Large-volume Center Research Articles

Sex-related outcomes after percutaneous coronary intervention of in-stent restenosis.

Limited data are available for sex-related long-term outcomes of patients treated for coronary drug-eluting stent (DES) restenosis. The aim of this observational, retrospective analysis was to close this lack of evidence. Between January 2007 and February 2021, a total of 3511 patients with 5497 in-stent restenosis (ISR) lesions were treated at two large-volume centers in Munich, Germany, of which 763 (21.7%) were female. Endpoints of interest were all-cause mortality and rates of repeat revascularization. Outcomes are presented as Kaplan-Meier event rates. Univariate and multivariate analyses were performed. Female patients were older (72.1 ± 10.4 versus 68.4 ± 10.4 years, p < 0.001) and suffered more often from diabetes (38.8% versus 34.4%, p = 0.029). There was no statistical difference regarding the clinical presentation and interventional treatment strategy. After 10 years, the risk of all-cause mortality was higher in female patients [hazard ratio (HR) 1.18 (1.02-1.35); p = 0.022]; however, after adjustment for age, the risk did not differ significantly between both sexes [adjusted HR 0.96 (0.83-1.11); p = 0.6]. Regarding target vessel revascularization (TVR) and non-target vessel revascularization (NTVR), the risk was lower in female patients [HR 0.73 (0.61-0.87); p < 0.001 and HR 0.74 (0.64-0.86); p < 0.001] even after age adjustment. No statistical differences were found regarding the risk of target lesion revascularization, target vessel myocardial infarction and stent thrombosis. In the long term, all-cause mortality after percutaneous coronary intervention of DES-ISR did not differ between both sexes after age adjustment. The risk of TVR and NTVR was lower in female patients even after age adjustment.

Lung Transplantation - Indications, Follow-Up Care and Long-Term Results.

Lung transplantation is the treatment of choice for end-stage nonmalignant lung disease. It has become a routine procedure through advances in donor lung preservation, extracorporeal membrane oxygenation, immunosuppression, intensive care medicine, and follow-up care. This review is based on publications about lung transplantation that were retrieved by a selective literature search, and on the procedures and experience of two large-volume lung transplantation centers. The mean survival time after lung transplantation is six years, which is the shortest after the transplantation of any solid organ. Chronic graft dysfunction is present in 41% of patients at five years and is the main cause of death after lung transplantation, followed by infection and cancer. Despite all the advances in lung transplantation, acute and - above all - chronic graft dysfunction still pose a major challenge for large-volume transplantation centers. Immunosuppression that is individually tailored to prevent both graft rejection and infection is important for these patients' long-term survival. Xenotransplantation and so-called lung bioengineering may become available in the future as alternatives to allotransplantation.

P0943 Estimated benefits and willingness of remote monitoring in IBD patients under maintenance therapy – ATTENDANT study

Abstract Background Following STRIDE II guidelines, patients with inflammatory bowel diseases (IBD) are tightly monitored evaluating effectiveness of IBD-therapies and predicting flares. In many centres, patients on stable conventional therapy typically have annual outpatient visits with their IBD physician, while patients on advanced therapies are seen every six months. However, the growing number of IBD patients in active follow-up is straining outpatient clinic capacity and increasing time pressures on healthcare professionals. Furthermore, many patients do not require specialised interventions during these visits, and those in long-term remission often prefer less frequent follow-up to reduce absenteeism from work or school. We aimed to evaluate the potential optimization of resources of remote monitoring for IBD patients in a large-volume referral centre. Methods An anonymous survey was conducted in 300 adult IBD patients, either untreated or on stable subcutaneous or oral maintenance therapy for at least two years, to assess their interest in a remote monitoring program and gather insights into their preferences for its implementation. Results Of the 300 patients, 48% were male, 68% had Crohn’s disease, 31% ulcerative colitis and 1% IBD type unclassified. Forty-one percent had a disease duration of more than 20 years. Additionally, 17% were without any IBD-related therapy, 9% were on conventional therapy only, and 74% were receiving subcutaneous or oral advanced therapy. Most patients (68%) were actively employed, 70% of whom worked full-time. Notably, 77% (n=230) expressed interest in significantly reducing their outpatient visits in favour of remote monitoring. The study also identified cost and time savings for patients, as an outpatient visit takes approximately 3 hours (range 2-4 hours). Also, 24% incur public transport cost of 25 to 56 euros to attend the clinic (N = 41). Among the patients interested in remote monitoring, 94% were willing to complete three-monthly questionnaires taking about 10 minutes, and 94% agreed to annual blood analyses. Regarding faecal calprotectin, 66% were open to conducting home-based stool analyses every three months, while 72% would agree to bring a stool sample to their general practitioner or local hospital. Also, 79% were willing to attend biennial outpatient visits (Fig1). Patients also emphasized the importance of personal contact in establishing a trustworthy and safe remote monitoring system. Conclusion Remote monitoring is a promising program for IBD patients in stable remission, offering potential financial and time savings for employers, patients, and society. However, further research is required to evaluate the safety and feasibility of this approach.

P0357 Comparing Surgical Outcomes Between Crohn’s disease and Gastrointestinal Behçet’s disease: A Single-Center Retrospective Cohort Study

Abstract Background Crohn’s disease (CD) and gastrointestinal Behçet’s disease (GIBD) are chronic inflammatory bowel disorders with similar presentations. Although they share treatment guidelines, empirical observations suggest worse postoperative outcomes in GIBD. This study compared long-term surgical outcomes between CD and GIBD patients undergoing primary bowel resection. Methods We conducted a retrospective cohort study of patients undergoing primary bowel resection for CD or GIBD at a single center (2001-2021). CD was confirmed by pathology, while GIBD was diagnosed using colonoscopic criteria and clinical manifestations. Clinical recurrence was defined as symptom recurrence with radiologic/endoscopic evidence. Surgical recurrence was defined as reoperation due to disease recurrence/progression. Patient characteristics and outcomes were compared between CD (n=183) and GIBD (n=73) groups. Cumulative incidence functions analyzed recurrence rates. Propensity score matching (PSM) was performed to adjust for baseline differences, followed by survival analyses on the matched cohort. Results GIBD patients were significantly older at diagnosis (38.37 vs 25.06 years, p&amp;lt;0.001) and operation (45.96 vs 30.12 years, p&amp;lt;0.001), had longer disease duration (95.76 vs 62.80 months, p=0.005), higher BMI (21.27 vs 19.03, p&amp;lt;0.001), and lower preoperative hemoglobin (10.29 vs 11.51 g/dL, p&amp;lt;0.001). Postoperative hospital stay was longer in GIBD (19.93 vs 10.36 days, p=0.003). Clinical recurrence rates were higher in GIBD (67.1% vs 48.1%, p=0.008), as were surgical recurrence rates (20.7% vs 8.7%, p&amp;lt;0.001). Cumulative incidence analysis showed significantly higher recurrence rates in GIBD (Gray’s test, p&amp;lt;0.001 for both recurrences). After PSM (n=30 per group), GIBD patients had significantly lower clinical recurrence-free survival (HR 1.97, 95% CI 1.02-3.78, p=0.042) and showed a trend towards lower surgical recurrence-free survival (HR 3.62, 95% CI 0.98-13.41, p=0.054). Kaplan-Meier analysis confirmed lower recurrence-free survival in GIBD for both clinical and surgical recurrence (log-rank p=0.039 for both). Conclusion Despite similar postoperative complications, GIBD patients demonstrated significantly higher clinical and surgical recurrence rates after primary bowel resection. These findings persisted after PSM, particularly in time-to-event analyses, suggesting GIBD may have a more aggressive postoperative course than CD. Future prospective studies are warranted to develop tailored treatment guidelines for GIBD patients undergoing surgery. References Yazisiz V. Similarities and differences between Behçet’s disease andCrohn’s disease. World J Gastrointest Pathophysiol. 2014.15; 5(3): 228-238. Baek SJ, Kim CH, Cho MS et al. Surgical Treatment and Outcomes in Patients WithIntestinal Behçet Disease: Long-term Experience ofa Single Large-Volume Center. Dis Colon Rectum 2015; 58: 575–581DOI: 10.1097 Zeng L, Meng WJ, Wen ZH et al. Management and outcomes of surgical patients with intestinalBehçet’s disease and Crohn’s disease in southwest China. World J Clin Cases. 2021; 9(16): 3858-3868.

Use of risk assessment tools in emergency general surgery: a cross-sectional survey of surgeons and trainees.

The applicability of risk assessment tools (RATs) for preoperative risk assessment (PRA) in Emergency General Surgery (EGS) is unclear. Limited knowledge of surgeons' approach to risk assessment is available. We investigated how Canadian surgeons approach PRA for EGS and their awareness of available RATs. Canadian Association of General Surgeons members were invited to complete an online cross-sectional survey. Descriptive statistics were reported. Of 278 respondents, 70% were attending surgeons (44% had 5-10years in practice, 43% > 10years), 5% fellows, and 25% residents. Most worked in medium-/large-volume centers (89%) and teaching hospitals (77%). During preoperative risk assessment, 2/3 of respondents reported applying clinical experience/instinct and referring to literature, while 55% used RATs. The best-known and used tools were the ACS-NSQIP calculator (68% and 59%) and the Emergency Surgery Acuity Score (ESAS, 66% and 47%, respectively). Surgeons were divided regarding the accuracy of RAT estimates, with 47% considering them generally accurate and 49% inaccurate. Trainees reported greater interest in major morbidity risk (86% vs. 65%) and probability of supported discharge (45% vs. 29%) than surgeons. Among participants not using RATs, 41% indicated they are scarcely accessible in the EGS context, while 33% found them cumbersome and time-consuming. RATs are underused in favor of personal judgment. The use of RATs may facilitate decision-making in elderly/complex patients and help reduce variability in practice, particularly for trainees and less-experienced surgeons. A greater effort in education is needed to spread the culture of RATs for PRA.

Outcomes of Coccidioides Seropositive Solid Organ Transplant Recipients After Self-discontinuation of Antifungal Prophylaxis: The EIA-IgM-only Conundrum.

Solid organ transplant recipients are at risk of severe coccidioidomycosis and are given prophylaxis to mitigate the risk. Patients with seropositive testing typically receive lifelong prophylaxis; currently, this prophylaxis strategy includes patients who are positive only for IgM by enzyme immunoassay (EIA-IgM-only), although this result may be falsely positive. We conducted a retrospective study at a large-volume transplant center in an endemic coccidioidomycosis region to compare outcomes of non-lung transplant recipients who were seropositive for Coccidioides but discontinued prophylaxis (case patients) to outcomes of patients who continued prophylaxis (controls). No case or control patients developed active coccidioidomycosis during the follow-up period. Before transplant, 62 of 77 case patients (80.5%) had a single positive serologic test, of whom 27 of 62 were EIA-IgM-only positive (43.5%). In contrast, 57 of 77 controls (74.0%) had a single seropositive result (16/57 [28.1%] were EIA-IgM-only). The single EIA-IgM-only result was classified as falsely positive by infectious disease consultants in 20 of 43 patients (46.5%) compared with all other Coccidioides serologic results (13/111 [11.7%], P < 0.001). Lifetime antifungal prophylaxis was felt to be unnecessary for 28 of 43 patients (65.1%) who were EIA-IgM-only versus 31 of 111 patients (27.9%) with other serologic results (P < 0.001). For patients repeatedly positive for EIA-IgM-only and no evidence of seroconversion, compatible clinical illness, or radiographic findings, discontinuing antifungal prophylaxis may be reasonable after the first posttransplant year.

Bathing with 2% chlorhexidine gluconate versus routine care forpreventing surgical site infections after pancreatic surgery: asingle-centre randomized controlled trial.

The study aims to investigate whether bathing with 2% chlorhexidine gluconate (CHG) reduces the incidence of surgical site infection (SSI) in patients undergoing routine pancreatic surgery. A randomized controlled trial was conducted at a large-volume pancreatic centre between 1 January 2021 and 31 December 2022. Patients undergoing clean-contaminated pancreatic surgery were enrolled and randomized into an intervention arm (bathing with a 2% CHG wipe) and a control arm (routine care, soap, and water). The primary outcome was the incidence of SSI after pancreatic surgery within 30days. Overall, 614 patients (intervention arm, 311; control arm, 303) were included in intention-to-treat analysis. In total, 8.8% (54/614) patients developed SSI. The incidence of SSI in the intervention arm was 6.8% (21/311) and 10.9% (33/303) in control arm, and the difference did not reach the level of statistical significance (p 0.070). The time to SSI was significantly extended when patients were in the intervention arm (log-rank test, p 0.047). The intervention did not significantly reduce the incidence of healthcare-associated infection, hospital-acquired pneumonia, and bloodstream infection. No adverse events were observed. However, in the per-protocol analysis among 519 patients, the intervention arm showed a significantly lower incidence of overall SSI than that of those in the control arm (21/272, 7.7% vs. 33/242, 13.4%, p 0.036). Bathing with 2% CHG could potentially reduce the incidence of SSI for the patients scheduled to undergo pancreatic surgery for which further well-designed clinical trials are warranted.

Predictors of mortality at 3 months in patients with skull base tumor resections in a low-income setting.

Globally, skull base tumors are among the most challenging tumors to treat and are known for their significant morbidity and mortality. Hence, this study aimed to identify robust associated factors that contribute to mortality of patients following surgical resection for a variety of skull base tumors at the 3-month follow-up period. This in turn helps devise an evidence-based meticulous treatment strategy and baseline input for quality improvement work. A retrospective cohort study of patients undergoing skull base tumor resection was conducted at two large-volume neurosurgery centers in Ethiopia. The categorical variables were expressed in frequencies and percentages. Normal distribution of continuous data was checked by histogram and the Shapiro-Wilk test. Median with interquartile range (IQR) was calculated for skewed data, while mean with standard deviation (SD) was used for normally distributed data. Odds ratio and adjusted odds ratio (AOR) were used to express the result of univariate and multivariate binary logistic analyses, respectively. A p-value <0.005 was considered statistically significant at 95% confidence interval (CI). The study involved 266 patients. Of this, women accounted for 63.5% of patients. The median age of patients was 37 (±IQR = 17) years while the median size of the tumor in this study was 4.9 (±IQR 1.5) cm. The mean duration of symptoms at time of presentation was 17.3 (±SD = 11.1) months. Meningioma, pituitary adenoma, and craniopharyngioma contributed to 68.4%, 19.2%, and 9% of the skull-based tumors, respectively. Mortality following skull base tumor resection was 21.1%. On multivariable binary logistic regression analysis, intraoperative iatrogenic vascular insult (AOR = 28.76, 95% CI: 6.12-135.08, p = 0.000), intraventricular hemorrhage (AOR = 6.32, 95% CI: 1.19-33.63, p = 0.031), hospital-associated infection (AOR = 6.96, 95% CI: 2.04-23.67, p = 0.002), and extubation time exceeding 24 h (AOR = 12.89, 95% CI: 4.89-40.34, p = 0.000) were statistically significant with 3-month mortality. Mortality from skull base tumor resection remains high in our setting. Holistic pre-operative surgical planning, meticulous intraoperative execution of procedures, and post-operative dedicated follow-up of patients in a neurointensive care unit alongside quality improvement works on identified risks of mortality are strongly recommended to improve patient outcomes. The urgent need for setup improvement and further training of neurosurgeons is also underscored.

Management of Sacrocolpopexy Mesh Complications-A Narrative Review and Clinical Experience from a Large-Volume Center.

Despite the reputation of sacrocolpopexy as a highly durable reconstructive surgery for pelvic organ prolapse, mesh-related complications remain a significant deterrent for patients. This review discusses the incidence, presentation, diagnosis, management and prevention of sacrocolpopexy mesh complications. We reviewed the literature on sacrocolpopexy focusing on long-term mesh complications and their management. As the literature is not specifically robust, we also give our recommendations based on experience from a large-volume center. Intraoperative videos and images are provided to illustrate findings and management techniques. Sacrocolpopexy mesh complications include vaginal mesh exposure; bladder or bowel erosions; inflammatory and infectious conditions including spondylodiscitis; and mesh-related pain. Presentation ranges from overt symptoms such as mesh palpated in the vagina to insidious-like spondylodiscitis manifesting as back pain and malaise. Diagnosis relies on methodical history taking, review of operative reports, and a physical examination, with office-based endoscopy studies and imaging as indicated. Various management options have been described in the literature. We recommend an expectant approach for asymptomatic patients; For symptomatic vaginal exposure, we encourage removal of entire mesh arm(s) via an abdominal approach; however, many prefer to utilize a transvaginal or partial excisional approach first. Spondylodiscitis is managed with long-term antibiotics and often requires mesh removal. Prevention strategies include using a lightweight polypropylene mesh attached to well- vascularized vaginal walls, avoiding direct placement on any sutured vaginotomy or cystotomy. Delayed absorbable monofilament suture is non-inferior to permanent suture. Sacrocolpopexy mesh complications can be challenging to diagnose and manage. Symptomatic cases often require a proactive approach; listening to patients when they describe persistent symptoms with postoperative onset; a low threshold for further evaluation; and upfront discussion of management options.

Safety of pediatric cardiac catheterisation procedures performed in rural India in a catheterisation lab setup for adult work

Introduction: The congenital heart disease (CHD) makes the largest group of congenital defects children are born with. The conservative estimate points towards 1% prevalence of CHD among the newborn. In India, each year approximately 2.4 lakh children are born with CHD, which is largest in the world. There are very centres offering paediatric cardiology services in India and they are unevenly distributed. Because of this, a lot of paediatric patients with CHD get treated at an adult cardiology facility, not always equipped with proper setup to handle complexities associated with paediatric cardiology work. The study aims to assess the safety and complications associated with paediatric cardiology catheterization-based procedures in a Cath lab is primarily used for adult cardiology work.Methods: The current study is a retrospective review of pediatric cardiac cath-lab-based procedures performed between April 2018 and March 2021.Results: During the study, 110 pediatric patients underwent 110 cath-lab-based procedures. A total of 20 procedures were performed as an emergency, and 90 were performed as planned procedures. Out of 110 procedures performed, 86.4% were completed without complications. Minor complications were observed in 9.1% of the procedure. Major complications were seen in 3 patients, and two patients died.Conclusion: The analysis shows that the complications associated with pediatric cardiac procedures performed on rural-based cath-lab oriented toward adult cardiology work are comparable to those of other large-volume pediatric cardiac centres.

Thyroid-stimulating hormone suppression in low-risk papillary thyroid cancer: a large-scale retrospective analysis of real-world data

Over 500,000 new cases are diagnosed with papillary thyroid cancer (PTC) globally per year, of whom the vast majority are in the low-risk stratification. Although thyroid-stimulating hormone (TSH) suppression is traditionally recommended for all postoperative PTCs in current guidelines, its necessity remains highly controversial in low-risk patients. Since relevant recommendations in current guidelines are still empirical, we aim to provide a direct, large-scale, real-world evidence. This large-scale real-world retrospective study included 11,140 low-risk PTC patients from two Chinese large-volume centers (Fudan University Shanghai Cancer Center [FUSCC] and Cancer Hospital of Chinese Academy of Medical Sciences [CH-CAMS]) treated from January 1, 2000 to June 30, 2022. The mean TSH level was calculated based on postoperative serum TSH values during follow-up. The primary outcome was the association between postoperative TSH level and structural recurrence assessed by Kaplan-Meier, log-rank, multivariate Cox regression analyses and equivalence testing by Two One-Sided Tests (TOST) procedure. Propensity score matching (PSM) was used to adjust for confounders among groups. A total of 11,140 patients with low-risk PTC were included with a median follow-up of 70 months. Based on the mean TSH level, we classified these patients into ≤0.5 (n=1,504, 13.5%), (0.5-1] (n=4,336, 38.9%), (1-2] (n=4,285, 38.5%), (2-3] (n=704, 6.3%) and >3 (n=311, 2.8%) mU/L groups. After PSM adjusting for age, sex, T and N stage, 8991 patients were included in further analysis, for whom the log-rank analyses showed no significant differences between any two groups (all P>0.05) in recurrence-free survival (RFS), locoregional recurrence-free survival (LRRFS) and distant metastasis-free survival (DMFS), and suppressed TSH was not associated with tumor recurrence in the multivariate Cox analysis (TSH > 2 group vs TSH ≤ 2 group: HR=1.30, 95% CI=0.85-2.01, P=0.23). Furthermore, the TOST equivalence tests showed that tumor recurrence status of any two TSH groups were statistically comparable (all Bonferroni-corrected P values<0.005). Subgroup multivariate analyses showed that TSH level did not impact tumor recurrence regardless of age, tumor size, lymph node metastasis, multifocality, surgical extent, biochemical evidence. Our results suggested that postoperative TSH level was not associated with tumor recurrence in patients with low-risk PTC, for whom deliberate TSH suppression may be exempted to avoid potential secondary complications. Maintaining a TSH level within the normal range may be safe for these patients. The study was supported by the National Natural Science Foundation of China (82072951 to Y.W.; 82373008 to X.S.), Shanghai Hospital Development Center (SHDC2020CR6003-001 to Y.W., SHDC2024CRI087 to Y.-J.W.), the Science and Technology Commission of Shanghai Municipality (22Y21900100/23DZ2305600 to Y.W.; 23ZR1412000 to X.S.), the Shanghai Anticancer Association Foundation (SACA-AX202213 to Yu Wang), Shanghai Municipal Health Commission and Shanghai Medicine and Health Development Foundation (WJWRC202302 to X.S.).

Smaller intrinsic QRS area and smaller reduction of QRS area during cardiac resynchronisation therapy are associated with higher risk of ventricular arrhythmias and appropriate ICD therapy

Abstract Background Cardiac resynchronisation therapy (CRT) patients are at high risk for ventricular arrhythmias (VAs), and little is known about which characteristics are associated with an increased risk for arrhythmic events. Purpose To investigate the association between QRS area parameters and the risk for VAs in patients with heart failure undergoing primary preventive CRT with defibrillator (CRT-D) implantation. Methods All patients receiving CRT-D between 2015 and 2020 at a large-volume tertiary care center were retrospectively evaluated. Digital 12-lead electrocardiograms (ECGs) were collected before and after CRT implantation. Patients were included if they had native LBBB and were implanted with a primary preventive CRT-D. Kors’ regression transformation was used to derive vectorcardiographic QRS area from the 12-lead ECGs. QRS area parameters were analysed in relation to a primary endpoint of first appropriate ICD therapy, i.e., ATP or shock therapy. Results 177 patients with LBBB (68.9 years [60.7–73.8]; 21.5% female; 52.9% New York Heart Association (NYHA) class III-IV; LVEF 25.9±6.3%) were followed over a median follow-up time of 2.5 years [1.6–3.0] after CRT-D implantation. 27 patients reached the primary endpoint. The median pre-CRT QRS area was 134.5 μVs [102.3–163.8]. Multivariable Cox regression identified a small pre-CRT QRS area (HR, per 10 μVs decrease, 1.30; [1.12–1.51]; p=&amp;lt;.001) and a small post-CRT reduction in QRS area (HR, per 10 μVs decrease, 1.30; [1.13–1.49]; p=&amp;lt;.001) as independent predictors of an increased risk of appropriate ICD therapy. In analyses with a scoring variable combining pre-CRT QRS area and QRS area reduction both above or below median, the combination of a small pre-CRT QRS area and a small QRS area reduction was strongly associated with an increased risk of reaching the endpoint (HR, per point increase, 2.47; [1.2–4.9]; p=0.01). Conclusion A small intrinsic QRS area, by itself or in combination with a small reduction of post-CRT QRS area, was strongly associated with a higher risk of ventricular arrhythmias in this cohort of CRT-D treated patients. In conjunction with other parameters, further risk stratification for arrhythmic events could be achieved by assessing QRS area data pre- and post-CRT.Figure 1.K-M pre-CRT QRS area quartilesFigure 2.K-M QRS area score

Implementing a novel selection criteria and pathway for same-day discharge after TAVI

Abstract Background The expansion in indications for transcatheter aortic valve implantation (TAVI) has fuelled an increase in demand worldwide. Prolonged waiting lists and waiting list mortalities are not infrequent and often arise from limited hospital capacity and infrastructure. Approaches to address this have included procedural modifications – ‘minimalist TAVI’ and more recently the development of pathways to facilitate early discharge post-TAVI, such as same-day discharge (SDD) post-procedure. Purpose This study aims to evaluate the safety and effectiveness of a novel SDD pathway a large volume tertiary referral cardiac centre. Methods A new SDD pathway was established between March 2023 and February 2024 at a large-volume tertiary cardiac centre in UK. All patients accepted for TAVI were screened for SDD suitability based on three factors: 1) availability of adequate social support, (defined as presence of able-bodies adult individual to assist in home recovery), 2) technically suitable for transfemoral approach and 3) presence of previous pacemaker or low risk for conduction abnormalities (defined as no baseline conduction disturbances). Following TAVI, patients were deemed suitable for SDD if they were clinically stable, the procedure was technically successful and there were no procedural complications. Demographic, clinical, procedural and outcome data were collected for all patients enrolled onto the SDD pathway and reasons for non-SDD were identified. Ethical approval was obtained in accordance with local institutional policies. Results From March 2023 to February 2024, 81 out of 305 patients (26.6%) were enrolled onto the SDD pathway (median age 82 years old, 66.7% male, median STS risk score 2.34%). Indications for TAVI were severe native aortic stenosis (74/81, 91.4%), severe native aortic regurgitation (2/81, 2.5%) and severe surgical valve degeneration (5/81, 6.2%). SDD was feasible for 58/81 (71.6%) of patients, with 10/81 (12.3%) discharged the following day and 13/81 (16.0%%) requiring &amp;gt;24 hours hospital admission (Figure 1). Reasons for non-SDD included new conduction abnormality (10/81, 12.3%), vascular complication (6/81, 7.4%), acute stroke (3/81, 3.7%), patient preference (2/81, 2.5%) and haemodynamic instability (2/81, 2.5%). Out of the 58 SDD patients, 25/58 (43.1%) had no previous permanent pacemaker system and in these patients a balloon-expandable valve was selected for 24/25 (96.0%) of patients (Figure 2). Conclusions Patient selection based on the presence of social support at home, low risk of conduction abnormalities or previous pacemaker combined with appropriate valve selection can facilitate a safe and effective SDD post-TAVI programme.

Sex-specific prognostic implications of new-onset atrial fibrillation in patients treated with dual chamber pacemakers

Abstract Background Right ventricular pacing induces ventricular dyssynchrony, which over time may result in left ventricular dysfunction, increased left ventricular filling pressures, and ensuing left atrial dilatation, with increased risk of atrial arrhythmias. Atrial fibrillation (AF) prior to device implant is associated with worse prognosis, but the prognostic effects of new-onset AF during pacemaker treatment are less well described. Purpose To describe risk factors, incidence, and prognostic effects of new-onset AF after treatment is initiated with a dual chamber pacemaker. To evaluate mortality and risk of heart failure diagnosis or hospitalisation for heart failure in patients who develop AF, compared to those who do not develop AF. Methods All patients without pre-existing heart failure or atrial fibrillation, who received a dual chamber pacemaker at a large-volume tertiary care center during the period 2005–2020 were included. Data was crossmatched between the national pacemaker registry, the population registry and national disease registries. The primary outcome was 10-year mortality, and the secondary outcome was new-onset heart failure. Results 37127 patients were included in the study, of which 14760 (30%) were female. Median age was 76.4 years [interquartile range, IQR, 68.0–83.1] and the most common indication for pacemaker implant was AV block (57.7%), see Table 1. Overall, 10-year survival was higher for female patients, compared to male patients, p&amp;lt;0.0001 (see Kaplan-Meier curve in Figure 1A). Patients who developed new-onset AF had more comorbidities, were slightly older and a higher percentage were men. During follow-up 3661 (9.9%) developed atrial fibrillation within two years (9.1% of female and 10.3% of male patients, p&amp;lt;0.001), at a median of 291 [88–461] days after implant. In multivariable Cox regression analysis with new-onset AF as time dependent covariable and adjusted for clinically relevant covariables, AF was an independent predictor of higher all-cause mortality (HR 1.43 [1.37–1.49], p&amp;lt;0.0001). Risk factors for new-onset AF included increasing age, male sex, hypertension, malignancy, diabetes, chronic obstructive lung disease, chronic renal disease, and sick sinus syndrome indication (all p&amp;lt;0.01). In separate analyses for men and women, the risk factors and magnitude of odds ratios were the same. Conclusion In patients treated with dual chamber pacemakers due to bradycardia or AV block, development of new-onset AF within two years was associated with a higher 10-year mortality. The risk of developing AF was higher for men, but the negative prognostic effect was more pronounced for women.Figure 1A.-B. K-M survival curves

A larger reduction of spatial mean QRS-T angle during cardiac resynchronisation therapy is associated with a lower risk of mortality and heart failure hospitalisation

Abstract Background Predicting clinical outcome in heart failure patients undergoing cardiac resynchronization therapy (CRT) remains challenging, necessitating improved risk stratification for CRT recipients. Previous studies have shown an association between large spatial peak and mean QRS-T angles and cardiovascular disease. Little is known, however, about their relation to clinical outcome following CRT. Purpose To investigate the association between spatial peak and mean QRS-T angles and long-term clinical outcome following CRT initiation. Methods All patients with native LBBB receiving CRT at a large-volume tertiary care center between 2015 and 2020 were retrospectively evaluated. Spatial peak and mean QRS-T angles were derived from digital pre- and post-CRT 12-lead ECGs that were processed using Glasgow algorithm and Kors’ regression transformation. The QRS-T angles and their change after CRT were analyzed in relation to the primary composite endpoint of heart failure hospitalisation or all-cause mortality using Cox regression analysis adjusted for clinical covariates (age, gender, CRT-P or CRT-D, secondary ICD indication, ischemic etiology, NYHA class, LVEF, diabetes, atrial fibrillation, baseline QRS duration, NT-proBNP, and eGFR). Results The study group comprised 250 patients (a median age [Q1–Q3] of 72.2 years [64.5–76.3]; 22% female; 58% New York Heart Association (NYHA) class III-IV; LVEF 27% [22–30]) who were followed over a median follow-up time of 4.5 years [3.2–5.8] after CRT implantation. The median post-CRT spatial peak and mean QRS-angles were 142° [116–160] and 152° [127–166], and the median angle was decreased by 16° [-0.6–41] and 14° [-0.4–38], respectively. Both a larger post-CRT mean QRS-T angle (HR 1.20, 95%CI 1.08-1.33, p=&amp;lt;.001) and peak QRS-T angle (HR 1.08, 95%CI 1.01-1.17, p=0.046) were associated with the primary endpoint. A larger reduction of mean QRS-T angle, but not peak QRS-T angle, was associated with a risk reduction (HR 0.87, 95%CI 0.79-0.95, p&amp;lt;0.003). In Kaplan-Meier analysis, patients with a post-CRT mean QRS-T angle above median had a higher risk of reaching the endpoint (log-rank p=0.002, Figure 1). Conclusion Our results show that a larger magnitude of the post-CRT spatial peak and mean QRS-T angles, and a larger reduction of the latter, are associated with long-term heart failure hospitalisation and death. These findings suggest that spatial QRS-T angle may have a potential role in refined risk stratification of CRT patients.Figure 1.K-M curve spatial mean QRS-T

Cardio-pulmonary exercise testing in adult congenital heart patients: a new data-focused approach to predict mortality

Abstract Background/Introduction The cardio-pulmonary exercise test (CPET) has been a pivotal tool for functional and prognostic evaluation in adults with congenital heart disease (ACHD). During a routine CPET test, a myriad of variables are collected reflecting the cardiovascular, pulmonary, and skeletal muscle systems. However, clinicians typically use only a few easily and accessible variables to establish prognosis, which can come at an accuracy cost. Machine learning algorithms have undergone significant development in recent years and have found applications in the medical field. One of their main advantages is the ability to handle a large number of variables and extract information from their various combinations, while excluding redundant data, thus offering a higher level of prediction accuracy. Purpose Our objective was to develop a machine learning model to predict death during follow-up in a large population of ACHD patients who have undergone routine CPET in a large-volume single specialist centre. Methods All available CPET studies for adult ACHD patients (age &amp;gt; 15 years) performed from December 1999 to December 2021 at our centre were included, and all standard available variables were extracted. The primary outcome was all-cause mortality since the CPET, collected up to November 2023. Data exploration, data cleaning, and feature engineering steps were conducted using Python (v3.8). Continuous variables were standardised. The supervised machine learning algorithm XGBoost was used for classification (all-cause mortality), with the best hyperparameters selected through cross-validation. For the final model, a feature importance analysis based on permutation techniques was used to explore the variables with more impact on model accuracy. Results A total of 6361 studies were included, with median age of 31 years (IQR 23-43), 56% male. During follow-up, a total of 491 deaths were recorded. Of available demographic, clinical and exercise parameters (n=129 variables), 21 were deemed sufficient in terms of completeness, absence of significant correlation and clinically relevant for the subsequent analysis. These included demographic variables (age and sex) and CPET variables (peak VO2, FEV1, peak heart rate, exercise time, etc.) and were used to train the model. The accuracy of the model in predicting death after CPET in the test set had an accuracy of 93.5% and an area under the ROC curve (AUC) of 85.0% (Figure1). The parameters with the highest relative feature importance were FEV1, body mass index and percent predicted peak VO2 (Figure 2). Conclusions Machine learning models can be effectively employed in specialised cardiac populations, such as ACHD, potentially providing a high level of prediction accuracy by efficiently harnessing the potential of available data. However, its applicability to mortality prediction for ACHD patients requires further external validation.ROC curve AUC for the model predictionsFeature importance using permutation

Discontinuation of Cerebro-Spinal Fluid (CSF) Drainage in Acute Hydrocephalus: A Prospective Cohort Study and Exploratory Data Analysis.

The optimal management of CSF drainage in acute hydrocephalus, in particular when to initiate drain weaning, remains uncertain. This study aimed to evaluate the impact of timing and method of drain weaning on patient outcomes. This prospective observational study in a large-volume tertiary neuroscience centre included all adult patients who required temporary CSF drainage for acute hydrocephalus of any cause between January 2020 and March 2021. Contemporaneous data collection was conducted, including patient demographics, time to clamp, weaning methods, and clinical outcomes of hospital length of stay (LOS), rate of shunt insertion, drain-related infections, and mechanical complications. Univariate and multivariate statistical analyses were performed to identify the independent associations of timing-related factors. A total of 69 patients were included (mean age = 59.4 years). A total of 59% had CSF diversion for aneurysmal subarachnoid haemorrhage, and 88% had EVD drainage. The length of drainage prior to the first clamp was significantly associated with the overall length of drainage (p < 0.0001), LOS (p = 0.004), and time to shunt (p = 0.02) following multivariate adjustment. For each day delayed in initiating the drain challenge, the overall LOS increased by an additional 1.25 days. There was no association between the weaning method and LOS, the rate of shunting, or CNS infection; however, those in the gradually weaned group had more mechanical complications, such as drain blockage or CSF leakage, than those rapidly weaned (p = 0.03) after adjustment. This study recommends challenging the drain early via a rapid wean to reduce LOS, mechanical complications, and possibly infections. The consequences of temporary CSF diversion have significant implications at financial and patient levels, but the quality of evidence regarding weaning remains poor. Further randomised multicentre studies and national databases of practice are required to allow definitive conclusions to be drawn.

Determining the association of hyperoxia while on extracorporeal life support with mortality in neonates following Norwood operation.

Patients requiring extracorporeal life support (ECLS) support post-Norwood operation constitute an extremely high-risk group. We retrospectively aimed to evaluate the relationship of hyperoxia with mortality and other clinical outcomes in patients who required ECLS following Norwood operation between January/2010 and December/2020 in a large volume center. During the study period 65 patients required ECLS post-Norwood. Using receiver operating characteristic (ROC) curve analysis, mean PaO2 of 182mmHg in the first 48-hour on ECLS was determined to have the optimal discriminatory ability for mortality (sensitivity 68%, specificity 70%). Of the 65 patients, 52% had PaO2>182mmHg and were designated as hyperoxia group. Patients in the hyperoxia-group had longer cardiopulmonary bypass time (187 vs. 165min, p=0.023), shorter duration from CICU arrival to ECLS-cannulation (13.28 vs. 132.58h, p=0.003), higher serum lactate within 2-hours from ECLS-canulation (14.55 vs. 5.80, p=0.01), higher ECLS flows in the first 4-hours (152.68 vs. 124.14, p=0.006), and higher mortality (77% vs. 39%, p=0.005).In the unadjusted-analysis, using a derived cut-point, patients in the hyperoxia-group had 5.15 higher odds of mortality (p=0.003). However, this association was insignificant when adjusting for confounding variables (p=0.104). Using a functional status scale, new morbidity (38% vs. 21%), and unfavorable outcomes (13% vs. 5%) were higher in the hyperoxia group. Despite being higher in the hyperoxia group, this did not reach statistical significance. Neonates with hyperoxia (PaO2>182Torr) during the first 48-hour of ECLS post-Norwood operation had 5 times higher odds of mortality in the unadjusted analysis, however, this was insignificant when adjusting for confounding variables. Patients in the hyperoxia group had shorter duration from CICU arrival to ECLS-cannulation, higher serum lactate prior to ECLS-canulation, and higher ECLS flows in the first 4-hours, (p<0.05). Multicenter evaluation of this modifiable risk factor is imperative to improve the care of this high-risk cohort.

Controlling the structure of nitrogen-doped zeolite-templated carbon for CO2 capture based on the synthesis conditions

The surface chemistry and the textural properties of nitrogen-doped zeolite-templated carbon materials (N-ZTC) are decisive for their functionality in CO2 capture. This study analyses how the synthesis conditions affect the structure, formation of N-containing functional groups, thermal stability and CO2 capture of N-ZTC in comparison with nitrogen-free ZTC. Faujasite as a hard template and chemical vapour depositions (CVD) with propene and acetonitrile were used for the synthesis of ZTC and N-ZTC, respectively. XRD, SEM, N2 and CO2 sorption, XPS and TG/DSC analyses showed that the structural ordering and microporous volume in N-ZTC increases with increasing synthesis temperature. Conversely, at higher temperatures, the content of basic pyridinic groups in N-ZTC decreases in favour of stable graphitic nitrogen. The Lewis acid−base interaction of CO2 with the pyridinic groups provides the highest adsorption heats, the highest affinity for CO2 compared to N2 and enhances CO2/N2 selectivity (CO2/N2 selectivities of 127, 95, 89, and 66 for N-ZTC750°C, N-ZTC800°C, N-ZTC850°C and ZTC, respectively). The maximum adsorption capacity was achieved for N-ZTC800°C still yielding a high content of basic groups and a larger micropore volume compared to N-ZTC750°C. The decisive factor for the selectivity is thus the presence of basic centers attainable in N-ZTC at a lower synthesis temperature. The maximum adsorption capacity is associated with a large microporous volume and basic centers in N-ZTC synthesized at medium temperatures. The energy of CO2 adsorption by Lewis acid−base interactions and well-developed micropores are decisive for high selectivity and large adsorption capacity for efficient CO2 capture using N-ZTC materials.

Cardio-Renal-Metabolic Outcomes Associated With the Use of GLP-1 Receptor Agonists After Heart Transplantation.

The use of glucagon-like-peptide 1 receptor agonists (GLP1-RA) has dramatically increased over the past 5 years for diabetes mellitus type 2(T2DM) and obesity. These comorbidities are prevalent in adult heart transplant (HT) recipients. However, there are limited data evaluating the efficacy of this drug class in this population. The aim of the current study was to describe cardiometabolic changes in HT recipients prescribed GLP1-RA at a large-volume transplant center. We retrospectively reviewed all adult HT recipients who received GLP1-RA after HT for a minimum of 1-month. Cardiometabolic parameters including body mass index (BMI), lipid panel, hemoglobin A1C, estimated glomerular filtration rate (eGFR), and NT-proBNP were compared prior to initiation of the drug and at most recent follow-up. We also evaluated for significant dose adjustments to immunosuppression after drug initiation and adverse effects leading to drug discontinuation. Seventy-four patients were included (28% female, 53% White, 20% Hispanic) and followed for a median of 383 days [IQR 209, 613] on a GLP1-RA. The majority of patients (n = 56, 76%) were prescribed semaglutide. The most common indication for prescription was T2DM alone (n = 33, 45%), followed by combined T2DM and obesity (n = 26, 35%). At most recent follow-up, mean BMI decreased from 33.3 to 31.5 kg/m2 (p < 0.0001), HbA1C from 7.3% to 6.7% (p = 0.005), LDL from 78.6 to 70.3 mg/dL (p = 0.018) and basal insulin daily dose from 32.6 to 24.8 units (p = 0.0002). HT recipients prescribed GLP1-RA therapy showed improved glycemic control, weight loss, and cholesterol levels during the study follow-up period. GLP1-RA were well tolerated and were rarely associated with changes in immunosuppression dosing.