May Measurement Month 2018: an analysis of blood pressure screening results from Oman.

As per WHO estimates, around 17% of the adult Omani population are hypertensive. However, people with hypertension are often unaware of the diagnosis, and so the May Measurement Month (MMM) programme was set up to raise awareness of the importance of blood pressure (BP) screening. A cross-sectional screening of BP of subjects aged 18 years or more was carried out in May 2018 at various sites in Muscat, Oman. Screening sites were set up at the reception areas of participating hospitals, and at a few public areas such as shopping malls and workplaces of the volunteers. Blood pressure was measured according to a standardized protocol, and hypertension was defined as per the 2018 European Society of Hypertension guidelines. The data were analysed centrally by the MMM project team. A total of 12 689 individuals (mean age 40.6 ± 12.5 years, 72% male) were screened. The crude mean BP of the second and third readings (where three readings were taken, n = 4 738) was 127.1/79.2 mmHg. After multiple imputations, the average age and sex standardized BP was 127.3/80.2 mmHg. Of all participants, 29.8% had hypertension. There were 1 983 patients with a previous diagnosis of hypertension, of whom 1 810 were on antihypertensive medication. A further 1 973 subjects were newly diagnosed with hypertension. Of those on antihypertensive medication, 34.9% had uncontrolled BP readings. Screening programmes such as MMM are useful to identify persons with undiagnosed hypertension. However, more educational activities are required to increase the public awareness regarding the dangers of hypertension.

Association Between Family History, a Genetic Risk Score, and Severity of Coronary Artery Disease in Patients With Premature Acute Coronary Syndromes.

OBJECTIVE: A genetic risk score (GRS) for coronary artery disease has recently been shown to be independent of family history (FHx) in predicting future cardiovascular events. We sought to determine whether the presence of these risk factors, either individually or together, was associated with a higher burden of angiographic coronary artery disease. APPROACH AND RESULTS: We included 763 patients with premature acute coronary syndrome (median age, 50 [46-53] years; 30.8% women) with at least 1 major epicardial vessel stenosis enrolled in the Gender and Sex Determinants of Cardiovascular Disease From Bench to Beyond in Premature Acute Coronary Syndrome (GENESIS-PRAXY) study, a multicentre prospective cohort study of premature patients with acute coronary syndrome (aged ≤55 years). The prevalence of multivessel disease (ie, ≥2 vessels with >50% stenosis) in individuals with FHx was 49.7% as compared with 37.9% in those without FHx (P<0.01 for comparison). In adjusted models for age, sex, traditional risk factors, and GRS, FHx was associated with a higher prevalence of 3-vessel disease (odds ratio [OR], 1.42; 95% confidence interval, 0.91-2.21; P=0.12 for 2-vessel disease and OR, 2.26; 95% confidence interval, 1.29-3.95; P=0.005 for 3-vessel disease). Individuals with a high GRS were also more likely to have multivessel disease (OR, 1.41; 95% confidence interval, 1.01-1.99; P=0.047) after adjustment for traditional risk factors, including FHx. Individuals with both a FHx and a high GRS as compared with those with neither had the highest ORs for multivessel disease (adjusted OR, 2.14; 95% confidence interval, 1.24-3.69; P=0.0064). CONCLUSIONS: In patients with premature acute coronary syndrome, the presence of either a high GRS or FHx is associated with greater severity of coronary artery disease at angiography. Whether preventive strategies targeted to genetically predisposed individuals will reduce the burden of early acute coronary syndrome warrants further study.

Permanent pacemaker implantation after transcatheter aortic valve implantation: impact on late clinical outcomes and left ventricular function.

BACKGROUND: Very few data exist on the clinical impact of permanent pacemaker implantation (PPI) after transcatheter aortic valve implantation. The objective of this study was to assess the impact of PPI after transcatheter aortic valve implantation on late outcomes in a large cohort of patients. METHODS AND RESULTS: A total of 1556 consecutive patients without prior PPI undergoing transcatheter aortic valve implantation were included. Of them, 239 patients (15.4%) required a PPI within the first 30 days after transcatheter aortic valve implantation. At a mean follow-up of 22±17 months, no association was observed between the need for 30-day PPI and all-cause mortality (hazard ratio, 0.98; 95% confidence interval, 0.74-1.30; P=0.871), cardiovascular mortality (hazard ratio, 0.81; 95% confidence interval, 0.56-1.17; P=0.270), and all-cause mortality or rehospitalization for heart failure (hazard ratio, 1.00; 95% confidence interval, 0.77-1.30; P=0.980). A lower rate of unexpected (sudden or unknown) death was observed in patients with PPI (hazard ratio, 0.31; 95% confidence interval, 0.11-0.85; P=0.023). Patients with new PPI showed a poorer evolution of left ventricular ejection fraction over time (P=0.017), and new PPI was an independent predictor of left ventricular ejection fraction decrease at the 6- to 12-month follow-up (estimated coefficient, -2.26; 95% confidence interval, -4.07 to -0.44; P=0.013; R(2)=0.121). CONCLUSIONS: The need for PPI was a frequent complication of transcatheter aortic valve implantation, but it was not associated with any increase in overall or cardiovascular death or rehospitalization for heart failure after a mean follow-up of ≈2 years. Indeed, 30-day PPI was a protective factor for the occurrence of unexpected (sudden or unknown) death. However, new PPI did have a negative effect on left ventricular function over time.

Advanced chronic kidney disease in patients undergoing transcatheter aortic valve implantation: insights on clinical outcomes and prognostic markers from a large cohort of patients.

AIM: The aim of this study was to determine the effects of advanced chronic kidney disease (CKD) on early and late outcomes after transcatheter aortic valve implantation (TAVI), and to evaluate the predictive factors of poorer outcomes in such patients. METHODS AND RESULTS: This was a multicentre study including a total of 2075 consecutive patients who had undergone TAVI. Patients were grouped according the estimated glomerular filtration rate as follows: CKD stage 1-2 (≥60 mL/min/1.73 m(2); n = 950), stage 3 (30-59 mL/min/1.73 m(2); n = 924), stage 4 (15-29 mL/min/1.73 m(2); n = 134) and stage 5 (<15 mL/min/1.73 m² or dialysis; n = 67). Clinical outcomes were evaluated at 30-days and at follow-up (median of 15 [6-29] months) and defined according to the VARC criteria. Advanced CKD (stage 4-5) was an independent predictor of 30-day major/life-threatening bleeding (P = 0.001) and mortality (P = 0.027), and late overall, cardiovascular and non-cardiovascular mortality (P < 0.01 for all). Pre-existing atrial fibrillation (HR: 2.29, 95% CI: 1.47-3.58, P = 0.001) and dialysis therapy (HR: 1.86, 95% CI: 1.17-2.97, P = 0.009) were the predictors of mortality in advanced CKD patients, with a mortality rate as high as 71% at 1-year follow-up in those patients with these 2 factors. Advanced CKD patients who had survived at 1-year follow-up exhibited both a significant improvement in NYHA class (P < 0.001) and no deterioration in valve hemodynamics (P = NS for changes in mean gradient and valve area over time). CONCLUSIONS: Advanced CKD was associated with a higher rate of early and late mortality and bleeding events following TAVI, with AF and dialysis therapy determining a higher risk in these patients. The mortality rate of patients with both factors was unacceptably high and this should be taken into account in the clinical decision-making process in this challenging group of patients.

Navigating the crossroads: cardiometabolic risks in cancer survivorship - a comprehensive review.

The landscape of cancer survivorship is increasingly populated by individuals facing a spectrum of cardiometabolic risks, attributed to both their oncological history and treatment regimens. This manuscript synthesizes findings from various studies, highlighting the prevalence of traditional risk factors-hypertension, dyslipidemia, diabetes-as well as emergent concerns like obesity and metabolic syndrome among survivors. The impact of demographic variables, specific cancer types, and treatment modalities on cardiometabolic health is explored. Through a lens of multidisciplinary management and future research directives, we advocate for an integrative approach to cardiometabolic health in cancer survivors, aiming to ensure their victory over cancer extends into long-term well-being. Furthermore, we discuss the outcome implications of these cardiometabolic risk factors on cardiovascular disease development, future cardiovascular events, and overall survival, supported by studies showing improved outcomes through exercise and risk factor control.

Non-infarct-related artery revascularization during primary percutaneous coronary intervention for ST-segment elevation myocardial infarction: a systematic review and meta-analysis.

BACKGROUND: In patients with ST-elevation myocardial infarction (STEMI) and multivessel disease, guidelines recommend infarct-related artery (IRA) only intervention during primary percutaneous coronary intervention (PCI) except in patients with hemodynamic instability. To assess the available evidence, we performed a systematic review and meta-analysis comparing outcomes of non-IRA PCI as an adjunct to primary PCI (same sitting PCI [SS-PCI]) with IRA only PCI (IRA-PCI) in the setting of STEMI. METHODS AND RESULTS: A comprehensive search identified 14 studies [11 cohort, 3 randomized controlled trials] comprising of 35,239 patients. For cohort studies, patients undergoing SS-PCI had higher rate of anterior infarction (48% vs. 45%, P = .04) and cardiogenic shock (11% vs. 9%, P = .0001) at baseline compared with IRA-PCI. The primary composite end point of death, myocardial infarction and revascularization was higher in the SS-PCI group in the short term (OR, 1.63; CI, 1.12-2.37) and long term (OR, 1.60; CI, 1.18-2.16). However, after excluding patients with shock, there was no difference in primary endpoint for the short (OR, 1.33; CI, 0.67-2.63) and long term (OR, 1.39; CI, 0.80-2.42) follow-up. In analyses limited to randomized controlled trials, primary end point was similar during short term (OR, 0.79; CI, 0.19-3.28) and significantly lower for SS-PCI group in the long term (OR, 0.55; CI, 0.34-0.91). CONCLUSIONS: There is paucity of randomized data to guide management of STEMI patients with multivessel disease. SS-PCI group in cohort studies has higher baseline risk compared to IRA-PCI. The primary end point is higher for SS-PCI in observational cohort studies but this difference did not persist after exclusion of shock patients and for analysis limited to randomized controlled trials. These findings underscore the need of a large randomized controlled trial to guide therapy for a commonly encountered clinical situation.

Successful Management of Maternal Left Atrial Myxoma in Pregnancy.

A 29-year-old woman (gravida 3, para 2) presented at 28 weeks+2 days of gestation with a two-months history of dyspnea associated with orthopnea and occasional palpitations. On transthoracic echocardiography, she was diagnosed with a 3.2 × 2.7 cm left atrial myxoma. The patient underwent open surgical resection at 30 weeks of gestation. She had an uneventful postoperative recovery and was discharged on the ninth day. At 41 weeks of gestation, she gave birth by cesarean to a healthy baby of normal weight. Both the mother and the baby were discharged in stable condition.

Angiographic Predictors of Viability During Intervention for a ST Elevation Myocardial Infarction.

Objectives: This study aimed to identify angiographic features that would predict myocardial viability after coronary intervention for ST elevation myocardial infarction (STEMI). Methods: This retrospective study included patients who attended Sultan Qaboos University Hospital, Muscat, Oman, between January and December 2019 with a STEMI. Results: A total of 72 patients (61 male; mean age = 54.9 ± 12.7 years) were included in the study; 11 patients had evidence of non-viability on echocardiography. There were 13 patients with viable myocardium and 3 with non-viable myocardium who had a myocardial blush grade (MBG) of 2 or lower. Similarly, 10 patients with viability and 1 with non-viable myocardium had thrombolysis in myocardial infarction (TIMI) flow of 2 or lower in the infarct related artery (IRA). However, none of these were statistically significant. The TIMI flow in the IRA at the end of the procedure correlated with the MBG. Conclusion: There were no clear angiographic features during primary angioplasty that could predict myocardial viability.

Yield of Cardiac Investigations in Patients Presenting with Acute Ischaemic Stroke: A single tertiary centre experience.

Objectives: Strokes are a major cause of morbidity and mortality. This study aimed to evaluate the effectiveness of routine cardiac investigations in identifying a cardioembolic aetiology for ischaemic strokes. Methods: This retrospective study involved patients who presented with a stroke to the Sultan Qaboos University Hospital, Muscat, Oman, between January and December 2019. Results: A total of 183 patients (mean age = 66.2 ± 13.5 years), the majority of which were male (n = 109, 59.6%), were included. The common risk factors included hypertension (74.9%), diabetes (61.7%) and hyperlipidaemia (54.6%). The middle cerebral artery was the most common artery affected, in 44 patients (24.0%). On admission, 14 (7.6%) patients were in atrial fibrillation (AF), while the rest were in sinus rhythm. The 24-hour electrocardiogram (ECG) Holter monitoring revealed no abnormalities in 135 patients. AF was observed in 15 (8.1%) patients (inclusive of the 14 who had AF on resting ECG). Furthermore, 32 (17.4%) patients had evidence of non-sustained atrial arrhythmia, and nine (4.9%) had non-sustained ventricular tachycardia. Frequent supraventricular ectopics (>30/hour) was noted on 30 patients (16.3%), while five (2.7%) patients had a high ventricular ectopic burden (>10% burden). No significant abnormalities were noted in the echocardiograms of the patients; however, 10 out of 132 (7.5%) patients presented a positive bubble echo. Enlarged left atria were found in 24 (13.1%) patients. Conclusion: The overall diagnostic yield of the abnormalities from routine cardiac testing for patients with stroke appears to be low. Targeted screening of patients with cryptogenic stroke, as suggested by newer guidelines, is recommended.

Incidence, Risk Factors, Maternal and Neonatal Outcomes of Peripartum Cardiomyopathy (PPCM) in Oman.

Background: Peripartum cardiomyopathy (PPCM) is an idiopathic life-threatening condition occurring towards the end of pregnancy or in the first few months following delivery that might affect the maternal and neonatal outcomes. Objectives: To assess the incidence and to evaluate the antenatal risk factors and the maternal and neonatal outcomes in Omani women diagnosed with PPCM. Methods: A retrospective cohort study was conducted at two tertiary institutions in Oman between the 1st of January 2010 to the 31st of December 2018. All cases fitting the standard definition of PPCM were included in the analysis. Patients with pre-existing dilated cardiomyopathy, chronic obstructive pulmonary disease and significant valvular heart disease have been excluded. Results: A total of 113,104 deliveries were screened during the study period. PPCM was confirmed in 116 cases with an incidence of 1.02 per 1000 deliveries. Independent predictors for the development of PPCM were age; especially women at the mid reproductive age (26-35 years), singleton pregnancy and gestational hypertension. In general, maternal outcomes were favorable, with full recovery of left ventricular ejection fraction in 56.0%, recurrence of 9.2%, and an overall mortality rate of 3.4%. The most common maternal complication was pulmonary edema (16.3%). The neonatal mortality rate was 4.3% and the preterm birth rate was 35.7%. Neonatal outcomes included 94.3% live births, out of which 64.3% were term with Apgar scores of more than 7 at five minutes in 91.5% of the neonates. Conclusion: Our study resulted in an overall incidence of PCCM in Oman of 1.02 in 1000 deliveries. Given the significance of maternal and neonatal complications, establishing a national PPCM database and local practice guidelines, and emphasizing their implementations in all regional hospitals, are fundamental for early recognition of the disease, timely referral, and application of therapy. Future studies, with a clearly defined control group, are highly recommended to appraise the significance of antenatal comorbidities in PPCM compared to non-PPCM cases.

ST-segment elevation after abdominal aortic aneurysm repair.

We describe a case of post-operative inferior myocardial infarction after abdominal aortic aneurysm repair due to compromise of a gastroepiploic coronary arterial graft.

The role of echocardiography in the management of structural valve degeneration of transcatheter valves.

Transcatheter valve implantation in patients with aortic stenosis has evolved as an acceptable alternative to surgical aortic valve replacement in a subset of patients at excessively high risk from surgery. The structural valve degeneration (SVD) is a known phenomenon in catheter-based valves too, which was hitherto seen with surgical bioprosthetic valves. Echocardiography plays a pivotal role not only in early detection but also in the management of SVD of Transcatheter valves. The goal of this report is to agglomerate our experience of an unusual case of SVD of a catheter-based valve implanted inside the bioprosthetic aortic and mitral valve apparatus and its management with aortic and mitral valve replacement with mechanical valve prosthesis.

One-Year Outcomes for Patients Undergoing Transcatheter Aortic Valve Replacement: The Gulf TAVR Registry.

BACKGROUND: The use of transcatheter aortic valve replacement (TAVR) is steadily increasing with TAVR procedures offered to patients across the entire spectrum of surgical risks. The Gulf TAVR registry captures the demographics of patients undergoing TAVR in the Gulf region, comorbidities that drive outcomes, procedural success, complications, and one-year outcomes of death or rehospitalization. METHODS: This is a retrospective cohort study for adult patients aged at least 18 years undergoing TAVR at eight centers in the Gulf region. The primary outcome was a composite of death or re-hospitalization at one-year. Secondary outcomes included the individual components of the composite, stroke, and myocardial infarction (MI). We used multivariable Cox regression to determine factors associated with the composite endpoint. RESULTS: A total of 795 patients (56% male) were included in the final analysis with a mean age of 74.6 (standard deviation (SD) 8.9) years, Society of Thoracic Surgeons Score (STS) Score 4.9 (4.2), ejection fraction of 53% (12.7%). Transfemoral approach was employed in over 95% (762/795). The primary outcomes rate was 12.8% (95% confidence interval [CI]: 10.6-15.4); secondary endpoints were death 5.4% (95% CI 4.0-7.2); stroke 0.8% (95% CI 0.3, 1.7), MI 0.8% (95% CI 0.4-1.9), rehospitalization: 9.3% (95% CI 7.5-11.5) of whom 71.6% were related to cardiovascular causes. 77% of the cardiovascular admissions were attributable to heart failure or the need for pacemaker implantation. Stage IV or V chronic kidney disease was significantly associated with the primary composite endpoint (Hazard Ratio: 2.49, [95% CI: 1.31, 4.73], p = 0.005). Although not significant, paravalvular leak and severe left ventricular dysfunction showed a 2-fold and 3-fold increased risk for the composite endpoint, respectively. CONCLUSIONS: The Gulf TAVR registry is the first of its kind in the region. It profiles an elderly population with a high procedural success rate and a low rate of complications. One-year outcomes were primarily driven by repeat hospitalization for heart failure and pacemaker implantation indicating a need to optimize heart failure management and improve algorithms for the detection of conduction abnormalities.

Prevalence of high blood pressure and cardiovascular risk factors from a community screening programme in the Middle-East; a 3-year analysis of data from the May Measurement Month programme (2017-2019) in Oman.

The May Measurement Month (MMM) programme is a global cross-sectional blood pressure (BP) screening programme. Here we present the combined data for the years 2017-2019 from Oman. BP was measured at various screening sites, according to standard protocol and hypertension was diagnosed if the BP was ≥140/90 mmHg or if the individual was already on antihypertensive medication. A total of 15,679 individuals (mean age 41.1 ± 12.6 years range 18-89 years; 71% male) were screened over the 3-year period. 7702 individuals (mean age 41.8 ± 13.9 years; 71.5% male) had three BP readings. The mean of the last two BP readings was 127.3 ± 17.1 mmHg. 1573 readings were in the hypertensive range (1004 newly diagnosed hypertension). A further 749 individuals were on antihypertensive medications with normal BP readings giving a proportion of 30.1% of the entire cohort being hypertensive. BP was high in 43% of patients on antihypertensive medications, 28.1% of those with previous myocardial infarction, 33.9% of those with previous stroke and 37.6% of the diabetic patients. BP strongly correlated with body mass index (BMI) and age (both p < 0.001), with a large proportion (68.5%) of individuals having high BMI(>25 kg/m2). Arab and South Asian ethnicity was associated with higher BMI and BP (both p < 0.001).Community screening programmes help identify previously undiagnosed hypertension and hypertensives with high BP. They also help to identify those at high cardiovascular risk. More emphasis should be given to monitoring those in high cardiovascular risk categories and high-risk ethnic groups.

WIN Gulf TAVR Registry: Describing Sex Differences in Patient Characteristics, Prognosis, and Outcomes.

Background: Several international registries have examined outcomes in women undergoing transcatheter aortic valve replacement (TAVR). However, none of these studies included women from the Gulf region. The Women IN Gulf Transcatheter Aortic Valve Replacement (WIN Gulf TAVR) registry aimed to examine sex-based differences in patient characteristics and outcomes in patients undergoing TAVR in the region. Methods: This registry is a prespecified subanalysis of the main Gulf TAVR registry. Baseline characteristics, procedural details and success, and 1-year outcomes were recorded. The primary outcome consisted of a composite of all causes of death, myocardial infarction (MI), and rehospitalizations at 1 year. The secondary outcomes were a composite of the individual components of the primary composite. Results: A total of 347 women (44% of the Gulf TAVR registry) were included in the final analysis, with a mean age of 74.1 ± 9.1 years; mean ejection fraction of 56.20% ± 10.52%; and mean Society of Thoracic Surgeons score of 5.30 ± 4.35. The composite primary end point occurred in 12.4% (95% CI, 9.3-16.2). The individual components of the primary end point were as follows: death, 4.3% (95% CI, 2.6-7.0); MI, 1.1% (95% CI, 0.4-2.9); and rehospitalization, 9.8% (95% CI, 7.1-13.3), with 7.2% (95% CI, 4.9-10.4) related to cardiac causes. Conclusions: Women in the WIN Gulf TAVR registry had outcomes and baseline characteristics similar to men. Although higher rehospitalizations for cardiac causes and MI at 1 year in women were noted, the overall survival was better in women. These observations warrant a larger cohort to identify the drivers of events.

Valve Replacement for Massive Hemoptysis in Mitral Stenosis: An Uncommon Course in Modern Practice.

Massive hemoptysis is uncommon in mitral stenosis in contemporary practice. We report a patient without any previous illness presenting with life-threatening pulmonary hemorrhage, who was initially managed as cryptogenic hemoptysis. Once mitral stenosis was confirmed, the patient underwent mitral valve replacement with total and complete cessation of bleeding.

Rivaroxaban for Treatment of Left Ventricular Thrombus: A Case Report.

BACKGROUND Left ventricular thrombus (LVT) is a complication of left ventricular dysfunction and myocardial infarction (MI) and is associated with systemic thromboembolism. Two-dimensional transthoracic echocardiography (TTE) is considered the first-line diagnostic tool for detection of LVT. Vitamin K antagonists (VKA) targeting an international normalized ratio (INR) from 2 to 3 are the only approved treatments by the Food and Drug Administration (FDA). New emerging observational data support the use of direct oral anticoagulants (DOACs) as an alternative therapeutic option; however, their safety and efficacy have not been assessed in a good-quality randomized controlled trial. CASE REPORT Here, we present a case of a 43-year-old man diagnosed with human immunodeficiency virus (HIV)-associated dilated cardiomyopathy complicated with an LVT. He was treated with rivaroxaban for 9 consecutive months with no interruption of therapy at any point in time; however, he presented to the emergency department with symptoms of decompensated heart failure. A follow-up TTE demonstrated a significant increase in the size of his LVT. This case questions the efficacy of using factor Xa inhibitor (rivaroxaban) as an alternative option for LVT treatment. CONCLUSIONS This case demonstrates a failure of rivaroxaban in treating LVT in a patient with HIV-associated dilated cardiomyopathy. Good-quality randomized clinical trials or prospective studies are required to establish the efficacy and safety of DOACs for LVT treatment as an alternative to VKA.

Use of Intracoronary Thrombolysis for Huge Thrombus Burden in an Ectatic Right Coronary Artery.

Managing a high intracoronary (IC) thrombus burden is a major challenge in patients with ectatic coronary arteries who present with an ST-elevation myocardial infarction (STEMI). We report a 45-year-old male patient who presented to the Department of Medicine, Sultan Qaboos University Hospital, Muscat, Oman, in 2017 with an inferior STEMI. Coronary angiography revealed ectatic coronary arteries with an occluded right coronary artery (RCA). The RCA had a massive thrombus burden that did not resolve with aspiration thrombectomy or balloon angioplasty. Subsequently, IC thrombolysis was administered resulting in significant reperfusion. During the course of his treatment, the patient suffered from intracranial bleeding as a complication; however, he recovered completely with no residual neurological sequelae. This case report demonstrates that IC thrombolysis is a valid option in patients with a massive thrombus burden in the setting of a STEMI, albeit with an increased risk of major bleeding.

Impact of Blood Transfusion on Troponin I Levels and Outcomes after Cardiac Surgery: A Cohort Study.

OBJECTIVES: Increased cardiac troponin I (TI) has been suggested to be a sensitive indicator of intraoperative myocardial injury. We investigated the association of transfusion on TI levels post-surgery and outcomes in patients undergoing elective cardiac surgeries. METHODS: We conducted a retrospective review of 542 patients. Patients were divided into two groups based on TI levels at 24 hours (TI24) (> 6.5 µg/L vs. ≤ 6.5 µg/L). The impact of transfusion on TI levels was estimated using logistic regression and adjusted for using a multivariable model that included aortic cross-clamp time and preoperative ejection fraction. The effect of TI on the clinical outcomes was examined. RESULTS: Red blood cell (RBC) transfusion was found to be associated with high TI levels (odds ratio (OR) = 2.33, p = 0.007, 95% confidence interval (CI): 1.30-4.30). A trend was observed when aortic cross-clamp time and preoperative ejection fraction were adjusted for (OR = 2.06, p = 0.080, 95% CI: 0.90-4.70). An association was found between aortic cross-clamp time and high TI levels in the multivariable model (OR = 1.01, p = 0.028, 95% CI: 1.00-1.02). Elevated TI levels was associated with higher mortality (OR = 4.15, p = 0.017, 95% CI: 1.29-13.08), renal failure (OR = 2.99, p = 0.004, 95% CI: 1.41-6.32), and increased length of stay in-hospital (OR = 4.50, p = 0.020, 95% CI: 0.69-8.30). CONCLUSIONS: RBC transfusion is associated with increased TI24 post-cardiac surgery and worse outcomes, albeit a confounding effect cannot be excluded. Larger studies are required to confirm these findings.