Measures of social deprivation and outcomes after percutaneous coronary intervention.

BACKGROUND: Disparities in socioeconomic status are a frequently cited factor associated with worse cardiovascular outcomes. The social deprivation index (SDI) can be used to quantify socioeconomic resources at the population level. OBJECTIVES: The aim of this study was to assess the association of SDI with clinical outcomes following percutaneous coronary interventions (PCI). METHODS: This was a retrospective observational analysis of patients who underwent PCI and were included in a multicenter cardiac catheterization registry study. Baseline characteristics, congestive heart failure (CHF) readmission rates and survival were compared between patients with the highest and lower SDI. SDI was calculated based on the US community survey census tract-level data. RESULTS: Patients within the highest SDI quintile (n = 1843) had more comorbidities and a higher risk of death [hazard ratio (HR): 1.22 (95% confidence interval, CI: 1.1-1.39, p = 0.004); log rank: p = 0.009] and CHF readmission [HR: 1.56 (1.39-1.75, p < 0.001); log rank: p < 0.001) as compared with those in the lower quintiles (n = 10,201) during mean follow-up of 3 years. Increased risk of highest SDI for all-cause mortality and CHF remained significant after adjustment in multivariable analysis for factors associated with highest SDI. CONCLUSIONS: Patients within the highest SDI quintile had a greater proportion of comorbidities as well as higher risk for adverse outcomes as compared with patients with a lower SDI following PCI.

Aortic root thrombosis leading to STEMI in a Heartmate 3 patient.

Despite left ventricular assist device (LVAD) therapy becoming established for end-stage heart failure (HF), complications remain. Thromboembolic complications are rare with the newest iteration of LVADs. We managed a case of a continuous-flow LVAD-related thromboembolic event that presented as an acute myocardial infarction. A 64-year-old male who underwent Heartmate III® LVAD implantation had crushing substernal chest pain and ventricular tachycardia with acute anterolateral myocardial infarction on electrocardiogram on post-operative day 9. Echocardiography showed closed aortic valve and mild aortic regurgitation, but CT angiography showed thrombus within the left coronary cusp despite full anticoagulation. Continuous suction of blood from the left ventricle despite pulsatile flow into the ascending aorta resulted in a minimally opening aortic valve and stagnation of blood leading to thrombosis on the coronary cusp. Apart from post-operative ventricular tachycardia and right ventricular failure, he had adequate body size (body surface area 2.13 m2) and no post-operative or coagulopathy which could predispose him to thrombosis. Coronary angiography revealed stable severe three-vessel disease and thrombus in left main and proximal circumflex artery, and he had aspiration thrombectomy, and international normalized ratio target was increased to 3-3.5 with aspirin 325 mg daily. He survived to discharge but died 60 days after LVAD implant with multiple low flow alarms, and cardiac arrest. We review the literature and propose a management algorithm for patients with impaired AV opening and aortic root thrombosis.

Social deprivation index and ischemic events after percutaneous coronary intervention in patients with diabetes mellitus.

The aim of this study was to assess neighborhood-based differences in outcomes of diabetics versus non-diabetics undergoing percutaneous coronary interventions. Disparities in healthcare access impact long-term outcomes in safety net populations. Diabetes mellitus (DM) is associated with worse clinical outcomes in patients with coronary artery disease (CAD) and may disproportionately impact patients with CAD from underserved populations. We created a geocoded retrospective cohort of patients who underwent percutaneous coronary intervention (PCI) at an urban safety net hospital in this single-center cohort analysis. We evaluated long-term ischemic events in diabetics versus nondiabetics through review of electronic medical records. Social deprivation index (SDI) was calculated based on US-census tract level and stratified according to quintiles. Among 1002 patients, 46% (n = 463) were diabetic and among those 48% (n = 222) were in the highest quintile of SDI. Baseline and angiographic characteristics were similar among diabetic and nondiabetic subjects. Among diabetic patients, those in the highest SDI quintile had significantly higher risk of cardiovascular death and myocardial infarction as compared to those in the remaining quintiles (log rank: p = 0.029) (adjusted hazard's ratio: 1.72 [95% CI: 1.01-2.92], p = 0.04). There was no association of the SDI with outcomes in nondiabetic patients (log rank: p = 0.39). In an underserved population, patients with diabetes and high SDI demonstrate higher rates of adverse ischemic events and cardiovascular death during long-term follow up after PCI. Further research examining the impact of disparities in healthcare access on outcomes after PCI in patients with diabetes is warranted.

Introducing echocardiography to medical students: A novel echocardiography E-Learning experience.

BACKGROUND: Echocardiography is fundamental in the understanding of cardiology; however, echocardiography is not routinely taught in medical schools. The aim of this study is to assess whether teaching echocardiography to preclinical medical students using an e-learning software (ELS) is practical and appropriate. METHODS: From 2017 to 2019, 1084 second-year medical students at Indiana University School of Medicine were introduced to echocardiography by using the ELS. In 2017 and 2018 students had a postcourse survey to assess echocardiography appropriateness and cardiology learning. Students in 2018 and 2019 were assessed for any association between the use of the ELS and learning cardiology by comparing examination scores. RESULTS: In 2017-2018, 127 students responded to the survey (18% response rate). In 2017, 79% of responders and in 2018, 89% reported that introducing echocardiography to medical students is appropriate. In 2017, 78% and in 2018, 87% reported that it improved the understanding of cardiology. Student ELS usage was high for 2017-2018 (93% and 70%) but dropped in 2019 (30%). In 2018 and 2019, students who used ELS did statistically significantly better on the examination (total scores 84% vs. 82% (P = .008) in 2018; 84% vs. 81% (P = .002) in 2019). CONCLUSIONS: Many 2nd year medical students felt learning echocardiography with ELS was appropriate and enhanced their learning cardiology. Using echocardiography to help learn cardiology appears to be supported with an association of ELS usage and improved examination scores. Our study suggests that echocardiography learning can and probably should begin in medical school.

Association between social vulnerability index and admission urgency for transcatheter aortic valve replacement.

Background: Transcatheter aortic valve replacement (TAVR) are not offered equitably to vulnerable population groups. Adequate levels of insurance may narrow gaps among patients with higher social vulnerability index (SVI). Among a national population of individuals with commercial or Medicare insurance, we sought to determine whether SVI was associated with urgency of receipt of TAVR for aortic stenosis. Methods and results: Using Optum's de-identified Clinformatics Data Mart Database (CDM), we identified admissions for TAVR with aortic stenosis between January 2018 and March 2022. Admission urgency was identified by CDM claims codes. SVI was cross-referenced to patient zip codes and grouped into quintiles. Generalized linear mixed effects models were used to predict the probability of a TAVR admission being urgent based on SVI quintiles, adjusting for patient and hospital-level covariates. Results: Among 6680 admissions for TAVR [median age 80 years (interquartile range 75-85), 43.9 % female], 8.5 % (n = 567) were classified as urgent. After adjusting for patient and hospital-level variables, there were no significant differences in the odds of urgent admission for TAVR according to SVI quintiles [OR 5th (greatest social vulnerability) vs 1st quintile (least social vulnerability): 1.29 (95 % CI: 0.90-1.85)]. Conclusions: Among commercial or Medicare beneficiaries with aortic stenosis, SVI was not associated with admission urgency for TAVR. To clarify whether cardiovascular care delivery is improved across SVI with higher paying beneficiaries, future investigation should identify whether relationships between SVI and TAVR urgency vary for Medicaid beneficiaries compared to commercial beneficiaries.

Spontaneous duodenal hematoma: a rare complication of triple antithrombotic therapy case report.

Triple therapy is defined as concurrent use of an anticoagulant and dual antiplatelet therapy. We aimed to review the clinical course of a patient who developed a spontaneous duodenal hematoma on triple therapy and appraise current guidelines regarding triple antithrombotic therapy use. A 59-year-old man presented with acute heart failure and an apical mural thrombus. After medical stabilization, the patient underwent elective coronary stent placement. He was placed on triple antithrombotic therapy and subsequently developed a spontaneous duodenal hematoma. This case describes a rare but potentially fatal complication of triple therapy and underscores the importance of underutilizing this therapy. In conclusion, we report the clinical presentation and management of a rare bleeding complication in a patient on triple therapy.

The use of multiple types of blood-thinning medications is common in patients with blood clots, atrial fibrillation and heart disease, which can increase their risk of bleeding. We present the case of a rare type of gastrointestinal bleeding (a spontaneous duodenal hematoma) that occurred shortly after a patient with new heart failure and a blood clot in the left ventricle was placed on three different types of blood-thinning medications following a cardiac stent procedure. This case highlights the importance of careful management of comorbid cardiac conditions as well as the avoidance of using three blood-thinning medications simultaneously.

Athlete ECG T-wave abnormality interpretation patterns by non-experts.

Background: The presence of T-wave abnormalities (TWA) on an athlete's electrocardiogram (ECG) presents as a diagnostic challenge for physicians. Types of TWA patterns classified as abnormal by inexperienced readers have not been systematically analyzed. Methods: ECGs from the 2011-2015 National Football League Scouting Combine (initially interpreted by general cardiologists) were retrospectively reviewed by expert sports cardiologists with strict application of the 2017 International Criteria. Patterns of TWA that were altered from the original interpretation were analyzed. Results: The study included 1643 athletes (mean age 22 years). There was a 67 % reduction in the number of athletes with any TWA (p < 0.001) with 111 ECGs changed to normal. Inferior TWA was the most common interpreted initial ECG abnormality altered followed by anterior and lateral. Discussion: This analysis revealed an initial high rate of TWA by non-expert readers. Tailored education programs to physicians who interpret athlete ECGs should highlight these specific T-wave patterns. We see this as an opportunity to make more clinicians aware of ECG interpretation guidelines as sports trained cardiologists are mostly self-taught.

Cardiogenic shock following cardiac tamponade and Takotsubo in COVID-19.

Introduction: Takotsubo is often described as stress-induced cardiomyopathy and is a known cause of heart failure. Objective: Review the clinical course of a young coronavirus disease 2019 (COVID-19) patient who developed Takotsubo following cardiac tamponade. Case presentation: A 42-year-old woman presented to the emergency department with fever, altered mental status and hypoxia. She was ultimately found to be in cardiac tamponade and within 2 hours of a pericardiocentesis she developed Takotsubo and was in cardiogenic shock. Her family decided to place her on comfort measures and she died the same day. Discussion: This case illustrates the increasing number of cardiovascular complications being reported in COVID-19 and highlights the importance of clinicians to be aware of these challenges. Conclusion: Here, we report a distinct presentation of cardiogenic shock in a young COVID-19 patient. The rapid onset of her suspected Takotsubo and the severity of her disease were striking features in this case.

Expression of transient receptor potential vanilloid channels TRPV5 and TRPV6 in retinal pigment epithelium.

PURPOSE: Hydration and ionic composition of the subretinal space (SRS) is modulated by the retinal pigment epithelium (RPE). In particular calcium concentration (Ca(2+)) in the SRS varies with light exposure, and although this change is regulated by RPE transport activity, the specific transport proteins involved have yet to be defined. Two members of the transient receptor potential vanilloid family, TRPV5 and TRPV6, are calcium selective ion channels and are known to be expressed in calcium-transporting epithelial tissues. The present work characterizes of TRPV5 and TRPV6 in RPE. METHODS: Reverse transcriptase PCR was used to examine the presence of TRPV5 and TRPV6 mRNA in cultured human RPE. Protein expression was assessed by western blotting using TRPV5- and TRPV6-specific antibodies. Immunocytochemistry was employed to examine subcellular localization of TRPV5 and TRPV6 in frozen, formaldehyde-fixed sections of native RPE-choroid tissue and in cultured human RPE monolayers. Finally, TRPV5/TRPV6 activity was assessed in cultured RPE, using Ca(2+) indicator dyes to follow [Ca(2+)](i) as a function of changes in [Ca(2+)](o) with and without addition of the TRPV5/TRPV6 inhibitor ruthenium red. RESULTS: Direct sequencing of PCR DNAs documented the presence of TRPV5 and TRPV6 transcripts in human RPE. Immunocytochemistry showed that TRPV5 and TRPV6 are expressed in native RPE-choroid tissue with strong immunoreactivity for both channels on the apical as well as the basal plasma membranes. Immunostaining for both channels was also positive in monolayers of cultured RPE cells. In cultured cells subcellular localization was variable with immunoreactivity present in the cytoplasmic domain as well as on the plasma membrane. Plasma membrane staining was increased with phagocytosis. The reported molecular weight of the core protein for both TRPV5 and TRPV6 is about 75 kDa, with the expected size of the glycosylated proteins in the range of 85-100 kDa. Western blot analysis of TRPV6 in RPE detected a distinct band at approximately 85 kDa, with another strong band at approximately 60 kDa. A similar pattern was seen for TRPV5, with strong bands at 82 kDa and 71 kDa. In live-cell imaging experiments, [Ca(2+)](i) was lower in the presence of the TRPV5/TRPV6 inhibitor ruthenium red. CONCLUSIONS: RPE expresses the epithelial calcium channels TRPV5 and TRPV6, the most calcium-selective channels of the TRP superfamily. Present findings suggest that these channels could function in RPE to mediate calcium influx from SRS and thus regulate changes in SRS calcium composition that accompany light/dark transitions.

A Cardiology Handbook App to Improve Medical Education for Internal Medicine Residents: Development and Usability Study.

BACKGROUND: At most institutions, internal medicine residents struggle with balancing clinical duties and learning opportunities, particularly during busy cardiology ward rotations. To improve learning experiences for residents, we helped develop a cardiology handbook app to supplement cardiology education. OBJECTIVE: The aim of this study was to report the development, implementation, and preliminary impact of the Krannert Cardiology Handbook app on graduate medical education. METHODS: In June 2017, 122 residents at Indiana University were invited to download the digital handbook in the Krannert app. The Krannert app featured a total of 13 chapters written by cardiology fellows and faculty at Indiana University. Residents were surveyed on their self-reported improvement in cardiology knowledge and level of satisfaction after using the Krannert app. Residents were also surveyed regarding their preference for a digital handbook app versus a paper handbook. RESULTS: Of the 122 residents, 38 trainees (31.1%) participated in survey evaluations. Among all respondents, 31 app users (82%) reported that the app helped improve their cardiology knowledge base. The app had an overall favorable response. CONCLUSIONS: The Krannert app shows promise in augmenting clinical education in cardiology with mobile learning. Future work includes adding new topics, updating the content, and comparing the app to other learning modalities.

Removal of Retained Pacing Leads With Vena Caval Inflow Occlusion When Cardiopulmonary Bypass Is Contraindicated.

Treatment of infected pacing leads ranges from percutaneous extraction to surgical removal with the use of cardiopulmonary bypass (CPB). Vena caval inflow occlusion (VCIO) is an old technique that has been used with success in the pediatric population. We report on the use of inflow occlusion (IO) in removing infected pacing leads from the right side of the heart in patients in whom endovascular lead extraction failed. VCIO is a safe and simple technique in patients with infected leads who have contraindications for CPB.

Off-pump right atrial surgery: Vena caval inflow occlusion in cardiac lesions.

BACKGROUND: Vena caval inflow occlusion, despite its utility in pediatrics, is rarely used in adults. We report the use of inflow occlusion in adults when cardiopulmonary bypass is contraindicated. METHODS: Between January 1999 and July 2014, 35 patients in 3 hospitals presented with right-sided cardiac lesions; 27 had right-sided endocarditis with sepsis despite maximal medical therapy, the rest had organized sterile masses with embolic potential in the right side of the heart. Comorbidities included immunosuppression, malignancy, and dialysis-dependent renal failure. Twelve patients had heparin-induced thrombocytopenia. Using inflow occlusion on a beating heart, tricuspid valve vegetectomy was performed in 23 patients, vegetectomy and tricuspid valve repair in 3, removal of infected pacing leads in 7, and removal of a migrated inferior vena cava filter in 1. Eight patients had a single 2-min period of vena caval inflow occlusion, and 25 had additional periods of vena caval inflow occlusion after periods of reperfusion. The first 23 procedures were performed through a sternotomy. Nine patients underwent a right minithoracotomy (redo in 2). RESULTS: There were no deaths. Infected patients had resolution of sepsis and improvement in respiratory status. Three patients had moderate tricuspid regurgitation, the rest had trivial to mild tricuspid regurgitation. One patient had a transient neurological deficit postoperatively, and one had late empyema. CONCLUSION: Removal of infective material, sterile masses, and retained foreign bodies can safely be performed under vena caval inflow occlusion when cardiopulmonary bypass is contraindicated.