Unmasking Severe Systolic Anterior Motion With Left Ventricular Outflow Tract Obstruction Following Mitral Valve Repair

A 38-year-old male with a history of myxomatous mitral valve disease post-repair presented with recurrent dyspnea during exertion. Initial evaluation showed mild systolic anterior motion and mitral regurgitation, but medical management was unsuccessful. The patient underwent reoperation; intraoperative transesophageal echocardiogram with provocation unmasked severe systolic anterior motion and torrential mitral regurgitation.

Prediction of interactions between cell surface proteins by machine learning

Cells detect changes in their external environments or communicate with each other through proteins on their surfaces. These cell surface proteins form a complicated network of interactions in order to fulfill their functions. The interactions between cell surface proteins are highly dynamic and, thus, challenging to detect using traditional experimental techniques. Here, we tackle this challenge using a computational framework. The primary focus of the framework is to develop new tools to identify interactions between domains in the immunoglobulin (Ig) fold, which is the most abundant domain family in cell surface proteins. These interactions could be formed between ligands and receptors from different cells or between proteins on the same cell surface. In practice, we collected all structural data on Ig domain interactions and transformed them into an interface fragment pair library. A high-dimensional profile can then be constructed from the library for a given pair of query protein sequences. Multiple machine learning models were used to read this profile so that the probability of interaction between the query proteins could be predicted. We tested our models on an experimentally derived dataset that contains 564 cell surface proteins in humans. The cross-validation results show that we can achieve higher than 70% accuracy in identifying the PPIs within this dataset. We then applied this method to a group of 46 cell surface proteins in Caenorhabditis elegans. We screened every possible interaction between these proteins. Many interactions recognized by our machine learning classifiers have been experimentally confirmed in the literature. In conclusion, our computational platform serves as a useful tool to help identify potential new interactions between cell surface proteins in addition to current state-of-the-art experimental techniques. The tool is freely accessible for use by the scientific community. Moreover, the general framework of the machine learning classification can also be extended to study the interactions of proteins in other domain superfamilies.

Infective Endocarditis in Patients Addicted to Injected Opioid Drugs

BACKGROUND

Persons who inject drugs and require surgery for infective endocarditis have 2 potentially lethal diseases. Current postoperative rehabilitation efforts seem ineffective in preventing loss to follow-up, injection drug use relapse (relapse), and death.

OBJECTIVES

The purpose of this study was to characterize drug use, psychosocial issues, surgical outcome, and postoperative addiction management, as well as loss to follow-up, relapse, and mortality and their risk factors.

METHODS

From January 2010 to June 2020, 227 persons who inject drugs, age 36 ± 9.9 years, underwent surgery for infective endocarditis at a quaternary hospital having special interest in developing addiction management programs. Postsurgery loss to follow-up, relapse, and death were assessed as competing risks and risk factors identified parametrically and by machine learning. CIs are 68% (±1 SE).

RESULTS

Heroin was the most self-reported drug injected (n = 183 [81%]). Psychosocial issues included homelessness (n = 56 [25%]), justice system involvement (n = 150 [66%]), depression (n = 118 [52%]), anxiety (n = 104 [46%]), and post-traumatic stress disorder (n = 33 [15%]). Four (1.8%) died in-hospital. Medication for opioid use disorder prescribed at discharge increased from 0% in 2010 to 100% in 2020. At 1 and 5 years, conditional probabilities of loss to follow-up were 16% (68% CI: 13%-22%) and 59% (68% CI: 44%-65%), relapse 32% (68% CI: 28%-34%) and 79% (68% CI: 74%-83%), and mortality 21% (68% CI: 18%-23%) and 68% (68% CI: 62%-72%). Younger age, heroin use, and lower education level were predictors of relapse.

CONCLUSIONS

Infective endocarditis surgery can be performed with low mortality in persons who inject drugs, but addiction is far more lethal. Risk of loss to follow-up and relapse require more effective addiction strategies without which this major loss to society will continue.

Aortic valve cusp repair does not affect durability of modified aortic valve reimplantation for tricuspid aortic valves

Objective

During aortic valve reimplantation, cusp repair may be needed to produce a competent valve. We investigated whether the need for aortic valve cusp repair affects aortic valve reimplantation durability.

Methods

Patients with tricuspid aortic valves who underwent aortic valve reimplantation from January 2002 to January 2020 at a single center were retrospectively analyzed. Propensity matching was used to compare outcomes between patients who did and did not require aortic valve cusp repair.

Results

Cusp repair was performed in 181 of 756 patients (24%). Patients who required cusp repair were more often male, were older, had more aortic valve regurgitation, and less often had connective tissue disease. Patients who underwent cusp repair had longer aortic clamp time (124 ± 43 minutes vs 107 ± 36 minutes, P = .001). In-hospital outcomes were similar between groups and with no operative deaths. A total of 98.3% of patients with cusp repair and 99.3% of patients without cusp repair had mild or less aortic regurgitation at discharge. The median follow-up was 3.9 and 3.2 years for the cusp repair and no cusp repair groups, respectively. At 10 years, estimated prevalence of moderate or more aortic regurgitation was 12% for patients with cusp repair and 7.0% for patients without cusp repair (P = .30). Mean aortic valve gradients were 6.2 mm Hg and 8.0 mm Hg, respectively (P = .01). Ten-year freedom from reoperation was 99% versus 99% (P = .64) in the matched cohort and 97% versus 97%, respectively (P = .30), in the unmatched cohort. Survival at 10 years was 98% after cusp repair and 93% without cusp repair (P = .05).

Conclusions

Aortic valve reimplantation for patients with tricuspid aortic valves has excellent long-term results. Need for aortic valve cusp repair does not affect long-term outcomes and should not deter surgeons from performing valve-sparing surgery.

Effect of ascending aorta replacement on the long-term outcomes of bicuspid aortic valve repair

OBJECTIVE

The study objective was to determine the effect of sinutubular junction stabilization on long-term outcomes of bicuspid aortic valve repair.

METHODS

From January 1998 to January 2020, 419 patients underwent bicuspid aortic valve repair with ascending aorta replacement and 421 without (bicuspid aortic valve repair alone). Propensity score matching (97 pairs) was used to compare outcomes.

RESULTS

Before matching, prevalence of severe aortic regurgitation at 10 years was 5.4% after bicuspid aortic valve repair + ascending aorta replacement and 10% after bicuspid aortic valve repair alone; aortic valve gradient was 20 mm Hg after bicuspid aortic valve repair + ascending aorta replacement and 19 mm Hg after bicuspid aortic valve repair alone. Ten-year freedom from reoperation overall was 79% after bicuspid aortic valve repair + ascending aorta replacement and 75% after bicuspid aortic valve repair alone; freedom from late aortic regurgitation was 93% after bicuspid aortic valve repair + ascending aorta replacement and 92% after bicuspid aortic valve repair alone; and freedom from aortic stenosis was 87% after bicuspid aortic valve repair + ascending aorta replacement and 93% after bicuspid aortic valve repair alone. Ten-year survival was 95% after bicuspid aortic valve repair + ascending aorta replacement and 96% after bicuspid aortic valve repair alone. After matching, prevalence of severe aortic regurgitation at 10 years was 11% after bicuspid aortic valve repair + ascending aorta replacement and 9.1% after bicuspid aortic valve repair alone (P = .33); aortic valve gradient was 16 mm Hg after bicuspid aortic valve repair + ascending aorta replacement and 25 mm Hg after bicuspid aortic valve repair alone (P < .0001). Ten-year freedom from reoperation was 85% after bicuspid aortic valve repair + ascending aorta replacement and 72% after bicuspid aortic valve repair alone (P = .08) overall. Ten-year freedom from reoperation for late aortic regurgitation was 88% after bicuspid aortic valve repair + ascending aorta replacement and 86% after bicuspid aortic valve repair alone (P = .65). Freedom from aortic stenosis was 97% after bicuspid aortic valve repair + ascending aorta replacement and 91% after bicuspid aortic valve repair alone (P = .03). Ten-year survival was 96% after bicuspid aortic valve repair + ascending aorta replacement and 96% after bicuspid aortic valve repair alone (P = .16).

CONCLUSIONS

Bicuspid aortic valve repair with or without ascending aorta replacement is associated with good short- and long-term outcomes. Bicuspid aortic valve repair + ascending aorta replacement has a minimal effect on long-term repair durability. Sinutubular junction stabilization should not be performed for the sole purpose of long-term repair durability.

Aortic valve reimplantation in patients with connective tissue disorders: Are the leaflets durable?

OBJECTIVE

The durability of reimplanted myxomatous aortic valves in root replacements for patients with connective tissue disorders (CTD) is unclear; therefore, we sought to evaluate the long-term resilience of these repairs.

METHODS

From January 1980 to January 2020, 214 patients with CTD and 645 without CTD underwent primary, elective aortic valve reimplantation operations at Cleveland Clinic. The CTD cohort included 164 (77%) with Marfan, 23 (11%) with Loeys-Dietz, and 7 (3.3%) with Ehlers-Danlos CTD. We accounted for differing patient characteristics between the groups by propensity score matching to compare outcomes, yielding 96 matched pairs. Longitudinal echocardiographic measures were compared using nonlinear mixed effects models.

RESULTS

In the CTD cohort, there were no operative mortalities (30-day or in-hospital), 1 (0.47%) stroke, and 1 (0.47%) early in-hospital reoperation for valve dysfunction. Ten-year prevalence of no aortic regurgitation was 86%, mild 11%, and moderate 3%. Ten-year freedom from reoperation was 97%. In propensity matched cohorts, there were no significant differences in in-hospital outcomes, longitudinal aortic regurgitation and mean gradient, risk of reoperation on the aortic valve, or risk of late death.

CONCLUSIONS

Aortic valve reimplantation is a durable operation in patients with CTD and root aneurysms. These patients do not experience early degeneration of their reimplanted aortic valves.

Prediction of Interactions between Cell Surface Proteins by Machine Learning

Cells detect changes of external environments or communicate with each other through proteins on their surfaces. These cell surface proteins form a complicated network of interactions in order to fulfill their functions. The interactions between cell surface proteins are highly dynamic and thus challenging to detect using traditional experimental techniques. Here we tackle this challenge by a computational framework. The primary focus of the framework is to develop new tools to identify interactions between domains in immunoglobulin (Ig) fold, which is the most abundant domain family in cell surface proteins. These interactions could be formed between ligands and receptors from different cells, or between proteins on the same cell surface. In practice, we collected all structural data of Ig domain interactions and transformed them into an interface fragment pair library. A high dimensional profile can be then constructed from the library for a given pair of query protein sequences. Multiple machine learning models were used to read this profile, so that the probability of interaction between the query proteins can be predicted. We tested our models to an experimentally derived dataset which contains 564 cell surface proteins in human. The cross-validation results show that we can achieve higher than 70% accuracy in identifying the PPIs within this dataset. We then applied this method to a group of 46 cell surface proteins in C elegans. We screened every possible interaction between these proteins. Many interactions recognized by our machine learning classifiers have been experimentally confirmed in the literatures. In conclusion, our computational platform serves a useful tool to help identifying potential new interactions between cell surface proteins in addition to current state-of-the-art experimental techniques. The tool is freely accessible for use by the scientific community. Moreover, the general framework of the machine learning classification can also be extended to study interactions of proteins in other domain superfamilies.

Efficiency of charge transfer in changing the dissociation dynamics of OD+ transients formed after the photo-fragmentation of D2O

We present an investigation of the relaxation dynamics of deuterated water molecules after direct photo-double ionization at 61 eV. We focus on the very rare D+ + O+ + D reaction channel in which the sequential fragmentation mechanisms were found to dominate the dynamics. Aided by theory, the state-selective formation and breakup of the transient OD+(a1Δ, b1Σ+) is traced, and the most likely dissociation path-OD+: a1Δ or b1Σ+ → A 3Π → X 3Σ- → B 3Σ--involving a combination of spin-orbit and non-adiabatic charge transfer transitions is determined. The multi-step transition probability of this complex transition sequence in the intermediate fragment ion is directly evaluated as a function of the energy of the transient OD+ above its lowest dissociation limit from the measured ratio of the D+ + O+ + D and competing D+ + D+ + O sequential fragmentation channels, which are measured simultaneously. Our coupled-channel time-dependent dynamics calculations reproduce the general trends of these multi-state relative transition rates toward the three-body fragmentation channels.

Atomic autoionization in the photo-dissociation of super-excited deuterated water molecules fragmenting into D+ + O+ + D

We present the relaxation dynamics of deuterated water molecules via autoionization, initiated by the absorption of a 61 eV photon, producing the very rare D+ + O+ + D breakup channel. We employ the COLd target recoil ion momentum spectroscopy method to measure the 3D momenta of the ionic fragments and emitted electrons from the dissociating molecule in coincidence. We interpret the results using the potential energy surfaces extracted from multi-reference configuration interaction calculations. The measured particle energy distributions can be related to a super-excited monocationic state located above the double ionization threshold of D2O. The autoionized electron energy shows a sharp distribution centered around 0.5 eV, which is a signature of the atomic oxygen autoionization occurring in the direct and sequential dissociation processes of D2O+* at a large internuclear distance. In this way, an O+ radical fragment and a low-energy electron are created, both of which can trigger secondary reactions in their environment.

Redefining "low risk": Outcomes of surgical aortic valve replacement in low-risk patients in the transcatheter aortic valve replacement era

OBJECTIVES

Guidelines suggest aortic valve replacement (AVR) for low-risk asymptomatic patients. Indications for transcatheter AVR now include low-risk patients, making it imperative to understand state-of-the-art surgical AVR (SAVR) in this population. Therefore, we compared SAVR outcomes in low-risk patients with those expected from Society of Thoracic Surgeons (STS) models and assessed their intermediate-term survival.

METHODS

From January 2005 to January 2017, 3493 isolated SAVRs were performed in 3474 patients with STS predicted risk of mortality <4%. Observed operative mortality and composite major morbidity or mortality were compared with STS-expected outcomes according to calendar year of surgery. Logistic regression analysis was used to identify risk factors for these outcomes. Patients were followed for time-related mortality.

RESULTS

With 15 observed operative deaths (0.43%) compared with 55 expected (1.6%), the observed:expected ratio was 0.27 for mortality (95% confidence interval [CI], 0.14-0.42), stroke 0.65 (95% CI, 0.41-0.89), and reoperation 0.50 (95% CI, 0.42-0.60). Major morbidity or mortality steadily declined, with probabilities of 8.6%, 6.7%, and 5.2% in 2006, 2011, and 2016, respectively, while STS-expected risk remained at approximately 12%. Mitral valve regurgitation, ventricular hypertrophy, pulmonary, renal, and hepatic failure, coronary artery disease, and earlier surgery date were residual risk factors. Survival was 98%, 91%, and 82% at 1, 5, and 9 years, respectively, superior to that predicted for the US age-race-sex-matched population.

CONCLUSIONS

STS risk models overestimate contemporary SAVR risk at a high-volume center, supporting efforts to create a more agile quality assessment program. SAVR in low-risk patients provides durable survival benefit, supporting early surgery and providing a benchmark for transcatheter AVR.

Imaging and haemodynamic parameters associated with clinical outcomes following isolated tricuspid valve surgery

INTRODUCTION

Isolated tricuspid valve surgery (TVS) may be associated with high morbidity and mortality. The aim of this study was to investigate the association of preoperative imaging and haemodynamic data derived from echocardiography (ECHO), cardiac magnetic resonance (CMR) and right heart catheterisation (RHC) with postoperative outcomes following TVS.

METHODS

In a retrospective cohort study, patients who underwent isolated TVS at our institution between 2012 and 2020 were screened and followed up to 1 year. We only included those who had all three tests before surgery: ECHO, CMR and RHC. Patients with congenital heart disease, infective endocarditis and those who underwent concomitant valve or pericardial surgery were excluded. The primary outcome was a composite of mortality and congestive heart failure at 1 year. Time-to-event analyses at 1 year and Cox proportional hazards regression analyses were performed.

RESULTS

A total of 60 patients were included (mean age of 60±14 years, 63% women), of whom 67% underwent TV repair. The primary outcome occurred in 16 patients (27%) with a 1-year mortality of 7%. It was associated with ECHO-derived right ventricular (RV) free wall strain and RHC-derived RV systolic and diastolic as well as mean pulmonary pressures. On multivariable Cox regression analysis, only RV systolic and diastolic pressures were significantly associated with the primary outcome at 1 year (HRs=5.9 and 3.4, respectively, p<0.05).

CONCLUSION

Baseline invasive haemodynamic assessment could have a strong association with clinical outcomes and help risk-stratify patients undergoing isolated TVS.

Impact of weight loss on cardiac function: improvement in left ventricular global longitudinal strain following metabolic surgery

Introduction

Obesity leads to an increased risk of cardiovascular disease (CVD) morbidity and mortality and is associated with the metabolic risk factors such as hypertension, diabetes mellitus, hyperlipidemia [1]. Metabolic surgery has been proven to be the most effective long term weight management tool and has known benefits in CVD prevention [2]. Global longitudinal strain (GLS) is an effective quantitative measurement of left ventricular (LV) function that is also a powerful predictor of future CVD events and mortality [3]. The impact of metabolic surgery on LV structure and function is unknown.

Purpose

This study investigated the changes in cardiac structure and function after metabolic surgery, including GLS. To our knowledge there has not been a study investigating this relationship previously reported.

Methods

Consecutive patients undergoing metabolic surgery at our center between March 2005 and February 2019 were recruited. Patients with transthoracic echocardiographic imaging (TTE) pre and post metabolic surgery (May 2005 to January 2019) were included. Electronic medical records were searched to obtain demographic, surgical and clinical data. GLS was calculated with Velocity Vector Imaging (VVI, Siemens, v2.0, Pennsylvania, USA). Averaged GLS values were derived from 4 chamber, 2 chamber and 3 chamber calculations.

Results

398 patients with pre- and post-operative cardiac imaging were included. Please see Table 1 for the baseline demographics of our study population. The mean age was 60.0 years with 70% being female. There were significant rates of CVD risk factors such as: hypertension (76.4%), diabetes mellitus (58.8%) and hyperlipidemia (76.4%).

The clinical and echocardiographic changes noted post metabolic surgery are detailed in Table 2. Along with decreases in weight post operatively, there were significant improvements in the markers of CVD risk factors such as mean blood pressure (134/75 to 129/72 mmHg, p value &lt;0.001), mean gylcated hemoglobin levels (7.0 to 6.1%, p value &lt;0.001) and mean low density lipoprotein (LDL) levels (97.7 to 88.2 mg/dl, p value &lt;0.001).

There were a number of statistically significant positive changes in the left ventricular structure and function. The mean LV ejection fraction increased from 56.3% to 57.4% (p=0.008); left ventricular mass decreased from 238.2 g to 179.3 g (p value &lt;0.001), and both septal and posterior wall thicknesses decreased significantly (p value &lt;0.001). The LV mass indexed to body surface area (BSA) also decreased from 93.5 g/m2 to 83.1 g/m2.

The average global LV GLS was −15.7% pre-operatively, improving significantly to −17.9% post-operatively (p&lt;0.001).

Conclusion

Our study has shown for the first time the impact of metabolic surgery on ventricular structure and function, with reduction in LV mass and improvement in LV GLS. These novel findings lends further support to the cardiovascular benefits of metabolic surgery.

Funding Acknowledgement

Type of funding sources: None.

Association Between Atrial Uptake on Cardiac Scintigraphy With Technetium-99m-Pyrophosphate Labeled Bone-Seeking Tracers and Atrial Fibrillation

BACKGROUND

Transthyretin cardiac amyloidosis (ATTR-CA) is an increasingly recognized disease, in which atrial fibrillation (AF) has been shown to be prevalent. Cardiac scintigraphy with technetium-99m-pyrophosphate (99mTc-PyP) labeled bone-seeking tracers is used to noninvasively make the diagnosis of ATTR-CA, based on ventricular myocardial uptake. Assessment of atrial wall uptake (AU) on 99mTc-PyP is currently not used in the clinical setting Methods: We analyzed a cohort of patients referred for 99mTc-PyP scan at a tertiary center to explore AU and associations between any and incident AF, ATTR-CA, and all-cause mortality.

RESULTS

Among 580 patients included, 296 patients (51%) had a diagnosis of AF; 164 patients (28%) had scans consistent with ATTR-CA while 117 patients (20%) had AU. Of 117 patients with AU, 107 (91%) had any AF. In contrast, of 463 patients without AU 191(41%) had any AF. Of those with AU, 59/117(50%) patients had a 99mTc-PyP diagnosis of ATTR-CA while 58/117(50%) patients did not have such a diagnosis (P=1.00). Patients with AU had significantly more any AF (hazard ratio [HR], 1.03 [95% CI, 1.02-1.04]; P<0.001), independent of ATTR-CA diagnosis and sex. On multivariable Cox proportional hazards analyses adjusting for age, AU, ATTR-CA diagnosis, sex, smoking, hypertension, diabetes, left ventricular ejection fraction, and coronary artery disease, both age (HR, 1.03 [95% CI, 1.02-1.04]; P<0.0001) and AU (HR, 2.68 [95% CI, 2.11-3.41]; P<0.0001) were independently associated with the development of any AF. Freedom from incident AF at 1-year was significantly lower in patients with AU, both in patients with and without ATTR-CA respectively (HR, 2.27 [95% CI, 1.37-3.78]; P<0.0001 versus HR, 2.21 [95% CI, 1.46-3.34]; P<0.0001).

CONCLUSIONS

In a consecutive cohort of patients undergoing 99mTc-PyP scans, 20% had AU, which was statistically associated with any AF, independently of ATTR-CA diagnosis and sex. AU was associated with significantly lower freedom from incident AF at 1-year. Overlooking AU on 99mTc-PyP scans could potentially miss an earlier disease manifestation, or an additional risk factor for any/incident AF.

Clinical, functional and prognostic implications of severe atrial dilation in secondary mitral regurgitation

Objective

Atrial dilation is known to be a poor prognostic indicator. However, its clinical, functional and prognostic implications have not been thoroughly explored in secondary mitral regurgitation (SMR). We sought to describe the implications of severe atrial dilation (SAD) in SMR.

Methods

We included all adult patients with severe SMR due to left ventricle dysfunction (with no organic mitral valve disease) who underwent transthoracic echocardiography between January 2012 and March 2021 at our institution. The concomitant presence of severe left atrial (LA) dilation (>48 mL/m²) defined SADMR (SAD in SMR), and these patients were compared with those without SAD.

Results

A total of 2011 patients were included (mean age 70% and 41% females), with 71% having SADMR. MR severity and ejection fraction were similar between both groups. Patients with SADMR were older, less females and had more diabetes, but similar rates of atrial fibrillation. Mechanistically, they had lower A wave velocity (0.61 vs 0.72 cm/sec, p<0.001) and more impaired LA reservoir strain (9.7% vs 15.5%, p<0.001). Geometrically, SADMR had shallower leaflets’ angulations, lower tenting height, larger annuli and smaller leaflet length/annular diameter ratios (all p<0.001). They underwent fewer MV interventions, although these were associated with better outcomes (log-rank p<0.001). Over the study period, SAD was an independent predictor of mortality (HR 1.26, p=0.04).

Conclusion

SADMR is associated with specific mechanistic and functional alterations and confers a worse prognosis.

Sex-based differences in left ventricular remodeling in patients with chronic aortic regurgitation: a multi-modality study

BACKGROUND

Significant aortic regurgitation (AR) leads to left ventricular (LV) remodeling; however, little data exist regarding sex-based differences in LV remodeling in this setting. We sought to compare LV remodeling and AR severity, assessed by echocardiography and cardiovascular magnetic resonance (CMR), to discern sex-based differences.

METHODS

Patients with ≥ moderate chronic AR by echocardiography who underwent CMR within 90 days between December 2005 and October 2015 were included. Nonlinear regression models were built to assess the effect of AR regurgitant fraction (RF) on LV remodeling. A generalized linear model and Bland Altman analyses were constructed to evaluate differences between CMR and echocardiography. Referral for surgical intervention based on symptoms and LV remodeling was evaluated.

RESULTS

Of the 243 patients (48.3 ± 16.6 years, 58 (24%) female), 119 (49%) underwent surgical intervention with a primary indication of severe AR, 97 (82%) men, 22 (18%) women. Significant sex differences in LV remodeling emerged on CMR. Women demonstrated significantly smaller LV end-diastolic volume index (LVEDVI) (96.8 ml/m2 vs 125.6 ml/m2, p < 0.001), LV end-systolic volume index (LVESVI) (41.1 vs 54.5 ml/m2, p < 0.001), blunted LV dilation in the setting of increasing AR severity (LVEDVI p value < 0.001, LVESVI p value 0.011), and LV length indexed (8.32 vs 9.69 cm, p < 0.001). On Bland Altman analysis, a significant interaction with sex and LV diameters was evident, demonstrating a significant increase in the difference between CMR and echocardiography measurements as the LV enlarged in women: LVEDVI (p = 0.006), LVESVI (p < 0.001), such that echocardiographic measurements increasingly underestimated LV diameters in women as the LV enlarged. LV length was higher for males with a linear effect from RF (p < 0.001), with LV length increasing at a higher rate with increasing RF for males compared to females (two-way interaction with sex p = 0.005). Sphericity volume index was higher for men after adjusting for a relative wall thickness (p = 0.033).

CONCLUSIONS

CMR assessment of chronic AR revealed significant sex differences in LV remodeling and significant echocardiographic underestimation of LV dilation, particularly in women. Defining optimal sex-based CMR thresholds for surgical referral should be further developed.

TRIAL REGISTRATION

NA.

Incidence, Predictors, and Implications of Permanent Pacemaker Requirement After Transcatheter Aortic Valve Replacement

Transcatheter aortic valve replacement (TAVR) is a safe and feasible alternative to surgery in patients with symptomatic severe aortic stenosis regardless of the surgical risk. Conduction abnormalities requiring permanent pacemaker (PPM) implantation remain a common finding after TAVR due to the close proximity of the atrioventricular conduction system to the aortic root. High-grade atrioventricular block and new onset left bundle branch block (LBBB) are the most commonly reported conduction abnormalities after TAVR. The overall rate of PPM implantation after TAVR varies and is related to pre-procedural and intraprocedural factors. The available literature regarding the impact of conduction abnormalities and PPM requirement on morbidity and mortality is still conflicting. Pre-procedural conduction abnormalities such as right bundle branch block and LBBB have been linked with increased PPM implantation and mortality after TAVR. When screening patients for TAVR, heart teams should be aware of various anatomical and pathophysiological conditions that make patients more susceptible to increased risk of conduction abnormalities and PPM requirement after the procedure. This is particularly important as TAVR has been recently approved for patients with low surgical risk. The purpose of this review is to discuss the incidence, predictors, impact, and management of the various conduction abnormalities requiring PPM implantation in patients undergoing TAVR.

Novel Approach to Risk Stratification in Left Ventricular Non-Compaction Using A Combined Cardiac Imaging and Plasma Biomarker Approach

Background

Left ventricular non‐compaction remains a poorly described entity, which has led to challenges of overdiagnosis. We aimed to evaluate if the presence of a thin compacted myocardial layer portends poorer outcomes in individuals meeting cardiac magnetic resonance criteria for left ventricular non‐compaction .

Methods and Results

This was an observational, retrospective cohort study involving individuals selected from the Cleveland Clinic Foundation cardiac magnetic resonance database (N=26 531). Between 2000 and 2018, 328 individuals ≥12 years, with left ventricular non‐compaction or excessive trabeculations based on the cardiac magnetic resonance Petersen criteria were included. The cohort comprised 42% women, mean age 43 years. We assessed the predictive ability of myocardial thinning for the primary composite end point of major adverse cardiac events (composite of all‐cause mortality, heart failure hospitalization, left ventricular assist device implantation/heart transplant, ventricular tachycardia, or ischemic stroke). At mean follow‐up of 3.1 years, major adverse cardiac events occurred in 102 (31%) patients. After adjusting for comorbidities, the risk of major adverse cardiac events was nearly doubled in the presence of significant compacted myocardial thinning (hazard ratio [HR], 1.88 [95% CI, 1.18‒3.00]; P=0.016), tripled in the presence of elevated plasma B‐type natriuretic peptide (HR, 3.29 [95% CI, 1.52‒7.11]; P=0.006), and increased by 5% for every 10‐unit increase in left ventricular end‐systolic volume (HR, 1.01 [95% CI, 1.00‒1.01]; P=0.041).

Conclusions

The risk of adverse clinical events is increased in the presence of significant compacted myocardial thinning, an elevated B‐type natriuretic peptide or increased left ventricular dimensions. The combination of these markers may enhance risk assessment to minimize left ventricular non‐compaction overdiagnosis whilst facilitating appropriate diagnoses in those with true disease.

Imaging to evaluate suspected infective endocarditis

Although echocardiography is fundamental in diagnosing infective endocarditis, sometimes it reveals no evidence of endocarditis while clinical indicators remain consistent with the diagnosis. In such cases, repeat imaging is necessary, and the appropriate timeline for it and whether it should be done with transthoracic echocardiography (TTE), trans esophageal echocardiography (TEE), or an advanced imaging method are important.

Improvement in left ventricular mechanics following medical treatment of constrictive pericarditis

OBJECTIVE

Patients with constrictive pericarditis (CP) with active inflammation may show resolution with anti-inflammatory therapy. We aimed to investigate the impact of anti-inflammatory medications on constrictive pathophysiology using echocardiography in patients with CP.

METHODS

We identified 35 patients with CP who were treated with anti-inflammatory medications (colchicine, prednisone, non-steroidal anti-inflammatory drugs) after diagnosis of CP (mean age 58±13; 80% male). Clinical resolution of CP (transient CP) was defined as improvement in New York Heart Association class during follow-up. We assessed constrictive pathophysiology using regional myocardial mechanics by the ratio of peak early diastolic tissue velocity (e') at the lateral and septal mitral annulus by tissue Doppler imaging (lateral/septal e') or the ratio of the left ventricular lateral and septal wall longitudinal strain (LS_lateral/LS_septal) by two-dimensional speckle-tracking echocardiography. Longitudinal data were analysed using a mixed effects model.

RESULTS

During a median follow-up of 323 days, 20 patients had transient CP, whereas 15 patients had persistent CP. Transient CP had higher baseline erythrocyte sedimentation rates (ESR) (p=0.003) compared with persistent CP. There were no significant differences in LS_lateral/LS_septal and lateral/septal e'. During follow-up, only transient CP showed improvement in lateral/septal e' (p<0.001) and LS_lateral/LS_septal (p=0.003), and recovery of inflammatory markers was similar between the two groups. In the logistic model, higher baseline ESR and greater improvement in lateral/septal e' and LS_lateral/LS_septal were associated with clinical resolution of CP using anti-inflammatory therapy.

CONCLUSIONS

Improvement of constrictive physiology detected by lateral/septal e' and LS_lateral/LS_septal was associated with resolution of clinical symptoms after anti-inflammatory treatment. Serial monitoring of these markers could be used to identify transient CP.

705. Factors Associated with Local Invasion in Infective Endocarditis: a Nested Case-control Study

Background

A substantial proportion of infective endocarditis (IE) cases are complicated by local invasion. The purpose of this study was to identify patient and disease characteristics that increase the odds of local invasion in surgically treated IE patients.

Methods

This was a nested case-control study. All episodes of IE for patients admitted to Cleveland Clinic from January 1^st, 2013 – June 30^th, 2016 were identified from the Cleveland Clinic IE Registry. Patients >18 years of age who underwent surgery for IE were included. Data was compiled by manual review of the Electronic Medical Record. Local invasion, defined as peri-annular extension, peri-valvular abscess, intra-cardiac fistula or pseudoaneurysm, was ascertained from the surgical operative note. Associations of selected factors with local invasion were examined in a multivariable logistic regression model.

Results

Among 510 patients who met inclusion criteria, 206 had local invasion. Mean age was 56 years and 369 (72 %) were male. Overall 344 (67 %) had aortic valve, 228 (45%) mitral valve, and 66 (13%) tricuspid or pulmonic valve involvement. Aortic valve involvement (OR 5.76, 95% CI 3.44 – 9.98), mechanical valve (OR 7.63, 95% CI 3.63 – 17.07), bioprosthetic valve (OR 3.20, 95% CI 1.99 – 5.19), significant paravalvular leak (OR 2.27, 95% CI 1.09 – 4.97), new atrioventricular nodal block (OR 3.05, 95% CI 1.57 – 6.09), Staphylococcus aureus infection (OR 2.11, 95% CI 1.20 – 3.76), coagulase negative staphylococcal infection (OR 2.38, 95% CI1.27 – 4.54), and non- viridans group streptococcal infection (OR 4.21, 95% CI 1.81 – 10.06) were significantly associated with local invasion.

Conclusion

Intra-cardiac and microorganism factors, but not comorbid conditions, are associated with local invasion in IE.

Disclosures

All Authors: No reported disclosures

Real-world opioid prescribing after cataract surgery among patients who received intracameral phenylephrine and ketorolac 1.0%/0.3

OBJECTIVE

To examine opioid prescribing following cataract surgery among patients who did or did not receive Omidria (phenylephrine and ketorolac intraocular solution 1.0%/0.3%) referred to as "P/K".

METHODS

The retrospective study compared adults over 65 without recent opioid use in the MarketScan databases who had a cataract-related surgical procedure between 1 January 2015 and 31 July 2019. Opioid prescription fills in the initial 2 and 7 days following surgery were compared between patients who did or did not receive P/K during surgery.

RESULTS

We identified 218,672 older adults with cataract-related surgical procedures, of whom 5145 received P/K during surgery. Within 2 days of surgery, 0.50% of P/K patients and 0.68% of non-P/K patients received at least one opioid prescription. Pill counts in the first prescription post-surgery were lower for patients who received P/K than those who did not receive P/K (20 vs 45 respectively, p = .015). Findings were similar when a 7 day window was used. The reduction in opioids prescribed to patients who received P/K occurred despite the P/K-treated patients having a significantly higher incidence of preoperative comorbidities or risk factors for surgical complexity than patients who did not receive P/K (46.6% vs 31.3%, p < .001).

CONCLUSIONS

Patients without recent opioid use who received P/K during cataract surgery, despite greater incidence of preoperative comorbidities and higher risk for surgical complexity, were prescribed fewer opioid pills following surgery than patients who did not receive P/K.

PSIX-28 Examining the effects of estradiol, trenbolone acetate, or polyamines on bovine satellite cell differentiation

The mechanism through which anabolic implants improve skeletal muscle growth of beef animals is incompletely understood. Polyamines (PA) are bioactive amino acid derivatives that act as potent growth stimulants. The objective of this study was to determine effects of anabolic implants, PA and their precursors on bovine satellite cell (BSC) differentiation. Primary BSC were cultured to approximately 80% confluency, at which time they were induced to differentiate in the presence of 3% horse serum (Con) and treated with 10nM TBA, 10 nM E2, or 10nM TBA and 10 nM E2 (ETBA), 10 mM methionine (Met), 8 mM ornithine (Orn), 2 mM putrescine (Put), 1.5 mM spermidine (Spd) or 0.5 mM spermine (Spe). Total mRNA was isolated 0, 2, 4, 8, 12, 24, or 48 h post-treatment and abundance of paired box transcription factor 7 (Pax7) and myogenic differentiation factor (MyoD) were analyzed. Treatment with the hormones (TBA, E2, or ETBA) and PA (Orn, Put, Spd, and Spe) increased (P &lt; 0.05) abundance of MyoD 4 h post-treatment when compared to Con cultures. However, 24 h post-treatment, MyoD abundance was decreased in the presence of hormone treatments when compared to the Con, while the PA treatments increased (P &lt; 0.05) abundance of MyoD when compared to the Con cultures. Treatment with either the hormones or PA had no effect (P &gt; 0.05) on Pax7 abundance at 2, 4, 8, 12, 24, or 48 h post-treatment when compared to Con cultures (P &gt; 0.05). These results indicate that treatment with PA or hormones increases abundance of MyoD, though temporally different indicating that these two classes of growth promoters impact differentiation via alternate physiological pathways. Additional research is underway in order to determine the effects of both PA and hormones on differentiation of primary BSC.

Diagnostic performance of cardiac computed tomography versus transesophageal echocardiography in infective endocarditis: A contemporary comparative meta-analysis

OBJECTIVE

To compare the diagnostic accuracy of transesophageal echocardiography (TEE) and cardiac computed tomography (CCT) in diagnosing infective endocarditis (IE).

BACKGROUND

TEE is a mainstay imaging modality for IE, while the use of CCT is becoming increasingly prevalent. Data directly comparing the diagnostic performance of these two imaging modalities for IE are limited.

METHODS

We conducted a systematic review and meta-analysis of published literature in Embase, PubMed and Cochrane databases through October 1, 2020 for studies comparing diagnostic performance of CCT and TEE for the diagnosis of IE in the same patient populations. A meta-analysis of diagnostic accuracy was performed using the bivariate model based on studies that used surgical pathology as a reference standard for defining endocarditis. From a total of 10 studies included in the meta-analysis, a total of 872 patients were evaluated.

RESULTS

The pooled sensitivities and specificities of TEE for detecting vegetations were 96% and 83% respectively, whereas for CCT, they were 85% and 84%, respectively. In the prosthetic valve sub-group, the pooled sensitivities and specificities of TEE for detecting vegetations were 89% and 74% respectively, whereas for CCT, they were 78% and 94%, with CCT being more specific than TEE (p < 0.05). The pooled sensitivities and specificities of TEE for detecting periannular complications were 70% and 96% respectively, whereas for CCT, they were 88% and 93%, respectively. CCT showed a trend (p = 0.06) towards higher sensitivity than TEE for detection of periannular complications. The pooled sensitivities and specificities of TEE for detecting leaflet perforation were 79% and 93% respectively, whereas for CCT, they were 48% and 93% respectively, with TEE being more sensitive (p < 0.05). The two modalities also showed comparable diagnostic performance for detecting fistulae, paravalvular leaks and prosthetic valve dehiscence.

CONCLUSION

In a contemporary comparative meta-analysis, TEE and CCT demonstrated both good diagnostic accuracy for detecting valvular involvement and complications of IE. TEE performed better for detecting leaflet defects, whereas CCT performed better in cases of prosthetic valve involvement, and showed a trend towards improved detection of periannular complications. Appropriate, complementary use of both TEE and CCT in a multimodality imaging approach in clinical practice may achieve the highest diagnostic performance.

Machine Learning-Based Risk Assessment for Cancer Therapy-Related Cardiac Dysfunction in 4300 Longitudinal Oncology Patients

Background The growing awareness of cardiovascular toxicity from cancer therapies has led to the emerging field of cardio-oncology, which centers on preventing, detecting, and treating patients with cardiac dysfunction before, during, or after cancer treatment. Early detection and prevention of cancer therapy-related cardiac dysfunction (CTRCD) play important roles in precision cardio-oncology. Methods and Results This retrospective study included 4309 cancer patients between 1997 and 2018 whose laboratory tests and cardiovascular echocardiographic variables were collected from the Cleveland Clinic institutional electronic medical record database (Epic Systems). Among these patients, 1560 (36%) were diagnosed with at least 1 type of CTRCD, and 838 (19%) developed CTRCD after cancer therapy (de novo). We posited that machine learning algorithms can be implemented to predict CTRCDs in cancer patients according to clinically relevant variables. Classification models were trained and evaluated for 6 types of cardiovascular outcomes, including coronary artery disease (area under the receiver operating characteristic curve [AUROC], 0.821; 95% CI, 0.815-0.826), atrial fibrillation (AUROC, 0.787; 95% CI, 0.782-0.792), heart failure (AUROC, 0.882; 95% CI, 0.878-0.887), stroke (AUROC, 0.660; 95% CI, 0.650-0.670), myocardial infarction (AUROC, 0.807; 95% CI, 0.799-0.816), and de novo CTRCD (AUROC, 0.802; 95% CI, 0.797-0.807). Model generalizability was further confirmed using time-split data. Model inspection revealed several clinically relevant variables significantly associated with CTRCDs, including age, hypertension, glucose levels, left ventricular ejection fraction, creatinine, and aspartate aminotransferase levels. Conclusions This study suggests that machine learning approaches offer powerful tools for cardiac risk stratification in oncology patients by utilizing large-scale, longitudinal patient data from healthcare systems.

Subthreshold Aortic Valve Calcium Scores in Severe Aortic Stenosis and Transthyretin Cardiac Amyloidosis

We have clinically observed that some patients with transthyretin cardiac amyloidosis and severe aortic stenosis may have lesser degrees of calcification than one might expect. We report a case series of 3 patients with transthyretin cardiac amyloidosis and severe aortic stenosis despite discordant aortic valve calcium scores. (Level of Difficulty: Intermediate.)

Contemporary predictors of readmission outcomes in patients with infective endocarditis: analysis from a national readmission database

Background/Introduction

Infective endocarditis (IE) remains a serious illness that is associated with remarkable morbidity and mortality in the United States (US). There are limited studies that investigated predictors of 30-day readmission risk in this population.

Purpose

We aimed to perform a contemporary analysis to investigate predictors of 30-day readmission in IE patients in the US.

Methods

We used the 2017 national readmission database to identify index admissions among adults (age ≥18) with the diagnosis of IE. Appropriate International Statistical Classification (ICD-10) codes were used to identify patients with IE. Primary outcome of interest was 30-day readmission, and hospital cost was the secondary outcome.

Results

Out of 49,692 admissions for IE, 5,743 (11.6%) patients were readmitted within 30 days. Patients who had 30-day readmission were younger (55±20 vs 61±19 years, P&lt;0.001), 44.8% were females (P=0.08), 27.9% had diabetes mellitus (DM), 56.8% had hypertension, 37.9% had heart failure (HF), 31.3% had chronic kidney disease (CKD), 12.2% had end stage renal disease, and 47.8% had Medicare insurance. Patients who had readmissions within 30 days were more likely to have non-elective index admission (96.9% vs 93.4%, P&lt;0.001), more likely to have hepatitis C (19.5% vs 12.2%, P&lt;0.001), human immunodeficiency virus (HIV) (1.7% vs 1.2%, P&lt;0.001), substance abuse (8.6% vs 5.4%, P&lt;0.001), opioid abuse (24% vs 14.7%, P&lt;0.001), and cocaine use (7.4% vs 4.3%, P&lt;0.001). Overall, 5,393 (10.9%) patients died during index admission. Median cost for readmissions within 30 days was $83,217 [$41,457-$165,487], compared to the index admission cost of $90,257 [$41,945- $208,851] (P&lt;0.001). After adjusting for age, DM, HF, and CKD, substance abuse (odds ratio (OR): 1.19 [1.07–1.33]; P 0.001), opioid abuse (OR: 1.37, [1.26- 1.48]; P&lt;0.001), cocaine use (OR: 1.33 [1.18- 1.48]; P&lt;0.001), HIV (OR: 1.25 [1.01–1.56]; P=0.04), and hepatitis C (OR: 1.34 [1.24–1.45]; P&lt;0.001) correlated with higher odds of readmissions within 30 days (Figure 1).

Conclusion

Approximately 1 in 4 patients admitted for IE in the US had a history of opioid abuse and almost one fifth had hepatitis C. The 30-day readmission rate remains significant in IE with high financial burden on the health system. Both opioid abuse and hepatitis C were among the highest predictors of readmission within 30 days. Identifying modifiable predictors of readmission in this population may reduce readmission risk and healthcare cost.

Figure 1

Funding Acknowledgement

Type of funding source: None

Impact of timing of atrial fibrillation, CHA2DS2-VASc score and cancer therapeutics on mortality in oncology patients

OBJECTIVES

To investigate timing and age distribution of atrial fibrillation (AF) in selected oncology patients, and the impact of AF timing, CHA2DS2-VASc score and cancer therapeutics on mortality.

METHODS

This is a retrospective cohort study of oncology patients referred to the cardio-oncology service from 2011 to 2018 for echocardiographic cardiosurveillance and/or pre-existing cardiovascular risk factor/disease management. Rates of first AF diagnosis was assessed using a parametric multiphase hazard model (predictive modelling) and non-parametrically by Kaplan-Meier with transformations tested using a bootstrap methodology.

RESULTS

Among 6754 patients identified, 174 patients had their first AF diagnosis before cancer while 609 patients had their first diagnosis of AF after cancer. Most first AF diagnosis occurred at/early after cancer diagnosis. Increasing AF prevalence at time of cancer diagnosis was seen across older age groups ranges. Diagnosis of cancer at an older age and exposure to cardiotoxic treatment (anthracyclines, HER2-neu inhibitors, tyrosine kinase inhibitors including ibrutinib and radiation) were associated with an increased risk of AF.Modelling of the hazard function of AF identified a high left-skewed peak within 3 years after cancer diagnosis ('early phase'), followed by a gradual late slight rise 3 years after cancer diagnosis ('late phase'). AF diagnosis was only associated with death in the early phase (p<0.001), while CHA2DS2-VASc score was only associated with death in the late phase (p<0.001).

CONCLUSIONS

This study reports a nuanced/complex relationship between AF and cancer. First diagnosis of AF in patients with cancer was more common at/early after cancer diagnosis, especially in older patients and those exposed to cardiotoxic treatment. Pre-existing AF or a diagnosis of AF within 3 years after cancer diagnosis carried a negative prognosis. CHA2DS2-VASc score did not relate to mortality in those that developed AF within 3 years of cancer diagnosis.

Impact of Nonalcoholic Fatty Liver Disease on Arrhythmia Recurrence Following Atrial Fibrillation Ablation

OBJECTIVES

This study sought to investigate the association between nonalcoholic fatty liver disease (NAFLD) and arrhythmia recurrence following atrial fibrillation ablation; and to examine the impact of NAFLD stage on outcomes.

BACKGROUND

Metabolic derangements, including obesity and diabetes, are associated with incident and recurrent atrial fibrillation (AF), in addition to the development of NAFLD.

METHODS

This was a retrospective study of 267 consecutive patients undergoing AF ablation, 89 of whom were diagnosed with NAFLD prior to ablation and matched in a 2:1 manner based on age, sex, body mass index, ejection fraction, and AF type with 178 patients without NAFLD. Patients were monitored for arrhythmia recurrence during a mean follow-up of 29 months.

RESULTS

Recurrent arrhythmia was observed in 50 (56%) patients with NAFLD compared with 37 (21%) without NAFLD. Epicardial fat volume was measured on computed tomography and was significantly higher among those with NAFLD (248 ± 125 ml vs. 223 ± 97 ml; p = 0.01). On multivariable models adjusting for sleep apnea, body mass index, heart failure, AF type, and left atrial size, NAFLD was independently associated with increased rates of arrhythmia recurrence (hazard ratio: 3.010; 95% confidence interval: 1.980 to 4.680; p < 0.0001).

CONCLUSIONS

NAFLD is associated with significantly increased arrhythmia recurrence rates following AF ablation. Identification and reversal, where possible, may result in improved arrhythmia-free survival.

Diagnosis of Infective Endocarditis by Subtype Using 18F-Fluorodeoxyglucose Positron Emission Tomography/Computed Tomography: A Contemporary Meta-Analysis

Background Infective endocarditis (IE) remains a difficult to diagnose condition associated with high mortality. ¹⁸F-fluorodeoxyglucose positron emission tomography/computed tomography (¹⁸F-FDG PET/CT) has recently emerged as another IE imaging modality, although diagnostic accuracy varies across observational studies and types of IE. This meta-analysis assessed the diagnostic performance of ¹⁸F-FDG PET/CT for IE and its subtypes. Methods We searched Pubmed, Cochrane, and Embase from January 1980 to September 2019 for studies reporting both sensitivity and specificity of ¹⁸F-FDG PET/CT for IE. Meta-Disc 1.4 was used to pool data for all cases of IE and its subgroups of native valve IE, prosthetic valve IE, and cardiac implantable electronic devices IE. Results We screened 2566 records from the search, assessed 52 full-text articles, and included 26 studies totaling 1358 patients (509 IE cases). Pooled sensitivity and specificity (95% CI, inconsistency I-square statistic) were 0.74 (0.70-0.77, 71.5%) and 0.88 (0.86-0.91, 78.5%) for all cases of endocarditis. Corresponding parameters for native valve IE were sensitivity 0.31 (0.21-0.41, 29.4%) and specificity 0.98 (0.95-0.99, 34.4%); for prosthetic valve IE: sensitivity 0.86 (0.81-0.89, 60.0%) and specificity 0.84 (0.79-0.88, 75.2%); and for cardiac implantable electronic devices IE: sensitivity 0.72 (0.61-0.81, 76.2%) and specificity 0.83 (0.75-0.89, 83.6%). Pooled sensitivities and specificities were higher for the 17 studies since 2015 than the 9 studies published before 2015. Conclusions ¹⁸F-FDG PET/CT had high specificity for all IE subtypes; however, sensitivity was markedly lower for native valve IE than prosthetic valve IE and cardiac implantable electronic devices IE. It is, therefore, a useful adjunct modality for assessing endocarditis, especially in the challenging scenarios of prosthetic valve IE and cardiac implantable electronic devices IE, with improving performance over time, related to advances in ¹⁸F-FDG PET/CT techniques.

The role of cardiac imaging in hospitalized COVID-19-positive patients

COVID-19 infection is associated with several cardiac complications with high rates of adverse outcomes. Cardiac imaging has different utility in different clinical scenarios, and the importance of minimizing healthcare worker exposure should be considered. Cardiac imaging should only be ordered if its benefits outweigh its risks, with anticipated changes in acute treatment and outcomes, and no suitable alternative of sufficient adequacy is available. Indications for advanced cardiac imaging for COVID-19 patients in the acute phase are limited, although follow-up imaging in the convalescent stage may provide prognostic importance in recovered COVID-19 patients with positive troponin or decompensated heart failure.

Impact of tricuspid regurgitation on postoperative outcomes after non-cardiac surgeries

Objective

Tricuspid regurgitation (TR) severity has known adverse implications, its impact on patients undergoing non-cardiac surgery (NCS) remains unclear. We sought to determine the impact of TR on patient outcomes after NCS.

Methods

We performed a retrospective cohort study in patients undergoing NCS. Outcomes in patients with moderate or severe TR were compared with no/trivial TR after adjusting for baseline characteristics and revised cardiac risk index (RCRI). The primary outcome was defined as 30-day mortality and heart failure (HF), while the secondary outcome was long-term mortality.

Results

Of the 7064 patients included, 312 and 80 patients had moderate and severe TR, respectively. Thirty-day mortality was higher in moderate TR (adjusted OR 2.44, 95% CI 1.25 to 4.76) and severe TR (OR 2.85, 95% CI 1.04 to 7.79) compared with no/trivial TR. There was no difference in 30-day HF in patients with moderate TR (OR 1.48, 95% CI 0.90 to 2.44) or severe TR (OR 1.42, 95% CI 0.60 to 3.39). The adjusted HR for long-term mortality in moderate TR was 1.55 (95% CI 1.31 to 1.82) and 1.87 (95% CI 1.40 to 2.50) for severe TR compared with no/trivial TR.

Conclusion

Increasing TR severity has higher postoperative 30-day mortality in patients undergoing NCS, independent of RCRI risk factors, ejection fraction or mitral regurgitation. Severity of TR should be considered in risk stratification for patients undergoing NCS.

Efficacy and cultural appropriateness of psychosocial interventions for paediatric burn patients and caregivers: a systematic review

Background

Paediatric burns are highly painful and traumatising injuries that are overrepresented among Aboriginal and Torres Strait Islander people. Paediatric burn patients’ pain remains poorly managed by pharmacological interventions, leading to increased anxiety, distress, and trauma in patients and their caregivers. Non-pharmacological psychosocial interventions have been suggested as effective in reducing pain and psychological morbidities among paediatric burn patients and their caregivers; however, their degree of effectiveness and appropriateness for Aboriginal and Torres Strait Islander people is unclear.

Methods

A non-date restricted systematic review was conducted through four databases. Studies published in English assessing psychosocial interventions on paediatric burn patients’ physical pain along with theirs and/or their caregiver’s anxiety, distress, or trauma symptoms were identified and included in this review. Included studies were assessed for their ability to reduce one of the outcomes of interests and for their reflection of Aboriginal and Torres Strait Islander peoples’ perspectives of health.

Results

Of the 3178 identified references, 17 were eligible. These include distraction based techniques (n = 8), hypnosis/familiar imagery (n = 2), therapeutic approaches (n = 4), and patient preparation/procedural control (n = 3). Distraction techniques incorporating procedural preparation reduced pain, while discharge preparation and increased ‘patient control’ reduced patient and caregiver anxiety; and internet based Cognitive Behaviour Therapy reduced short-term but not long-term post-traumatic stress symptoms. No interventions reflected Aboriginal and Torres Strait Islander peoples’ perspectives of health; and few targeted caregivers or focused on reducing their symptoms.

Conclusions

The development and assessment of psychosocial interventions to appropriately meet the needs of Aboriginal and Torres Strait Islander paediatric burn patients is required.

Jeopardized Myocardium Defined by Late Gadolinium Enhancement Magnetic Resonance Imaging Predicts Survival in Patients With Ischemic Cardiomyopathy: Impact of Revascularization

Background The prognostic impact of jeopardized myocardium ( JM ) in patients with advanced ischemic cardiomyopathy ( ICM ) is unclear. We hypothesized that JM is an independent predictor of mortality in patients with advanced ICM . Methods and Results Patients with ICM who underwent cardiac magnetic resonance imaging between January 2002 and January 2013 were included in our study. JM was identified as a vascular territory with <50% myocardial scarring on cardiac magnetic resonance imaging and with >70% stenosis in a major coronary vessel that was not subsequently revascularized. A propensity score was developed for revascularization. A multivariable Cox proportional hazards model was used to evaluate the association of JM with all-cause mortality. We evaluated 631 patients over a mean follow-up of 5.1 years. Overall, 336 patients underwent subsequent revascularization during the follow-up period, among whom 23% had remaining JM , while 295 patients were medically treated (57% with JM ). There were 204 deaths (32%). On multivariable analysis, JM (hazard ratio, 1.88; 95% confidence interval, 1.38-2.55 [ P<0.001]) was independently associated with all-cause mortality after adjusting for multiple other factors. The risk associated with the presence of JM increased by 5% for every 10-unit increase in left ventricular end-systolic volume index. Conclusions JM is an independent and incremental predictor of mortality in patients with advanced ICM . Patients undergoing revascularization with residual JM had similar risk of mortality compared with medically treated patients with JM . The risk associated with JM significantly increased in the presence of worsening adverse left ventricular remodeling. Cardiac magnetic resonance viability assessment may provide important risk stratification in patients with ICM .

Geographic Trends, Patient Characteristics, and Outcomes of Infective Endocarditis Associated With Drug Abuse in the United States From 2002 to 2016

Background

There has been an increase in the prevalence of drug abuse (DA) in the national opioid epidemic. With increasing DA, there is an increased risk of infective endocarditis (IE). There are limited recent data evaluating national trends on the incidence and geographical distribution of DA‐IE. We aim to investigate those numbers as well as the determinants of outcome in this patient population.

Methods and Results

Hospitalized patients with a primary or secondary diagnosis of IE based on the International Classification of Diseases, Ninth and Tenth Revisions (ICD‐9, ICD‐10) were included. We described the national and geographical trends in DA‐IE. We also compared DA‐IE patients’ characteristics and outcomes to those with IE, but without associated drug abuse (non‐DA‐IE) using Poisson regression models. Incidence of DA‐IE has nearly doubled between 2002 and 2016 All US regions were affected, and the Midwest had the highest increase in DA‐IE hospitalizations (annual percent change=4.9%). Patients with DA‐IE were younger, more commonly white males, poorer, had fewer comorbidities, and were more likely to have human immunodeficiency virus, hepatitis C, concomitant alcohol abuse, and liver disease. Their length of stay was longer (9 versus 7 days; P<0.001) and were more likely to undergo cardiac surgery (7.8% versus 6.2%; P<0.001), but their inpatient mortality was lower (6.4% versus 9.1%; P<0.001).

Conclusions

DA‐IE is rising at an alarming rate in the United States. All regions of the United States are affected, with the Midwest having the highest increase in rate. Young‐adult, poor, white males were the most affected.