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Circulation, Volume 146, Issue Suppl_1, Page A10960-A10960, November 8, 2022. Introduction:Lymphatic complications are common in patients with Fontan circulation. 3D balanced steady-state free precession (3D-bSSFP) angiography by cardiovascular magnetic resonance (CMR) is widely adopted for cardiovascular anatomical assessment. We sought to determine the frequency of thoracic duct visualization using 3D bSSFP images and assess whether thoracic duct characteristics are markers of poor clinical outcomes.Methods:This was a retrospective, single-center study of patients with Fontan circulation who underwent CMR. Patients with repaired tetralogy of Fallot (rTOF) were included as a comparison. Thoracic duct characteristics included maximum diameter and a qualitative assessment of tortuosity (Figure). Clinical outcomes included protein-losing enteropathy (PLE), plastic bronchitis, listing for heart transplant, or death. A composite outcome was defined as presence of any of the above.Results:The study group was comprised of 189 Fontan patients and 36 rTOF patients (median age at CMR 16 years, IQR: 11-23 years). The thoracic duct diameter was larger (median 2.50 vs 1.95 mm, p

Circulation, Volume 146, Issue Suppl_1, Page A219-A219, November 8, 2022. Purpose:Effectiveness of cardiopulmonary resuscitation (CPR) is associated to return of spontaneous circulation (ROSC), but the alignment of the characteristics of compressions (rate and depth) to AHA recommendations has not been proven to improve outcome. In this study the power of the near infrared spectroscopy to discriminate productive CPR, i.e. chest compression sequences leading to ROSC, was evaluated.Material and methods:The cerebral oxygen saturation (rSO2) measured in both cerebral lobules was recorded with the Nonin SenSmart 100X oximeter by Emergentziak-Osakidetza, the emergency service of the Basque Country, in the out-of-hospital cardiac arrest (OHCA). Concurrently, the ECG and bioimpedance were recorded by the Lifepak 15 desfibrillator. Chest compressions were delivered by Lucas 2 & Lucas 3 devices. Sequences of compressions longer than 30 s were extracted, and changes in the left (rSO2,L) and right (rSO2,R) lobes were automatically computed by signal processing. The increase of rSO2, measured every 4 s during the CPR-sequence, was adjusted with linear regression and compared for ROSC/no-ROSC patients as registered in the emergency department (ED).Results:Chest compression intervals were identified in the bioimpedance, and 403 CPR-segments were extracted from 115 patients (80 from 43 patients with ED-ROSC) with a mean(std) duration of 2.46(1.07) min. The median(IQR) increase of brain saturation per patient, rSO2,Land rSO2,R, were 2.1(1.1-5.5) and 1.9(0.9-3.8) points. The figure shows the linear adjustment of the evolutions for both ROSC/no-ROSC groups, with slopes of: 1.81 vs 1.23 min-1for ΔrSO2,L(p >0.05), 1.78 vs 0.95 min-1(p

Circulation, Volume 146, Issue Suppl_1, Page A13028-A13028, November 8, 2022. Introduction:Adolescents and adults with a Fontan circulation demonstrate broad cognitive dysfunction. Neurological alterations and risk factors associated with worse outcomes are poorly characterized. Persisting hypoxemia and reduced exercise tolerance are also common and are associated with long-term morbidity and mortality. This study investigated white matter (WM) microstructure in adolescents and adults with a Fontan circulation and associations with CPET data and cognitive functioning.Methods:Ninety-two participants with a Fontan circulation (aged 13-49 years) underwent diffusion brain MRI. Diffusion tensor imaging MRI metrics were computed for 34 WM tracts of interest; Lower FA and higher MD and RD typically infers WM axonal injury and/or demyelination. RestingSaO2,peak exercise SaO2, and % predicted peak VO2(%pred VO2) were measured during CPET. Processing speed and executive function were assessed using Cogstate.Results:Mean resting and peak SaO2were 93.1% (± 3.81) and 90.1% (± 4.71) respectively and mean %pred VO2was 62.7% (± 18.5); all were significantly lower for participants with a patent fenestration compared to those without (p < 0.05). Mean processing speed and executive function z-scores were -0.72 (± 1.44) and -0.43 (± 1.09), respectively. Significant associations were identified between i) resting SaO2and the left corticospinal tract (CST) and bilateral superior longitudinal fasciculus I (SLF-I) ii) peak SaO2and bilateral CST, frontopontine tract, and SLF-I and -II, and the right SLF-III, and iii) %pred VO2and the right cingulum and left uncinate fasciculus (p < 0.05), whereby lower resting and peak SaO2and %pred VO2were associated with lower FA and/or higher MD and RD. Paradoxical associations were identified between processing speed and executive function and WM tract metrics (p < 0.05).Conclusion:Persisting hypoxemia and exercise intolerance may have long-term detrimental impact on WM microstructure in people with a Fontan circulation. Paradoxical associations between cognitive functioning and DTI-based metrics could be suggestive of compensatory WM remodeling. Longitudinal investigations are required to investigate the mechanisms and trajectory of altered WM microstructure in this cohort.

Circulation, Volume 146, Issue Suppl_1, Page A10515-A10515, November 8, 2022. Introduction:The prevalence and significance of mechanical dyssynchrony is not well known in the Fontan population.Methods:Single-center, retrospective analysis of CMRs in Fontan patients compared to healthy controls. Feature tracking was performed on all slices of a short-axis cine stack and dyssynchrony index (DI) was defined as the standard deviation of time-to-peak circumferential strain for all segments. A composite outcome was defined as death, heart transplant listing, or new ventricular arrhythmias.Results:A total of 512 cases (17±9 y) and 42 controls (16±9 y) were included. Figure 1 depicts differences in EDVi, EF, DI, and QRS duration between the cohorts. DI correlated with EDVi(r=0.35; p

Circulation, Volume 146, Issue Suppl_1, Page A15584-A15584, November 8, 2022. Introduction:Patients born with a range of cardiac defects, not amenable to biventricular repair are palliated with establishment of Fontan circulation. Although majority of patients with Fontan circulation survive childhood, eventually they experience multi-system dysfunction, mainly frailty, impaired exercise capacity, blunted exercise-augmented hemodynamics, progressive liver fibrosis, and shortened survival. Fontan circulation associated biochemical abnormalities have not been well described.Materials and Methods:Twenty adult patients with Fontan circulation and 20 age- and sex-matched healthy subjects underwent a non-targeted metabolomics assessment using an LC-QTOF-MS system to detect potential Fontan-related biomarkers. These study participants were also investigated for markers of frailty, cardiopulmonary exercise testing, and resting as well as exercise-augmented hemodynamic evaluation.Results:A total of 1679 known plasma metabolites were detected in electrospray positive and negative modes among which 37 metabolites were significantly different (T-Test Unpaired (p

Circulation, Volume 146, Issue Suppl_1, Page A200-A200, November 8, 2022. Introduction:Transesophageal echocardiography (TEE) has been proposed as a tool ideally suited for imaging patients during cardiac arrest (CA) resuscitation, allowing for the evaluation of the area of maximal compression (AMC) during CPR. Previous work has shown that compression of the left-ventricular outflow tract (LVOT) or the aortic root during CPR (AMC-LVOT/Ao) occurs in over 50% of patients; animal trials and small single-center retrospective clinical study have linked this finding to lower rates of ROSC. We aimed to prospectively investigate the AMC and its association with ROSC. We hypothesized that patients who have AMC-LVOT/Ao have lower likelihood of ROSC.Methods:A prospective, observational, multicenter cohort study involving patients with out-of-hospital CA (OHCA) in whom TEE was performed during CPR. The study aimed to compare patients with AMC over the LV (AMC-LV) vs AMC-LVOT/Ao and was conducted through a collaborative research network involving 16 hospitals (NCT04972526). Data was collected on clinical and TEE characteristics and findings. Primary outcome was ROSC. We performed univariate analysis followed by multivariate regression model evaluating variables known to impact resuscitation outcomes.Results:Eighty-four patients were included in the analysis. Mean age 62 (46-72), 28% female, 71% had witnessed arrest, 60% had bystander CPR, 47% had mechanical CPR. Overall 26 patients (32%) had ROSC. Initial AMC during CPR was determined in 55/84 (65%) patients, of whom 33 (60%) had AMC-LV, 18 (33%) had AMC-LVOT/Ao, and 4 (7%) had other locations. There was no significant difference in AMC when analyzed by demographic characteristics, height, weight or between patients who received manual vs mechanical CPR. In multivariate regression controlling for age, race, gender, initial rhythm of arrest, level of TEE operator, doses of epinephrine, now-flow time, and total time of arrest, AMC-LVOT/Ao was significantly associated with lower ROSC probability (OR 0.06, 95% CI 0.01-0.4; p=0.009).Conclusion:In this multicenter, prospective study of patients with OHCA, TEE-guided resuscitation showed a strong association between the AMC and ROSC.

Circulation, Volume 146, Issue Suppl_1, Page A13035-A13035, November 8, 2022. Mechanical circulatory support (MCS) is rarely used in adults with congenital heart disease and even more uncommon among those with single ventricle (e.g. Fontan) circulation. As survivorship among Fontan patients increases, evaluation for MCS is warranted. This systematic review’s objective is to study the outcomes of adult Fontan patients supported by MCS. METHODS We searched the literature in English in PubMed and Google Scholar in May 21 & 2, 2022 using MeSH terms: “VAD,” “Fontan,” and “circulatory assist device.” The search yielded 2785 results. After screening for title, abstract, patient age ( >18 y/o), and extractable individual patient data, 23 reports met the criteria. Ultimately, 15 full texts were reviewed and included in this report. RESULTS We identified 18 patients on MCS, including 7 on short-term devices (Impella), 4 on paracorporeal pulsatile devices (PPDs), and 7 on durable continuous flow ventricular assist devices (VADs). Short-term pumps were used for cardiogenic shock (5, with 3 survivors) or support of high-risk ablation procedures. PPDs were used as a bridge to transplantation, mean patient age of 23.5±3.4 years old; all survived after a mean time on MCS of 172±158 days.In the VAD cohort (7 patients, 85.7% males, age 25.1±4.0), 5 received Heartmate 3, one received Heartmate II, and one Heartware (Table 1). Indications for VAD included cardiogenic shock (4 patients, 2 on VA ECMO) or heart failure. VADs dramatically increased cardiac index from 1.6±0.14 to 3.6±0.1 L/min/m2, p=0.0003, and decreased Fontan pressure from 21.4±3.3 to 13.0±1.4 mmHg, p=0.02. Heartmate 3 mean speed was 6460±568.3 rpm. All patients survived, with mean time on VAD lasting 459.5±452.2 days. CONCLUSIONS Implanted mostly for catastrophic indications, adult Fontan patients demonstrated improved hemodynamics and excellent survival following MCS use. These improvements are promising, and earlier implantation prior to catastrophic events may lead to better outcomes.

Circulation, Volume 146, Issue Suppl_1, Page A10572-A10572, November 8, 2022. Introduction:Diversity and inclusion remain a concern in the field of cardiology. Female cardiologists have less opportunity to chair sessions in scientific meetings than men. However, cardiologists’ awareness and perspectives on feasibility of chairing sessions is poorly understood.Methods:A web-based survey on awareness regarding the commitment of chairing sessions was sent to 14,798 certificated cardiologists registered with the Japanese Circulation Society (JCS).Results:A total of 3,412 valid responses were obtained, including 523 women and 2,889 men. Female cardiologists exhibited less interest in serving as chairpersons in Japanese and English sessions (71% women vs. 82% men, P

Circulation, Volume 146, Issue Suppl_1, Page A218-A218, November 8, 2022. Background:Pulseless electrical activity (PEA) is a heterogeneous clinical state and increasingly observed during resuscitation from cardiac arrest. The aim of this study was to investigate whether the presence or emergence of sinus rhythm in patients with PEA influenced the likelihood of return of spontaneous circulation (ROSC).Methods:Single-lead ECGs were registered during resuscitation from in-hospital cardiac arrests (IHCAs) with PEA. We analyzed evidence of atrial/sinus rhythm as the presence or emergence of P-waves; expressed along the resuscitation timeline as a prevalence (between 0 and 1) during the preceding minute. This information was entered along with QRS-duration as a continuous, time-dependent covariate in an exponential multistate time-to-event model. We employed the software R version 4.1 for the statistical analyses.Results:99 episodes of CA from 90 patients were analyzed. We identified 189 segments of PEA without sinus rhythm and 52 segments with sinus rhythm. Almost none had sinus rhythm initially; usually it emerged as a response to resuscitation. Among segments with sinus rhythm, 22 transitioned to ROSC (42 %) while 55 without sinus rhythm transitioned to ROSC (29 %).According to the exponential model, a one-unit increase in the prevalence of sinus rhythm increased the chance of developing ROSC by a factor of 2.5 (95% CI 1.33-4.72).Conclusion:The emergence of sinus rhythm during treatment of PEA increases the probability of gaining ROSC. Sinus rhythm seems to be an intermediate stage in the development from PEA to ROSC. Sinus rhythm is easy to identify during cardiac arrest and may serve as a marker of treatment response. Occurrence of PEA with atrial rhythm during CA should encourage continuation of resuscitation.Figure:Left column displays rhythms before PEA with SR and right column displays rhythms following PEA with SR.Green: ROSC. Orange: PEA with sinus rhythm. Yellow: PEA. Red: VT/VF. Grey: ASY. Dark grey: Death.

Circulation, Volume 146, Issue Suppl_1, Page A221-A221, November 8, 2022. Introduction:Several factors are known to influence return of spontaneous circulation (ROSC) following out-of-hospital (OHCA) and in-hospital cardiac arrest (IHCA). Machine learning (ML) methods are capable of analyzing large datasets to elucidate the clinical and prognostic value of specific variables. In cardiac arrest, ML may help identify predictors of ROSC in OCHA and ICHA.Purpose:The present systematic review summarizes the literature on ML algorithms used to predict ROSC in OHCA and IHCA.Methods:PubMed, EMBASE, Web of Science, and Cochrane were searched to identify articles. Studies on human subjects with OHCA or IHCA which used ML methods to predict ROSC were included.Results:A total of 4,094 studies were identified through a literature search. Ten were included in the final analysis with a total sample size of 240,798 patients (240,798 (93%) male). Studies used logistic regression (n=7), random forest models (n=2), or deep learning (n=1). Sociodemographic variables beyond age (n=8) and sex (n=5) were not used. Variables used for predicting ROSC included age (n=8), type of rhythm (n=7), witnessed arrest (n=5), and time to emergency services arrival (n=5). Most models were built using data from OHCA patients (n=7), with only three focused on IHCA. Studies utilized a variety of parameters for reporting the prognostic value of their models, including predictive accuracy (69%-99%), area under the receiver operating characteristic curve (0.71-0.83), sensitivity (50.2%-76.0%), and specificity (61.0%-92.9%).Conclusion:Despite the prevalence of cardiac arrest and advances in AI, only ten studies examined ML in the prognostication of ROSC. Logistic regression was predominantly used in the included studies, and there is a paucity of data on the efficacy of deep learning models. Furthermore, heterogeneity in the predictive efficacy of studied ML models merits additional work and the need for large-scale trials comparing ML to conventional methods and clinician judgment. Critically, there is also a need for greater data inclusivity in model development, understanding that marginalized populations are less likely to receive CPR.

Circulation, Volume 146, Issue Suppl_1, Page A11115-A11115, November 8, 2022. Introduction:The ventricular fibrillation (VF) often occurs in acute heart failure patients with Impella support, percutaneous transvalvular left ventricular assist device. Although Impella can preserve blood pressure in some VF patients, the hemodynamic mechanism of Impella during VF remains unclear.Aim:In this study, we examined the impact of Impella on hemodynamics and cerebral and coronary blood flows in a goat model of VF. We also addressed the optimal blood volume status to maintain the Impella circulation during VF.Methods:In six goats, we inserted Impella CP via the left carotid artery. We simultaneously recorded right (RAP) and left atrial pressure (LAP), central blood pressure at ascending aorta (CBP), and the blood flows of pulmonary artery (PA), left coronary circumflex artery (LCX), and right carotid artery (CA). The VF was induced by direct current. We compared the impact of Impella support level (P0, P4 and P8) on hemodynamics and each blood flow. Under P8-Impella supported VF condition, we withdrew blood continuously and observed the left ventricular (LV) suction point at which a frequent negative LV pressure occurred.Results:As shown in Fig. 1 and 2, Impella maintained hemodynamics flow-dependently, indicating the establishment of acute Fontan circulation. In P8-Impella support, systemic (PA flow), LCX and CA blood flows were preserved by 50.1±27.7, 50.7±12.5 and 67.3±5.6%. from baseline, respectively. The blood volume reduction induced the suction of Impella (Fig. 3) at RAP below 9.9±1.9 mmHg.Conclusions:Impella establishes the acute Fontan circulation and preserves hemodynamics including coronary and cerebral blood flows during VF. The optimal blood volume status should be considered to maintain the Impella operation during VF.

Circulation, Volume 146, Issue Suppl_1, Page A151-A151, November 8, 2022. Background:Survival with favorable neurological outcomes is one of the goals in patients with out-of-hospital cardiac arrest (OHCA). Although previous studies have shown that a chance of neurologically intact survival was significantly lower at nighttime than at daytime in patients with OHCA, details are uncertain. The aim of this study was to evaluate the effect of time from collapse to prehospital return of spontaneous circulation (ROSC) on neurologically favorable survival in patients with OHCA at nighttime versus daytime.Methods:Using a nationwide OHCA registry database from 2005 to 2020 in Japan, a cohort of 1,902,986 patients with OHCA were retrospectively screened. In the present study, a total of 128,180 patients with witnessed OHCA who achieved prehospital ROSC were included. Nighttime was defined as 6:00 pm through 5:59 am. Neurologically favorable survival was defined as cerebral performance category score of 1 or 2 at 1 month.Results:Patients with witnessed OHCA at nighttime were likely to be younger (70.3±16.0 vs. 72.7±15.3 years, p

Circulation, Volume 146, Issue Suppl_1, Page A15324-A15324, November 8, 2022. Introduction:Single ventricle congenital heart disease such as hypoplastic left heart syndrome (HLHS) with a Fontan circulation accounts for the largest group of children hospitalized with circulation failure, with an in-hospital mortality of 20-50%. We sought to (i) evaluate the mechanisms underlying circulation failure and (ii) identify novel therapeutic targets.Methods:Blood was collected from patients with HLHS s/p Fontan and from controls with normal cardiac anatomy and function (N=5/group). Plasma microvesicles (MV) were isolated and proteomics assessed using data independent acquisition mass spectroscopy. Dysregulated proteins with a fold change >1.5 or < -1.5, p

Circulation, Volume 146, Issue Suppl_1, Page A157-A157, November 8, 2022. Background:Out-of-hospital cardiac arrest (OHCA) patients with acute coronary syndrome (ACS) needs emergent coronary angiography and subsequent percutaneous coronary intervention to improve their outcomes. ‘STEMI equivalents’ in electrocardiogram (ECG) are known to help the diagnosis of ACS. However, these findings have not been sufficiently evaluated among OHCA patients. This study aimed to evaluate the diagnostic test accuracy (DTA) of ‘STEMI equivalents’ to identify ACS among OHCA patients without ST-segment elevation.Methods/Results:Nine emergency medical departments among the Comprehensive Registry of In-Hospital Intensive Care for OHCA Survival (CRITICAL) study in Osaka, Japan collected the patients’ first 12 leads ECGs after return of spontaneous circulation (ROSC) from 2012 to 2017. Patients with non-traumatic OHCA aged >=18 years old with ventricular fibrillation / pulseless ventricular tachycardia as first documented rhythm or rhythm at hospital arrival were included. Of them, patients without ST-segment elevation nor complete left bundle branch block were extracted. The DTAs; sensitivity, specificity, positive likelihood ratio (LR+), and negative and likelihood ratio (LR-) of STEMI equivalents (i.e., Isolated T-wave inversion, Wellens signs) for the diagnosis of the ACS were evaluated. ACS was diagnosed by the physicians in each hospital based on the coronary angiography.Results:A total of 143 cases were included in the analysis and 79 patients were diagnosed as ACS. Isolated T-wave inversion was found in 7 (3.2%) patients in the ACS group and 3 (8.8%) in the non-ACS group. The Wellens signs was present in 5 (6.3%) and 5 (7.8%) patients, respectively. The isolated T-wave inversion and the Wellens signs had high specificity with 0.95 (95% CI: 0.87-0.99) and 0.92 (95% CI: 0.82-0.97), whereas these findings had low LR+ with wide range of 95% CI with 1.89 (95% CI: 0.51-7.02), and 0.81 (95% CI: 0.25-2.68), respectively.Conclusion:In this study, the DTA of STEMI equivalents of single 12 leads ECG alone were not sufficient for the diagnosis of ACS after ROSC among OHCA patients without ST-segment elevation. Further investigation of the DTA evaluation considering the measurement timing and the change of the ECG is needed.

Circulation, Volume 146, Issue Suppl_1, Page A320-A320, November 8, 2022. Introduction:Literature on neuroprognostication suggests that gray-white matter ratio (GWR) measured from head computed tomography (CT) within two hours after return of spontaneous circulation (ROSC) can’t adequately predict neurological outcomes in out-of-hospital cardiac arrest (OHCA) patients. However, severe cerebral edema may predict poor outcomes within two hours after ROSC.Hypothesis:We evaluated if GWR measurements obtained early after OHCA (≤ 2 hours) indicated poor neurological outcomes in patients with severe cerebral edema.Methods:We conducted a multicenter, retrospective cohort study using data from five hospitals collected between 2007 and 2019 in Japan. Inclusion criteria: adult comatose OHCA survivors with head CT within two hours after ROSC. Exclusion criteria was trauma, stroke, or pre-existing neurological disorders. Primary outcome was poor neurological outcome, defined as Cerebral Performance Category (CPC) score ≥ 3 at one month after admission. GWR was measured at the levels of the basal ganglia (BG), corpus callosum (CC), and posterior internal capsule (PIC). The prognostic value of GWR for predicting poor outcome was assessed using a receiver operating characteristic (ROC) curve analysis, area under the curve (AUC) with sensitivity/specificity.Results:A total of 377 patients were included. Of those, 281 (74.6%) exhibited poor neurological outcome at one month after admission. GWR values did not alter by the time of obtaining head CT: 1.22 (0-30 min: n=194); 1.22 (31-60 min: n=127); 1.22 (61-120 min: n=56). Using a cut-off GWR value of

Circulation, Volume 146, Issue Suppl_1, Page A216-A216, November 8, 2022. Introduction:The level of end-tidal carbon dioxide (EtCO2) reflects the blood flow generated by cardiopulmonary resuscitation (CPR). Static EtCO2parameters, such as average EtCO2levels, has been reported to be associated with outcomes following out-of-hospital cardiac arrest (OHCA).Hypothesis:Distinct trajectories of EtCO2during CPR was associated with OHCA outcomes.Methods:This was a retrospective analysis of a prospectively collected database on patients with OHCA who had been resuscitated in the emergency department of a tertiary medical center between 2015 and 2020. Adult patients with ≥3 measurements of EtCO2were included. The primary outcome was the return of spontaneous circulation (ROSC). Group-based trajectory modelling was used to identify the EtCO2trajectories. Multivariable logistic regression analysis was performed to evaluate the association between EtCO2trajectories and ROSC. The predictive performance of the EtCO2trajectories was assessed using the area under the receiver operating characteristic curve (AUC).Results:The study comprised 655 patients with OHCA. In the primary analysis, three distinct EtCO2trajectories, including 10-mmHg, 30-mmHg, and 50-mmHg trajectories, were identified. Compared with the 10-mmHg trajectory, both 30-mmHg (odds ratio [OR]: 4.66, 95% confidence interval [CI]: 3.15-6.90) and 50-mmHg (OR: 7.58, 95% CI: 4.30-13.35) trajectories were associated with a higher likelihood of ROSC. In a sensitivity analysis of excluding EtCO2measured before tracheal intubation or after sodium bicarbonate administration, the predictive ability of the identified EtCO2trajectories remained. As a single predictor of ROSC, EtCO2trajectories had an acceptable discriminative performance (AUC: 0.69, 95% CI: 0.66-0.73).Conclusion:Three distinct EtCO2trajectories during CPR were identified and significantly associated with OHCA outcomes, which may assist in guiding the ongoing resuscitation efforts.