2024 Heart Disease and Stroke Statistics: A Report of US and Global Data From the American Heart Association

BACKGROUND

The American Heart Association (AHA), in conjunction with the National Institutes of Health, annually reports the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, nutrition, sleep, and obesity) and health factors (cholesterol, blood pressure, glucose control, and metabolic syndrome) that contribute to cardiovascular health. The AHA Heart Disease and Stroke Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, brain health, complications of pregnancy, kidney disease, congenital heart disease, rhythm disorders, sudden cardiac arrest, subclinical atherosclerosis, coronary heart disease, cardiomyopathy, heart failure, valvular disease, venous thromboembolism, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs).

METHODS

The AHA, through its Epidemiology and Prevention Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States and globally to provide the most current information available in the annual Statistical Update with review of published literature through the year before writing. The 2024 AHA Statistical Update is the product of a full year's worth of effort in 2023 by dedicated volunteer clinicians and scientists, committed government professionals, and AHA staff members. The AHA strives to further understand and help heal health problems inflicted by structural racism, a public health crisis that can significantly damage physical and mental health and perpetuate disparities in access to health care, education, income, housing, and several other factors vital to healthy lives. This year's edition includes additional global data, as well as data on the monitoring and benefits of cardiovascular health in the population, with an enhanced focus on health equity across several key domains.

RESULTS

Each of the chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics.

CONCLUSIONS

The Statistical Update represents a critical resource for the lay public, policymakers, media professionals, clinicians, health care administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.

World's first en bloc heart-lung transplantation using the paragonix lungguard donor preservation system

We present the first en bloc heart-lung donor transplant procurement using the Paragonix LUNGguard™ donor preservation system. This system offers reliable static hypothermic conditions designed to prevent major complications such as cold ischemic injury, uneven cooling and physical damage. While this represents a single case, the encouraging results warrant further investigation.

Relation of Length of Survival After Orthotopic Heart Transplantation to Age of the Donor

We aim to evaluate the impact of donor age on the outcomes in orthotropic heart transplantation recipients. The United Network for Organ Sharing database was queried for adult patients (age; ≥60) underwent first-time orthotropic heart transplantation between 1987 and 2019 (n = 18,447). We stratified the cohort by donor age; 1,702 patients (9.2%) received a heart from a donor age of <17 years; 11,307 patients (61.3%) from a donor age of 17 ≥, < 40; 3,525 patients (19.1%) from a donor age of 40 ≥, < 50); and 1,913 patients (10.4%) from a donor age of ≥50. There was a significant difference in the survival likelihood (p < 0.0001) based on donor's age-based categorized cohort, however, the median survival was 10.5 years in the cohort in whom the donor was <17, 10.3 years in whom the donor was 17 ≥, < 40, 9.4 years in whom the donor was 40 ≥, < 50, and 9.0 years in whom the donor was ≥ 50. Additionally, there was no significant difference in the episode of acute rejection (p = 0.19) nor primary graft failure (p = 0.24). In conclusion, this study demonstrated that patients receiving hearts from the donor age of ≥50 years old showed slight inferior survival likelihood, but appeared to be equivalent median survival.

Successful Heart-Lung Transplant for a Patient on Continuous-Flow Left Ventricular Assist Device Support Complicated With Amiodarone-Induced Pulmonary Fibrosis

In this case report, we present a successful case of en bloc heart-lung transplant in a patient with advanced cardiopulmonary respiratory failure from amiodarone-associated pulmonary fibrosis that occurred post-left ventricular assist device implantation.

Augmented Reality System for Ultrasound Guidance of Transcatheter Aortic Valve Implantation

OBJECTIVE

Transcatheter aortic valve implantation (TAVI) relies on fluoroscopy and nephrotoxic contrast medium for valve deployment. We propose an alternative guidance system using augmented reality (AR) and transesophageal echocardiography (TEE) to guide TAVI deployment. The goals of this study were to determine how consistently the aortic valve annulus is defined from TEE using different aortic valve landmarks and to compare AR guidance with fluoroscopic guidance of TAVI deployment in an aortic root model.

METHODS

Magnetic tracking sensors were integrated into the TAVI catheter and TEE probe, allowing these tools to be displayed in an AR environment. Variability in identifying aortic valve commissures and cuspal nadirs was assessed using TEE aortic root images. To compare AR guidance of TAVI deployment with fluoroscopic guidance, a TAVI stent was deployed 10 times in the aortic root model using each of the two guidance systems.

RESULTS

Commissures and nadirs were both investigated as features for defining the valve annulus in the AR guidance system. The commissures were identified more consistently than the nadirs, with intraobserver variability of 2.2 and 3.8 mm, respectively, and interobserver variability of 3.3 and 4.7 mm, respectively. The precision of TAVI deployment using fluoroscopic guidance was 3.4 mm, whereas the precision of AR guidance was 2.9 mm, and its overall accuracy was 3.4 mm. This indicates that both have similar performance.

CONCLUSIONS

Aortic valve commissures can be identified more reliably than cuspal nadirs from TEE. The AR guidance system achieved similar deployment accuracy to that of fluoroscopy while eliminating the use and consequences of nephrotoxic contrast and radiation.

The role of visual and direct force feedback in robotics-assisted mitral valve annuloplasty

BACKGROUND

The objective of this work was to determine the effect of both direct force feedback and visual force feedback on the amount of force applied to mitral valve tissue during ex vivo robotics-assisted mitral valve annuloplasty.

METHODS

A force feedback-enabled master-slave surgical system was developed to provide both visual and direct force feedback during robotics-assisted cardiac surgery. This system measured the amount of force applied by novice and expert surgeons to cardiac tissue during ex vivo mitral valve annuloplasty repair.

RESULTS

The addition of visual (2.16 ± 1.67), direct (1.62 ± 0.86), or both visual and direct force feedback (2.15 ± 1.08) resulted in lower mean maximum force applied to mitral valve tissue while suturing compared with no force feedback (3.34 ± 1.93 N; P < 0.05).

CONCLUSIONS

To achieve better control of interaction forces on cardiac tissue during robotics-assisted mitral valve annuloplasty suturing, force feedback may be required.

Phantom study of an ultrasound guidance system for transcatheter aortic valve implantation

A guidance system using transesophageal echocardiography and magnetic tracking is presented which avoids the use of nephrotoxic contrast agents and ionizing radiation required for traditional fluoroscopically guided procedures. The aortic valve is identified in tracked biplane transesophageal echocardiography and used to guide stent deployment in a mixed reality environment. Additionally, a transapical delivery tool with intracardiac echocardiography capable of monitoring stent deployment was created. This system resulted in a deployment depth error of 3.4mm in a phantom. This was further improved to 2.3mm with the custom-made delivery tool. In comparison, the variability in deployment depth for traditional fluoroscopic guidance was estimated at 3.4mm.

Recalcitrant prosthetic valve endocarditis requiring repeated reconstruction: running out of options

In this report we describe a previously healthy 36-year-old man who presented with septic shock secondary to bacterial endocarditis with multiple cerebral, mesenteric, and peripheral embolic phenomena. He underwent emergent porcine prosthetic valve replacement with aortic annular reconstruction. Subsequently, he developed recalcitrant Candida parapsilosis endocarditis requiring treatment with multiple antifungal agents and 4 repeated complex reconstructions of the aortic root and fibrous trigones over 3 years, before the infection was successfully controlled. This case underscores the significant morbidity associated with fungal endocarditis and importance of an early combined medical and surgical approach.

Myocardium at risk is associated with adverse clinical events in women but not in men, after coronary artery bypass grafting

BACKGROUND

Women undergoing coronary artery bypass grafting (CABG) are at increased risk for morbidity and mortality. Factors responsible for this observation include smaller coronary size and delayed presentation. To date, no studies have examined the effect of the degree of myocardium at risk (MAR) on the relationship between female sex and adverse postoperative events.

METHODS

Consecutive patients undergoing first-time isolated CABG at a single institution from 2002-2007 were identified. MAR was calculated using the weighted Duke Index and was categorized as low, moderate, or high. Multivariable logistic regression models were created to compare the impact of MAR on adverse clinical events.

RESULTS

We identified 3741 patients, 3325 (89%) of whom had complete angiographic data. Women (n = 755) were older (P = 0.0001) and presented more often with hypertension (P = 0.0001), diabetes (P = 0.0001), heart failure (P = 0.0001), and an urgent/emergent situation (P = 0.002). After surgery, women experienced greater rates of adverse events (15.2% vs 9.3%; P = 0.0001). In a fully adjusted logistic regression model, the nested interaction of sex in MAR showed that women had a significantly greater risk of major adverse cardiovascular events (MACE) when MAR was high (odds ratio [OR], 1.9; 95% confidence interval [CI], 1.3-2.6; P = 0.0004). Greater severity of MAR emerged as an independent predictor of adverse events among women (high: OR, 2.9; 95% CI, 1.2-7.3; moderate: OR, 2.2; 95% CI, 0.8-5.7; low: OR, 1.0), but not among men.

CONCLUSIONS

MAR was independently associated with higher rates of adverse events among women but not in men undergoing CABG. This finding may help explain differences in outcomes seen between women and men after revascularization.

Knowledge, attitudes, and practice patterns in surgical management of bicuspid aortopathy: a survey of 100 cardiac surgeons

OBJECTIVE

Clinical practice guidelines have been established for surgical management of the aorta in bicuspid aortic valve disease. We hypothesized that surgeons' knowledge of and attitudes toward bicuspid aortic valve aortopathy influence their surgical approaches.

METHODS

We surveyed cardiac surgeons to probe the knowledge of, attitudes toward, and surgical management of bicuspid aortopathy. A total of 100 Canadian adult cardiac surgeons participated.

RESULTS

Fifty-two percent of surgeons believed that the mechanism underlying aortic dilation in those with bicuspid aortic valve was due to an inherent genetic abnormality of the aorta, whereas only 2% believed that altered valve-related processes were involved in this process. Only a minority (15%) believed that bicuspid valve leaflet fusion type is associated with a unique pattern of aortic dilatation aortic phenotype. Sixty-five percent of surgeons recommended echocardiographic screening of first-degree relatives of patients with bicuspid aortic valve. Most surgeons (61%) elected to replace the aorta when the diameter is 45 mm or greater at the time of valve surgery. Fifty-five percent of surgeons surveyed suggested that in the absence of concomitant valvular disease, they would recommend ascending aortic replacement at a threshold of 50 mm or greater. Approximately one third of surgeons suggested that they would elect to replace a mildly dilated ascending aorta (40 mm) at the time of valve surgery. The most common surgical approach (61%) for combined valve and aortic surgery was aortic valve replacement and supracoronary replacement of the ascending aorta, and only a minority suggested the use of deep hypothermic circulatory arrest and open distal anastomosis. More aggressive approaches were favored with greater surgeon experience, and when circulatory arrest was chosen, the majority (68%) suggested they would use antegrade cerebral perfusion. In the setting of aortic insufficiency and a dilated aorta, 42% of surgeons suggested that they would perform valve-sparing surgery. Of note, 40% of respondents used an index measure of aortic size to body surface area in addition to absolute aortic diameter in assessing the threshold for intervention.

CONCLUSIONS

This large survey uncovered significant gaps in the knowledge and attitudes of surgeons toward the diagnosis and management of bicuspid aortopathy, many of which were at odds with current guideline recommendations. Efforts to promote knowledge translation in this area are strongly encouraged.

Can internal thoracic arteries be used for both coronary artery bypass and breast reconstruction?

OBJECTIVES

Recently, the internal thoracic arteries have been preferentially used in autologous breast reconstruction at the levels of the third or fourth intercostal spaces. This may compromise future treatment of occult coronary disease. We hypothesized that internal thoracic artery length at the fourth intercostal space would allow both breast reconstruction and future coronary artery bypass grafting (CABG).

METHODS

Anatomic analysis of 20 female patients undergoing CABG was performed examining internal thoracic artery length from its origin to the third, fourth, fifth intercostal spaces and the left anterior descending (LAD) artery target.

RESULTS

The left internal thoracic artery was anastamosed to the LAD target at a mean length of 11.4 ± 1.4 cm. The mean lengths of the pedicled left internal thoracic artery from its origin to the third, fourth and fifth intercostal space were 8.5 ± 1.0, 10.9 ± 1.2 and 13.0 ± 1.4 cm, respectively. Therefore, the left internal thoracic artery length was adequate at the fourth intercostal space in 6 of 20 (30%) patients.

CONCLUSIONS

Dissection of the left internal thoracic artery to the fourth intercostal space would allow for concomitant use in CABG and breast reconstruction in one-third of cases. However, skeletonization of the internal thoracic artery at the level of the fourth intercostal space would be sufficient for CABG in all cases following autologous breast reconstruction.

Abstract P186: Extent of Myocardium at Risk in Women, but Not in Men, is Associated With Major Adverse Cardiac Events Following Coronary Artery Bypass Grafting

Objective: Many studies have reported higher rates of adverse outcomes in women than men following CABG surgery. To date, the mechanism has not been elucidated. We studied a large group of CABG patients for whom detailed angiographic data were available and investigated the impact of myocardium at risk (MAR) on major adverse cardiac events (MACE) in men and women post-CABG.

Methods: For patients undergoing isolated primary CABG, a Duke Index score was calculated from angiographic data. Duke Index is a validated score that quantifies MAR using distribution and severity of coronary artery disease. Categories of MAR were defined as Low, Moderate and High based on number of diseased vessels as well as location of disease, with proximal lesions conferring a higher weight than distal stenoses. The post-CABG outcome was in-hospital MACE (1 or more of mortality, low cardiac output, stroke, MI, sepsis, deep sternal wound infection, ventilation >48 hrs or return to ICU). Logistic regression was used to examine the impact of MAR as a predictor of MACE in women and in men, after adjusting for clinical comorbidities.

Results: Of 3744 CABG patients, 70% (2614) had complete angiographic data and were included in the analysis; 23% (607 of 2614) were women. Compared with men, women undergoing CABG had similar Duke Index scores but were older and more likely to have diabetes, hypertension, vascular disease, disabling angina, and require urgent surgery. Completeness of revascularization did not differ between men and women. Prevalence of MACE was higher in women than in men: 19.9% (121 of 607) versus 13.0% (262 of 2007), p=0.0001. In a logistic regression model fully adjusted for comorbidities, there was a significant interaction between female sex and increased MAR as predictors of MACE. In separate logistic regression models for each sex, increasing MAR was an independent predictor of MACE for women (High MAR: OR 3.2, 95% CI 1.4-7.6, Moderate MAR: OR 2.5, 95% CI 1.0-6.2), but not for men (High MAR: OR 1.0, 95% CI 0.6-1.7, Moderate MAR: OR 1.1, 95% CI 0.6-1.8).

Conclusions: Myocardium at risk impacts post-CABG outcome differently for women than for men. This novel finding suggests that CABG surgery may not provide the same potential for recovery of ischemic myocardium for women compared with men.