Total Ischemic Time Research Articles

Symptom-to-balloon time and risk of ventricular arrhythmias in patients with STEMI undergoing percutaneous coronary intervention: The VERY-STEMI study

BackgroundVentricular arrhythmias (VAs) mainly occur in the early post-myocardial infarction (MI) period. However, studies examining the association between total myocardial ischemia time interval and the risk of new-onset VAs during a long-term follow-up are scarce. MethodsThis study (symptom-to-balloon time and VEntricular aRrhYthmias in patients with STEMI, VERY-STEMI study) was a multicenter, observational cohort and real-world study, which included patients with ST-segment elevation MI (STEMI) undergoing percutaneous coronary intervention (PCI). The primary endpoint was cumulative new-onset VAs during follow-up. The secondary endpoints were the major adverse cardiovascular events (MACE) and changes in left ventricular ejection fraction (ΔLVEF, %). ResultsA total of 517 patients with STEMI were included and 236 primary endpoint events occurred. After multivariable adjustments, compared to patients with S2BT of 24 h-7d, those with S2BT ≤ 24 h and S2BT > 7d had a lower risk of primary endpoint. RCS showed an inverted U-shaped relationship between S2BT and the primary endpoint, with an S2BT of 68.4 h at the inflection point. Patients with S2BT ≤ 24 h were associated with a lower risk of MACE and a 4.44 increase in LVEF, while there was no significant difference in MACE and LVEF change between the S2BT > 7d group and S2BT of 24 h-7d group. ConclusionsS2BT of 24 h-7d in STEMI patients was associated with a higher risk of VAs during follow-up. There was an inverted U-shaped relationship between S2BT and VAs, with the highest risk at an S2BT of 68.4 h.

Is the cardioprotective effect of pre-infarction angina blunted by age?

Abstract Funding Acknowledgements None. Background Pre-infarct angina (PIA) has been demonstrated to reduce infarct size and improve prognosis in ST-elevation myocardial infarction (STEMI). However, the effects of ischemic preconditioning with aging are still controversial. Purpose We aimed at comparing the effect of pre-infarction angina (PIA) on infarct size between two age groups. Methods We retrospectively studied consecutive STEMI patients treated by primary percutaneous coronary intervention (PCI) from January 2008 to December 2017. PIA was diagnosed if a patient had arm, jaw, or chest pain in the preceding eight days. Peak creatine kinase (CK) concentration was used as a surrogate of infarct size. Patients were divided into two groups, based on the median age: ≤62 years and >62 years. Multiple linear regression was used to identify independent predictors for infarct size that included total ischemic time and classic cardiovascular risk factors (hypertension, diabetes, dyslipidaemia, and smoking). Interaction between age and PIA was evaluated by 2-way factorial ANOVA. Results From the 1131 patients included in the study, 590 (52,2%) had ≤62 years and 541 (47,8%) had >62 years. Older patients were more often women (17.2% vs 8.6%, p<0.001) and had longer total ischemic time [4.6(3.0-9.0) vs 3.5(2.3-6.0) hours, p<0.001]. They also had higher prevalence of hypertension (32.8% vs 22.8%, p<0.001), diabetes (30.7% vs 18.7%, p<0.001) and were less likely to be smokers (26.9% vs 71.4%, p<0.001). The prevalence of PIA was similar across age groups (≤62Y 31.2% vs >62Y 32.0%, p=0.668). In older patients, PIA was associated with smaller infarct size [1.29(0.72-2.33) vs. 1.76(0.97-2.91) U/Lx103, p<0.001]. This difference was not observed for younger patients [1.72(0.95-3.40) vs. 1.81(0.94-3.37) U/Lx103, p=0.392]. There was no significant interaction between the existence of PIA and age on peak CK (p=0.280 for interaction) (Figure 1). In multivariate analysis, overall, PIA was associated with reduced peak CK (β=-0,320, p=0.011). On subgroup group analysis, PIA was a predictor of infarct size only in the older patients (β=-0,459, p=0.005), but not in the younger group (β=-0,182, p=0.394). Conclusion Older patients with PIA had significantly lower infarct size compared to patients in the same age group without PIA. After adjustment for risk factors and total ischemic time, PIA was a predictor of lower infarct size only for the older patients. These results suggest that the effect of pre-ischemic conditioning is not blunted by age, indicating that older patients should not be excluded from clinical trials investigation of cardioprotective strategies in STEMI patients.

Differences in mortality between patients with cardiogenic shock due to STEMI treated with PCI vs thrombolysis

Abstract Funding Acknowledgements None. Introduction STEMI is complicated with cardiogenic shock (CS) in approximately 5-10% of cases and mortality is about 40% at 30-day and 50% at 1 year worldwide. In Mexico the incidence of CS in STEMI that received revascularization therapy (PCI or thrombolysis) is between 4.4-4.8%. In our country, pharmacoinvasive strategy (PIs) is the preferred modality due to the lack of PCI centers and demographics. Purpose To demonstrate differences in total ischemia time and 30-day in-hospital mortality in patients treated with PIs or PCI. Methods This was a retrospective observational study of patients that arrived to the emergency room and coronary care unit of the National Institute of Cardiology from January 2018 to March 2023 with CS due to STEMI at presentation, who received reperfusion therapy (PCI or PIs) during the first 12 hours of symptom onset. Results We included 61 patients with CS due to STEMI at presentation, 60.7% received PIs and 39.3% underwent PCI. The prevalence of type 2 diabetes was 38%, hypertension was 28% and obesity was 10% with no significant differences between groups, however the presence of CKD differed significantly with approximately 3% in PCI group versus 0% in PIs group. 21% were smokers and 13% previous smokers. Only 8 patients (13.1%) had a previous MI, 5 patients (8.2%) had previous angioplasty and 4 patients (6.6%) had previous HF. The first medical contact (FMC) occurred at a median of 120 minutes (IQR 75-240 min) overall. For patients undergoing PIs, the FMC was 120 minutes (IQR 70-185 min), whereas for those undergoing PCI, it was 185 minutes (IQR 87-300 min). The total ischemia time was 270 minutes (IQR 180-470 min) overall, with a median of 229 minutes (IQR 163-405 min) for PIs and 396 minutes (IQR 267-592 min) for PCI. The 30-day in-hospital mortality rate was 27.9% overall, significantly lower at 18.9% in the PIs group compared to 41.7% in the PCI group (p=0.01). The average length of hospital stay was 8 days for the PIs population, slightly longer than the 6.5 days observed in the PCI group (p=0.09). Conclusion In this real-world retrospective analysis conducted in our center in a middle-income country showed that PIs impacted positively in 30-day in-hospital mortality of patients who arrived with CS due to STEMI at presentation compared to those that underwent PCI. This effect seems to be secondary to shorter ischemic times since symptom onset due to the use of a prompt reperfusion therapy.

Cardiogenic shock following ST-segment elevation myocardial infarction in women: complications and outcomes

Abstract Funding Acknowledgements None. Background Differences in women’s prognosis have been described for both ST-segment elevation myocardial infarction (STEMI) and cardiogenic shock (CS). These might reflect asymmetries in clinical management, but also gender-specific comorbidities and pathologic mechanisms. Purpose We aimed to evaluate the risk of in-hospital complications and mid-term outcomes of women with CS following STEMI. Methods We retrospectively studied STEMI patients treated by primary percutaneous coronary intervention (PCI) from 2008 to 2017 in a tertiary care centre, presenting or evolving in Killip class IV (defined as cardiogenic shock or hypotension and organ hypoperfusion). Clinical and demographic characteristics, as well as complications and outcomes, were collected. Major adverse cardio-cerebrovascular events (MACCE) at 1-year follow-up was a composite of death, cerebrovascular accident, new myocardial infarction in any vessel, or target lesion revascularization. Results Among 1131 patients presenting with STEMI, our study included 117 (10.3%) patients in CS, of which 40 (34.2%) were women. Women were older [71.8(±13.4) vs 64.6(±11.72) years, p=0.002] and less frequently smokers (25.0% vs 50.7%, p=0.008). Prevalence of classic cardiovascular risk factors, namely diabetes (34,1% vs 39.2%, p=0.860), hypertension (71.5% vs 60.8%, p=0.212), and dyslipidaemia (47.5% vs 70.0%, p=0.799), was the same for both groups. Body mass index was also similar [26.6(±5.2) vs 26.1(±3.4) kg/m2, p=0.539]. Women had lower haemoglobin [12.4(±1.9) vs 13.8(±1.9) g/dl, p<0.001] and lower creatinine clearance at admission [52.4(±30.6) vs 67.3(±29.4) ml/min, p=0.017]. Door-to-balloon times [80(59-180) vs 68(48-105) min, p=0.302], total ischemic time [210(120-360) vs 203(120-476) min, p=0.302] and prevalence of anterior STEMI (35.0% vs 50.0%, p=0.123) were not significantly different between sexes. The prevalence of in-hospital complications was generally similar for both sexes (Table 1), except for the risk of advanced atrioventricular (AV) block that was higher in women (32.5% vs 10.7%, p=0.004). Also, haemoglobin nadir was lower in women [10.6(±2.1) vs 11.7(±2.1) g/dl, p=0.023]. In a 1-year follow-up, the occurrence of MACCE was similar for both sexes (60.0% vs 59.7%, log-rank P 0.734) (Figure 1). Conclusion Women with STEMI complicated by CS submitted to PCI had a similar prevalence of in-hospital complications as men. Also, mid-term outcomes, assessed by MACCE at 1 year, did not differ between groups.

Sex disparities in mid-term outcomes of ST-segment elevation myocardial infarction across age

Abstract Funding Acknowledgements None. Background Women with ST-segment elevation myocardial infarction (STEMI) have been reported to have higher short-term mortality than men, especially in younger patients. However, data on long-term outcomes did not corroborate this association. Purpose We aimed to evaluate if sex was an independent predictor of major adverse cardio-cerebrovascular events (MACCE) at 1-year follow-up. A sub-analysis across different age subgroups was performed. Methods We retrospectively studied consecutive STEMI patients treated by primary percutaneous coronary intervention (PCI) from January 2008 to December 2017. Cox proportional hazard models were used to identify predictors of MACCE at 1-year follow-up (death, cerebrovascular accident, new myocardial infarction in any vessel, or target lesion revascularization). Patients were divided into four age groups, according to quartiles, for subgroup analysis (≤50, 51-60, 61-70, >71 years). Results Of the 1131 patients included in the study, 291 (25.7%) were women. Women were older [68.2 (±14.2) vs 60.6 (±12.2) years, p<0.001], more often non-smokers (21.5% vs 60.2%, p<0.001), and had a higher prevalence of diabetes (34,8% vs 20.9%, p<0.001) and hypertension (71.6% vs 50.2%, p<0.001). They also had lower haemoglobin [12.8 (±1.6) vs 14.5 (±1.7) g/dl, p<0.001] and lower creatinine clearance at admission [73.8 (±35.3) vs 92.6 (±35.2) ml/min, p<0.001], as well as longer door-to-balloon times [90 (60-166) vs 75(50-120) min, p=0.005]. However, total ischemic time was not significantly different between groups [250(175-480) vs 224(150-440) min, p=0.054]. Overall, women had a higher occurrence of MACCE (22.1% vs 15.4%; log-rank P = 0.008, Figure 1). On multivariate analysis, sex was not found to be an independent predictor of MACCE (HR 1.12; 95% CI, 0.77–1.65; P = 0.547). The risk of unfavourable outcomes was mainly driven by other comorbidities (namely, age, presence of peripheral arterial disease, lower haemoglobin concentration, lower systolic blood pressure on admission, a higher peak CK activity, and the utilization of a femoral approach). When MACCE was stratified by age, sex was not an independent predictor of MACCE in any age group (Figure 2). Conclusion Women with STEMI submitted to PCI had a higher rate of MACCE at 1-year follow-up compared with men, however, sex was not an independent predictor of these events on multivariate analysis, regardless of the age subgroups considered.

Impact of Prolonged Cold Ischemia Time on Long-Term Survival in Lung Transplant Recipients

Cold ischemia time (CIT) influences short- and long-term outcomes in lung transplant recipients. Most studies proved that prolonged CIT causes increased mortality. This study aimed to investigate the impact of prolonged CIT on patient survival time after lung transplantation (LTx). The retrospective study group consisted of 139 patients who underwent double LTx in a single center between January 2018 and August 2022. Prolonged ischemic time (PIT) was defined as total ischemic time >6 hours and divided into smaller time intervals according to increasing PIT (6-8, 8-10, 10-12, >12 hours). The assessed outcomes were 1- and 4-year survival. Among the study group, PIT was observed in 98% (n = 137), and its average value was 10.33 hours. The prolonged CIT of 6 to 8 hours occurred in 10% (n = 14), 8 to 10 hours in 34% (n = 47), 10 to 12 hours in 36% (n = 49), and >12 hours in 20% (n = 27). In a comparison of 1-year survival between the PIT 6- to 10-hour group and the >10-hour arm (88% vs 78%), the difference was not statistically significant (P > .05). PIT is a risk factor for reduced long-term survival in LTx recipients. Increasing PIT may be associated with higher mortality at 1 and 4 years. All efforts to reduce the duration of ischemic time can benefit patient survival after LTx.

Risk assessment in liver transplantation for hepatocellular carcinoma: long-term follow-up of a two-centre experience.

Liver transplantation (LT) is a well-established treatment for hepatocellular carcinoma (HCC), but there are ongoing debates regarding outcomes and selection. This study examines the experience of LT for HCC at a high-volume centre. A prospectively maintained database was used to identify HCC patients undergoing LT from 2000 to 2020 with more than or equal to 3-years follow-up. Data were obtained from the centre database and electronic medical records. The Metroticket 2.0 HCC-specific 5-year survival scale was calculated for each patient. Kaplan-Meier and Cox-regression analyses were employed assessing survival between groups based on Metroticket score and individual donor and recipient risk factors. Five hundred sixty-nine patients met criteria. Median follow-up was 96.2 months (8.12years; interquartile range 59.9-147.8). Three-year recurrence-free (RFS) and overall survival (OS) were 88.6% ( n =504) and 86.6% ( n =493). Five-year RFS and OS were 78.9% ( n =449) and 79.1% ( n =450). Median Metroticket 2.0 score was 0.9 (interquartile range 0.9-0.95). Tumour size greater than 3cm ( P =0.012), increasing tumour number on imaging ( P =0.001) and explant pathology ( P <0.001) was associated with recurrence. Transplant within Milan ( P <0.001) or UCSF criteria ( P <0.001) had lower recurrence rates. Increasing alpha-fetoprotein (AFP)-values were associated with more HCC recurrence ( P <0.001) and reduced OS ( P =0.008). Chemoembolization was predictive of recurrence in the overall population ( P =0.043) and in those outside-Milan criteria ( P =0.038). A receiver-operator curve using Metroticket 2.0 identified an optimal cut-off of projected survival greater than or equal to 87.5% for predicting recurrence. This cut-off was able to predict RFS ( P <0.001) in the total cohort and predict both, RFS ( P =0.007) and OS ( P =0.016) outside Milan. Receipt of donation after brain death (DBD) grafts (55/478, 13%) or living-donor grafts (3/22, 13.6%) experienced better survival rates compared to donation after cardiac death (DCD) grafts ( n =15/58, 25.6%, P =0.009). Donor age was associated with a higher HCC recurrence ( P =0.006). Both total ischaemia time (TIT) greater than 6hours ( P =0.016) and increasing TIT correlated with higher HCC recurrence ( P =0.027). The use of DCD grafts for outside-Milan candidates was associated with increased recurrence ( P =0.039) and reduced survival ( P =0.033). This large two-centre analysis confirms favourable outcomes after LT for HCC. Tumour size and number, pre-transplant AFP, and Milan criteria remain important recipient HCC-risk factors. A higher donor risk (i.e. donor age, DCD grafts, ischaemia time) was associated with poorer outcomes.

Correlation Between Corrected TIMI Frame Count with the Extent of Myocardial Fibrosis on ST-Elevation Myocardial Infarction Patients Undergoing Primary Percutaneous Coronary Intervention

Background: Microvascular injury after primary percutaneous coronary intervention (PPCI) reperfusion contributes to necrosis propagation. Corrected TIMI Frame Count (CTFC) is a surrogate marker of microvascular dysfunction and can stratify in-hospital mortality risk in patients with final TIMI flow 3. The extent of myocardial fibrosis after STEMI is associated with a higher incidence of major cardiovascular events. This study aimed to determine the relationship between CTFC in the infarct-related artery and myocardial fibrosis area based on cardiac magnetic resonance (CMR) in STEMI patients undergoing PPCI.Methods: This retrospective cohort study included 31 STEMI patients who had undergone PPCI and CMR examination between days 60 and 75 after STEMI as the sample. CTFC was measured in the infarct-related artery from post-PPCI angiogram recordings. Myocardial fibrosis area was measured from late gadolinium enhancement CMR (LGE-CMR) imaging results.Results: In this study, the mean age was 51.61±10.49 years, 90.3% were male, non-anterior infarction location was 58.1%, mean total ischemic time was 489.48±228.33 minutes, mean CTFC was 27.4±9.3 frames, and mean myocardial fibrosis was 18.33±7.87%. There was no significant correlation found between CTFC and myocardial fibrosis (p=0.530), however total ischemic time had a positive and significant correlation with myocardial fibrosis (p=0.025, r=0.403).Conclusion: CTFC in the infarct-related artery is not correlated with myocardial fibrosis area in STEMI patients undergoing PCI.

Impact of Total Ischemic Time on No Reflow Phenomenon

Background: Ischemic heart disease, particularly ST-segment elevation myocardial infarction (STEMI), remains a major cause of morbidity and mortality globally. Despite advancements in primary percutaneous coronary intervention (PPCI), the no-reflow phenomenon, characterized by inadequate myocardial reperfusion despite successful vessel recanalization, continues to pose significant challenges, affecting clinical outcomes adversely. Objective: This study aims to investigate the relationship between total ischemic time and the incidence of the no-reflow phenomenon in STEMI patients undergoing PPCI, to identify potential strategies for improving therapeutic outcomes. Methods: Conducted at Hayatabad Medical Complex, Peshawar, this retrospective cohort study included 160 STEMI patients treated over eight months (February to October 2022). We collected data on demographic characteristics, clinical presentation, and outcomes. Inclusion criteria were patients over 18 years, undergoing PPCI within 12 hours of symptom onset, without prior MI, severe bleeding disorders, or previous significant revascularization. Statistical analysis was performed using SPSS 25.0, considering P ≤0.05 as statistically significant. Results: The average total ischemic time was significantly longer in patients experiencing no-reflow (Group I, 7.91 hours) compared to those with normal reperfusion (Group II, 3.41 hours) (P=0.001). Group I also showed higher rates of cardiogenic shock (17.6% vs. 6.8%, P=0.012) and reinfarction (11.8% vs. 2.9%, P=0.010). Mortality was significantly higher in Group I (5.8% vs. 1.9%, P=0.020). Conclusion: Longer total ischemic time is associated with an increased risk of the no-reflow phenomenon and poorer clinical outcomes in STEMI patients. Reducing ischemic time could be crucial in improving reperfusion success and reducing complications post-PPCI.

Classification and treatment of vaginal strictures at the donor-recipient anastomosis after uterus transplant

To describe the incidence and management of vaginal stricture after uterus transplantation (UTx) in the US, to propose a grading system to classify stricture severity, and to identify risk factors for stricture formation. Prospective cohort study. University Hospital. Recipients undergoing UTx from 2016-2023 at Baylor University Medical Center in Dallas, Cleveland Clinic, the University of Pennsylvania, and the University of Alabama at Birmingham were monitored postoperatively with regular pelvic examinations. Stricture was defined as vaginal narrowing of <3 cm in patients with graft survival of at least 7 days. Demographic and surgery characteristics. Stricture development and severity (grade 1 for diameter 2-<3 cm, grade 2 for 1-<2 cm, or grade 3 for <1 cm). Of the 45 UTx from 2016-2023 (16 deceased donors and 29 living donors), 3 were excluded from the analysis because of graft loss within 7 days. Of the 42 remaining recipients, 39 (92.9%) had Mayer-Rokitansky-Küster-Hauser syndrome and 3 (7.1%) had a prior hysterectomy. Twenty-eight (66.7%) UTx recipients developed postoperative vaginal strictures with a median time to stricture of 33 days (interquartile range 19-53 days). Most strictures were of moderate severity, with 4 (14.3%) strictures categorized as grade 1, 19 (67.9%) as grade 2, and 5 (17.9%) as grade 3. History of Mayer-Rokitansky-Küster-Hauser syndrome and preoperative recipient vaginal length were significant risk factors for stricture, after adjustment for donor and recipient age and body mass index, anastomosis technique, total ischemia time, center, and year. Patients with longer preoperative vaginal length had a lower risk of stricture (hazard ratio 0.45, 0.29-0.70). The severity grading of the stricture was associated with the effectiveness of a nonoperative treatment approach (grade 1 vs. grade 3). No patients with grade 3 strictures improved with self-dilation alone; all required surgical repair and/or dilation under anesthesia. Conversely, for grade 1 or 2 strictures, self-dilation alone was successful in 47.8% (11/23), and no grade 1 strictures required surgical repair. Vaginal stricture is a common postoperative complication after UTx, affecting >65% of recipients. Short preoperative vaginal length and history of müllerian agenesis in the recipient are significant risk factors. Vaginal self-dilation was effective for some mild to moderate strictures, although dilation under anesthesia or surgical repair was required in most cases. Dallas UtErus Transplant Study (DUETS) at Baylor University Medical Center (NCT02656550), Uterine transplantation for the treatment of uterine factor infertility at the Cleveland Clinic (NCT02573415), The University of Pennsylvania Uterus Transplant for Uterine Factor Infertility Trial (UNTIL) (NCT03307356).

Early Outcomes in Patients With LVAD Undergoing Heart Transplant via Use of the SherpaPak Cardiac Transport System.

Heart transplant (HT) in recipients with left ventricular assist devices (LVADs) is associated with poor early post-HT outcomes, including primary graft dysfunction (PGD). As complicated heart explants in recipients with LVADs may produce longer ischemic times, innovations in donor heart preservation may yield improved post-HT outcomes. The SherpaPak Cardiac Transport System is an organ preservation technology that maintains donor heart temperatures between 4 °C and 8 °C, which may minimize ischemic and cold-induced graft injuries. This analysis sought to identify whether the use of SherpaPak versus traditional cold storage was associated with differential outcomes among patients with durable LVAD undergoing HT. Global Utilization and Registry Database for Improved Heart Preservation-Heart (NCT04141605) is a multicenter registry assessing post-HT outcomes comparing 2 methods of donor heart preservation: SherpaPak versus traditional cold storage. A retrospective review of all patients with durable LVAD who underwent HT was performed. Outcomes assessed included rates of PGD, post-HT mechanical circulatory support use, and 30-day and 1-year survival. SherpaPak (n=149) and traditional cold storage (n=178) patients had similar baseline characteristics. SherpaPak use was associated with reduced PGD (adjusted odds ratio, 0.56 [95% CI, 0.32-0.99]; P=0.045) and severe PGD (adjusted odds ratio, 0.31 [95% CI, 0.13-0.75]; P=0.009), despite an increased total ischemic time in the SherpaPak group. Propensity matched analysis also noted a trend toward reduced intensive care unit (SherpaPak 7.5±6.4 days versus traditional cold storage 11.3±18.8 days; P=0.09) and hospital (SherpaPak 20.5±11.9 days versus traditional cold storage 28.7±37.0 days; P=0.06) lengths of stay. The 30-day and 1-year survival was similar between groups. SherpaPak use was associated with improved early post-HT outcomes among patients with LVAD undergoing HT. This innovation in preservation technology may be an option for HT candidates at increased risk for PGD. URL: https://www.clinicaltrials.gov; Unique identifier: NCT04141605.

Pandemic effect on ischaemic burden and prehospital time in acute coronary syndrome

Background: Acute coronary syndrome (ACS) requires rapid identification and intervention. Early recognition of symptoms, detection of ischaemic markers in electrocardiograms (ECGs) and timely reperfusion therapy all reduce the total ischaemic time. In 2020, SARS-CoV-2 emerged as a new threat to people with cardiac disease: calls to emergency departments, emergency department visits and hospital admissions for acute cardiac conditions decreased, possibly because patients delayed seeking care because of fear of SARS-CoV-2 exposure. The hypothesis of this study was that patients presenting with ACS during the pandemic would have more ischaemic features and longer prehospital time intervals than those presenting before the pandemic. However, there were no significant differences between pre-pandemic and pandemic groups regarding incidence of ECG ischaemic markers, elevated troponin, adverse outcomes or prehospital time intervals. Non-ST-elevation myocardial infarction was significantly higher in the pandemic sample, which suggests that patients with less severe symptoms sought treatment during the pandemic.

(944) - Impact of Total Allograft Ischemic Time on Heart-Lung Transplantation Outcomes in the United States

(944) - Impact of Total Allograft Ischemic Time on Heart-Lung Transplantation Outcomes in the United States

Impact of prolonged storage time on homograft ultrastructures: an attempt to find optimal guidelines for homograft processing

According to guidelines, total ischemic time for homografts at processing must be kept short to avoid degeneration. Many homografts are discarded due to practical inability to finish all steps from procurement to cryopreservation within the time limit. Although, several studies have shown that homografts with prolonged ischemic time show adequate quality and performance. Twenty aortic and 12 pulmonary homografts were collected and biopsies were retrieved at preparation (day 0) and after 1, 2, 3, 4, 7, 14, 21, 28, and 60 days in antibiotic decontamination at 4 °C. Biopsies were prepared for light microscopy (LM) and transmission electron microscopy (TEM). Assessment generated scores for cells, elastin, and collagen. Relative differences between times were compared with Wilcoxon signed rank test. Bonferroni corrected p value of 0.0056 was considered significant. LM could only reveal decrease in cell count at 60 days in aortic homografts, no other differences was detected. TEM showed affected cell appearance in day 3 and day 4 and beyond for aortic and pulmonary homografts respectively. Elastin appearance was affected at day 60 for aortic and day 21 for pulmonary homografts. Collagen appearance was affected at day 28 for aortic homografts, with no significant differences in pulmonary homografts. Cell degeneration starts early after homograft procurement, but elastic and collagen fibers are more resistant to degeneration. Overall structure integrity as seen in LM was not affected at all, while TEM could reveal small degeneration signs in individual elastic fibers and collagen bundles at 21 and 28 days respectively.

Impact of Total Ischemic Time on Clinical Outcome in Stemi Patients Undergoing Percutaneous Coronary Intervention

Background: ST-segment elevation myocardial infarction (STEMI) represents a critical condition requiring prompt treatment to minimize myocardial damage. Percutaneous coronary intervention (PCI) is the preferred reperfusion strategy, with the total ischemic time (TIT) being a crucial determinant of clinical outcomes. Despite the recognized importance of minimizing door-to-balloon (DTB) time, the impact of TIT on STEMI outcomes necessitates further exploration. Objective: This study aimed to evaluate the association between TIT and clinical outcomes in STEMI patients undergoing PCI, specifically focusing on all-cause mortality, re-hospitalization, and revascularization rates. Methods: A descriptive study was conducted at the cardiology ward of Lady Reading Hospital from May 2023 to October 2023. Ninety patients diagnosed with STEMI and undergoing PCI were enrolled. Patients were excluded if they had a history of cardiac surgeries or a DTB time &gt;90 minutes. TIT was categorized into ≤120 minutes (Group A) and &gt;120 minutes (Group B). Clinical outcomes assessed at 6 months post-PCI included all-cause mortality, cardiac mortality, re-hospitalization, and revascularization. Data were analyzed using SPSS version 25, employing Chi-Square tests for categorical variables, with a p-value ≤ 0.05 considered statistically significant. Results: Among the participants, Group A (TIT ≤ 120 mins) comprised 33 patients, while Group B (TIT &gt; 120 mins) included 57 patients. Increased TIT was associated with higher rates of all-cause mortality (21.1% in Group B vs. 6.1% in Group A, p=0.05), re-hospitalization (22.8% vs. 6.1%, p=0.04), and revascularization (29.8% vs. 12.1%, p=0.05). Cardiac mortality was also higher in Group B (10.5%) compared to Group A (3.0%), though this difference was not statistically significant (p=0.20). Conclusion: The study highlights the significant impact of TIT on the prognosis of STEMI patients undergoing PCI. Shorter TIT is associated with markedly better clinical outcomes, emphasizing the need for healthcare systems to adopt strategies that reduce both pre-hospital and in-hospital delays.

Culprit Lesion Vessel Size and Risk of Reperfusion Injury in ST-Segment Elevation Myocardial Infarction: A Cardiac Magnetic Resonance Imaging Study.

Microvascular obstruction (MVO) and intramyocardial hemorrhage (IMH) are well-established imaging biomarkers of failed myocardial tissue reperfusion in patients with ST-segment elevation-myocardial infarction treated with percutaneous coronary intervention. MVO and IMH are associated with an increased risk of adverse outcome independent of infarct size, but whether the size of the culprit lesion vessel plays a role in the occurrence and severity of reperfusion injury is currently unknown. This study aimed to evaluate the association between culprit lesion vessel size and the occurrence and severity of reperfusion injury as determined by cardiac magnetic resonance imaging. Patients (n=516) with first-time ST-segment-elevation myocardial infarction underwent evaluation with cardiac magnetic resonance at 4 (3-5) days after infarction. MVO was assessed with late gadolinium enhancement imaging and IMH with T2* mapping. Vessel dimensions were determined using catheter-based reference. Median culprit lesion vessel size was 3.1 (2.7-3.6) mm. MVO and IMH were found in 299 (58%) and 182 (35%) patients. Culprit lesion vessel size was associated with body surface area, diabetes, total ischemic time, postinterventional thrombolysis in myocardial infarction flow, and infarct size. There was no association between vessel size and MVO or IMH in univariable and multivariable analysis (P>0.05). These findings were consistent across patient subgroups with left anterior descending artery and non-left anterior descending artery infarctions and those with thrombolysis in myocardial infarction 3 flow post-percutaneous coronary intervention. Comprehensive characterization of myocardial tissue reperfusion injury by cardiac magnetic resonance revealed no association between culprit lesion vessel size and the occurrence of MVO and IMH in patients treated with primary percutaneous coronary intervention for ST-segment-elevation myocardial infarction.

Sequence of Surgical Approach in a Patient with Autosomal Dominant Polycystic Kidney Disease Treated with Renal Transplantation

Introduction: Describe the surgical sequence in a 55-year-old woman with an Autosomal Dominant Polycystic Kidney (ADPKD) Case Presentation: We performed three surgical procedures in a woman with Chronic Kidney Disease (CKD) secondary to ADPKD of 13 years of evolution from June to November 2023 which are as follows: Resection of 2 liver cysts and Laparoscopic cholecystectomy, Related living donor renal transplant, and Bilateral open nephrectomy, all of them with the use of innovative technology. Result: The first procedure was performed for risk reduction and two cysts of 3.5 cm x 1.6 cm x 1.5 cm and 3.3 cm x 2.0 cm x 1.4 cm and chronic cholecystitis were reported. The second one was performed one month later; the patient had previous creatinine values of 4.73. The graft was positioned in the right iliac fossa where end-to-side anastomosis of renal vessels was performed with external iliac vessels and uretero-vesical anastomosis was executed with the Lich-Gregoir technique; the total ischemia time was 109 minutes and the kidney presented immediate function. At 48 hours, a Doppler ultrasound was performed, which reported a renal artery resistance index of 0.5, with homogeneous cortical perfusion, without collections, vessels, and ureter without stenosis or thrombosis; therefore, the patient was discharged 5 days after the transplant with optimal graft function and creatinine levels of 1.75. In the last procedure, two kidneys of 1.6 kg each were obtained and pathology reported adult polycystic disease with interstitial fibrosis, chronic inflammation, dystrophic calcification, tubular and glomerular atrophy. At the moment she has stable graft function and went from having creatinine levels of 4.73 to 1.2 and her glomerular filtration rate went from 9.68 to 50.84.

Recipient Outcomes With Extended Criteria Donors Using Advanced Heart Preservation: An Analysis of the GUARDIAN-Heart Registry

PurposeThe prevalence of end stage heart failure and patients that could benefit from heart transplantation requires an expansion of the donor pool, relying on the transplant community to continually re-evaluate and expand the use of extended criteria donor organs. Introduction of new technologies such as the Paragonix SherpaPak Cardiac Transport System aids in this shift. We seek to analyze the impact of the SherpaPak system on recipient outcomes who receive extended criteria organs in the GUARDIAN Heart Registry. MethodsBetween October 2015-December 2022, 1,113 adults from 15 US centers receiving donor hearts utilizing either SherpaPak (N=560) or conventional ice storage (Ice, N=453) were analyzed from the GUARDIAN-Heart registry using summary statistics. A previously published set of criteria was used to identify extended criteria donors, which included 193 SherpaPak and 137 ice. ResultsThere were a few baseline differences among recipients in the 2 cohorts, most notably IMPACT Scores, distance traveled and total ischemic time were significantly greater in SherpaPak, and significantly more donor hearts in the SherpaPak cohort had >4 hours total ischemia time. Post-transplant MCS utilization (SherpaPak 22.3% vs. ice 35.0%, p=0.012) and new ECMO/VAD (SherpaPak 7.8% vs. ice 15.3%, p=0.033) was significantly reduced, and the rate of severe PGD (SherpaPak 6.2% vs. ice 13.9%, p=0.022) was significantly reduced by over 50% in hearts preserved using SherpaPak. One-year survival between cohorts was similar (SherpaPak 92.9% vs. ice 89.6%, p=0.27). ConclusionThis subgroup analysis demonstrates that SherpaPak can be safely used to utilize extended criteria donors, with low severe PGD rates.

Impact of a New Referral System on Time to Treatment in Referred STEMI Patients Compared With Traditional Referral System at Maharat Nakhon Ratchasima Hospital

Background: Acute ST-segment elevation myocardial infarction (STEMI) is an emergency condition with a high risk of death if not promptly treated with a reperfusion strategy. Delayed transfer of STEMI patients to the catheterization room is associated with poor outcomes and high mortality. The data recording and transmission system is an important factor that may help shorten the time to access treatment. Objective: To compare the time to reperfusion between 2 referral systems, the time-oriented transfer system with the traditional referral system. Methods: The retrospective study of confirmed STEMI patients within 2 distinct timeframes: May 1, 2019, to March 31, 2020, for the traditional referral system; and May 1, 2022, to March 31, 2023, for the time-oriented referral system. Patients between April 1, 2020, and April 30, 2022, were excluded due to the COVID-19 pandemic outbreak. Results: There were 330 (42.4%) patients referred through the traditional referral system, and 449 (57.6%) patients referred through the time-oriented referral system. Patients in both referral systems had comparable age and sex distributions. The Killip classification was also comparable. Patients in both referral systems were transferred from the community hospitals within comparable distance. The proportion of timely reperfusion was higher, and time to reperfusion were shorter than traditional referral system with statistically significant (median [IQR], 245 [160 - 340] and 203 [129 - 353] minutes, P &lt; .05). Conclusions: The new referral system can reduce total ischemic and reperfusion time.

Association of Total Ischemia Time with No-Reflow Phenomenon in Patients Presenting with STElevation Myocardial Infarction, Undergoing Primary Percutaneous Coronary Intervention

Objective: To find out the association of total ischemic time with no-reflow phenomenon, in terms of Thrombolysis in Myocardial Infarction (TIMI) flow grade, in patients presenting with ST-Elevation Myocardial Infarction and undergoing Primary Percutaneous Coronary Intervention(PPCI). Study Design: Analytical Cross-Sectional study. Place and Duration of Study: Armed Forces Institute of Cardiology/National Institute of Heart Diseases Rawalpindi Pakistan, from Nov, 2022 to Jan, 2023. Methodology: This analytical cross-sectional study was conducted on n=184 patients, recruited through consecutive sampling technique to collect data prospectively. Patients were divided into no-reflow and normal flow group. Patients’ total ischemic time was documented and pre &amp; post-procedural TIMI flow was noted. SPSS version-24:00 was used to enter and analyze data. Chi-square, Fisher exact test and t-test were applied and p-value≤0.05 was taken as statistically significant. Results: Out of 184 study participants, 17(9.2%) were females as compared to 167(90.8%) males. The mean age was 60.23±10.28 years. No-reflow phenomenon was observed in 20(10.9%) patients. The mean age was higher in the no-reflow group than that of the normal flow group (62.65±11.61 vs 59.94±10.12 years). Total ischemic time, pre &amp; post-procedural TIMI flow were found to be significantly associated with no-reflow phenomenon (p&lt;0.05). Conclusion: There exists a strong association between total ischemic time and the occurrence of no-reflow phenomenon. Patients with delayed reperfusion present with greater frequency of no-reflow and low TIMI grade and vice versa.