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Circulation, Volume 146, Issue Suppl_1, Page A11421-A11421, November 8, 2022. Background:Transcatheter Aortic Valve Implantation (TAVI) is associated with 2-3% clinical stroke rate and much higher incidence of silent cerebral infarction. This study investigated the neuroprotective benefits of minimising air emboli in TAVI. It aimed to demonstrate a reduction in vascular brain injury by flushing TAVI valves with CO2and saline compared to saline only as per standard practise.Methods:Patients undergoing transfemoral TAVI for aortic stenosis were enrolled. Patients were randomised to CO2and saline (TAVI-CO2) versus saline only (TAVI-S) flushing of TAVI valves during preparation. Patients underwent MRI brain following TAVI to identify new cerebral infarcts and any reduction in vascular brain injury by reducing air emboli.Results:Twenty-Two patients were enrolled in the study with a mean age of 79±10 years. Fifteen (68%) were males. Nine patients (41%) had history of hypertension, 5 (23%) had previous cerebrovascular disease and 5 (23%) had diabetes. Two (9%) patients did not have their TAVI valve implanted and hence were excluded. No patients had any procedural related complications. Three (14%) patients required permanent pacemaker insertion post procedure and could not have their MRI. Fifteen patients (68%) had MRI brain post-TAVI, 7 patients in the TAVI-CO2group and 8 patients in the TAVI-S group. TAVI-CO2group had a total of 41 new cerebral lesions compared to 66 lesions in TAVI-S group. TAVI-CO2had on average 6.80 new lesions/patient compared to 8.25 lesions/patients in TAVI-S (p=0.34) Cerebral infarcts were also analysed according to valve type. In self-expanding valves (n=7), TAVI-CO2had 8 lesions/patient compared to 10 lesions/patient in TAVI-S (p=0.46). In balloon-expanding valves (n=8), TAVI-CO2had 4.25 lesions/patient compared to 6.25 lesions/patient in TAVI-S (p=0.25).Conclusion:There is a trend in the reduction in the number of new cerebral lesions in the TAVI-CO2arm compared to the TAVI-S patients. This is the first study that identifies the importance of air emboli in TAVI and the associated potential vascular brain injury. As brain injury remains a significant concern during TAVI, a larger randomised trial is required to further investigate the neuroprotective benefit of flushing TAVI valves with CO2.

Circulation, Volume 146, Issue Suppl_1, Page A14760-A14760, November 8, 2022. Introduction:Although several studies have demonstrated that elevated troponin predicts mortality in septic patients, data concerning the independent risk factors predisposing to higher chance of troponin leak are conflicting.Hypothesis:In this study we aim to identify predictors of troponinemia and lactatemia in the setting of sepsis and more specifically to clarify how hemodynamics affect these biomarkers.Methods:This is a retrospective cohort study on patients admitted to the intensive care units with severe sepsis. A total of 354 patients were included. Elevated admission troponin-T and lactate were defined as ≥0.01ng/mL and 2.5mmol/L respectively. Modified shock index defined as heart rate/mean arterial blood pressure (MSI) was used as a surrogate of hemodynamic instability. Linear regression models where generated to examine multi variate associations and Cox regression models were used for mortality outcomes. Analysis was done using STATA I/C 16.1.Results:The only independent predictor of elevated troponin in the setting of septic shock was pre-existing coronary artery disease (Coef.= 6 [1.9 – 10] p = 0.001). Troponin was not associated with mean arterial pressure (MAP) nor Modified Shock Index (Heart rate/MAP). On the other hand, elevation of lactate was significantly associated with Modified Shock index (Coef.=1.7 [CI 0.4 – 3] p= 0.001) and history of Diabetes (Coef.=1.2[0.04-2.3] p= 0.04). In a Cox regression modeling assessing for predictors of mortality in septic shock, lactate levels were strongly associated with death (OR= 1.17 [1.12-1.2] p= 0.0001) followed by male sex (OR= 1.8 [1.02-3] p=0.04) and Modified Shock Index (OR=1.5 [1.23-3.2] p=0.03) but troponin leak failed to show any correlation with mortality.Conclusions:Troponin leak is associated only with pre-existing CAD, not associated with hemodynamics and does not predict mortality.

Circulation, Volume 146, Issue Suppl_1, Page A15817-A15817, November 8, 2022. Introduction:In the current United States Organ Sharing heart transplant allocation system, hemodynamic criteria, systolic blood pressure (SBP), cardiac index (CI), and pulmonary capillary wedge pressure (PCWP), are utilized to justify certain listing statuses.Hypothesis:We sought to identify how currently utilized, and advanced, hemodynamics discriminated patients by listing status.Methods:Retrospective analysis of the Scientific Registry of Transplant Candidates including all adults listed for heart transplant since the updated listing criteria went live in October 2018 was completed. In addition to SBP, CI, and PCWP, the mean advanced hemodynamic metrics of aortic pulsatility index (API), cardiac power output (CPO), left ventricular stroke work index (LVSWI), right ventricular stroke work index (RVSWI), and pulmonary artery pulsatility index (PAPI), were calculated for each status.Results:Since October 2018, 9,418 patients were listed for heart transplant, and 8,636 had complete hemodynamic data at time of listing. Currently utilized hemodynamic metrics failed to discriminate lower acuity statuses (3 through 6 for PCWP and CI; 4 through 6 for SBP). For advanced hemodynamic metrics, mean API was lowest for Status 1 patients, and rose consistently with increasing status with a clear stepwise and statistically significant difference for sequential statuses (p < 0.001). CPO and LVSWI were unable to discriminate statuses 3-6. For right-sided hemodynamics, PAPI was unable to discriminate statuses 2 through 6, and there were no significant differences across any status for RVSWI.Conclusions:API is the only hemodynamic metric that is able to differentiate patients on the heart transplant waiting list across all active statuses by increasing in a stepwise fashion. Incorporation of API into future iterations of the UNOS heart allocation system may help better risk stratify patients and minimize waitlist mortality.

Circulation, Volume 146, Issue Suppl_1, Page A14458-A14458, November 8, 2022. Introduction:We present a case of a 65 year-old man with severe aortic regurgitation requiring a stented 23mm Edwards bioprosthetic aortic valve (BioAVR), who presented with 3-months of fevers and fatigue found to haveStreptococcus gordonii(S. gordonii) infectious endocarditis (IE). He underwent dental cleaning 3-months prior sans prophylactic antibiotics. An echocardiogram on admission revealed increased peak/mean systolic gradients across the BioAVR to 46/26mmHg compared to gradients one year prior (32/19mmHg). Initially, a vegetation was not visualized by transthoracic echocardiogram (TTE) despite radiographic evidence of multi-organ emboli. Serial TTEs and transesophageal echocardiograms (TEEs) were performed due to persistent symptoms. Eventually, a new vegetation was visualized by TEE. A team effort involving cardiology, infectious disease, neurology, and cardiac surgery was required for management. Revision of the BioAVR was not pursued due to resolution of the vegetation. The patient was discharged after a prolonged hospitalization with recommendations to take amoxicillin 2g prior to future dental work.Results:Figure 1. A new 0.5cm vegetation visualized by TEE (A) with enlargement to 0.8cm (B), followed by a healed vegetation (C), and resolution 7-months later.Conclusions:S. gordoniihas historically been a rare cause of IE therefore requiring a high clinical suspicion for diagnosis. Approximately 8% of IE cases are caused by streptococci. However, a recent study in Denmark on streptococci IE implicatedS. gordoniiin 44.2% of IE cases. S. gordoniiis a gram-positive cocci found in oral flora known to cause subacute bacterial endocarditis. Our case highlights the importance of detailed history-taking to identify sources of infection, serial multi-modal imaging evaluation despite initial negative findings particularly with persistent clinical symptoms, and a multidisciplinary approach to IE cases due to multi-organ involvement.

Circulation, Volume 146, Issue Suppl_1, Page A11381-A11381, November 8, 2022. Introduction:Previous studies indicate that dietary omega-3 polyunsaturated fatty acids (PUFA) are modifiable risk factors for CVD and cognitive decline. This study aimed to investigate the association between serum and dietary omega-3/omega-6 PUFA ratio and cognitive function were measured in a general population.Hypothesis:We assessed the hypothesis that the serum and dietary omega-3/omega-6 PUFA ratio preserve a cognitive function. Method: A total of 976 residents (381 males, 595 females, mean age 62.6 years) underwent a physical examination, a nutrition survey and the mini-mental state examination as an evaluation of cognitive function in 2009 and followed up in 2018.Results:The serum omega-3/omega-6 ratio were significantly associated with age (p < 0.0001), sex (male, p <0.0001), MMSE ( p < 0.0001), LDL-c ( inversely, p < 0.01), and salt intake ( p < 0.05), using by multiple stepwise regression analysis. The dietary intake of proteins from fish ( p < 0.0001), trace elements, ( p < 0.01), vitamin D, B6, B12 ( p <0.0001), and salt ( p < 0.0001) showed dose dependent relationships with the serum omega-3/omega-6 ratio using analysis of covariance. Subjects were divided into 4 groups according to their progression of cognitive decline in 10 years. Serum omega-3/omega-6 ratio of group with normal cognitive function (NC) were significantly higher than those of group with cognitive decline (CD) (p < 0.05). However, dietary intakes of omega-3 and omega-6 PUFA were not significant. Interestingly, salt intakes in group with CD were higher than those in group with NC (p < 0.05). The logistic regression analysis revealed that salt intakes was associated with cognitive decline 10 years later after adjustments for confounding factors (odds ratio, 1.1; 95% C.I., 1.01-1.13; p = 0.01) In conclusion, the present study demonstrated that omega-3 PUFA may preserve a cognitive function and excessive intakes of salt may have an adverse effect on cognitive function.

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 A11018-A11018, November 8, 2022. Introduction:Wearable devices such as smartwatches and fitness trackers are widely used. While marketed to consumers for general wellness, many devices measure physiologic parameters with implications for cardiovascular health. The prevalence of wearable device use in contemporary patient populations is unknown. We sought to 1) determine characteristics of current and prospective device users within a large healthcare system and 2) assess user interest in incorporating device data into the electronic health record for clinical research purposes.Methods:Participants were selected from a database of adults aged ≥ 18 years who received longitudinal primary or cardiac care at one of 11 hospitals within the Mass General Brigham network between 1/2010 and 7/2021. We identified living patients with an active electronic portal account for direct communication. Portal users were invited to complete a survey about use and medical applications of wearable devices. Multivariable logistic regression was used to identify factors associated with device use.Results:Between 11/2021 and 4/2022, 214,935 patients were contacted with 10,947 (5%) unique survey respondents. Rates of device use were similar among primary care (56%, n=4,739) and cardiology (53%, n=2,190) patients. Almost all non-users (97%, n=4,540) reported that they would use a device if not for cost. In a multivariable model, factors associated with device use included: age (odds ratio [OR] per 5-year increase 0.89, 95% CI [0.87,0.90]), female sex (1.19 [1.09, 1.29]), cardiac vs primary care (1.27 [1.16, 1.39]), median household income by zip code (OR per 1-standard deviation increase 1.10 [1.06, 1.15]), and better self-reported health (OR for “excellent” vs “poor” health 3.35 [2.27, 4.99]). Almost all users and potential users (96%, n=9,811) would share device data with researchers studying health outcomes.Conclusion:Among survey respondents, younger age, female sex, cardiac care, higher income, and better self-reported health were associated with wearable device use. Current and prospective device users are interested in sharing longitudinal data, which will enable further study of wearable devices and their role in care delivery, clinical outcomes, and health disparities.

Circulation, Volume 146, Issue Suppl_1, Page A15382-A15382, November 8, 2022. Introduction:Transthyretin amyloid cardiomyopathy (ATTR) is thought to be a rare cause of HF, but recent studies showed this is the cause of 30% of HFpEF patients older than 75. With new treatments for amyloidosis, timely diagnosis has become critical.Case:A 78-female with HFpEF, HTN, and diabetes followed for progressive functional decline and hospitalizations for HFpEF exacerbations. EKG at baseline showed LBBB with normal QRS voltages. Serial echocardiogram (echo) showed an ejection fraction (EF) of 60-70%, mild LVH, and moderate TR with RVSP >50 mmHg. Latest echo showed progressive LA enlargement, MR, a new small pericardial effusion, and EF 50%. Regadenoson nuclear scan showed normal perfusion with preserved LVEF. Despite adequate control of her HTN, dyspnea continued to worsen. Because of this, the diagnosis of Cardiac amyloidosiswas considered. Further review revealed a history of Carpal Tunnel Syndrome (CTS) and speckled pattern within the ventricular wall on echo. A technetium pyrophosphate scintigraphy (99mTc-PYP) confirmed ATTR with grade three uptake, AL amyloid was ruled out with normal SPEP/UPEP, and she was started on Tafamidis.Discussion:Cardiac amyloidosis should be considered in HFpEF patients with functional decline despite medical optimization. It can mimic LVH caused by HTN on echo and easily dismissed in patients with traditional risk factors, but presence of CTS or lumbar spinal stenosis can be supportive. Traditionally ATTR is associated with low-voltage EKG, however this patient presented with normal QRS voltages for years, making the diagnosis more elusive.Conclusion:Advances in noninvasive imaging and treatments allow for early diagnosis of cardiac amyloidosis, reducing morbidity and mortality. Diagnosis is often delayed or missed, as features could be subtle and mimic other more common cardiac disease. Screening 99mTc-PYP for elderly patients with HFpEF could translate to improved outcomes

Circulation, Volume 146, Issue Suppl_1, Page A183-A183, November 8, 2022. Introduction:Cardiac arrest (CA) co-survivors i.e., close family members of CA survivors, have high levels of caregiver burden and poor quality of life. We aim to prioritize potential patient-, and co-survivor-centric interventions that may alleviate caregiver burden.Methods:We distributed an online survey to adult, co-survivor members of the Sudden Cardiac Arrest Foundation and Parent Heart Watch national databases and CA-specific Facebook groups. Participants provided demographics, details on their loved ones’ CA, and their caregiving role. They then ranked their top choice among 8 unique interventions focusing on either patient-centric education-based needs (n=4) or co-survivor-centric resources for self-care and enhanced psychological support (n=4). The survey was developed by a multidisciplinary research team and patient and co-survivor stakeholders.Results:Of 657 responses received, 550 co-survivors (57% were between the age of 18-40 years, 65% were women, 51% of minority race/ethnicity, 53% partners or spouse, an average of 8 hours of caregiving, for an average of 5 months) with the complete ranking data, were analyzed. A total of 347 (63%) co-survivors ranked patient-centric education-based interventions as their top choice (Figure 1 shows distributions). A multivariate model estimating the drivers of preferences for education-based interventions over co-survivors resource-based interventions showed age >40 years, direct discharge to home after CA vs inpatient rehabilitation, co-survivor witnessing the CA, or assuming the caregiver role during hospitalization or within 1-month of CA, were significant predisposing factors.Conclusions:Education-based interventions, particularly information related to their loved ones’ recovery, are the top priorities for co-survivors during the early phase of CA survivorship. Future studies should focus on developing and testing these interventions for alleviation of caregiver burden.

Circulation, Volume 146, Issue Suppl_1, Page A14826-A14826, November 8, 2022. Introduction:Due to pro-arrhythmic effects associated with Sotalol, inpatient initiation with QTc monitoring for five doses is recommended. An IV loading dose followed by two oral doses has been shown to achieve steady-state concentrations.Hypothesis:To evaluate the safety of single day loading of IV sotalol in patients with atrial fibrillation and atrial flutter (AF/AFL).Methods:We prospectively evaluated 40 patients at our institution who received IV sotalol as single day loading dose for initiation of oral sotalol therapy for AF/AFL. IV sotalol dose was calculated based on target oral dose as indicated by baseline QTc interval and renal function. Patients’ QTc (in sinus) was measured via ECG on 15 minutes intervals and after IV loading completion. Loading was considered complete after second oral dose. All patients were monitored via a mobile cardiac outpatient monitor for 3 days followed by a final 12 ECG.Results:A total of 40 patients were included in the study. The mean age was 69+8.2 years, 78.9% of patients were men. QTc significantly increased from 435.9+26.4 to 462.9+31.6 with following IV loading (p

Circulation, Volume 146, Issue Suppl_1, Page A10774-A10774, November 8, 2022. Introduction:Syncope affects up to 50% of people during a lifetime and is a common presentation to Emergency Departments (EDs). The Ambulatory Emergency Care Unit (AECU) Syncope pathway was established at our institution as a route by which low-risk patients presenting with syncope can undergo investigations without requiring hospital admissions as well as reducing length of stay for patients awaiting cardiology input.Hypothesis:The AECU Syncope pathway at Northwick Park Hospital, London, UK is safe and effective in reducing hospital admissions.Methods:We conducted a retrospective study of patients seen via the AECU Syncope pathway in 2020. These were referrals from the Emergency Department, General Practice and Inpatient departments for 24-hour tapes and echocardiograms.Results:A total of 221 patients were referred to the AECU syncope pathway in 2020. Of these, 36 patients (16%) had abnormalities on 24-hour tape. The majority were ectopics (n=12) but patients were also found to have arrhythmias (n=10), bradycardia (n=8) and heart block (n=6). 10 patients had aortic valve dysfunction identified on echocardiogram: 4 had severe aortic stenosis and the rest had milder classifications of aortic valve dysfunction. In total, 42 of the 221 patients had an abnormality on echocardiogram and/or 24-hour tape. Of these 42 patients, 14 were discharged as their abnormalities were insignificant for further cardiology input. 28 were referred to cardiology clinic for review as an outpatient. In terms of readmissions, 6 patients had readmissions within 30 days but only 1 patient had a readmission attributed to syncope, and this was a presyncope episode for which the patient was safety netted for during the previous admission. There were no deaths reported within 30 days of presentation. Within 1 year, there were 2 deaths, but neither were attributed to a major adverse cardiovascular event.Conclusions:The AECU syncope pathway presents a viable, efficient and safe route by which low-risk patients who are under investigation for a presumed syncopal episode can receive cardiology input without requiring a prolonged hospital admission. In doing so, there is a significant benefit to hospitals by reducing strain on bed space and staffing, thereby improving patient flow.

Circulation, Volume 146, Issue Suppl_1, Page A15388-A15388, November 8, 2022. Background:Patients with heart failure (HF) commonly remain symptomatic after medical treatment. Symptoms are associated with rehospitalizations and mortality. We developed a 6-month nutrition intervention targeting the 3 most common HF symptoms: edema, shortness of air, and fatigue. The intervention involves 3 nutrients that target the pathologic pathways underlying symptoms: sodium, omega-3 fatty acids, and lycopene.Hypothesis:Time to first event will be longer in the nutrition intervention group than in the placebo group at 1-year follow-up.Methods:This was a randomized controlled double-blind clinical trial where 118 patients (mean age 63±12 years; 40% female; 64% NYHA class III or IV) with HF were randomized to active intervention vs placebo groups. The active intervention included a skill-building strategy based on Theory of Planned Behavior using Motivational Interviewing. It included a low sodium (LS) diet (2500mg sodium/day), lycopene supplementation daily (8 ounces [oz] of LS sodium tomato juice or 11.5 oz of LS V8 juice), and omega-3 fatty acid capsules (350mg EPA, 50 mg DHA/capsule) 3/meal with each meal. Placebo patients received generic instructions to follow a LS diet, 8 oz/day of fruit juice with no lycopene (e.g. cranberry juice) and capsules that contained soybean oil, but that looked like intervention capsules. Cox proportional hazards modeling was done to determine time to event of cardiac hospitalization or death based on intervention group. Models were adjusted for age, gender, NYHA class and HF medications.Results:The two groups were similar at baseline. The active intervention group had better event-free survival (Figure, p = 0.03) independent of covariates. Placebo patients were 2.2 (95% CI 1.025 – 4.584) times more likely to experience an event.Conclusion:A diet-based intervention aimed at the pathologic pathways underlying the 3 most common HF symptoms is successful in reducing cardiac rehospitalizations and mortality.

New England Journal of Medicine, Ahead of Print.

Innovative prospettive terapeutiche per rallentare la malattia

A trial found that adults who took oral vitamin D supplements during the SARS-CoV-2 pandemic when vaccine coverage was low were not protected against COVID-19 or any other acute respiratory tract infections.

Circulation, Volume 146, Issue 17, Page 1266-1267, October 25, 2022.