Cardiopulmonary Comorbidities Research Articles

The value of cardiopulmonary comorbidity in patients with acute large vessel occlusion stroke undergoing endovascular thrombectomy: a retrospective, observational cohort study

BackgroundChronic lung and heart diseases are more likely to lead an intensive end point after stroke onset. We aimed to investigate characteristics and outcomes of endovascular thrombectomy (EVT) in patients with acute large vessel occlusion stroke (ALVOS) and identify the role of comorbid chronic cardiopulmonary diseases in ALVOS pathogenesis.MethodsIn this single-center retrospective study, 191 consecutive patients who underwent EVT due to large vessel occlusion stroke in neurological intensive care unit were included. The chronic cardiopulmonary comorbidities and several conventional stroke risk factors were assessed. The primary efficacy outcome was functional independence (defined as a mRS of 0 to 2) at day 90. The primary safety outcomes were death within 90 days and the occurrence of symptomatic intracranial hemorrhage(sICH). Univariate analysis was applied to evaluate the relationship between factors and clinical outcomes, and logistic regression model were developed to predict the prognosis of ALVOS.ResultsEndovascular therapy in ALVOS patients with chronic cardiopulmonary diseases, as compared with those without comorbidity, was associated with an unfavorable shift in the NHISS 24 h after EVT [8(4,15.25) versus 12(7.5,18.5), P = 0.005] and the lower percentage of patients who were functionally independent at 90 days, defined as a score on the modified Rankin scale of 0 to 2 (51.6% versus 25.4%, P = 0.000). There was no significant between-group difference in the frequency of mortality (12.1% versus 14.9%, P = 0.580) and symptomatic intracranial hemorrhage (13.7% versus 19.4%, P = 0.302) or of serious adverse events. Moreover, a prediction model showed that existence of cardiopulmonary comorbidities (OR = 0.456, 95%CI 0.209 to 0.992, P = 0.048) was independently associated with functional independence at day 90.ConclusionsEVT was safe in ALVOS patients with chronic cardiopulmonary diseases, whereas the unfavorable outcomes were achieved in such patients. Moreover, cardiopulmonary comorbidity had certain clinical predictive value for worse stroke prognosis.

Chronic Pulmonary Aspergillosis after Surgical Treatment for Non-Small Cell Lung Cancer-An Analysis of Risk Factors and Clinical Outcomes.

Chronic pulmonary aspergillosis (CPA) is a rare but significant complication of lung cancer surgery. Its effect on survival remains unclear. Our aim was to describe the outcomes of the patients who developed CPA following the surgery for non-small cell lung cancer (NSCLC), identify the risk factors associated with its development following lung resection, and evaluate its impact on survival. All the patients with a diagnosis of CPA and operated NSCLC were identified in the National Aspergillosis Centre (NAC) database (2009-2020). Additional patients were identified in the Northwest Clinical Outcomes Research Registry (2012-2019) database. A regression analysis was performed to examine potential links between CPA and long-term outcomes and also to identify the factors associated with the development of CPA. The primary outcomes were the development of CPA, 1-year and 5-year mortality, and overall survival. Thirty-two patients diagnosed with CPA after lung resection were identified in the NAC database, of which 11 were also contained within the NCORR database, with a prevalence of 0.2% (n = 11/4425). Post-operative CPA was associated with significantly lower survival on log-rank analysis (p = 0.020). Mortality at one year was 25.0% (n = 8) and 59.4% (n = 19) at five years after the CPA diagnosis. On univariable analysis, a lower mean percentage-predicted forced expiratory volume in 1 s, ischaemic heart disease, and chronic obstructive pulmonary disease were all significantly associated with CPA development. CPA is a rare complication following lung cancer surgery which has a significant impact on long-term survival. Its development may be associated with pre-existing cardiopulmonary comorbidities. Further research in larger cohorts is required to substantiate these findings.

Cardiopulmonary phenotype in systemic sclerosis associated pulmonary hypertension

IntroductionPulmonary hypertension (PH) associated with systemic sclerosis (SSc) increases morbidity and mortality. Cardiopulmonary comorbidities, as per the 2021 PH consensus, play a role in the choice of therapy between monotherapy and combination therapy. MethodsA cross-sectional study was conducted in patients with SSc based on the 2013 ACR/EULAR criteria or very early disease (VEDOSS 2011). PH was considered if they met the following criteria: pulmonary artery systolic pressure (PASP)>39mmHg or peak tricuspid regurgitation velocity (PTRV)>3.4m/s, PASP between 33 and 39mmHg or PTRV between 2.9 and 3.4m/s plus two additional findings suggestive of PH. PH was classified as type 2 if LVEF<50% or moderate to severe diastolic dysfunction was present; type 3 if extensive interstitial disease on tomography>20% or forced vital capacity (FVC)<75%; type 4 if abnormalities related to embolism were detected on scintigraphy or tomography. If patients did not meet these criteria, they were classified as type 1 PH. Complete data on cardiopulmonary risk factors and other factors were required. The frequency of these factors in the population and differences between groups based on risk factors were estimated. ResultsA total of 228 patients were selected. Three had type 2 PH, 24 had type 3, and 40 had type 1 PH, with the majority (75%) having at least one cardiopulmonary risk factor, and 47.5% having more than one. Mild diastolic dysfunction (25%) and hypertension (35%) were the most prevalent. In the type 1 PH group, those with risk factors experienced an increase in the number of years with Raynaud's phenomenon, anticentromere antibodies, and gastrointestinal symptoms (p<0.05). ConclusionIn patients with PH, 75% have one, and 45% have two or more risk factors.

Perioperative morbidity and 3-year survival in non-intubated thoracoscopic surgery: a propensity matched analysis.

Non-intubated thoracoscopic surgery with spontaneous breathing is rarely utilized, but may have several advantages over standard intubation, especially in those with significant cardiopulmonary comorbidities. In this study we evaluate the safety, feasibility, and 3-year survival of thoracoscopic surgery without endotracheal intubation for oncologic and non-oncologic indications. All consecutive patients [2018-2022] selected for lung resection or other pleural space intervention under local anesthesia and sedation were compared to a cohort undergoing elective thoracoscopic procedures with endotracheal intubation. A propensity-score matched cohort was used to compare perioperative outcomes and 3-year overall survival. A total of 72 patients underwent thoracoscopic surgery without intubation compared to 1,741 who were intubated. Non-intubated procedures included 19 lobectomies (26.4%), 9 segmentectomies (12.5%), 25 wedge resections (34.7%), and 19 pleural or mediastinal resections (26.4%). Non-intubated patients had a lower average body mass index (BMI; 24.6 vs. 27.1 kg/m2, P<0.001) and a higher comorbidity burden. Primary lung cancer was the indication in 30 (41.7%) non-intubated patients. The non-intubated cohort had no operative or 30-day mortality. After propensity-score matching, there was no significant difference in pre-operative factors. In propensity-score matched analysis, non-intubated patients had shorter median total operating room time (109 vs. 159 min, P<0.001) and procedure time (69 vs. 119 min, P<0.001). Peri-operative morbidity was rare and did not differ between intubated and non-intubated patients. There was no significant difference in 3-year survival associated with non-intubation in the propensity-score matched cohorts (95% vs. 89%, P=0.10) or in a Cox proportional hazard model [hazard ratio (HR), 1.15; 95% confidence interval (CI): 0.36-3.67; P=0.81]. Non-intubated thoracoscopic surgery is safe and feasible in carefully selected patients for both benign and oncologic indications.

Time Trend Analysis of Comorbidities in Ankylosing Spondylitis: A Population-Based Study from 53,142 Hospitalizations in Poland.

(1) Influence of comorbidities on life expectancy and treatment outcomes is one of the main concerns of modern rheumatology, due to their rising prevalence and increasing impact on mortality and disability. The main objective of our study was to analyze the time trends and shifts in the comorbidity profile and mortality over 10 years in the Polish population with ankylosing spondylitis (AS). (2) Data from 2011-2020 years were acquired from the General Hospital Morbidity Study in the National Institute of Public Health-National Institute of Hygiene (NIH-PIB) as ICD-10 codes. Based on ICD10 codes, we calculated the percentage shares for comorbidities, with the relative risk ratios and odds ratios. We analyzed the hospitalization rates and mortality from the overlapping conditions. Also, we analyzed age and sex related differences in the clinical manifestations of AS patients. (3) Results: From 53,142 hospitalizations of patients with AS, we found that the male population presented higher rates of cardiovascular (2.7% vs. 1.3% p < 0.001) and pulmonary conditions (1.2% vs. 0.8% p < 0.025). Inflammatory bowel diseases were more common in the female population than in males (2.3% vs. 1.7%, p < 0.001). In the years 2011-2020, we observed a decline in the number of hospitalized patients due to cardiovascular (p < 0.001) and respiratory system conditions (p < 0.001), yet the relative risk and odd ratios remained high. In the years 2011-2020, 4056 patients received biological treatment (7%). The number of initiated biological therapies correlated negatively with the number of reported hospitalizations due to ischemic heart diseases (IHD) (p < 0.031, r = -0.8). Furthermore, in the logistic regression model, we found strong collinearity between cardiovascular and pulmonary comorbidities (VIF = 14; tolerance = 0.1); also, the number of reported IHD's correlated positively with the number of pulmonary infections (p < 0.031, r = 0.7) (4). Cardiopulmonary comorbidities are a main factor associated with increased mortality in patients with AS, especially in hospitalized patients. The mortality rates among patients with AS admitted to hospital due to other conditions other than movement disorders exceed the populational risk. The number of biologically treated patients correlated negatively with hospital admissions due to IHD.

Sex disparities in popliteal artery aneurysms

ObjectiveOnly 5% of patients with popliteal artery aneurysms (PAAs) are female. Evidence on PAA treatment and outcomes in women is therefore scarce. The POPART Registry provides one of Europe’s largest data collections regarding PAA treatment. Data on clinical presentation, aneurysm morphology, and perioperative outcomes after open surgical PAA repair in women will be presented. MethodsPOPART is a multicenter, noninterventional registry for open and endovascular PAA repair, with 42 participating centers in Germany and Luxembourg. All patients aged >18 years who have been treated for PAA since 2010 are eligible for study inclusion. Data collection is based on an online electronic case report form. ResultsOf the 1236 PAAs, 58 (4.8%) were in women. There were no significant differences in age or cardiopulmonary comorbidities. However, female patients had a lower prevalence of contralateral PAAs and abdominal aortic aneurysms (P < .05). PAAs in women were more likely to be symptomatic before surgery (65.5% vs 49.4%; P = .017), with 19% of women presenting with acute limb ischemia (vs 11%; P = .067). Women had smaller aneurysm diameters than men (22.5 mm vs 27 mm; P = .004) and became symptomatic at smaller diameters (20 mm vs 26 mm; P = .002). Only 8.6% of women and 11.6% of men underwent endovascular aneurysm repair (P > .05); therefore, the perioperative outcome analysis focused on open surgical repair. In total, 23.5% of women and 16.9% of men developed perioperative complications (P > .05). There were no differences in major cardiovascular events (P > .05), but women showed a higher incidence of impaired wound healing (15.7% vs 7.2%; P = .05) and major amputation (5.9% vs 1.1%; P = .027). Female sex was significantly associated with the need for nonvascular reinterventions within 30 days after surgery (odds ratio: 2.48, 95% confidence interval: 1.26-4.88), whereas no significant differences in the odds for vascular reinterventions were observed (odds ratio: 1.98, 95% confidence interval: 0.68-5.77). In the multiple logistic regression model, female sex, symptomatic PAAs, poor quality of outflow vessels, and graft material other than vein graft were independently associated with perioperative reinterventions. ConclusionsWomen have smaller PAAs, are more likely to be symptomatic before treatment, and are more often affected by nonvascular reinterventions in the perioperative course. As our understanding of aneurysmatic diseases in women continues to expand, sex-specific treatment strategies and screening options for women in well-selected cohorts with modified screening protocols should be continuously re-evaluated.

Phenotypes and treatment outcomes in idiopathic pulmonary arterial hypertension patients with comorbidities.

Idiopathic pulmonary arterial hypertension (IPAH) is often diagnosed in elderly patients with many comorbidities. Whereas a clear treatment strategy and risk assessment is recommended for patients with rare classical IPAH, monotherapy with phosphodiesterase type 5 inhibitors or endothelin receptor antagonists followed by regular follow-up and individualised therapy should be used for patients with many cardiopulmonary comorbidities. Here, we focus on these patients with IPAH and comorbidities, present a review of the literature with a focus on recently published work and summarise factors that may help to provide guidance for individualised treatment approaches in such patients.

Readmission rates following major colorectal surgery

BackgroundReadmissions following colorectal surgery (CRS) have negative clinical, psychological and financial implications. Identifying patients at risk of readmission remains challenging. AimsTo determine factors predictive of those likely to require readmission at 40-days following major CRS and to identify novel strategies capable of reducing readmissions. MethodsConsecutive patients were studied from a prospectively maintained database. All patients were operated on by a single surgeon in a high-volume centre. Where applicable, photography was recorded by patients and emailed directly to the institutional email of the consultant surgeon. Data was recorded and analysed using descriptive statistics. Results515 patients were included over a 15-year period (2007-2022). The mean age at surgery was 64 years (18-93). The majority of patients were male (56.9%, n=293) and underwent cancer surgery (58.2%, n=299). Overall, 55 patients were readmitted within 40 days of major CRS (10.7%). Patients with pre-treatment diagnoses of heart failure (P=0.012), ischemic heart disease (P=0.002), renal impairment (P<0.001), atrial fibrillation (P=0.006), hypercholesterolemia (P=0.001), asthma (P=0.013) and hypertension (P=0.001) were more likely to require readmission. The majority of patients were readmitted for definitive management of surgical site issues (SSIs) (43.7% n=24). Other reasons included bowel obstruction (9.1%, n=5), pelvic sepsis (7.3%, n=4) and gastrointestinal upset (7.3%, n=4). ConclusionThis series demonstrated that patients with cardiopulmonary comorbidities were more likely to be readmitted following major CRS and most readmissions are SSI related. Readmissions for SSIs can be reduced by patients sending photography to the treating surgeon which could reduce readmissions and A&E attendances.

Impact of Left Heart Disease Risk Factors on Outcomes in Pulmonary Arterial Hypertension Therapy

BackgroundCurrent guidelines recommend initial monotherapy for pulmonary arterial hypertension (PAH) with ‘cardiopulmonary comorbidities’, despite limited available evidence to guide management. Research QuestionDo left heart disease (LHD) risk factors have an impact on treatment response and influence applicability of risk assessment in a real-world cohort of PAH patients? Study Design and MethodsThe AMBITION trial criteria was used to define the phenotype of PAH patients with risk factors for LHD. Treatment strategy, functional outcome, long term survival and risk discrimination were compared with a reference PAH cohort using the PHSANZ registry. Results487 incident PAH patients diagnosed between 2011-2020 were included. Of these, 103 (21.1%) fulfilled the definition of PAH with LHD risk factors with 384 (78.9%) remaining as reference group. PAH with LHD risk factors were older (66±13 vs. 58±19years, p<0.001), had lower pulmonary vascular resistance (393±266 vs 708±391dynes/sec/cm-5, p=0.031) and worse 6-minute walk distance (286±130 vs. 327±136m, p=0.005) at diagnosis. PAH with LHD risk factors were less likely to receive less initial combination therapy (27% vs. 44%, p=0.02). Changes in 6-minute walk distance at 12-months were similar in both groups, 43±77 in PAH with LHD risk factors and 50±90m in reference group (p=0.5), including when stratified by initial treatment strategy (monotherapy: 40±81 vs. 38±95m p=0.87 and combination therapy: 53±78 vs. 64±106m, p=0.511; PAH with LHD risk factors vs. reference PAH). Functional class improvements were also similar in both groups. REVEAL 2.0 risk score effectively discriminated risk in both populations (C-statistic=0.756 for PAH with LHD risk factors and C-statistic=0.750 for reference PAH). There was no difference in survival between the two groups (log-rank test p=0.29). InterpretationIn a real-word cohort, PAH patients with LHD risk factors were less likely to be exposed to initial combination therapy. Nevertheless, selected PAH patients with LHD risk factors who were treated with initial combination therapy derived similar functional response compared to reference group. Further studies are needed to phenotype PAH patients with cardiopulmonary comorbidities who may benefit from initial combination therapy.

Abstract 13633: Modern Treatment Patterns in Incident Pulmonary Arterial Hypertension (PAH) Patients: Real-World Data From the Pulmonary Hypertension Association (PHA) Registry

Purpose: New 2022 European Society of Cardiology/European Respiratory Society PAH guidelines recommend treatment guided by a multi-parameter risk assessment. 1 Patients with low/intermediate risk without cardiopulmonary comorbidities should start dual PAH combination therapy; those with cardiopulmonary comorbidities should be reassessed early for rapid escalation to dual therapy. Initial triple therapy is recommended for high-risk patients. We examined use of dual and triple PAH therapy in the US (before guideline update). Methods: We used the Pulmonary Hypertension Association Registry (PHAR), a prospective US registry of pulmonary hypertension (PH) patients, enrolled within 6 months of their first outpatient visit at one of 54 participating PH care centers in the US, between Sep 2015-Jun 2022. We included adults (≥18 years at enrollment) with incident PAH (newly diagnosed and treated within 6 months of enrollment) and ≥1 follow-up clinic visit post baseline visit. Chronic thromboembolic PH patients were excluded. Results: We analyzed (descriptive statistics) 794 incident patients (baseline characteristics in Table 1). Treatment patterns at baseline (n=794)/last follow-up visit (n=610) were 289 (36.4%)/102 (16.7%) on monotherapy, 419 (52.8%)/314 (51.5%) on dual combination, 83 (10.5%)/179 (29.3%) on triple combination therapy, respectively. Mean time from enrollment to dual and triple combination therapy was 86.1 (standard deviation [SD]: 209.0) and 346.1 days (SD: 430.8), respectively. Conclusions: Among incident PHAR patients, half received initial dual and 10% triple upfront combination therapy. At last follow-up, most (&gt;80%) patients had escalated to dual/triple combination therapies. Clinical Implications: At PH care centers, most incident PHAR patients are escalated to dual and triple therapy (at last follow-up) per current guidelines. Reference 1. Humbert M, et al. Eur Heart J. 2022;43:3618-731.

Abstract 12978: Real-World Treatment Patterns in Hispanic and White Patients With Pulmonary Arterial Hypertension (PAH) in the United States

Introduction: ESC/ERS guidelines recommend initial double oral combination therapy (endothelin-receptor antagonist plus phosphodiesterase 5 inhibitor) in low or intermediate risk PAH patients without cardiopulmonary comorbidities. Upfront use of prostacyclin pathway analogue (PPA) is recommended for patients with high risk of 1-year mortality. Few studies have evaluated treatment patterns/adherence in PAH patients across ethnic groups. Aims: To describe demographic/clinical characteristics and treatment patterns in US Hispanic and White PAH patients. Methods: A retrospective, observational, analysis using Optum’s de-identified Clinformatics ® Data Mart database identified patients aged ≥18 years with pulmonary hypertension (PH) diagnosis (excluding chronic thromboembolic PH) and were new users of PAH medications. Index date was the 31 st day after first PAH-specific medication use (1 Jan 2016-30 Jun 2022); the 30-day window between first PAH medication use and index date was used to identify the initial PAH regimen. Patient characteristics and PAH treatment patterns were analyzed descriptively, with standardized mean differences (SMD) between cohorts assessed (SMD &gt;0.1 indicated significant difference). Results: Hispanic patients were younger, with lower income, lower education level, and higher comorbidity burden than White patients (Table). Few patients received initial combination PAH treatment with similar use of combination therapy in the two cohorts (~14% in each). Hispanic patients were less likely to receive a PPA-containing index treatment regimen and had lower index treatment adherence (Table). Conclusions: In Hispanic and White patients, index combination PAH therapy use was low. Hispanic patients were less likely to receive a PPA-containing index treatment and had lower index treatment adherence. Further research and awareness of the influence of ethnicity on treatment management is needed to improve PAH care.

Risk of dysphagia in a population of infants born pre-term: characteristic risk factors in a tertiary NICU

ObjectiveTo examine the prevalence and characteristics of dysphagia and suck-swallow-breath incoordination as phenotypes of oral feeding difficulties. MethodA cross-sectional study with secondary data collected consecutively over 2 years from October 2020 to October 2022 to measure the prevalence of swallowing and oral feeding difficulty in preterm infants using Flexible endoscopic evaluation of swallowing examination at the tertiary Integrated Dysphagia Clinic. ResultsThe prevalence of swallowing disorders was 25 % and the prevalence of suck-swallow-breath incoordination was 62.5 %. The significant risk factor that may show a possible correlation with oral feeding difficulty was mature post-menstrual age (p = 0.006) and longer length of stay (p = 0.004). The dominant percentage of upper airway abnormality and disorder were retropalatal collapse (40 %), laryngomalacia (42.5 %), paradoxical vocal cord movement (12.5 %), and gastroesophageal reflux disease (60 %). The dominant characteristic of oral motor examination and flexible endoscopic evaluation of swallowing examination was inadequate non-nutritive sucking (45 %), inadequate postural tone (35 %), and inadequate nutritive sucking (65 %). ConclusionDysphagia in preterm infants is mostly observed in those with mature post-menstrual age, longer length of stay, and the presence of gastroesophageal reflux disease with inadequate non-nutritive sucking and nutritive sucking abilities. Suck-swallow-breath incoordination is primarily observed in those with immature post-menstrual age, a higher prevalence of cardiopulmonary comorbidity, and a higher prevalence of upper airway pathologies (laryngomalacia, paradoxical vocal cord movement) with inadequate nutritive sucking ability.

Pulmonary arterial hypertension

Pulmonary arterial hypertension (PAH) is a rare and progressive disease characterised by remodelling of the pulmonary arteries and progressive narrowing of the pulmonary vasculature. This leads to a progressive increase in pulmonary vascular resistance and pulmonary arterial pressure and, if left untreated, to right ventricular failure and death. A correct diagnosis requires a complete work-up including right heart catheterisation performed in a specialised centre.Although our knowledge of the epidemiology, pathology and pathophysiology of the disease, as well as the development of innovative therapies, has progressed in recent decades, PAH remains a serious clinical condition. Current treatments for the disease target the three specific pathways of endothelial dysfunction that characterise PAH: the endothelin, nitric oxide and prostacyclin pathways.The current treatment algorithm is based on the assessment of severity using a multiparametric risk stratification approach at the time of diagnosis (baseline) and at regular follow-up visits. It recommends the initiation of combination therapy in PAH patients without cardiopulmonary comorbidities. The choice of therapy (dual or triple) depends on the initial severity of the condition. The main treatment goal is to achieve low-risk status. Further escalation of treatment is required if low-risk status is not achieved at subsequent follow-up assessments. In the most severe patients, who are already on maximal medical therapy, lung transplantation may be indicated.Recent advances in understanding the pathophysiology of the disease have led to the development of promising emerging therapies targeting dysfunctional pathways beyond endothelial dysfunction, including the TGF-β and PDGF pathways.

Management of Pulmonary Arterial Hypertension.

Pulmonary arterial hypertension (PAH) is a rare pulmonary vascular disease characterized by progressive pulmonary arterial remodeling, increased pulmonary vascular resistance, right ventricular dysfunction, and reduced survival. Effective therapies have been developed that target three pathobiologic pathways in PAH: nitric oxide, endothelin-1, and prostacyclin. Approved therapies for PAH include phosphodiesterase type-5 inhibitors, soluble guanylate cyclase stimulators, endothelin receptor antagonists, prostacyclin analogs, and prostacyclin receptor agonists. Management of PAH in the modern era incorporates multidimensional risk assessment to guide the use of these medications. For patients with PAH and without significant comorbidities, current guidelines recommend two oral medications (phosphodiesterase type-5 inhibitor and endothelin receptor antagonist) for low- and intermediate-risk patients, with triple therapy including a parenteral prostacyclin to be considered in those at high or intermediate-high risk. Combination therapy may be poorly tolerated and less effective in patients with PAH and cardiopulmonary comorbidities. Thus, a single-agent approach with individualized decisions to add-on other PAH therapies is recommended in older patients and those with significant comorbid conditions. Management of PAH is best performed in multidisciplinary teams located in experienced centers. Other core pillars of PAH management include supportive and adjunctive treatments including oxygen, diuretics, rehabilitation, and anticoagulation in certain patients. Patients with PAH who progress despite optimal treatment or who are refractory to best medical care should be referred for lung transplantation, if eligible. Despite considerable progress, PAH is often fatal and new therapies that reverse the disease and improve outcomes are desperately needed.

Brain fog in long COVID limits function and health status, independently of hospital severity and preexisting conditions.

The U.S. government has named post-acute sequelae of COVID-19 (longCOVID) as influential on disability rates. We previously showed that COVID-19 carries a medical/functional burden at 1 year, and that age and other risk factors of severe COVID-19 were not associated with increased longCOVID risk. Long-term longCOVID brain fog (BF) prevalence, risk factors and associated medical/functional factors are poorly understood, especially after mild SARS-CoV-2 infection. A retrospective observational cohort study was conducted at an urban tertiary-care hospital. Of 1,032 acute COVID-19 survivors from March 3-May 15, 2020, 633 were called, 530 responded (59.2 ± 16.3 years, 44.5% female, 51.5% non-White) about BF prevalence, other longCOVID, post-acute ED/hospital utilization, perceived health/social network, effort tolerance, disability. At approximately 1-year, 31.9% (n = 169) experienced BF. Acute COVID-19 severity, age, and premorbid cardiopulmonary comorbidities did not differ between those with/without BF at 1 year. Patients with respiratory longCOVID had 54% higher risk of BF than those without respiratory longCOVID. BF associated with sleep disturbance (63% with BF vs.29% without BF, p < 0.0001), shortness of breath (46% vs.18%, p < 0.0001), weakness (49% vs.22%, p < 0.0001), dysosmia/dysgeusia (12% vs.5%, p < 0.004), activity limitations (p < 0.001), disability/leave (11% vs.3%, p < 0.0001), worsened perceived health since acute COVID-19 (66% vs.30%, p < 0.001) and social isolation (40% vs.29%, p < 0.02), despite no differences in premorbid comorbidities and age. A year after COVID-19 infection, BF persists in a third of patients. COVID-19 severity is not a predictive risk factor. BF associates with other longCOVID and independently associates with persistent debility.

The Effects of Exercise Training in Patients With Persistent Dyspnea Following Pulmonary Embolism: A Randomized Controlled Trial

Persistent dyspnea, functional limitations, and reduced quality of life (QoL) are common following pulmonary embolism (PE). Rehabilitation is a potential treatment option, but the scientific evidence is limited. Does an exercise-based rehabilitation program improve exercise capacity in PE survivors with persistent dyspnea? This randomized controlled trial was conducted at two hospitals. Patients with persistent dyspnea following PE diagnosed 6 to 72months earlier, without cardiopulmonary comorbidities, were randomized 1:1 to either the rehabilitation or the control group. The rehabilitation program consisted of two weekly sessions of physical exercise for 8weeks and one educational session. The control group received usual care. The primary end point was the difference in Incremental Shuttle Walk Test between groups at follow-up. Secondary end points included differences in the Endurance Shuttle Walk Test (ESWT), QoL (EQ-5D and Pulmonary Embolism-QoL questionnaires) and dyspnea (Shortness of Breath questionnaire). A total of 211 subjects were included: 108 (51%) were randomized to the rehabilitation group and 103 (49%) to the control group. At follow-up, participants allocated to the rehabilitation group performed better on the ISWT compared with the control group (mean difference, 53.0 m; 95%CI, 17.7-88.3; P= .0035). The rehabilitation group reported better scores on the Pulmonary Embolism-QoL questionnaire (mean difference, -4%; 95%CI, -0.09 to 0.00; P= .041) at follow-up, but there were no differences in generic QoL, dyspnea scores, or the ESWT. No adverse events occurred during the intervention. In patients with persistent dyspnea following PE, those who underwent rehabilitation had better exercise capacity at follow-up than those who received usual care. Rehabilitation should be considered in patients with persistent dyspnea following PE. Further research is needed, however, to assess the optimal patient selection, timing, mode, and duration of rehabilitation. ClinicalTrials.gov; No.: NCT03405480; URL: www. gov.

Prevalence of and Risk Factors for Emergency Department Visits After Outpatient Gynecologic Surgery

ABSTRACT Outpatient gynecologic surgeries are very common; in 2014 alone, 500,000 procedures were performed with 70% and 85% of hysterectomies and oophorectomies, respectively, performed in the outpatient setting. Although risk factors for overnight or prolonged admission after outpatient hysterectomy have been studied, less is known about the postoperative emergency department (ED) burden generated by other outpatient gynecologic surgeries. The objective of this retrospective cohort study was to identify the incidence of ED visits within 30 days of outpatient gynecologic surgery and to identify risk factors for these visits. This study included all adult patients undergoing scheduled outpatient gynecologic surgery for a benign condition at the Vanderbilt University Medical Center (VUMC), a tertiary academic medical institution, between January 2018 and September 2019. Demographic data, as well as comorbidities, surgical history, and surgical outcomes data, were obtained from the electronic medical record. Primary procedure performed was characterized into 1 of 4 categories: hysterectomy, other intra-abdominal nonprolapse surgery, prolapse surgery without hysterectomy, or other nonprolapse vulvovaginal procedure. The primary study outcome was evaluation in the VUMC ED within 30 days of surgery. Logistic regression models were used to evaluate associations between potential risk factors and the risk of an ED visit. A total of 2373 surgeries met the inclusion criteria, with 109 patients (5%) visiting the VUMC ED for a total of 125 visits within 30 days of surgery. After adjustment for potential confounders, younger age (adjusted odds ratio [aOR], 1.2; 95% confidence interval [CI], 1.1–1.3; P &lt; 0.001), history of abdominal surgery (aOR, 1.7; 95% CI, 1.1–2.6; P = 0.02), cardiopulmonary comorbidities (aOR, 1.9; 95% CI, 1.2–3.0; P = 0.004), undergoing hysterectomy (aOR, 2.0; 95% CI, 1.1–3.8; P = 0.03), and a vulvovaginal surgical route as opposed to abdominal surgical route (aOR, 2.4; 95% CI, 1.2–5.1; P = 0.02) were all related to an increased risk of visiting the emergency room. Patients who visited the ED were more likely to have undergone hysterectomy (26% vs 20%, P = 0.05) and less likely to have undergone prolapse surgery (4% vs 12%, P = 0.05). The median time to first ED presentation was 7 days following surgery and surgical site pain (n = 52 [42% of visits]), nausea and/or vomiting (n = 18 [14%]), and fever (n = 15 [12%]) were the most common chief complaints. Of the 125 visits, 45 (36%) resulted in admission, and 36 of these (80%) were surgery related. The results of this study demonstrate that although ED visits after outpatient gynecologic surgery are uncommon, younger patients with underlying cardiopulmonary comorbidities and/or a history of abdominal surgery are at greater risk.

PO-03-163 CONCOMITANT LAAO AND ATRIAL FIBRILLATION ABLATION VS. A STAGED APPROACH: INSIGHTS FROM THE NATIONWIDE READMISSIONS DATABASE

Percutaneous left atrial appendage occlusion (LAAO) is increasingly performed in patients with atrial fibrillation (AF). It is sometimes combined with catheter ablation (CA), either in a concomitant procedure or a staged approach. To compare the safety, efficacy, and costs of concomitant LAAO and CA versus a staged approach. The Nationwide Readmissions Database (NRD) is a nationally representative sample of all US hospitalizations, containing longitudinal patient data on almost half of all hospitalizations. The 2019 NRD was used to identify patients who underwent CA and LAAO from January to November 2019. Only patients who underwent CA and LAAO on the same date were included in the concomitant group; patients who underwent CA and LAAO on different dates or hospitalizations were included in the short-interval staged (SIS) group (within 6 months). In the SIS group, comorbidities were obtained from the first staged admission; outcomes were pooled from both procedures. Analysis accounted for the complex survey design of the NRD. Per NRD data reporting guidelines, any variable with n<10 was not reported. Out of the 25,392 patients who underwent LAAO during the study period, 191 patients underwent a concomitant procedure, and 392 patients underwent a SIS procedure. In the SIS group, mean time between the procedures was 92.4 ± 5.2 days, and LAAO was performed first in 52.3%. Patients in the concomitant group were significantly less likely to have heart failure (41.8% vs 56.5%, p=0.044), chronic obstructive pulmonary disease (11.1% vs 32.2%, p<0.01), fluid/electrolyte disorders, (<10 vs 17.5%, p=0.01), pulmonary circulation disorders (14.4% vs <10, p<0.01), and total Elixhauser comorbidities (4.1 ± 0.2 vs. 5.3 ± 0.2, p<0.01). Thirty-day readmissions (5.8% vs 4.3%, p<0.01), major bleeding (7.2% vs 19.3%, p=0.014), total length of stay (LOS) (1.8 ± 0.2 vs. 7.1± 0.6, p<0.01), and total charges ($184,566 ± $20,430 vs. $303,812± $18,308) were all significantly less in the concomitant group. After multivariate adjustment, 30-day readmissions, LOS, and total cost remained significantly different (Figure 1). Concomitant and SIS CA and LAAO procedures are performed infrequently. Patients undergoing concomitant procedures are healthier with less cardiopulmonary and overall comorbidities. After multivariate adjustment, concomitant procedures were associated with less 30-day readmissions, shorter LOS, and less total charges.

PC47. Physiologic Effects of Thoracic Duct Lymphovenous Bypass

PURPOSE: The lymphatic system is still largely enigmatic, but mechanical obstruction at the thoracic duct is one pathology we are starting to treat well. Patients with thoracic duct obstruction who have failed conservative treatment as well as minimally invasive therapies may be candidates for microsurgical lymphovenous bypass. At our institution, we have developed a multidisciplinary, collaborative intraoperative protocol with interventional radiologists. Postoperatively, lymphovenous bypass is thought to cause physiological derangements as a result of the increased venous return, but no data exist on specifically what changes can be expected. We herein report on a case series of thoracic duct lymphovenous bypass patients and their postoperative physiologic changes. METHODS: A retrospective review of all nonsyndromic adult patients who underwent thoracic duct lymphovenous bypass by the senior authors from 2016-2021 was performed. Demographic, preoperative, perioperative, and postoperative data were collected. Postoperative changes in vital signs including oxygen requirements, heart rate, and blood pressure were analyzed. RESULTS: Nine patients were included in the study. Immediate postoperative heart rate increased significantly among this heterogeneous patient population, but within 4 - 6 hours the change in heart rate was no longer significant. Mean arterial pressure and oxygen requirement were not significantly different before and after bypass. CONCLUSION: Thoracic duct lymphovenous bypass appears to be well tolerated in the short-term even in patients with cardiopulmonary comorbidities. Further data are necessary to continue to better understand the resulting physiologic changes and to optimize patient outcomes.

Refined risk stratification, current treatment, and new therapeutic approaches in pulmonary arterial hypertension.

The 2022 European Society of Cardiology/European Respiratory Society (ESC/ERS) guidelines for pulmonary hypertension have introduced arefined risk stratification to guide both initial and subsequent treatment of pulmonary arterial hypertension (PAH). The risk stratification at PAH diagnosis still comprises three risk categories (low, intermediate, high) and lists some new parameters. As the estimated 1‑year mortality is more than 20% in high-risk patients after diagnosis, an initial triple-combination therapy including parenteral prostacyclin analogues is recommended for this group. All other patients should receive adual-combination therapy with an endothelin receptor antagonist and aphosphodiesterase‑5 inhibitor. However, this approach of initial combination therapy is only recommended for classic PAH, while monotherapy followed by regular follow-up and individualized therapy should be used for patients with cardiopulmonary comorbidities. For PAH patients without cardiopulmonary comorbidities, it is recommended to assess their risk at follow-up with anew 4‑strata classification, where the intermediate-risk group is split on the basis of three noninvasive parameters. Importantly, changes from intermediate-high to intermediate-low risk have been shown to be associated with abetter prognosis. In addition, the recommendations on treatment escalation became more precise with the addition of aprostacyclin receptor agonist or switching aphosphodiesterase‑5 inhibitor to asoluble guanylate cyclase stimulator for intermediate-low risk and proceeding to triple-combination therapy with parenteral prostacyclin analogues already for intermediate-high risk. With sotatercept, the first non-vasodilator PAH treatment will become available in the near future to further enrich our treatment options for this chronic and still severe disease.