Mazankowski Alberta Heart Institute Research Articles

Mitral valve surgery in octogenarians: long-term and hemodynamic results.

Octogenarians are often denied mitral valve (MV) surgery secondary to concerns over increased perioperative morbidity and mortality. The objective of this study was to examine the outcomes of octogenarians undergoing mitral valve repair (MVr) and replacement (MVR). The outcomes of 139 patients between the ages of 80-90 who underwent MVR/MVr between 2004-2018 at the Mazankowski Alberta Heart Institute (Edmonton, AB, Canada) were retrospectively analyzed. Follow-up was extended to a maximum of 15.8 years. Following MVR, all-cause mortality at 30 days, 1 year, 5 years, 10 years, and the longest follow-up was 7%, 14%, 36.3%, 61.8%, and 67.7%, respectively. Post-MVr, all-cause mortality at the same time points was 1.9%, 7.6%, 22.5%, 55.5%, and 100%, respectively. During the Hospitalization Index, rates of new-onset atrial fibrillation, sepsis, acute kidney injury, superficial sternal wound infection, deep sternal wound infection, mediastinal bleeding, and permanent pacemaker insertion ranged from 22.1-34.0%, 3.8-11.0%, 7.6-22.0%, 1.9-2.4%, 0-1.2%, 0%, and 0-6.1%, respectively. Rates of overall rehospitalization, as well as readmission for heart failure, stroke, myocardial infarction, and MV reoperation ranged from 71.0-85.5%, 52.2-63.3%, 10.9-22.8%, 1.9-6.0%, and 0% during the follow-up period. There were significant reductions in peak MV gradient (P=0.042) and left ventricular internal diameter in diastole (LVIDd; P=0.008) post-MVR, as well as LVIDd (P<0.001) and Left Atrial (LA) Volume Index (P=0.019) post-MVr. Octogenarians exhibit positive left atrial and left ventricular remodeling following MVR. Perioperative morbidity is low, late survival is reasonable, and long-term morbidity is considerable. Overall, these results add to the growing literature that MV surgery is relatively safe and effective in octogenarians.

Abstract 13531: Uptake of SGLT2i and Outcomes in Patients With Diabetes and Chronic Heart Failure: A Community-Based Cohort and a Specialized Clinic Cohort

Introduction: Sodium/glucose cotransporter 2 inhibitors (SGLT2i) have an established benefit in people with diabetes mellitus (DM) and chronic heart failure (HF). We aimed to evaluate the uptake and impact of these agents in two cohorts: a community-based cohort of all adults with DM and HF in Alberta who had an echocardiogram and a cohort of people with DM and HF being cared for in a specialized heart failure clinic (HFC). Methods: We identified the community-based cohort using validated ICD code-based case definitions for DM and HF (physician claims, outpatient, hospitalization databases) with an echocardiogram study (available from two major centres) from 2015 (when SGLT2i were available provincially) to March 2022. In addition, we identified the HFC cohort by chart review of patients seen in the Mazankowski Alberta Heart Institute HFCconsented between February 2018 and August 2021 with HF and DM and followed them until August 2022. We examined the association between SGLT2i use and all-cause mortality and/or cardiovascular (CV)-related hospitalizations using Cox proportional hazard models adjusted for clinical covariates and time-varying SGLT2i use. Results: In 12,150 people with DM and HF in the community-based cohort, 2,321 (19.1%) were dispensed an SGLT2i compared to 208 (39.2%) of the 530 patients with DM and HF followed in the HFC. SGLT2i was associated with less CV-related hospitalization and all-cause mortality (the composite outcome) (aHR 0.65 [95%CI 0.58 - 0.73]) in the community but no difference (aHR 0.88 [95% CI 0.64 - 1.21] in the HFC. SGLT2i use was associated with less all-cause mortality (aHR 0.50 [95% CI 0.44 - 0.57]) in the community but no difference (aHR 0.81 [95% CI 0.54 - 1.20]) in the HFC. Conclusion: Despite robust randomized trial evidence of clinical benefit, the uptake of SGLT2i even in people with DM and HF remains low. Although uptake is higher in a specialized HFC overall the rate is below optimal. Multifaceted Strategies (targeted to healthcare professionals, patients, and policymakers) to guide risk identification and raise awareness on the clinical benefits of these agents are warranted.

A Novel 3D-to-3D Diffeomorphic Registration Algorithm With Applications to Left Ventricle Segmentation in MR and Ultrasound Sequences

Left ventricular segmentation is a difficult and time-consuming task performed by clinicians, requiring the use of manual contours. We propose a novel three-dimensional diffeomorphic registration algorithm for endocardial segmentation of the left ventricle in magnetic resonance images and ultrasound temporal sequences. The proposed diffeomorphic registration method computes a voxel-to-voxel correspondence in three-dimensional space and is parameterized by one radial and three curl components to emulate the cardiac deformations. In addition, the proposed method allows for enforcing constraints to control the amount of deformation. The method was evaluated on 521 temporal frames from 20 patients from the Automated Cardiac Diagnosis Challenge magnetic resonance imaging dataset and 213 frames from 10 patients undergoing ultrasound scans from the Mazankowski Alberta Heart Institute. The algorithm was compared against six other registration methods, the Symmetric Normalization algorithm from the Dipy package, two variants of the Demons algorithm from the Insight Toolkit software package, two versions of RealTiTracker, and Elastix. The proposed method yielded overall Dice scores of 98.10 (0.90)% for the MRI dataset and 92.90 (2.42)% for the ultrasound dataset. The robustness of the algorithm is demonstrated by the high performance on multiple imaging modalities and various patient abnormalities.

Abstract 11518: Incidence of Peripheral Arterial Disease in Patients With Coronary Artery Disease Following Cardiac Catheterization: A Prospective Observational Study

Introduction: Peripheral arterial disease (PAD) is a common vascular condition affecting roughly 800,000 Canadians annually with up to 50% being asymptomatic. As such, PAD is underdiagnosed and undertreated, despite being an independent predictor of cardiovascular (CV) risk. Moreover, PAD is commonly seen in patients with coronary artery disease (CAD) due to their shared atherosclerotic pathophysiology. Our aim was to gain a better understanding of the incidence and symptomatology of PAD in patients with established CAD on coronary angiography. Methods: Prospective subjects with CAD demonstrated on coronary angiography were immediately screened for PAD at the Mazankowski Alberta Heart Institute Cardiac Catheterization Laboratory. Following consent, a bedside ankle-brachial-index (ABI) (Microlife WatchBP Office ABI) was performed and the Edinburgh Claudication Questionnaire (ECQ) (validated for PAD) was administered. PAD was defined as an ABI≤0.90. Results: We recruited 100 patients (67.5 age ± 9.5 years, 18.0% female) between June 2021 to April 2022. Eighteen subjects (18.0%) had PAD as demonstrated by an abnormal ABI. In those with diabetes (n=34), PAD was more frequent (26.5% vs. 14.1%, p=0.068). Kappa agreement between ECQ and ABI was 0.32. Conclusions: In a prospective cohort of angiographically confirmed CAD patients, one-quarter had ABI confirmed PAD (even more common in diabetics). The ECQ provided modest agreement with ABI suggesting many of these subjects are asymptomatic. ABI can be used as a simple non-invasive tool at the bedside following cardiac catheterization to screen for PAD which has implications on subsequent guideline-directed medical therapy.

A New Semi-automated Algorithm for Volumetric Segmentation of the Left Ventricle in Temporal 3D Echocardiography Sequences.

Echocardiography is commonly used as a non-invasive imaging tool in clinical practice for the assessment of cardiac function. However, delineation of the left ventricle is challenging due to the inherent properties of ultrasound imaging, such as the presence of speckle noise and the low signal-to-noise ratio. We propose a semi-automated segmentation algorithm for the delineation of the left ventricle in temporal 3D echocardiography sequences. The method requires minimal user interaction and relies on a diffeomorphic registration approach. Advantages of the method include no dependence on prior geometrical information, training data, or registration from an atlas. The method was evaluated using three-dimensional ultrasound scan sequences from 18 patients from the Mazankowski Alberta Heart Institute, Edmonton, Canada, and compared to manual delineations provided by an expert cardiologist and four other registration algorithms. The segmentation approach yielded the following results over the cardiac cycle: a mean absolute difference of 1.01 (0.21) mm, a Hausdorff distance of 4.41 (1.43) mm, and a Dice overlap score of 0.93 (0.02). The method performed well compared to the four other registration algorithms.

Mid-term outcomes with adult endovascular treatment of coarctation of the aorta

BackgroundThis study examines the contemporary medium- and long-term outcomes of endovascular repair of aortic coarctation in the adult. MethodsWe reviewed the clinical and imaging data of 56 consecutive adult patients with aortic coarctation who underwent endovascular repair at the Mazankowski Alberta Heart Institute, Edmonton, Alberta, Canada, from 2003 to 2018. ResultsThere were 20 (35.7%) female and 36 (64.3%) male patients (including 9 re-intervention cases) with a mean age of 33.6 ± 13.6 years. Thirty-seven (66.1%) were treated with balloon-expandable covered stent and 12 (21.4%) were treated with balloon-expandable bare-metal stent. Pressure gradients decreased from baseline level of 27.99 ± 12.75 (8–70) mm Hg to 5.33 ± 4.42 (0–17.5) mm Hg following the procedure. There were 2 (3.6%) procedure related complications (aortic dissection [n = 1] and stent malposition [n = 1]). During a median (Q1 - Q3) follow up of 5.36 (2.28–7.58) years, 2 deaths (4.2%) and 9 (19%) re-interventions occurred, and the overall survival was 95.8%. ConclusionPercutaneous coarctoplasty, with either covered or bare metal stents, is a safe and durable option for aortic coarctation repair with excellent long-term survival.

The Mechanism of Mitral Regurgitant Jets Identified by 3-Dimensional Transesophageal Echocardiography.

This study is a case report, which presents a case of severe mitral regurgitation in a 77-year-old man. Two-dimensional transesophageal echocardiography (TEE), regurgitant jets directed anteriorly in early systole and centrally to laterally in late systole were seen, while three-dimensional TEE showed a flail posterior middle scallop not only angulated centrally, but also laterally, which provided insight into the mechanism of mitral regurgitant jet direction. This case demonstrates the clinical usefulness of 3-dimensional TEE for identifying the mechanism of mitral regurgitant jets.The institution where the figures and the videos were recorded: Division of Cardiology, Mazankowski Alberta Heart Institute, University of Alberta Hospital, Edmonton, Alberta, Canada.

Common Hospital Ingredient Perfusate Equivalent to Standard Krebs–Henseleit Buffer with Serum Albumin Derived Perfusate in Negative Pressure Ventilation Ex Vivo Lung Perfusion

Introduction Normothermic ex-vivo lung perfusion (EVLP) using negative pressure ventilation (NPV) and red blood cell-based perfusate solutions have been shown to decrease edema formation and pro-inflammatory cytokine production compared to positive pressure ventilation (PPV). We sought to develop a common hospital ingredient derived perfusate (CHIP) with equivalent functional and inflammatory characteristics to the standard Krebs–Henseleit buffer with 8% serum albumin derived perfusate (KHB-Alb) in order to improve access and reduce costs of ex vivo organ perfusion. Methods Porcine lungs were perfused using NPV-EVLP for 12 hours in a normothermic state, and were allocated to two groups: KHB-Alb (n=8) vs CHIP (n=4). Physiologic parameters, cytokine profiles, and edema formation were compared between treatment groups. Results Perfused lungs in both groups demonstrated equivalent oxygenation (partial pressure of arterial oxygen/ fraction of inspired oxygen ratio >350 mmHg) and physiologic parameters. There was equivalent generation of tumor necrosis factor-α, irrespective of perfusate solution used, when comparing CHIP vs KHB-Alb. Pig lungs developed equivalent edema formation between groups (CHIP: 15.7 ± 5.8%, STEEN 19.5 ± 4.4%, p>0.05). Conclusion A perfusate derived of common hospital ingredients provides equivalent results to standard Krebs–Henseleit buffer with 8% serum albumin based perfusate in NPV-EVLP. Canadian Institutes for Health Research - Canadian National Transplant Research Program (CIHR-CNTRP). University Hospital Foundation (UHF). Mazankowski Alberta Heart Institute - University Hospital Foundation Gerald Averback Award in Cardiovascular Gene Therapy / Genomics and Vascular Biology.

A Novel 4D Semi-Automated Algorithm for Volumetric Segmentation in Echocardiography.

Segmentation of the left ventricle (LV) in temporal 3D echocardiography sequences poses a challenge. However, it is an essential component in generating quantitative clinical measurements for the diagnosis and treatment of various cardiac diseases. Identifying the endocardial borders of the left ventricle can be difficult due to the inherent properties of ultrasound. This study proposes a 4D segmentation algorithm that segments over temporal 3D volumes that has minimal user interaction and is based on a diffeomorphic registration approach. In contrast to several existing algorithms, the proposed method does not depend on training data or make any geometrical assumptions. The algorithm was evaluated on seven patients obtained from the Mazankowski Alberta Heart Institute, Edmonton, Canada in comparison to expert manual segmentation. The proposed approach yielded Dice scores of 0.94 (0.01), 0.91 (0.03) and 0.92 (0.02) at end diastole, at end systole and over the entire cardiac cycle, respectively. The corresponding Hausdorff distance values were 4.49 (1.01) mm, 4.94 (1.41) mm, and 5.05 (0.85) mm, respectively. These results demonstrate that the proposed 4D segmentation approach for the left ventricle is robust and can potentially be used in clinical practice.

Outcomes of Solo Smart valve in a single-center experience of 270 patients.

The Solo Smart pericardial aortic valve has been widely used in Europe as an option for aortic valve replacement (AVR). We are reporting early and midterm clinical outcomes of AVR with the Solo Smart valve in a single North America center. This is a retrospective study of 270 consecutive patients who had AVR at Mazankowski Alberta Heart Institute from February 2011 to March 2015. Follow-up and echocardiographic data were collected retrospectively from electronic and paper charts. Univariate and multivariate analysis were performed to evaluate the results. The mean age was 71.2±10.0 years, 67.4% were male, and 79.3% had combined procedures. Mean STS Score was 4.18±3.91. Early mortality was 3.7% for the entire group and 0% for isolated AVR group. Mean cross-clamp time for isolated AVR and AVR with concomitant procedure was 70.8±12.7 min and 117.0±45.0 min, respectively. Permanent pacemaker implantation was necessary in 2.2% of patients. Echocardiography demonstrated a reduction in mean gradients from 40.8±17.4 mmHg to 7.6±3.7 mmHg and peak gradient from 72.5±48.8 mmHg to 15.5±7.5 mmHg. The 1-, 3-, and 5-year overall survival was 93.0%, 86.5% and 75.9%, respectively. At 5 years, freedom from valve-related death was 92.4%, freedom from structural valve deterioration and freedom from aortic valve reoperation were 96.4% and 98%, respectively. The Solo Smart valve is safe and has excellent hemodynamic performance. Aortic valve reoperation and rates of valve-related adverse events during midterm follow-up were low.

CODE BLUE: AN INNOVATIVE APPROACH TO IMPROVE THE RESPONSE

Within the Mazankowski Alberta Heart Institute, a Code Blue is activated for any clinical event necessitating an urgent medical response. During a Cardiovascular (CV) Surgery Ward quality improvement meeting, responding to Code Blue calls was identified as an area warranting exploration and improvement given a series of recent challenging events. A staff survey identified specific areas to focus including three priority areas: 1) Role Standardization 2) Education & Communication and 3) Accessing Equipment. Utilizing the PDSA quality improvement framework, and informed by front-line staff, Code Blue roles were standardized and a process map was developed for the CV Surgery unit. A Code Blue evaluation and debrief tool was created and implemented to foster staff education and increased communication. In addition, a nurse led initiative to improve timely access to auxiliary equipment during a Code event was established. To support the quality improvement efforts an education and communication plan was developed and includes: resource binders, information huddles, and code simulations. To determine if the change was an improvement a survey was rolled out to all unit staff following recent learning sessions on Code Blue documentation. The session was augmented with a visual media tool that reflected a Code Blue scenario specific to the CV Surgery ward. Elements of change were recognized by the majority of staff who attended. Staff engagement was weaved throughout the improvement plan which increased staff confidence during a code. The team’s response to Code Blue calls has contributed to both patient and staff experience.

PRE-OPERATIVE PATIENT PACKAGE FACILITATES SURGICAL PREPAREDNESS

A collaborative multidisciplinary team sought to improve the patient and family experience. The Mazankowski Alberta Heart Institute (Maz) Cardiology Unit identified a gap in the resources provided to semi-urgent patients, as stabilized semi-urgent patients discharged home prior to cardiovascular (CV) surgery would return for their open heart surgery unprepared. In November 2014, a semi-urgent pre-operative patient package (SUPPP) was developed to support patients and staff. A checklist was designed to guide staff through preparatory tasks requiring completion prior to the patient’s discharge and patient resources developed included guidance and information supporting the CV surgery journey. To determine if the SUPPP met patient needs, interviews were conducted with patients and staff. Patients indicated that the SUPPP explained integral parts of their CV surgery and alleviated their anxiety while preparing them for surgery. Staff articulated their satisfaction indicating that patients were consistently prepared, preventing operating room delays or postponements. The Cardiology Unit participated in an innovative quality improvement project to fill a patient education gap. The team partnered to create a patient resource package and tools for staff to ensure patient preparedness. Efforts were reinforced with increased patient, family and staff satisfaction rates. This work facilitated the development of an Emergent and Urgent Pre-Operative Patient Package supporting the needs of a vulnerable surgical population. In addition, the SUPPP will be introduced to all Edmonton zone sites which decant CV Surgery patients to the Maz. This initiative resulted in enhanced quality care and an improved CV surgery patient experience.

Comparison of two commonly used clinical cognitive screening tests to diagnose mild cognitive impairment in heart failure with the golden standard European Consortium Criteria

IntroductionThis study on mild cognitive impairment (MCI) in heart failure (HF) compares the utility of Montreal Cognitive Assessment (MoCA) to the Mini-Mental Status Exam (MMSE) for diagnosing MCI in a HF population when compared to the golden standard European Consortium Criteria (ECC). MethodsParticipants were recruited from the Alberta HEART study at the Mazankowski Alberta Heart Institute in Edmonton and St. Mary's hospital in Camrose. This study enrolled 53 community adults aged>50years: 33 HF and 20 controls. Participants were assessed using both the MMSE and MoCA for MCI. MCI was diagnosed using the golden standard, European Consortium Criteria. Sensitivity and specificity analysis, positive and negative predictive values, likelihood ratios and kappa statistic were calculated. ResultsThe mean age was 72.8years (SD 8.4), 60.4% were females and 34% had underlying ischemic heart disease. Overall, two thirds of patients (22/33, 66%) with HF had MCI. In comparison to European Consortium Criteria, the sensitivity and specificity of MoCA were 82% and 91% in identifying individuals with MCI, and MMSE were 9% and 91%, respectively. The positive and negative predictive values for MoCA were 95% and 71%, and for MMSE were 67% and 33%, respectively. Kappa statistics showed good agreement between MoCA and consortium criteria (kappa=0.68) and a low agreement between MMSE and consortium criteria (kappa=0.07). ConclusionCognitive dysfunction is common in patients with HF. Overall, the MoCA seems to be a better screening tool than MMSE for MCI in HF patients.

Specialized Clinical Competency (SCC) Recertification: A Collaborative Approach

As a standard of practice within the cardiac sciences program at the Mazankowski Alberta Heart Institute, staff skills are evaluated on a yearly basis. In 2008, the nursing recertification program was redesigned to optimize accountability, readiness, and maintenance of required SCC’s.

MORAL DISTRESS AND BURNOUT AMONG HEALTHCARE PROVIDERS IN A CARDIOVASCULAR INTENSIVE CARE

The intensive care unit (ICU) is a busy, high stress, complex environment. The cardiovascular ICU (CVICU) at the Mazankowski Alberta Heart Institute (Maz) has recently been characterized by high acuity and complexity, strained occupancy and challenging end-of-life care, raising concern health care providers are experiencing high levels of moral distress and burnout. An inter-professional team aimed to describe the prevalence and contributing factors to moral distress and burnout among all CVICU providers.

The Effect of Nurse Practitioner-Led Intervention in Diabetes Care for Patients Admitted to Cardiology Services.

To determine the benefits of diabetes nurse practitioner (DNP) intervention on glycemic control, quality of life and diabetes treatment satisfaction in patients with type 2 diabetes (T2DM) admitted to cardiology inpatient services at a tertiary centre. Patients admitted to the cardiology service with T2DM who had suboptimal control (HbA1c >6.5%) were approached for the study. Diabetes care was optimized by the DNP through medication review, patient education and discharge care planning. Glycemic control was evaluated with 3-month post-intervention HbA1c. Secondary outcomes of lipid profiles, quality of life and treatment satisfaction were evaluated at baseline and at 3 months with fasting lipids, Audit of Diabetes-Dependent Quality of Life questionnaires (ADDQoL) and Diabetes Treatment Satisfaction Questionnaires (DTSQ) respectively. With almost 49% of patients admitted to the Mazankowski Alberta Heart Institute having HbA1c <6.5%, only 23 patients completed the study over a 12-month period. We found a significant decrease in HbA1c values at 3 months post-intervention from 8.0% (SD=1. 2) to 6.9% (SD=0.7), p=0.002. LDL showed a significant decrease at 3 months from 1.7 mmol/L (SD=0.7) to 1.1 mmol /L (SD=0.6), p=0.011. Overall median ADDQoL impact scores improved at follow up, from -1.4 to -0.4, p = 0.0003. Overall no significant changes in DTSQ scores were seen. Short-term DNP intervention in T2DM patients admitted to the inpatient cardiology service was associated with benefits in areas of glycemic control and various domains of QoL. Our study provides support for the involvement of DNP in the care of cardiology inpatients at tertiary centres.

BETTER TOGETHER: BOOKING THE OR COLLABORATIVELY

Five percent above the National Healthcare Safety Network (NHSN) benchmark for surgical site infections, the Zone Clinical Department Head and Chief of Cardiac Surgery initiated a quality improvement project to review the issue. Supported by an Infection Control Professional and an Improvement Advisor, a collaborative team of health care practitioners from across the CV surgery program were brought together to improve the quality and safety of surgical care at the Mazankowski Alberta Heart Institute. METHODS: The surgical site infection data was analyzed to differentiate between infection types; organ space, superficial sternum, and leg. To understand the cause of the deep surgical site infections the multi-disciplined team used Plan-Do-Study-Act methodology to review the patient journey starting in the same day admission or in house ward unit and progressed to the operating room (OR), CV Intensive Care Unit (ICU) and CV Ward. Process mapping and chart reviews were conducted to provide in-depth contextual knowledge of each patient identified with a surgical site infection. The collaborative team observed the CV surgical journey through multiple innovative methods: enabling the identification and removal of multiple vectors of infection. RESULTS: Several opportunities for improvement were identified in the OR, CVICU and CV Ward. Table 1 provides an overview of the changes made to decrease contamination thought to contribute to infection. As a result, infection rates decreased from 5.3% in Q2 2012/2013 to 0.5% in Q2 2014/ 2015. A reduction in hospital stays due to infection tapered from 588 days in 2013 to 242 days in 2014. Significant cost savings were also achieved as the CV ward experienced a 55% cost diversion. CONCLUSION: Through innovative collaborative efforts the CV Surgery Program at the Mazankowski Alberta Heart Institute achieved its target rate of 0.5% deep sternal infections. Engagement from all levels of the CV surgery program, healthcare providers, clinicians and leadership, supported improvement efforts to improve the quality and safety of patient care while reducing hospital length of stay and program costs. A culture of partnership and learning enabled a diverse team to explore multiple factors resulting in improved patient care. 093 BETTER TOGETHER: BOOKING THE OR COLLABORATIVELY

ANTICOAGULATION AND ANTIPLATELET PATTERNS IN PATIENTS WITH ATRIAL FIBRILLATION POST-PERCUTANEOUS CORONARY INTERVENTION

Guidelines recommend the use of triple antithrombotic therapy (TAT), defined as ASA, clopidogrel, and warfarin, in patients with non-valvular atrial fibrillation (NVAF) who undergo percutaneous coronary intervention with stent implantation (PCI). This is based on observational data, expert opinion, and standard of care. The objective of this study was to characterize the use of anticoagulant and antiplatelet therapy at discharge in patients with NVAF post-PCI at our institution, and to identify determinants of the most commonly utilized regimens. A retrospective chart review was conducted at the Mazankowski Alberta Heart Institute from January 1, 2011 to December 31, 2013. Adult inpatients with NVAF and a CHADS2 score ≥1 who received PCI were included. Patients with mechanical devices requiring anticoagulation or who underwent cardiac surgery during hospitalization were excluded. Patients were identified using the Alberta Provincial Project for Outcome Assessment in Coronary Heart Disease (APPROACH) database and medical records. The primary outcome was the proportion of patients discharged on TAT. A total of 108 patients were screened with 74 patients included. The median age was 73 years and 73% were male. The majority of patients had dyslipidemia (70%) and hypertension (60%). The median CHADS2 and HASBLED scores were 2 and 3, respectively. Nine patients (12.2%) had a previous gastrointestinal bleed (GIB). Table 1 summarizes the discharge therapy results. Male patients were more likely to receive TAT in a multivariate logistic regression analysis. No patients with a previous GIB received TAT. Positive predictors in a multivariate logistic regression analysis for use of DAT included female sex and previous GIB. Despite a guideline-based indication, less than half of patients received TAT. Non-evidence based combinations of NOACs and ticagrelor were used in one-fifth of patients. Other than consideration of GIB, the rationale for using DAT in place of TAT was unclear. Further studies are needed to elucidate variance from guideline-based therapy.

LIFE AFTER TAVI: EXPLORING PATIENTS' PERCEIVED HEALTH STATUS AFTER TRANSCATHETER AORTIC VALVE IMPLANTATION

Key initiatives jointly developed by the Government of Alberta and Alberta Health Services include improving cardiac health of Albertans, reducing stay in Emergency Departments for discharged patients, and providing a patientfocused health system that is accessible and sustainable for all Albertans. This is partly achieved by establishing clinical pathways to assist patient movement towards best possible outcomes, as well as expanding the scope of practice of Nurse Practitioners (NP).The Chest Pain Program Clinic (CPPC) was established in 2012, as a NP led outpatient clinic at the Mazankowski Alberta Heart Institute, Edmonton, Alberta, within a collaborative practice model. Observations regarding prevalence of cardiovascular risk factors in this cohort, Emergency Department wait times, and continuing challenges facing the NP role will be presented. Findings suggest that the majority of patients were in the high risk category as per Framingham Risk Score, and had 2 or more risk factors for heart disease. Majority of the patients were discharged from the Emergency Departments within 8 hours of admission. Multiple challenges continue to exist for NP practice, and recommendations to possibly reduce these will be highlighted.

EVALUATION OF A NURSE PRACTITIONER LED OUTPATIENT CHEST PAIN PROGRAM CLINIC AT THE MAZANKOWSKI ALBERTA HEART INSTITUTE: A FOLLOW-UP

Key initiatives jointly developed by the Government of Alberta and Alberta Health Services include improving cardiac health of Albertans, reducing stay in Emergency Departments for discharged patients, and providing a patient-focused health system that is accessible and sustainable for all Albertans. This is partly achieved by establishing clinical pathways to assist patient movement towards best possible outcomes, as well as expanding the scope of practice of Nurse Practitioners (NP).The Chest Pain Program Clinic (CPPC) was established in 2012, as a NP led outpatient clinic at the Mazankowski Alberta Heart Institute, Edmonton, Alberta, within a collaborative practice model.