Robotic Assisted Versus Manual Percutaneous Coronary Intervention: Systematic Review and Meta-Analysis

INTRODUCTION

Robotics in percutaneous coronary intervention (R-PCI) has been one such area of advancement where potential benefits may include reduced operator radiation exposure, improved outcomes, and reduced rate of adverse events. Limited data exist about the benefits of R-PCI versus conventional manual PCI (M-PCI). We appraised the latest evidence in the form of a meta-analysis of observational and retrospective studies.

METHODS

A comprehensive literature search was performed in PubMed, Embase, and Cochrane to identify relevant clinical studies. Summary effects were calculated using a DerSimonian and Laird random-effects model as the pooled odds ratio or mean differences (MDs) with 95% confidence intervals (CIs). All studies adhering to the inclusion criteria of direct comparisons between R-PCI and M-PCI were evaluated.

RESULTS

Seven studies with a total of 2230 patients were identified. There was significant decrease in the chest-level operator radiation exposure (MD = -442.32; 95% CI = -675.88 to -208.76), fluoroscopy time (MD = -1.46; 95% CI = -2.92 to 0.00), and amount of contrast used (MD = -18.28; 95% CI = -24.16 to -12.41) in the robotic group compared to the manual group. PCI time and the procedural success rate was not statistically different between the 2 groups. Clinical outcomes of major adverse cardiac events, all-cause mortality, and myocardial infarction were not different between the 2 groups.

CONCLUSIONS

Robotic PCI is associated with reduced operator radiation exposure, fluoroscopy time, and amount of contrast used. While there is a significant reduction in the procedural characteristics with robotic PCI, the clinical outcomes are not different compared to M-PCI. R-PCI is safe and effective with potential benefits to both the operator and the patient simultaneously.

Takotsubo Syndrome in Orthotopic Liver Transplant: A Systematic Review and Pooled Analysis of Published Studies and Case Reports

BACKGROUND

Takotsubo syndrome (TTS) has been reported in solid-organ transplant recipients. However, the pooled data regarding TTS after liver transplant remain limited.

METHODS

A systematic review was performed through February 2022 using PubMed, Embase, Scopus, and Google Scholar to review case reports/series and original studies on liver transplant-associated TTS. Descriptive analysis was performed for case reports and pooled analysis for the prevalence using random effects models.

RESULTS

A total of 56 case reports were included from 30 articles (51.8 % male; mean age, 53 years; India 56%, US 27%, and Europe 8.93%) and 10 original studies (US 88.65%, India 10.92%) revealing liver transplant-associated TTS. The pooled prevalence of TTS was 1.1% (95% Cl, 0.6%-1.7%) of all liver transplants with comparable rates in studies from India and the US (P = .92). Indications for liver transplant included end-stage liver disease due to alcohol-related cirrhosis (25%), hepatitis C virus infection (17.9%), hepatocellular carcinoma (10.7%), and non-alcohol-related steatohepatitis (8.9%); the average Model for End-Stage Liver Disease score was 24.75. TTS commonly presented as hypotension (30%), dyspnea (14%), and oliguria, occurring mostly post-transplant (82%), whereas 14% were intraoperative. Common electrocardiogram findings were ST changes, ventricular tachycardia, and atrial fibrillation. Common echocardiogram findings showed left ventricular apical ballooning in 46.5% of cases and reduced ejection fraction < 20% in 41.9% of cases. Common complications were cardiogenic shock (32.1 %), acute kidney injury (12.5%), arrhythmia, stroke, cardiac arrest, and hepatic artery thrombosis. Mechanical circulatory support was required in 30.3%. Recurrence was reported in 15, and mortality in 30.4% of patients.

CONCLUSIONS

Takotsubo syndrome prevalence after liver transplant is significantly higher than TTS prevalence in general US hospitalizations with potentially worse outcomes. Prospective registries reporting TTS in liver transplant recipients are warranted.

COVID-19 vaccination and myocarditis: A review of current literature

Vaccination for coronavirus disease 2019 (COVID-19) is a critical strategy in controlling the current pandemic of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2). After widespread COVID-19 vaccine imple-mentation, isolated case reports about myocarditis as a potential adverse reaction started coming. As of November 12, 2021, Centers for Disease Control and Prevention (CDC) has reported 1793 cases of myocarditis or pericarditis among young people with age 12-29 years, most cases have been reported in the male adolescent age group after the second dose of mRNA COVID-19 vaccines. It is very important to monitor the safety standards and adverse reactions of vaccines to effectively implement the vaccination policies. The CDC and the United States Food and Drug Administration actively monitor vaccine-associated adverse reactions a well-known platform such as Vaccine Adverse Event Reporting System. CDC continues to recommend COVID-19 vaccines and booster doses for eligible individuals (age limit according to the type of vaccine) after careful consideration from risk-benefit assessment and favorable outcomes from vaccination. Mechanisms behind COVID-19 vaccine-induced myocarditis are not clear yet but several possibilities such as molecular mimicry between the spike protein of SARS-CoV-2 and self-antigens, immune response to mRNA, and activation of host immunological system, trigger of the pre-existing dysregulated immunological system have been documented in the literature. Overall, data suggests a good prognosis, especially in young patients. In this review article, we cover currently available data on COVID-19 vaccine-related myocarditis incidence, concerns, possible mechanisms of myocarditis, current treatment, and outcome trends, risk vs benefit assessment of COVID-19 vaccination in this current pandemic.

Levamisole-Adulterated Cocaine-Induced Thrombotic Vasculopathy With Negative Serology

Substance abuse is an important public health issue in the United States. The prevalence of cocaine use is wide, and it is noted to be adulterated with a substance called levamisole, which can increase the bulk and possibly potentiate cocaine’s euphoric effect. Literature shows that levamisole-induced vasculopathy has a strong association with antineutrophil cytoplasmic antibodies (ANCA) antibodies. However, we report a case of biopsy-confirmed levamisole-related thrombotic vasculopathy with negative perinuclear antineutrophil cytoplasmic antibody (p-ANCA) and cytoplasmic antineutrophil cytoplasmic autoantibody (c-ANCA) antibodies. Our case highlights the serious consequences of substance abuse. Here, we provide educational value and encourage physicians to keep the differentials broad when encountering a dermatological case in patients with cocaine use and highlight the importance of skin biopsy for the diagnosis and appropriate management.

Abstract 69: Predictors Of Cardiac Arrest-related Hospitalizations In Young (18-44 Years) Females - An Artificial Neural Network Analysis Using A Nationwide Cohort

Background: Considering the limited availability of data on Cardiac Arrest (CA) in young patients and especially females, we aimed to determine the predictors of CA in this population using Artificial Neural Network (ANN) Model in a national cohort from the United States.

Methods: We identified CA-related hospitalizations among young females (18-44 years) using 2018’s National Inpatient Sample database. ANN’s predictive factors were selected for this cohort. Young females with CA (n=10810, 0.2% of all 2018 young female admissions) were randomly split into training data (n=7567, 70%) which were used to calibrate ANN and testing data (n=3243, 30%) which were used to evaluate the accuracy of the algorithm. We compared the frequency of incorrect prediction between training and testing data and measured the Area under Receiver Operator Curve (AUC) to determine ANN’s efficacy in predicting CA.

Results: Young females with CA often consisted of older (median age 36 vs 30 years), blacks (25.3% vs 18%), and patients from lower-income quartile (0-25% income quartile:36.4% vs 29.9%) with higher rates of modifiable cardiovascular disease risk factors vs. females admitted without CA (p<0.001). Females with CA expectedly had significantly high (48.4%) in-hospital mortality. Normalized Predictors are displayed in Table 1. Our ANN model had AUC 0.902 (Fig 1) which correlates with an excellent prediction model. Our data showed 0.2% error in both testing and training models.

Conclusion: Our ANN model achieved high performance to predict risk factors for CA admissions in young females. It will enable clinicians to screen high-risk young female hospitalized patients and improve survival in them.

Abstract 61: Major Adverse Cardiovascular And Cerebrovascular Events Among Homeless Cancer Survivors: A Decade-apart Nationwide Hospitalizations Analysis

Background: Homelessness being one of the independent risks for cardiovascular disease (CVD), we explored the burden of CVD risk factors and major adverse cardiac and cerebrovascular events (MACCE) and in-hospital outcomes among homeless cancer survivors in the USA two-decade apart.

Methods: We compared the baseline demographic, comorbidities, and inpatient MACCE outcomes (all-cause mortality, cardiac arrest including arrhythmia, and stroke) between 2007 and 2017 using homeless cancer survivors' hospitalizations from National Inpatient Sample datasets.

Results: A total of 14973 (median age 59 years, 53.4% male) admissions among homeless cancer survivors were studied (4778 in 2007 & 10195 in 2017, Table 1). Cohort 2017 had younger (median age 57 vs. 71 years), male (59.5% vs. 40.5%), Hispanic (8.0% vs. 5%), non-elective (93.8% vs. 87.4%) and low household income (24.7% vs. 20.8%) (p<0.001) admissions, and had a significantly higher burden of traditional cardiovascular risk factors like smoking, hypertension, hyperlipidemia, diabetes with chronic complications, congestive cardiac failure, alcohol abuse, drug abuse and depression compared to 2007 cohort. Univariate incidence of composite MACCE (16.2 vs 19.5%) and all-cause mortality (0.9 vs 1.3%) were significantly lower in 2017 compared to 2007. Multivariate analysis after socio-demographics, admitting hospital-related characteristics and comorbidities did not reveal worsening for MACCE-related hospitalizations (aOR 1.16, 95 CI 0.83-1.62, p=0.381).

Conclusion: Homeless cancer survivors tend to be younger in 2017 than in 2007, with higher prevalence of cardiovascular risk factors and hospitalizations related to MACCE. However, they also tend to have improved in-hospital outcomes. Propagating aggressive screening in such survivors may further prevent MACCE-related hospitalizations.

Abstract 158: Burden And Predictors Of Mortality And Major Adverse Cardiovascular Outcomes In Heart Failure Preserved Ejection Fraction Patients Admitted With Acute Respiratory Distress Syndrome (ARDS)

Background: Relation between Acute Respiratory Distress Syndrome (ARDS) and heart failure with preserved ejection fraction (HFpEF) are understudied and the data on these two concomitantly is lacking in the literature. Therefore, we sought to assess the burden and predictors of major adverse cardiovascular and cerebrovascular events (MACCE) and all-cause mortality in ARDS patients with HFpEF.

Methods: The National Inpatient Sample (NIS) database was used to identify patients with HFpEF (after excluding patients with heart failure reduced ejection fraction) who required inpatient hospitalization for ARDS. Administrative ICD10 codes were used to identify the population of interest. Multivariate regression analysis was performed to assess the predictors of all-cause mortality and major adverse cardiovascular outcomes in the selected cohort.

Results: Of 28,731,562 hospital admissions, 3,010 (0.14%) patients were admitted with ARDS and had HFpEF. Of those patients, 1,095 (36.4%) had all-cause mortality, and 1,415 (47.0%) had MACCE. In multivariate regression analysis, older age (OR 3.60, CI 1.40-9.28), 26-50 th quartile income (OR 2.10, CI 1.13-3.91), urban hospital admissions (OR 2.19, CI 1.20-4.01) as well as comorbidities such as coagulopathy (OR 1.77, CI 1.09-2.88), fluid and electrolyte imbalance (OR 1.65, CI 1.05-2.60), prior CABG (OR 2.99, CI 1.19-7.47), need for mechanical ventilation (OR 2.18, CI 1.12-4.23) were significant predictors of all-cause mortality. In our analysis, chronic pulmonary disease, valvular heart disease, hypertension, smoking, obesity were not significant predictors. The result of our analysis is reported in Table 1.

Conclusion: These results suggest HFpEF remains important comorbidity in ARDS patients. Here, we identified predictors of poor outcomes in this patient population which may help physicians to identify the high-risk patients and decrease mortality.

Implementing and Optimizing Inpatient Access to Dermatology Consultations via Telemedicine: An Experiential Study

Background/Introduction: In-house dermatology consultation services for hospitalized patients are not universally available in acute care hospitals. We encountered an unanticipated access gap for in-person dermatology consultations in our tertiary care hospital that routinely cares for complex high acuity patients with multiple comorbidities. To bridge this gap in specialist expertise in a timely manner, we expeditiously designed and implemented a telemedicine-supported inpatient dermatology consultation service. Methods: We conducted a retrospective review of 155 teledermatology consultations conducted between November 2017 and March 2019 as well as periodic prospective multidisciplinary process improvement meetings to optimize service-associated process maps and workflows. Results: Teledermatology consultations changed the working diagnosis of the primary team in 52.3% of cases and most commonly recommended medical management (61.9% of cases). In total 100% of patients accepted telemedicine support and rated their experience as positive. The first three periodic process improvement meetings led to significant improvements in teledermatology-related process maps and workflows. Discussion: Diagnostic concordance rates between the primary team and the teledermatologist were similar to those reported in the literature for in-person dermatology consultations. Important process improvements include establishing central responsibility of preparing and overseeing the consultation process, mandating the presence of a primary team representative during consultation and patient chart review by the teledermatologist before teleconsultation. Conclusion: Inpatient teledermatology consultation services can be instituted timely and continuously improved to reliably and effectively bridge access gaps, improve diagnostic accuracy and differentiate therapeutic approaches while maintaining patient satisfaction.