Cardiac Tamponade Research Articles

Abstract 13019: Differences in Outcomes Among Elderly Patients on Medicare Undergoing Transapical Access and Non-Transapical Access Transcatheter Aortic Valve Replacement

Introduction: While a recent study reported a decreasing trend in the use of transapical access (TA) transcatheter aortic valve replacement (TAVR) over non-transapical access (non-TA) TAVR, their burden on Medicare remains considerable. We aim to investigate differences in outcomes among elderly patients covered by Medicare undergoing TA and non-TA-TAVR. Methods: Medicare-insured elderly (ages≥ 60 years) undergoing TAVR (TA and non-TA) were recruited from the National Inpatient Sample (2016-2020), and differences in outcomes between the two procedures were evaluated. Results: We found 259385 procedures of TAVR involving 256145 (98.8%) cases of non-TA-TAVR and 3240(1.2%) cases of TA-TAVR. Between 2016-2020, a continuous drop in TA-TAVR use was observed (vs. non-TA-TAVR). Mortality rates among non-TA-TAVR patients also decreased from 1.8% in 2016 to 1.1% in 2020. Meanwhile, patients with TA-TAVR experienced a rise in mortality from 3.8% in 2016 to 5.8% in 2018, which decreased in 2019(3.7%) and 2020 (2.2%). TA-TAVR cases had a higher mean Charlson Comorbidity Index (CCI) score (3.65 in TA-TAVR cases vs. 3.02 in non-TA-TAVR patients) and higher odds of major bleeding (aOR 1.554, 95% CI 1.442-1.675, p<0.01), postprocedural pneumothorax (aOR 2.853, 95% CI 1.689-4.820, p<0.01), postprocedural respiratory failure (aOR 5.106, 95% CI 4.149-6.284, p<0.01), use of mechanical ventilation (aOR 3.077, 95% CI 2.653-3.569, p<0.01), or Major Adverse Cardiac Events (MACE) (aOR 1.512, 95% CI 1.325-1.727, p<0.01) vs. non-TA-TAVR cases. No differences in cardiac tamponade (aOR 1.350, 95% CI 0.957-1.904, p=0.087) were seen. Finally, TA-TAVR cases required a longer stay (mean length of stay 7.15 vs. 3.76 days). Conclusions: The use of non-TAVR over TA-TAVR continued between 2016-2020 with favorable short-term survival rates and fewer complications such as major bleeding, postprocedural pneumothorax, respiratory failure, MACE, and the need for mechanical ventilation.

Abstract 15941: Efficacy of Frozen Elephant Trunk for Acute Type A Aortic Dissection

Objectives: There are various treatment strategies for acute type A aortic dissection (ATAAD). In our department, total arch replacement (TAR) using the Frozen Elephant Trunk (FET) is the standard technique for DeBakey type I, which has a patent false lumen, and we assessed the outcomes and postoperative complications. Methods: Of 71 consecutive patients who underwent surgical treatment for ATAAD at our department from October 2020 to May 2023, 42 patients were included, excluding 29 patients whose the descending aorta was thrombosed or not dissected. Results: Age 64±11 years, 30 male patients (71.4%). Preoperatively, cardiac tamponade was observed in 5 cases, malperfusion in 5 cases of head, 2 cases of coronary artery, 3 cases of celiac artery, 3 cases of superior mesenteric artery, 13 cases of renal artery, and 13 cases of lower limbs. The surgical procedures were ascending aortic replacement (AAR) in 6 cases (14.2%), partial arch replacement (PAR) in 2 cases (4.8%), TAR in 5 cases (11.9%), and TAR with FET in 29 cases (69.0%). The mean operation time was 304±70 minutes, the mean cardiopulmonary bypass time 168±45 minutes, the mean cardiac arrest time 100±26 minutes, the mean circulatory arrest time 42±8 minutes, and the mean minimum bladder temperature 26.1±1.4°C. There was no hospital death, and complications included new stroke in 2 patients (4.8%). The residual dissection was AAR5/6 (83.3%), PAR1/2 (50.0%), TAR5/5 (100%), and TAR with FET24/29 (82.8%), of which AAR5/5 (100%), PAR1/1 (100%), TAR2/5 (40.0%), and TAR with FET1/24 (4.2%) had residual dissection in the proximal descending aorta. There were 3 deaths (meningitis, cerebral hemorrhage, gastrointestinal hemorrhage) with a mean follow-up of 8.9±6.7 months. The only additional treatment was preemptive TEVAR in 1 case (2.4%) for residual dissection of proximal descending aorta of TAR with FET. There was no case of stent induced new entry. Conclusions: We consider the early results for ATAAD to be favorable. Furthermore, TAR with FET promotes good thrombosis and remodeling down to the proximal descending level, suggesting that FET may contribute to improved outcomes during follow-up period. Further clinical research on mid-term outcomes is needed.

Abstract 18486: Recurrent Pericarditis Following Atrial Fibrillation Ablation: Unmasking Latent Tuberculosis Infection

Background: Tuberculous pericarditis is rare in the United States but can lead to serious sequelae in the absence of diagnosis and treatment. We report a case of recurrent pericarditis following catheter ablation of atrial fibrillation (AF) due to reactivation of latent TB infection. Case Summary: A 52-year-old male with no past medical history underwent a difficult trans-septal puncture & cryo-balloon PV isolation, complicated by acute pericarditis and pericardial effusion with cardiac tamponade. He underwent pericardiocentesis with removal of 260cc bloody fluid. He had resolution of chest pain with ibuprofen, but experienced recurrence after 3 months and was given a longer NSAID course. Two months later, he presented with chest pain along with night sweats & low-grade fever. He had an elevated C-reactive protein, and echocardiography revealed thickened pericardium & constrictive physiology. He received high-dose aspirin, prednisone, and colchicine for recurrent pericarditis. Extensive Infectious Disease & Rheumatology work-up ruled out autoimmune & viral etiologies but his T-Spot TB test was positive. He denied personal or contact history of TB except travel to Asia 20 years ago. CT scan ruled out pulmonary TB infection. A 6-month course of Rifampin was prescribed. He experienced a 4th episode of pericarditis while tapering off prednisone, and restarted prednisone, Ibuprofen, and colchicine. Additionally, Rilonacept was prescribed. After completing 6-months of Rifampin and Rilonacept, he had significant improvement and no further recurrences on 1 year follow up. Discussion: Pericarditis is a common complication of catheter ablation, often resulting from direct injury. We report a case of recurrent pericarditis, initially believed to be a traumatic complication of AF ablation. However, investigation revealed underlying latent pericardial TB infection. Appropriate treatment led to complete resolution without sequelae.

Abstract 17187: The Relationship Between N-Terminal Pro-Brain Natriuretic Peptide Levels and Poor Outcomes in Covid-19 Patients

Introduction: N-terminal pro-brain natriuretic peptide (NT-proBNP) is a biomarker reflecting increased cardiac stress. It is a key variable in assessing patients with various pathologies. However, assessment of NT-proBNP as a variable in the prognostication of poor outcomes in COVID-19 patients is lacking. In addition, COVID-19 has brought its own variables and sequelae along with overlapping pathologies in a variety of systems. Hypothesis: With the systemic impact that COVID-19 can have, NT-proBNP represents a variable that will aid in identifying patients at higher risk of poor outcomes. We aim to assess the utility of NT-proBNP to help predict the incidence of major adverse cardiovascular events (MACE) and mortality in patients hospitalized with COVID-19. Methods: Using a multi-center observational database, we analyzed 1,692 hospitalized COVID-19 PCR-positive patients at Methodist Health System from March to July 2020. We examined NT-proBNP levels, in-hospital death or hospice referral rates, and incidence of MACE in the cohort. MACE was defined as congestive heart failure (CHF) exacerbation, pericardial effusion, cardiac tamponade, myocarditis, pericarditis, myocardial infarction (MI), stroke, pulmonary embolism/deep vein thrombosis, or shock. The incidence of mortality and MACE were compared between patients with and without elevated NT-proBNP levels. Elevated NT-proBNP levels were those >900 pg/mL. A chi-square ( X 2 ) and odds ratio (OR) test were used to analyze observed variables. Results: Of the 1,692 hospitalized patients, 576 patients (34.0%) arrived with elevated NT-proBNP levels. Patients with elevated NT-proBNP had a higher incidence of mortality (OR=3.2559, 95% CI=2.522-5.203, p<0.0001) and MACE (OR=6.564, 95% CI=5.255-8.199, p<0.0001) compared to patients with NT-proBNP levels <900 pg/mL. Additionally, the elevated NT-proBNP patients had a higher incidence of CHF exacerbation, MI, and shock compared to patients with NT-proBNP levels <900 pg/mL. Conclusions: NT-proBNP levels can be a vital tool in recognizing COVID-19 patients who are at higher risk of poor outcomes. The use of NT-proBNP can further aid in prognostication in patients presenting to the hospital with COVID-19.

Abstract 14541: Pericardiocentesis is Associated With Higher Mortality in Patients With Pulmonary Hypertension

Background: Pericardiocentesis in patients with Pulmonary Hypertension (PH) and pericardial effusions has unclear benefits, as it has been associated with acute hemodynamic collapse and increased mortality. Data on in-hospital outcomes in this population is limited. Aims. Describe pericardiocentesis-related patient characteristics and in-hospital outcomes in patients with PH versus without. Methods: The National Inpatient Sample database was used to identify adult patients undergoing pericardiocentesis during hospitalizations between 2016 and 2020. Data were stratified between patients with and without PH. A multivariate regression model was used to estimate the association of PH with pericardiocentesis in-hospital outcomes, adjusting for statistically significant comorbidities. Results: A total of 95,665 hospitalizations with a procedure diagnosis of pericardiocentesis were included, of which 7,770 had PH. Patients with PH tended to be older (67 ± 15.7) and female (56%), had significantly higher rates of hypertension (79% vs 66%, P<0.01), diabetes (26% vs 17%, P<0.01), chronic lung disease (32% vs 23%, P<0.01), chronic liver disease ( 15% vs 12%, P<0.01), CKD ( 44% vs 25%, P<0.01), and chronic heart failure (19% vs 10%, P<0.01). Pericardiocentesis in PH was associated with higher in-hospital all-cause mortality, post-procedure shock, cardiogenic shock, cardiac arrest, and mechanical circulatory support compared to patients without PH. Those presenting with cardiac tamponade had higher odds of mortality, post-procedural shock, and mechanical circulatory support (Figure 1) compared to patients without PH. All P values were < 0.001. Conclusion: PH was associated with higher mortality and a higher rate of cardiovascular complications in patients undergoing pericardiocentesis. Those presenting with tamponade had particularly worse outcomes. Further research on the outcomes of pericardiocentesis in these patients is needed.

Abstract 18363: Readmission & Temporal Trends of Post LVAD Placement Complications in Patients With End-Stage Heart Failure

Introduction: 5-10% of heart failure (HF) patients progress to advanced stages. Left ventricular assist devices (LVADs) have emerged as a favored therapy for end-stage HF as destination therapy or as a bridge to heart transplantation. However, complications and provider expertise hinder its widespread use. Third generation LVAD was introduced in 2018 to enhance usability and reduce complications. We aim to investigate the temporal trends in post-LVAD complications with the latest generation LVAD vs the previous version. Methods: We utilized the 2016-2020 Nationwide Readmission Database to identify patients ≥ 18 years of age with advanced HF implanted with an LVAD. Variables were identified using International Classification of Diseases, Tenth revision codes. We compared 2 groups based on the implant year (2016-2018 and 2019-2020). The primary outcome was 30-day readmission (30-dr), while secondary outcomes were trends in complications, mortality rate, and healthcare cost. Multivariate analyses and descriptive bivariate analyses were performed. A p-value <0.05 was considered statistically significant. Results: We identified 7,975 patients (21.3% females) of which 17.1 % (n = 1,214) were readmitted within 30 days. Readmission rates were 17.7% (n = 778) for 2016-2018 and 16.2% (n = 435) for 2019-2020 (adjusted Wald test, p = 0.26). The 2019-2020 group exhibited lower rates of cardiac device complications, vasopressor usage, cardiac tamponade, and peri-procedural circulatory complications than the 2016-2018 group (adjusted Wald test, p < 0.05). No significant differences in mortality or LOS were observed between the two groups (adjusted Wald test, p > 0.05). Healthcare costs were higher in the 2019-2020 group (mean $276,439 vs $315,332, adjusted Wald test, p = 0.01). Conclusions: Complications following LVAD placement continue to impede broader adoption for advanced HF. Nonetheless, advancements in newer LVAD generations and improved provider expertise hold promise for increased utilization. Our study indicates a decline in complications, including cardiac tamponade and post-procedural complications, which may be attributed to newer device innovations. Further research is necessary to explore this correlation in greater depth.

Abstract 13315: Recurrent Cardiac Tamponade Due to Minoxidil Associated Drug Induced Lupus Erythematosus

Case description A 59 year old man with history of MGUS, CKD stage 2, DM, HTN, and OSA presented with gradual worsening of dyspnea and intermittent dizziness over the past few days. Echocardiography showed diastolic collapse of the RV, RA collapse, IVC plethora, marked tricuspid in-flow velocities, and pericardial effusion suggestive of cardiac tamponade (CT). Subxiphoid pericardial window was emergently performed. Serosanguineous fluid 900 mL was drained, and fluid analysis was negative for malignancy or infection. Pericardial biopsy revealed fibro-connective tissue with mild peri-vascular chronic inflammation. He significantly improved and was discharged after 5 days. One month later, he presented again with 1 day symptom of severe dyspnea due to recurrent pericardial effusion with CT physiology. Emergent pericardiocentesis was performed to remove 1,800 ml of serous fluid. Serologic workup for autoimmune disease was strongly positive for anti-histone antibody. ESR (124 mm/hr) and c-reactive protein (5.8 mg/dL) were elevated. Upon review of prescription list, he had been treated for HTN in the past 5 years with minoxidil, amlodipine, lisinopril, and carvedilol. Discussion The use of topical minoxidil, a potent peripheral arterial vasodilator, has been approved for androgenetic alopecia in both men and women for decades, whereas oral minoxidil is limited to refractory hypertension due to side effects such as reflex tachycardia, fluid retention, hypertrichosis, and, rarely, idiosyncratic pericardial effusion. Pericardial effusion was reported in approximately 3-5% of patients receiving minoxidil therapy, which could be attributed to volume overload associated with underlying renal insufficiency. Besides hydralazine, another direct arterial vasodilator commonly implicated in drug-induced lupus erythematosus (DILE), minoxidil also carries a trivial risk of DILE, as suggested by a positive anti-histone antibody and biopsy-proven serositis. Although the association between topical minoxidil and pericardial effusion has never been reported, receding hairline has become a major cosmetic concern and the clinicians should be aware of this rare, but serious, complication associated with minoxidil due to its widespread use.

Abstract 16504: Hospital Frailty Risk Score (HFRS) Predicts Adverse Events in Patients Undergoing Elective Percutaneous Left Atrial Appendage Closure (LAAC) With WATCHMAN Device

Introduction: Frailty and its association with adverse events are well-known in transcatheter aortic valve replacement. However, this association has not been well-studied in patients undergoing Left Atrial Appendage Closure (LAAC). Hypothesis: Frailty predicts adverse events in patients undergoing elective LAAC with WATCHMAN device. Methods: Patients aged ≥65 years who underwent elective LAAC with WATCHMAN device were identified using ICD-10 procedure code 02L73DK from the 2016-2018 HCUP-NIS Database. Hospital Frailty Risk Score (HFRS) was calculated for each patient based on 109 ICD-10 diagnosis codes and classified into non-frail (HFRS < 5) and frail (HFRS score ≥ 5) groups. In-hospital major adverse event (MAE) was defined as the composite of mortality, stroke (ischemic or hemorrhagic) or TIA, bleeding or transfusion, vascular complications, myocardial infarction, systemic embolization, and pericardial effusion or tamponade requiring pericardiocentesis or surgery. Multivariate regression and receiver operating characteristic (ROC) analyses were used to assess the relationship between the HFRS and MAE. Results: 28,050 patients (Age = 77.3 ± 6.4 years; Female = 42.6%) were included, and 4.7% experienced in-hospital MAE. Frail patients (HFRS score ≥ 5) constituted 12.5% of the cohort. Frail patients were older and had a more significant proportion of women. Rates of MAE were significantly greater in frail patients (4% vs. 9.7%; p<0.001). Increasing Hospital Frailty Risk Score was associated with a greater risk of in-hospital MAE. The AUC - ROC was 0.63 (Figures: A and B). Conclusions: HFRS predicts adverse events after LAAC. HFRS could be implemented in hospital information systems to facilitate the identification of at-risk patients.

Abstract 16630: Economic Impact of Frailty in Patients Undergoing Elective Percutaneous Left Atrial Appendage Closure (LAAC) With WATCHMAN Device

Introduction: Frailty is associated with significant morbidity and mortality in older adults. Currently, standard practice after percutaneous left atrial appendage closure involves monitoring patients overnight and discharging them the following day. Hypothesis: Frailty predicts increased hospital cost and length of stay (LOS) in patients undergoing elective LAAC with WATCHMAN device. Methods: Patients aged ≥65 years who underwent elective LAAC with WATCHMAN device were identified using ICD-10 procedure code 02L73DK from 2016-2018 HCUP-NIS Database. In-hospital major adverse event (MAE) was defined as the composite of mortality, stroke (ischemic or hemorrhagic) or TIA, bleeding or transfusion, vascular complications, myocardial infarction, systemic embolization, and pericardial effusion or tamponade requiring pericardiocentesis or surgery. Hospital Frailty Risk Score (HFRS) was calculated for each patient based on 109 ICD-10 diagnosis codes and classified into non-frail (HFRS < 5) and frail (HFRS score ≥ 5) groups. Multivariate regression analysis was used to assess the relationship between the HFRS and hospital cost hospitalization (≥90 centile) and prolonged LOS (>72 hours). Results: 28,050 patients (Age = 77.3 ± 6.4 years; Female = 42.6%) were included. Median hospitalization cost was $24,500 (inter-decile range: $14,000-37,100) and median LOS was 1 day (inter-decile range: 1-2 days) and 4.7% experienced in-hospital MAE. Frail patients (HFRS score ≥ 5) constituted 12.5% of the cohort. Increasing Hospital Frailty Risk Score was associated with a greater risk of high-cost hospitalization and LOS > 72 hours (Figure). Conclusions: Increasing frailty is a significant predictor of increased hospital cost and LOS in elective LAAC. This effect is independent of age and in-hospital MAE.

Abstract 17596: Association of Racial-Ethnic Disparities and Frailty on Adverse Outcomes in Geriatric Patients Undergoing Elective Percutaneous Left Atrial Appendage Closure With Watchman Device

Introduction: Use of left atrial appendage closure (LAAC) has become more widespread in the geriatric population. Frailty, a geriatric syndrome, is associated with significant morbidity and mortality. Hypothesis: Race/Ethnicity influences frailty status and may differentially impact adverse outcomes in elective LAAC procedure. Methods: Patients aged ≥65 years who underwent elective LAAC were identified using ICD-10 procedure code 02L73DK from 2016-2018 HCUP-NIS Database. Hospital Frailty Risk Score (HFRS) was calculated for each patient based on 109 ICD-10 diagnosis codes and classified into non-frail (HFRS < 5) and frail (HFRS score ≥ 5) groups. Charlson comorbidity index (CCI) was used to assess comorbidity burden. In-hospital major adverse event (MAE) was defined as the composite of mortality, stroke (ischemic or hemorrhagic) or TIA, bleeding or transfusion, vascular complications, myocardial infarction, systemic embolization, and pericardial effusion or tamponade requiring pericardiocentesis or surgery. Outcome was in-hospital MAE. Multivariate regression analysis was used to assess the association of race/ethnicity and frailty on MAE. Results: 27,155 patients (Age = 77.3 ± 6.4 years; Female = 42.4%, White: 88%, Black: 3.4%, Hispanic:5.2%, Other: 3.4%) were included. Overall, the prevalence of frailty was 12.5% (White:12.4%, Black: 13.7%, Hispanic: 11.8%, Other: 13%). Overall, in-hospital MAE was 4.7%, with increased rates in frail patients (4% vs.9.6%; p<0.001). Rates of in-hospital MAE were frail-White: 9.3%, frail-Black: 8%, frail-Hispanic:20.6%, and frail-Other: 4.2% (p<0.001). On multivariate analysis, frail-White and frail-Hispanic patients were at increased risk of in-hospital MAE compared to non-frail patients (Figure). Conclusion: Further research is needed to highlight disparities by race/ethnicity and to identify potentially modifiable factors to mitigate adverse events in frail geriatric population undergoing LAAC.

Abstract 14942: Austrian Syndrome Complicated by Purulent Pericarditis

Introduction: Austrian syndrome is a triad of pneumonia, endocarditis, and meningitis due to S. pneumoniae . First characterized by Robert Austrian in 1956, it is a rare condition with an unknown incidence since the advent of the antibiotic age and introduction of the pneumococcal vaccine. Case Presentation: A 69-year-old female with a history significant for alcohol abuse presented with shortness of breath, productive cough and encephalopathy. The patient was septic with concurrent NSTEMI. She was emergently intubated for hypoxia and CT chest revealed multifocal pneumonia with a pericardial effusion. Echocardiogram (TTE) demonstrated a mitral annular calcification extending into the ventricle and confirmed a small fibrinous effusion without tamponade physiology. Infectious workup revealed S. pneumoniae bacteremia and pneumonia and he was initiated on ceftriaxone. The patient remained encephalopathic despite antibiotic treatment. Lumbar puncture revealed S. pneumoniae meningitis. The patient’s mentation continued to decline. MRI brain revealed an embolic shower. Repeat echocardiogram showed worsening pericardial effusion and the patient suffered a cardiac arrest due to pericardial tamponade resolved with emergent pericardiocentesis. Pericardial fluid was noted to be serofibrinous with predominance of leukocytes albeit culture negative. Unfortunately the patient succumbed to her illness and passed. Conclusions: Males, alcoholics, the immunocompromised, or those with a history of heart valve surgery are at risk for Austrian Syndrome. Mortality is as high as 60%-75%. This patient was at risk due to her history of alcoholism. Her presentation is unique in that she had concurrent purulent pericarditis, which is rarely attributed to S. pneumoniae. The condition is fatal if untreated and mortality ranges from 15%-40%. Treatment entails prompt drainage and appropriate antibiotic coverage. The advent of pneumococcal vaccination has significantly reduced the incidence of S. pneumoniae infection. This case represents the widespread effects of this organism if left unrecognized and untreated. Clinicians should have a high index of suspicion in any patient with pneumococcal infection and underlying predisposing factors.

Abstract 14046: Cardiac Tamponade: A Handy Case of Early Detection

Case Presentation: A 63-year-old man with severe bicuspid aortic valve stenosis underwent surgical aortic valve replacement and the post operative echocardiogram was normal.In the month after discharge, the patient developed progressive episodes of lightheadedness, fatigue, and exertional weakness. He had no associated dyspnea on exertion, chest pain or fever. He was alerted of new sinus tachycardia on his Apple Watch, and the ECG morphology began changing with an overall decrease in QRS amplitude as well as alternating QRS amplitudes consistent with electrical alternans (Figure 1). These ECG strips were sent to the patient’s cardiologist who suspected a pericardial effusion due to these characteristic ECG findings.The patient underwent outpatient echocardiography which showed a normal functioning bioprosthetic valve with new large circumferential pericardial effusion and signs of cardiac tamponade physiology. The patient was admitted and underwent urgent pericardial drain placement with removal of 250cc of serosanguineous fluid. He recovered and was discharged with 3 months of colchicine. Discussion: Pericardial effusions are a known potential complication after cardiac surgery and often have an occult presentation making detection difficult. Smart watches with ECG capabilities provide valuable data because they can be used to detect the development of a new tachycardia and changes in QRS morphology. By observing the progressive changes in the QRS morphology from baseline, it is possible to monitor for the development of electrical alternans. This finding coupled with the patient’s clinical presentation prompted rapid evaluation and treatment. Conclusions: The Apple Watch can perform single-lead ECGs which are capable of diagnosing arrhythmias including atrial fibrillation. This case now opens the door to the early detection of postoperative pericardial effusions by monitoring the Apple watch for electrical alternans.

Abstract 18352: Impact of Approach Site on Conduction Defect in Right Ventricular Biopsy

Introduction: Myocardial biopsy is a fundamental procedure for diagnosing myocarditis and cardiomyopathy. Complete right bundle branch block (CRBBB) is a potential complication of right ventricular biopsy (RV-EMB) that occurs at a certain rate. Consequently, patients with complete left bundle branch block (CLBBB) often exhibit reluctance to undergo RV-EMB due to the risk of complete atrioventricular block. However, it is precisely in such cases that the diagnosis of CLBBB through myocardial biopsy becomes crucial and concerns clinicians.Although there are two approaches to RV-EMB, namely the transfemoral vein and transjuglar vein approaches, and each institution has its preferred method, no study has investigated the variation in complication rates, particularly the occurrence of CRBBB, based on the different approach sites for RV-EMB. AIMS:This study aims to analyze the disparity in complication rates, primarily CRBBB, attributable to differences in the approach site during the RV-EMB procedure. METHODS/RESULTS: Over all 266 cases who underwent RV-EMB at Kanazawa University between January 2017 and December 2022 including 87 cases with transfemoral venous approach (Group TF) and 179 cases with transjugular venous approach (Group TJ) were enrolled in this retrospective single-center study. Group TF exhibited a higher usage of warfarin (15.1% vs. 3.4%, p=0.001) and obtained fewer specimens compared to Group TJ (2.97±0.98 vs. 3.90±0.65 pieces, p<0.001).Transient CRBBB was observed in 26 (29.9%) patients in Group TF and 13 (7.3%) patients in Group TJ (p<0.001); CRBBB persisted beyond 24 hours in 8 (9.1%) and 2 (1.1%) patients(p=0.004), respectively. One case of cardiac tamponade occurred in Group TF, and two cases of VF were reported in Group TJ, with no instances of stroke, permanent pacemaker implantation, or mortality.Multivariate logistic regression analysis identified approach cite (Group TF/TJ) as an independent predictor of CRBBB (p<0.001, odds ratio 0.43). CONCLUSIONS: The transjugular venous approach in RV-EMB demonstrates potential in reducing the occurrence of CRBBB as a complication. In cases where complete atrioventricular block is a concern, such as those with CLBBB, the transjugular vein approach may be preferable.

Abstract 11516: Micra vs Transvenous Pacemaker: A Comparative Systematic Review and Meta-Analysis

Background: Leadless pacemakers (LP) represent an emerging modality for treating bradyarrhythmias. We performed a meta-analysis and systematic review comparing safety and efficacy outcomes of Micra LP and transvenous pacemakers (TVP). Methods: A literature search was performed. The primary efficacy endpoints were successful implantation rate and acceptable capture threshold of <2V at 1 year. Primary safety outcomes were vascular injury, tamponade, device or lead dislodgement, pneumothorax, and major complications (needing intervention, prolonged hospital stay, readmission or death). A double-arm analysis was performed comparing LP and TVP. Data was pooled as mean differences (MD) or risk ratio (RR) including the 95% CI. Results: A total of 60 studies were included. There was no significant difference between the LP and TVP groups in terms of the rate of successful implantation (RR=1.02, P=0.95) and acceptable capture threshold (RR=0.90, P=0.11). LP was associated with a significantly lower incidence of major complications (RR = 0.54, [0.44, 0.67], P < 0.001) and dislodgment (RR= 0.31, [0.21, 0.46], P < 0.001). TVP had a significantly lower incidence of vascular injury (RR= 2.62, P=0.001) and a lower incidence of cardiac tamponade (RR= 2.29, P=0.001). There was no statistically significant difference regarding the incidence of infection (RR=0.76, P=0.6) and pneumothorax (RR= 0.58, P = 0.37). Conclusion: LP and TVP have equivalent implant success and long-term efficacy. LP had lower rates of major complications and dislodgement. TVP had lower rates of vascular injury and tamponade. Infection and pneumothorax rates were the same in both groups.

Abstract 13611: Right Ventricular Perforation and Subsequent Tamponade Due to Fractured Inferior Vena Cava Filter Strut

Description of Case: A 39-year-old woman with a remote history of unprovoked pulmonary embolism (PE) treated with a retrievable inferior vena cava (IVC) filter presented with chest pain and syncope. Initial vital signs and examination were unremarkable. ECG showed diffuse ST elevations with PR depression consistent with acute pericarditis (Figure 1A). Given her history, CT angiogram (CTA) was performed and revealed complex pericardial effusion without PE. Echocardiogram confirmed large pericardial effusion with evidence of right ventricular diastolic collapse, raising concern for impending cardiac tamponade (Figure 1B). Urgent pericardiocentesis yielded 500 mL of sanguineous fluid, with resolution of effusion. A pericardial drain was left in place. Overnight she became hypotensive, tachycardic, diaphoretic, with muffled heart sounds on exam. Rapid re-accumulation of blood was noted from the drain, confirmed by repeat echo showing enlargement of the pericardial effusion. She was diagnosed with recurrent hemorrhagic pericardial effusion (HPE) of unclear etiology and was emergently taken for mediastinal exploration, where a metal shard measuring 2.2 cm was seen protruding though the RV (Figure 1C), confirmed on intraoperative TEE (Figure 1D). It was determined that a fractured IVC filter strut had migrated into the RV causing perforation and recurrent HPE. The strut was removed and RV defect patched. The patient did well post-operatively without effusion recurrence. Follow up CTA confirmed fractured IVC filter strut, with another filter strut also seen extending through the IVC wall (Figure E). Discussion: Rapid reaccumulation of a hemorrhagic, hemodynamically significant pericardial effusion without clear etiology, as in this case, should prompt consideration of surgical exploration to assess for bleeding source. As strut fractures are a known complication of retrievable IVC filters, these filters should be removed when no longer indicated.

Abstract 11705: Events of Device Failure in Elderly Patients Undergoing Watchman Device Insertion in the United States

Introduction: Watchman device implant reduces various cardio-cerebral events in patients with left atrial appendage. As there is a lack of data on device failure among the elderly undergoing this procedure, we aim to provide a perspective via the 2016-2020 National Inpatient Sample(NIS). Methods: Watchman procedures in patients ages ≥60 years, with a history of atrial fibrillation or flutter, were examined for our study from the NIS. Events of device failure were considered, and variables that may influence such events were studied via logistic regression models. Results: We found 85190 procedures for Watchman device insertion conducted in the United States, and 510 (0.6%) cases reported an event of device failure. Procedures at rural centers reported higher odds of device failure than urban teaching centers (1.3% of rural center procedures vs. 0.6% of urban teaching hospital procedures, aOR 2.970, 95% CI 1.965 -4.488, p<0.01). Meanwhile, patients with a history of CKD (aOR 0.565, p<0.01), hypertension (aOR 0.500, p<0.01), and peripheral vascular diseases (aOR 0.513, p=0.012) showed reduced odds. Several complications were also noted among those with device failure, as 20 cases (3.9% ) had acute kidney injury, 45 patients (8.8%) developed cardiac tamponade, 70 cases (13.7%) had pericardial effusion, and 20 cases (3.9%) necessitated mechanical ventilation. The mean CHA 2 DS 2 -VASc score among patients with device failure was 4.65 (vs. 4.68, p=0.029), and the mean Charlson Comorbidity Index score was 1.42 (vs 1.65, p<0.01). Patients with device failure had a more expensive stay (mean hospital charge $144936 vs. $122504). Conclusions: Device failure was a rare but severe complication involving 0.6% of procedures in our analysis. Many comorbidities influenced events of device failure. As our study found a higher incidence among procedures done in rural centers, further studies to screen and assess the patients and monitor their condition may help improve the outcomes.

Blinatumomab with Tyrosine Kinase Inhibitor for Ph-Positive B-Acute Lymphoblastic Leukemia (B-ALL): Multicenter Retrospective Review

Background: Ph-positive B-ALL has long been considered an adverse cytogenetic abnormality in ALL, and it is generally recommended to proceed with a stem cell transplant (SCT) in first remission. Historically, the addition of Tyrosine Kinase Inhibitors (TKI) to the stander chemotherapy backbone improved long-term survival, with better results noted in the second-generation than in first-generation TKIs. Recent reports on a non-chemotherapy-based approach with the combination of immunotherapy (Blinatumomab) and TKI showed encouraging results and potentially eliminated the need for consolidative SCT (Foà NEJM 2020, Jabbour Lancet Haematol 2023). In this retrospective analysis, we reviewed all Ph-positive B-ALL treated with blinatumomab and TKI at two major academic centers. Methods: A retrospective review of adolescents and adults (14 years or older) with Ph-positive B-ALL patients who received blinatumomab with TKI at two major institutions (KFSHRC & KFMC) between 7/2018 and 7/2023. Patients who received up to 3 cycles of chemotherapy before being transitioned to therapy with blinatumomab and TKI were considered as frontline if there was no history of relapsed disease. Relapse/refractory patients with Ph-positive B-ALL treated with blinatumomab and TKI were also included in the R/R cohort, excluding patients with prior single-agent exposure to blinatumomab or ponatinib. Patients with a history of CNS disease were included. Chronic myeloid leukemia in a lymphoid blast phase (LBP-CML) treated with blinatumomab and TKI were also included. Patients were assessed for toxicity as well as for efficacy. Results: We identified 17 patients, with a median age of 40 yrs (range, 15-78): 9 pts (53%) were frontline Ph-positive B-ALL, 5 (29%) pts were relapsed/refractory Ph-positive B-ALL, and 3 (18%) were LBP-CML patients. Pt characteristics and outcomes by cohort are outlined in Table. All patients in all the cohorts achieved complete remission and were included in the RFS analysis [ Figure]. Of 7 evaluable pts in the frontline cohort, all patients achieved complete molecular response (CMR) using PCR for BCR::ABL (CMR=100%). No relapse was documented, with a median follow-up of 6.9 months. In the relapse/refractory cohort, all patients achieved complete molecular response (CMR) using PCR for BCR::ABL (CMR=100%). No relapse was documented, with a median follow-up of 6.7 months. In 3 patients with LBP-CML, two patients achieved complete molecular response (CMR) using PCR for BCR::ABL, and one patient achieved MMR (0.036%). No relapse was documented, with a median follow-up of 19.7 months. Only four patients proceeded to SCT, two with LBP-CML and two with newly diagnosed Ph-positive B-ALL. All patients proceeded with SCT in CMR except one with LBP-CML with positive PCR for BCR::ABL at 0.03%, although with undetectable MRD by flow cytometry (<0.01%). Patients were treated with dasatinib (4 patients) and ponatinib (13 patients). The median number of blinatumomab cycles was 4 (1-5). One death occurred at seven months in a patient treated with dasatinib and blinatumomab. The patient presented to the emergency department with pleural effusion and cardiac tamponade and died during her ICU stay with infectious complication. The death is likely contributed to by dasatinib. Conclusion: Although with short follow-up, combining TKI with blinatumomab seems to have a high complete molecular response rate in patients with newly diagnosed and relapsed/refractory Ph-positive B-ALL. Similar to prior reports, patients with newly diagnosed Ph-positive B-ALL perhaps they could be spared the toxicities associated with chemotherapy and the need for allogeneic hematopoietic stem-cell transplantation in the first remission using this approach. Further evaluation of this novel strategy is warranted.

Primary pericardial tumor presenting with cardiac tamponade: a case report

Primary pericardial tumor presenting with cardiac tamponade: a case report

Intrahospital mortality of patients presenting with cardiac tamponade: retrospective analysis

Intrahospital mortality of patients presenting with cardiac tamponade: retrospective analysis

Cardiac Tamponade Secondary to Campylobacter Fetus Infection in a Kidney Transplant Recipient

Cardiac Tamponade Secondary to Campylobacter Fetus Infection in a Kidney Transplant Recipient