Risultati per: Circulation

Circulation, Volume 148, Issue Suppl_1, Page A12754-A12754, November 6, 2023. A 20-year-old transgender male presented with one week of intermittent shortness of breath and chest pain. He reported dizziness and increasing pain when playing the trumpet. His exam was unremarkable, but chest X-ray showed mediastinal widening and opacification of the retrosternal space (Fig. 1A). Chest CT showed a well-defined centrally enhancing prevascular mediastinal mass abutting the superior vena cava (SVC) and right heart (Fig. 1B). He was referred to a thoracic surgeon for evaluation. Subsequent chest CT venography and MRI demonstrated a progressively enhancing, part-solid and cystic mass with dilated veins draining into the SVC and a phlebolith. Due to imaging and clinical features, including a low probability of malignancy given negative tumor markers, lymphovascular malformation was favored over other possibilities such as thymoma, germ cell tumor, sarcoma, or Kaposiform hemangioendothelioma. After multidisciplinary discussions between cardiology, radiology, cardiothoracic and pediatric surgery, and a review at a dedicated vascular anomalies center, the consensus was for close surveillance. A 6-week follow-up MRI showed no significant change, but given increased dyspnea and chest pain, the decision was made to proceed with surgical resection via median sternotomy. The tumor was densely adherent to the right phrenic nerve, pericardium, and SVC but was excised completely without complications (Fig. 1C). Pathology confirmed a benign vascular malformation with lymphatic and venous components (Fig 1D). This diagnosis is more common in the pediatric population but a rare cause of dyspnea and chest pain in a young adult. This case illustrates the value of multimodality imaging and multidisciplinary collaboration among adult and pediatric subspecialists in the diagnosis and treatment of a rare, complex mediastinal mass in a young adult patient.

Circulation, Volume 148, Issue Suppl_1, Page A13272-A13272, November 6, 2023. Background:Patients who have undergone Fontan palliation for single ventricle CHD exhibit reduced cardiac output.Aims:To study the safety and acute hemodynamic effects of enhanced external counterpulsation (EECP) in a cohort of Fontan patients.Methods:Pilot study of adult Fontan patients recruited through the ambulatory clinic at a single, large-volume ACHD center. Patients underwent TTE and measurement of pulmonary blood flow (PBF), a surrogate for cardiac output, followed by 1 hour of EECP divided into 20-minute stages (80 mmHg, 160 mmHg, 240 mmHg). TTE and PBF measurement were repeated at each stage and 15-30 minutes after completion of EECP. Patients were monitored for symptoms throughout the visit. A repeated measures linear-mixed-model (robust to non-normality) was used to estimate the mean at each time point and to test for differences across time points.Results:There were 23 patients enrolled (52% male, 91% cis-gender, 74% White). Mean age at enrollment and at Fontan completion was 33.0 ± 7.8 years and 5.1 ± 4.1 years, respectively. Six patients (26%) had a pacemaker. Twenty-two (96%) completed a full hour of EECP. Pressure was reduced in the third stage for 3 patients due to discomfort. No patients reported chest pain or increased dyspnea during EECP. PBF was increased at each stage of EECP compared to baseline and returned to baseline post-EECP (Fig. 1). There was a small qualitative improvement in ventricular systolic function in the second and third stages of EECP compared to baseline (160 mmHg: p=0.048; 240 mmHg: p=0.024). O2saturation was increased at each stage of EECP compared to baseline (baseline: 93.0%, 80 mmHg: 94.3% [p=0.008], 160 mmHg: 94.6% [p=

Circulation, Volume 148, Issue Suppl_1, Page A15065-A15065, November 6, 2023. Introduction:Unsustained return of spontaneous circulation (ROSC) is a critical barrier to survival in cardiac arrest patients. However, no parameter so far can be used to predict the sustainability of ROSC.Research Questions:End-tidal carbon dioxide (ETCO2) is regarded as an indicator of ROSC in cardiac arrest patients. Pulse oximetry photoplethysmogram (POP) parameters have been shown to be associated with peripheral perfusion in critically ill patients. We hypothesized that the combination of ETCO2and POP parameters might be discriminative for early recognition of patients at risk of unsustained ROSC before rearrest.Aims:This study examined whether ETCO2and POP parameters can be used to identify unsustained ROSC.Methods:We conducted a multicenter observational prospective cohort study of consecutive patients with cardiac arrest managed from 2013 to 2014. Patients’ general information, ETCO2, and POP parameters, including area under the curve (AUCp) and amplitude (Amp) of POP waveform, were collected and statistically analyzed.Results:The included 105 ROSC episodes (from 80 cardiac arrest patients) comprised 51 sustained ROSC episodes and 54 unsustained ROSC episodes. Patients with unsustained ROSC had lower 24-hour survival rate than sustained ROSC patients (11.5% vs. 25.0%, respectively; P

Circulation, Volume 148, Issue Suppl_1, Page A12955-A12955, November 6, 2023. Introduction:Since blood flow through the lungs is passive in patients with the Fontan circulation, cardiac output is sensitive to power loss through the pulmonary vasculature. Prior smallin vitrostudies of how changes in blood viscosity at venous shear rates (“non-Newtonian behavior”) affect power loss have yielded conflicting results. The purpose of this study was to evaluate the extent to which non-Newtonian behavior contributes to power loss in a large number of pediatric patient-specific models of the Fontan circulation.Hypothesis:Shear-dependent changes in blood viscosity cause increased power loss in the low-shear Fontan circulation.Methods:Pulmonary vascular geometry was segmented from clinical cardiac MRI images. Pressure and velocity fields were then calculated using computational fluid dynamic simulations. Cardiac index was set at 2 L/min/m2 to simulate a low cardiac output state. A constant viscosity model (“Newtonian”) was compared to a shear-dependent viscosity model (“non-Newtonian”). Power loss was calculated by simplified power loss (using bulk flow and pressure changes) and viscous dissipation rate (using element-wise shear rates and viscosities). Both metrics were indexed to adjust for cardiac output and body surface area. Wilcoxon signed-rank test was used to compare differences between the two viscosity models.Results:Twenty patients (mean 10.9 years, 35% female) were included. Mean viscosity was nearly 10-fold higher in the non-Newtonian vs. Newtonian simulations (mean non-Newtonian to Newtonian viscosity ratio 9.7, SD 0.6). Accordingly, power loss by both metrics was significantly larger for the non-Newtonian simulations (Figure).Conclusions:Shear-dependent increases in blood viscosity cause increased power loss in computational models of the Fontan circulation under low cardiac output conditions. Further studies are needed to evaluate the degree to which this correlates with clinical outcomes.

Circulation, Volume 148, Issue Suppl_1, Page A315-A315, November 6, 2023. Introduction:Non-traumatic cardiac arrest (NTCA) is associated with low survival and substantial societal cost. Standard-of-care treatments, such as cardiopulmonary resuscitation (CPR) and advanced cardiac life support (ACLS), have limitations in restoring cardiac function and improving outcomes. Resuscitative endovascular balloon occlusion of the aorta (REBOA) has emerged as an adjunct to CPR for NTCA. However, the optimal patient population that will benefit most from REBOA remains uncertain.Goals:This translational study investigated the impact of varying low-flow duration (15- vs 30-mins) on REBOA’s hemodynamic performance and ability to achieve return of spontaneous circulation (ROSC) in a swine model of NTCA.Methods:Thirty-two swine were anesthetized and placed into ventricular fibrillation. All animals received a 4-min “no-flow” period before mechanical CPR was initiated. Animals were randomized into four groups to receive: 1) 15- vs 30-minutes of CPR; 2) REBOA vs. no-REBOA (control). After completion of the 15- or 30-minute low-flow period, ACLS was initiated and REBOA was fully-inflated in experimental animals.Results:There were no differences in demographics or hemodynamics at baseline (T = -10-mins) or at randomization (T = +10-mins). In the 15-mins groups, there were no differences in the rates of ROSC between REBOA (4 / 8, 50%) and control (4 / 8, 50%; p = 0.99). However, in the 30-min group the REBOA animals had a significantly higher rate of ROSC (6 / 8, 75%) compared to control (1 / 8, 12.5%; p = 0.04). In the 7-mins (T = 34 – 41 mins) after REBOA deployment in the 30-min animals there was a statistically significant difference in diastolic blood pressure (repeated measures ANOVA; p = 0.027). Importantly, 5 / 6 (83%) animals that received ROSC in the 30-min group with REBOA re-arrested at least once with 3 / 6 (50%) maintaining ROSC until study completion.Conclusion:In our swine model of NTCA, REBOA preferentially improved hemodynamics and ROSC after a 30-mins period of low-flow CPR, compared to 15-mins of low-flow CPR. REBOA may be a viable strategy to improve ROSC after prolonged downtime. More hemodynamic support will be required to maintain ROSC. This has implications for patient selection in upcoming human trials of REBOA in NTCA.

Circulation, Volume 148, Issue Suppl_1, Page A17257-A17257, November 6, 2023. Background:Aortopulmonary collaterals (APC) are a common source of volume load in patients with a Fontan circulation and their burden can be quantified by CMR. Longitudinal trends in APC flow and their relationship with outcomes have not been described.Hypothesis:Higher APC flow will be associated with worse clinical outcomes in Fontan patients.Aims:To assess longitudinal changes in APC flow in the Fontan circulation using CMR and their relationship with outcomes.Methods:Single-center retrospective analysis of Fontan patients who had at least 1 CMR with APC flow data. APC flow was estimated as the difference between aortic and systemic venous flows and also expressed as a percent of aortic flow. Primary outcome was a composite of death or heart transplantation; secondary outcomes included protein losing enteropathy, ascites, chylothorax, and hemoptysis. The baseline (time at Fontan=time 0) and trend in APC flow were estimated using a linear mixed model with a random intercept and slope for each patient.Results:Analysis included 758 CMRs from 356 patients; 123 of whom had ≥ 2 CMRs. Median age at first CMR was 14 y (IQR 10-19 y) and median CMRs per patient were 2 (range 1-12). Baseline APC flow was 0.6 (±0.5) L/min/m2or 17 (±10) % of aortic flow. Increasing APC flow over time correlated with increasing trend in ventricular dilation and decreasing trend in SaO2. Over a median follow-up of 17 years, 22 patients (6%) had the composite outcome. High baseline APC flow as well as an increasing trend in APC flow were associated with clinical outcomes including an independent association with death or heart transplantation (Table).Conclusions:APCs represent a significant hemodynamic burden in functional single ventricle hearts palliated to the Fontan circulation. Higher and increasing APC flow is associated with worse clinical outcomes. Factors contributing to APC development and whether APC occlusion results in a lasting reduction in the burden remain to be elucidated.

Circulation, Volume 148, Issue Suppl_1, Page A17366-A17366, November 6, 2023. Introduction:The presence of a restrictive atrial septum in the setting of transposition of the great arteries (TGA) is associated with a high risk of hypoxic ischemic injury upon transition to postnatal circulation. Fetal cardiovascular magnetic resonance (CMR) measures of vessel flow and oxygen saturation provide a unique opportunity to study fetal TGA hemodynamics at baseline and during acute maternal hyperoxygenation.Methods:Thirty-one pregnant mothers with fetuses diagnosed with TGA and an intact ventricular septum (n=23) or small ventricular septal defect (n=8) were recruited and underwent fetal CMR in room air and during administration of 10L/min of oxygen by face mask for up to 45 minutes. Blood flow and oxygen saturations were measured in the major fetal vessels using cine phase contrast MRI and MR relaxometry at baseline and during hyperoxygenation.Results:Two patients exhibited severe restriction at the atrial septum, one undergoing fetal atrial septostomy at 37 weeks and one requiring cannulation onto ECMO shortly after birth. Both revealed reversal of the usual relationship of oxygen saturation between the aorta and the main pulmonary artery at baseline and during hyperoxygenation, i.e. in TGA with restrictive atrial septum the saturations are higher in the aorta than pulmonary. Acute maternal supplemental oxygen was associated with increased pulmonary blood flow (p=0.008) and reduced foramen ovale (p=0.01) and ductus arteriosus shunting (p=0.01). There were no significant changes in umbilical vein, descending aorta and superior vena cava flow. Fetal oxygen saturations increased throughout fetal circulation (p

Circulation, Volume 148, Issue Suppl_1, Page A217-A217, November 6, 2023. Background:Current CPR guidelines recommend applying chest compression at “the center of the chest” for patients undergoing out-of-hospital cardiac arrest (OHCA). However, studies revealed that following this recommendation, around half of OHCA patients would receive compressions on the aortic valve (AV), potentially obstructing blood flow and worsening prognosis.Hypothesis and Aim:We aimed to use transesophageal echocardiography (TEE) during cardiopulmonary resuscitation (CPR) to test the hypothesis of the impact of AV compression vs AV non-compression on adult OHCA patients’ outcomes.Methods:This prospective cohort study included OHCA patients receiving TEE exams during CPR. Exclusion criteria were the return of spontaneous circulation (ROSC) before TEE, unidentifiable compression site, or unqualified TEE image. Patients were divided into AV-compressed or non-compressed groups based on initial TEE findings. Patient characteristics, TEE recordings, resuscitation data, and critical time points were analyzed. Primary outcome was sustained ROSC. Secondary outcomes included any ROSC, survival to admission, survival to discharge, and favorable neurological outcomes upon discharge defined by MRS ≤ 2. The sample size was pre-estimated as 37 patients per group.Results:A total of 76 patients from October 2020 to January 2023 were enrolled for analysis, with 39 in the AV non-compressed group and 37 in the AV-compressed group. Baseline characteristics were similar between groups. Compared to the compressed group, the non-compressed group had a better chance of sustained ROSC [adjusted odds ratio (aOR) 4.72, p=0.010], any ROSC (aOR 3.30, p=0.033), and survival to admission (aOR 6.74, p=0.010). The main results were tabulated as below.Conclusions:CPR with compressed AV decreased the chances of ROSC among OHCA patients.

Circulation, Volume 148, Issue Suppl_1, Page A136-A136, November 6, 2023. Introduction:High value of end-tidal carbon dioxide (EtCO2), measured at the end of a tracheal tube, is closely associated with return of spontaneous circulation (ROSC) in out-of-hospital cardiac arrest (OHCA) resuscitation. The aim of this study was to evaluate whether EtCO2 measured at the face mask (FM) before an intubation procedure, may also predict ROSC in OHCA.Material and Methods:This was a prospective non-interventional study. Between May 1st2022 and January 30th2023, all patients ≥ 18 years with an OHCA on EMS arrival and for whom a laryngoscopy for tracheal intubation was considered, were included. An EtCO2 sensor was directly placed between the valve of the bag-valve-mask and the FM while cardiopulmonary resuscitation was continued. Age, gender, initial rhythm, ROSC on scene and last EtCO2 at the FM (FM-EtCO2) value before laryngoscopy were collected. Patients were assigned to 3 groups: FM-EtCO2 < 10 mmHg ; 10 mmHg

Circulation, Volume 148, Issue Suppl_1, Page A297-A297, November 6, 2023. Introduction:Unsustained return of spontaneous circulation (ROSC) is a critical barrier to survival in cardiac arrest patients. However, no parameter so far can be used to predict the sustainability of ROSC.Research Questions:end-tidal carbon dioxide (ETCO2) is regarded as an indicator of ROSC in cardiac arrest patients. pulse oximetry photoplethysmogram (POP) parameters have been shown to be associated with peripheral perfusion in critically ill patients. We hypothesized that the combination of ETCO2and POP parameters might be discriminative for early recognition of patients at risk of unsustained ROSC before rearrest.Aims:This study examined whether ETCO2and POP parameters can be used to identify unsustained ROSC.Methods:We conducted a multicenter observational prospective cohort study of consecutive patients with cardiac arrest managed from 2013 to 2014. Patients’ general information, ETCO2, and POP parameters, including area under the curve (AUCp) and amplitude (Amp) of POP waveform, were collected and statistically analyzed.Results:The included 105 ROSC episodes (from 80 cardiac arrest patients) comprised 51 sustained ROSC episodes and 54 unsustained ROSC episodes. Patients with unsustained ROSC had lower 24-hour survival rate than sustained ROSC patients (11.5% vs. 25.0%, respectively; P

Circulation, Volume 148, Issue Suppl_1, Page A408-A408, November 6, 2023. Aim:This work provides an epidemiological overview of out-of-hospital cardiac arrest (OHCA) in children in Germany between 2007 and 2021. We wanted to identify modifiable factors associated with survival.Methods:Data from the German Resuscitation Registry (GRR) was used, and we included patients registered between 1stJanuary 2007 and 31stDecember 2021. We included children aged >7 days and

Circulation, Volume 148, Issue Suppl_1, Page A210-A210, November 6, 2023. Background:Free fatty acids (FFA) are a known risk factor in the development of sudden cardiac death. However, the relationship between FFA and the outcome of out-of-hospital cardiac arrest (OHCA) patients remains unclear. We aimed to examine the association between FFA and neurological outcomes in OHCA patients.Methods:This prospective observational study included adult (≥ 18 years) OHCA patients between February 2016 and December 2022. We measured serial FFA levels within 1 h after ROSC and at 6 h, 12 h, 24 h, 48 h, and 72 h after the return of spontaneous circulation (ROSC). The primary outcome was neurological outcome at 6 months. A poor neurological outcome was defined by cerebral performance categories 3, 4, and 5.Results:A total of 147 patients were included. Of them, 104 (70.7%) had poor neurological outcomes, whereby the median FFA levels within 1 h after ROSC (0.72 vs. 1.01 mol/L), at 6 h (1.19 vs. 1.90 mol/L), 12 h (1.20 vs. 1.66 mol/L), and 24 h (1.20 vs. 1.95 mol/L) after ROSC were significantly lower than in good outcome group. The FFA levels at 6 h (odds ratio [OR], 0.583; 95% confidence interval [CI], 0.370-0.919; P = 0.020), and 12 h (OR, 0.509; 95% CI, 0.303-0.854; P = 0.011) after ROSC were independently associated with poor neurological outcomes.Conclusions:The lower FFA levels at 6 h and 12 h after ROSC were associated with poor neurological outcomes in patients with OHCA. FFA may reflect oxidative metabolism as well as oxidative stress.

Circulation, Volume 148, Issue Suppl_1, Page A15269-A15269, November 6, 2023. Background:The clinical care of adults with a systemic right ventricle with biventricular circulation (sRV-biV) is influenced by cardiorespiratory fitness (CRF) evaluation. However, prognostic markers for CRF are derived from analyses of adults with a systemic left ventricle (sLV). While some studies suggest that CRF is lower in adults with sRV-biV compared to those with a sLV, they have not controlled for key clinical characteristics and ventricular function of the systemic ventricle.Research Question:Is CRF lower in adults with a sRV-biV compared to adults with sLV matched for clinical characteristics and systemic ventricular function?Methods:A retrospective cross-sectional comparison of exercise stress test results was performed comparing 24 adults with sRV-biV to 24 adults with a sLV matched for sex (4 females), age (sRV-biV: 46 ± 9 years, sLV: 46 ± 11 years), body mass index (sRV-biV: 28 ± 4 kg/m2, sLV: 27 ± 4 kg/m2), ejection fraction of the systemic ventricle (normal: 2, mild: 4, moderate: 11, severe: 7), NYHA class (I: 6, II: 17, III: 1), and doses of diuretics (spironolactone ≤ 25 mg: 24, furosemide ≤ 80 mg: 24 ). Peak VO2was compared between groups with Wilcoxon signed-rank tests. Effect sizes are reported as Cohen’sd.Results:Peak VO2did not differ significantly between groups (sRV-biV: 20.3 ± 4.2 vs. sLV: 20.9 ± 6.0 mL/kg/min, p=0.43,d=0.18). When patients were dichotomized according to the Weber criterion for optimal versus suboptimal CRF (sLV peak VO2 > or ≤ 20 mL/kg/min), peak VO2was lower in sRV-biV in those with optimal CRF (sRV-biV: 21.0 ± 4.8 vs sLV: 26.6 ± 5.1 mL/kg/min, p=0.006,d=0.72). In contrast, peak VO2was greater in sRV-biV in those with suboptimal CRF (sRV-biV: 19.3 ± 3.5 vs. sLV: 16.9 ± 2.0 mL/kg/min, p=0.12,d=NA).Conclusion:Although peak VO2values are similar among patients with a sRV-biV and matched controls with a sLV, differences are observed when stratified according to the Weber criteria for optimal CRF. These results may reflect different pathophysiological adaptive mechanisms of a sRV vs sLV. Further studies are required to establish specific prognostic thresholds for patients with sRV-biV.

Circulation, Volume 148, Issue 16, Page 1254-1258, October 17, 2023.

Circulation, Volume 148, Issue 10, Page 848-851, September 5, 2023.

Stroke, Ahead of Print. BACKGROUND:Endovascular treatment (EVT) for acute ischemic stroke (AIS) patients presenting with National Institutes of Health Stroke Scale score of 0 to 5 is common in clinical practice but has not yet been proven safe and effective. Our objective is to assess whether EVT on top of best medical treatment (BMT) in AIS patients with large-vessel occlusion of the anterior circulation presenting with mild symptoms is beneficial compared with BMT.METHODS:We searched MEDLINE, SCOPUS, and reference lists of retrieved articles published until December 28, 2022. A systematic literature search was conducted to identify clinical trials or observational cohort studies evaluating patients with AIS due to anterior circulation large-vessel occlusion and admission National Institutes of Health Stroke Scale score ≤5 treated with EVT versus BMT alone. The primary outcome was excellent functional outcome (modified Rankin Scale score 0–1) at 3 months. The protocol had been registered before data collection (PROSPERO).RESULTS:Eleven observational eligible studies were included in the meta-analysis, comprising a total of 2019 AIS patients with National Institutes of Health Stroke Scale score ≤5 treated with EVT versus 3171 patients treated with BMT. EVT was not associated with excellent functional outcome (risk ratio, 1.10 [95% CI, 0.93–1.31]). When stratified for different study design (per-protocol versus intention-to-treat), there were no significant subgroup differences. EVT was not associated with good functional outcome (modified Rankin Scale score 0–2; risk ratio, 1.01 [95% CI, 0.89–1.16]) or reduced disability at 3 months (common odds ratio, 0.92 [95% CI, 0.60–1.41]). Symptomatic intracranial hemorrhage was more common in the patients receiving EVT (risk ratio, 3.53 [95% CI, 2.35–5.31]). No correlation was found between EVT and mortality at 3 months (risk ratio, 1.34 [95% CI, 0.83–2.18]). The same overall associations were confirmed in the sensitivity analysis of studies that performed propensity score matching.CONCLUSIONS:EVT appears equivalent to BMT for patients with anterior circulation large-vessel occlusion AIS with low baseline National Institutes of Health Stroke Scale, despite the increased risk for symptomatic intracranial hemorrhage.Registration:URL:https://www.crd.york.ac.uk/PROSPERO/; Unique identifier: CRD42022334417.