Risk Patients Research Articles

HPB SO72 - Predicting Major Intra-operative Blood Loss in Patients undergoing Liver Resection: A Machine Learning Radiomics Analysis Using Pre-Operative Liver CTs

Abstract Background Liver resection offers the best opportunity for curing patients with colorectal metastases and is an important treatment option for patients with hepatocellular carcinoma. However, it can be associated with significant morbidity and mortality, with one of the primary reasons being due to intra-operative blood loss which serves as an important predictor of post-operative outcomes. Predicting blood loss pre-operatively would be a powerful tool for clinicians in identifying higher risk patients. In this study, we examine whether radiomic features of the liver can predict major blood loss (>500 mls) alongside clinical and morphometric features in patients undergoing resection for colorectal metastases. Method Patient data was extracted from a prospectively maintained database of individuals undergoing resection for colorectal liver metastases (CRLMs). Radiomic features were extracted from pre-operative portal venous phase CTs. The background liver was randomly segmented in a two-dimensional plane away from cancer areas. Highly correlated features were dropped, and further feature selection techniques applied. Nested cross validation was performed to train and evaluate the machine learning models with the selected radiomic, clinical, and morphometric features. Results Radiomic features (159) were extracted from 106 patients, and 10 radiomic features comprised of first order and texture features, 3 morphometric, and 4 clinical features were selected for the machine learning models. The models demonstrated a robust ability to discriminate between major and minor blood loss. The best performing machine learning model demonstrated an AUC of 0.76 (95% CI 0.7-0.82). Other performance metrics for this model included a mean accuracy of 0.78 and an F1 Score of 0.87 on the validation data. Conclusion Pre-operative CT radiomic, clinical, and morphometric features have shown a modest ability to predict major intra-operative blood loss in patients undergoing hepatic resection for colorectal liver metastases. Further work is needed to validate and refine these models to improve performance. Additionally, we plan to incorporate data from other centres to validate our findings in further experiments to create a robust tool to guide surgical practice in this patient cohort.

HPB SO20 - Evaluating the Impact of Enhanced Recovery After Surgery Protocols Post Hepatectomy in Patients with Chronic Liver Disease: A Meta-Analysis

Abstract Background Defined criteria for the resectability of liver disease continue to be refined. In the era of enhanced recovery after surgery (ERAS), data regarding its safety and efficacy in specific patient populations is required. Patients with liver cirrhosis are particularly vulnerable, owing to both operative and peri-operative risk. However, the application of ERAS in cirrhotic patients undergoing hepatectomy is absent from the most recent ERAS Society Group recommendations from 2022. We present a meta-analysis assessing outcomes after liver resection in patients with cirrhosis following an ERAS protocol compared to standard post-operative care. Method A systematic literature search was performed using PubMed, Embase and Web of Science. Studies were included if comparing ERAS protocols versus standard post-operative care in patients undergoing liver resection in which more than 50% of the patient population had cirrhosis at time of surgery. The primary outcome analysed was overall complication rates with secondary outcomes of post-operative mortality, estimated blood loss, operation time, post-operative incidence of liver failure, readmission and reoperation rates. Statistical analysis was performed using Review Manager by the Cochrane Collaboration. Results 930 records were screened for eligibility. Five articles were eligible for inclusion(ERAS n = 425 vs control group n = 423 patients). Cirrhotic patients enrolled in an ERAS program post-hepatectomy had a significantly reduced risk of overall complications (OR 0.45, 95% CI 0.33, 0.61, p<0.00001) and a shorter hospital stay when compared to standard post-operative care by 1.8 days (mean difference -1.83, 95% CI -2.22, -1.45, p<0.00001). No significant differences were noted in post-operative mortality, estimated blood loss, operation time, post-operative incidence of liver failure, readmission or reoperation rates between the ERAS group and control. Conclusion Application of an ERAS protocol for patients undergoing liver resection is safe and feasible in cirrhotic patients. ERAS protocols were successful in significantly reducing overall complication rates and length of inpatient hospital stay, and did not negatively impact secondary post-operative outcomes or mortality. ERAS protocols should be reflected in future guidelines, specifically for cirrhotic patients undergoing hepatectomy, and additional research on the utility of ERAS in higher risk patients is encouraged.

HPB SO39 - Incidence for the need of blood transfusion for Laparoscopic Cholecystectomy :Is a group and save always needed ?

Abstract Background Major bleeding is rare but among the most serious complications of laparoscopic surgery. As low as 1.3% of patient undergoing laparoscopic cholecystectomy may require a blood transfusion. We propose that not all patients undergoing laparoscopic cholecystectomy require a valid group and save sample, as the risk of bleeding is minimal. Method Health records of 458 patients who underwent cholecystectomy at our two hospital sites were reviewed for blood transfusion up to 30 days post-operatively. This review included elective and emergency procedures from January 2023 till March 2024. Demographics and surgical outcomes, including preoperative Haemoglobin (Hb) levels, need for transfusion, reason for transfusion and amount of units transfused were recorded. We analysed nominal values in proportions and percentages. Results Average pre-operative Hb levels were 13.38 g/dl. 7 patients required peri-operative blood transfusion. Three patients requiring transfusion had conversion to open cholecystectomy. Three patients requiring transfusion underwent emergency procedures. Time to transfusion ranged from 2 hours-5 days. All patients requiring transfusion were at our main hospital site (Watford General Hospital). Our yearly cost of ordering routine group and save sample throughout the audit period was £12,824 Conclusion Routine group and save is not required prior to Laparoscopic Cholecystectomy. In case transfusion is required sufficient time to process a group and save samples is present. High risk patients i.e those with known haematological malignancies, coagulopathy, concurrent use of blood thinner, higher ASA grades can be identified and selective blood grouping performed.

Abstract 4134977: Utility of Coronary Artery Calcium Scoring in Low-Risk Patients: the Multi-Ethnic Study of Atherosclerosis (MESA)

Introduction: Coronary artery calcium (CAC) scoring is a powerful tool for atherosclerotic cardiovascular disease (ASCVD) risk assessment. Guidelines recommend consideration of CAC scoring in intermediate risk patients, but it’s utility in low and borderline risk patients is less clear. Methods: We used data from 2,894 participants from MESA with low (<5%) or borderline (5-<7.5%) 10-year ASCVD risk defined by the pooled cohort equations (PCE). We evaluated the association between CAC score and coronary heart disease (CHD) and ASCVD risk using multivariable adjusted Cox proportional hazard models. We also evaluated if the addition of CAC to the pooled cohort equations (PCE) improved risk prediction using Harrell’s C-index and net reclassification improvement (NRI). Results/Data: Mean age was 54.1 ± 5.8 years with 66.9% women. Among low-risk individuals, the ASCVD event rate was 3.3% with CAC=0, and 7.8% with CAC>0, and 4.7% vs. 11.4% among borderline-risk individuals. Natural-log transformed CAC score was associated with increased ASCVD risk in low-risk (HR 1.35, 95% CI 1.22-1.50) and borderline-risk (HR 1.29, 95% CI 1.15-1.45) individuals. Similar results were seen for CHD with higher HRs ( Table 1 ). The addition of CAC to the PCE improved the C-index (SE) among low/borderline risk individuals from 0.620 (0.023) to 0.671 (0.024). Continuous NRI was also significant with the addition of CAC to the PCE in low/borderline risk (0.422, 95% CI 0.248-0.611). Greater improvement was seen for CHD ( Table 2 ). Conclusions: The presence of CAC in low and borderline risk individuals is associated with increased ASCVD and CHD risk. The addition of CAC scoring to the PCE improved risk prediction in low and borderline risk individuals, suggesting potential clinical utility in this population.

Abstract 4138517: Role of Coronary Computed Tomographic Angiography in Patients with Discordant Findings on Exercise Stress Echocardiography

Background: Exercise stress echocardiography is routinely used for risk stratification and diagnosis of myocardial ischemia in low-to-intermediate risk patients with suspected coronary artery disease (CAD). Discrepancies between exercise electrocardiography (EKG) and echocardiography (ECHO) are common in clinical practice. Prior literature suggests that patients with discordant stress test results generally have worse outcomes, though the extent of epicardial atherosclerotic disease remains unclear. Coronary computed tomographic angiography (CTA) has gained a class I recommendation for the assessment of atherosclerotic burden per ACC/AHA chest pain guidelines. Using non-invasive fractional flow reserve (CT-FFR), the functional significance of lesions can also be assessed. This study investigates the incidence and burden of CAD in patients with discordant exercise echocardiography findings. Methods: Patients aged 18 or older who had exercise echocardiography followed by CTA from January 1, 2013, to January 31, 2023, were retrospectively enrolled in this study and categorized into two discordant result groups: EKG+/ECHO- or EKG-/ECHO+. Those who failed to achieve the target heart rate or had a paced rhythm/left bundle branch block on baseline EKG were excluded. CTA findings were classified as no CAD, non-obstructive CAD (<50% stenosis), obstructive CAD (≥50% stenosis), and obstructive CAD with FFR+ (<0.75). Results: The study included 198 patients, the majority female (56.0%), with a mean age of 61 ±10 years. Among them, 159 (80.3%) were EKG+/ECHO- and 39 (19.7%) were EKG-/ECHO+ (Table 1). In the EKG+/ECHO- group, 55 (34.6%) had no CAD, 48 (30.2%) had non-obstructive CAD, and 56 (35.2%) had obstructive CAD, out of which 19 (33.9%) were FFR+. In the EKG-/ECHO+ group, 13 (33.3%) had no CAD, 17 (43.6%) had non-obstructive CAD, and 9 (23.2%) had obstructive CAD of which 3 (33.3%) was FFR+. There was no statistically significant difference in the degree of CAD between the two cohorts. Conclusions: The majority of patients with discordant results on exercise echocardiography were found to have CAD. There was no significant difference in the degree of disease between the EKG+/ECHO- or EKG-/ECHO+ groups. Overall, discordant results on exercise echocardiography should not be discounted and warrant further evaluation. CTA provides important information that can impact the diagnosis and further medical management of patients with chest pain and suspected CAD.

Prenatal Acetaminophen Exposure and its Associated Risk for Attention Deficit Hyperactivity Disorder

Acetaminophen is one of the most commonly used over-the-counter antipyretic and analgesic drugs on the market and has been relevant in the medical world for almost a hundred years. It has maintained an excellent reputation as a safe therapeutic in several types of patient profiles. However, the number of children diagnosed with neurodevelopmental disorders, namely ADHD, have been on the rise. Recent findings have indicated an association between in utero exposure to acetaminophen and an increased risk of developing neurodevelopmental disorders such as ADHD in offspring. The mechanism by which this potential side effect occurs is difficult to pinpoint. However, it is known that the metabolism of acetaminophen is known to cause oxidative stress, which has been shown to influence the developing fetus. This review highlights the epidemiological data indicating the correlation between prenatal acetaminophen exposure and ADHD and discusses several proposed theories by which this phenomenon may occur. While there is not yet enough clinical evidence to prove that acetaminophen may cause ADHD, there is a strong enough correlation to indicate a warning to pregnant patients of the potential risks. The risks and benefits of treatment should be considered so that the patient may continue with the course of action with the most favorable outcome. This review was mainly based on manuscripts pulled from Google Scholar and PubMed. The purpose of this literature review is to assist clinicians to better understand lesser-known risks in acetaminophen usage in pregnant patients.

The Neutrophil-to-Lymphocyte Ratio Predicts Cardiovascular Outcomes in Patients With Diabetes: A Systematic Review and Meta-Analysis

The neutrophil-to-lymphocyte ratio (NLR) has been found as a potential biomarker for acute inflammation and the prognosis of different diseases. Here, we provided a meta-analysis of studies evaluating the association of NLR with cardiovascular outcomes among patients with diabetes. We searched PubMed, Scopus, and Web of Science databases from inception to April 06, 2024, to include papers based on eligible criteria. The outcomes of interest were all-cause mortality, cardiovascular mortality, major adverse cardiovascular events, myocardial infarction, and stroke. The pooled risk ratio (RR) and corresponding 95% confidence intervals (CI) were reported. Meta-analysis was performed using StataMP 14.0. A total of 15 studies involving 407,512 participants were included. Meta-analysis revealed that both categorical and continuous NLRs are linked to increased risk of all-cause mortality (RR = 1.68; 95% CI, 1.49–1.88; P < 0.001 and RR = 1.03; 95% CI, 1.03–1.03; P < 0.001, respectively) and cardiovascular mortality (RR = 2.04; 95% CI, 1.58–2.63; P < 0.001 and RR = 1.25; 95% CI, 1.19–1.32; P < 0.001, respectively) in patients with diabetes. However, NLR was not associated with the risk of major adverse cardiovascular events, myocardial infarction, and stroke in patients with diabetes. Subgroup analysis revealed sample size as the main source of the heterogeneity found between studies. The findings suggest NLR as a prognostic marker for mortality outcomes in patients with diabetes, providing clinicians with a noninvasive and readily available indicator for risk assessment and patient management.

Abstract 4126158: Persistence to once weekly GLP-1 RAs is associated with lower risk of MI, stroke, and 2-point MACE among patients with T2D and ASCVD in the real world.

Introduction: Studies have shown the reduction of CV events in patients with T2D treated with GLP-1 RAs. However, little is known about how persistent use of GLP-1 RA therapy affects CV outcomes in patients with T2D and ASCVD. The objective of this study was to estimate the association between persistent use of once weekly (OW) GLP-1 RAs and 2-point MACE and its components (MI, stroke) in patients with T2D and ASCVD in a real-world setting. Methods: Adult patients with T2D and ASCVD with ≥1 pharmacy claim for OW GLP-1 RAs during Jan 2018-Nov 2022 were identified in the Optum Research Database. The date of the first OW GLP-1 RA claim was defined as the index date. Patients were followed until a CV event occurred or censored. Discontinuation was defined as a ≥60-day gap in supply of OW GLP-1 RAs. All patients were required to be persistent for ≥3 months of follow-up to allow titration of the therapy. CV events of interest include 2-point MACE, MI and stroke. Kaplan-Meier analyses were used to examine risk of CV events by persistent status within 6, 12, or 18 months of follow-up. Cox proportional hazards models with time-varying exposures were used to assess associations between persistent status and MACE, with persistent status of patients updated for each day of follow-up, adjusting for demographic and baseline clinical characteristics. Results: Among a total of 29516 patients, the median follow up duration was 412 days, median persistence was 254 days, and 63.9% of patients (n=18849) were persistent throughout their variable follow up period. Kaplan-Meier analyses indicated risk of 2-point MACE, MI, and stroke was significantly lower in patients who were persistent within 6, 12 or 18 months of follow-up compared to patients who discontinued within 6, 12 or 18 months of follow-up (all p<0.05); longer persistence led to a qualitatively greater risk reduction. Adjusted hazard ratio (95% confidence interval) from Cox regression with time-varying persistence status during the full variable follow up in all patients for risk of 2-point MACE, MI, and stroke associated with persistent use of OW GLP-1 RAs was 0.70 (0.63-0.77), 0.71 (0.62-0.81), and 0.67 (0.57-0.78), respectively. Conclusions: Patients with T2D and ASCVD who were persistent with OW GLP-1 RAs had a lower risk of 2-point MACE, MI, and stroke than those who discontinued the therapy in real-world clinical practice. Longer persistence of OW GLP-1 RAs appeared to provide greater CV benefits.

Abstract 4136463: Novel Systemic Inflammatory Biomarkers Can Predict Significant Coronary Disease in High Risk Patients

Background: Coronary artery disease (CAD) is a major cause of morbidity and mortality worldwide. Chronic inflammation is a known risk factor for atherosclerosis, plaque formation, disease progression, and plaque instability. Novel inflammatory biomarkers have been recently linked to excess risk of adverse cardiovascular events, including incident myocardial infarction. Elevated inflammatory biomarkers may help identify patients at higher risk for severe CAD. Aim: This study aimed to evaluate the use of novel systemic inflammatory markers in predicting the pretest probability of severe CAD in patients referred to diagnostic coronary angiography in a single tertiary care center. Methods: This was a prospective observational cohort study enrolling consecutive patients referred to diagnostic coronary angiography in a tertiary care center. Preprocedural laboratory results were obtained from medical charts, including complete blood counts with differentials. Three novel systemic inflammatory markers were computed using existing mathematical formulas: systemic immune-inflammation index (SII = neutrophil count*platelet/lymphocyte); systemic inflammation response index (SIRI = neutrophil*monocyte/lymphocyte); and systemic immune inflammatory response index (SIIRI = neutrophil*monocyte*platelet/lymphocyte). The primary study outcome was severe CAD defined as the presence of ≥70% stenosis in one of three main coronary arteries requiring percutaneous coronary intervention). The outcome was adjudicated by an independent reviewers blinded to computations of biomarkers. Result: The sample included 264 patients (age 59.3±10.8, 47% Females). Overall, 84 patients (32%) met the primary study outcomes. In univariate analysis, those with severe CAD had significantly higher SIRI (2.9±0.7 vs. 2.6±0.6, p = 0.001) and SIIRI (8.4±0.8 vs. 8.1±0.7, p = 0.015) compared to their counterparts. In multivariate analysis adjusted for age and sex, only SIRI was an independent predictor of severe CAD. Using SIRI > 20.8 (upper quartile) was associated with nearly three-fold excess risk of severe CAD (OR = 2.72, 95% CI 1.45-5.09). Conclusion: Elevated SIRI, a marker of ongoing systemic inflammatory response, could be indicative of severe CAD. As an inexpensive biomarker based exclusively on complete blood count, SIRI can be used to prioritize patients referred for diagnostic angiography and potentially expedite treatments in those at higher risk for coronary events.

Performance of Computerised Self-Reported Medical History-Taking and HEAR Score for Safe Early Rule-Out of Cardiac Events in Acute Chest Pain Patients: The CLEOS-CPDS Prospective Cohort Study

Abstract Objective A simplified version of the History, ECG, Age, Risk factors, Troponin (HEART) score, excluding troponin, has been proposed to rule out major adverse cardiac events (MACE). Computerised history taking (CHT) provides a systematic and automated method to obtain information necessary to calculate the HEAR score. We aimed to evaluate the efficacy and diagnostic accuracy of CHT in calculating the HEAR score for predicting MACE. Methods Prospective study including clinically stable adults presenting with chest pain at the emergency department of Danderyd University Hospital (Stockholm, Sweden), in 2017-2019. Participants entered their medical histories on touchscreen tablets using CHT software. HEAR and HEART scores were calculated from CHT data. 30-day MACE and ACS outcomes were retrieved, and the diagnostic accuracy was assessed. Logistic regression was used to determine the most predictive components of the HEAR score. Results Among 1,000 patients, HEART and HEAR scores could be calculated from CHT data in 648 and 666 cases, respectively, with negative predictive values (95% CI) of 0.98 (0.97–0.99) and 0.99 (0.96–1.00). Two patients with HEAR score <2 experienced a 30-day MACE. The Age (OR 2.75, 95% CI 1.62–4.66) and History (OR 2.38, 95% CI 1.52–3.71) components of the HEAR score were most predictive of MACE. ACS outcomes provided similar results. Conclusions HEAR score acquired by CHT identifies very-low risk patients with chest pain in the ED, safely ruling out ACS and MACE. This highlights the value of computerised history-taking by patients, which may reduce unnecessary tests and hospital admissions. Trial Registration ClinicalTrials.gov NCT03439449.

Abstract 4135178: Short Term Outcomes Of Transcatheter Tricuspid Valve Interventions On Post-Procedural Length Of Hospital Stay, Readmissions For Heart Failure And Procedure Success If An Intracardiac Device Is Present: A Systematic Review And Meta-Analysis In A New Era Of Tricuspid Interventions

Background: Tricuspid regurgitation (TR) is no longer considered forgotten. Transcatheter tricuspid valve repair/replacement (TVRR) has become widely accepted as gauged by clinical outcomes. FDA approved two tricuspid valve devices for the purpose of improving quality of life and not necessarily to improve TR severity. We aim to support evidence-based use of TVRR, by summarizing the latest evidence on the clinical effectiveness in terms of post-procedural length of hospital stay, readmissions for heart failure and procedure success if an Intracardiac device is present. Methods: We searched Pubmed, Embase and Cochrane databases and performed a meta-analysis of the included cohort studies using a fixed-effects model. Studies were excluded if they did not present an outcome in each intervention group or did not have enough information required for continuous data comparison. We performed a meta-analysis of hazard ratio (HR) for two outcomes and odds ratio (OR) for one outcome using the random effects model to remove inconsistency and compared the results with fixed effects model. The compared findings of both methods were similar. The variables used for analysis were number of events in exposure group and total amount of events. All data analyses were performed using MedCalc® Statistical Software version 22.023. Results: Of 161 potentially relevant studies, 8 retrospective studies with a total of 1,717 patients were included in the meta-analysis. Procedure (TVRR) success was associated with fewer readmissions for heart failure in all three studies included in the analysis of pooled HR (HR = 0.46, 95% confidence interval [CI]: 0.33 - 0.63, p<0.001). Procedure success was also associated with shorter length of hospitalization post-procedure in all three studies included in the analysis of pooled HR (HR = 0.48, 95% CI: 0.33 - 0.72, p<0.001). There was no significant association between procedure success and having an intra-cardiac device in all three studies included in the analysis of pooled OR (OR = 0.79, 95% CI: 0.56 - 1.12, p=0.18). Conclusion: Our meta-analysis showed that successful TVRR for high risk patients with severe TR is associated with significant positive outcomes on post-procedural length of hospital stay and readmissions for heart failure, regardless of presence of an intracardiac device. With emerging improvements in device technology and procedural performance, TVRR should be considered in severe and functional TR, to improve clinical prognosis.

Abstract 4134309: From Heartache to Headache: Cryptococcal Meningitis Post-Heart Transplant in a Chronic Hepatitis B and Sarcoidosis Patient

Introduction: We report the case of a heart transplant patient on chronic immunosuppression diagnosed with cryptococcal meningitis. Up to 5% of solid organ transplant patients develop cryptococcosis, carrying a 50% mortality rate in central nervous system involvement. Case Presentation: This is a 57-year-old male with a past medical history of heart failure with reduced ejection fraction (HFrEF) status post orthotopic heart transplantation (on prednisone 7.5 mg daily, mycophenolate, tacrolimus and sirolimus), pulmonary sarcoid, and chronic hepatitis B (on tenofovir and entecavir) who presented with headache, nausea, vomiting and seizure-like activity. The patient’s heart rate was 129 beats per minute, blood pressure 188/92 mmHg, but was afebrile. He eventually underwent a lumbar puncture with the cerebrospinal fluid (CSF) positive for cryptococcal antigen (1:2560). The patient was started on liposomal amphotericin B and flucytosine. Mycophenolate and sirolimus were held in the setting of his infection. The patient’s hospital course was complicated by acute kidney injury likely secondary to elevated tacrolimus levels while on fluconazole. He was ultimately discharged with plans to repeat CSF studies as an outpatient. Discussion: Here we report a case of cryptococcal meningitis in a heart transplant patient in the context of pulmonary sarcoidosis, chronic hepatitis B and quadruple immunosuppression. Of note, as part of rejection surveillance, the patient undertook serial AlloSure and AlloMap testing. Sirolimus was added to his regimen due to persistently elevated AlloSure scores. Indeed, immunosuppressive agents are the leading risk factor for cryptococcosis in organ transplant patients. Our patient also has two important risk factors for cryptococcal infection. Firstly, sarcoidosis is associated with T-cell dysregulation, compromising cell-mediated immunity. Additionally, hepatitis B carriers have an increased predisposition for cryptococcal infections, notwithstanding that our patient had been on dual antiviral therapy. Conclusion: Quadruple immunosuppression in heart transplant patients, especially in the context of risk factors such as sarcoidosis and hepatitis B infection, can result in cryptococcal meningitis and should be considered in patients with suggestive symptoms. Effective prophylactic regimens for such higher risk patients may be a potential area for further investigation.

Abstract 4140154: Highly Sensitized Heart Transplant Recipients Who Have Undergone Pre-Transplant Desensitization Therapies Demonstrate Acceptable Medium-Term Outcomes

Introduction/Research Question: Allosensitization, the presence of circulating anti-HLA antibodies, is a barrier in heart transplantation (HT), restricting the donor pool size, and leading to increased waitlist mortality and rejection risk post-HT. Desensitization therapies can be used to broaden the donor pool in highly sensitized patients, defined as pre-HT calculated panel reactive antibodies (cPRA)≥50%, for antibodies with mean fluorescence intensity (MFI)>10,000. There is paucity of data on longer-term outcomes in such high-immunological risk patients. Methods: Sensitized patients with pre-HT cPRA>50%, who were treated with desensitization and then received HT between 2011-2022 at Cedars-Sinai Medical Center were included. Desensitization therapies included bortezomib, rituximab, tocilizumab, obinutuzumab, intravenous immunoglobulin (IVIG), and plasmapheresis. cPRA, donor-specific antibody (DSA) levels, and post-HT clinical outcomes were assessed up to 5-year follow-up, loss to follow-up, or death. Results: 40 patients were analyzed. 77.5% of patients were female, and all had at least 1 risk factor for sensitization. cPRA decreased from 84.5±13.5% at baseline to 74.1±22.4% after completion of desensitization therapy, prior to transplant (p=0.005). Mean follow-up time post-HT was 4.3±2.9 years. 45.0% of patients had antibody-mediated rejection (AMR), 12.5% had CAV. Overall survival was 94.9%, 92.1%, and 87.5% at 1, 3, and 5 years respectively. All patients except 1 had normal left ventricular function at last follow-up. 72.5% of patients were transplanted in the presence of DSA, and 60.0% underwent post-HT induction with eculizumab in addition to antithymocyte globulin (ATG)/IVIG, while the remaining received ATG/IVIG alone. Among HT recipients with pre-formed DSA, 41.4% had high-level DSA (MFI > 10,000) at time of HT. At 6-12 months post-HT, only 17.2% had high-level DSA, and 41.4% had resolution of DSA. Conclusion: Highly sensitized HT candidates who underwent pre-HT desensitization had comparable survival and CAV rates as compared to the general HT population reported in the literature. However, sensitized patients experienced higher rates of AMR which were not associated with graft dysfunction or mortality.

Abstract 4124369: Mid-term Outcomes of Transcatheter Versus Surgical Aortic Valve Replacement in Low to Moderate Risk Patients with Severe Aortic Stenosis: A Meta-analysis of Randomised Clinical Trials

Background: Several clinical trials have demonstrated non-inferiority of transcatheter aortic valve replacement (TAVR) compared with surgical aortic valve replacement (SAVR) in patients with severe aortic stenosis (AS) and low to intermediate surgical risk. However, mid-term results are still contentious. Question: Is TAVR superior to SAVR in the mid-term in terms of mortality outcomes or adverse cardiovascular events? Methods: We searched Embase, Pubmed and Cochrane databases for RCTs that compared TAVR with SAVR in patients with symptomatic severe AS with a follow-up of at least 4 years. Outcomes of interest were all-cause mortality and disabling stroke. Results: We included six RCTs involving 6,444 patients with severe AS, of whom 3,282 (50.9%) underwent TAVR. There was no difference in mortality from all causes (RR 1.08; 95%CI 0.94-1.25; p=0.30; I 2 =45%) and disabling stroke (RR 0.95; 95%CI 0.75-1.21; p=0.67; I 2 =9%) between groups. In the subgroup analysis, 5-year mortality (RR 1.28; 95%CI 1.10-1.49; I 2 =0%) was higher in the TAVI group. The new pacemaker implantation rate was higher in the TAVI group (RR 2.22; 95%CI 1.42-3.45; p=0.0004 ; I 2 =91%). However, new atrial fibrillation rate was higher in the SAVR group (RR 0.42; 95%CI 0.37-0.49; p=0.00001; I 2 =62%). Conclusion: Mid-term mortality and disabling stroke of patients with severe AS treated with TAVR or SAVR were similar.

Abstract 4120785: Differential Cardiovascular Impact of ω-3 Fatty Acid in Patients at High Cardiovascular Risk in Asians versus non-Asians: Sub-analysis of the STRENGTH Randomized Clinical Trial

Background: Racial differences in lipid and cardiovascular risk profiles are well-established including for Asians. The STRENGTH trial found that ω-3 carboxylic acid (CA) formulation of eicosapentaenoic acid and docosahexaenoic acid did not result in significant changes in cardiovascular event rates compared with corn oil in statin-treated patients at high cardiovascular risk, however drug efficacy may vary by race. We evaluated and compared the cardiovascular treatment effect of ω-3 CA between Asians and non-Asians in this sub-analysis of the STRENGTH trial. Methods: The STRENGTH trial was a double-blinded 1:1 randomized controlled trial of 13,078 high cardiovascular risk patients enrolled during 10/30/2014-6/14/2017 at 675 centers. Efficacy of ω-3 CA for Asians (n=1,355) and non-Asians (n=11,723) and interactions between race and treatment effect were assessed. The primary endpoint is a composite of cardiovascular death, non-fatal myocardial infarction, stroke, coronary revascularization and unstable angina hospitalizations. Results: Key differences in baseline characteristics include Asians having significantly higher prevalence of men, secondary prevention, and lower total cholesterol, LDL, apoB100, and hsCRP. In Asians, ω-3 CA was associated with significantly lower primary endpoint during follow-up, with 81/698 events [Kaplan-Meier (KM) Estimate: 14.8%] in the ω-3 CA group, 103/657 events (KM Estimate: 20.4%) in the corn oil group, and hazard ratio (HR) 0.72, 95% CI 0.54-0.96, P=0.026 (Figure A). In non-Asians, there was not a significant difference in primary endpoint rates between the two groups, with 704/5841 events (KM Estimate: 15.6%) in the ω-3 CA group, 692/5882 events (KM Estimate: 15.9%) in the corn oil group, and HR 1.03 95% CI 0.93-1.14, P=0.60 (Figure B). There were significant interactions between race (Asian versus non-Asian) and treatment group for the primary endpoint (P=0.021) and non-fatal stroke (P=0.016) and remained significant after adjusting for other covariates. Conclusion: ω-3 CA was associated with significant reduction in major adverse cardiovascular events compared with corn oil in Asians but not in non-Asian patients with high cardiovascular risk. Further research is necessary to elucidate the mechanisms for potentially beneficial effects of ω-3 CA unique to Asian race.

Abstract 4120680: Language AI Chat BOTs as Pioneers in Cardiovascular Diagnosis? A Retrospective Analysis on Real-Time Patients in a Tertiary Care Centre

GPT-3 and GPT-4, show promise in assisting healthcare professionals with clinical questions. Their performance in real-time clinical scenarios, particularly with cardiovascular symptoms, remains underexplored. This study aims to evaluate their precision and reliability compared to physicians. Hypothesis: We hypothesize that board-certified emergency department attendings at Maimonides Medical Center exhibit higher accuracy and reliability than GPT-3.5 and GPT-4 in generating differential diagnoses based on history and physical examination for patients presenting to the emergency department. Methods: Patient data from Maimonides Medical Center's emergency department, collected from January 1, 2023, to April 30, 2023, was analyzed. Demographics, symptoms, medical history, and discharge diagnoses recorded by emergency room attendings were examined. ChatGPT-3.5 and GPT-4 generated differential diagnoses, which were compared with those by attending physicians. Accuracy was determined by comparing each rater's diagnoses with discharge diagnosis, calculating the proportion of correctly identified cases. Precision was assessed using Cohen's kappa coefficient and Intraclass Correlation Coefficient to measure agreement between raters. Results: Patient demographics showed mean age of 49.12 years, with 57.3% males and 42.7% females. Chief complaints included fever/sepsis (24.7%), gastrointestinal issues (17.7%), and cardiovascular problems (16.4%). Diagnostic accuracy against discharge diagnoses was highest for Chat GPT-4 (85.5%), followed by Chat GPT-3.5 (84.6%) and ED attendings (83%). Cohen’s kappa demonstrated moderate agreement (0.7) between AI models, with lower agreement observed for ED attendings. Stratified analysis revealed higher accuracy for gastrointestinal complaints with Chat GPT-4 (87.5%) and cardiovascular complaints with Chat GPT-3.5 (81.34%). Conclusion: Our study demonstrates that Chat GPT-4 and GPT-3.5 exhibit comparable diagnostic accuracy to attendings, highlighting their potential to aid decision-making in dynamic clinical settings. The stratified analysis revealed comparable reliability and precision of the AI chat bots for cardiovascular complaints which represents a significant proportion of the high risk patients presenting to the emergency department. This study contributes to integrating AI models into medical practice, enhancing efficiency and effectiveness in clinical decision-making

Abstract 4115139: The Clinic Ottakring – Lipid Registry: a Contemporary Single-Center Real-World Analysis from a Tertiary Hospital

In the real world only about 20 % of patients with ASCVD are at the target range, as shown by the SANTORINI trial (1). Therefore, there is still a great need for the improvement of lipid-lowering therapy (LLT). Our Lipid Registry was set up as a retrospective study including patients who visited our outpatients ward focusing on lipid-lowering therapy (LLT). The indications were: low-density lipoprotein cholesterol (LDL-c) > 130 mg/dL in LLT- naive patients with acute coronary syndrome (ACS), coronary artery disease (CAD) not on optimal LLT, familial hypercholesterolemia and LLT intolerance. We collected baseline characteristics as well as laboratory parameters of these patients during their visits. The dual LLT (high-potency statin and ezetimibe) was initiated in every patient during the hospitalization, if not contraindicated, as target variable we used non-HDL-C. In total 181 patients were included, of which 136 (75.1%) patients visited our clinic for control purposes. Patients who didn’t visit the clinic were predominantly men and had no or few pre-experiences with LLT. Fourty-one (36.9%) patients had a BMI>30, 126 (92.6%) of patients had CAD of which 85 (63%) had the diagnosis of a recent ACS. Arterial hypertension was present in 78.7% and diabetes mellitus type 2 in 23.5% of cases. At the 1 st visit to our LLT department 4-6 weeks after dismission from the hospital, 86 patients (61.9%) reached the recommended (ESC/EAS 2019) non-HDL-C goal. At the 2 nd visit (8-12 weeks after index hospitalization), 117 patients (86.2%) and at the 3 rd visit 120 patients (88.2%) reached their target. The analysis of patients initially presenting with ACS showed that 60 (69.8%) of them after 4-6 weeks and 77 (90.6%) patients after 8-12 weeks reached the recommended non-HDL-c goal. Among the study population 108 (79.4%) of patients, and 81 (95.3%) of ACS patients received dual LLT immediately during the index event. After the first visit, 31 (36.5%) of ACS patients needed the addition of the third lipid-lowering drug to achieve the recommended goal (see attached tables). Our strategy for managing hyperlipidemia in patients with a very-high cardiovascular risk showed high achievement of the non-HDL-C goal as recommended by the recent ESC guidelines in contrast to real-world data. We were able to demonstrate, that the strategy based on the idea to treat high-CV risk patients early and strong is the way to reach the treatment goal in a high percentage of patients (2).

Abstract 4134796: Safety of over 1000 consecutive, selected low risk patients with accelerated discharge from a chest pain unit with early generation cardiac troponin use, no cardiac functional or anatomic testing and no clinical risk scores

Introduction: Over 6 million patients (pts) present to US emergency departments annually with chest pain (CP), of which the majority are found to have no serious disease. Evaluation of these pts results in substantial costs for unnecessary hospitalization and extensive testing. We evaluated the utility of early discharge of selected low-risk (LR) CP pts from a chest pain unit (CPU) in which no predischarge testing or risk scores were used. Methods: This retrospective study analyzed 1,037 consecutive LR CP pts from a prospectively recorded database. LR was based on normal examination, stable hemodynamics, normal electrocardiograms (ECG), and negative cardiac troponin I, without pre-discharge functional or anatomic cardiac testing or risk scores. We assessed demographics, comorbidities, medications, and major cardiac events at 30 d and 6 mos post-discharge. Results: The study group of 1037 pts comprised 26% of the 4010 pts admitted to the CPU during the study interval from May 2005 to March 2015. Mean patient age was 55 yrs, 56% (n=575) were women, and comorbid conditions were frequent: hypertension (64.1%), dyslipidemia (46.1%), diabetes (25.7%), documented coronary artery disease (19.3%), previous revascularization (20.6%), previous myocardial infarction (10.1%). Length of stay (LOS) in the CPU to discharge was 10.4 hrs. Women received more discharge cardiac medications than men: antiplatelet agents, statins, beta blockers, ACE inhibitors, angiotensin II blockers, calcium channel blockers, and nitrates (p=0.0002 - 0.04). Follow-up (F/U) at 30 d was 91% (n=948) complete and revealed 0.3% (n=3) cardiac deaths, 0.6% (n=6) acute coronary syndromes (ACS), and 6.2% (n= 64) receiving revascularization. F/U at 6 mos was 90% (n=936) complete and total cumulative cardiac deaths were 0.9% (n=9), 0.7% (n=7) ACS and 6.3% (n=65) revascularization. Discussion: Cardiac events at both 30 d and 6 mos were very low and did not differ in men and women (P=0.8). LOS in CPU was minimized and patient safety was maintained. These selected LR pts remained at reduced risk for cardiac events despite a high rate of comorbidities. Early discharge of selected LR CP pts based on history, examination, ECG, and biomarker evaluation was safe and effective. Conclusion: This approach in selected LR pts has the potential to reduce unnecessary diagnostic testing and CPU LOS. This strategy could lead to substantial savings in healthcare costs without compromising patient safety.

A Dynamic, D-dimer-based Thromboprophylaxis Strategy in Patients with COVID-19

Background COVID-19 pandemics increases venous thromboembolism (VTE) risk during hospitalization, despite prophylactic anticoagulation. Limited radiological diagnosis in pandemic requires a guided protocol for anticoagulant adjustment. Methods This retrospective cohort study was conducted at a single center as part of a quality improvement program evaluating the efficacy and safety of anticoagulation protocols. The study focused on implementing a guideline for anticoagulant dosing protocol based on dynamic changes in D-dimer levels in COVID-19 hospitalized patients. The dosing guideline allowed for dose escalation from standard prophylactic levels to escalated prophylactic or therapeutic levels, depending on the patient's risk profile for VTE. The primary endpoints included in-hospital survival comparing between fix and dynamic adjustment treatment groups. Secondary endpoints encompassed major and clinically relevant non-major bleeding (CRNMB) events, incidence of breakthrough thrombosis, length of hospitalization and ICU stay, days of mechanical ventilator use, and survival duration. Findings Among the 260 COVID-19-infected patients hospitalized between March 15th and June 15th, 2020. The patients received fixed anticoagulant dosage in 188, 72.3%) patients, while 72 (27.7%) were up-titrated according to the protocol. In-hospital survival at 30 days demonstrated superiority among patients whose anticoagulation was up-titrated to either escalated prophylactic or therapeutic (80.2%) compared to receiving fixed anticoagulant dosage (51.3%) (p=0.01). Bleeding events were significantly higher in up-titrate group (12.5%) compared to fixed anticoagulant dosage group (2.13%). Most of them are CRNMB. Conclusion A dynamic, D-dimer-based dose escalation of anticoagulation for hospitalized patients with COVID-19 holds promise in improving in-hospital mortality rates without a significant increase in fatal bleeding events.

Establishment of a Predictive Model for Seroma Formation After TAPP Repair for Unilateral Indirect Inguinal Hernia in Males

Background Inguinal hernia repair, particularly using TAPP, is common in males, and acclaimed for minimal invasiveness but often complicated by seromas, significantly affecting recovery and health care costs. Methods This retrospective study analyzed data from 266 male patients with unilateral indirect inguinal hernia who underwent transabdominal preperitoneal (TAPP) repair. We divided the patients into a training set (n = 188) and a validation set (n = 78). We employed logistic regression to identify independent risk factors for post-TAPP seroma and developed a nomogram to predict the occurrence of seromas. The model’s accuracy was evaluated using receiver operating characteristic (ROC) curves, Hosmer-Lemeshow goodness-of-fit test, calibration curves, and decision curve analysis (DCA). Results Postoperatively, 20.3% of patients developed a seroma. Multivariate logistic regression analysis highlighted several independent risk factors for seroma formation: the use of anticoagulants, an internal ring defect ≥5 cm, scrotal hernia, incarcerated hernia, and transected hernia sac ( P < 0.05). The ROC curves for the training and validation sets demonstrated areas under the curve of 0.893 (95% CI: 0.845-0.942) and 0.864 (95% CI: 0.765-0.963), respectively, indicating good model fits ( P > 0.05). DCA confirmed significant clinical applicability of the model. Conclusion The findings suggest that the use of anticoagulants, an internal ring defect ≥5 cm, scrotal hernia, incarcerated hernia, and transected hernia sac are significant independent risk factors for seroma formation after TAPP repair. Clinical consideration of these factors and proactive preventive measures are essential. Although many of these factors are non-modifiable, understanding them is crucial for preoperative risk assessment and patient management.