Cardiovascular Disease and Inpatient Complications in Turner Syndrome: A Propensity Score Analysis

BACKGROUND

Turner syndrome is a genetic disorder that occurs in female individuals and is characterized by the absence of 1 of the X chromosomes. This study examined the risk of cardiovascular disease and inpatient clinical outcomes in patients with Turner syndrome.

METHODS

Data were extracted from the Nationwide Inpatient Sample 2016 database. Propensity score analysis was used to match women with Turner syndrome and women without Turner syndrome admitted to a hospital in the same year to evaluate the risk of cardiovascular disease and inpatient clinical outcomes in patients with Turner syndrome.

RESULTS

After 1:1 matching, 710 women with Turner syndrome and 710 women without Turner syndrome were included in the final analysis. Compared with women without Turner syndrome, women with Turner syndrome were more likely to have a bicuspid aortic valve (9.4% vs 0.01%; P < .01), coarctation of the aorta (5.8% vs 0.3%; P < .01), atrial septal defect (6.1% vs 0.8%; P < .01), and patent ductus arteriosus (4.6% vs 0.6%; P < .01). Patients with Turner syndrome were more likely to have an aortic aneurysm (odds ratio [OR], 2.46 [95% CI, 1.02-5.98]; P = .046), ischemic heart disease (OR, 1.66 [95% CI, 1.10-2.5]; P = .02), heart failure (OR, 3.15 [95% CI, 1.99-4.99]; P < .01), and atrial fibrillation or flutter (OR, 2.48 [95% CI, 1.42-4.34]; P < .01). Patients with Turner syndrome were more likely to have pulmonary arterial hypertension (OR, 2.12 [95% CI, 1.08-4.14]; P = .03) and acute kidney injury (OR, 1.60 [95% CI, 1.06-2.42]; P = .03) and to require mechanical ventilation (OR, 1.66 [95% CI, 1.04-2.68]; P = .04).

CONCLUSION

Turner syndrome is associated with an increased rate of cardiovascular disease and inpatient complications. These findings suggest that patients with Turner syndrome should be screened and monitored closely for cardiovascular disease and inpatient complications.

Electronic Cigarette Use and Myocardial Infarction

BACKGROUND

Current electronic cigarettes (e-cigarettes) is associated with myocardial infarction, controlling whether the subjects smoke cigarettes. However, no studies have been conducted on subjects who never smoked cigarettes. This study aimed to determine the association between e-cigarette use and myocardial infarction among subjects who have never smoked cigarettes.

METHODS

The National Health Interview Survey (NHIS) data from 2014 to 2021 was used to evaluate the relationship between e-cigarette use and myocardial infarction in subjects who have never smoked cigarettes after adjusting for risk factors, including age, sex, diabetes, hypertension, hypercholesterolemia, and obesity/overweight, using logistic regression.

RESULTS

 A total of 139,697 subjects were never users, and 1,237 subjects were current e-cigarette users. E-cigarette users were significantly younger than never users. E-cigarette users were less likely to be female (40% vs. 60%, p <0.01), or have diabetes (3% vs. 10%, p <0.01), have hypertension (11% vs. 32%, p <0.01), have hypercholesterolemia (8% vs. 27%, p <0.01), or be overweight or obese (56% vs. 65%, p <0.01) compared to never users. The current e-cigarette users had a 2.6-fold increase in the odds of having a myocardial infarction (OR 2.62, 95% CI 1.44-4.77; p <0.01) after adjusting for sex, age, hypertension, diabetes, hypercholesterolemia, and obesity/overweight.  Conclusions: This study suggests that current e-cigarette use increases the risks of cardiovascular disease, including myocardial infarction and stroke, in subjects who never smoked cigarettes. Further longitudinal studies are needed to confirm the results of this study.

Takotsubo Syndrome in Black Americans: Insights From the National Inpatient Sample

BACKGROUND

Data on race-related differences in the clinical outcomes of Takotsubo syndrome are limited, particularly for Black patients. This study aimed to assess whether race and sex may have an additional impact on the inpatient mortality of patients with Takotsubo syndrome.

METHODS

A total of 4,628 patients from the United States' National Inpatient Sample from 2012 to 2016 were identified; propensity score analysis revealed a similar propensity score between Black patients (n = 2,314) and White patients (n = 2,314), which was used to balance observed covariates. Sex and age distributions were identical between the 2 groups. The groups were also similar in baseline characteristics, including cardiovascular risk factors. White patients were compared with Black patients on in-hospital outcomes and inpatient mortality. A logistic regression analysis was conducted to measure the difference in mortality based on race and sex.

RESULTS

Compared with White patients, Black patients had a higher percentage of in-hospital complications, including cerebrovascular accidents (4.9% vs 2.5%, P ≤ .01), acute kidney injury (25% vs 19%, P ≤ .01); longer lengths of stay (8 vs 7 days, P ≤ .01); and higher inpatient mortality (6.1% vs 4.5%, P < .01). When analysis was conducted with race and sex combined, inpatient mortality was higher among Black men than among White women (odds ratio, 2.7 [95% CI, 1.80-3.95]; P ≤ .01).

CONCLUSION

This study showed that Black patients with Takotsubo syndrome have higher in-hospital complications and inpatient mortality rates. When race and sex were combined, inpatient mortality was significantly higher among Black men than among either White men and women or Black women.

The Prevalence of Electronic Cigarette Use Among College Students of Taibah University and Symptoms of Cardiovascular Disease

Background

Electronic cigarettes (e-cigarettes) have been increasing in popularity among young adults due to the misconception about the safety of e-cigarettes. Our study aims to identify the prevalence rate of e-cigarette use among college students, the reason behind their use, and the relationship between the use of electronic cigarettes and cardiovascular symptoms among college students.

Methods

An online questionnaire was sent to students of Taibah University between 2021 and 2022. Data from this survey were analyzed to obtain the prevalence of e-cigarette use among Taibah University students and to compare the demographic and health characteristics differences between e-cigarette users and non-users. The prevalence of cardiovascular symptoms was also compared between the two groups.

Results

A total of 519 students participated in this study. The prevalence rate of e-cigarette use was 24%. Compared to non-users, e-cigarette users were more likely to be male (71% vs. 40%, p < 0.01), overweight (44% vs. 32%, p = 0.01), and drug users (4% vs. 1%, p = 0.01). E-cigarette users were likelier to complain of cardiovascular symptoms, including chest pain (19% vs. 10%, p = 0.01), shortness of breath (14% vs. 7%, p = 0.02), and palpitation (12% vs. 6%, p = 0.03). The association between e-cigarette use and cardiovascular symptoms was significant even after adjusting for students' characteristics. Students' main reasons for e-cigarette use were to enjoy the flavors of e-cigarettes, quit tobacco smoking, and improve depression.

Conclusion

The prevalence rate of e-cigarette use among college students was 24%. The self-reported cardiovascular disease symptoms rate was doubled among e-cigarette users compared to non-users.

Takotsubo Cardiomyopathy Triggered by Acute Intermittent Porphyria

Background Takotsubo cardiomyopathy (TC) is a reversible condition characterized by myocardial akinesis due to catecholamine-mediated myocardial stunning. Acute intermittent porphyria (AIP) is associated with a rise in catecholamine, which could trigger TC. This study aims to evaluate patients with porphyria-triggered TC. Methods Data from the National Inpatient Sample (NIS) was used to study the prevalence rate and clinical outcome of porphyria-triggered TC among patients with TC. Results Overall, 32,500 cases were admitted between 2012 and 2016 with TC. The rates of smoking, hypertension, hyperlipidemia, and diabetes mellitus were 28%, 54%, 45%, and 23%, respectively. Six and three percent had cardiogenic shock and cardiac arrest, respectively. The overall inpatient mortality was 5.4%. Out of 32,500 patients with takotsubo cardiomyopathy, only three of these cases were found to have porphyria. Patients with porphyria were not significantly different in the baseline health characteristics from patients without porphyria. Additionally, there were no significant differences in the inpatient clinical outcomes between patients with porphyria vs. patients without porphyria.  Conclusion TC triggered by porphyria is a rare disease. Patients with this disease have an excellent short-term prognosis. Beta-blocker medications might be effective in these patients to reduce the risk of recurrence. Further prospective studies are needed to test the effectiveness of beta-blocker in reducing the recurrence of TC.

Age-sex effect on in-hospital complications and mortality in patients with Takotsubo syndrome. Insights from the National Inpatient Sample

Age and sex differences in Takotsubo syndrome (TTS) are still a matter of debate. The present study aimed to evaluate the difference in cardiovascular (CV) risk factors, CV disease, in-hospital complications, and death within different sex-age groups. Using the National Inpatient Sample database between 2012 and 2016, 32,474 patients older than 18 years of age hospitalized with the primary diagnosis of TTS were identified. A total of 32,474 patients were enrolled; 27,611 (85.04%) were female. CV risk factors were higher in females, while CV diseases and in-hospital complications were significantly higher in males. The mortality in males was twice as high as that of female patients (9.83% versus 4.58%, p<0.01), and in the logistic regression model after adjustment for confounders, the odds ratio (OR) was 1.79, the confidence interval was 1.60-2.02, and p<0.01. After dividing the group based on age, in-hospital complications were inversely related to age in both sexes, and the length of in-hospital stay was double in the youngest group compared to the oldest one. Mortality increased progressively with age in both groups but was constantly higher in males for each age group. Multiple logistic regression analysis for mortality was performed for the two sexes separately and for the three age groups, considering the youngest one as the reference group. In females, the OR was 1.59 and 2.88, respectively, for groups 2 and 3; for males, the OR was 1.92 and 3.15, all of them statistically significant (p<0.01). In-hospital complications were more common in younger patients with TTS, particularly in males. Mortality was positively correlated with age for both sexes, but mortality was higher in males compared to females in all age groups.

Cardiovascular Outcomes in Patients With Mitochondrial Disease in the United States: A Propensity Score Analysis

Mitochondrial disease comprises a wide range of genetic disorders caused by mitochondrial dysfunction. Its rarity, however, has limited the ability to assess its effects on clinical outcomes. To evaluate this relationship, we collected data from the 2016 National Inpatient Sample, which includes data from >7 million hospital stays. We identified 705 patients (mean age, 22 ± 20.7 yr; 54.2% female; 67.4% white) whose records included the ICD-10-CM code E88.4. We also identified a propensity-matched cohort of 705 patients without mitochondrial disease to examine the effect of mitochondrial disease on major adverse cardiovascular events, including all-cause in-hospital death, cardiac arrest, and acute congestive heart failure. Patients with mitochondrial disease were at significantly greater risk of major adverse cardiovascular events (odds ratio [OR]=2.42; 95% CI, 1.29-4.57; P=0.005), systolic heart failure (OR=2.37; 95% CI, 1.08-5.22; P=0.027), and all-cause in-hospital death (OR=14.22; 95% CI, 1.87-108.45; P<0.001). These findings suggest that mitochondrial disease significantly increases the risk of inpatient major adverse cardiovascular events.

Relation of Bariatric Surgery to Inpatient Cardiovascular Outcomes (from the National Inpatient Sample)

Approximately one in 3 patients in the United States are obese. There is a strong association between obesity and an increased rate of cardiovascular disease (CVD)-related mortality. Bariatric surgery (BS) has emerged as an effective strategy to achieve reduction of excess weight. Our study aims to explore the relationship between BS and major adverse cardiovascular events (MACE) among obese hospitalized patients in the United States. This is a retrospective study of all obese adult patients with BMI ≥35 kg/m² (n= 1,700,943) in the National Inpatient Sample between 2012 and 2016. Differences in the clinical characteristics of obese patients with a history of BS versus obese patients without a history of BS were analyzed as well as the association between BS and MACE after adjusting for CVD risk factors. Among 50,296 obese patients with a history of BS (2.96%), the mean age was 53 ± 12 years with the majority being female (75.32%) and Caucasian (71.85%). Multivariate analysis revealed that obese patients with a history of BS had a1.6-fold decrease odds of MACE compared with patients without BS (OR 0.62; 95% CI, 0.60 to 0.65; p <0.001). In conclusion, this study illustrates that among obese patients with BMI ≥35 kg/m², history of BS was associated with a significantly lower odds of inpatient MACE, after adjusting for CVD risk factors.

Abstract 211: Association of Bariatric Surgery With Major Adverse Cardiovascular Outcomes: Insights From the National Inpatient Sample 2012-2016

Background: Approximately one in every three people in the United States has obesity. There is a strong association between obesity and an increased rate of cardiovascular disease (CVD)-related mortality. Bariatric surgery (BS) refers to a variety of procedures performed to achieve a reduction of excess weight. Many small randomized controlled trials and observational studies have demonstrated the association between BS and reduction in major adverse cardiac events (MACEs) among patients with obesity and Type 2 diabetes. However, these studies have been limited by small sample sizes, localized database, or inclusion of surgical procedures no longer commonly used. Our study aims to explore the relationship between BS and inpatients MACEs among obese inpatients in the United States, using a large and contemporary national database.

Methods: This is a retrospective study using the National Inpatient Sample between 2012 and 2016. Adult obese patients with BMI ≥35 (ICD 9/10 codes V85.35, V85.4x/ Z68.35, Z68.4x) were included (n= 1,700, 943). First, a univariate analysis was performed to study differences in clinical characteristics between obese patients with BS status (identified by ICD9/10 codes V45.86 / Z98.84, respectively) versus obese patients without BS status. A logistic regression model was then constructed to study the association between undergoing BS and having MACEs, including all-cause mortality, cardiac arrest, acute heart failure, acute myocardial infarction (MI), and cerebrovascular accident after adjusting for CVD risk factors such as gender, diabetes, hypertension, hyperlipidemia, prior MI, chronic kidney disease, atrial fibrillation, and smoking.

Results: Among 50, 296 patients with BS (2.96%), the mean age was 53 ± 12 years; the majority was female (75.32%), Caucasian (71.85%) and from the hospital region of the South (33.73%). 33.92% had diabetes, 53.27% had hypertension, and 29.60% had hyperlipidemia. Multivariable analysis revealed that obese patients with BS status had a 1.6-fold decrease in the rate of MACEs compared to patients without BS (odds ratio, 0.623; 95% CI, 0.598-0.649; P<0.001).

Conclusion: The study illustrated that among obese patients with BMI ≥35, a history of bariatric surgery was associated with a statistically significant lower risk of inpatient MACEs, after adjusting for CVD risk factors.

Outcomes of Acute Conduction Abnormalities Following Transcatheter Aortic Valve Implantation With a Balloon Expandable Valve and Predictors of Delayed Conduction System Abnormalities in Follow-up

Transcatheter aortic valve implantation (TAVI) is an acceptable treatment for severe aortic stenosis in high or intermediate risk patients. Conduction abnormalities are a known complication of TAVI. Most abnormalities occur perioperatively but can develop later. The predictors of delayed conduction abnormalities are unknown. Patients who underwent TAVI at our institution were reviewed. Patients with a pre-existing pacemaker were excluded. Baseline, in-hospital, and 30-day follow-up ECGs were reviewed. Patient and procedural characteristics were analyzed to look for predictors of acute and delayed abnormalities. Ninety-eight patients were included. All valves implanted were balloon expandable, most commonly SAPIEN S3 (78%). Thirty-seven (37.7%) patients developed abnormalities before discharge. Of these patients, 20 (57.1%) had complete resolution at 30-day follow-up. No patients with new conduction abnormalities during hospitalization had additional abnormalities at 30-day follow-up. Five (5.1%) patients developed new conduction abnormalities following discharge. Overall, 22 (22.4%) patients had conduction abnormalities at 30-day follow-up which were not present at baseline. Predilatation (p = 0.003), higher ratios of balloon (p = 0.03) or valve (p = 0.05) size to left ventricular outflow tract, and previous myocardial infarction (p = 0.034) were predictive of acute conduction abnormalities. Baseline right bundle branch block (p = 0.002), longer baseline (p <0.001) and discharge (p = 0.004) QRS duration, moderate, or severe aortic insufficiency (p = 0.002) and atrial fibrillation (p = 0.031) were predictors of new conduction abnormalities after discharge. In conclusion, most new in-hospital conduction abnormalities resolve by 30-day follow-up. In-hospital conduction abnormalities are related to technical aspects of TAVI while delayed conduction abnormalities are related to baseline conduction system disease.

Rate Versus Rhythm Control in Patients with Normal to Mild Left Atrial Enlargement: Insights from the AFFIRM Trial

Background

Atrial fibrillation is the most commonly encountered sustained arrhythmia and is associated with significant morbidity and mortality. Several trials have demonstrated that no mortality benefit exists when choosing a rhythm-control strategy over a rate-control strategy, with some trials suggesting an increase in mortality. Using the AFFIRM trial database we sought to determine the effect of rhythm control strategy in patients with normal or mild atrial enlargement.

Methods

AFFIRM Trial database was used to evaluate the effect of rhythm-control strategy compared to rate-control strategy in a subgroup of patients with normal to mild left atrial (LA) enlargement. The primary outcome measures of this study were all-cause mortality, cardiovascular mortality, non-cardiovascular mortality, and hospitalization/ED visit.

Results

We identified a subgroup of subjects from the AFFIRM trial with normal or mild LA enlargement (n=2022 of 4060 total subjects). Subjects in the rhythm-control group(n= 1022) had an increased risk of all-cause mortality by 34% (RR 1.34, 95% CI 1.08-1.67; P=0.007) and hospitalization/ED visits by 10% (RR 1.10, 95% CI 1.05-2.16; P=<0.001) compared to rate control group(n= 1000).

Conclusion

This study demonstrated that rhythm-control strategy increases the risk of mortality and hospitalization in a subgroup of patients with normal to mild atrial enlargement compared to rate-control strategy. Amiodarone use in this subgroup of patients likely drove these findings.

Abstract 5: Cardiovascular Disease in Transgender Populations

Background: As of 2016, approximately 1.4 millions persons in the United States identify as transgender. Despite their growing number and increasing specific medical needs, there has been lack of research regarding cardiovascular disease (CVD) and CVD risk factors in this population. Recent studies have showed that transgender population had a significant higher rate CVD risk factors without a significant increase in overall CVD morbidity and mortality. These studies are limited by their small sample sizes and their predominant focus on younger transgender populations. With larger sample size and inclusion of broader age range, our study aims to provide more insights into the association between being transgender and cardiovascular risk factors, as well as, myocardial infarction (MI).

Methods: The 2017 Behavioral Risk Factor Surveillance System (BRFSS) data was used to evaluate the correlation between being transgender and the rate of myocardial infarction (MI) and CVD risk factors. Logistic regression model was constructed to study the association between being transgender and rate of myocardial infarction after adjusting for CVD risk factors including age, diabetes, hypertension, hypercholesterolemia, chronic kidney disease, smoking, and exercise. Analyses were performed using SAS, version 9.4 and accounted for the complex survey design of BRFSS.

Results: The weighted frequency of transgender men and transgender women in our cohort were 354,048 (0.46%) and 437,886 (0.61%), respectively. Multivariable analysis revealed that transgender men had more than seven-fold increase in the rate of MI (OR=7.39, 95% CI=2.95, 18.55, p<0.001) compared to cisgender women while transgender women did not have significant increase in the rate of MI (OR=1.54, 95% CI=0.95, 2.51, p=0.081) compared to cisgender men after adjusting for age, diabetes, hypertension, hypercholesterolemia, chronic kidney disease, smoking, and exercise.

Conclusion: Transgender men are at higher rate of MI compared to cisgender women after adjusting for CVD risk factors.

Abstract 287: Does a Higher Level of Education Translate Into a Lower Prevalence of Cardiovascular Disease

Background: Education is one of the determinants of health as described by the WHO, and it is one of the primary determinants of Socio-Economic Class (SEC), a higher level of education is associated with a higher level of SEC. Few researchers have addressed the link between the level of education and cardiovascular disease. However, there remains a need for a national study to determine the relationship between the level of education and cardiovascular disease. In this study, we investigated the effect of the level of education on the rate myocardial infarction (MI) and cardiovascular risk factors including diabetes mellitus, hypertension, hypercholesterolemia, and smoking status.

Methods: The National Health Interview Surveys of 2016 (n=73,353) were utilized to measure the effect of level of education on MI and other risk factors. Subjects were assigned into four groups based on the level of education. The first group labeled as no education till the 12th grade, the second group identified as General Education Diploma (GED) or a high school diploma, the third group included subjects with some college, associate degree or bachelor, and the fourth group designated for subjects with master’s degrees, professional degrees, or doctorates. Logistic regression models were used to examine the association between level of education and cardiovascular risk factors. The final model examined the association between level of education and MI after adjusting for demographics and cardiovascular risk factors.

Results: A higher level of education was associated with lower odds of having cardiovascular risk factors. The final logistic regression model revealed that subjects with GED and high school education (OR 0.80, 95% CI 0.65-0.97; p 0.027), subjects with some collage degree/ bachelor degree (OR 0.74, 95% CI 0.61-0.90; p <0.003), and subjects with master degrees or professional degrees (OR 0.58, 95% CI 0.43-0.78; p <0.001) have lower odds of having MI compared to the first group after adjusting for other risk factors including age, gender, diabetes mellitus, hypertension, hypercholesterolemia, and tobacco use.

Conclusion: This study unveiled that a higher level of education is associated with a lower rate of myocardial infarction and cardiovascular risk factors.

Abstract 197: Predictors of Early Left Ventricular Ejection Fraction Recovery in Patients Following Transcatheter Aortic Valve Replacement

Background: Transcatheter aortic valve replacement (TAVR) is recommended by guidelines in severe aortic stenosis (AS) in patients with high or intermediate surgical risk. However, AS and reduced left ventricular ejection fraction (LVEF) is associated with worse clinical outcomes. Many of these patients will have LVEF recovery after TAVR. The purpose of this study was to evaluate the predictors of early LVEF recovery.

Methods: All patients with a baseline LVEF < 50% who underwent TAVR and had an echocardiogram within one-month post-TAVR (n=39) at a single center were included to determine the factors that predict an improvement in early LVEF. A 10% increase in LVEF within one month was used as a definition of early improvement in LVEF. Chi-square and T-test were used to examine differences in baseline characteristics between subjects with and without improvement in early LVEF.

Results: The patient cohort was 77 ± 9 years, 76.9% male, STS 6.2 ± 3.7. Among the 56% who had an improvement in early LVEF, they were more likely to have a lower left ventricular end diastolic diameter (LVEDD) (5.0±0.8 cm vs. 5.7±0.6 cm; p-value = 0.01) and left ventricular end systole diameter (LVESD) (3.7±0.8 cm vs. 4.5±1.1 cm; p-value = 0.02). These patients were more likely to have a higher interventricular septum diastolic thickness (IVSd) (1.2±0.2 cm vs. 1.0±0.2 cm; p-value = 0.01) and less likely to have a pre-existing peripheral vascular disease (PVD; 13% vs. 50%; p-value=0.01).

Conclusion: Our study suggests that LVEDD, LVESD, IVSd, and PVD may be used to predict early improvement in LVEF. These factors need to be further prospectively validated to determine patients who are more likely to benefit from TAVR.

Abstract 113: Mitral Leaflet Clip Procedure Outcomes: Analysis from the National Cardiovascular Data Registry

Introduction: Mitral regurgitation is one of the most common valvular diseases worldwide. Treatment for severe mitral regurgitation (MR) commonly involves surgical replacement of the mitral valve, but for those who are poor surgical candidates, another option has become mitral valve repair with a mitral leaflet clip procedure (MLCP). In this study, we conducted a descriptive analysis for all patients who underwent MLCP in the United States to investigate preoperative, intraoperative, and postoperative characteristics, techniques, complications, and clinical outcomes.

Methods: The National Cardiovascular Data Registry (NCDR) was used to summarize the baseline demographics and procedural quality measures of all patients who underwent MLCP between 2014 and 2017. The change in the demographics, mortality, complications, and clinical outcomes were summarized and visualized in graphs.

Results: The number of subjects who underwent mitral valve repair increased from 1,023 subjects in 2014 to 5,075 in 2017. The overall mortality rates are relatively unchanged (2.6% to 2.4%). However, there was an improvement in 30-day mortality (4.5% to 4.0%). The rate of patients with low STS scores increased (34% to 50%). Overall, the rate of patients with functional MR who received mitral clips are low (&lt10%). Of note, there has been a decrease in the number of patients who are 80 years old and older (62% to 56%). Intra-operatively, there were fewer complications (14.6% to 12.2%) including fewer clips not deployed (5.3% to 3.5%) related to a decrease in leaflets not being able to be grasped. Interestingly, there was an increase in the percentage of patients with mitral valve pressure gradient &lt= 5 mmHg (71.5% to 72.5%). Regarding 30-day follow-ups, our results have shown that residual mitral valve regurgitation (moderate or greater) has decreased from 39% to 5%, with a decrease in the number of clips attempted per patient. NYHA class IV symptoms at 30 days decreased from 4.2% to 3.1%. Finally, follow up echocardiograms changed in approach, with an increase in trans-thoracic (TTE) and a decrease in trans-esophageal (TEE) (86% TEE in 2014 vs. 86% TTE in 2017).

Conclusions: Our interpretation shows a trend that MLCP continues to be a viable option for MR. The rate of procedures is expected to increase especially among younger patients with low STS scores and functional MR as results of the COAPT trial. We expect a continued decrease in complications and continued intra-operative success shown by improvement in mitral regurgitation.

Adalimumab-induced acute myeloid leukaemia in a patient with Crohn's disease

We present a patient with Crohn's disease under treatment with adalimumab who developed acute myeloid leukaemia (AML) with core-binding factor beta gene rearrangement. This case report emphasises the importance of long-term close follow-up of patients receiving adalimumab because of the increased risk of developing AML and other malignancies.

The effect of angiotensin-converting enzyme inhibitors on clinical outcomes in patients with ischemic cardiomyopathy and midrange ejection fraction: a post hoc subgroup analysis from the PEACE trial

Background:

There have been significant advances in the treatment of patients with cardiomyopathy with reduced ejection fraction (EF < 40%). However, there is a dearth of information in the treatment of patients with cardiomyopathy and midrange EF (40–50%). Current guidelines state to treat these patients similarly to patients with cardiomyopathy and preserved EF. Data from the Prevention of Events with Angiotensin-Converting Enzyme Inhibition (PEACE) trial were used to elucidate whether angiotensin-converting enzyme (ACE) inhibitors improve clinical outcomes in patients with ischemic cardiomyopathy and midrange EF.

Methods:

A post hoc subgroup analysis of the PEACE trial was conducted to evaluate the effect of ACE inhibitors in a subgroup of patients with ischemic cardiomyopathy and midrange EF (40–50%). A Chi-square test and a Student‘s t-test were used to examine and compare the binary and continuous variables of baseline characteristics and outcomes between experimental and comparison groups.

Results:

We studied a subgroup of patients from the PEACE trial with ischemic cardiomyopathy and midrange EF (n = 2512 of 8290 total patients). Patients were assigned to either the interventional group (n = 1247) or the placebo group (n = 1265). There were no significant differences in baseline demographic and health characteristics between the two groups. During a total of 7 years (mean 4.7 years) of follow up, the risk of composite outcomes [all-cause mortality, nonfatal myocardial infarction, and stroke; relative risk (RR) 0.79, 95% confidence interval (CI) 0.63–0.98; p = 0.03] and all-cause mortality (RR 0.85, 95% CI 0.73–0.99; p = 0.03) was reduced in patients treated with trandolapril.

Conclusion:

This study revealed the benefit of ACE inhibitors among patients with ischemic cardiomyopathy and midrange EF.

Association Between Electronic Cigarette Use and Myocardial Infarction

INTRODUCTION

Electronic cigarettes (e-cigarettes) are promoted as a less risky alternative to conventional cigarettes and have grown in popularity. Experimental and clinical evidence suggests that they could increase the risk of myocardial infarction.

METHODS

The National Health Interview Surveys of 2014 (n=36,697) and 2016 (n=33,028) were used to examine the cross-sectional association between e-cigarette use (never, former, some days, daily) and cigarette smoking (same categories) and myocardial infarction in a single logistic regression model that also included demographics (age, gender, BMI) and health characteristics (hypertension, diabetes, and hypercholesterolemia) using logistic regression. Data were collected in 2014 and 2016 and analyzed in 2017 and 2018.

RESULTS

Daily e-cigarette use was independently associated with increased odds of having had a myocardial infarction (OR=1.79, 95% CI=1.20, 2.66, p=0.004) as was daily conventional cigarette smoking (OR=2.72, 95% CI=2.29, 3.24, p<0.001). Former and some day e-cigarette use were not significantly associated with having had a myocardial infarction (p=0.608 and p=0.392) whereas former (OR=1.70, p<0.001) and some day cigarette smoking (OR=2.36, p<0.001) were. Odds of a myocardial infarction were also increased with history of hypertension (OR=2.32, p<0.001); high cholesterol (OR=2.36, p<0.001); and diabetes (OR=1.77, p<0.001); and age (OR=1.65 per 10 years, p<0.001). Women (OR=0.47, p<0.001) had lower odds of myocardial infarction.

CONCLUSIONS

Daily e-cigarette use, adjusted for smoking conventional cigarettes as well as other risk factors, is associated with increased risk of myocardial infarction.

Preoperative antibiotics and cardiovascular implantable electronic device infection: A cohort study in veterans

BACKGROUND

Cefazolin is used as standard preoperative prophylaxis for a variety of surgical procedures that involve the skin. In contrast, vancomycin is recommended for a minority of patients, specifically those with an IgE-mediated allergy to beta-lactams and considered in patients with known colonization with methicillin-resistant Staphylococcus aureus or at high risk for such. Vancomycin, however, has been overprescribed, has nephrotoxicity risk, and may be less effective due to its inferior coverage of methicillin-susceptible S. aureus and lack of Gram-negative coverage. This study was performed to assess whether vancomycin use was associated with an increased incidence of cardiovascular implantable electronic device infection (CIEDI) as compared to that of cefazolin or other antistaphylococcal beta-lactam antibiotics.

METHODS

The VA Informatics and Computing Infrastructure database, which included all veterans who underwent CIED placement or revision between 2008 and 2015, was used. A logistic regression model was constructed to estimate the adjusted odds of CIEDI.

RESULTS

Overall, 10,454 CIED procedures were included, and 98% of them were performed in men with a mean age of 71 ± 12 years. The logistic regression analysis showed that vancomycin use alone or in combination with other antibiotics was associated with an increased risk of CIEDI (odds ratio 2.99 [1.76-5.06], P-value < 0.001), after controlling for other effects.

CONCLUSIONS

Our study revealed that among patients who received surgical site infection prophylaxis for CIED placement or revision, there was: (1) an unanticipated high rate of vancomycin use, and (2) a threefold increase in the incidence of subsequent CIEDI among vancomycin recipient.

Abstract 266: Preoperative Vancomycin and the Risk of Cardiovascular Implantable Electronic Device Infection: A Cohort Study in a Veteran Population

Background: The rate of cardiovascular implantable electronic device infection (CIEDI) has increased, despite the use of preoperative antibiotics at the time of device placement or revision. Cefazolin, a beta-lactam antibiotic, is used as standard preoperative prophylaxis in the bulk of patients. Vancomycin is used in the small minority of patients who have IgE-mediated allergies to beta-lactams or have a history of colonization/infection with MRSA. As compared to cefazolin, vancomycin is less effective against methicillin-susceptible Staphylococcus aureus, has no gram-negative coverage, and has nephrotoxicity risk.

Methods: A retrospective cohort study was performed to assess whether vancomycin use increased the risk of CIEDI in comparison to the standard preoperative prophylaxis. The VA Informatics and Computing Infrastructure (VINCI) database, which includes all veterans who underwent CIED placement or revision between 2008 and 2015, was used. A logistic regression model was constructed to estimate the adjusted risk of CIEDI among patients who received vancomycin after adjusting for confounding factors.

Results: Overall, 10,454 CIED procedures were included, and 98% of them were performed in men with a mean age of 71 ± 12 years. Vancomycin was given in 40.6% of these procedures. The rate of diabetes mellitus, heart failure, and advanced chronic kidney diseases were 20.5%, 13.5%, and 2.3%, respectively. The logistic regression analysis showed that vancomycin increased the risk of CIEDI three-fold (OR 2.99 [1.76-5.06], P-value <0.001) as compared to the standard preoperative prophylaxis, after controlling for other effects including MRSA colonization.

Conclusions: Our study revealed that among patients who received vancomycin as preoperative for CIED placement or revision, there was a three-fold increase in the risk of subsequent CIEDI.

Statin use and the risk of cardiovascular implantable electronic device infection: A cohort study in a veteran population

BACKGROUND

The rate of cardiovascular implantable electronic device infection (CIEDI) has increased, despite the use of perioperative antibiotics at the time of device placement or revision. This is due, in part, to the presence of multiple comorbid conditions in an elderly population, in general, who require CIED. Statins may have an antibacterial effect, although there is currently no evidence that the likelihood of CIEDI has been impacted by statin use.

METHODS

A retrospective cohort study was performed to assess whether statins are associated with a reduced risk of CIEDI. The VA Informatics and Computing Infrastructure (VINCI) database, which includes all veterans who underwent CIED placement between 2008 and 2015, was used. A logistic regression model was constructed to estimate the adjusted risk of CIEDI among patients who were receiving statins after adjusting for confounding factors.

RESULTS

Overall, 18,970 CIED procedures were included, and 98% of them were performed in men with a mean age of 71 ± 11 years. The rate of diabetes mellitus, heart failure, advanced chronic kidney diseases, CIEDI, positive methicillin-resistant Staphylococcus aureus nasal colonization, and statin use were 23%, 15.7%, 3.3%, 1.14%, 12.6%, and 56%, respectively. The logistic regression analysis showed that statins were significantly associated with a reduced risk of CIEDI; after controlling for other effects, the reduction was 66% (odds ratio 0.34 [0.2-0.59], P-value < 0.001). The effect of statins was confirmed by propensity score analysis.

CONCLUSIONS

Our study showed that among patients receiving statins who had undergone CIED placement, there was a 66% reduction in subsequent CIEDI.

Abstract 303: Optical Tissue Interrogation Technology Incorporated in Irrigated Radiofrequency Ablation Provides Real Time Monitoring of Ablation Lesion Depth

Background: Radiofrequency ablation (RFA) is an effective therapy to treat cardiac arrhythmias. The success rate depends on the location and size of ablation lesions. Electroanatomic Mapping and Contact force-sensing catheters have been shown to enhance the success rates of RFA. We used real-time optical tissue interrogation within the NADH fluorescence (fNADH) range to assess the progression of ablation lesion depth in real time during RF delivery (LuxCath catheter).

Methods: Multiple RFA lesions (n=20) were made on an intubated and mechanically ventilated canine (Mongrel) thigh muscles using 7 Fr quadripolar RFA catheter with a 3.5 mm tip open 3.5 mm irrigated electrode incorporating imaging optic. Light was delivered at (360+/-25nm), and fluorescence acquired through fiberoptic bundle at (370-660 nm) by a spectrometer and analyzed in real time. Two types of plots were created for each lesion: intensity (in counts) vs. wavelength (nm), and 465nm peak amplitude (normalized) vs. time (sec). The lesions were made at room temperature with fixed power (15W) and four different durations (10, 20,30,40 sec). After ablation the muscle was stained with 2,3,4-triphenyl-2H-tetrazolium chloride (TTC), bisected at the center and measured the with and depth of the lesion using imageJ software.

Results: We performed a total of twenty lesions that were divided into four groups based on the duration of the ablation (10, 20, 30, 40 seconds). The mean lesion depth for those groups was 4.05+/-1.28, 4.99+/-0.9, 6.9+/-1.06 and 7.14+/-1.41 mm, respectively. Lesion depth was correlated with the duration of ablation and fNADH signal intensity with a correlation coefficient of 0.93 and 0.99, respectively. Finally, there was a significant correlation between lesion size and fNADH signal intensity with a correlation coefficient of 0.96.

Conclusion: Real-time optical tissue characterization can provide an excellent assessment of lesion progression during RF delivery. Lesion depth was directly correlated to the decrease in fNADH signal intensity. This information may be used to optimize the selection of RF power and RF application time to maximize RF lesion formation and improve the success of ablation procedures.

Levetiracetam-induced pancytopenia

Pancytopenia is a rare side effect of levetiracetam (LEV) that is associated with severe morbidity that requires hospitalization. Here, we report a patient with a right temporoparietal tumor who underwent a temporal craniotomy with resection of the mass and was started on LEV for seizure prophylaxis per the neurosurgery local protocol. The patient developed LEV-induced pancytopenia, which was successfully managed by discontinuation of this medication. Our report aims to increase awareness of this rare cause of pancytopenia among clinicians.

Short beveled sharp cutting needle is superior to facet tip needle for ultrasound-guided rectus sheath block in children with umbilical hernia: a case series

BACKGROUND

The most common peripheral nerve blocks used in umbilical hernia repair are rectus sheath block and regional block (caudal block). Ultrasound guidance of peripheral nerve blocks has reduced the number of complications and improved the quality of blocks. The aim of this study is to assess the post rectus sheath block pain relief in pediatric patients coming for umbilical surgery, and to evaluate the easiness of soft tissue puncture and ultrasonic appearance of two different needle types.

METHODS

Twenty two (22) pediatric patients (age range: 1.5-8 years) scheduled for umbilical hernia repair were included in the study. Following the induction of general anesthesia, the ultrasonographic anatomy of the umbilical region was studied with a 5-16 MHz linear probe. An ultrasound-guided rectus sheath block in the lateral edge of both rectus abdominis muscles (RMs) was performed (total of 44 punctures). A 22 gauge short beveled sharp cutting needle 1.1 x 30 mm needle A (BD Insyte--W, Vialon material. Spain) was used in one side, and a Stimuplex A insulated Needle 22G 50mm (needle B) was used on the other side. Surgical conditions, intraoperative hemodynamic parameters, and postoperative analgesia were evaluated.

RESULTS

Ultrasonograghic visualization of the posterior sheath was possible in all patients. Needle A scored 72.7% of excellent needle tip and shaft view (16 out of 22) compared to 63.63% for needle B (14 out of 22). None of the needles scored poor view. The ultrasound guided rectus sheath blockade provided sufficient analgesia in all children with no need for additional analgesia except for one child who postoperatively requested morphine 0.1 mg/kg intravenously in recovery room. There were no complications.

CONCLUSIONS

Ultrasound guidance enables performances of an effective rectus sheath block for umbilical hernia in the lateral edge of the rectus muscle. Use of the sharp short beveled needle of 22 gauge intravenous (IV) cannula stylet provides easy, less traumatic skin and rectus muscle penetration and better needle visualization by the ultrasound.

Percutaneous tracheotomy: Forceps vs. cone dilatation techniques

Background:

Percutanoeous tracheotomy (PT) is a minimal invasive procedure alternative to surgical tracheotomy. PT offers an added advantage of enormous decrease of time interval between decision of doing tracheotomy and actually doing it. Moreover hazards of patient transport can be avoided as it can be safely performed at the bedside. We started doing PT in 2003 and performed 100 cases using forceps dilatation. Later we switched over to cone dilatation where we performed 215 cases. This study aims to compare two techniques of forceps vs. cone dilatation methods for PT.

Methods:

A total of 100 cases of PT were performed starting from December 2003 to August 2005 using the forceps dilatation method (group A). Further 215 cases were conducted (group B) from September 2003 to July 2008 using the cone dilatation method. Time of performing both procedures was recorded. Also incidence of complications was also recorded in both groups.

Results:

The incidence of minor bleeding in group A was 9%, whereas in group B was 5.58%. Major bleeding occurred in two patients in group B. Both cases suffered of pneumothorax and emphysema. One patient developed life-threatening tension pneumothorax and required cardio pulmonary resuscitation. This was one case in this series, in which the procedure has contributed to patient's morbidity. Guide wire-related technical difficulties were seen in 2% of the cases in group A, and 3.7% of cases in group B.

Conclusion:

forceps dilatation PT is superior to the cone dilatation technique in terms of safety. Further studies are needed to confirm our results.