Higher Rates Of Stroke Research Articles

Factors Relating to Sprint Swimming Performance: A Systematic Review.

Swimming performance depends on a wide variety of factors; however, the interaction between these factors and their importance varies between events. In sprint events, the characterized pacing underlines its specific development, as swimmers must achieve the highest possible speed while sustaining it to the greatest extent possible. The aim of this review was to identify the key factors underlying sprint swimming performance and to provide in-depth and practical evidence-based information to optimize performance. The review protocol was not registered. PubMed, Web of Science and Scopus databases were searched up to October 31, 2023. Studies involving competitive swimmers and investigating sprint swimming performance were included, while studies conducted with young or masters' swimmers, triathletes or waterpolo players or not investigating sprint swimming performance were excluded. The Downs and Black Quality Assessment Checklist was performed on the included articles to assess the methodological quality. After applying the PICOS framework, 39 of the 1330 articles initially identified were included according to the PRISMA guidelines. The included records focused mainly on dry-land strength and in-water forces of both upper and lower limbs. A wide range of kinematic variables were also examined, together with the importance of anthropometric and various physiological parameters. This review highlights the importance of developing muscular strength and effectively transferring it to performance in the water. The evidence suggests that muscular development should prioritize enhancing velocity and effective displacement, rather than merely increasing force and performance in loaded tests. However, further research is needed to confirm this. While in-water forces have been well studied, there is a notable lack of analysis regarding drag. The optimal balance between stroke rate and stroke length should be determined individually, with a primary focus on achieving a high stroke length from a high stroke rate. Although anthropometry may play an important role in performance, the interaction of these traits appears to be complex, suggesting that other factors may be more important in determining performance outcomes. From a physiological perspective, the results indicate that the lactate peak and rate of accumulation should be thoroughly developed. Notwithstanding, this review shows the lack of a solid body of knowledge on the importance of anaerobic and especially aerobic factors. Finally, the absence of a list of potential confounders, together with the lack of high-quality studies involving elite swimmers (level 1 and 2), complicates the interpretation of the results.

Impact of new-onset atrial fibrillation in patients with ST-segment elevation myocardial infarction.

New-onset atrial fibrillation (NOAF) complicating ST-segment elevation myocardial infarction (STEMI) remains clinically challenging. The aim of this study was to assess the incidence of NOAF, identify risk factors for the development of atrial fibrillation (AF), and analyze the impact on patient care, therapy, and outcomes during long-term follow-up. This retrospective single-center study reviewed consecutive patients undergoing coronary angiography (CAG) for acute STEMI between May 2015 and September 2023. Patients were stratified in NOAF, defined as AF diagnosed during the index hospitalization or within 12months of follow-up, AF prior to the hospitalization for STEMI, and patients with no AF. We analyzed 1301 consecutive patients undergoing CAG for STEMI. NOAF was detected in 112 patients (9.8%), and 68 patients (5.2%) had prior AF. NOAF patients were 74% males, with a mean age of 69 ± 11years. During a median follow-up of 683days, the rates of stroke were 10% in patients with NOAF compared to 3.8% (p = 0.001) in patients without AF. Major bleeding occurred in 7% vs. 1.7%, p = 0.001, and death in 16% vs. 6.8%, p < 0.001 of patients with NOAF vs. no AF. NOAF was detected in almost 1 out of 10 STEMI patients and was associated with a higher rate of stroke, major bleeding, and death as in patients with no AF and with similar rates compared with prior AF. Future studies assessing optimal anticoagulation therapy in this challenging patient population are warranted.

Abstract 287: Trial Haven: the Ethical Risks of Offshore Mechanical Thrombectomy Trials

Introduction Randomized controlled trials (RCTs) in low‐ and middle‐income countries (LMICs) offer significant potential for advancing global health. However, these RCTs often face conflicts between pharmaceutical industry incentives and global health priorities. The high costs, strict regulations, and extensive requirements of Phase 3 trials make LMICs more appealing than high income countries (HICs). For MT trials, LMICs offer advantages such as higher stroke rates, lower costs, more flexible regulations, shorter timelines, and a strong willingness to participate from both patients and local clinicians. However, the industry's motivations extend beyond these practical considerations. These collaborative trials present several ethical concerns, including power imbalances between industry or HICs investigators and those from LMICs, vulnerabilities of patients and clinicians in LMICs, health system unprepared for RCTs and the limited availability of interventions to locals once the RCTs are concluded. Major ethical issues include using control arms (SMT) that fall below the standard of care in HICs and inadequate post‐protocol treatment. Accepting inferior SMT and minimal post‐protocol care in LMICs hospital settings can introduce bias favoring experimental devices. Data from these RCTs, used for FDA approval, could lead to negative outcomes for patients in both LMICs and HICs. We plan to do a global mapping of current RCTs scenario in MT for acute ischemic stroke. Methodology: The search terms “Stroke,” “Large Vessel Occlusion,” and “Mechanical Thrombectomy” were entered into the ClinicalTrials.gov search form. Filters were then set to show only new RCTs that are either currently recruiting participants or are planning to recruit. RCTs that were completed, terminated, or had unknown statuses were excluded. Results Our search identified 44 ongoing RCTs across various countries. The USA leads with 14 trials (25.45%), followed by China with 13 trials (23.64%), and France with 8 trials (14.55%). Turkey and Brazil each have 3 trials (5.45%), while Spain has 2 trials (3.64%). Argentina, Canada, Germany, Hungary, India, Israel, Italy, the Netherlands, Pakistan, Paraguay, Poland, and Taiwan each have 1 trial (1.82%). In terms of funding sources, industry funded 18 trials (40.91%), the NIH funded 1 trial (2.27%), and other sources funded 25 trials (56.82%). Of the industry‐sponsored trials, 10 (55.55%) are conducted offshore, 5 (27.77%) are in the USA, and 3 (16.66%) involve both domestic and international sites. Conclusion Globalizing MT RCTs offers benefits but also risks if oversight is inadequate. It's crucial to ensure that trials benefit local populations and local needs. Advocacy should prioritize locally relevant, need based, investigator‐initiated stroke trials in LMICs, rather than industry‐driven “parasitic” or “parachute” RCTs that may exploit LMICs patients for drug approvals in HICs. Even non‐industry‐funded trials in LMICs can be influenced by industry interests through collaborating researchers from HICs who is getting industry benefits. Rigorous ethical oversight is essential to prevent exploitation and ensure the integrity of these trials.

Refining the CHA2DS2VASc risk stratification scheme: Shall we drop the Sex Category criterion?

The CHA2DS2VASc score is recommended for stroke risk stratification in patients with atrial fibrillation (AF). This score assigns one extra point to female sex based on evidence from the early 2000s suggesting higher thromboembolic risk in women. This incremental risk of thromboembolism in women has decreased over time between 2007 and 2018, becoming non-significant in recent years. To assess the impact of removing the sex category (Sc) from the CHA2DS2VASc score, thus validating a non-sex CHA2DS2VASc (i.e., CHA2DS2VA) score. We analysed UK primary and secondary care data comprising 195,719 patients with AF followed between 1998-2016 (mean age: 75.9±12.3 years; 49.2% women). Among 126,428 non-anticoagulated patients, we compared the CHA2DS2VASc vs. CHA2DS2VA scores every calendar year. Throughout 413,007 patient-years, a total of 8,742 events of ischaemic stroke or systemic embolism were recorded. Sex differences in thromboembolic risk were not observed in the lower-risk population, but higher stroke rates were consistently seen in female patients in the higher-risk category (i.e., CHA2DS2VA ≥2). C-statistics for both CHA2DS2VA and CHA2DS2VASc scores were similar over the years (ranging from 0.62 to 0.71). With CHA2DS2VA no relevant differences were observed in IDI, and NRI resulted in improved reclassification (11%) in lower thromboembolic risk groups. NRI suggested misclassification in higher thromboembolic risk patients (-7%), but this did not affect their indication for anticoagulation (i.e., patients retained their high-risk status). Removing Sc from the CHA2DS2VASc score does not affect its ability to discriminate thromboembolic events in the AF population. Use of CHA2DS2VA may simplify initial decision-making for thromboprophylaxis.

Carotid web: Pathophysiology, diagnostic, and therapeutic options. A narrative review.

A carotid web (CaWeb), otherwise known as a carotid bulb diaphragm, is a spur of intimal fibrous tissue extending into the carotid bulb. It is a rare, underdiagnosed cause of ischemic strokes in young people. The purpose of this narrative review was to provide an update on CaWebs, highlighting recent evolutions in their management. We undertook a comprehensive literature search on main electronic databases - MEDLINE/PubMed, Cochrane Library, Web of Science, and EMBASE - using a dedicated equation to include studies up to February 13, 2024. We also searched for the most recent guidelines about carotid disease or stroke including CaWeb management. A CaWeb is found in up to 10% of young patients, particularly young women, with severe anterior stroke due to an arterial-arterial embolism from the intra-nidus thrombus. Most patients with a CaWeb have less than 50% stenosis on duplex ultrasound, and diagnosis is mostly obtained by computed tomography angiography. When applying traditional stenosis criteria for symptomatic disease (> 50% stenosis), this highly morbid condition is easily overlooked, leading to recurrent strokes. Antithrombotic treatment is associated with a high recurrence rate of stroke after the index event. The first-line treatment of symptomatic CaWebs is increasingly based on endarterectomy or stenting. The lack of recommendations before 2021 and recent discordant guidelines make CaWeb management complex. No guidelines are available to manage patients with asymptomatic CaWebs. Results from ongoing multicenter registries will be useful in guiding management decisions.

Analyzing stroke burden and risk factors in India using data from the Global Burden of Disease Study.

Stroke remains a critical global health issue, significantly impacting India with substantial contributions to mortality and disability. This study comprehensively analyses stroke incidence, mortality, and disability-adjusted life years (DALYs) across India from 1990 to 2021, using the latest Global Burden of Disease (GBD) 2021 data. We evaluate how Universal Health Coverage (UHC), health expenditure, human development index (HDI), and gross national income (GNI) influence stroke outcomes. Our findings reveal significant regional disparities, with higher stroke rates in urban areas and states like Goa and Kerala. Higher health expenditure and HDI are linked to lower stroke rates, while higher GNI per capita correlates with increased stroke incidence, likely due to lifestyle changes. Risk factors include air pollution, tobacco use, dietary risks, and high blood pressure. Air pollution notably impacts stroke mortality in Bihar and Jharkhand, while tobacco use is a major risk factor in Mizoram and Manipur. Dietary risks and hypertension are prevalent in Maharashtra and Jammu & Kashmir. The study highlights the need for targeted public health strategies addressing regional disparities and socioeconomic factors. Policymakers should focus on lifestyle modification programs, public awareness campaigns, and enhanced access to quality stroke care to reduce stroke-related morbidity and mortality effectively.

Does disease etiology matter in long-term patency in extracranial-intracranial bypass?

OBJECTIVE Extracranial-intracranial (EC-IC) bypass has been well described in chronic vaso-occlusive cerebrovascular diseases, including both moyamoya disease (MMD) and atherosclerotic disease (AD). This study aimed to compare factors associated with bypass occlusion between these two diseases. METHODS An institutional database of 357 patients with intracranial bypass procedures performed between August 2001 and May 2022 was retrospectively reviewed. Patients with MMD and AD were selected for study. Baseline characteristics, surgical technique, and flow-related measurements were compared in relation to the outcome of bypass occlusion. RESULTS A total of 232 patients met inclusion criteria (AD, n = 108; MMD, n = 124). The average age and sex differed significantly between groups (AD 57.2 years, 56.5% male; MMD 36.6 years, 31.5% male; p &lt; 0.001). The modified Rankin Scale scores at surgery and at follow-up were higher in the AD group (p = 0.004 and p &lt; 0.001, respectively), showing a slightly worse baseline functional status, and higher rates of stroke were observed in the AD group by last follow-up (p = 0.005). Patients with AD also were more likely to require an interpositional graft (p &lt; 0.001). At last follow-up, rates of occlusion did not differ between AD and MMD groups (25.2% vs 25.4%, respectively). Of occluded bypasses, the AD group had more occlusions within 1 week compared to MMD (51.9% vs 35.5%, p = 0.176), although the difference was not significant. In patients with more than 1 year of follow-up and in those with more than 2 years of follow-up, MMD tended to have higher rates of occlusion (31.2% vs 26.1% [p = 0.558], and 26.4% vs 20.7% [p = 0.564]). Flow measurements did not differ between AD and MMD groups, but in subgroup analyses of patients with AD and those with MMD, both bypass flow and cut flow index predicted occlusion in both groups. CONCLUSIONS Despite different disease etiologies treated with bypass, rates of occlusion at last follow-up did not vary between groups, although short-term follow-up would suggest earlier bypass failure in AD, and extended follow-up trended toward higher occlusion rates in MMD. Additionally, patients with AD were more likely to have further occurrences of stroke by last follow-up. Importantly, the bypass flow and cut flow index at the time of surgery predicted occlusion in both AD and MMD.

Best Medical Therapy for Asymptomatic Carotid Stenosis: Imminent or Ineffective?

Carotid artery disease accounts for approximately 20% of all ischemic strokes, a major cause of morbidity, and the fifth leading cause of death in United States. Landmark trials in the 1990s such as Asymptomatic Carotid Atherosclerosis Study (ACAS) and Asymptomatic Carotid Surgery Trial (ACST) establish carotid endarterectomy (CEA) plus best medical therapy (BMT) as the standard of care for patients with asymptomatic carotid stenosis over 60%. However, advances in medical therapy and the emergence of carotid artery stenting (CAS) have prompted a reevaluation of treatment efficacy. Recent studies have questioned the superiority of CEA over BMT alone in reducing stroke risk, suggesting no significant difference in outcomes with contemporary medical management. Additionally, analysis from the US Department of Veterans Affairs indicated minimal net benefit of CEA over BMT when accounting for all-cause mortality. Comparative studies have found no significant difference in long-term stroke free survival between CEA and CAS. However, procedural risks vary, with higher myocardial infarction rates associated with CEA and higher stroke rates with CAS. Identifying high-risk plaques and patient-specific risk factors remains crucial. Meta-analyses have highlighted features such as neovascularization and lipid rich cores as predictors of stenosis progression and ischemic events. Ongoing research, particularly the CREST-2 trial, aims to provide clear guidance on the optimal treatment of asymptomatic carotid stenosis. This trial emphasizes stringent adherence to modern BMT protocols and includes comprehensive lifestyle modification programs. The evolving landscape of medical and surgical interventions necessitates continuous evaluation to optimize treatment strategies for asymptomatic carotid stenosis, which is the impetus for this review. Future findings from ongoing trials are expected to refine current guidelines and improve patient outcomes.

Endovascular Treatment Strategies for Ruptured Vertebral Artery Dissecting Aneurysms

Ruptured vertebral artery dissecting aneurysms(VADA) carry a poor prognosis owing to the high rates of rebleeding, stroke, and mortality without appropriate treatment. Various endovascular techniques are employed to treat these aneurysms. Deconstructive techniques, involving internal trapping with coils, often achieve complete angiographic occlusion at higher rates; however, they carry a risk of medullary infarction. Reconstructive techniques using neck-bridge stents preserve the parent vessel and reduce perioperative morbidity. Nevertheless, these techniques are associated with a higher rate of aneurysmal rebleeding or recurrence. Optimal treatment modalities should be chosen based on the anatomical characteristics of the aneurysm and the trade-off between risks and benefits.

Associations Between Changes in Maximum Daily Atrial Fibrillation Duration, Ischemic Stroke, and Mortality

BackgroundAtrial fibrillation (AF) outcomes are strongly associated with continuous measures of AF burden. ObjectivesThis study sought to assess the association between changes in maximum daily AF duration (MDAFD) and stroke or mortality in patients with cardiac implantable electronic devices (CIEDs). MethodsThe Optum deidentified electronic health record data set (2007-2021) was linked with the Medtronic CareLink heart rhythm database. Patients with CIEDs and health care activity recorded in the electronic health record were included, excluding those with oral anticoagulation prescription. MDAFD was assessed 30 days post implant (baseline period) and 30 days before censoring or an event. HRs for the primary analysis were adjusted for components of CHA2DS2-VASc, baseline MDAFD category, and chronic kidney disease. ResultsOf 26,400 patients (age 68 ± 13 years; follow-up 2.6 ± 1.6 years) analyzed, 2,544 (9.6%) had AF during baseline. Increased (vs stable or decreased) MDAFD category in follow-up was associated with a higher adjusted rate of stroke and mortality (HR: 1.80; 95% CI: 1.61-2.01). There was no association between decreased MDAFD in follow-up and the combined endpoint (HR: 0.82; 95% CI: 0.68-1.00). Subgroup analysis by baseline MDAFD category demonstrated that increased MDAFD in follow-up was associated with a greater risk of stroke or mortality among patients with no AF at baseline, and decreased MDAFD in follow-up was associated with a lower risk of stroke or mortality among patients with baseline MDAFD of 1 to <5.5 hours and 5.5 to <23.5 hours. ConclusionsIn CIED patients not on oral anticoagulation, increased MDAFD in follow-up was associated with a higher rate of stroke and mortality. These results suggest that AF burden, and associated risk, s not stable over time.

Apixaban vs Aspirin in Patients With Cancer and Cryptogenic Stroke

Approximately 10% to 15% of ischemic strokes are associated with cancer; cancer-associated stroke, particularly when cryptogenic, is associated with high rates of recurrent stroke and major bleeding. Limited data exist on the safety and efficacy of different antithrombotic strategies in patients with cancer and cryptogenic stroke. To compare apixaban vs aspirin for the prevention of adverse clinical outcomes in patients with history of cancer and cryptogenic stroke. Post hoc analysis of data from 1015 patients with a recent cryptogenic stroke and biomarker evidence of atrial cardiopathy in the Atrial Cardiopathy and Antithrombotic Drugs in Prevention After Cryptogenic Stroke (ARCADIA) trial, a multicenter, randomized, double-blind clinical trial conducted from 2018 to 2023 at 185 stroke centers in North America. Data analysis was performed from October 15, 2023, to May 23, 2024. Oral apixaban, 5 mg (or 2.5 mg if criteria met), twice daily vs oral aspirin, 81 mg, once daily. Subgroups of patients with and without cancer at baseline were examined. The primary outcome for this post hoc analysis was a composite of major ischemic or major hemorrhagic events. Major ischemic events were recurrent ischemic stroke, myocardial infarction, systemic embolism, and symptomatic deep vein thrombosis or pulmonary embolism. Major hemorrhagic events included symptomatic intracranial hemorrhage and any major extracranial hemorrhage. Among 1015 participants (median [IQR] age, 68 [60-76] years; 551 [54.3%] female), 137 (13.5%) had a history of cancer. The median (IQR) follow-up was 1.5 (0.6-2.5) years for patients with history of cancer and 1.5 (0.6-3.0) years for those without history of cancer. Participants with history of cancer, compared with those without history of cancer, had a higher risk of major ischemic or major hemorrhagic events (hazard ratio [HR], 1.73; 95% CI, 1.10-2.71). Among those with history of cancer, 8 of 61 participants (13.1%) randomized to apixaban and 16 of 76 participants (21.1%) randomized to aspirin had a major ischemic or major hemorrhagic event; however, the risk was not significantly different between groups (HR, 0.61; 95% CI, 0.26-1.43). Comparing participants randomized to apixaban vs aspirin among those with cancer, events included recurrent stroke (5 [8.2%] vs 9 [11.8%]), major ischemic events (7 [11.5%] vs 14 [18.4%]), and major hemorrhagic events (1 [1.6%] vs 2 [2.6%]). Among participants in the ARCADIA trial with history of cancer, the risk of major ischemic and hemorrhagic events did not differ significantly with apixaban compared with aspirin. ClinicalTrials.gov Identifier: NCT03192215.

Comparing the Surgical Outcomes of Carotid Endarterectomy: Assessing the Impact of Consultant versus Trainee Cases on Patient Care and Surgical Training

ObjectiveThis study assesses the impact of having a surgical trainee performing a carotid endarterectomy procedure on the post-operative rates of stroke and death. DesignObservational Retrospective study MethodsConsecutive patients, who underwent carotid endarterectomy between 01/05/2016 and 31/7/2022, were entered into a retrospectively collected database. Patients were stratified into two categories – consultant-led cases and trainees-led cases. Primary outcomes were 30- day stroke rate, and 30-day morbimortality. A sub analysis was performed after grouping the patients in whether there was a neurological event in the previous six months – symptomatic or asymptomatic. Results/ConclusionsTrainees-led cases had significantly longer clamping times and higher rates of stroke in asymptomatic patients compared with consultant-led cases. Patient’s safety should be our top priority. Any practice leading to a significantly increased rate of post-operative stroke must be discontinued. Training protocols and adequate supervision must ensure that trainees possess the necessary skills and knowledge to safely and effectively perform carotid endarterectomy (CEA) procedures, thereby prioritizing patient safety.

Ethnic Density as a Key Factor to Narrow Health Disparities: A Case of American Indians and Alaska Natives.

Out of all the racial groups in the United States, people who identify as American Indian and Alaska Native (AI/AN) have disproportionately worse health as a result of living in poverty. The preponderance of research connects poor health with a socioeconomic perspective, which might create prejudice against AI/AN. As already known, AI/AN's high rates of obesity, diabetes, and stroke in comparison with that of other ethnic groups are mainly derived from their impoverished economic conditions that have forced them to consume the food distributed by the U.S. government. When minority health is discussed generally, the ethnic density perspective explains a minority population's positive health despite low socioeconomic status. This perspective helps researchers and practitioners understand the connections of psychological and social factors with physical health and demonstrates positive health effects on minority groups. Despite the high correlation between ethnic density and health having been validated, little to no research has explored AI/AN's health from this perspective. Using 13,064 electronic health records, this research tests the relationship between AI/AN density and health outcomes. This article introduces an innovative analytical strategy (i.e., a data mining technique), which is ideal for discovering frequently appearing health outcomes in a group. The finding reveals positive relationships between health outcomes and AI/AN density.

Cost-Effectiveness Analysis of Rehabilitation Methods for Stroke Survivors

Background: One of the challenges in stroke management is how to provide rehabilitation services to stroke patients in Iran. Objectives: This study aimed to evaluate and compare the cost-effectiveness of rehabilitation interventions for stroke patients in three settings: Hospitals, stroke units, and homes. Methods: This cross-sectional study was conducted from the perspective of the health system. A Markov model with a 20-year time horizon and 3-month cycles was used to analyze costs and outcomes. Cost data were collected from 210 patients undergoing rehabilitation in hospitals, homes, or stroke units. The cost-effectiveness analysis (CEA) was conducted by calculating the incremental cost-effectiveness ratio (ICER) using Tree Age software. Results: The average rehabilitation cost for the home strategy ($2306 ± 35.018) was less than that for the hospital ($2955 ± 48.18) and stroke unit ($3485 ± 51.63) strategies. Furthermore, the QALY of the home strategy (26.03) was 8 times higher than that of the hospital (17.99) and 19 times higher than that of the stroke unit (7.03). The average cost-effectiveness ratios for the hospital, stroke unit, and home groups were $11424, $33159, and $7233 per QALY, respectively. The ICERs for stroke unit and home rehabilitation relative to hospital rehabilitation were $2517 and $2145 per QALY, respectively. Conclusions: According to the results, the home-based rehabilitation strategy is more cost-effective than hospital and stroke unit rehabilitation strategies. Given the high rates of stroke and its associated costs in Iran, it is suggested that policymakers lay the groundwork for providing these services at home.

Swimming Performance in Elite Triathletes: Comparison Between Open Water and Pool Conditions.

This study aimed to compare performance, kinematic, and physiological variables between open water and pool swimming conditions in elite triathletes and to examine the associations between conditions on these variables. Fourteen elite triathletes (10 males and 4 females [23.4 ± 3.8 years]) performed two 1500-m swimming tests in open water and in a 25-m pool. Swimming speed, stroke rate (SR), length (SL) and index (SI), heart rate (HR), blood lactate concentrations [La-], and end-exercise oxygen uptake (EEV̇O2) were assessed in both conditions. Lower SL and SI and higher SR were obtained in open water compared with pool swimming (p < 0.05). Moreover, kinematic variables changed as a function of distance in both conditions (p < 0.05). No differences were found in the main physiological variables (HR, [La-], and EEV̇O2) between conditions. Respiratory exchange ratio presented lower values in open water than in pool conditions (p < 0.05), while time constant was higher in open water (p = 0.032). The fastest triathletes in open water obtained the best performance in the pool (r = 0.958; p < 0.001). All kinematic variables, HR and peak [La-] presented positive associations between conditions (r > 0.6; p < 0.05). Despite physiological invariance, triathletes and coaches should monitor specific open water training to adapt their swimming technique to the competitive environment.

Longitudinal outcomes of thoracic endovascular aortic repair for ruptured thoracic aortic aneurysms

BackgroundLimited data exist on long-term mortality and reintervention rates after emergent thoracic endovascular aortic repair (TEVAR) for ruptured thoracic aortic aneurysm (rTAA). This study aimed to characterize the long-term outcomes of emergent TEVAR for rTAA. MethodsAll TEVARs for rTAA and elective intact thoracic aortic aneurysms (iTAAs) were reviewed at a large academic medical center from 2005 to 2022. Long-term clinical outcomes were considered over eight years. ResultsOf 321 patients undergoing TEVAR for TAA, 20% (65/321) presented with rTAA. Median clinical follow-up was 5.1 years. rTAA patients had much lower 30-day survival (69.2% vs 96.9%; P < .001) and higher rates of stroke, pneumonia, and prolonged ventilation (all P ≤ .01). Long-term survival was worse for all rTAA patients compared to all iTAA patients at 1 year (46% vs 86%), 5 years (27% vs 48%), and 8 years (20% vs 32%; all P < .001), driven largely by frequent early mortality. However, for patients surviving at least 90 days, the long-term survival difference over 8 years was minimal (34% vs 33%, log-rank P = .43) among patients presenting with ruptured vs intact TAA. Ruptured aneurysms required more reinterventions within 30 days, but had comparable late reintervention rates, with type I endoleak as the leading cause. ConclusionsThe present study is the largest to focus on long-term outcomes following TEVAR for rupture TAA. Unsuprisingly, short-term outcomes are worse in patients presenting with ruptured vs intact aneurysms. However, importantly, long-term survival in rTAA patients who do survive 90 days is comparable to that of iTAA patients.

Analysis of UNOS: Longitudinal Cognitive and Motor Delay After Pediatric Heart Transplantation and Associated Survival

BackgroundWe investigated factors associated with the longitudinal presence of neurodevelopmental delays in pediatric heart transplant recipients. MethodsThe United Network for Organ Sharing Registry was queried for patients aged <18 years who received a first-time isolated heart transplant between March 2008 and December 2022. Two patient cohorts were developed, those with and without (1) definitive motor delay (MD) and (2) definitive cognitive delay (CD). ResultsThe MD cohort was comprised of 3847 patients (n = 3267 [no MD], n = 580 [definitive MD]) and the CD cohort was comprised of 3446 patients (n = 2689 [no CD], n = 757 [definitive CD]). The MD cohort and the CD cohort shared 3189 patients. Compared with the intracohort nondelayed patients, definitive MD and CD cohorts each independently had higher rates of congenital heart disease, ventilator support at transplant, and stroke before discharge (P < .001 for all). Patients with a definitive delay at follow-up had worse longitudinal survival, with hazard ratios of 2.82 (95% CI, 2.32-3.44; P < .001) for the MD cohort and 1.67 (95% CI, 1.32-2.05; P < .001) for the CD cohort. Stroke before discharge and symptomatic cerebrovascular disease at listing were both predictors of CD and MD at follow-up. The definitive MD and CD cohorts each independently had higher rates of stroke before discharge (MD cohort, 57 of 580 [9.8%] vs 48 of 3267 [1.5%]; CD cohort, 53 of 757 [7.0%] vs 42 of 2689 [1.6%]; P < .001 for both), and symptomatic cerebrovascular disease at listing was a predictor of CD (odds ratio, 4.16; 95% CI, 2.62-6.58) and MD (odds ratio, 3.30; 95% CI, 2.06-5.22) at follow-up. ConclusionsPatients with MD and/or CD after receiving a heart transplant share several characteristics, including increased stroke before discharge, and have decreased longitudinal survival compared with their nondelayed counterparts.

Lung Transplantation in the United States for COVID-19 Related Lung Disease During the Pandemic.

Lung transplantation (LTx) is a potential intervention for end-stage COVID-19 lung disease. Current literature is sparse regarding the outcomes of LTx for COVID-19 related acute respiratory distress syndrome (ARDS) and pulmonary fibrosis (PF). This study aims to characterize outcomes and patterns of LTx for COVID-19 related lung disease throughout the pandemic. Patients who underwent LTx during the pandemic for COVID-19 related lung disease were retrospectively identified using the UNOS registry. Demographics, as well as outcomes measures and nationwide patterns of care were collected and analyzed. A total of 510 adult cases of LTx for COVID-19 (259 ARDS, 251 PF) were compared to 4,031 without COVID-19 (3,994 PF, 37 ARDS). Patients who received LTx for COVID-19 ARDS did not differ in 2-year survival when compared to those with COVID-19 PF (81.9% vs 77.2%, p = 0.4428). Compared to non-COVID-19 etiologies, COVID-19 ARDS patients had higher rates of stroke (2.3% vs 0%, p = 0.0005), lower rates of graft failure (12.8% vs 36.1%, p = 0.0003) and post-transplant ECMO (29.6% vs 41.7%, p = 0.0002), and improved 2-year survival following LTx (81.9% vs 61.7%, p = 0.0064). No difference in 2-year survival following LTx was observed between patients with COVID-19 and non-COVID-19 PF (77.2% vs 71.8%, p = 0.34). Rates of LTx spiked with variant emergence and declined with rounds of vaccination. Our results are consistent with early reports of survival outcomes following LTx for COVID-19 ARDS and PF while providing an increased layer of granularity. LTx may be considered as a safe and effective intervention for COVID-19 lung disease.

Higher stroke risk after carotid endarterectomy and transcarotid artery revascularization is associated with relative surgeon volume ratio

ObjectiveAdoption of transcarotid artery revascularization (TCAR) by surgeons has been variable, with some still performing traditional carotid endarterectomy (CEA), whereas others have shifted to mostly TCAR. Our goal was to evaluate the association of relative surgeon volume of CEA to TCAR with perioperative outcomes. MethodsThe Vascular Quality Initiative CEA and carotid artery stent registries were analyzed from 2021 to 2023 for symptomatic and asymptomatic interventions. Surgeons participating in both registries were categorized in the following CEA to CEA+TCAR volume percentage ratios: 0.25 (majority TCAR), 0.26 to 0.50 (more TCAR), 0.51 to 0.75 (more CEA), and 0.76 to 1.00 (majority CEA). Primary outcomes were rates of perioperative ipsilateral stroke, death, cranial nerve injury, and return to the operating room for bleeding. ResultsThere were 50,189 patients who underwent primary carotid revascularization (64.3% CEA and 35.7% TCAR). CEA patients were younger (71.1 vs 73.5 years, P < .001), with more symptomatic cases, less coronary artery disease, diabetes, and lower antiplatelet and statin use (all P < .001). TCAR patients had lower rates of smoking, obesity, and dialysis or renal transplant (all P < .001). Postoperative stroke after CEA was significantly impacted by the operator CEA to TCAR volume ratio (P = .04), with surgeons who perform majority TCAR and more TCAR having higher postoperative ipsilateral stroke (majority TCAR odds ratio [OR]: 2.15, 95% confidence interval [CI]: 1.16-3.96, P = .01; more TCAR OR: 1.42, 95% CI: 1.02-1.96, P = .04), as compared with those who perform majority CEA. Similarly, postoperative stroke after TCAR was significantly impacted by the CEA to TCAR volume ratio (P = .02), with surgeons who perform majority CEA and more CEA having higher stroke (majority CEA OR: 1.51, 95% CI: 1.00-2.27, P = .05; more CEA OR: 1.50, 95% CI: 1.14-2.00, P = .004), as compared with those who perform majority TCAR. There was no association between surgeon ratio and perioperative death, cranial nerve injury, and return to the operating room for bleeding for either procedure. ConclusionsThe relative surgeon CEA to TCAR ratio is significantly associated with perioperative stroke rate. Surgeons who perform a majority of one procedure have a higher stroke rate in the other. Surgeons offering both operations should maintain a balanced practice and have a low threshold to collaborate as needed.

Femoro-axillary versus femoro-femoral veno-arterial extracorporeal membrane oxygenation for refractory cardiogenic shock: A monocentric retrospective study.

For veno-arterial extracorporeal membrane oxygenation (ECMO), the femoral artery is the preferred cannulation site (femoro-femoral: Vf-Af). This results in retrograde aortic flow, which increases the left ventricular afterload and can lead to severe pulmonary edema and thrombosis of the cardiac chambers. Right axillary artery cannulation (femoral-axillary: Vf-Aa) provides partial anterograde aortic flow, which may prevent some complications. This study aimed to compare the 90-day mortality and complication rates between VF-AA and VF-AF. Consecutive adult patients with cardiogenic shock who received peripheral VA-ECMO between 2013 and 2019 at our institution were retrospectively included. The exclusion criteria were refractory cardiac arrest, multiple VA-ECMO implantations due to vascular access changes, weaning failure, or ICU readmission. A statistical approach using inverse probability of treatment weighting was used to estimate the effect of the cannulation site on the outcomes. The primary endpoint was the 90-day mortality. The secondary endpoints were vascular access complications, stroke, and other complications related to retrograde blood flow. Outcomes were estimated using logistic regression analysis. VA-ECMO was performed on 534 patients. Patients with refractory cardiac arrest (n = 77 (14%)) and those supported by multiple VA-ECMO (n = 92, (17%)) were excluded. Out of the 333 patients studied (n = 209 Vf-Aa; n = 124 VF-AF), the main indications for VA-ECMO implantation were post-cardiotomy (33%, n = 109), dilated cardiomyopathy (20%, n = 66), post-cardiac transplantation (15%, n = 50), acute myocardial infarction (14%, n = 46) and other etiologies (18%, n = 62). The median SOFA score was 9 [7-11], and the crude 90-day mortality rate was 53% (n = 175). After IPTW, the 90-day mortality was similar in the Vf-Aa and VF-AF groups (54% vs 58%, IPTW-OR = 0.84 [0.54-1.29]). Axillary artery cannulation was associated with significantly fewer local infections (OR = 0.21, 95% CI:0.09-0.51), limb ischemia (OR = 0.37, 95% CI:0.17-0.84), bowel ischemia (OR = 0.16, 95% CI:0.05-0.51) and pulmonary edema (OR = 0.52, 95% CI:0.29-0.92) episodes, but with a higher rate of stroke (OR = 2.87, 95% CI:1.08-7.62) than femoral artery cannulation. Compared to VF-AF, axillary cannulation was associated with similar 90-day mortality rates. The high rate of stroke associated with axillary artery cannulation requires further investigation.