Search Results for: Associazione FANS e Warfarin

Circulation, Volume 150, Issue Suppl_1, Page A4139226-A4139226, November 12, 2024. Background:Anticoagulation is the standard treatment for the majority of patients with atrial fibrillation (AF) to reduce the risk of stroke. Anticoagulation is also utilized in patients with end-stage renal disease (ESRD) on hemodialysis (HD) who have AF. Such patients are at high risk for bleeding and stroke. However, limited data is available regarding utility of anticoagulation in such patients. The goal of this project was to assess the efficacy of anticoagulation to reduce the risk of stroke for patients with ESRD on HD who developed new onset AF.Methods:The national Veterans Affairs (VA) electronic health records were utilized to identify patients with ESRD on HD from 01/01/2000 to 01/01/2018. Those with AF prior to HD were excluded. In addition, those with stroke, mitral or aortic valve surgery prior to AF were excluded. Anticoagulants included warfarin, or apixaban, rivaroxaban, edoxaban and dabigatran, collectively termed DOACs. Patients were considered to be on an anticoagulation if they received anticoagulation for >1 month. All diagnoses were based on International Classification of Disease (ICD) 9thand 10thversions, and Current Procedural Terminology codes. Follow up period extended from the onset of AF to 01/01/2020 or death.Results:Over the study period 12,559,292 patients visited any of the VAs nationally. Of these, 89,081 were on HD without prior AF. Of those, 17,192 (19.3%) developed new AF. Of these 13,649 had no stroke, mitral or aortic surgery prior to the AF diagnosis. Of the 9,227 patients in the no anticoagulation cohort, 476 patient subsequently had stroke (5.16%). Of the 3,708 warfarin treated patients, 533 had subsequent stroke (14.37). Of the 358 DOAC patients, 34 (9.95%) had subsequent stroke. The difference in the stroke rates between those anticoagulated and those not anticoagulated was significant (P

Circulation, Volume 150, Issue Suppl_1, Page A4141755-A4141755, November 12, 2024. Background:Mechanical heart valve replacement (MHVR) is an effective method for the treatment of severe heart valve disease. However, it subjects patients to lifelong warfarin therapy after MHVR, with the attendant risk of bleeding and thrombosis. Whether internet-based warfarin management reduces complications and improves patient quality of life remains unknown.Objective:This study aimed to compare the effects of internet-based warfarin management and the conventional approach in patients who received MHVR in order to provide evidence regarding alternative strategies for long-term anticoagulation.Methods:This was a prospective, multicenter, randomized, open-label, controlled clinical trial with a 1-year follow-up. Patients who needed long-term warfarin anticoagulation after MHVR were enrolled and then randomly divided into conventional and internet-based management groups. The percentage of time in the therapeutic range (TTR) was used as the primary outcome while bleeding, thrombosis, and other events were the secondary outcomes.Results:A total of 721 patients were enrolled. The baseline characteristics did not reach statistical differences between the two groups, suggesting the random assignment was successful. As a result, the internet-based group showed a significantly higher TTR (mean 0.53, SD 0.24 vs. mean 0.46, SD 0.21; P < .001) and fraction of time in the therapeutic range (mean 0.48, SD 0.22 vs. mean 0.42, SD 0.19; P < .001) than did those in the conventional group. Furthermore, as expected, the anticoagulation complications, including bleeding and embolic events, had a lower frequency in the internet-based group than in the conventional group (6.94% vs. 12.74%; P = .01). Logistic regression showed that internet-based management increased the TTR by 7% (odds ratio [OR] 1.07, 95% CI 1.05-1.09; P < .001) and reduced the bleeding and embolic risk by 6% (OR 0.94, 95% CI 0.92-0.96; P = .01). Moreover, low TTR was found to be a risk factor for bleeding and embolic events (OR 0.87, 95% CI 0.83-0.91; P = .005).Conclusions:Internet-based warfarin management is superior to the conventional method, as it can reduce anticoagulation complications in patients who receive long-term warfarin anticoagulation after MHVR.

Circulation, Volume 150, Issue Suppl_1, Page A4138915-A4138915, November 12, 2024. Introduction:Although extracranial major bleeding (EMB) is often transient and manageable with supportive care, there is concern that EMB may have a subsequent detrimental effect on CV outcomes. However, a causal relationship is unclear, because the association is often confounded by underlying disease and comorbidities. Clinical trial data for more comprehensive analyses via advanced modeling are limited.Research Question:What is the effect of rivaroxaban vs. warfarin on CV outcomes mediated through EMB?Aim:To determine the extent of the effect of rivaroxaban vs. warfarin on CV outcomes that is mediated through their differential impact on EMB using a novel, advanced modeling approach (EUPAS1000000168).Methods:Using 5 US observational databases from routine clinical practice (01-11-2010 to 31-12-2022), adult patients with non-valvular atrial fibrillation (NVAF) were identified to establish the target and comparator cohorts, with 1stexposure as index date. Treatment balance was achieved by matching on propensity scores derived from large-scale regularized regression. Cox proportional hazards models estimated the main effect on CV outcomes (myocardial infarction, ischemic stroke, and composite endpoint) for rivaroxaban vs warfarin, with target and comparator time-at-risk right-censored at therapy end or switch, event occurrence, or database observation end. The EMB mediation effect on outcomes was estimated by including EMB as time-varying covariate, while controlling mediator-outcome confounding by including a mediator risk score in the outcome model. Comparative analyses were conducted only when pre-specified diagnostics passed for covariate balance, equipoise, and systematic error estimated through negative controls.Results:In 5 databases, 378,384 rivaroxaban initiators were matched to 601,174 warfarin initiators with NVAF. Common comorbidities included hypertension, hyperlipidemia, coronary artery disease, and heart failure. Main effects and indirect effects (mediation effects) are in Table A.Conclusion:This analysis suggested that EMB had no impact on the effect of rivaroxaban vs. warfarin on CV outcomes. A limitation is that EMB occurrence and CV events after EMB were limited, which reduced mediation impact.

Circulation, Volume 150, Issue Suppl_1, Page A4145271-A4145271, November 12, 2024. A 42-year-old female with SLE, lupus cerebritis with related seizure disorder, and mesenteric venous thrombosis on warfarin initially presented for syncope. Acute stroke workup was negative, and syncope was attributed to possible brief seizure. Six months later, the patient was evaluated by cardiology for hypertension diagnosed during hospitalization. She reported no further syncope, but exam revealed a 3/6 holosystolic murmur. Subsequent TTE identified severe MR with primary MV degeneration and LVEF >60%. A TEE confirmed severe MR with myxomatous MV leaflets and moderate-sized nonmobile vegetations attached to the atrial side of A2 and P2 of the MV. Subsequent infectious workup including serial blood cultures were negative. The patient was diagnosed with non-bacterial Libman-Sacks endocarditis (LSE). Given a lack of symptoms and plan to resume immunosuppressive therapy and continue her anticoagulation (AC), surgical intervention was initially deferred with close follow-up.The patient continued to endorse worsening headaches and brain MRI revealed new chronic small ischemic strokes. One morning, the patient noted sudden aphasia and presented to the ED. Stroke workup revealed an acute ischemic stroke with total left M2 occlusion of her MCA, and she underwent thrombectomy. Cerebral angiogram further revealed FMD. Given ongoing embolic phenomena, likely from LSE, she underwent MVR with mechanical valve and LA appendage ligation and continued mycophenolate and warfarin. Two months postoperatively, the patient remained asymptomatic with normal prosthetic valve function and neurologic status. However, evaluation for extracranial FMD with CTA revealed interval development of PV vegetations. These lesions and moderate PR were confirmed on TTE.Discussion:While response to immunosuppressive therapy and AC has been reported to improve early-phase LSE, this patient continued to experience thromboembolic events resulting from LSE vegetations while on mycophenolate and warfarin. Despite continuing these therapies after MVR, she later developed PV vegetations and PR. Pulmonary valve involvement is rare in LSE, and development of new disease while on recommended medical therapy represents unusual disease progression.

Circulation, Volume 150, Issue Suppl_1, Page A4144488-A4144488, November 12, 2024. Background:Oral anticoagulants (OAC) including Vitamin K antagonists such as warfarin and direct oral anticoagulants like Apixaban, Rivaroxaban, and Edoxaban, have long been the standard treatment for stroke prevention in patients with atrial fibrillation (AF). However, they increase the risk of bleeding, making them unsuitable for certain patient populations, particularly those with a personal history of bleeding, elderly individuals prone to falls or those with high-risk occupation with safety hazards. In cases of non-valvular AF, where thrombi typically form in the left atrial appendage, mechanical left atrial appendage closure (LAAC) has come out as an alternative for selected patients. Numerous studies have shown that LAAC is comparable to OAC in preventing strokes while significantly reducing major bleeding events. This meta-analysis aims to compare the 4–5-year outcomes of these two treatment strategies in non-valvular AF.Methods:4 studies (3 randomized controlled trials and 1 observational study) comparing the 4–5-year outcomes of LAAC versus OAC in patients with AF were included in this meta-analysis. These studies were identified after a thorough search of PUBMED, COCHRANE, and MEDLINE databases from inception till May 2024. The outcomes of interest were MACE (composite of stroke, embolism, and death), ischemic stroke, major bleeding episodes, cardiovascular (CV) deaths, and all-cause death. The results were reported as Risk Ratio (RR) with 95% confidence intervals (CI), using a random effects model.Results:6,012 patients were identified from the 4 studies. After a median follow-up of 4–5 years, LAAC was associated with a clinically significant reduction in MACE (RR: 0.76, 95% CI: 0.61-0.94, p=0.01), all-cause mortality (RR: 0.77, 95% CI: 0.62-0.96, p=0.02), and CV mortality (RR: 0.64, 95% CI: 0.45-0.90, p=0.01). Additionally, a significant reduction in major bleeding episodes (RR: 0.63, 95% CI: 0.44-0.91, p=0.01) was also noted between the two treatment strategies favoring LAAC treatment group. There was no significant difference in the incidence of ischemic stroke (RR: 1.07, 95% CI: 0.62-1.85, p=0.80) between the two groups.Conclusion:Over a median follow-up of 4-5 years, LAAC was found to be as effective as OAC in preventing ischemic strokes, while also showing lower incidence of MACE, all-cause, CV mortality and major bleeding episodes. More RCTs are needed to further assess the long-term outcomes between the two strategies.

Circulation, Volume 150, Issue Suppl_1, Page A4147071-A4147071, November 12, 2024. Introduction/Background:Marantic endocarditis and valvulitis are cardiovascular manifestations of autoimmune disease that can be challenging to diagnose.Case Presentation:A 23-year-old female with SLE presented with brief episodes of intermittent left eye vision loss and left sided weakness. She also reported fevers, a malar rash, and new onset dyspnea on exertion.Serologic work-up was consistent with an SLE flair. MRI of the brain/orbits demonstrated two acute infarcts in the frontal and parieto-occipital lobes. CTA head and neck did not show any large vessel vasculitis. Transthoracic echocardiography showed thickening of the mitral valve (MV) leaflets, with moderate MR and an elevated MV gradient of 11 mm Hg. The posterior leaflet was not visualized, concerning for absent or hypoplastic posterior leaflet. A transesophageal echocardiogram was performed and showed severe thickening of posterior mitral leaflet with restricted motion and shortening secondary to extensive thrombus burden. In addition, there was evidence of thrombus at the tip of the anterior MV leaflet. The patient was managed with high dose steroids and warfarin for SLE flair and marantic endocarditis, respectively.Two months later, she presented with amaurosis fugax. Cardiac MRI showed thickened MV leaflets with delayed enhancement along the posterior leaflet and MV annulus consistent with an organized thrombus. After multidisciplinary discussion, the patient underwent surgical MV replacement with a bioprosthetic valve. Intraoperative evaluation revealed severely thickened MV leaflets with fused commissures. In addition, there was fusion of the posterior leaflet and lateral side of the anterior leaflet to the papillary muscles as a result of thickened and shortened chordae. These findings were believed to be due to inflammatory changes involving the MV apparatus. Surgical pathology confirmed the diagnosis of valvulitis. The patient has done well post operatively.Conclusion:Valvulitis and marantic endocarditis can have devastating consequences if not treated promptly. Use of multimodality imaging can aid in the diagnosis. Multidisciplinary discussion is critical in achieving desired clinical outcomes.

Circulation, Volume 150, Issue Suppl_1, Page A4139594-A4139594, November 12, 2024. Background:Studies related to the Watchman device generally report data at the 45-day, 6-month, 1-year, and 2-year intervals, with outcomes supportive of Watchman closure. The imaging of the device at 45 days is believed to coincide with substantial completion of device endothelization and the end of the high risk period for device related thrombus (DRT). Thus, prophylactic systemic anticoagulation (SA) is often discontinued at this time.Objective:To report the incidence of delayed DRT in patients following the 45 day post-implant imaging and the cessation of SA.Methods:In this single center retrospective study, we assessed patients undergoing Watchman device placement between April 16, 2016, and June 30, 2022. Patient data was retrieved from our institutional Cardiovascular Data Registry database. Following Watchman device implantation, all patients underwent a 45-day surveillance TEE or CT. Our primary interest was assessing the incidence and timing of delayed DRT and determining the anti-platelet and/or SA regimen at the time of DRT.Results:A total of 861 patients who underwent Watchman device placement were included in the study. The 45-day surveillance imaging revealed that 2.2% (19/861) of patients exhibited a DRT during the initial follow up imaging while on SA and aspirin (ASA). These patients continued on SA/ASA until the 6-month imaging, at which point 84% (16/19) patients showed DRT resolution. Among the 2 with persistent thrombus, one was on ASA/warfarin, while the other was on DAPT. The 3rd patient did not complete subsequent imaging after 45 days.The patients without DRT at 45-day imaging had a 0.83% (7/842) incidence of DRT with 42.9% (3/7) revealed at 6 month, 42.9% (3/7) revealed at 12 months and the remaining 14.3% (1/7) at 24 month imaging. SAPT/SA protection was in place in 57.1% (4/7) of these cases, while the remainder were on SAPT 28.5% (2/7), or nothing at all 14.3% (1/7). Alarmingly, 2/7 of these cases resulted in an ischemic stroke in the absence of SA. In 85% of cases, DRT was associated with peridevice leak.Conclusion:These findings underscore the importance of ongoing surveillance in patients with Watchman devices and do not suggest a clear association between continued anticoagulation therapy and reduced risk of delayed DRT formation. Further investigations are warranted to determine whether there are predictive patient or implant characteristics and elucidate optimal management strategies for this patient population.

Circulation, Volume 150, Issue Suppl_1, Page A4135975-A4135975, November 12, 2024. Introduction:Coronary artery ectasia (CAE) is a rare but well-recognized anatomical abnormality of the coronary arteries with a prevalence of up to 9% in patients presenting with acute coronary syndrome (ACS). While anticoagulants have been suggested to reduce recurrent events, the optimal antithrombotic therapy in CAE and ACS remains unclear.Research Question:What is the comparative effect of anticoagulation therapy versus no anticoagulation in patients with CAE and ACS receiving background antiplatelet therapy?Goals:To perform a systematic review and meta-analysis evaluating the efficacy of anticoagulation in preventing major adverse cardiovascular events (MACE) among patients with CAE and ACS.Methods:We searched PubMed, Embase, and Cochrane to identify studies comparing the use of anticoagulants versus no use of anticoagulants as part of the antithrombotic therapy in patients presenting CAE and ACS, and reported MACE. Statistical analysis was performed using R version 4.2.2 adopting the Mantel-Haenszel random-effects model. Heterogeneity was assessed using Cochrane’s Q statistic and Higgins and Thompson’s I2 statistics. Pooled risk ratios were used to evaluate the effectiveness of anticoagulant therapy in CAE and ACS.Results:We included 3 studies, including 1 randomized controlled trial and 2 observational studies, comprising a total of 441 patients, of whom 162 (36.7%) received anticoagulants, including vitamin K antagonists (warfarin and acenocoumarol) or direct oral anticoagulants (rivaroxaban, apixaban, and dabigatran). Time of follow-up ranged from 12 to 52 months, mean age was 57.9 ± 11.4 years, and 388 (87.9%) were male. We found no significant difference in MACE between patients who received anticoagulation and patients who did not (RR 0.64; 95% CI 0.31, 1.32; p=0.22; I2 = 0%). Additionally, there was no difference in the risk of re-infarction (RR 0.71; 95% CI 0.43, 1.18; p=0.19; I2 = 0%). Finally, there was no significant difference in risk of bleeding between both groups (RR 1.41; 95% CI 0.70, 1.85; p=0.19; I2 = 0.59%).Conclusion:Our findings suggest that, among patients with CAE and ACS, anticoagulation does not reduce the risk of MACE or re-infarction as compared with no anticoagulation.

Circulation, Volume 150, Issue Suppl_1, Page A4141024-A4141024, November 12, 2024. Background:Atrial fibrillation (AF) is increasingly prevalent in patients with liver cirrhosis, which is associated with both bleeding and thromboembolism. Patients with cirrhosis have been excluded from randomized controlled trials on the efficacy and safety of anticoagulants in AF. We performed a systematic review to compare direct oral anticoagulants (DOACs) with warfarin in patients with AF and concomitant cirrhosis.Methods:We systematically searched Pubmed and Embase from inception to the present. The primary outcome of interest was the hazard ratio of major bleeding. Secondary outcomes included gastrointestinal bleeding, all-cause bleeding, and ischemic stroke/systemic embolism[AN1] . Random effects models were used to calculate the weighted pooled hazard ratios for the outcomes. A two-tailed p

Circulation, Volume 150, Issue Suppl_1, Page A4144096-A4144096, November 12, 2024. Background:The patient population undergoing left atrial appendage occlusion (LAAO) in the US is older and at a higher bleeding and thromboembolic risk than that enrolled in the initial trials that led to FDA approval. Real world outcomes in this population have implications for the use of LAAO.Goals:We sought to compare clinical outcomes of LAAO in patients with atrial fibrillation (AF) with prior major gastrointestinal (GI) bleeding to continued oral anticoagulation (OAC).Methods:Using data from a large US hospital system, patients with AF who underwent LAAO from 01/2016 to 11/2022 with a history of at least one major (requiring admission or transfusion) GI bleed event (LAAO group) were identified and compared to a control group with prior GI bleed with continued OAC. Controls were selected in a 1:2 fashion using propensity score matching based on 17 variables. Hospital admissions for major bleeding, ischemic stroke or transient ischemic attack (TIA) as well as survival were tracked during follow-up.Results:Patients in the LAAO group (n=642, age 76.5±8.2 years, 47.8% female) had higher CHA2D2-VASc (4.3±1.7 vs. 4.1±1.6, p=0.003) and lower HAS-BLED (3±0.9 vs. 3.3±0.9, p

Circulation, Volume 150, Issue Suppl_1, Page A4124430-A4124430, November 12, 2024. Introduction:Heart failure can be a manifestation of underlying immune mediated myopathies like dermatomyositis/polymyositis which can present in broad range of clinical manifestations and sometimes dermatologic lesions can be the only manifestation of these underlying pathologies without typically involving the muscle weakness. Calcinosis cutis is the deposition of calcium salts in the skin and subcutaneous tissue. There are five subtypes of calcinosis cutis, dystrophic, metastatic, idiopathic, iatrogenic and calciphylaxis.Case summary:70-year-old female was evaluated for bilateral lower extremity swelling. Past medical history was significant for Graves’ disease, atrial fibrillation, mechanical aortic valve on warfarin, hypertension, hyperlipidemia, ascending aortic aneurysm. Work up showed BNP of 4700 pg/ml with normal cardiac enzymes. Transthoracic echocardiogram revealed newly reduced ejection fraction of 25—30% with severely dilated left ventricle. Patient refused cardiac catheterization. Nuclear stress test showed no evidence of ischemia. Patient was started on guideline directed medical therapy and biventricular Implantable cardioverter defibrillator device was placed as per cardiology recommendation. Six months later patient developed multiple calcinosis cutis lesions on abdominal wall requiring surgical excisions. Endocrine work up including PTH, serum Ca level was normal, however creatin kinase level was high normal (150 U/L). Serum aldolase was ordered which was found to be elevated(25U/L). Muscle biopsy was performed as per recommendations of rheumatology which was diagnostic of dermatomyositis. Patient was started on high dose steroids and methotrexate and eventually IV immunoglobulins as per rheumatology recommendation. Follow up echocardiogram revealed improved ejection fraction to 40–45% with resolution of any further lesion of calcinosis cutis afterwards.Conclusion:Cardiac involvement such as congestive heart failure can be a part of presentation of underlying untreated myopathies. Calcinosis cutis can be the only clinical manifestation of dermatomyositis affecting heart. Etiology of calcinosis cutis in patients with heart failure should be worked up properly. Dystrophic calcinosis cutis is the subtype associated with underlying autoimmune connective tissue diseases.

Circulation, Volume 150, Issue Suppl_1, Page A4140488-A4140488, November 12, 2024. Background:Central venous catheters (CVC) are common in cancer pts but provide a nidus for right atrial thrombus (RA-Th). CMR can identify presence and risk factors for RA-Th.Objectives:To evaluate predisposing factors and embolic risk conferred by RA-Th.Methods:The population comprised adult (≥18yo) cancer pts with CVC who underwent CMR at two sites; RA-Th was defined by avascularity on LGE-CMR. Registry data included clinical and CVC indices and chart review for pulmonary embolism (PE) 1 month pre- or 6 months post-CMR.Results:211 pts with CVC (52±17yo; 45% M) were studied, inclusive of RA-Th and controls matched for cancer etiology/stage (heme 28%| GI 27%| sarcoma 22%). CVC type varied (Mediport 81% |PICC 9%| pheresis 6%| HD 4%), as did time between RA-Th and catheter insertion (6.5[2.4-15.8] mo). Pts with and w/o RA-Th were of similar age, sex, CVC type/duration, and cardiac function on CMR (p=NS). CVC depth was greater in pts with RA-Th (2.8±1.6cm vs. 1.5±1.6cm, p

Circulation, Volume 150, Issue Suppl_1, Page A4141243-A4141243, November 12, 2024. Description of Case:A 36-year-old male with a history of non-ischemic cardiomyopathy status post HeartMate 3 left ventricular assist device (LVAD) presented with a 2-day history of dizziness, lightheadedness, chest pain, and an increase in low flow alarm frequency from his LVAD. On admission, his temperature was 37.2, return to flow was 86, oxygen saturation was 100% on room air, heart rate was 99, and respiratory rate was 23. His lungs were clear to auscultation, and his abdomen was distended, tense, and non-tender. His extremities were warm, with moderate edema in his legs bilaterally. He had mild increased work of breathing without accessory muscle uses. Laboratory evaluation revealed a prothrombin time of 2.6 seconds, a B-type natriuretic peptide level of 176 pg/mL, and a hemoglobin of 13.7 g/dL. Imaging revealed a chest CT demonstrating a complete obstruction of the distal outflow cannula near its attachment to the aorta. Patient hemodynamics worsened after admission, necessitating transfer to the cardiac intensive care unit. After an unsuccessful attempt at warfarin reversal and tissue plasminogen activator administration, the patient was eventually taken for surgical intervention with cardiothoracic surgery. During the procedure, there were no signs of outflow graft thrombus; instead, a sizeable peri-graft fluid collection was observed and drained, which relieved the outflow graft obstruction. The patient’s post-operative course was uneventful, and he was eventually discharged home with a resolution of his symptoms.Discussion:This patient’s presentation presents a few key features that suggest an alternative cause of an outflow obstruction other than an acute thrombus. The most important feature is that the patient had been diligent with his anticoagulation to indicate his being a therapeutic prothrombin time on admission, consistent with the patient’s reported anticoagulation adherence. We believe that cases such as this one provide clinical support for the reevaluation of the way we approach outflow tract obstructions in LVADs; especially as we continue to develop devices that have lower thrombus risk that their predecessors. We hope that this patient’s clinical presentation and course will be helpful in the future differentiation of intrinsic vs extrinsic compression of LVAD cannulas and the management of such obstructions.

Circulation, Volume 150, Issue Suppl_1, Page A4143844-A4143844, November 12, 2024. A 35-year-old gravida 1, para 0 with biventricular heart failure (LVEF 25%), nonischemic cardiomyopathy, history stroke, history of left ventricular thrombus, class III obesity, and chronic kidney disease who had been followed by Cardio-Obstetrics throughout her pregnancy presented at 34 weeks gestation for planned induction of labor. Upon presentation, she underwent assessment with a pulmonary artery catheter (PAC) and was noted to be in cardiogenic shock with elevated biventricular filling pressures and low cardiac index necessitating hemodynamic stabilization followed by primary cesarean section.The patient was admitted to the cardiac ICU for medical optimization prior to delivery. Home medications including isosorbide dinitrate, metoprolol, and hydralazine were continued. The patient was briefly placed on inotropic support with dobutamine, which was discontinued due to ectopy. After PAC-guided IV diuresis, anticoagulation transition from enoxaparin to heparin, and twice daily fetal monitoring via non-stress test, a multidisciplinary team, including cardiology, maternal fetal medicine, cardiac anesthesia, and cardiothoracic surgery assembled for the C-section. Following pre-delivery cannulation for potential ECMO support, the patient underwent C-section and elective salpingectomy under epidural anesthesia with delivery of a healthy neonate.Post-delivery, the patient was monitored in the ICU, focusing on fluid management, anticoagulation transition to warfarin, and titration of heart failure medications, as the patient did not plan to breastfeed. After discharge, she was scheduled for a 2-week postpartum visit including echocardiogram, EKG, and NT-proBNP.Discussion:Given the patient’s acute decompensation and fluid overload, medical optimization was essential prior to delivery. However, stabilization was expected to be temporary due to ongoing physiologic changes of pregnancy. Her limited mobility and concern for multiorgan compromise, such as new oxygen dependency and rising creatinine, made a prolonged induction of labor unfeasible. Due to concern for maternal intolerance of labor, unstable fetal lie, fetal distress due to decreased perfusion, and an increased likelihood of emergency C-section, a primary C-section was recommended as a safer option. The successful delivery of a healthy neonate and post-operative maternal stabilization highlights the importance of a multidisciplinary approach in managing complex cardio-obstetric cases.

Circulation, Volume 150, Issue Suppl_1, Page A4142289-A4142289, November 12, 2024. Description of Case:This case presents a 32-year-old woman with history of rheumatoid arthritis who presented with symptoms of worsening dyspnea on exertion, fatigue, and stable angina five weeks after starting abatacept.Methods:Performed a comprehensive retrospective analysis of one patient’s medical history, clinical presentation, diagnostic assessment, therapeutic intervention, and clinical outcome.Results:Physical exam was remarkable for signs of volume overload. Electrocardiogram showed sinus tachycardia and diffuse nonspecific T-wave inversions. Laboratory studies revealed a complete blood count significant for eosinophilia of 26,000, representing 79.5% of the differential. Troponins were negative. A brain natriuretic peptide was 903 pg/ml. Echocardiogram findings included mild reduction in biventricular systolic function with wall motion abnormality seen at the apex. Cardiac MRI (CMR) demonstrated mild biventricular systolic dysfunction, left ventricular intracavitary filling defect consistent with thrombi, and diffuse biventricular subendocardial late gadolinium enhancement (LGE) consistent with fibrosis. Abatacept was stopped with resolution of eosinophilia. Patient was treated with a short course of steroids and initiated on warfarin for left ventricular thrombi. Repeat CMR four months later showed resolution of left ventricular thrombi and biventricular dysfunction, with persistence of diffuse subendocardial fibrosis in both left and right ventricles.Discussion:CMR demonstrates findings consistent with Loeffler Endocarditis as evident by ventricular intracavitary filling defects and diffuse biventricular subendocardial late gadolinium enhancement. Initial management of involves prompt discontinuation of the suspected offending drug. Corticosteroids may be employed to mitigate eosinophilic infiltrate and myocardial inflammation. Diagnostic modalities such as cardiac imaging, endomyocardial biopsy, and laboratory testing play crucial roles in confirming the diagnosis and assessing severity. Follow-up CMR can help follow the response to cessation of the offending agent and rule-out confounding disease processes, as seen in this case. In conclusion, abatacept-induced eosinophilic endocarditis is a rare phenomenon that is poorly understood. Drug-induced eosinophilic endocarditis should be considered as a differential in patients that develop heart failure symptoms and eosinophilia after initiating abatacept.

Circulation, Volume 150, Issue Suppl_1, Page A4135327-A4135327, November 12, 2024. Background:With the aging population, the prevalence of malignancies in patients undergoing percutaneous coronary intervention (PCI) is increasing. Active malignancy is increasingly recognized as a significant contributor to high bleeding risks. In cases where anticoagulant (AC) therapy is required, it becomes crucial to determine which is the optimal choice for cancer patients, direct oral anticoagulants (DOACs) or warfarin. The aim of this study was to investigate long-term bleeding events in patients with malignancy undergoing PCI.Methods:CLIDAS (Clinical Deep Data Accumulation System) is a multicenter database with 7 tertiary medical hospitals in Japan. This retrospective analysis using CLIDAS database included 6838 patients who underwent PCI during April 2014 and March 2020 and also who have completed 3-year follow-up were divided into two groups; No malignancy group (n=6155) and malignancy group (n=683). Malignancy was defined as patients with treatment history of malignancy. Furthermore, these patients were categorized into six groups based on the presence of malignancy and the type of AC therapy;1)No malignancy without AC (n=5369),2)No malignancy with DOAC (n=294),3)No malignancy with warfarin (n=492),4)Malignancy without AC (n=586),5)Malignancy with DOAC (n=44), and6)Malignancy with warfarin (n=53). The primary outcome was the incidence of bleeding events, defined according to the Global Use of Streptokinase and t-PA for Occluded Coronary Arteries classification of moderate and severe bleeding.Results:During the 3-year follow-up period, 260 (3.8%) patients experienced major bleeding events after PCI. Among these patients, 180 (3.4%) were in group 1, 9 (3.1%) in group 2, 33 (6.7%) in group 3, 27 (4.6%) in group 4, 2 (4.5%) in group 5, and 9 (17.0%) in group 6. Multivariate Cox regression analysis showed that patients in the malignancy group had a significantly higher rate of bleeding events (HR, 1.50; 95% CI, 1.03-2.18). Furthermore, only the malignancy with warfarin group showed a significantly higher rate of bleeding events compared to the no malignancy without AC group (HR, 4.03; 95% CI, 1.94-8.37).Conclusions:Patients with malignancies receiving warfarin were associated with a higher risk of bleeding events. DOACs may be a safer alternative to warfarin in reducing bleeding risk in this population.