Safety and Effectiveness of an Anti-Xa-based Unfractionated Heparin Protocol for Impella Percutaneous Ventricular Assist Devices

Background: Impella devices are used for mechanical circulatory support in patients with cardiogenic shock or those undergoing high-risk percutaneous coronary intervention (PCI). Anticoagulation protocols in this population are not well established and are complicated by concomitant use of purge solutions containing unfractionated heparin (UFH) and intravenous UFH continuous infusion (CI) for systemic anticoagulation. Objectives: To evaluate thrombotic and bleeding complications when using a novel UFH protocol with a reduced initial UFH CI dose of 6 units/kg/hour targeting an anti-Xa goal of 0.3 to 0.5 units/mL in patients receiving Impella support. Methods: This single-center, retrospective study included 41 patients on Impella support who received an UFH purge solution and/or an IV UFH infusion. The primary outcome was overall composite bleeding. Secondary outcomes included thrombotic events and systemic UFH exposure. An exploratory analysis was performed to identify risk factors for bleeding. Results: Anti-Xa values were in therapeutic range 46% of the time while on support (interquartile range 16.6%-75%), with a median IV UFH dose of 6 units/kg/hour. The overall bleeding rate was 29.2%, with 6 minor bleeds and 2 major bleeds with no fatal bleeding or intracranial hemorrhage. Rate of overall thrombosis was 4.9%, including 1 ischemic stroke and 1 occurrence of limb ischemia. Conclusion: Use of a modified UFH protocol to target an anti-Xa goal of 0.3 to 0.5 units/mL resulted in bleeding and thrombotic event rates similar to previous literature. This protocol utilizing an initial rate of 6 units/kg/hour may be a useful approach to achieve therapeutic anticoagulation while accounting for UFH exposure from the purge solution and minimizing need for frequent calculations.

Percutaneous Left Atrial Appendage Closure for Stroke Prevention in Hypertrophic Cardiomyopathy Patients with Atrial Fibrillation

BACKGROUND

Percutaneous left atrial appendage closure (LAAC) is an effective alternative strategy for stroke prevention in atrial fibrillation (AF) patients at high risk for bleeding with anticoagulation (AC). Efficacy of this strategy in hypertrophic cardiomyopathy (HCM) remains uncertain.

OBJECTIVE

Compare risk of stroke in HCM-AF patients treated with LAAC to those treated with AC.

METHODS

Using TriNetX Global Research Network, HCM-AF patients from 2015 to 2024 were categorized into those treated with LAAC vs. solely with AC, and followed for 3-years for ischemic stroke, systemic embolism, and all-cause mortality. Propensity-score matching was used to limit confounders.

RESULTS

14,867 HCM-AF patients were identified; 364 (2.5%) treated with LAAC vs. 14,503 (97.5%) treated with AC. HCM-LAAC patients were older (72 vs. 67, p<0.001), had more comorbidities, and more prior bleeding events, including higher rate of prior gastrointestinal bleeding (68% vs. 18%, p<0.001), compared to HCM patients treated solely with AC. After propensity matching, there was no baseline difference between groups including prior bleeding events (p>0.05). During follow-up, HCM patients treated with LAAC had higher rates of ischemic stroke (13% vs. 8%, HR 1.9, p=0.006) and systemic embolism (14% vs. 9%, HR 1.8, p=0.006), but no difference in mortality compared to matched HCM patients on AC.

CONCLUSION

This real-world data does not support percutaneous LAAC in HCM-AF patients as the primary treatment strategy over long term AC to reduce stroke risk. However, LAAC may remain a reasonable option for HCM-AF patients who are unable to tolerate AC due to prohibitive bleeding risk.

Exploring the Role of ChatGPT in Cardiology: A Systematic Review of the Current Literature

Chat Generative Pre-Trained Transformer (ChatGPT) is a chatbot based on a large language model that has gained public interest since its release in November 2022. This systematic review examines the current literature on the potential applications of ChatGPT in cardiology. A systematic literature search was conducted to retrieve all publications on ChatGPT in PubMed, Scopus, MedRxiv, and the Cochrane Library published on or before September 30, 2023. Search terms relating to ChatGPT and cardiology were used. Publications without relevance to ChatGPT and cardiology were excluded. The included publications were divided into cohorts. Cohort A examined ChatGPT's role in improving patient health literacy. Cohort B explored ChatGPT's role in clinical care. Cohort C examined ChatGPT's role in future literature and research. Cohort D included case reports that used ChatGPT. A total of 115 publications were found across all databases. Twenty-four publications met the inclusion criteria and were included in the review. Cohort A-C included a total of 14 records comprised of editorials/letters to the editor (29%), research letters/correspondence (21%), review papers (21%), observational studies (7%), research studies (7%), and short reports (7%). Cohort D included 10 case reports. No relevant systematic literature reviews, meta-analyses, or randomized controlled trials were identified in the search.  Based on this review of the literature, ChatGPT has the potential to enhance patient education, support clinicians providing clinical care, and enhance the development of future literature. However, further studies are needed to understand the potential applications of ChatGPT in cardiology and to address ethical concerns regarding the delivery of medical advice and the authoring of manuscripts.

A high burden of diabetes and ankle brachial index abnormalities exists in Mexican Americans in South Texas

Ethnic differences exist in the United States in the interrelated problems of diabetes (DM), peripheral arterial disease (PAD), and leg amputations. The purpose of this study was to determine the prevalence and risk factor associations for subclinical PAD in a population sample of Mexican Americans using the ankle brachial (ABI) index. The ABI-High (higher of the two ankle pressures/highest brachial pressure) and ABI-Low (lower of the two ankle pressures/highest brachial pressure) were calculated to define PAD. Toe brachial index (TBI) was also calculated. 746 participants were included with an age of 53.4 ± 0.9 years, 28.3 % had diabetes mellitus (DM), 12.6 % were smokers, and 51.2 % had hypertension (HTN). Using ABI-High ≤ 0.9, the prevalence of PAD was 2.7 %. This rose to 12.7 % when an ABI-Low ≤ 0.9 was used; 4.0 % of the population had an ABI-High > 1.4. The prevalence of TBI < 0.7 was 3.9 %. DM was a significant risk factor for ABI-High ≤ 0.9 and ABI-High > 1.4, and TBI < 0.7. Increased age, HTN, smoking was associated with ABI-High ≤ 0.9, while being male was associated with ABI-High > 1.4. Increased age, smoking, and lower education were all associated with abnormal TBI. Despite relatively younger mean age than other studied Hispanic cohorts, the present population has a high burden of ABI abnormalities. DM was a consistent risk factor for PAD. These abnormalities indicate an important underlying substrate of vascular and metabolic disease that may predispose this population to the development of symptomatic PAD and incident amputations.

Heart Failure With Preserved Ejection Fraction With CKD: A Narrative Review of a Multispecialty Disorder

Heart failure with preserved ejection fraction (HFpEF) is a heterogenous syndrome with varying phenotypic expression. The phenotype chronic kidney disease (CKD) associated HFpEF is increasing in prevalence globally and is associated with increased morbidity and mortality compared to other HFpEF variants. These 2 conditions share common risk factors, including obesity, diabetes, and metabolic syndrome, as well as similar pathophysiology, including systemic inflammation, oxidative stress, elevated neurohormones, mineralocorticoid-receptor activation, and venous congestion. Given the coexistence of CKD and HFpEF, the diagnosis of HFpEF can be difficult. Moreover, treatment options for HFpEF have remained limited despite the success seen in its counterpart, heart failure with reduced ejection fraction. HFpEF encompasses complex multisystem pathophysiological perturbations beyond neurohormones, it is unlikely that a single agent can have significant benefit in this population. Recent data on sodium-glucose cotransporter 2 (SGLT2) inhibitors in HFpEF and CKD, and on glucagon-like peptide-1 (GLP-1) agonists and mineralocorticoid-receptor antagonists in metabolic syndrome, which target multiple pathways simultaneously, have led to promising therapeutics for HFpEF and CKD. In this perspective, our goal is to increase awareness of HFpEF as a multisystem disorder that shares the same disease processes seen in CKD and to emphasize that its management in individuals with CKD warrants a collective and multidisciplinary approach.

Transcatheter Aortic Valve Replacement: Variations in Use, Charges, and Geography in the United States

The use of transcatheter aortic valve replacement (TAVR) in the United States has been increasing but with variability. We used a 100% sample of Medicare beneficiaries (MBs), from the Centers for Medicare and Medicaid Services database, who underwent TAVR by cardiologists between 2015 and 2019. We stratified data by geographic region, rural/urban areas, and provider's gender. We examined the average number of TAVRs performed per 100,000 MBs, the average number of TAVRs performed per individual cardiologist, and the average submitted charge (ASC) per procedure. The number of TAVR per 100,000 MBs was significantly variable among regions in all years (all P≤0.028), except in 2015 (P=0.103), with the highest rates being in the Northeast and the lowest being in the West. The number of TAVRs per cardiologist was significantly different among regions only in 2019 (P=0.04), with the Northeast showing the highest numbers and the South showing the lowest. The ASC was also significantly variable among regions in all years (all P≤0.01). The highest ASC was in the Midwest for all years, whereas the lowest was in the West in 2015 to 2016 and in the South in 2017 to 2019. In all years, the number of TAVRs per cardiologist was higher in urban areas than in rural areas (all P<0.05); however, rural cardiologists had higher ASCs (all P<0.05). The number of TAVR procedures per cardiologist was not significantly different between male and female cardiologists (all P>0.1). Female cardiologists had a significantly higher ASC only in 2015 (P=0.034). In conclusion, there are variations in TAVR use and charges for MBs according to geographic, urban, and rural regions and the performing cardiologist's gender.

Implications of Kidney Disease in Patients with Peripheral Arterial Disease and Vascular Calcification

Persons with chronic kidney disease (CKD) are at a higher risk of developing peripheral artery disease (PAD) and its adverse health outcomes than individuals with normal renal function. Among patients with CKD, PAD is predominantly characterized by the calcification of the medial layer of arterial vessels in addition to intimal atherosclerosis and calcification. Vascular calcification (VC) is initiated by CKD-associated hyperphosphatemia, hypercalcemia, high concentrations of parathyroid hormone (PTH) as well as inflammation and oxidative stress. VC is widely prevalent in this cohort (>80% dialysis and 50% patients with CKD) and contributes to reduced arterial compliance and symptomatic peripheral arterial disease (PAD). The most severe form of PAD is critical limb ischemia (CLI) which has a substantial risk for increased morbidity and mortality. Percutaneous endovascular interventions with transluminal angioplasty, atherectomy, and intravascular lithotripsy are the current nonsurgical treatments for severe calcific plaque. Unfortunately, there are no randomized controlled trials that address the optimal approach to PAD and CLI revascularization in patients with CKD.

Human papillomavirus related oropharyngeal cancer: identifying and quantifying topics of patient interest

OBJECTIVE

As the incidence of human papillomavirus related oropharyngeal cancer continues to rise, it is increasingly important for public understanding to keep pace. This study aimed to identify areas of patient interest and concern regarding human papillomavirus and oropharyngeal cancer.

METHOD

This study was a retrospective survey of search queries containing the keywords 'HPV cancer' between September 2015 and March 2021.

RESULTS

There was 3.5-fold more interest in human papillomavirus related oropharyngeal cancer (15 800 searches per month) compared with human papillomavirus related cervical cancer (4500 searches per month). Among searches referencing cancer appearance, 96.8 per cent pertained to the head and neck region (3050 searches per month). Among vaccination searches, 16 of 47 (34.0 per cent; 600 searches per month) referenced human papillomavirus vaccines as being a cause of cancer rather than preventing cancer.

CONCLUSION

The vast majority of online searches into human papillomavirus cancer pertain to the oropharynx. There are relatively few search queries on the topic of vaccination preventing human papillomavirus associated oropharyngeal cancer, which highlights the continued importance of patient education and awareness campaigns.

Overview of the cardio-metabolic impact of the COVID-19 pandemic

Evidence has shown that cardiometabolic disorders (CMDs) are amongst the top contributors to COVID-19 infection morbidity and mortality. The reciprocal impact of COVID-19 infection and the most common CMDs, the risk factors for poor composite outcome among patients with one or several underlying diseases, the effect of common medical management on CMDs and their safety in the context of acute COVID-19 infection are reviewed. Later on, the changes brought by the COVID-19 pandemic quarantine on the general population's lifestyle (diet, exercise patterns) and metabolic health, acute cardiac complications of different COVID-19 vaccines and the effect of CMDs on the vaccine efficacy are discussed. Our review identified that the incidence of COVID-19 infection is higher among patients with underlying CMDs such as hypertension, diabetes, obesity and cardiovascular disease. Also, CMDs increase the risk of COVID-19 infection progression to severe disease phenotypes (e.g. hospital and/or ICU admission, use of mechanical ventilation). Lifestyle modification during COVID-19 era had a great impact on inducing and worsening of CMDs. Finally, the lower efficacy of COVID-19 vaccines was found in patients with metabolic disease.

Educational Experience of Interventional Cardiology Fellows in the United States and Canada

BACKGROUND

The COVID-19 pandemic and iodinated contrast shortage may have affected interventional cardiology (IC) fellowship training.

OBJECTIVES

The aim of this study was to investigate the educational experience of first-year IC fellows in the United States and Canada.

METHODS

A 59-question online survey was conducted among 2021-2022 first-year IC fellows in the United States and Canada.

RESULTS

Of the 360 IC fellows invited to participate, 111 (31%) responded; 95% were from the United States, and 79% were men. Participants were mostly from university programs (70%), spent 61 to 70 hours/week in the hospital, and had an annual percutaneous coronary intervention case number of <200 (5%), 200 to 249 (8%), 250 to 349 (33%), 350 to 499 (39%), 500 to 699 (12%), or ≥700 (3%). For femoral access, a micropuncture needle was used regularly by 89% and ultrasound-guided puncture by 81%, and 43% used vascular closure devices in most cases (>80%). Intravascular ultrasound was performed and interpreted very comfortably by 62% and optical coherence tomography (OCT) by 32%, and 20% did not have access to OCT. Approximately one-third felt very comfortable performing various atherectomy techniques. Covered stents, fat embolization, and coil embolization were used very comfortably by 14%, 4%, and 3%, respectively. Embolic protection devices were used very comfortably by 11% to 24% of IC fellows. Almost one-quarter of fellows (24%) were warned about their high radiation exposure. Eighty-four percent considered IC fellowship somewhat or very stressful, and 16% reported inadequate psychological support.

CONCLUSIONS

This survey highlights opportunities for improvement with regard to the use of intravascular imaging, atherectomy techniques, complication prevention and management strategies, radiation awareness and mitigation, and psychological support.

Hippocampus Segmentation-Based Alzheimer's Disease Diagnosis and Classification of MRI Images

Alzheimer's disease represents a neurological condition characterized by steady cognitive decline and eventual memory loss due to the death of brain cells. It is one of the most prominent dementia types observed in patients and which hence underlines the imminent need for potential methods to diagnose the disease early on. This work considers a novel approach by utilizing a reduced version of one of the datasets used in this work to achieve a considerably accurate prediction while also enabling quicker training. It leverages image segmentation to isolate the hippocampus region from brain MRI images and then strikes a comparison between models trained on the segmented portions and models trained on complete images. This research uses two datasets-4 classes of images from Kaggle and a popular OASIS 2 MRI and demographic dataset. A deep learning-based approach was adopted to train the Kaggle dataset to perform severity classification, and the hippocampus region segmented from a reduced version of the OASIS dataset was trained on supervised and ensemble learning algorithms to detect Alzheimer's disease. The metric used for the assessment of model performance is classification accuracy. A comparative analysis between the proposed approach and existing work was also performed, and it was observed that the proposed approach is effective in the early diagnosis of Alzheimer's disease.

Innovative Approach to Manage Transcatheter Aortic Valve Embolization

We describe the case of a patient with an ascending aortic aneurysm who underwent valve-in-valve transcatheter aortic valve implantation, which was complicated by valve embolization. After a multidisciplinary discussion and an innovative approach, the free-floating embolized valve was anchored securely in the aortic arch with an uncovered aortic endovascular stent. (Level of Difficulty: Intermediate.).

Attributable Mortality and Excess Length of Stay associated with Third-Generation Cephalosporin Resistant Enterobacterales Bloodstream Infections - a prospective cohort study in Suva, Fiji

OBJECTIVES

There are scant primary clinical data on antimicrobial resistance (AMR) burden from low- and middle-income countries (LMICs). We adapted recent World Health Organization methodology to measure the impact of third-generation cephalosporin resistance (3GC-R) on mortality and excess length of hospital stay in Fiji.

METHODS

We conducted a prospective cohort study of inpatients with Enterobacterales bloodstream infections (BSIs) at Colonial War Memorial Hospital, Suva. We used cause-specific Cox proportional hazards models to estimate the effect of 3GC-R on the daily risk (hazard) of in-hospital mortality and being discharged alive (competing risks), and multistate modelling to estimate the excess length of hospital stay.

RESULTS

From July 2020 to February 2021 we identified 162 consecutive Enterobacterales BSIs, 3GC-R was present in 66 (40.7%). Crude mortality for patients with 3GC-susceptible and 3GC-R BSIs was 16.7% (16/96) and 30.3% (20/66), respectively. 3GC-R was not associated with the in-hospital mortality hazard rate (adjusted hazard ratio (aHR) 1.13, 95% CI 0.51-2.53) or being discharged alive (aHR 0.99, 95% CI 0.65-1.50), whereas Charlson comorbidity index score (aHR 1.62, 95% CI 1.36-1.93) and Pitt bacteraemia score (aHR 3.57, 95% CI 1.31-9.71) were both associated with an increased hazard rate of in-hospital mortality. 3GC-R was associated with an increased length of stay of 2.6 days (95% CI 2.5-2.8). 3GC-R was more common among hospital-associated infections, but genomics did not identify clonal transmission.

CONCLUSION

Patients with Enterobacterales BSIs in Fiji had high mortality. There were high rates of 3GC-R, which was associated with increased hospital length of stay but not with in-hospital mortality.

DyeVert Contrast Reduction System Use in Patients Undergoing Coronary and/or Peripheral Angiography: A Systematic Literature Review and Meta-Analysis

Background

Contrast-associated acute kidney injury (CA-AKI) is an important adverse effect associated with injecting iodinated intra-arterial contrast media (CM) during coronary angiography. The DyeVert™ Contrast Reduction System is a medical device intended to reduce the intra-arterial CM volume (CMV) administered. The aim of this study was to assess DyeVert System clinical effectiveness and safety by implementing a systematic review and meta-analysis of existing evidence.

Methods

Systematic electronic literature searches were conducted in MEDLINE, Embase, the Cochrane Database of Systematic Reviews, ClinicalTrials.gov, and the International Clinical Trials Registry Platform database. Relevant data were extracted from included studies and meta-analyses were performed to synthesize evidence across studies.

Results

The review included 17 eligible studies involving 1,731 DyeVert System cases and 1,387 control cases (without the use of DyeVert). Meta-analyses demonstrated use of the DyeVert System reduced CMV delivered to the patient by 39.27% (95% CI, 36.10-42.48%, P < 0.001), reduced CMV/baseline renal function ratios (Hedges's g, -0.56; 95% CI, -0.70 to -0.42, P < 0.001) and percentage of cases exceeding the maximum CMV threshold (risk difference -0.31, 95% CI, -0.48 to -0.13, P < 0.001) while maintaining adequate image quality in 98% of cases. DyeVert System cases demonstrated lower CA-AKI incidence vs. controls (absolute risk reduction 5.00% (95% CI, 0.40-9.80%; P = 0.03), relative risk 0.60 (95% CI, 0.40-0.90; P = 0.01) with a pooled estimate of the number needed to treat with the DyeVert System to avoid 1 CA-AKI event of 20.

Conclusion

DyeVert System use significantly reduces CMV delivered to the patient, CMV/baseline renal function ratios, and CA-AKI incidence while maintaining image quality. Accordingly, the device may serve as an adjunctive, procedure-based strategy to prevent CA-AKI. Future multi-center studies are needed to further assess effects of minimizing CMV on endpoints such as CA-AKI prevention, incidence of adverse cardiac and renal events, and health care costs.

Clinical and angiographic success and safety comparison of coronary intravascular lithotripsy: An updated meta-analysis

Background

Intravascular lithotripsy (IVL) can be used to assist stent deployment in severe coronary artery calcifications (CAC).

Methods

Studies employing IVL for CAC lesions were included. The primary outcomes included clinical and angiographic success. The secondary outcomes, including lumen gain, maximum calcium thickness, and calcium angle at the final angiography site, minimal lumen area site, and minimal stent area site, were analyzed by the random-effects model to calculate the pooled standardized mean difference. Tertiary outcomes included safety event ratios.

Results

Seven studies (760 patients) were included. The primary outcomes: pooled clinical and angiographic success event ratio parentage of IVL was 94.4% and 94.8%, respectively. On a random effect model for standard inverse variance for secondary outcomes showed: minimal lumen diameter increase with IVL was 4.68 mm (p-value < 0.0001, 95% CI 1.69–5.32); diameter decrease in the stenotic area after IVL session was −5.23 mm (95 CI –22.6–12.8). At the minimal lumen area (MLA) and final minimal stent area (MSA) sites, mean lumen area gain was 1.42 mm² (95% CI 1.06–1.63; p < 0.00001) and 1.34 mm² (95% CI 0.71–1.43; p < 0.00001), respectively. IVL reduced calcium thickness at the MLA site (SMD −0.22; 95% CI −0.40–0.04; P = 0.02); calcium angle was not affected at the MLA site. The tertiary outcomes: most common complication was major adverse cardiovascular events (n = 48/669), and least common complication was abrupt closure of the vessel (n = 1/669).

Conclusions

Evidence suggests that IVL safely and effectively facilitates stent deployment with high angiographic and clinical success rates in treating severely calcified coronary lesions.

Amelioration of fly annoyance in dairy cattle by using illuminated fly traps

Blood-sucking and biting flies are a significant source of annoyance to warm-blooded animals. Behavioural changes in animals may include attempts to pursue, remove or avoid the disturbance caused by the fly by means of body movement. In the presesnt study the behaviour during a 10 min period in each four-hour interval i.e. 1 AM, 5 AM, 9 AM, 1 PM, 5 PM and 9 PM was analysed and noted for inclusion in the ethogram. The cows with light trap (treatment) were compared with those without light traps (control) to study the effectivenss of the fly trap in reducing annoyance in cattle. All the seven avaoidance behaviours were counted such as head movement, ear shaking, tail movement, skin twitching, licking, kicking on belly and restlessness and were recorded by scan method. The results of this study indicated that the incidence of all the seven fly avoidance behaviours were significantly higher (p<0.01) in the control group. It could also be concluded that the occurance of all the behaviours in the control group at 1 PM were significantly high followed by 5 PM. The findings of the study suggest that fly activity in dairy farms was high during the afternoon hours followed by evening time and illuminated fly traps could be used effectively in controlling flies, so that the fly avoidance behavior by cattle was reduced on dairy farms.

Seroprevalence to common infectious abortifacient and infertility causing agents in the dairy herds of India

BACKGROUND

Information on the prevalence of infectious agents in dairy farms forms the basis for formulating a suitable control strategy; especially in endemic situations.

AIMS

A cross-sectional study was undertaken to determine the prevalence of six economically important bovine diseases, causing reproductive disorders including bovine abortion in organized dairy herds in India.

METHODS

A total of 1,075 animals (cattle and buffaloes) from 09 dairy farms were screened by ELISA tests.

RESULTS

Bovine viral diarrhoea (BVD) was the most prevalent (56.5%) disease followed by infectious bovine rhinotracheitis (IBR) (45.4%). Prevalence of Q-fever (5.4%) and neosporosis (6.1%) were less on the farms. Although 16.3% of the samples turned positive for brucellosis, the contribution of calf-hood vaccination (B. abortus S19 vaccine) to the prevalence of antibodies cannot be ruled out. The overall prevalence of bovine anaplasmosis, known to cause sporadic abortions in dairy herds, was 34.1% in the 9 farms with a prevalence of less than 20% in 5 farms. Infection of multiple abortifacient (seroprevalence to more than two pathogens) was recorded in 56.8% of animals. A very strong association was observed between BVD and brucellosis (Odds ratio 14.2; P<0.001). Further, a positive association was also seen between seroprevalence of IBR and anaplasmosis, and neosporosis and Q fever (P<0.05).

CONCLUSION

Viral diseases were found to be more common in the dairy herds than bacterial and protozoan diseases. Increased susceptibility of IBR seropositive cows to other bacterial and viral infections was observed.