Episodes Of Cardiac Arrest Research Articles

B-PO04-155 RECURRENT OUT-OF-HOSPITAL SUDDEN CARDIAC ARREST: BURDEN AND ASSOCIATED FACTORS

Despite major improvements in management of sudden cardiac arrest survivors and wide availability of implantable defibrillators for secondary prevention, a subgroup of individuals will suffer separate, multiple episodes of sudden cardiac arrest (SCA) over time.

Impact of insurance type on outcomes in cardiac arrest patients from 2004 to 2015: A nation-wide population-based study.

ObjectivesThere do not appear to be many studies which have examined the socio-economic burden and medical factors influencing the mortality and hospital costs incurred by patients with cardiac arrest in South Korea. We analyzed the differences in characteristics, medical factors, mortality, and costs between patients with national health insurance and those on a medical aid program.MethodsWe selected patients (≥20 years old) who experienced their first episode of cardiac arrest from 2004 to 2015 using data from the National Health Insurance Service database. We analyzed demographic characteristics, insurance type, urbanization of residential area, comorbidities, treatments, hospital costs, and mortality within 30 days and one year for each group. A multiple regression analysis was used to identify an association between insurance type and outcomes.ResultsAmong the 487,442 patients with cardiac arrest, the medical aid group (13.3% of the total) had a higher proportion of females, rural residents, and patients treated in low-level hospitals. The patients in the medical aid group also reported a higher rate of non-shockable conditions; a high Charlson Comorbidity Index; and pre-existing comorbidities, such as hypertension, diabetes mellitus, and renal failure with a lower rate of providing a coronary angiography. The national health insurance group reported a lower one-year mortality rate (91.2%), compared to the medical aid group (94%), and a negative association with one-year mortality (Adjusted OR 0.74, 95% CI 0.71–0.76). While there was no significant difference in short-term costs between the two groups, the medical aid group reported lower long-term costs, despite a higher rate of readmission.ConclusionsMedical aid coverage was an associated factor for one-year mortality, and may be the result of an insufficient delivery of long-term services as reflected by the lower long-term costs and higher readmission rates. There were differences of characteristics, comorbidities, medical and hospital factors and treatments in two groups. These differences in medical and hospital factors may display discrepancies by type of insurance in the delivery of services, especially in chronic healthcare services.

Comparative Characteristics of Beta-Blockers in Patients with Congenital Long QT Syndrome

Congenital long QT syndrome is a pathology that requires special attention and knowledge about the safety and effectiveness of various medications. Prolongation of the QT interval due to congenital or acquired causes is an important factor in the development of an unfavorable life forecast with the formation of an elongated QT syndrome. With an unfavorable course, patients suffer from loss of consciousness, episodes of tachycardia. Often, stable polymorphic ventricular tachycardia develops. The risk of sudden cardiac death in this pathology can vary from 0.33% to 5%. In people who have suffered an episode of cardiac arrest, and do not have a permanent prescribed antiarrhythmic therapy, the mortality rate reaches 50% within 15 years. Preventive administration of antiarrhythmic drugs is not always effective. A positive result of treatment depends on the severity of long QT syndrome and its genotype. Beta-blockers are often prescribed to patients of different ages with various cardiac pathologies, including for the prevention of arrhythmia in long QT syndrome. Beta-blockers differ in various pharmacokinetic and pharmacodynamic parameters (lipophilicity/hydrophilicity, selectivity, presence/absence of internal sympathomimetic activity), which, along with the variant of the disease genotype, can affect their effectiveness and safety in the considered pathology. This review article presents the results of major studies on the safety and effectiveness of different groups of beta blockers in various variants of long QT syndrome. The preferred beta-blockers for various genotypes of the syndrome were determined, and a comparative characteristic of beta-blockers for their safety and preventive effectiveness was given.

Resuscitative endovascular occlusion of the aorta (REBOA) for refractory out of hospital cardiac arrest. An Utstein-based case series

AimsOut of hospital cardiac arrest (OHCA) is still a leading cause of mortality worldwide. In recent years, resuscitative endovascular balloon occlusion of the aorta (REBOA) has been progressively studied as an adjunct to standard advanced life support (ALS) in both traumatic and non-traumatic refractory OHCA.Since January 2019, the REBOA procedure has been applied to all the patients experiencing both traumatic and non-traumatic refractory OHCA (≥15 min of cardiopulmonary resuscitation) not eligible for ECPR for clinical or logistic reasons.We aimed at describing the feasibility and effects of REBOA performed both in the Emergency Department and in the pre-hospital environment served by the local HEMS for refractory OHCA. MethodsTwenty consecutive patients experiencing refractory OHCA and in whom REBOA was attempted in 2019 and 2020 were included in the study, Utstein data and REBOA specific variables were recorded. ResultsSuccessful catheter placement was achieved in 18 out of 20 patients, 11 of these were non-traumatic OHCAs while 7 were traumatic OHCAs, the 2 failures were related to repeated arterial puncture failure.Median time between the EMS dispatch and REBOA catheter placing attempt was 46 min.An increase in etCO2 over 10 mmHg was observed after balloon inflation in 12 out of 18 patients (8/11 non-traumatic and 4/7 traumatic OHCAs), a sustained ROSC was observed in 5 patients (1 traumatic and 4 non-traumatic OHCA) that were subsequently admitted to the ICU. Four out of the 5 patients reached the criteria for brain death in the subsequent 24 h while one patient experienced another episode of refractory cardiac arrest in ICU and subsequently died. ConclusionOur data confirm the feasibility of REBOA technique as an adjunct to ALS in both the ED and prehospital phase and most of the treated patients experienced a transient ROSC after balloon inflation while 5 out of 18 experienced a sustained ROSC.However, while in the trauma setting increasing evidence suggests an improved survival when REBOA is applied to refractory OHCA, in non-traumatic OHCA this has yet to be demonstrated and large studies are needed.

Physical morbidity and mortality in male adolescent anorexia: a scoping review

AimsAnorexia Nervosa (AN) mimics a state of starvation as a result of extreme calorific restriction, often with associated extreme exercise or purging behaviours. The physiological demands are known to lead to a number of health complications and contribute to a significantly increased mortality compared to the general population. Although males account for 10% of the AN population, they are often underrepresented in research. There is a particular gap in evidence for males under 18 despite the unique physiological requirements of adolescence including growth, puberty and achieving peak bone mass.This review aims to bring together current research on physical health complications in male adolescent anorexia and help understand the knowledge gaps which exist.MethodA scoping literature review was undertaken between January and March 2020. A single researcher searched OvidSP, psychinfo, relevant grey literature and undertook hand searches of key reference lists. Following PRISMA-SCR protocol, abstracts and articles were screened against inclusion/exclusion criteria to identify relevant papers. Papers were then subjected to critical appraisal and findings summarised using a narrative approach. Key data for blood pressure, pulse and body temperature were pooled and analysed in the context of wider findings.ResultData from 219 patients were included from 20 studies. 13 of these studies were case studies or case series, 5 were cross sectional and 2 were cohort studies. Cardiovascular compromise including bradycardia (61%) and hypotension (30.3%) were common and a single episode of cardiac arrest was documented in the literature. Bone density was reduced (Z score ≤1) in 36.7% of cases. A wide variety of single episodes of physical morbidity were also documented including pneumothorax, liver dysfunction, growth retardation and thyroid dysfunction.ConclusionThis scoping review highlights the physiological compromise experienced by some male adolescents with AN. Guidelines for the identification, assessment and management of physical health complications - including MARSIPAN by the Royal College of Psychiatrists - continues to use data heavily drawn from female-biased populations. Given the evidence summarised, there is concern that in the absence of specific guidance, adolescent males may be at high risk of negative outcomes including acute cardiovascular compromise, osteoporosis and reduced linear growth.

Urgent liver retransplantation in patient with sepsis, multiple organ failure and unstable hemodynamics

In the presented case, the patient after orthotopic liver transplantation from an optimal cadaveric donor against the background of a smooth postoperative period and satisfactory graft function was followed by a series of biliary complications in the form of ongoing necrosis of the bile ducts of the graft, which required repeated surgical interventions, which led to the formation of a separate bicholangiostomy. The patient was put on the waiting list for a repeated liver transplantation. The developed complications led to sepsis, multiple organ failure and unstable hemodynamics, that required using of substitution therapy and high doses of inotropic, vasopressor drugs. A decision was made to assign the patient a «high-urgency» status with priority graft obtaining, and the coordination centers of St. Petersburg, Moscow, Leningrad and Moscow Regions and FMBA were notified. From the assignment of the «high urgency» status to receiving an organ has passed 10 hours. Hepatectomy with the formation of a temporary portocaval shunt began in advance of the donor liver’s admission to the clinic, which made it possible to stabilize the hemodynamic parameters and the recipient’s condition. However, against the background of massive blood loss, at the stage of graft revascularization, two episodes of cardiac arrest occurred, requiring indirect heart massage with chest and diaphragm compressions. Due to severe peripheral circulatory insufficiency, dry gangrene of the nail phalanx of the right forefinger was developed. Nevertheless, from the first postoperative day and thereafter, the graft demonstrated satisfactory function. Two months after the repeated transplantation, the patient was discharged in satisfactory condition. Subsequently, the index finger was amputated. Six months after the second operation, the patient returned to the work of a teacher.

Prehospital Sinus Node Dysfunction and Asystole in a Previously Healthy Patient with COVID-19

We report a case of a previously healthy 47-year-old female with syncope due to multiple episodes of nodal dysfunction and asystole. During these brief episodes, she was hypoxic in the mid-80’s as a result of COVID-19 pneumonia. The patient was admitted and treated for viral pneumonia and found to have normal electrocardiograms (ECG’s), normal troponin levels and a normal echocardiogram during her hospital stay. As she recovered from COVID-19, no further episodes of bradycardia or bradyarrhythmia were noted. This case highlights a growing body of evidence that arrhythmias, specifically bradycardia, should be anticipated by prehospital providers as a potential cardiac complication of SARS-CoV-2 infection.

AL type cardiac amyloidosis: a devastating fatal disease

ABSTRACT Introduction Cardiac amyloidosis is a rare entity with a grave prognosis. Due to the low index of suspicion secondary to non-specific symptoms, it is often diagnosed at an advanced stage with multi-organ involvement. Methods We report a case of systemic AL amyloidosis with predominant cardiac and renal involvement associated with multiple myeloma. Case Summary A 60-year-old male presented with progressive anasarca, orthopnea and weight gain over 8 months. On clinical examination, 3+ pitting edema was found in bilateral extremities and scrotum. Serum N-type proBNP and troponin T were elevated, and EKG showed diffuse low voltage QRS, right axis deviation, and 1st degree AV block. Echocardiography revealed granular myocardium, biventricular hypertrophy, bi-atrial dilation and apical sparing pattern on global longitudinal strain which was suggestive of cardiac amyloidosis. Light chain assessment showed elevated kappa and lambda chains with kappa to lambda ratio of 16.2. Endomyocardial biopsy revealed AL type cardiac amyloidosis, and bone marrow biopsy confirmed the diagnosis of multiple myeloma. He received six cycles of bortezomib, cyclophosphamide, and dexamethasone but continued to deteriorate. He experienced an episode of cardiac arrest following which he had a return of spontaneous circulation but due to poor prognosis, the family opted for pursuing comfort measures only. Conclusions Cardiac involvement in AL type amyloidosis imparts significant morbidity and mortality. The management of cardiac amyloidosis entails a multidisciplinary approach with an emphasis on cardiology and oncology. Despite the novel diagnostic modalities and treatment regimens, the outcome for AL-type cardiac amyloidosis remains poor.

Cardiac Arrest in a Child with Non-classic Lipoid Congenital Adrenal Hyperplasia Associated with a New STAR Gene Mutation

Abstract Introduction: Steroidogenic acute regulatory (STAR) protein regulates steroid hormone synthesis by transporting cholesterol into mitochondria. STAR gene mutations lead to lipoid congenital adrenal hyperplasia (LCAH), the rare but most severe form of congenital adrenal hyperplasia in children. We present an unusual case with an episode of cardiac arrest in a young girl during an acute febrile illness and later she was diagnosed with adrenal insufficiency secondary to a non-classic LCAH. Case: 2-year 11-month-old previously healthy white female was brought to an urgent care clinic due to severe lethargy and a seizure-like activity during a fever illness. She was found to have an undetectable blood glucose level and went into cardiac arrest shortly after arrival. CPR was performed for approximately 11 minutes. She then developed sever respiratory distress and was intubated. She was transferred to the PICU with IV sodium bicarbonate given en route. On admission, her body weight was 13.26 kg (36.80th percentile), height 90 cm (17.56th percentile), and BMI 16.17 (62.88th percentile). Her physical exam revealed normal external female genitalia and normal skin pigmentation. Lab evaluation revealed normal sodium and potassium but elevated anion gap, hyperuricemia, elevated creatinine kinase, abnormal liver function tests and abnormal coagulation profile. Brain MRI revealed findings consistent with hypoxic-ischemic encephalopathy. Renal function improved within 24 hours and hepatic function returned to normal after 20 days. Due to her severe hypoglycemic event, a high-dose ACTH stimulation test was performed. The results were consistent with adrenal insufficiency: baseline cortisol level, 7.3 μg/dL; 30 minutes cortisol, 7.8 μg/dL; 60 minutes cortisol, 9 μg/dL (normal response, ≥18 mcg/mL at 30 or 60 minutes). The baseline ACTH level was significantly elevated, 1688 pg/mL (0–46) as well as the renin activity, 24.3 ng/hour (1.7–11.2). Genetic testing revealed a 46 XX karyotype. STAR gene analysis identified compound heterozygosity; a novel deletion (c.811delC, p.Leu271Cysfs*50) and a previously reported missense mutation (c.661G>A, p.Gly221Ser). The girl is now 11 years old and exhibits normal growth, normal cognitive development, and she has developed early signs of puberty (Tanner stage 2 for breast). She takes daily hydrocortisone, fludrocortisone and stress dose hydrocortisone as needed. Conclusion: In non-classic LACH, the onset is generally late or not acute. Initial clinical features are variable and nonspecific. For this reason, non-classic LCAH may be overlooked. Adrenal crisis is a life-threatening complication, and it is important that clinicians are aware of the clinical features of non-classic LCAH and consider it in the differential diagnoses. Genetic testing for STAR should be considered in individuals with non-autoimmune primary adrenocortical insufficiency.

Asystole episodes and bradycardia in patients with end-stage renal disease.

Knowledge of arrhythmias in patients with end-stage renal disease (ESRD) is mainly based on ambulatory electrocardiography (ECG) studies and observations during haemodialysis (HD). We used insertable cardiac monitors (ICMs) to define the prevalence of arrhythmias, focusing on bradyarrhythmias, in ESRD patients treated with several dialysis modes including home therapies. Moreover, we assessed whether these arrhythmias were detected in baseline or ambulatory ECG recordings. Seventy-one patients with a subcutaneous ICM were followed for up to 3 years. Asystole (≥4.0 s) and bradycardia (heart rate <30 bpm for ≥4 beats) episodes, ventricular tachyarrhythmias and atrial fibrillation (AF) were collected and verified visually. A baseline ECG and a 24- to 48-h ambulatory ECG were recorded at recruitment and once a year thereafter. At recruitment, 44 patients were treated in in-centre HD, 12 in home HD and 15 in peritoneal dialysis. During a median follow-up of 34.4 months, 18 (25.4%) patients had either an asystolic or a bradycardic episode. The median length of each patient's longest asystole was 6.6 s and that of a bradycardia 13.5 s. Ventricular tachyarrhythmias were detected in 16 (23%) patients, and AF in 34 (51%) patients. In-centre HD and Type II diabetes were significantly more frequent among those with bradyarrhythmias, whereas no bradyarrhythmias were found in home HD. No bradyarrhythmias were evident in baseline or ambulatory ECG recordings. Remarkably many patients with ESRD had bradycardia or asystolic episodes, but these arrhythmias were not detected by baseline or ambulatory ECG.

"Ictal" Bradyarrhythmias in Patients with Drug-Resistant Epilepsy: Results of Long-Term Heart Rhythm Monitoring

Aim To determine the type and incidence of ictal bradyarrhythmias in patients with drug-resistant types of epilepsy by long-term electrocardiogram (ECG) monitoring.Material and methods Subcutaneous ECG monitors programed for recording pauses &gt;3 sec and episodes of bradycardia ≤45 bpm were implanted in 193 patients with persistent epileptic seizures without organic pathology of the myocardium. Recording was activated by the patient/family at the onset of epileptic seizure. The follow-up period was 36 months with visits to the clinic every three months.Results For 36 months of monitoring, 6494 ECG fragments were recorded. Ictal bradycardia was observed in 6.7 % of patients, including ictal asystole in 2.6 % of patients. Episodes of bradycardia and asystole during epileptic seizures were transient and developed significantly more frequently in men, patients with long duration of the disease, bilateral tonic-clonic or focal seizures with disorder of consciousness, during sleep, on the background of treatment with several antiepileptic agents, mostly from the group of potassium channel blockers.Conclusion Bradyarrhythmias accompanying epileptic seizures are transient and reproducible from seizure to seizure. They reflect functional changes in the myocardium and do not determine the life prediction for patients with epilepsy without organic pathology of the heart.

Prognostic factors for adults with cardiac arrest in the emergency department: a retrospective cohort study

Cardiac arrest in the emergency department is associated with the following three scenarios: out-of-hospital cardiac arrest, primary emergency department cardiac arrest (EDCA), and patients transferred from other hospitals after the return of spontaneous circulation from cardiac arrest. Among them, the primary cardiac arrest episode in the emergency department has been less studied. This aim of this study was to explore patient characteristics and the relationship between causes of EDCA and survival outcomes according to different patient management strategies. The main finding of this study was that EDCA with Cardiogenic etiology was associated with higher survival to discharge (OR: 2.31; 95% CI: 1.59–3.91) and discharged neurological outcome (OR: 2.84; 95% CI: 1.57–5.97). More favorable discharged neurological outcome were also found in EDCA patients with initial shockable rhythm (OR: 4.83; 95% CI: 2.33–10.01) and shorter resuscitation time (≤11.5 min, OR: 3.62; 95% CI: 1.57–8.32). EDCA patients under sedative medication (OR: 0.24; 95% CI: 0.10–0.59) and ventilator support by intubation before EDCA episode (OR: 0.26; 95% CI: 0.09–0.75) had poor neurological outcome. We conclude that EDCA patients with cardiogenic etiology have more favorable survival to discharge and discharged neurological outcomes. Prolonged CPR time during EDCA, post-intubation status and sedative medication use were prognostic factors of negative survival and neurological outcomes.

Clinical Implications for Cardiovascular Compromise in Patients With Spinal Cord Injury: A Case Study of Autonomic Dysreflexia, Cardiac Pacing Abnormality, and Orthostatic Hypotension in Contemporary Physical Therapy Management

Purpose: Although recent advances in the neurological care of spinal cord injury have made great strides, cardiovascular disease has emerged as a leading contributor to mortality within this population. Achieving a greater understanding of the pathophysiology of acute cardiovascular dysfunction may aid the physical therapist in establishing more effective clinical care and decision making. The purpose of this article is to review the pathophysiology of acute cardiovascular dysfunction after cervical and thoracic spinal cord injury (injuries above the T6 vertebrae) and translate this knowledge to the clinical management of a medically complex patient case. Methods: A 62-year-old man sustained a traumatic sensory and motor complete T2 spinal cord injury. During the course of acute hospitalization, the patient suffered multiple episodes of cardiac arrest, and a permanent pacemaker was implanted. Inpatient rehabilitation was further complicated by orthostatic hypotension and emergence of autonomic dysreflexia. Results: Orthostatic hypotension was addressed with a combination of positional tolerance progression and patient education. Autonomic dysreflexia episodes required prompt recognition and appropriate response. After a 6-month hospitalization, the patient was discharged to home. Conclusion: Cardiovascular concerns after spinal cord injury have become increasingly prevalent leading to significant implications to physical therapists. Understanding the pathophysiology of these conditions as well as normal and abnormal cardiovascular responses to activity is crucial for establishing safe patient outcomes.

Abstract 308: Automated Detection of Patients with Return of Spontaneous Circulation in the Retrospective Analysis of Resuscitation Episodes

Introduction: Retrospective analysis of out-of-hospital cardiac arrest episodes is important to evaluate the performance of resuscitation teams, and to advance research. Large numbers of electronic files are compiled in cardiac arrest registries and identifying patients with return of spontaneous circulation (ROSC) is expensive and time-consuming. The aim of this study was to analyze the feasibility of automatically annotating ROSC using the signals recorded by defibrillators. Materials and methods: A set of 893 patients (261 with ROSC, of which 127 were transient) recorded by the Dallas-Fort Worth Center for Resuscitation Research using Philips HeartStart MRx devices were included. Every record contained the ECG and the thoracic impedance (TI) signals. ROSC was automatically identified as follows: 1) chest compression pauses longer than 60 s were identified using either the TI or the compression depth signals. 2) Organized ECG rhythms were identified using a comercial defibrillator's algorithm. 3) Pulsatile rhythms were identified using a published machine learning algorithm based on the ECG or the ECG and TI signals. The model uses up to 9 features, extracted from both the ECG (6) and the TI (3) signals. ROSC was identified when a 10s-interval was classified as pulsatile and the ROSC onset was set at the beginning of the pause. The performance was assessed in terms of Sensitivity (Se, ROSC patients), Specificity (Sp, no ROSC patients) and overall F1-score. Error in the ROSC onset was calculated comparing the automatically detected onset to the reviewed time of the clinical annotation of ROSC. Results: The algorithm based exclusively on ECG showed Se, Sp and F1 scores of 90.0%, 92.7% and 90.5%, respectively. The algorithm that included both ECG and TI improved scores to 91.2%, 94.3% and 92.1%. For the set of patients with transient ROSC the algorithm showed a Se of 81.9% (95.6% for permanent ROSC) using the ECG and TI signals. The median (IQR) absolute error on the time of first ROSC onset was 0.8 (0.6-8.2) s. Conclusions: An accurate algorithm to automatically identify patients with ROSC is demonstrated. This technique could be useful for retrospective analysis of cardiac arrest registries.

Abstract 15102: Benign Cardiac Neoplasms in the United States - A Thirteen-year Review

Introduction: Benign cardiac neoplasms (BCN) are rare; with varying reported incidence and a paucity of epidemiologic studies. The purpose of our review was to add to the small body of literature describing the characteristics and trends of BCN in the US. Methods: This study is a retrospective review of data from the HCUP-NIS Database from 2002-2014. Inclusion criteria consisted of the presence of indication for BCN. Additionally, we queried the database for BCN-associated comorbidities. SAS studio was utilized for analysis. Results: The data consisted of 482,872,274 weighted discharges. There were 45,568 weighted discharges that had BCN. Sixty four percent were women. Median cost per admission was 51,799 USD, five times higher than the national average. A total of 1,267 (2.78%) patients died during the admission. Stroke and arterial embolization were reported in 6730 (14.76%) and 573 (1.26%) weighted discharges. Weight loss, fever and endocarditis were reported in 311 (0.68%), 383 (0.84%) and 869 (1.91%) patients, respectively. Pulmonary hypertension co-occurred in 3440 (7.55%) patients. Episodes of atrial tachyarrhythmias, ventricular arrhythmias, syncope and cardiac arrest were reported in 13,184 (28.93%), 1,471 (3.23%), 1,055 (2.32%) and 393 (0.86%) cases. Sinus node dysfunction, severe AV nodal block co-occurred in 1,005 (2.21%) and 930 (2.04%) patients. Conclusions: We identified a low incidence of BCN in the US over the 13-year study period. Since the prevalence for BCN is low, clinicians must maintain a high index of suspicion due to the high morbidity and mortality.

Abstract 157: Multicenter Evaluation of Etiology and Observed Transition Intensities Between Pulseless Electrical Activity and Return of Spontaneous Circulation

Background: Cardiac arrest presents with one of three clinical states; Cardiac standstill (asystole), Pulseless Electrical Activity (PEA), or ventricular fibrillation/tachycardia (VF/VT). PEA results from multiple etiologies and accounts for most in-hospital cardiac arrests. We quantified the dynamic nature of transitions in and out of PEA, in terms of hospital sites and presumed etiology. Methods: We analyzed 538 episodes of cardiac arrest at one Norwegian hospital and three U.S. hospitals. ECG, chest compressions and ventilations were recorded by defibrillators during CPR. Each event was assessed using a graphical application. We quantified the transition intensity, i.e. the immediate probability of a transition given the current state, between PEA and ROSC using Aalen’s additive model for time-to-event data. Results: The overall transition intensity from PEA to ROSC was about 0.10 min -1 , so an average patient in PEA has about 10 % chance to gain ROSC the following 1 minute. The intensity peaked at 7 minutes of CPR (Figure), with some heterogeneity between hospitals (0.07 to 0.11 min -1 ). The reverse transition intensity from ROSC to PEA was rather constant at 0.10 min -1 (range 0.05-0.11). Information regarding assumed cardiac or non-cardiac etiology was available in 208 episodes (123 cardiac). Patients with a cardiac etiology had a marginally smaller (-0.03 min -1 ) chance of making the transition from PEA to ROSC (p=0.049), but etiology did not impact on the ROSC to PEA transition (p=0.39). Discussion: For transitions between PEA and ROSC we observed an overall intensity of 0.1 min -1 , with some hospital heterogeneity. This may be due to heterogeneity in the underlying patient populations. We found the probability of transitioning from PEA to ROSC to increase from the start event recording until an average peak intensity at 7 minutes. This information may increase the clinicians’ understanding of the process from PEA to ROSC.

Abstract 284: Looking Back to Glance Ahead: The Impact of Last Minute's Qrs Width &amp; Frequency in Pulseless Electrical Activity

Background: Observed heart rate and QRS-width during CPR in Pulseless Electrical Activity (PEA) develop differently in patients who gain ROSC compared to those who do not. In this study we investigated the impact of heart rate and QRS width on the transition from PEA to ROSC. Method: Defibrillator data from 293 episodes of cardiac arrest at two US and one Norwegian hospital were reviewed. The files contained ECG, impedance signal and compression depth. In total 178 episodes containing PEA intervals were included. Episodes with excessive ECG noise and signs of an active pacemaker were excluded. The files were processed in a MATLAB graphical application, and the clinical states were determined based on clinical documentation and the visual appearance of the ECG. ROSC was defined as an organized rhythm lasting longer than 1 minute without ongoing compressions. During pauses in compressions, heart rate and QRS-width was automatically measured and averaged over the preceding minute until current time and controlled and corrected manually. The results were analyzed using Aalen’s additive model for time-to-event data, using R version 3.6.3. Results: The average transition intensity, corresponding to the probability of gaining ROSC in one minute, was about 0.20 per min of CPR peaking at approximately 7 min. An increase in the average heart rate by 10/min increased the transition intensity by 0.03/min (p &lt;0.01). Narrowing of the QRS in average by 100 milliseconds (ms) increased the transition intensity by 0.14/min (p &lt;0.01). Our figure shows QRS width and heart rate for one patient with PEA approaching ROSC (gray area), with smoothed curves overlaid. Conclusion: Higher heart rates and narrower QRS complexes during PEA are strongly and significantly associated with a transition from PEA to ROSC. These changes could indicate whether a patient responds to ongoing CPR. In addition, there is a potential for predicting the immediate outcome based on these ECG characteristics.

Prognostic value of non-ischemic ring-like left ventricular scar pattern in patients with apparently idiopathic ventricular arrhythmias: a CMR imaging study

Abstract Background The presence of left ventricular (LV) late gadolinium enhancement (LGE) at cardiac magnetic resonance (CMR) has been correlated to life-threatening arrhythmic events in patients with apparently idiopathic ventricular arrhythmias (VAs). Aim of the present study was to investigate the prognostic significance of a specific LV-LGE phenotype characterized by a subepicardial/midmyocardial “ring-like” pattern of fibrosis. Methods Out of a total of 518 consecutive patients with apparently idiopathic VAs who underwent CMR study, 79 (15%) had evidence of LV-LGE. Of these, 23 (4%) patients had LV LGE with ring-like pattern, defined as subepicardial or midmyocardial LGE involving at least 3 contiguous segments in the same slice (group A), while 56 (11%) patients had LV LGE with no ring-like pattern (group B). The remaining 439 patients had no LGE (group C). The end-point of the study was a composite SCD, resuscitated cardiac arrest and nonfatal episodes of ventricular fibrillation or documented sustained ventricular tachycardia. Results Group A patients were more frequently males compared to groups B and C (96% vs. 79% vs. 52%; p&amp;lt;0.01) and had more frequently a family history of SCD and/or cardiomyopathy (30% vs. 11% vs. 5%; p&amp;lt;0.01). All patients in Group A showed VAs with a predominant RBBB morphology vs. 38 (68%) patients in Group B and 65 (15%) in Group C (p&amp;lt;0.01). During a follow-up of 63±39 months, the composite outcome occurred in 13 patients (57%) in Group A vs. 11 (20%) in Group B and 2 (1%) in Group C (p&amp;lt;0.01). Conclusion In patients with apparently idiopathic VAs, a nonischemic LV-LGE with a ring-like pattern at CMR is associated with a high rate of malignant arrhythmic events during follow-up. Funding Acknowledgement Type of funding source: None

AMPHETAMINE-INDUCED TAKOTSUBO CARDIOMYOPATHY COMPLICATED BY RECURRENT TORSADES DE POINTES AND CARDIAC ARREST: A CASE REPORT

SESSION TITLE: Medical Student/Resident Cardiovascular Disease Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Takotsubo cardiomyopathy (TCM) is characterized by transient left ventricular dysfunction in the absence of coronary artery disease. 36% of TCM cases had a physical stressor such as illness, while 27.7% reported an emotional trigger which lead to an inappropriate catecholamine release and response. TCM then presents with substernal chest pain, EKG changes, transient systolic dysfunction and rarely arrythmias such as Torsades de Pointes (TdP). Patients will usually recover systolic left ventricular function within 4 weeks. CASE PRESENTATION: A 63 year old female was brought to the ED after being found altered. History and urine toxicology showed she was taking Adderall. She initially presented with no focal neurologic deficits and an EKG at the time showed a QTc interval of 600ms (QTc baseline 485 from records). Patient underwent further workup before being noted ot have seizure like activity and agonal breathing. Repeat EKG at this time showed a lengthening of the QTc to 641 before the patient went into ventricular fibrillation cardiac arrest. Magnesium was administered, ROSC was achieved and patient was transferred to the ICU.In the ICU the patient had another episode of TdP and cardiac arrest. Immediately prior an EKG showed a QTc >700ms. ROSC was achieved but QTc remained >600ms and isoproterenol was begun. Patient tolerated this treatment well and her QTc normalized to 459ms. Her first TTE showed an EF of 35% and wall motion abnormalities. Repeat TTE in 6 days showed resolution of wall motion abnormalities and improved EF to 75%. DISCUSSION: TCM affects approximately 1% of all troponin positive acute coronary syndrome patients.2,3,4,5 QTc prolongation was seen in 86% of patients and VF in 3.4%.6,7,8 Only 15 cases have been reported of TCM leading to TdP and none secondary to amphetamine overdose. An overdose of amphetamines (Adderall) precipitated this patient’s TCM. Supportive care was provided for the amphetamine overdose and β-agonist support was initiated in order to shorten the QTc, a temporary measure that can be used in refractory TdP.9 The data on pharmacologic treatment of TCM is largely empiric, with pressors and beta agonists recommended only when absolutely necessary, due to the similar catecholamine mechanism of TCM.9,10,11 Treatment is largely centered around supportive care until resolution of myocardial dysfunction. CONCLUSIONS: Takotsubo cardiomyopathy is associated with prolonged QTc intervals, rarely progressing to torsades de pointes. Management is supportive therapy. Beta agonists can be given to accelerate rhythm to shorten QTc but care must be taken due to sympathetic overload driving TCM. Amphetamines and other sympathomimetic drugs should be considered as a source of stressor when diagnosing TCM. Reference #1: Tsuchihashi K, et. al. Transient left ventricular apical ballooning without coronary artery stenosis: a novel heart syndrome mimicking acute myocardial infarction. Angina Pectoris-Myocardial Infarction Investigations in Japan. J Am Coll Cardiol. 2001;38(1):11. Reference #2: Sharkey SW, Lesser JR, Maron MS, et al. Why not just call it tako-tsubo cardiomyopathy: a discussion of nomenclature. J Am Coll Cardiol 2011;57:1496–7. 10.1016/j.jacc.2010.11.029 Reference #3: Kurowski V, Kaiser A, von Hof K, Killermann DP, Mayer B, Hartmann F, Schunkert H, Radke PW. Apical and midventricular transient left ventricular dysfunction syndrome (tako-tsubo cardiomyopathy): frequency, mechanisms, and prognosis. Chest. 2007;132(3):809. DISCLOSURES: No relevant relationships by Young Lee, source=Web Response No relevant relationships by Steven Lim, source=Web Response

When Third Time's a Charm: Successful Outcome after Third Orthotopic Heart Transplantation

IntroductionCardiac re-transplantation represents a small but growing proportion of total transplants being performed. Medical, ethical, moral and social dynamics continue to remain individualized and highly debated but more evolved with advancement in medicine for patients needing cardiac re-transplantation. We describe a case of a successful outcome in a patient requiring her third orthotopic heart transplant.CaseA 26 year old female with history of orthotopic heart transplant at age 11 for hypertrophic cardiomyopathy and subsequent re-transplantation for cardiac allograft vasculopathy (CAV) ten years later presented to our emergency room with cardiac arrest. Prior to the index hospitalization, the patient had an echocardiogram with a mildly reduced ejection fraction and an angiogram with chronic total occlusions of the right coronary artery and left circumflex artery with excellent collaterals and preserved cardiac output. Nuclear stress test showed no evidence of ischemia. Cardiac allograft vasculopathy prophylaxis with aspirin and pravastatin in addition to a triple regimen of immunosuppression of tacrolimus, sirolimus and mycophenolate mofetil were verified.The hospitalization was complicated by rapidly deteriorating biventricular function and three more episodes of cardiac arrest ultimately requiring extracorporeal membrane oxygenation (ECMO). Fortunately, the patient had negative HLAs with 0% CPRA and preserved end organ function. The selection committee thoughtfully considered her history of intermittent social marijuana use, active COVID 19 precautions in the hospital and a third sternotomy at such a young age, with likely need of possible 4th heart transplant in the future, but ultimately approved the patient for listing. Despite being Status 1, the patient had near daily loss of pulsatility for greater than 10-15 minutes which made us consider the possibility of total artificial heart. Fortunately, the patient received a local heart due to the COVID travel restrictions with total ischemic time of 98 minutes. She was induced with basiliximab and had negative retrospective and prospective crossmatches. There were no intra-op complications and post-op the patient had mild RV dysfunction requiring 4 days of inotropes. Patient was successfully discharged 9 days following her third OHT.ConclusionPatients undergoing re-transplantation have overall poorer outcomes than those undergoing primary transplantation. Several factors influence these outcomes including timing from prior transplant, previous sternotomy, sensitization status, and renal dysfunction. With advances in medicine and pediatric patients living well into adulthood, there will be more patients requiring re-transplantation. As these trends emerge, individualized patient selection remains the key factor to improved outcomes. Our case presents an otherwise healthy young woman with graft failure without evidence of sensitization who underwent a successful third transplantation.