume 146, Issue Suppl_1, Page A11087-A11087, November 8, 2022. Introduction:The impact of frailty on short-term and long-term outcomes in a contemporary STEMI population is unclear. We hypothesized that in STEMI patients undergoing primary percutaneous coronary intervention (pPCI) frailty would be independently associated with adverse in-hospital and 1-year outcomes.Methods:We retrospectively identified 1,579 STEMI patients aged ≥ 65 years who had received pPCI (2007 – 2020). A frailty index (FI) was determined using the health deficit accumulation model (Table 1). Frail patients were defined as those with a FI > 0.25. The primary outcome was 1-year all-cause mortality. The composite adverse outcome comprised in-hospital all-cause mortality, cardiogenic shock, heart failure, re-infarction, major bleeding, or stroke. A multivariable model adjusting for age, sex, heart failure on presentation, infarct territory, prolonged reperfusion time, initial heart rate, and systolic blood pressure was performed.Results:There were 228 (14.4%) frail patients. Compared to non-frail patients, frail patients were older (mean 80.3 vs. 75.3 years, p < 0.001) and had a higher comorbidity burden. After multivariable adjustment, baseline frailty was independently associated with increased 1-year all-cause mortality, in-hospital all-cause mortality, and the composite adverse outcome (Figure 1).Conclusions:In conclusion, among STEMI patients receiving pPCI, frailty was common and was independently associated with increased in-hospital and long-term adverse outcomes. These findings raise the need for early recognition of frailty and implementation of a comprehensive care model towards the management of frail patients.

Circulation, Volume 146, Issue Suppl_1, Page A13963-A13963, November 8, 2022. Introduction:Torsade de Pointe (TdP) is defined as a polymorphic VT (pVT) typically associated with QTc prolongation. However, not all pVT occur in the presence of QTc prolongation and respond to different forms of therapy. Hence defining their etiology is important.Case:A 48-yo Female with H/O resolved peripartum cardiomyopathy, hypertension & obesity presented to the hospital following a syncopal episode. Her BP was 207/125 mmHg, and ECG showed sinus rhythm with a QTc of 436. No history of heart disease or SCD in her family. Physical exam was unremarkable, labs showing K-3.2 without troponin elevation. On day 2, she developed a pVT requiring defibrillation and amiodarone. Telemetry revealed a PVC causing R on T phenomenon with a coupling interval of 260 msec prior to initiation of SVT with QTc 484 and K-2.8. On day 3, despite electrolyte correction, she had multiple non-sustained pVTs with QTc 482. Amiodarone was switched to lidocaine and QTc normalized to 447. TTE and LHC were unremarkable with a small LV aneurysm on cMRI. On day 4, the patient continued to have incessant runs of pulseless pVT requiring defibrillation and started on verapamil. A 12 lead ECG during VT demonstrated left bundle branch mimicry with a left axis consistent with a VT exit site along the RV moderator band. The patient underwent emergent ablation with targets along the right anterolateral papillary muscle. AICD was placed prior to discharge.Discussion:The critical timing of PVC falling on the peak of the preceding T wave differentiates ‘Short-coupled TdP’ from other malignant VTs with normal QTc. These PVCs typically originate from distal ramifications of Purkinje fibers in both ventricles. PVC morphology with LBBB pattern, left axis and late precordial R-S transition points to the moderator band as the source of idiopathic VT. Contrasting with typical TdP, medical management with Quinidine and Verapamil may be efficacious. Catheter ablation is curative in most cases.

Circulation, Volume 146, Issue Suppl_1, Page A13503-A13503, November 8, 2022. Background:Short-term variability of repolarization derived from the QT-interval (STV-QT) has previously been demonstrated to increase prior to arrhythmias in both humans and animals. To continuously monitor the arrhythmic risk by a cardiovascular implantable electronic device (CIED), a fully automatic method to determine STV on intracardiac electrograms (STV-EGMauto) has been developed. This method demonstrated high effectiveness in monitoring and predicting Torsade de Pointes arrhythmias in the CAVB dog model. However, this technique has not been evaluated in arrhythmias related to ischemia yet.Purpose:To assess the novel automatic method of arrhythmic risk monitoring by CIEDs through STV-EGMautomeasurements in a porcine model of ischemia-induced ventricular fibrillation (VF).Methods:Myocardial infarction was induced in 8 anesthetized pigs by balloon occlusion of the left anterior descending coronary artery for 75 minutes, followed by reperfusion. Monitoring included a 12-lead ECG and a duodecapolar EGM catheter in the right ventricle. STV-EGMautoand STV-QT, our gold standard calculated by the method of fiducial segment averaging, were assessed at baseline, occlusion, one minute before VF and just before VF. The STV values and the percentual changes from baseline to the successive three timepoints were compared between STV-EGMautoand STV-QT.Results:VF occurred 21±8.8 minutes after occlusion. Both STV-EGMautoand STV-QT increased significantly from baseline to VF (1.1±0.8 msvs2.4±1.5 ms, p

Circulation, Volume 146, Issue Suppl_1, Page A331-A331, November 8, 2022. Background:Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is one of effective therapeutic modalities for patients with cardiogenic shock (CS) and acute coronary syndrome (ACS). While VA-ECMO maintains end-organ perfusion, it increases damaged left ventricular (LV) wall tension. Combined treatment of VA-ECMO and a micro-axial Impella pump, referred to as ECPELLA, simultaneously provides systemic circulatory support and LV unloading. However, it remains unknown whether LV unloading effect on ECPELLA support further reduces mortality compared to currently available VA-ECMO+IABP support.Purpose:Investigate whether ECPELLA can reduce mortality in ACS patients with severe cardiogenic shock who required VA-ECMO.Methods:From January 2012 to May 2022, 100 consecutive patients with ACS and CS who received VA-ECMO before or after percutaneous coronary intervention were enrolled. Patients were divided into two groups; 39 patients in the ECPELLA; and 61 patients in the VA-ECMO with IABP. We assessed peak serum CPK-MB levels and 30-day mortality.Results:There were no significant differences in age, rate of male sex, coronary risk factors, ST-elevated ACS, left main trunk (LMT) lesion, multi-vessel disease (MVD), number of coronary lesions, extracorporeal cardiopulmonary resuscitation, and the time from onset to reperfusion between two groups. The ECPELLA had lower peak CPK-MB levels compared to VA-ECMO with IABP, but the difference did not reach statistical significance (p=0.056). Kaplan-Meier analysis revealed that the ECPELLA had significantly lower 30-day mortality (p=0.0016). Multivariable Cox proportional hazard analysis revealed that ECPELLA (HR: 0.22 95% confidence interval:0.11-0.45; p

Circulation, Volume 146, Issue Suppl_1, Page A15646-A15646, November 8, 2022. Introduction:Ablation is a cornerstone of therapy for atrial fibrillation (AF), as well as one of the most common procedures in electrophysiology. Use of intermediate-power ablation has given way to high-power short duration radiofrequency ablation. However, more recently the emergence of very high-power very short duration (vHPvSD) ablation at 90W may prove to be more efficient and effective in the management of AF. The radius of the resistive heating zone is increased, while the conductive heating zone tapers off more quickly, potentially reducing collateral tissue damage.Methods:This was a single centre prospective study using the QDOTTM(Biosense Webster, Irvine, California) ablation catheter. Our workflow involves double trans-septal puncture via TOE guidance, use of a deflectable sheath, LASSO 10-pole mapping for first time AF ablations or PENTARAYTMfor redo procedures, ablation while paced in sinus rhythm were possible, general anaesthetic, low tidal volumes, and an I:E ratio of 1:4. All pulmonary vein isolations (PVI) and posterior wall isolations (PWI) were performed at 90W for 4s, while cavo-tricuspid isthmus (CTI) lines were completed using QMode at 40W for 20s.Results:65 patients under went vHPvSD for treatment of atrial fibrillation. Of these 12 were re-do cases that had previously been treated with either radiofrequency or cryo-ablation. The average age was 58.9±9.7 (yrs) with 73% males. Paroxysmal atrial fibrillation was seen in 69%, 31% had persistent AF, and 7% had co-morbid atrial flutter. The average CHADSVASC score was 1.18±1.03. Pulmonary vein isolation was achieved in 100% of patients, 10% had posterior wall isolation, and 16% underwent cavo-tricuspid isthmus ablation. Average skin-to-skin and total ablation times were 58.2±13.1 (mins) and 23.4±6.5 (mins), respectively. Average RF time was 8.1±0.7 (mins). Mean follow up was 126±21 days, where 2 recurrences were seen. We saw no complications in our patient cohort.Conclusions:The method of vHPvSD is safe and durable in the treatment of atrial fibrillation. Total procedure time and RF time were significantly lower than previous RF ablation therapies. This relatively large study on the safety and early efficacy of vHPvSD adds to the emerging data on this promising technology.

Circulation, Volume 146, Issue Suppl_1, Page A12402-A12402, November 8, 2022. Introduction:Doxorubicin-mediated adverse cardiovascular events are among the leading causes of morbidity and mortality in breast cancer patients. Sacubitril-valsartan (LCZ 696) is a combination drug, made up of neprilysin inhibitor sacubitril and angiotensin II receptor blocker valsartan, used for the treatment of heart failure in patients with a reduced ejection fraction.Hypothesis:We hypothesized that LCZ 696, administered during doxorubicin, could improve cardiac functionMethods:Female C57Bl/6 mice were untreated (Sham, n=6) or treated for 10 days with doxorubicin i.p at 2.17 mg/kg (DOXO, n=6), LCZ-696 at 60 mg/kg (LCZ, n=6) or doxorubicin combined to LCZ-696 (DOXO-LCZ, n=6). Ejection fraction, radial and longitudinal strain were analyzed through transthoracic echocardiography (Vevo 2100). Cardiac tissue expression of NLRP3 inflammasome, Myd88, DAMPs (galectine 3 and calgranulinS100) , pAMPK, NF-kB, and 13 chemokines (IL-1α, IL-1β, IL-2, IL-4, IL-6, IL-10, IL-12, IL17-α, IL-18, IFN-γ, TNF-α, G-CSF, and GM-CSF) were quantified through ELISA and western blot methods.Results:LCZ 696 improved significantly the EF and prevented the reduction of radial and longitudinal strain after 10 days of treatment with doxorubicin. A reduced expression of NLRP3, MyD88, DAMPs and NF-kB in cardiac tissues was seen in DOXO-LCZ group compared to DOXO mice (p