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

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

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 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 A4138624-A4138624, November 12, 2024. Case Presentation:A 67-year-old man with recurrent pleural effusions and concern for cirrhosis was referred for liver transplant. Pleural fluid was transudative by Light’s criteria with a high total protein level of 3.5 g/dL, which made hepatic hydrothorax unlikely. Liver biopsy confirmed congestive hepatopathy without advanced fibrosis. Transthoracic echocardiogram showed left ventricular (LV) ejection fraction 55%, right ventricular (RV) systolic pressure 35 mmHg, normal mitral annular tissue doppler velocities, and early diastolic septal bounce. Right and left heart catheterization showed prominent X and Y descent, elevated and equalized diastolic pressures, but no respiratory discordance in the LV-RV pressure gradient. As etiology of these findings were unclear, he underwent aggressive diuresis and hemodialysis, but repeat right heart catheterization showed persistently elevated right and left filling pressures. Cardiac MRI had no evidence of myocardial or pericardial inflammation/edema but showed pericardial thickening (7.9 mm) and septal bounce. There was no inspiratory septal shift, but the large pleural effusion appeared to limit diaphragm excursion. Given lack of respirophasic ventricular interdependence and thickened pericardium on MRI, CT was ordered, showing pericardial calcifications. Diagnosis of constrictive pericarditis was made, and patient underwent complete pericardiectomy. Pathology confirmed calcified and thick pericardium without acute inflammation. Post-operatively, patient developed RV failure, but recovered with inotrope support and was discharged with improvement in congestive symptoms.Discussion:Constrictive pericarditis classically exhibits respirophasic ventricular interdependence, but large pleural effusions may decrease respiratory variation in intrathoracic pressures, blunting this response. Normal mitral annulus tissue doppler velocities and lack of infiltrative process on cardiac MRI made restrictive cardiomyopathy unlikely. In the absence of respirophasic changes on multimodality testing, constriction can be diagnosed with other supportive features such as diastolic septal bounce, rapid Y descent, diastolic pressure equalization, and pericardial thickening and calcifications.

Circulation, Volume 150, Issue Suppl_1, Page A4139380-A4139380, November 12, 2024. Background:Imaging of conventional PM’s and ICDs are infrequently performed via MRI. While many studies, including theMagnaSafeTrialhave unequivocally supported MRI safety in patients with such devices, theaddedclinical value has rarely been considered. Accordingly, we performed an observational, IRB-approved, prospective study to determine the ‘Additive Value’beyondsafety for patients with conventional PM/ICD’s undergoing clinical MRI.Wehypothesizethat MRI in PM/ICD patients is critical to an existing diagnosis and often markedly alters diagnosis and subsequent downstream patient management.Methods:An MRI Device exam (GE 1.5T,WI) pioneered by cardiologists ( >90% over 10 yrs; 100% over 20 years) was performed. Subsequently, a series of prospective defining questions using Boolean Logic Construct were answered within 1 week of MRI by both MRI technologist and MRI physicians.Questions:1) Did the primary diagnosis change?2) Did the MRI provide additional information to existing diagnosis?3) Was the pre-MRI (tentative) diagnosis confirmed?4) Did subsequent patient management change?If ‘Yes’ was answered to any of the above questions, it was considered that MRI was of value to pt diagnosis and/or impending therapy.Results:Average MRI: 25±14min for 2,008 consecutive patients of which 1,526 (76%) were neuro/neurosurgery, 141 (7%) were musculoskeletal and 341(17%) were CV cases. Upon review: of the Neuro/neurosurgeryMRIs, 1,376 (89%) provided additional information.The diagnosis changed in 1018 (74%), while medical therapy changed in 977 (71%). In only 124 (9%) did MRI simply confirm original diagnosis. ForCardiacpatients, MRI changed the original diagnosis in 235 (69%). MRI did not contribute in 42 (12%) as it was uninterpretable (ICD artifact), while in 64 pts, the diagnosis did not change. Finally, in 146Orthopedicpts, MRI provided additional information in 143 (98%) and in 130 (89%), changed pt care, and in 4 pts (3%), simply confirmed the diagnosis. Importantly, with careful attention to device reprogramming and scanner sequences, no safety or device issues were encountered in any patient all with tracking for >1 year.Conclusion:Via a dedicated program of MRI in PM/ICD patients adds substantial clinical value to diagnosis and subsequent management justifying ant inherent risk(s). Herein, we propose that yet another impediment to the advancement of CMR-PM/ICD strategies can become routine and often life-changing.

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 A4141052-A4141052, November 12, 2024. Introduction:Cardio-cerebral infarction, a rare clinical presentation involving simultaneous acute ischemic stroke and acute myocardial infarction, poses significant therapeutic challenges. The incidence of this dual infarction is currently unknown due to its rarity. Delaying intervention for one condition to address the other can lead to permanent morbidity, disability, or even death. Coronary artery fistulas are uncommon with estimated incidence of 0.3%. Among these, a fistula between the left anterior descending artery and the pulmonary artery is the rarest variant, comprising about 17% of all coronary artery fistula cases.Case:A 54-year-old male, with a known history of atrial fibrillation and hypertension, presented to our emergency department with non-rotatory dizziness. Physical examination was unremarkable, but neurological examination revealed medial rectus palsy and left facial asymmetry. A cranial MRI indicated a hyperacute infarction in the left cerebellum. Laboratory tests showed markedly elevated troponin I levels ( >50 ng/ml) and atrial fibrillation, along with inferior wall ST elevation on the electrocardiogram. Due to the high risk of hemorrhagic conversion, the loading of antiplatelets was deferred. Instead, the patient was treated with Aspirin 80 mg once daily, Clopidogrel 75 mg once daily, and Enoxaparin 0.4 ml subcutaneously once daily. A 2D echocardiogram revealed an ejection fraction of 43%, hypokinesia of the anterior and intraventricular septum from base to apex, and severe mitral stenosis. Cardiac catheterization identified a coronary artery fistula from the left anterior descending coronary artery to the main pulmonary artery. Treatment for acute coronary syndrome and acute cerebellar infarct continued. An open-heart surgery was considered. However, during his hospital stay, the patient experienced hemorrhagic conversion and altered sensorium. His condition further deteriorated, necessitating a tracheostomy and long-term care.Conclusion:Cardio-cerebral infarction is an extremely rare and poorly studied syndrome that presents significant treatment challenges and carries a grave prognosis if not addressed immediately. The medical conundrum of deciding which condition to treat first underscores the need for further research. Both interventional cardiologists and interventional neuroradiologists play crucial roles in the effective management of this emergency condition.

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 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 A4145166-A4145166, November 12, 2024. Background:Interest in hospital at home (HaH) has grown, driven by recognition of potential to ameliorate capacity constraints and lower total costs of care associated with traditional “brick-and-mortar” (BaM) hospitalizations. Heart failure (HF) patients often require decongestion with intravenous diuretics and titration of multiple guideline-directed medical therapies (GDMT). We aimed to demonstrate that a virtual HaH model represents a safe and feasible option for patients with acute heart failure (AHF).Methods:This was a retrospective cohort analysis of patients admitted to the Cleveland Clinic HaH after clinical and social screening and enrollment in HaH from 4/2023 to 1/2024 (Fig 1). Patients with AHF were identified through pre-specified ICD-10 codes. We performed chart abstraction to evaluate demographic characteristics, admissions, vitals, lab values, 30-day readmissions/death, use of individual HF medications, and tabulated GDMT scores among this cohort of HaH patients. Statistical analysis involved parametric and non-parametric paired analysis at admission and discharge.Results:81% of patients (78/96) with AHF that were offered HaH as an alternative to BaM hospitalization opted to enroll in HaH. Patient were of median age 81 years [IQR 16], median LVEF 51.0% [IQR 20], and median admission NTproBNP 3518 [IQR 4619]; 66% of patients were male. Among the cohort, 7 (8.9%) patients were readmitted 30 days from discharge, and there were no deaths in the cohort at 30 month follow-up. By paired analysis, there was a net increase in GDMT score. Systolic blood pressure, diastolic blood pressure, and weight significantly trended down after admission to the HaH (Fig 2).Conclusions:In an early cohort of patients, HaH was selected by most eligible patients over BaM hospital care. There were low rates of readmission and net improvement in GDMT use. HaH can be safe and effective for selected HF patients, though further prospective research is needed.

Circulation, Volume 150, Issue Suppl_1, Page A4145402-A4145402, November 12, 2024. INTRODUCTION:Peripartum cardiomyopathy (PPCM) is a form of systolic heart failure, which occurs late in pregnancy or within the first 5 months postpartum and it is the most common cause of death related to heart failure in pregnant women. To establish the diagnosis, other causes of heart failure must be ruled out and a left ventricular ejection fraction (LVEF)

Circulation, Volume 150, Issue Suppl_1, Page A4122369-A4122369, November 12, 2024. Background:Internal mammary artery (IMA) side branch flow diversion post- coronary artery bypass grafting (CABG) and its role in coronary steal syndrome remains controversial. However, evident association persists when substantial side branches stem from the IMA, possibly due to relatively lower peripheral resistance as compared to higher coronary resistance. Intervention has shown promise in ameliorating reversible ischemia in these cases. Recanalization of previously occluded side branch is rare and has only been reported within a 6 month period. We report a case of recanalization of a previously occluded side-branch after 4 years with recurrence of symptoms.Case:A 63-year-old male underwent CABG with LIMA-LAD in 2020 and coil embolization of LIMA side branch for symptomatic coronary steal syndrome (figure 1). Angina recurred 3 years later, leading to right coronary artery stent placement. He now presents with palpitations and dyspnea on exertion. Vital signs and physical exam was unremarkable. ECG showed a normal sinus rhythm with no signs of ischemia. A 24-hour Holter showed significant polymorphic ventricular ectopy and episodes of sustained ventricular tachycardia (arrhythmic burden 12.4%). Transthoracic echocardiogram showed an ejection fraction of 71% and slightly decreased left ventricular global longitudinal strain (-16.6%).Decision-making:A diagnostic cardiac catheterization was performed which showed patency of bypass and stent with no signs of occlusion or restenosis, rather revealing a permeable, previously occluded side-branch (figure 2A) and resurgent coronary steal phenomenon. Repeat coiling was performed, achieving complete cessation of flow (figure 2B) and evident increased flow to the LAD. Resolution of symptoms was observed and post-procedure Holter showed normal sinus rhythm with no arrhythmic changes.Conclusion:Recanalization of an IMA side branch after complete occlusion with multiple coils is rare, particularly beyond 6 months. This appears to be the first reported case of the phenomenon, occurring after 4 years. Administration of heparin for recent stent placement, continuation of oral antiplatelet therapy and distal coil location may have contributed to restoration of flow, despite the presence of intraluminal coils. Repeat coiling proved successful in relieving symptoms.

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 A4145146-A4145146, November 12, 2024. INTRODUCTION:Familial Hypercholesterolemia (FH) is an underdiagnosed hereditary disorder of Low-density lipoprotein cholesterol (LDL-C) metabolism ,strongly associated with atherosclerotic cardiovascular disease (ASCVD). We present an FH case which shows the importance of early management.CASE REPORT:A 40 year old female with a history of Diabetes Mellitus, Hypertension (HTN), Non ST Elevation Myocardial Infarction (NSTEMI) came for angina like chest pain for 6 months. Her Coronary Angiography (CAG) showed Triple Vessel Coronary Artery Disease with 90% Left Main, 90% Left Anterior Descending, 80% Left Circumflex (LCX), 95% Right Coronary (RCA) arteries occlusion; Coronary Artery Bypass Grafting (CABG) was done. Her medical records showed poorly managed systolic blood pressure readings up to 180-200 mm Hg and hypercholesterolemia despite being on 3 antihypertensives and statins. On physical examination BMI 22 kg/m2, xanthelasmas, corneal arcus, elbow and achilles tendon xanthoma(figure.1),B/L Renal and carotid bruit was present. Her brother had premature CAD, daughters had hypercholesterolemia signs. Lab results indicated high cholesterol with, LDL 372.8 mg/dl; LDL/HDL 11.65. Multi-slice CT showed diffuse atheromatous changes of descending aorta, mesenteric arterial system and > 60% bilateral (L >R) renal artery stenosis(RAS). By Dutch Lipid Clinic Network criteria phenotypic FH was diagnosed and sent to lipid clinic for FH management.DISCUSSION:FH is an Autosomal Dominant disorder that leads to high LDL-C, escalating CAD risk by 20-fold. High intensity Statins cut LDL-C by 50%, pivotal in FH management. In our case late diagnosis of FH led to uncontrolled HTN due to RAS alongside CAD; Early diagnosis and medical management could have prevented the outcome as early initiation of statin in FH reduces their risk to age-matched population levels.Conclusion:FH is a systemic atherosclerosis often at subclinical level that needs to be investigated, also patients with premature ASCVD(male

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Circulation, Volume 150, Issue Suppl_1, Page A4135352-A4135352, November 12, 2024. Introduction:Living in an area with high Area Deprivation Index (ADI) is linked to worse cardiovascular disease (CVD) outcomes. However, the association of ADI with type 2 diabetes (T2D), a major CVD risk factor, is incompletely described. This knowledge may guide primary CVD prevention.Method:Rochester Epidemiology Project is a medical record linkage system of persons in southeast Minnesota and southwest Wisconsin. We identified 253,890 persons (aged 4–98 yrs on July 1, 2015) in 9 counties with >90% population coverage. ADI scores, from 2015 home addresses, were grouped into quartiles of low (Q1) to high (Q4) deprivation. We excluded persons with type 1 diabetes (T1D) or history of T2D and identified new T2D cases (2015-2020) using ICD codes, HbA1c and medications. We examined the association between ADI quartile and risk of incident T2D using Cox regression with persons right censored at death, T2D, T1D or last visit. Models were adjusted for age and gender, and reported adjusted hazard ratios (aHR [95% confidence interval]).Results:Age, gender, and race statistically differed across ADI quartiles (Table). Age × ADI interaction was significant (P