Risultati per: Circulation

Stroke, Volume 55, Issue Suppl_1, Page A153-A153, February 1, 2024. Objective:To determine whether first pass effect (FPE) after mechanical thrombectomy (MT) for anterior circulation large vessel occlusion acute ischemic stroke (LVO-AIS) is modified by procedural time (PT).Methods:The Stroke Thrombectomy and Aneurysm Registry (STAR), a multi-center international dataset, was retrospectively analyzed for anterior circulation LVO-AIS treated by MT who achieved excellent reperfusion (TICI 2c/3). The primary outcome was good functional outcome as defined by a 90-day modified Rankin Scale (mRS) 0-2. The primary study exposure was first pass success (FPS, 1 pass vs ≥2 passes) and the secondary exposure was PT. Logistic regression models were fit-adjusted and marginal effects used to assess the interaction of PT (≤30 vs >30 minutes) and FPS, adjusting for potential confounders including time from last known well to start of MT.Results:A total of 1,310 patients had excellent reperfusion. These patients were divided into two cohorts based on PT: ≤30 minutes (777 patients, 59.3%) and > 30 minutes (533 patients, 40.7%). Good functional outcome was observed in 658 patients (50.2%). The interaction term between FPS and PT was significant (p=0.018). Individuals with FPS in ≤30 minutes had 11.5% higher adjusted predicted probability of good outcome compared with those who required ≥2 passes (58.2% vs. 46.7%, p=0.001). However, there was no significant difference in the adjusted predicted probability of good outcome based on FPS in individuals with PT >30 minutes (p=0.763). This relationship appeared identical in models with PT treated as a continuous variable.Conclusion:In a large, real-world, multi-national dataset, we find that FPE is importantly modified by PT. The added clinical benefit of FPE is lost in longer procedures ( >30 minutes). These data argue for a new metric for MT procedures, namely, FPE30, that better represents the ideal of fast, complete reperfusion with a single pass of a thrombectomy device.

Stroke, Volume 55, Issue Suppl_1, Page ATP175-ATP175, February 1, 2024. Background:Older patients with acute stroke due to anterior circulation large vessel occlusion (ACLVO) experience worse clinical outcomes. Fast progressors typically present early with high stroke severity and larger ischemic core volumes. However, the relationship between aging and early infarct growth rate is unknown. We examined the association between older age, baseline ischemic core volumes and fast or slow infarct growth during ACLVO.Methods:Retrospective study of patients with acute ICA or MCA occlusion across two academic centers in 2014-2019. Patients were included if they had baseline CTP or MRI within 24 hours after estimated stroke onset. Infarct growth rate (IGR) was calculated as ischemic core volume (ml) / stroke onset to imaging time (h). Fast or Slow progressor status was defined by IGR ≥ or < 10 ml/h. Univariate comparisons were made across age tertiles. Multivariable linear and logistic regression analysis examined the association of age tertile with ischemic core volume and slow progressor status adjusting for sex, vascular co-morbidities and NIHSS.Results:We included 312 patients (57% female; age tertiles [T1-T3]: 33—66, 67—81, and 82—102). Older age was associated with decreasing ischemic core volume (median [range] ml: T1, 29 [0-253]; T2, 12 [0-406]; T3, 6 [0-244]; p

Stroke, Volume 55, Issue Suppl_1, Page ATP252-ATP252, February 1, 2024. Objective:Forward head posturing (FHP) has been associated with chronic anatomic vertebral artery disturbances possibly leading to posterior circulation ischemia. The data supporting FHP as a true risk factor of posterior circulation stroke has not been well established. We aim to study if patients with severe cervical myalgias and FHP have an increased risk of posterior circulation stroke.Methods:We identified all adult patients with posterior circulation stroke and diagnosis of cervical myalgia at Loyola University Medical Center from January 2018 to January 2023. Information on demographics and comorbidities were also collected. We then identified matched pair case-controls (based on age and gender) with non-stroke cervical myalgia patients in the same 5-year period. We compared the relevant comorbidities, C2 tilt angle, and C2-C7 tilt angle of patients to their matched controls to for statistical difference.Results:76 patients (38 cases and 38 controls) with an average age of 64 years, including 38 (50%) females met our inclusion criteria. The average C2 tilt of cases was 22.9 degrees compared to 17.7 degrees in controls, and the average C2-C7 tilt of cases was 18.9 degrees in cases compared 10.5 degrees in controls. There were no significant differences between relevant comorbidities (including hypertension, hyperlipidemia, diabetes, atrial fibrillation, hyper-coagulopathy, or body mass index) of cases and controls. There was a significant difference of 5.2 degrees higher C2 tilt and 8.1 degrees higher C2-C7 tilt in cases compared to controls respectively (p-value = 0.03).Conclusion:In this single-center retrospective analysis, we found that after controlling for age, gender, and comorbidities, patients with posterior circulation stroke were more likely to have significantly higher C2 and C2-C7 cervical tilt (worse FHP based on radiographic standards) compared to their matched control counterparts.

Circulation, Volume 149, Issue 2, Page 155-159, January 9, 2024.

Stroke, Ahead of Print. BACKGROUND:The effectiveness of intravenous thrombolysis (IVT) before endovascular treatment (EVT) has been investigated in randomized trials and meta-analyses. These studies mainly concerned anterior circulation occlusions. We aimed to investigate clinical, technical, and safety outcomes of IVT before EVT in posterior circulation occlusions in a nationwide registry.METHODS:Patients were included from the MR CLEAN Registry (Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands), a nationwide, prospective, multicenter registry of patients with acute ischemic stroke due to a large intracranial vessel occlusion receiving EVT between 2014 and 2019. All patients with a posterior circulation occlusion were included. Primary outcome was a shift toward better functional outcome on the modified Rankin Scale at 90 days. Secondary outcomes were favorable functional outcome (modified Rankin Scale scores, 0–3), occurrence of symptomatic intracranial hemorrhages, successful reperfusion (extended Thrombolysis in Cerebral Ischemia ≥2B), first-attempt successful reperfusion, and mortality at 90 days. Regression analyses with adjustments based on univariable analyses and literature were applied.RESULTS:A total of 248 patients were included, who received either IVT (n=125) or no IVT (n=123) before EVT. Results show no differences in a shift on the modified Rankin Scale (adjusted common odds ratio, 1.04 [95% CI, 0.61–1.76]). Although symptomatic intracranial hemorrhages occurred more often in the IVT group (4.8% versus 2.4%), regression analysis did not show a significant difference (adjusted odds ratio, 1.65 [95% CI, 0.33–8.35]). Successful reperfusion, favorable functional outcome, first-attempt successful reperfusion, and mortality did not differ between patients treated with and without IVT.CONCLUSIONS:We found no significant differences in clinical, technical, and safety outcomes between patients with a large vessel occlusion in the posterior circulation treated with or without IVT before EVT. Our results are in line with the literature on the anterior circulation.

Annals of Internal Medicine, Ahead of Print.

Annals of Internal Medicine, Ahead of Print.

Circulation, Volume 149, Issue 1, Page 1-3, January 2, 2024.

Circulation, Ahead of Print.

Circulation, Volume 148, Issue 25, Page 2058-2063, December 19, 2023.

Circulation, Volume 148, Issue 20, Page 1593-1597, November 14, 2023.

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 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 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 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.