Electrocardiographic Z-axis QRS-T voltage-time-integral in patients with typical right bundle branch block - Correlation with echocardiographic right ventricular size and function.

BACKGROUND: Right bundle branch block (RBBB) can be benign or associated with right ventricular (RV) functional and structural abnormalities. Our aim was to evaluate QRS-T voltage-time-integral (VTI) compared to QRS duration and lead V1 R' as markers for RV abnormalities. METHODS: We included adults with an ECG demonstrating RBBB and echocardiogram obtained within 3 months of each other, between 2010 and 2020. VTIQRS and VTIQRST were obtained for 12 standard ECG leads, reconstructed vectorcardiographic X, Y, Z leads and root-mean-squared (3D) ECG. Age, sex and BSA-adjusted linear regressions were used to assess associations of QRS duration, amplitudes, VTIs and lead V1 R' duration/VTI with echocardiographic tricuspid annular plane systolic excursion (TAPSE), RV tissue Doppler imaging S', basal and mid diameter, and systolic pressure (RVSP). RESULTS: Among 782 patients (33% women, age 71 ± 14 years) with RBBB, R' duration in lead V1 was modestly associated with RV S', RV diameters and RVSP (all p ≤ 0.03). QRS duration was more strongly associated with RV diameters (both p < 0.0001). AmplitudeQRS-Z was modestly correlated with all 5 RV echocardiographic variables (all p ≤ 0.02). VTIR'-V1 was more strongly associated with TAPSE, RV S' and RVSP (all p ≤ 0.0003). VTIQRS-Z and VTIQRST-Z were among the strongest correlates of the 5 RV variables (all p < 0.0001). VTIQRST-Z.√BSA cutoff of ≥62 µVsm had sensitivity 62.7% and specificity 65.7% for predicting ≥3 of 5 abnormal RV variables (AUC 0.66; men 0.71, women 0.60). CONCLUSION: In patients with RBBB, VTIQRST-Z is a stronger predictor of RV dysfunction and adverse remodeling than QRS duration and lead V1 R'.

Evaluation of electrocardiographic criteria for predicting left ventricular hypertrophy and dilation in presence of left bundle branch block.

BACKGROUND: The utility of standard published electrocardiographic (ECG) criteria for left ventricular hypertrophy (LVH) in patients with left bundle branch block (LBBB) is not established. We have previously shown that in ECGs demonstrating LBBB, QRS duration outperforms vectorcardiographic X, Y, Z lead and root-mean-squared (3D) amplitudes and voltage-time-integrals in diagnosing LVH and dilation. We sought to evaluate diagnostic yields of published LVH criteria versus QRS duration for ECG based diagnosis of LVH and dilation in presence of LBBB. METHODS: We included adult patients with typical LBBB having ECG and transthoracic echocardiogram performed within 3 months of each other in 2010-2020. We obtained area under receiver-operator characteristic curve (AUC) for QRS duration and each of the published ECG LVH criteria to predict increased LV mass indexed (↑LVMi, women >95 g/m2, men >115 g/m2) and LV end diastolic volume indexed (↑LVEDVi, women >61 mL/m2, men >74 mL/m2). RESULTS: Among 413 adults (53 % women, age 73 ± 12 yr) with LBBB, the traditional LVH criteria performed poorly to detect ↑LVMi or ↑LVEDVi. Cornell voltage-duration product had the highest AUCs (↑LVMi 0.634, ↑LVEDVi 0.580). QRS duration had a higher AUC for diagnosing ↑LVMi (women 0.657, men 0.703) and ↑LVEDVi (women 0.668, men 0.699) compared to any other criteria. CONCLUSIONS: In patients with LBBB, prolonged QRS duration (women ≥150 ms, men ≥160 ms) is a superior predictor of LVH and dilation than traditional ECG-based LVH criteria.

Orthostatic variation of pulmonary artery pressure in ambulatory heart failure patients.

AIM: To study effect of change in position (supine and standing) on pulmonary artery pressure (PAP) in ambulatory heart failure (HF) patients. METHODS: Seventeen patients with CardioMEMS® sensor and stable heart failure were consented and included in this single center study. Supine and standing measurements were obtained with at least 5 min interval between the two positions. These measurements included PAP readings utilizing the manufacturer handheld interrogator obtaining 10 s data in addition to the systemic blood pressure and heart rate recordings. RESULTS: Mean supine and standing readings and their difference (Δ) were as follows respectively: Systolic PAP were 33.4 (± 11.19), 23.6 (± 10) and Δ was 9.9 mmHg (p = 0.0001), diastolic PAP were 14.2 (± 5.6), 7.9 (± 5.7) and Δ was 6.3 mmHg (p = 0.0001) and mean PAP were 21.8 (± 7.8), 14 (± 7.2) and Δ was 7.4 mmHg (p = 0.0001) while the systemic blood pressure did not vary significantly. CONCLUSION: There is orthostatic variation of PAP in ambulatory HF patients demonstrating a mean decline with standing in diastolic PAP by 6.3 mmHg, systolic PAP by 9.9 mmHg and mean PAP by 7.4 mmHg in absence of significant orthostatic variation in systemic blood pressure or heart rate. These findings have significant clinical implications and inform that PAP in each patient should always be measured in the same position. Since initial readings at the time of implant were taken in supine position, it may be best to use supine position or to obtain a baseline standing PAP reading if standing PAP is planned on being used.

Electrocardiographic prediction of left ventricular hypertrophy in women and men with left bundle branch block - Comparison of QRS duration, amplitude and voltage-time-integral.

BACKGROUND: Standard ECG criteria for left ventricular (LV) hypertrophy rely on QRS amplitudes. However, in the setting of left bundle branch block (LBBB), ECG correlates of LV hypertrophy are not well established. We sought to evaluate quantitative ECG predictors of LV hypertrophy in the presence of LBBB. METHODS: We included adult patients with typical LBBB having ECG and transthoracic echocardiogram performed within 3 months of each other in 2010-2020. Orthogonal X, Y, Z leads were reconstructed from digital 12­lead ECGs using Kors's matrix. In addition to QRS duration, we evaluated QRS amplitudes and voltage-time-integrals (VTIs) from all 12 leads, X, Y, Z leads and 3D (root-mean-squared) ECG. We used age, sex and BSA-adjusted linear regressions to predict echocardiographic LV calculations (mass, end-diastolic and end-systolic volumes, ejection fraction) from ECG, and separately generated ROC curves for predicting echocardiographic abnormalities. RESULTS: We included 413 patients (53% women, age 73 ± 12 years). All 4 echocardiographic LV calculations were most strongly correlated with QRS duration (all p < 0.00001). In women, QRS duration ≥ 150 ms had sensitivity/specificity 56.3%/64.4% for increased LV mass and 62.7%/67.8% for increased LV end-diastolic volume. In men, QRS duration ≥ 160 ms had a sensitivity/specificity 63.1%/72.1% for increased LV mass and 58.3%/74.5% for increased LV end-diastolic volume. QRS duration was best able to discriminate eccentric hypertrophy (area under ROC curve 0.701) and increased LV end-diastolic volume (0.681). CONCLUSIONS: In patients with LBBB, QRS duration (≥ 150 in women and ≥ 160 in men) is a superior predictor of LV remodeling esp. eccentric hypertrophy and dilation.

Gender-specific outcomes after percutaneous left atrial appendage closure: A nationwide readmission database analysis.

INTRODUCTION: Thromboembolism-associated stroke is the most feared complication of atrial fibrillation (AF). Percutaneous left atrial appendage closure (pLAAC) is indicated for stroke prevention in patients with AF who can not tolerate long-term anticoagulation. We aim to study gender differences in peri-procedural and readmissions outcomes in pLAAC patients. METHODS: Using the national readmission database from January 2016 to December 2018, AF patients undergoing the pLAAC procedure were identified. We used multivariate logistic regression analyses and time-to-event Cox regression analyses to conduct the study. Propensity matching with the Greedy method was done for the accuracy of results. RESULT: A total of 28 819 patients were included in our study. Among them 11 946 (41.5%) were women and 16 873 (58.6%) were men. The mean age of overall population was 76.1 ± 8.5 years, with women ~1 year older than men. The overall rate of complications was higher in women (8.6% vs. 6.6%, p < .001), primarily driven by bleeding-related complications, that is, major bleed (odds ratio [OR]: 1.32 95% confidence interval [CI]: 1.03-1.69, p = .029), blood transfusion (OR: 1.45, 95% CI: 1.06-1.97, p = .019), and cardiac tamponade (OR: 1.80, 95% CI: 1.13-2.89, p = .014). Women had two times higher peri-procedural ischemic stroke. There was no difference in peri-procedural mortality. Women remained at 20% and 13% higher risk for readmission at 30 days and 6 months of discharge. CONCLUSION: Women had higher peri-procedural complications and were at higher risk of readmissions at 30 days and 6 months. However, there was no difference in mortality during the index hospitalization. Further studies are necessary to determine causality.

Left Ventricular Unloading During Extracorporeal Life Support: Current Practice.

Venoarterial extracorporeal life support (VA-ECLS) is a powerful tool that can provide complete cardiopulmonary support for patients with refractory cardiogenic shock. However, VA-ECLS increases left ventricular (LV) afterload, resulting in greater myocardial oxygen demand, which can impair myocardial recovery and worsen pulmonary edema. These complications can be ameliorated by various LV venting strategies to unload the LV. Evidence suggests that LV venting improves outcomes in VA-ECLS, but there is a paucity of randomized trials to help guide optimal strategy and the timing of venting. In this review, we discuss the available evidence regarding LV venting in VA-ECLS, explain important hemodynamic principles involved, and propose a practical approach to LV venting in VA-ECLS.

Outcomes in Patients With Chronic Kidney Disease and End-stage Renal Disease and Durable Left Ventricular Assist Device: Insights From the United States Renal Data System Database.

BACKGROUND: There is paucity of data regarding durable left ventricular assist device (LVAD) outcomes in patients with chronic kidney disease (CKD) stages 3-5 and CKD stage 5 on dialysis (end-stage renal disease [ESRD]). METHODS AND RESULTS: We conducted a retrospective study of Medicare beneficiaries with ESRD and a 5% sample of patients with CKD with an LVAD (2006-2018) to determine 1-year outcomes using the United States Renal Data System database. The LVAD implantation, comorbidities, and outcomes were identified using appropriate International Classification of Diseases, 9th and 10th edition codes. We identified 496 patients with CKD and 95 patients with ESRD who underwent LVAD implantation. The patients with ESRD were younger (59 years vs 66 years; P < .001), had more Blacks (40% vs 24.6%, P = .009), compared with the CKD group. The 1-year mortality (49.5% vs 30.9%, P < .001) and index mortality (27.4% vs 16.7%, P = .014) rates were higher for patients with ESRD. A subgroup analysis showed significantly higher mortality in ESRD vs CKD 3 (49.5% vs 30.2%, adjusted P = .009), but no significant difference in mortality between stage 3 vs 4/5 (30.2% vs 30.8%, adjusted P = .941). There was no significant difference in secondary outcomes (bleeding, stroke, and sepsis/infection) during follow-up between the 2 groups. CONCLUSIONS: Patients with ESRD undergoing LVAD implantation had significantly higher index and 1-year mortality rates compared with patients with CKD.

Exception-Status Listing: A Critical Pathway to Heart Transplantation for Adults With Congenital Heart Diseases.

Adults with congenital heart diseases may not be candidates for conventional therapies to control ventricular systolic dysfunction, including mechanical circulatory support, which moves potential heart-transplantation recipients to a listing status of higher priority. This results in longer waitlist times and greater mortality rates. Exception-status listing allows a pathway for this complex and anatomically heterogenous group of patients to be listed for heart transplantation at appropriately high listing status. Our study queried the United Network for Organ Sharing registry to evaluate trends in the use of exception-status listing among adults with congenital heart diseases awaiting heart transplantation. Uptrend in the use of exception-status listing precedes the new allocation system, but it has been greatest since changes were made in the allocation system. It continues to remain a vital pathway for adults with congenital heart disease (whose waitlist mortality rates are often not characterized adequately by using the waitlist-status criteria) timely access to heart transplantation.

Clinical comparison of V122I genotypic variant of transthyretin amyloid cardiomyopathy with wild-type and other hereditary variants: a systematic review.

V122I genotype variant (pV142I) is the most common hereditary transthyretin amyloidosis (hATTR) in the USA, with 3-3.5% of African-Americans being the carriers of this mutation. We aimed to compare baseline clinical features, cardiac parameters, and mortality in V122I-ATTR with the wild-type ATTR and other hATTR subtypes. We systematically searched PubMed/Medline and Google Scholar databases to identify relevant studies from inception to 10th September, 2020 reporting phenotypic, echocardiographic, and/or laboratory parameters in patients with hereditary and wild types of cardiac amyloidoses. A total of 2843 patients from 7 individual studies with 67-100% males and an overall follow-up duration of 51.6 ± 30.4 months were identified. The mean age of diagnosis among wild-type ATTR patients was 77 years, followed by 71.2 and 65 years in V122I and T60A group patients, respectively. V122I patients were mostly black, had a poor quality of life, and highest mortality risk compared with other subtypes. Merely, the presence of V122I mutation was identified as an independent predictor of mortality. V30M subtype correlated with the least severe cardiac disease and a median survival duration comparable with T60A subtype. V122I ATTR is an aggressive disease, prevalent in African-Americans, and is associated with a greater morbidity and mortality, which is partly attributed to its misdiagnosis and/or late diagnosis. Current advances in non-invasive studies to diagnose hATTR coupled with concurrent drug therapies have improved quality of life and provide a survival benefit to these patients.

Impact of Underlying Congestive Heart Failure on In-Hospital Outcomes in Patients with Septic Shock.

Purpose: Septic shock (SS) manifests with profound circulatory and cellular metabolism abnormalities and has a high in-hospital mortality (25%-50%). Congestive heart failure (CHF) patients have underlying circulatory dysfunction and compromised cardiac reserve that may place them at increased risk if they develop sepsis. Outcomes in patients with CHF who are admitted with SS have not been well studied. Materials and Method: Retrospective cross sectional secondary analysis of the Nationwide Readmission Database (NRD) for 2016 and 2017. ICD-10 codes were used to identify patients with SS during hospitalization, and then the cohort was dichotomized into those with and without an underlying diagnosis of CHF. Results: Propensity match analyses were performed to evaluate in-hospital mortality and clinical cardiovascular outcomes in the 2 groups. Cardiogenic shock patients were excluded from the study. A total of 578,629 patients with hospitalization for SS were identified, of whom 19.1% had a coexisting diagnosis of CHF. After propensity matching, 81,699 individuals were included in the comparative groups of SS with CHF and SS with no CHF. In-hospital mortality (35.28% vs 32.50%, P < .001), incidence of ischemic stroke (2.71% vs 2.53%, P = .0032), and acute kidney injury (69.9% vs 63.9%, P = .001) were significantly higher in patients with SS and CHF when compared to those with SS and no CHF. Conclusions: This study identified CHF as a strong adverse prognosticator for inpatient mortality and several major adverse clinical outcomes. Study findings suggest the need for further investigation into these findings' mechanisms to improve outcomes in patients with SS and underlying CHF.

Nationwide study of six-month readmissions in critical limb ischemia: Predictors and impact of revascularization strategies.

OBJECTIVE: There is a paucity of data regarding six-month readmissions in critical limb ischemia patients and the influence of management strategy during index-admission [endovascular, surgical, hybrid procedure, medical therapy, and amputation]. We aimed to investigate the incidence, predictors, and impact of management strategies on six-month readmission in patients with critical limb ischemia. METHODS: A secondary analysis of the Nationwide Readmissions Database (2016-2017) was conducted. Propensity score matching was performed for subgroup analysis. RESULTS: We identified 50,058 patients with primary diagnosis of critical limb ischemia. Six-month all-cause and critical limb ischemia-related readmission rate was 52.36% and 10.86%, respectively. The risk of all-cause readmission was lower with amputation but was similar among other subgroups. Patients receiving surgical [HR 0.62, CI(0.48-0.79), p < 0.001] and hybrid procedure [HR 0.65 (0.46-0.93), p = 0.02] had lower risk of unplanned critical limb ischemia-related readmission compared to endovascular, though the risk of unplanned revascularization/amputation during readmission was similar between the three strategies. The risk of non-critical limb ischemia-related readmission was higher with surgical [HR 1.13, CI(1.04-1.23), p = 0.003] and hybrid procedure [HR 1.17, CI(1.08-1.28), p < 0.001], driven by increased procedure-related/wound complications. Eventhough endovascular patients were older with more severe critical limb ischemia presentation, a lower proportion received home-health or placement upon discharge from index-admission. This could account for higher readmission without higher repeat revascularization in endovascular group. CONCLUSION: The risk of critical limb ischemia and non-critical limb ischemia-related readmission differ according to the management strategy. Significant differences in discharge disposition exist depending on revascularization strategy. Study findings identify opportunities for reducing readmissions by focusing on nonprocedural aspects like wound-care, discharge planning and placement.

Ultrasound guided axillary vein access: An alternative approach to venous access for cardiac device implantation.

INTRODUCTION: Ultrasound guided axillary vein access (UGAVA) is an emerging approach for cardiac implantable electronic device (CIED) implantation not widely utilized. METHODS AND RESULTS: This is a retrospective, age and sex-matched cohort study of CIED implantation from January 2017 to July 2019 comparing UGAVA before incision to venous access obtained after incision without ultrasound (conventional). The study population included 561 patients (187 with attempted UGAVA, 68 ± 13 years old, 43% women, body mass index (BMI) 30 ± 8 kg/m2 , 15% right-sided, 43% implantable cardioverter-defibrillator, 15% upgrades). UGAVA was successful in 178/187 patients (95%). In nine patients where UGAVA was abandoned, the vein was too deep for access before incision. BMI was higher in abandoned patients than successful UGAVA (38 ± 6 vs. 28 ± 6 kg/m2 , p < .0001). Median time from local anesthetic to completion of UGAVA was 7 min (interquartile range [IQR]: 4-10) and median procedure time 61 min (IQR: 50-92). UGAVA changed implant laterality in two patients (avoiding an extra incision in both) and could have prevented unnecessary incision in four conventional patients. Excluding device upgrades, there was reduced fluoroscopy time in UGAVA versus conventional (4 vs. 6 min; IQR: 2-5 vs. 4-9; p < .001). Thirty-day complications were similar in UGAVA versus conventional (n = 7 vs. 26, 4 vs. 7%; p = .13, p = .41 adjusting for upgrades), partly driven by a trend towards reduced pneumothorax (n = 0 vs. 3, 0 vs. 1%; p = .22). CONCLUSIONS: UGAVA is a safe approach for CIED implantation and helps prevent an extra incision if a barrier is identified changing laterality preincision.

Artificial intelligence in cardiovascular medicine.

PURPOSE OF REVIEW: Artificial intelligence is a broad set of sophisticated computer-based statistical tools that have become widely available. Cardiovascular medicine with its large data repositories, need for operational efficiency and growing focus on precision care is set to be transformed by artificial intelligence. Applications range from new pathophysiologic discoveries to decision support for individual patient care to optimization of system-wide logistical processes. RECENT FINDINGS: Machine learning is the dominant form of artificial intelligence wherein complex statistical algorithms 'learn' by deducing patterns in datasets. Supervised machine learning uses classified large data to train an algorithm to accurately predict the outcome, whereas in unsupervised machine learning, the algorithm uncovers mathematical relationships within unclassified data. Artificial multilayered neural networks or deep learning is one of the most successful tools. Artificial intelligence has demonstrated superior efficacy in disease phenomapping, early warning systems, risk prediction, automated processing and interpretation of imaging, and increasing operational efficiency. SUMMARY: Artificial intelligence demonstrates the ability to learn through assimilation of large datasets to unravel complex relationships, discover prior unfound pathophysiological states and develop predictive models. Artificial intelligence needs widespread exploration and adoption for large-scale implementation in cardiovascular practice.

Percutaneous left atrial appendage occlusion.

PURPOSE OF REVIEW: To review recent evidence evaluating the long-term safety and efficacy outcomes of left atrial appendage occlusion (LAAO), current guideline recommendations for LAAO use, performance of LAAO in comparison with direct oral anticoagulants (DOAC) and recently approved LAAO device. RECENT FINDINGS: The last 18 months have been marked with increasing evidence of the utility of LAAO in patients who are not candidates for long-term oral anticoagulation (OAC). Long-term data from two continued access registries to PROTECT-AF and PREVAIL support LAAO as a safe and effective long-term anticoagulation therapy. This new evidence led to class IIb recommendation for LAAO in nonvalvular atrial fibrillation (NVAF) patients not eligible for long-term OAC. PRAGUE-17 randomized controlled trial showed LAAO is noninferior to DOAC lending support to use of this modality in current era. PINNACLE FLX trial showed improved implant success and adequate closure rate which led to the device's Food and Drug Administration approval. SUMMARY: In conclusion, percutaneous LAAO appears to be a promising option for NVAF patients who are not candidates for long-term OAC in the current era. Further evidence guiding optimal patient selection and periprocedural antithrombotic regimen will help identify the patients who would benefit the most from this procedure.

Incidence and clinical outcomes of bleeding complications and acute limb ischemia in STEMI and cardiogenic shock.

BACKGROUND: Bleeding complications and acute limb ischemia (ALI) are devastating vascular complications in patients with ST-segment elevation myocardial infarction (STEMI). Cardiogenic shock (CS) can further increase this risk due to multiorgan failure. In the contemporary era, percutaneous mechanical circulatory support is commonly used for management of CS. We hypothesized that vascular complications may be an important determinant of clinical outcomes for CS due to STEMI (CS-STEMI). OBJECTIVE: We evaluated 10-year national trends, resource utilization and outcomes of bleeding complications, and ALI in CS-STEMI. METHODS: We performed a retrospective cohort study of CS-STEMI patients from a large U.S. national database (National Inpatient Sample) between 2005 and 2014. Events were then divided into four different groups: no MCS, with intra-aortic balloon pump, percutaneous ventricular assist device includes Impella or Tandem Heart or extracorporeal membrane oxygenation. RESULTS: Bleeding complications and ALI were observed in 31,389 (18.2%) and 1,628 (0.9%) out of 172,491 admissions with CS-STEMI, respectively. Between 2005 and 2014, overall trends increased for ALI; however, the number of bleeding events decreased. ALI was associated with increased in-hospital mortality in comparison to those without any ALI. However, bleeding complications were not associated with increased in-hospital mortality. Compared to patients without complications, both bleeding and ALI were associated with increased length of stay (LOS) and hospitalization costs. CONCLUSIONS: Bleeding and ALI are common complications associated with CS-STEMI in the contemporary era. Both complications are associated with increased hospital costs and LOS. These findings highlight the need to develop algorithms focused on vascular safety in CS-STEMI.

Incidence and clinical outcomes of stroke in ST-elevation myocardial infarction and cardiogenic shock.

OBJECTIVE: The authors sought to evaluate 10-year national trends, incidence and clinical outcomes of stroke in CS-STEMI. BACKGROUND: Stroke is a devastating complication among patients with ST-elevation myocardial infarction (STEMI). Concomitant cardiogenic shock (CS) may further increase the risk of stroke. Use of percutaneous mechanical circulatory support (pMCS) devices may further increase stroke risk in CS-STEMI. No studies have evaluated the risk of stroke in contemporary CS-STEMI. METHODS: We performed a retrospective cohort study of CS-STEMI patients from a large U.S. national database between 2005 and 2014. Previously validated codes for stroke were used to identify events of ischemic or hemorrhagic stroke. They were then divided into different groups: without MCS, with intra-aortic balloon pump, percutaneous ventricular assist device (PVAD, includes Impella or TandemHeart devices), or extracorporeal membrane oxygenation. RESULTS: In 172,491 admissions, stroke was noted in 5,613 (3.2%). Between 2005 and 2014, we observed an increase in the events of overall stroke from 3.1% in 2005 to 5.0% in 2014 (p for the trend <.001). The number of ischemic stroke events (2.4%) was higher than hemorrhagic stroke (0.1%) during the study period. Presence of stroke was associated with higher in-hospital mortality (40.6 vs. 29.8%, 95% CI adjusted odds ratio: 1.57, 1.44-1.67; p < .0001 among stroke vs. without stroke). CONCLUSIONS: The incidence of stroke events in CS-STEMI patients increased between 2005 and 2014, and is associated with higher in-hospital mortality, length of stay, and cost of hospitalization. The incidence of both hemorrhagic and ischemic stroke was higher with pMCS device use. Stroke prevention is a priority for CS-STEMI patients.

Warfarin versus direct oral anticoagulants for treating left ventricular thrombus: a systematic review and meta-analysis.

BACKGROUND: Left ventricular thrombus (LVT) is not uncommon and pose a risk of systemic embolism, which can be mitigated by adequate anticoagulation. Direct oral anticoagulants (DOACs) are increasingly being used as alternatives to warfarin for anticoagulation, but their efficacy and safety profile has been debated. We aim to compare the therapeutic efficacy and safety of DOACs versus warfarin for the treatment of LVT. METHODOLOGY: We systematically searched PubMed/Medline, Google Scholar, Cochrane library, and LILCAS databases from inception to 14th August 2020 to identify relevant studies comparing warfarin and DOACs for LVT treatment and used the pooled data extracted from retrieved studies to perform a meta-analysis. RESULTS: We report pooled data on 1955 patients from 8 studies, with a mean age of 61 years and 59.7 years in warfarin and DOACs group, respectively. The pooled odds ratio for thrombus resolution was 1.11 (95% CI 0.51-2.39) on comparing warfarin to DOAC, but it did not reach a statistical significance (p = 0.76). The pooled risk ratio (RR) of stroke or systemic embolization and bleeding in patients treated with warfarin vs DOACs was 1.04 (95% CI 0.64-1.68; p = 0.85), and 1.15 (95% CI 0.62-2.13; p = 0.57), respectively; with an overall RR of 1.09 (95% CI 0.70-1.70; p = 0.48) for mortality. CONCLUSIONS: DOACs appears to be non-inferior or at least as effective as warfarin in the treatment of left ventricular thrombus without any statistical difference in stroke or bleeding complications.

Cardiac rehabilitation in patients with peripheral arterial disease after revascularization.

OBJECTIVES: To evaluate safety, feasibility, and benefit of cardiac rehabilitation (CR) in patients with peripheral arterial disease (PAD) who undergo revascularization. METHODS: We conducted a prospective, non-randomized, pilot study to assess the feasibility, safety, and benefit of CR in PAD patients after revascularization compared to standard of care (controls). CR feasibility was assessed by the ability to complete 36 sessions. Safety was defined as the absence of adverse cardiovascular events during CR. Quality of life (QoL) assessment was performed using SF-36 form (Medical Outcomes Study 36-Item Short-Form Health Survey) and PAD-specific quality of life questionnaire (VascuQOL6). Other endpoints included incidence of claudication during 6-minute walk test (6MWT), mean distance, and number of laps walked. All outcome data were collected before and after CR completion. Standard statistical tests were used for comparisons. RESULTS: This study enrolled 20 subjects (CR group = 10). Mean age was 60.70 (±7.13) and 63.1 (±9.17) years in CR and controls, respectively (p-value > 0.05). Fifty percent and 60% were female in CR and control group, respectively. All subjects completed 36 CR sessions without adverse events. The increase in mean distance walked during 6MWT was higher in the CR group compared to control group (63.7 m vs. 10.5 m, p = 0.043). Change in mean number of laps walked was higher in the CR group (3.5 vs. -1.1; p < 0.01). Scores on 6 of 8 scales of SF-36 and VascuQOL6 were higher in the CR group, though not statistically significant. CONCLUSION: CR is safe, feasible, and improves walking ability in ambulatory patients with PAD after arterial revascularization.

Chronic Thromboembolic Pulmonary Hypertension-Management Strategies and Outcomes.

Chronic thromboembolic pulmonary hypertension (CTEPH) is rare but complex pathophysiological disease with hallmark features of chronic thrombotic mechanical obstruction, right ventricular dysfunction, and secondary pulmonary arteriopathy. It increasingly is being understood that chronic infection/inflammation, abnormal fibrinolysis, and cytokines play an important role in pathogenesis such that only a subset of patients with pulmonary embolism develop CTEPH. Diagnosis remains challenging given the lack of early clinical signs and overlap with other cardiopulmonary conditions. Pulmonary endarterectomy is the surgical procedure of choice with good postoperative survival and functional outcomes, especially when done at high-volume centers with a multidisciplinary approach. There has been a resurgence of balloon pulmonary angioplasty (BPA) as salvage therapy for inoperable CTEPH or in its newfound hybrid role for persistent postoperative pulmonary hypertension with excellent 1-year and 3-year survival. Use of riociguat has shown promising improvements in functional outcomes up to 2 years after initiation. Endothelin receptor antagonists serve a supplemental role postoperatively or in inoperable CTEPH. The role of drug therapy preoperatively or in tandem with BPA is currently under investigation.

Increased Risk of Perioperative Ischemic Stroke in Patients Who Undergo Noncardiac Surgery with Preexisting Atrial Septal Defect or Patent Foramen Ovale.

OBJECTIVES: To evaluate whether a preoperative diagnosis of atrial septal defect (ASD) or patent foramen ovale (PFO) is associated with perioperative stroke in noncardiac surgery and their outcomes. DESIGN: Retrospective cohort analysis. SETTING: United States hospitals. PARTICIPANTS: Adults patients (≥18 years old) who underwent major noncardiac surgery from 2010 to 2015 were identified using the Healthcare Cost and Utilization Project's National Readmission Database. INTERVENTIONS: Preoperative diagnosis of ASD or patent foramen ovale. MEASUREMENTS AND MAIN RESULTS: Among the 19,659,161 hospitalizations for major noncardiac surgery analyzed, 12,248 (0.06%) had a preoperative diagnosis of ASD/PFO. Perioperative ischemic stroke occurred in 723 (5.9%) of patients with ASD/PFO and 373,291 (0.02%) of those without ASD/PFO (adjusted odds ratio [aOR], 16.7; 95% confidence interval [CI]: 13.9-20.0). Amongst the different types of noncardiac surgeries, obstetric, endocrine, and skin and burn surgery were associated with higher risk of stroke in patients with pre-existing ASD/PFO. Moreover, patients with ASD/PFO also had an increased in-hospital mortality (aOR, 4.6, 95% CI: 3.6-6.0), 30-day readmission (aOR, 1.2, 95% CI: 1.04-1.38), and 30-day stroke (aOR, 7.2, 95% CI: 3.1-16.6). After adjusting for atrial fibrillation, ischemic stroke remained significantly high in the ASD/PFO group (aOR: 23.7, 95%CI 19.4-28.9), as well as in-hospital mortality (aOR: 5.6, 95% CI 4.1-7.7), 30-day readmission (aOR: 1.19, 95%CI 1.0-1.4), and 30-day stroke (aOR: 9.3, 95% CI 3.7-23.6). CONCLUSIONS: Among adult patients undergoing major noncardiac surgery, pre-existing ASD/PFO is associated with increased risk of perioperative ischemic stroke, in-hospital mortality, 30-day stroke, and 30-day readmission after surgery.