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A diagnosis of chronic traumatic encephalopathy (CTE) can only be confirmed postmortem. Professional American-style football players appear to be especially at risk, and many have been diagnosed with the neurological condition after they’ve died.
Le differenze di stipendio cominciano già a inizio carriera. E intanto Paesi come Bulgaria e Romania investono sui dottori per non farli fuggire
Circulation, Volume 150, Issue Suppl_1, Page A4148074-A4148074, November 12, 2024. Introduction/Background:Transradial cardiac catheterization (TRC) is recommended for patients with acute coronary syndrome over femoral artery catheterization. Randomized controlled trials show TRC has significantly lower rates of bleeding, vascular complications, and mortality in high-risk acute coronary syndrome patients. However, vascular complications like radial artery spasm, occlusion, arteriovenous fistula, perforation, and pseudoaneurysm (PSA) can still occur. Despite TRC’s widespread adoption, recent data summarizing radial artery pseudoaneurysm post-TRC is lacking.Research Question/HypothesisThis review aims to identify at-risk patients, present a case of catheterization-related radial artery pseudoaneurysm, and provide diagnostic and management insights. We hypothesize that older patients with hypertension are at higher risk and that early detection and management are associated with low complication rates.Methods/Approach:Systematic searches were conducted in PubMed, Web of Science, EMBASE, and CINAHL databases. Two researchers independently selected articles, extracted data, and evaluated study quality on RA PSA post-TRC (2003–2023). A third reviewer resolved conflicts. The Joanna Briggs Institute (JBI) tool was used to evaluate bias risk. Additionally, a case report is presented.Results:From 3,262 records, 43 studies were selected, involving 67 patients (58.8% female, median age 73.5 years). Hypertension (39.5%) and atrial fibrillation (27.9%) were the most common comorbidities. Percutaneous interventions like stenting and angioplasty caused 58.1% of cases; diagnostic catheterizations accounted for 37.2%. Ultrasonography diagnosed 83.7% of cases. Symptoms appeared a few hours to four months post-TRC, with pulsatile mass (21.4%) and swelling (14.3%) being the most common, and pain and ecchymosis at 2.4% each. More than half of the patients (51.2%) required surgical intervention, but 66.7% recovered without deficits. Severe complications were rare, affecting fewer than 5%.Conclusions:A literature review of 43 articles with 67 patients suggests older female patients with hypertension may be more prone to radial artery pseudoaneurysm post-TRC. It typically presents as a pulsatile, painful swelling detectable by ultrasound. This complication precludes the use of the radial artery as a conduit for coronary artery bypass grafting. The review highlights the importance of vigilant post-catheterization monitoring to enable early detection and treatment.
Circulation, Volume 150, Issue Suppl_1, Page A4135629-A4135629, November 12, 2024. Background:Regular physical activity provides numerous health benefits including improved cardiovascular health. Population-level physical activity surveillance is critical for informing research, practice, and policy efforts for supporting population health and health disparities. The United States Report Card on Physical Activity for Children and Youth addresses physical activity surveillance needs by integrating data from numerous sources capturing levels of physical activity and related behaviors (e.g., sedentary behavior, sleep), and facilitators and barriers for physical activity among United States youth. The 2024 Report Card is the 5thand decennial iteration in the series, released October 2024.Methods:A Report Card Working Group was assembled under the auspices of the Physical Activity Alliance and National Physical Activity Plan. Members reviewed the evidence for 11 indicators using data from nationally representative surveys and assigned grades. Data were examined for the overall population and, when possible, by age, sex, race/ethnicity, and disability subgroups. A standardized grading rubric was used to assign a letter grade to each indicator ranging from A to F. Trends in key benchmarks over time were examined since the first report card (2014) or earliest available data.Results:Sufficient data were available to assign grades for 8 of the 11 indicators. The assigned grades ranged from B- to F, with overall physical activity levels earning a D- (Table 1). No indicators improved since 2014. Five indicators – overall physical activity, organized sport participation, active transportation, sedentary behaviors, and school – worsened since 2014.Conclusions:The compiled surveillance report indicates generally poor grades and concerning trends over the recent decade. These findings highlight opportunities to improve physical activity levels and resources for supporting cardiovascular health among United States youth. Policy approaches are needed to combat societal factors that interfere with physical activity. Gaps in data availability, specificity, and quality point to needs for improved surveillance to track impacts. The 2024 Report Card can be a tool for supporting advocacy of regular physical activity at the national and local level.
Circulation, Volume 150, Issue Suppl_1, Page A4144542-A4144542, November 12, 2024. Background:Radiation associated heart disease has a wide spectrum of manifestations including pericardial disease, coronary artery disease, and valvular heart disease. Mitral valve regurgitation is the second most common valvular dysfunction in patients with prior mediastinal radiation.Research Question:What are the outcomes of percutaneous or transcatheter mitral valve replacement/repair (T-MVR) versus surgical mitral valve replacement/repair (S-MVR) in patients with prior mediastinal radiation.Methods:The National Inpatient Sample (NIS) was analyzed from 2015-2020 to identify patients with mediastinal tumors and prior exposure to radiation therapy undergoing mitral valve repair/replacement. We subclassified the data into hospitalizations for S-MVR and T-MVR. Baseline characteristics were compared between the two groups and multivariate logistic regression was used to analyze hospitalization outcomes.Results:A total of 1725 patients with prior mediastinal radiation were hospitalized for MVR; 1110 (64.3%) patients underwent S-MVR and 615 (35.6%) patients underwent T-MVR. On a multivariable analysis, the odds of MACCE [aOR: 2.21; 95 % CI: (1.87-4.01); p
Circulation, Volume 150, Issue Suppl_1, Page A4144555-A4144555, November 12, 2024. Introduction/Background:Radiation therapy (RT) is one of the most common treatment modalities for mediastinal cancers. RT has multiple adverse cardiovascular effects and it has been identified as an independent risk factor for atrial fibrillation (AF). The efficacy of catheter ablation in AF is well established, however there is limited data on procedural safety and outcomes in patients with mediastinal cancers and history of radiationMethods:The National Inpatient Sample (NIS) was analyzed from 2015-2020 to identify admissions for AF catheter ablation among patients with previous history of mediastinal radiation exposure using the 10-PCS (International Classification of Diseases, procedure coding system) codes. Baseline characteristics were compared between the two groups and multivariate logistic regression was used to analyze hospitalization outcomes.Results:We identified 257,240 admissions for AF catheter ablation of which 1720 patients (0.67%) had a history of mediastinal radiation exposure. In the adjusted analysis, the odds of in-hospital mortality (aOR 0.639, 95% CI 0.34-1.20, p 0.1637), major complications (aOR 0.876, 95% CI 0.73-1.05, p 0.1443), any gastrointestinal or hematological complication (aOR 0.853, 95% CI 0.63-1.15, p 0.3017), renal complications (aOR 1.017, 95% CI 0.88-1.18, p 0.0509) were similar in both cohorts. The odds of any cardiovascular complication (aOR 0.825, 95% CI 0.70-0.97, p 0.0208) was lower and odds of any pulmonary complication (aOR 1.433, 95% CI 1.27-1.62, p
Circulation, Volume 150, Issue Suppl_1, Page A4141415-A4141415, November 12, 2024. Lead related venous obstruction (LRVO) is an often underrecognized complication of pacemaker implantation. Symptoms of LRVO may include mild asymmetric upper extremity swelling to highly morbid superior vena cava (SVC) syndrome. We present an unusual case of a 54-year-old man with a history of retained pacemaker leads placed 26 years ago who presents with abdominal distention, lower extremity edema, and shortness of breath. He was found to have new onset ascites and significant pleural effusions. A liver biopsy showed hepatic fibrosis and pleural studies were consistent with chylothorax. After significant workup and diagnostic testing, it was believed that he had late complications often seen in Fontan physiology, notably hepatic fibrosis, lymphatic leakage, and protein losing enteropathy. A venogram and pressure measurements were performed which confirmed obstruction at the junction of the SVC and right atrium with elevated central filling pressures and significant flow through a markedly dilated azygous vein. A lymphangiogram suggested lymphatic leakage through the thoracic duct. An SVC stent was placed in an attempt to relieve the obstruction but the patient had progressive hemodynamic compromise leading to placement of mechanical circulatory support. Ultimately, the patient underwent surgical extraction of the retained pacemaker leads and reconstruction of the superior vena cava and right atrial junction, leading to near-resolution of his symptoms. This unusual presentation of SVC syndrome as a late complication of retained pacemaker leads highlights the potential severity of cardiac implanted electronic device lead-related complications.
Circulation, Volume 150, Issue Suppl_1, Page A4120854-A4120854, November 12, 2024. Introduction:Familial hyper-alpha-lipoproteinemia (HALP) is a heterogenous genetic lipid disorder that is found in only 8% of the population and manifests as elevated HDL levels above the 90thpercentile. HALP is due to mutations in various genes including cholesteryl ester transfer protein (CETP), hepatic lipase, or apolipoprotein C-III (APOC3). While epidemiological studies have noted an inverse relationship between high HDL and the development of coronary artery disease, recent data have shown a lack of causal atheroprotective effects. We present a case of a patient with significantly elevated HDL and peripheral vascular disease.Case Description:Patient is a 64-year-old female with past medical history of peripheral artery disease with occlusion of the left femoral artery and popliteal arteries status post angioplasty, hypertension, type 2 diabetes, alcohol use, and CKD Stage 4 who presented to the advanced lipid clinic for management of elevated lipoproteins. Patient’s laboratory data was significant for total cholesterol (TC) of 375 mg/dL, a high-density lipoprotein (HDL) of >200 mg/dL, triglycerides (TG) of 66 mg/dL, and a low-density lipoprotein (LDL) of 175 mg/dL. Further testing revealed elevated apolipoprotein A-I of 231 mg/dL. Patient was subsequently initiated on a high intensity statin with improvement in her lipid panel with a TC of 247 mg/dL, HDL of 133 mg/dL, TG of 50 mg/dL, and LDL of 106 mg/dL, with plan for further uptitration of lipid therapy to target LDL
Circulation, Volume 150, Issue Suppl_1, Page A4142149-A4142149, November 12, 2024. Background:As patients progress through the single ventricle palliation, changing hemodynamics and non-cardiac conditions can prevent completion of Fontan. We sought to determine the incidence of completion of Fontan at our institution and to investigate the reasons for non-Fontan candidacy.Methods:Institutional database was queried to identify patients who underwent single ventricle palliation from 2010 to 2020. Patients who underwent stage 2 palliation were included for analysis. The primary outcome of interest was reason for non-Fontan candidacy or reason for delayed Fontan.Results:526 patients who reached stage 2 single ventricle palliation were analyzed. 378 (71.9%) underwent Fontan procedure or were referred for Fontan before the age of 4-years-old at our center at the time of the study (Figure 1). 19 patients died prior to the typical age of Fontan and 38 were lost to follow up. Of the remaining 91 patients, 21 (23.1%) had a 1.5 or 2 ventricle repair, 12 (13.2%) had a Fontan at another center, and 29 (32%) had a late Fontan. Most patients with late Fontan were due to provider practice variation (22), whereas there were only 3 patients with medical conditions delaying pre-Fontan testing, and 4 patients had a Kawashima. Only 3 patients out of the 12 who had Fontan at another center were for second opinions, whereas the remainder either moved or had surgery at another center due to family preference. Reasons for non-Fontan candidacy were divided into cardiac and respiratory sources. Cardiac reasons included severely depressed ventricular function (12), diastolic dysfunction (2), atrioventricular valve stenosis or regurgitation (7), and pulmonary vein stenosis (3). Respiratory conditions leading to non-Fontan candidacy included severe OSA (1), pulmonary arterial malformation (1), and pneumonectomy (2). There are 17 patients in the non-candidacy group who had a heart transplant or were listed for transplant at the time of the study. No patient in our study was deemed not a candidate for Fontan after stage 2 palliation for developmental delay or syndrome.Discussion:This study demonstrates that the reasons for non-Fontan candidacy after completion of stage 2 palliation are broadly due to hemodynamic and respiratory condition, with many patients who are not candidates developing severe ventricular dysfunction after stage 2. There is a subset of patients who either move, are lost to follow up, or are delayed due to provider practice variation.
Circulation, Volume 150, Issue Suppl_1, Page A4143176-A4143176, November 12, 2024. Background:Identifying predictors of mortality in CRT patients remains an active area of investigation.Objective:To establish a relationship between gait speed (GS) and mortality in heart failure patients with CRT.Hypothesis:Patients with slower gait speeds have worse survival rates after CRT implantation.Methods:This retrospective study included 504 patients who underwent CRT implantation at our institution between 2017-2022. All patients were followed up with a multidisciplinary team, including electrophysiology and heart failure physicians about 6 months after CRT implantation, where frailty was assessed. We used GS as a measure of frailty and divided patients into 2 groups: GS: 5% with reduction in LVESV >10%; anybody not meeting this definition was classified as a non-responder. Responder and non-responder rates among GS< 1 m/s and GS >1 m/s were 53.8% vs 66.4%; and 35.1% vs 26.2%, respectively. The median (IQR) GS was 1.15 m/s (0.91-1.37 m/s). 52 (10.3%) patients had a composite outcome within 2 years follow up. Non-parametric univariate analysis revealed that lower GS was significantly associated higher composite outcome rates (median GS 0.8 vs 1.18 m/s; p
Circulation, Volume 150, Issue Suppl_1, Page A4140981-A4140981, November 12, 2024. Introduction/Background:Patients with hematological malignancies are at a higher risk of developing atrial fibrillation. Additionally, it can predispose to an increased risk of bleeding limiting anticoagulation for stroke prevention. LAAO has been successfully utilized among patients with atrial fibrillation and contraindication to anticoagulation.Research Question:What are the outcomes and in-hospital complications of left atrial appendage occlusion (LAAO) among patients with atrial fibrillation and hematological malignancy?Methods:The National Inpatient Sample (NIS) was analyzed from 2015-2020 to identify admissions for LAAO among patients with and without a hematological malignancy. Baseline characteristics were compared between the two groups and multivariate logistic regression was used to analyze hospitalization outcomes.Results:We identified 89,920 weighted admissions for LAAO procedures of which 1,665 patients (1.85%) had a hematological malignancy. In the adjusted analysis, the odds of MACCE (aOR 1.86, 95% CI 1.10-3.14, p 0.0205), cardiogenic shock (aOR 3.76, 95% CI 1.95-7.24, p
Circulation, Volume 150, Issue Suppl_1, Page A4124065-A4124065, November 12, 2024. Introduction:CHIP is associated with CAD and mortality. The prognostic relevance of CHIP for high-risk patients with confirmed CAD is unknown.Hypothesis:CHIP variants are associated with cardiovascular (CV) events and mortality in high-risk patients with known CAD in the ISCHEMIA Trials Biorepository.Methods:895 ISCHEMIA and ISCHEMIA-CKD (hereafter, ISCHEMIA Trials) participants with moderate-severe ischemia and next-generation sequencing performed for CHIP variant allele fractions of ≥2% (CHIP) and ≥10% (large CHIP) were included. Unadjusted and multivariable adjusted (age, sex, diabetes, eGFR not on HD, HD, and LVEF) associations of CHIP and large CHIP with a) ISCHEMIA Trials initial phase primary endpoint (CV death, myocardial infarction (MI), or hospitalization for unstable angina, heart failure, or resuscitated cardiac arrest, RCA) and b) ISCHEMIA Trials combined initial and extended follow-up phase (hereafter, Cumulative) endpoint of all-cause death .Results:Median (IQR) age of sequenced participants was 67 (56 – 79) years, 19% were female, 83% white, and 6% Hispanic. Hypertension (84%), diabetes (45%) and obesity (47%) were common, 26% had an eGFR 1 gene. Over 3.1 years of RCT follow-up there were 135 (20%), 32 (16%) and 15 (18%) primary endpoints for no CHIP, CHIP and large CHIP, respectively. Over 6.8 years of EXTEND follow-up, there were 126 (18%), 47 (23%) and 24 (29%) deaths in the no CHIP, CHIP and large CHIP groups, respectively. After multivariable adjustment there was no association between CHIP or large CHIP and CV events or mortality (Figure 1c).Conclusion:Neither CHIP nor large CHIP was associated with adverse outcomes in 895 high-risk individuals with confirmed CAD, despite a high prevalence of these mutations.
Circulation, Volume 150, Issue Suppl_1, Page A4145273-A4145273, November 12, 2024. Background:Extraction of unstructured and semi-structured medical data is a key prerequisite for the application of bioinformatics. Portability, scalability, and protection of health information remain key problems in data analytics in medicine that cannot easily be solved using machine learning techniques alone, highlighting the importance of multi-faceted approaches.Research Question / Hypothesis:Can rule-based algorithms reliably and identify and extract transthoracic echocardiographic (TTE) report findings for use in a data analytics pipeline?Methods:Deidentified adult TTE reports were obtained between 09/14/2020 to 03/30/2023 within a single urban academic healthcare system. A rule-based algorithm was developed using derivatives of regular expressions in R to capture chamber parameters, cardiac function, and valvular disease. The accuracy was evaluated in a subset of manually adjudicated reports by study cardiologists.Results:Of the 1000 reports obtained, we were able to extract 23079 (78.4%) populated data points out of 29423 maximal data points for 37 variables. Out of 803 manually verified NA data points, 743 (92.5%) were accurate. The mean net accuracy of all variables was 99.8% (see Table 1). Continuous data points showed 100% accuracy. Modes of failure for data extraction were in categorical variables (7.5% of the 23 features), with the most common being in left atrial size (n=6), mitral valve structure (n=5), aortic valve structure (n=13), tricuspid valve structure (n=2) and right ventricular function (n= 7). All other categorical variables showed 93.6% mean accuracy of NA data points.Conclusions:A rule-based algorithm is effective at converting cardiologist-read TTE reports into datasets ready for use data analytics. Moving forward, it would be important to test this tool on metrics of speed, cluster computing and scalability.
Circulation, Volume 150, Issue Suppl_1, Page A4146286-A4146286, November 12, 2024. Introduction:The morphology and blood stasis of the left atrial appendage (LAA) in tandem with disorganized conduction in atrial fibrillation (AF) creates favorable conditions for thrombus formation. Left atrial appendage occlusion (LAAO) devices have become increasingly utilized for stroke prevention in select patients with AF who have contraindications to oral anticoagulation (OAC). We present a unique case of an embolized Amplatzer Amulet LAAO device through a MitraClip into the LV causing polymorphic VT and obstructive shock.Case Presentation:An 80-year-old man with AF and mitral valve prolapse status post MitraClip presented to the hospital for difficulty breathing and palpitations two days after implantation of a 31mm Amplatzer Amulet LAAO device. Notably, he underwent failed attempt at Watchman LAAO implantation due to peridevice leak one year prior. On arrival, he was hypotensive with numerous episodes of polymorphic VT, requiring cardioversion, vasopressors, and mechanical ventilation. TTE located the Amulet within the LV outflow tract (LVOT) creating LVOT obstruction and revealed single-leaflet attachment of the MitraClip. He was evaluated for device retrieval and mechanical support but was deemed not a surgical candidate due to severe thrombocytopenia and guarded prognosis. Despite ongoing resuscitative efforts, the patient became increasingly unstable and died in the cardiac ICU.Discussion:In patients who are unable to tolerate OAC, occlusion of the LAA for stroke prevention has garnered growing interest; however, these devices are not without complication and do not guarantee full occlusion of the LAA. Despite our patient’s history of failing Watchman deployment, he was discharged on the same day after implant of the Amulet device without post-procedure TTE. We postulate that the Amulet device dislodged shortly after deployment and was held within the left atrium by the MitraClip until detachment, allowing for device embolization and severe MR. To our knowledge this is the first documented instance of Amulet device migration into the LV in a patient with a MitraClip. This case highlights the need for heightened post-procedure monitoring, surveillance, and imaging in select patients.
Circulation, Volume 150, Issue Suppl_1, Page A4139467-A4139467, November 12, 2024. Introduction:Acute coronary syndrome (ACS) has been generally considered a relative contraindication to coronary atherectomy.Aims:The objective of this study was to investigate the temporal trends and hospital variability in the use of coronary atherectomy and its outcomes among patients undergoing percutaneous coronary intervention (PCI) for ACS from a nationwide PCI registry in Japan.Methods:First, we analyzed the temporal trend in the use of rotational atherectomy (RA) and orbital atherectomy (OA) during PCI for ACS patients between 2014 and 2022 (822,237 PCIs from 1,269 hospitals). Next, we assessed the outcomes of the patients who underwent RA for ACS between 2019 and 2022 (7,421 patients across 662 hospitals). The primary outcome was in-hospital mortality after PCI. Patient outcomes associated with hospital PCI volumes and the device policy change on coronary atherectomy in Japan in 2020, which allowed operators to perform coronary atherectomy without on-site surgical backup, were also evaluated.Results:The rate of RA for ACS was low at 2.0% in the overall cohort (16,264/822,237 PCIs); the rate slightly increased from 1.9% in 2014-2019 to 2.1% in 2020-2022 (after the device policy change). The rate of PCI with OA for ACS was also low at 0.8% in 2021-2022 (1,404/185,141 PCIs). Increasing the complexity of baseline characteristics, including advanced age, diabetes, chronic kidney disease, dialysis, peripheral arterial disease, prior coronary artery bypass grafting, ST-segment elevation myocardial infarction, cardiac arrest within 24 h, cardiogenic shock within 24 h, three-vessel disease, and mechanical circulatory support during PCI was significantly associated with increased in-hospital mortality after PCI with RA in ACS patients (P
Circulation, Volume 150, Issue Suppl_1, Page A4137805-A4137805, November 12, 2024. Background:Many of the 1.4 million adults with congenital heart disease (CHD) are lost to follow up (LTF). We aimed to identify factors associated with LTF and compare to those who remained in care.Methods:In the Congenital Heart Disease Project to Understand Lifelong Survivor Experience (CHD PULSE), we performed a cross-sectional survey in 2021-2023 of CHD survivors with a history of intervention at 11 centers in the Pediatric Cardiac Care Consortium, a large US-based registry of CHD procedures. Participants reported their cardiac history, general health, education, income, health insurance, healthcare utilization, and marital status. LTF was defined as having seen a cardiologist three or more years ago.Results:Among the 3109 respondents with CHD (median age 33) there were 1157 (37%) LTF and 1952 (63%) in care. Age, sex, marital status, and household income were not risk factors for LTF; but lack of health insurance, lower severity of CHD, and increasing time since last heart surgery were. Notably, respondents who reported being told in adolescence about the lifelong need for a cardiologist were almost three times as likely to report being in care (79% vs 28%, p
