Significant Arrhythmias Research Articles

Abstract 4124677: Left ventricular function and myocardial longitudinal strain analysis in patients with Chagas disease: case series and systematic literature review.

Introduction: Chagas disease is a significant cause of tropical disease-related mortality. It presents in acute, indeterminate, and chronic phases, with chronic cardiomyopathy being the most severe form, leading to heart failure, arrhythmias, and sudden cardiac death. Conventional echocardiography often fails to detect early subclinical dysfunction, whereas Global longitudinal strain (GLS) may provide earlier detection of myocardial strain abnormalities. Left ventricular dysfunction is an independent predictor of mortality and GLS is an emerging modality that may aid early detection of cardiac involvement. Objective: This study aims to compare left ventricular function using multiple echocardiographic parameters between patients with indeterminate and chronic forms of Chagas disease and to perform a systematic literature review. Methods: The observational study involved 11 patients (mean age 76.36 years) from a tertiary hospital in Brazil, classified as indeterminate (45%) or chronic (55%). Serological confirmation and detailed echocardiographic evaluations, including GLS, were performed. A systematic literature review was also conducted on GLS in Chagas cardiomyopathy. Results: Patients with chronic Chagas disease showed significantly lower LVEF and GLS compared to those with the indeterminate form. Segmental strain analysis revealed consistent contractility reductions across specific ventricular segments in both groups. Discussion: Chagas cardiomyopathy often leads to dilated cardiomyopathy with significant arrhythmias and heart failure. GLS can detect early myocardial changes even before a significant drop in LVEF, indicating its potential for early diagnosis and better management of Chagas cardiomyopathy. Literature review supports the use of GLS for detecting early cardiac involvement and predicting adverse outcomes. Conclusion: Incorporating GLS with conventional echocardiography offers enhanced early detection of myocardial changes in Chagas disease. While promising, further research is needed to establish the clinical significance and impact of these techniques in routine practice.

Abstract 4141488: Initial Real-World Experience with a Novel Wearable Cardioverter Defibrillator

Background: The wearable cardioverter defibrillator (WCD) can reduce sudden cardiac death; effectiveness depends on adherence. A novel WCD designed for sex specific comfort and noise immunity has reported improved compliance. Hypothesis: Patient compliance with the WCD maximizes device utility in treating significant arrhythmia. Aims: Report WCD patient compliance and efficacy in a cohort with balanced gender representation. Evaluate WCD performance in minimizing noise artifact leading to false alarms and unnecessary shocks. Methods: Retrospective analysis of patients prescribed the ASSURE WCD at the Cleveland Clinic. Clinical data was collected via medical chart review. All device-detected arrhythmia episodes were manually adjudicated by a Board-certified Electrophysiologist. Detected rhythms that persist, result in an audible alarm notifying that a shock is imminent. A conscious patient can manually divert a shock. An alarm was deemed true and shock appropriate if the underlying rhythm was sustained VT/VF. Results: Fifty-five patients were fitted with a WCD. Median daily use 22 hr/day (IQR 13,24) and median duration of use 43 days (IQR 8,79). Female representation was 49%, significantly greater than prior reports of WCD experience. 4 episodes of sustained VT/VF were detected in 4 patients. A single shock terminated VT/VF in 2, while spontaneous termination of VT/VF occurred in the other 2 patients who diverted shocks. One shock for hemodynamically unstable atrial fibrillation with heart rate >200bpm was delivered and deemed necessary. No deaths occurred while wearing a WCD. Of 163 recorded episodes, 62 (38%) persisted and triggered an alarm (Figure 1). 10 patients experienced a median of 1 (IQR 1,9.5) alarm during the WCD wear period. The majority (97%) of alarms were associated with a significant tachyarrhythmia, with only 3% due to noise artifact. No inappropriate, unnecessary shocks were delivered. Discussion: Patient compliance with the ASSURE WCD was high in this real-world observational study with equal representation of both sexes. The WCD effectively terminated sustained hemodynamically significant tachyarrhythmias, emitted few false alarms due to noise and resulted in no unnecessary and inappropriate shocks.

Effects of β-blockers on the Outcomes in Patients with Pulmonary Arterial Hypertension Stratified by the Presence of Comorbid Conditions: a Multicenter Prospective Cohort Study (BNP-PL)

The current guidelines do not recommend β-blockers in pulmonary arterial hypertension (PAH) unless indicated by comorbidities. However, the evidence regarding the role of β-blockers in PAH is contradictory. What are the effects of β-blockers on clinical outcomes in patients newly diagnosed with pulmonary arterial hypertension (PAH), and how do these outcomes differ based on the presence of cardiovascular comorbidities that are standard indications for β-blocker use? We analyzed data from 806 patients newly diagnosed with PAH enrolled prospectively in the Database of Pulmonary Hypertension in the Polish Population (BNP-PL). The endpoints were all-cause mortality and a composite of hospitalization due to right heart failure, syncope or death. Indications for β-blocker included hypertension, significant arrhythmia, and coronary artery disease(CAD). Propensity score matching (PSM) was used to form a control group based on age, PAH mortality risk variables and initially introduced PAH specific therapy. Out of the 806 patients, 469 (58.2%) received β-blockers at the time of PAH diagnosis. In PSM, β-blocker treatment showed a higher incidence of the composite endpoint (HR:1.44; 95% CI: 1.04-1.99; P = .03) and had neutral impact on mortality (HR, 1.22; 95% CI, 0.87-1.72; P = .25). When stratified by the presence of comorbidities, β-blockers showed adverse effects on composite endpoint in patients without comorbidities and a neutral effect in patients with at least one comorbidity INTERPRETATION: β-blockers pose significant risks in patients with PAH, especially in patients without coexisting systemic hypertension, CAD and arrhythmia.

Morphology and Function Assessment of Left Atrial Appendage in Patients With Atrial Fibrillation.

Atrial fibrillation (AF) is among the most prevalent forms of clinically significant arrhythmia, and stroke incidence is among the most serious AF-related complications, causing high rates of morbidity and mortality among affected patients. The European Society of Cardiology guidelines recommend a thromboembolic event risk assessment based on the CHA2DS2-VASC score. However, stroke also occurs in some patients with a low CHA2DS2-VASC score. Therefore, it is necessary to improve thromboembolic risk stratification in AF patients. The left atrial appendage (LAA) is considered to be the most frequent site of thrombus formation. Approximately 47% of thrombi in valvular AF and 91% of thrombi in nonvalvular AF are localized in the LAA. Therefore, identification or exclusion of LAA thrombi is critical in many clinical situations. It is essential to assess LAA morphology and function using imaging modalities (particularly echocardiography) before, during, and after interventional procedures such as AF ablation and LAA occlusion. This review article describes the anatomical, physiological, and LAA assessment in daily practice.

Effects of beta blockers on outcome in patients with PAH with and without comorbid conditions: a Multicenter Prospective Cohort Study (BNP-PL)

Abstract Background The current guidelines do not recommend the use of beta-blockers (BB) in patients with pulmonary arterial hypertension (PAH) unless necessitated by comorbidities. However, the evidence regarding the role of BB in PAH is contradictory. This study investigates the effects of BB on clinical outcomes in patients newly diagnosed with PAH, stratified by the presence of cardiovascular comorbidities that justify their use. Methods We analyzed data from 806 patients newly diagnosed with PAH, who were prospectively enrolled from March 1, 2018, to August 31, 2023, in the multicentre registry, Database of Pulmonary Hypertension in the Polish population (BNP-PL). The primary endpoints were all-cause mortality and a composite of hospitalization due to right heart exacerbation, syncope, or death. The follow-up period for these patients extended until August 31, 2023. Comorbidities in the study group that indicated the need for BB therapy included hypertension, significant arrhythmia, and coronary artery disease. In the Cox regression analysis, the association between BB use and the predefined endpoints was adjusted for age, baseline European Society of Cardiology risk score, and upfront therapy. Results Among the 806 patients, BBs were administered to 469 (58.2%) at the time of PAH diagnosis. In the entire cohort, BB therapy was linked to increased all-cause mortality (29.6% vs 21.4%; p=0.005, Fig 1.A) and a higher incidence of the composite endpoint (34.1% vs 22.6%; p<0.0001, Fig 1.B). The Number Needed to Harm (NNH) for BB treatment, regarding mortality and the composite endpoint, were 12.1 and 8.7, respectively. In patients without comorbidities, BB use significantly raised the risk of both all-cause mortality (Hazard Ratio [HR] 1.81, 95% Confidence Interval [CI]: 1.01-3.15) and the composite endpoint (HR 1.85, 95% CI 1.09-3.14), after adjustments for age, baseline three-strata PAH mortality risk, and upfront therapy. However, in patients with at least one comorbidity, BB therapy showed a neutral effect on both outcomes. Across the whole group, the use of nonselective BB was associated with a higher risk of the composite endpoint (HR 1.78, 95% CI 1.13-2.82, p=0.01) compared to selective β1 agents, although this did not extend to all-cause mortality (HR 1.34, 95% CI 0.79-2.25, p=0.28). Conclusion BBs, particularly nonselective, pose significant risks in patients with PAH who lack comorbidities that justify their use.

Sulcardine, an investigational multichannel blocker for atrial fibrillation with uniquely intense JTp inhibition to enhance safety

Abstract Background Sulcardine is a multi-ion channel blocker for treating atrial fibrillation (AF) with similar inhibitory potency on peak/late sodium, L-type calcium, and rapidly activating delayed-rectifier potassium (IKr) currents. The therapeutic effect of inhibiting IKr includes QT prolongation (accompanied by a proportional J to T peak [JTp] interval prolongation), which, when excessive, may cause malignant arrhythmias. As previously reported, sulcardine strongly mitigates the JTp increase that may contribute to excessive QT prolongation by inhibiting late sodium and L-type calcium currents, an intrinsic mechanism to protect from excessive IKr block. Purpose We explored the JTp mechanism, pharmacokinetics (PK), electrocardiogram (ECG) changes, safety, and drug-drug interaction (DDI) of a single sulcardine (as HBI-3000) intravenous (IV) infusion in healthy subjects. Methods An open-label Phase 1 study evaluated the PK interaction between sulcardine, dosed as a 350 mg 30-minute infusion of the sulfate salt HBI-3000, and a cytochrome P450 CYP2D6 enzyme inhibitor (paroxetine). Triplicate ECGs were extracted from continuous 12-lead Holter ECG recordings at baseline and 10 time points thereafter. Mean baseline-subtracted and heart rate-corrected QTcF (dQTcF), JTpc (dJTpc), and other ECG changes were calculated at each time point. Left ventricular ejection fraction (LVEF) was assessed at baseline, 30-, and 120-minutes post-infusion start by transthoracic echocardiography (TTE). Results 39 subjects received HBI-3000, 33 in the paired PK population. Expected ECG parameter changes proportional to sulcardine plasma concentrations were observed in the HBI-3000-alone portion of the study, including modest QTcF prolongation (Fig 1, blue slope, confidence band) and JTpc inhibition (Fig 1, red). The usual JTpc increase associated with IKr blockers, even those with mitigating channel block (such as the late sodium current), was not only reduced but actually reversed. We calculated the dQTcF change that would have been observed in the absence of JTpc reduction by sulcardine (Fig 1, green). Sulcardine reduced the QTcF increase that might have occurred by about 21 msec at the highest concentrations, and this mitigating effect was observed at all concentrations. No clinically significant safety findings or arrhythmias were observed. The most frequent TEAEs were nausea and headache (n=2 each [5.1%]). No LVEF changes were clinically significant. Sulcardine had minimal metabolic interactions. Conclusion Acute IV HBI-3000 administration resulted in no clinically significant safety findings, LVEF depression, or DDI with CYP2D6. Sulcardine facilitates QT prolongation, which has a therapeutic benefit in terminating AF, with simultaneous uncoupling and reversing of the JTpc interval increase, a potential mechanism for reducing proarrhythmic risk due to excessive QT prolongation.Figure 1.ECG Intervals vs Sulcardine Conc

Adverse Myocardial and vascular side effects of Immune Checkpoint Inhibitors: a prospective multimodal cardiovascular assessment (AMICI study)

Abstract Background Immune checkpoint inhibitors (ICIs) are transformative treatments in oncology, yet they are also associated with a range of cardiovascular (CV) events. Purpose To identify the incidence of CV events (including subclinical) in patients receiving ICIs for solid cancer, either alone or in association with other cancer therapies (e.g., chemotherapies, target therapies). Objectives and methods The Adverse Myocardial and vascular side effects of Immune Checkpoint Inhibitors(AMICI) study prospectively assessed the incidence of CV changes by means of a thorough multimodal assessment. This included repeated CV imaging (transthoracic echocardiograms (TTE), cardiac magnetic resonance imaging (CMR)), serum biomarkers (troponin, brain natriuretic peptides in a single laboratory), and ambulatory ECG monitoring, before and during (at 6 weeks and at 6 months) ICI therapy (Figure). Cardiovascular events included myocarditis, pericarditis, acute coronary syndrome, heart failure (HF), high degree conduction abnormalities (defined as new grade 2 or 3 atrioventricular block) or sustained ventricular arrhythmias (defined as 3 or more ventricular beats at a rate ≥ 120/min), CV death as a composite endpoint, validated by an independent expert panel Results Out of 130 solid cancer patients considered for ICI therapy, 49 patients (38 (77.6%) male; mean age 64.3 (­SD 11.0) years old) were included (June 2020 -December 2021). 22 (55.1%) suffered from kidney or bladder cancer; 7 (14.3%) had CV disease prior to cancer diagnosis; 4 (8.2%) received PD1 and CTLA4 inhibitors. Early CV events were observed in 9 (18.4%) patients at mean 40.1 (SD 5.9) days, with heart failure (HF) in 5 (10.2%), ventricular arrhythmias or new conduction disorders in 4 (8.2%) patients. History of AF (HR 4.49 (CI 1.11-18.14), P=0.035) predicted early CV events at 6 weeks (Table). At 6 months follow-up, 18 CV events were observed in 15/49 (31%) patients, with 6 (12.2%) HF events, 5 (10.2%) significant ventricular arrhythmias or conduction disorders and 4 (8.2%) AF. There was a significant decline in LVEF (P<0.001) in patients even in the absence of CV event (P=0.003) or HF (P=0.003). Higher creatinine at inclusion (HR 0.99 [0.98-1.00], P=0.006) predicted HF. Conclusions Cardiovascular complications arising during cancer treatment with ICIs are primarily due to the exacerbation of pre-existing HF or the onset of non-inflammatory heart rhythm disorders. The majority of these CV changes manifest shortly after starting ICIs and do not need hospital admission. Our results suggest that more close follow-up may be needed in patients with underlying CV conditions when starting ICI therapy, by means of CMR and ambulatory ECG holter monitoring.

Sodium-glucose co-transporter-2 inhibitors : a potential cardioprotective agent?

Abstract Background Sodium-glucose co-transporter-2 inhibitors (SGLT2i) are one of the cornerstones in the treatment of patients with heart failure (HF) , regardless the ejection fraction (EF) or the presence of diabetes mellitus (DM). Other types of medications used in the treatment of heart failure , like angiotensin converting enzyme inhibitors (ACEi) or beta-blockers (BB) have shown some degree of cardioprotection in high risk patients receiving cardiotoxic chemotherapy, but data on SGLT2i are very limited. Purpose To examine the possible differences in the development of anthracycline cardiotoxicity in diabetic patients receiving SGLT2i compared to those who don’t. Methods We retrospectively analysed the data from the oncological as well as hematological patients of our hospital. Group 1 (SGLT2) included patients with cancer who received anthracycline treatment and diabetes on treatment with SGLT2i. Group 2 (control) included patients with cancer who received anthracycline treatment and diabetes but with treatment other than SGLT2i. We recorded the basic demographic parameters, the development of cardiotoxicity (heart failure incidence, heart failure admissions, new cardiomyopathy [>10% decline in ejection fraction to <50%], and clinically significant arrhythmias) as well as the abnormal levels of troponin I (tnI) and natriuretic peptides (NTproBNP). Results Age, sex, ethnicity, cancer type, cancer stage, and other cardiac risk factors were similar between groups. The mean duration of the follow up was 2 years. In the SLT2 group were included 86 patients and in the control group 97. The rates of the cardiotoxicity events were recorded as follow : (SGLT2 vs control) Heart failure (7.4% vs 31.9%, p<0.01), heart failure admissions (3.4% vs 12.3%, p<0.05), new cardiomyopathy (6.1% vs 27.2%, p<0.05), arrhythmias (2.7% vs 24.3%, p<0.01), abnormal tnI levels (4.2% vs 14.7% , p< 0.01), abnormal NTproBNP levels (6.4% vs 30.9%, p<0.01) Conclusions SGLT2 inhibitors were associated with lower rate of cardiac events among patients with cancer and DM who were treated with anthracyclines. Further studies are needed in order to test the possible cardioprotective effects of SGLT2 inhibitors in patients at high cardiac risk treated with anthracyclines.

Effects of dialysate potassium concentration of 3.0mEq/l with sodium zirconium cyclosilicate on dialysis-free days versus dialysate potassium concentration of 2.0mEq/l alone on rates of cardiac arrhythmias in hemodialysis patients with hyperkalemia

The optimal approach towards managing serum potassium and hemodialysate potassium concentrations is uncertain. To study this, adults receiving hemodialysis for three months or more with hyperkalemia (pre-dialysis serum potassium (sK+) 5.1-6.5 mEq/l) had cardiac monitors implanted and were randomized to either eight weeks of 2.0 potassium/2.5 calcium mEq/l dialysate without sodium zirconium cyclosilicate (SZC) (2.0 potassium/noSZC) or 3.0 potassium/2.5 calcium mEq/l dialysate combined with SZC (3.0 potassium/SZC) on non-dialysis days to maintain pre-dialysis sK+ 4.0-5.5 mEq/l, followed by treatment crossover for another eight weeks. The primary outcome was the rate of adjudicated atrial fibrillation (AF) episodes of 2 minutes or more duration. Secondary outcomes included clinically significant arrhythmias (bradycardia, ventricular tachycardia, and/or asystole) and the proportion of sK+ measurements within an optimal window of 4.0-5.5 mEq/l. Among 88 participants (mean age: 57.1 years; 51% male; mean pre-dialysis sK+: 5.5 mmol/l) with 25.5 person-years of follow-up, 296 AF episodes were detected in nine patients. The unadjusted AF rate was lower with 3.0 potassium/SZC versus 2.0 potassium/noSZC; 9.7 vs. 13.4/person-year (modeled rate ratio 0.52; 95% confidence interval: 0.41; 0.65). Clinically significant arrhythmias were reduced with 3.0 potassium/SZC vs. 2.0 potassium/noSZC 6.8 vs. 10.2/person-year modeled rate ratio 0.47: 0.38;0.58). Fewer sK+ measurements outside the optimal window occurred with 3.0 potassium/SZC (modeled odds ratio: 0.27:0.12, 0.35). Hypokalemia was less frequent (33 vs. 58 patients) with 3.0 potassium/SZC compared with 2.0 potassium/noSZC. Thus, in patients with hyperkalemia on maintenance hemodialysis, a combination of potassium 3.0 mEq/l and SZC on non-hemodialysis days reduced the rates of AF, other clinically significant arrhythmias, and post-dialysis hypokalemia compared with potassium 2.0/noSZC.

Type and dimensions can predict ventricular arrhythmias and cardiac death in primary benign cardiac tumors in children

Despite being extremely rare in children, primary benign cardiac tumors can cause malignant ventricular arrhythmias (VA) or even sudden cardiac death. To assess the predictors of cardiovascular death and malignant VAs, we designed a retrospective single-center study enrolling paediatric patients. We defined as primary outcome a composite of cardiovascular death, sustained VT, ventricular fibrillation and rapid, symptomatic non-sustained VT. Our secondary endpoint was to assess the prevalence of clinically significant arrhythmias in our population. Methods and resultsWe fitted a multivariate Cox regression model to assess the predictors of the primary outcome. Over a period of 38 years, a total of 97 children were enrolled in the study. Among them, there were 73 rhabdomyomas, 13 fibromas, 3 myxomas, 3 teratomas, 1 lipoma, 2 haemangiomas and 2 fibroelastomas. Over a median follow up of 10.53 years, 16 patients met the primary outcome. Kaplan Meier unadjusted survival estimates showed that tumor dimensions larger than 2.3 cm and diagnosis of fibroma predicted worse outcomes compared with smaller tumors or other histotypes, (log rank p < 0.0002 and < 0.0001 respectively). In multivariate Cox proportional hazards analysis, diagnosis of fibroma and tumor dimensions were independently associated to the primary endpoint (HR: 5.06, 95 %CI (1.3–19); and 1.26 • (1.05–11), respectively). Clinically significant arrhythmias were reported in 24.5 % of the study population. ConclusionsAmong paediatric primary cardiac tumors, type and dimensions may predict the hazard of malignant VAs and cardiac death.

Association of Fragmented QRS Complex with Short Term Outcome in Patients with Acute ST-Elevation Myocardial Infarction

Background: Acute ST-elevated myocardial infarction is a life-threatening condition. Presence of fragmented QRS (fQRS) after acute STEMI is associated with alteration of myocardial activation due to myocardial scar and myocardial fibrosis. Previous studies have suggested that fQRS in acute STEMI is associated with increased mortality, morbidity, sudden cardiac death and recurrent adverse cardiovascular events. The study was designed to assess the association of fQRS complex with short-term outcome (in hospital and 30 days follow up) in patients with acute ST elevation myocardial infarction. Methods: This prospective cohort study was conducted in the Department of Cardiology, Dhaka Medical College Hospital among the STEMI patients who were thrombolysed. All patients underwent serial ECG at admission, within first 12 hours, at 24 hours and at 48 hours for detecting the presence of fQRS complex. Patients showing fQRS involving infarct territory within 48 h of admission were included in the “fQRS group” and those who did not develop fQRS within 48 h of admission were included in the “without fQRS” group. 114 patients had fQRS complex and 104 patients were without fQRS in their ECG. In-hospital outcomes such as: death, heart failure, significant arrhythmias (VT, VF AF, SVT, 20 AV block, CHB), cardiogenic shock were recorded. Among the study patients, sixteen patients were lost to follow up in 30 days of index hospitalization. Finally, 202 patients were tracked for follow up regarding death or re hospitalization information by personal contact or over telephone. Statistical analysis was performed using the statistical package for social science (SPSS) 21.0 software for windows. Results: Appearance of fQRS complex occurred at admission, within first 12 hours, 24 hours and 48 hours in 53.5%, 23.7%, 14.9% and 7.9% cases respectively. During index hospitalization, development of cardiogenic shock (27.19% vs 11.54%), heart failure (23.68% vs 9.62%) and significant arrhythmias were significantly higher in fQRS group (42.10% vs 11.53%, p&lt;0.05). Although mean duration of hospitalization was similar in both groups (p&gt;0.05), but in-hospital mortality was higher in fQRS group (11.40% vs 3.85%, p&lt;0.05). Rate of re-hospitalization was significantly higher in patients with fQRS complex (21.69% vs 7.29% p&lt;0.05). Overall mortality within 30 days of index hospitalization follow-up also differs significantly in presence of fQRS complex (19.81% vs 5.2%; p =0.006). Conclusion: Presence of fQRS complex is associated with adverse short-term outcome in patients with acute ST elevation myocardial infarction. Hence, these patients need more aggressive and early invasive treatment to reduce morbidity and mortality. Bangladesh Heart Journal 2024; 39(2); 93-101

Long-Term Results of the Atrial Septal Defect Occluder ASSURED Trial for Combined Pivotal/Continued Access Cohorts

BackgroundThe GORE CARDIOFORM ASD Occluder (GCA, W. L. Gore & Associates) was approved in 2019 for ostium secundum atrial septal defect (ASD) closure. ObjectivesThis study sought to report the combined pivotal and continued access cohorts of the ASSURED (Safety and Efficacy Study of Transcatheter Closure of Ostium Secundum ASDs) trial results through 36 months. MethodsThis prospective, multicenter, single-arm trial evaluated procedural and clinical outcomes of ASD closure with the GCA. The primary endpoints were 6-month closure success following device implantation and composite clinical success (deployment/retention of device, safety, and closure). Technical and procedure success, safety, clinically significant new arrhythmia (CSNA) secondary endpoints, and wire frame fracture (WFF, with fluoroscopy) at 6 and 36 months were evaluated. ResultsOf 569 patients (median age of 10.4 years and median weight of 35.0 kg) who underwent attempted secundum ASD closure, 526 were technical successes. The mean stop-flow ASD diameter was 17.6 ± 5.3 mm. All 478 patients with 6-month imaging achieved closure success. Composite clinical success at 6 and 36 months was achieved in 87.6% (468/534) and 84.0% (351/418) of patients, respectively. Technical failure occurred in 8.1% (43/548), 30-day device- or procedure-related serious adverse event in 3.9% (21/534), and 6-month device events in 2.8% (15/534) of patients. At 30 days, 21 of 569 patients (3.7%) had CSNA. At 6 months, 138 of 436 (31.7%) patients had WFFs and 105 of 185 (56.8%) at 36 months (without sequelae). ConclusionsIn this large congenital ASD device trial, the GCA had acceptable results. WFFs, although common, did not result in any clinical sequelae. The unique features, size range, and safety profile expand the options for secundum ASD closure. (Safety and Efficacy Study of Transcatheter Closure of Ostium Secundum ASDs [ASSURED]; NCT02985684)

Cardiovascular disease assessment and management in liver transplantation.

The prevalence and mortality related to end-stage liver disease (ESLD) continue to rise globally. Liver transplant (LT) recipients continue to be older and have inherently more comorbidities. Among these, cardiac disease is one of the three main causes of morbidity and mortality after LT. Several reasons exist including the high prevalence of associated risk factors, which can also be attributed to the rise in the proportion of patients undergoing LT for metabolic dysfunction-associated steatohepatitis (MASH). Additionally, as people age, the prevalence of now treatable cardiac conditions, including coronary artery disease (CAD), cardiomyopathies, significant valvular heart disease, pulmonary hypertension, and arrhythmias rises, making the need to treat these conditions critical to optimize outcomes. There is an emerging body of literature regarding CAD screening in patients with ESLD, however, there is a paucity of strong evidence to support the guidance regarding the management of cardiac conditions in the pre-LT and perioperative settings. This has resulted in significant variations in assessment strategies and clinical management of cardiac disease in LT candidates between transplant centres, which impacts LT candidacy based on a transplant centre's risk tolerance and comfort level for caring for patients with concomitant cardiac disease. Performing a comprehensive assessment and understanding the potential approaches to the management of ESLD patients with cardiac conditions may increase the acceptance of patients, who appear too complex, but rather require extra evaluation and may be reasonable candidates for LT. The unique physiology of ESLD can profoundly influence preoperative assessment, perioperative management, and outcomes associated with underlying cardiac pathology, and requires a thoughtful multidisciplinary approach. The strategies proposed in this manuscript attempt to review the latest expert experience and opinions and provide guidance to practicing clinicians who assess and treat patients being considered for LT. These topics also highlight the gaps that exist in the comprehensive care of LT patients and the need for future investigations in this field.

Association of admission blood glucose and in- hospital outcome after Primary Percutaneous Coronary Intervention in Acute Myocardial Infarction

Background: The effects of glucose abnormalities on in-hospital outcome after Primary Percutaneous Coronary Intervention (PCI) in acute STEMI remain unclear. The study assessed the relationship of admission blood glucose level to in-hospital outcome in patients presenting with a STEMI and treated with Primary PCI. Methods: This prospective study was conducted in the department of cardiology, NICVD, Dhaka Bangladesh from May 2018 to April 2019.Total 80 patients with admission normal blood glucose and hyperglycemia with acute STEMI underwent Primary PCI were considered for the study. Results: Mean age of the studied patient was 44.0±9.1 years ranging from 30 to 61 years and the mean age of the group II patients was 48.0±7.8 years ranging from 37 to 61 years. Itwas found that acute heart failure occurred 10% in group II and 2.5% in group I patients with statistically significant (p=0.04) difference. Cardiogenic shock observed 2.5% patients in group II and 2.5% patients in group I with statistically no significant (p=0.56) difference. Significant arrhythmias were found 5% patients in group II and 2.5% in group I patients with statistically no significant (p=0.40) difference. No MI and CVA were occurred in both group of patients. In group II, 2.5% patients died and no patients died in group I with statistically no significant (p=0.31) difference. Conclusion: Admission hyperglycemia is a predictor of poor prognosis in STEMI patients undergoing primary PCI. Cardiovasc j 2024; 16(2): 70-77

Randomized Trial of Patiromer on Efficacy to Reduce Episodic Hyperkalemia in Patients with ESKD Treated With Hemodialysis

Individuals with end-stage kidney disease (ESKD) maintained on hemodialysis (HD) carry a high risk of cardiac arrhythmias. This risk is heightened by episodic hyperkalemia. The purpose of the study was to investigate whether patiromer administered daily reduced episodes of hyperkalemia in those with ESKD who receive HD, and to explore whether prescription of patiromer reduced the number of significant arrhythmia events. This was a prospective, randomized, open-label trial. Eligible patients with ESKD on HD were identified. Participants were randomized 1:1 to patiromer versus usual care. Those randomized to patiromer were administered the medication daily, and the dose was titrated based on serum potassium concentrations at the start of weeks 1, 2, and 3. All participants received 7-day continuous cardiac monitors at baseline and at week4. Of the 33 participants who were randomized, 1 withdrew due to adverse symptoms, and 1 withdrew due to pregnancy, leaving 31 in our analytic cohort. The mean age of randomized participants was 56 years, 55% were male, 81% were Black, and 10% were Hispanic/Latino. In week 4, the number of episodes of serum potassium≥ 5.5 mEq/l was 13 in the patiromer group and 41 in the control group; with median number of episodes of hyperkalemia in the patiromer group significantly lower than that of control group (0 vs. 3, P= 0.024). In week 4 continuous cardiac monitors, 6 participants had > 1000/24 h premature ventricular contractions, 5 had no sustained ventricular tachycardia (VT), 3 had atrial fibrillation, and 1 had bradycardia, with no significant differences between the groups. Patiromer administered daily reduced the frequency of hyperkalemia in study participants with ESKD who receive thrice-weekly HD. Larger studies are needed to determine whether patiromer reduces significant cardiac events.

Association of Dialysate Bicarbonate with Arrhythmia in the Monitoring in Dialysis Study.

Sudden death accounts for ∼25% of deaths among maintenance hemodialysis (HD) patients, occurring more frequently on HD days. Higher dialysate bicarbonate (DBIC) may predispose to alkalemia and arrhythmogenesis. We conducted a 12-month analysis of session-level data from 66 patients with implantable loop recorders. We fit logistic regression and negative binomial mixed effects regression models to assess the association of DBIC with clinically significant arrhythmia (CSA - ventricular tachycardia ≥115 beats per minute (BPM) for at least 30 seconds, bradycardia ≤40 BPM for at least 6 seconds, or asystole for at least 3 seconds) and reviewer confirmed arrhythmia (RCA - implantable-loop-recorder-identified or patient-marked event for which a manual review of the stored ECG tracing confirmed the presence of atrial fibrillation, supraventricular tachycardia, sinus tachycardia with rate >130 BPM, ventricular tachycardia, asystole, or bradycardia). Models adjusted for age, sex, race, HD vintage, vascular access, and pre-HD serum bicarbonate and additionally for serum and dialysate potassium levels. Mean age was 56 ± 12 years, 70% were male, 53% were Black, and 35% were Asian. Fewer RCA episodes were associated with DBIC >35 than 35 mEq/L (incidence rate ratio [IRR] 0.45 (0.27, 0.75) and aIRR 0.54 (0.30, 0.97)), but the association was not significant when adjusting for serum and dialysate potassium levels (aIRR 0.60 (0.32, 1.11)). Otherwise, no associations between DBIC and arrhythmia were identified. We observed a lower frequency of RCA with higher DBIC, compared with DBIC of 35 mEql/L, contrary to our original hypothesis, but this association was attenuated in fully adjusted models. Validation of these findings in larger studies is required, with a further need for interventional studies to explore the optimal DBIC concentration.

Abstract Mo082: Polygenic Assessment for Atrial Fibrillation Liability Predicts Ventricular Arrhythmia Risk

Background: The risks for atrial and ventricular arrhythmias are increased with cardiomyopathy. Currently, left ventricular dysfunction is the major determinate of implantable cardioverter-defibrillator (ICD) placement despite left ventricular ejection fraction only having an odds ratio of 2.9 for subjects with an LVEF &lt;35% with sensitivity and specificity that suggests many patients are inappropriately receiving or not receiving a device. Additional testable variables would aid in arrhythmia risk stratification. There is growing evidence that atrial dysfunction is both a cause and consequence of ventricular disease. Atrial fibrillation (AFib) is the most common atrial arrhythmia and is highly heritable suggesting a strong genetic basis, and AFib occurs at increased frequency with cardiomyopathies. Genome-wide association studies (GWAS) identify &gt;100 loci that contribute to AFib, and signals from GWAS can be used to develop polygenic risk scores (PRS). Subjects in the top 3% of one AFib PRS were found to have ~2 fold greater risk for AFib (OR 1.7-4.6). Hypothesis: The genetic pathways represented in an AFib PRS account for a portion of arrhythmia risk associated with cardiomyopathy and can be exploited to predict ventricular arrhythmia risk. Approach: As part of an AHA Arrhythmia and Sudden Death Strategically Funded Research Network, we assembled a cohort with varying risk for sudden cardiac death ranging from low-risk individuals with non-ischemic cardiomyopathy without arrhythmia to higher risk individuals who underwent ICD placement for aborted sudden death and sudden death. Whole genome sequencing was completed 1043 individuals across the arrhythmia risk spectrum. Results: We examined an AFib PRS to define ventricular outcomes in the cohort. Of the 440 participants with disease, 81% had cardiomyopathy, 8% channelopathy and 7% idiopathic arrest. We found the AFib PRS stratified subjects without significant ventricular arrhythmia risk from subjects with known ventricular arrhythmia (p=0.03), indicating that the AFib PRS includes components that are important markers of ventricular dysfunction. Conclusions: The AFib PRS is a useful tool to stratify ventricular arrhythmia risk.

Predictors of left atrial appendage thrombus in atrial fibrillation patients undergoing cardioversion.

Atrial fibrillation and atrial flutter represent the most prevalent clinically significant cardiac arrhythmias. While the CHA2DS2-VASc score is commonly used to inform anticoagulation therapy decisions for patients with these conditions, its predictive power is limited. Therefore, we sought to improve risk prediction for left atrial appendage thrombus (LAAT), a known risk factor for stroke in these patients. We developed and validated an explainable machine learning model using the eXtreme Gradient Boosting algorithm with 5 × 5 nested cross-validation. The primary outcome was to predict the probability of LAAT in patients with atrial fibrillation and atrial flutter who underwent transesophageal echocardiogram prior to cardioversion. Our algorithm used 37 demographic, comorbid, and transthoracic echocardiographic variables. A total of 795 patients were included in our analysis. LAAT was present in 11.3% of the patients. The average age of patients was 63.3 years and 34.7% were women. Patients with LAAT had significantly lower left ventricular ejection fraction (29.9% vs 43.5%; p < 0.001), lower E' lateral velocity (5.7cm vs. 7.9cm; p < 0.001) and higher E/A ratio (2.6 vs 1.8; p = 0.002). Our machine learning model achieved a high AUC of 0.79, with a high specificity of 0.82, and modest sensitivity of 0.57. Left ventricular ejection fraction was the most important variable in predicting LAAT. Patients were split into 10 buckets based on the percentile of their predicted probability of having thrombus. The lower the percentile (e.g., 10%), the lower the probability of having thrombus. Using a cutoff point of 0.16 which includes 10.0% of the patients, we can rule out thrombus with 100% confidence. Using machine learning, we refined the predictive power of predicting LAAT and explained the model. These results show promise in providing better guidance for anticoagulation therapy and cardioversion in AF and AFL patients.

The Use of Extracorporeal Membrane Oxygenation in a Patient with Septic Myocarditis in the Postpartum Period

Introduction. Septic myocarditis is a rare disease (from 10 to 22 cases per 100 000 people). The cause of death is usually acute heart failure, hemodynamically significant cardiac arrhythmias, or thromboembolism. Patients in critical condition suffering from infectious myocarditis require massive cardiotonic support to maintain the necessary cardiac output with reduced myocardial contractile function, which leads to an increase in the need for cardiomyocytes for oxygen and aggravates their damage. Veno-arterial extracorporeal membrane oxygenation (ECMO) allows partial or complete replacement of cardiac function and reduces the dose of inotropic drugs, improve oxygen delivery and thereby contribute to the rapid restoration of cardiac function.The purpose of this publication is to demonstrate in a clinical case the successful experience of ECMO in the treatment of a patient with septic myocarditis in the early postpartum period.Materials and methods. A 28-year-old patient, data from medical records at the previous stages of treatment and at the Sverdlovsk Regional Clinical Hospital No. 1.Results. On the third day of treatment, the patient’s condition worsened due to the progression of cardiovascular and respiratory failure. A veno-arterial ECMO procedure was initiated, which lasted 6 days.Discussion. Positive dynamics in the patient’s condition were observed during six days of ECMO (normalization of echocardiography parameters, levels of cardiac enzymes and natriuretic peptide).Conclusion. Veno-arterial ECMO as a temporary method of mechanical support of the left ventricle and prosthetic pulmonary function can be successfully used until their recovery in patients with septic myocarditis in the postpartum period.

Precise risk-prediction model including arterial stiffness for new-onset atrial fibrillation using machine learning techniques.

Atrial fibrillation (AF) is the most common clinically significant cardiac arrhythmia and is an important risk factor for ischemic cerebrovascular events. This study used machine learning techniques to develop and validate a new risk prediction model for new-onset AF that incorporated the use electrocardiogram to diagnose AF, data from participants with a wide age range, and considered hypertension and measures of atrial stiffness. In Japan, Industrial Safety and Health Law requires employers to provide annual health check-ups to their employees. This study included 13 410 individuals who underwent health check-ups on at least four successive years between 2005 and 2015 (new-onset AF, n=110; non-AF, n=13 300). Data were entered into a risk prediction model using machine learning methods (eXtreme Gradient Boosting and Shapley Additive Explanation values). Data were randomly split into a training set (80%) used for model construction and development, and a test set (20%) used to test performance of the derived model. The area under the receiver operator characteristic curve for the model in the test set was 0.789. The best predictor of new-onset AF was age, followed by the cardio-ankle vascular index, estimated glomerular filtration rate, sex, body mass index, uric acid, γ-glutamyl transpeptidase level, triglycerides, systolic blood pressure at cardio-ankle vascular index measurement, and alanine aminotransferase level. This new model including arterial stiffness measure, developed with data from a general population using machine learning methods, could be used to identify at-risk individuals and potentially facilitation the prevention of future AF development.