Mookadam, Farouk

Mohave rattlesnakes ( Crotalus scutulatus ) are known to inhabit the deserts of southwestern United States, with their territory extending into southern Mexico. Envenomation can impart dramatic local and systemic effects on the body, ranging from local skin necrosis to neurotoxicity, depending on the protein complex in the venom. Kounis syndrome, or allergic angina, is an allergic response to a specific insult that results in myocardial injury often in the form of coronary artery vasospasm but can include myocardial infarction and coronary stent thrombosis. To our knowledge, there have not been any reports associating C scutulatus envenomation with Kounis syndrome. We describe a patient who developed Kounis syndrome presenting as an allergic myocardial infarction following envenomation by a Mohave rattlesnake. A second unique feature of this patient's envenomation is that he experienced respiratory failure secondary to right hemidiaphragmatic paralysis. Severe neurotoxicity from Mohave rattlesnake bites in humans has been reported rarely in the literature.

Heart failure with preserved ejection fraction (HFpEF) includes almost half of heart failure cases typified by a specific clinical syndrome. Despite diagnostic and management advances, HFpEF still presents a diagnostic challenge and a paucity of therapies specifically aimed at enhancing survival and improving quality of life is still lacking. This review elucidates the diagnostic complexity of HFpEF, highlighting the use of both subjective and objective criteria within algorithmic frameworks. It also examines the significant impact of comorbidities on the progression of HFpEF. Additionally, we explore the latest evidence on targeting these comorbidities therapeutically, although the benefits to mortality are still limited.

ABSTRACT Background Randomized controlled trials have highlighted the importance of exercise training on the severity of obstructive sleep apnea (OSA). The primary objective of this meta-analysis was to analyze the data from these studies on the severity of OSA indices as measured by formal polysomnography. The secondary objective was to evaluate the effect of exercise on oxygen desaturation index, body mass index and several metabolic parameters associated with OSA. Methods Two independent reviewers and an experienced librarian searched MEDLINE, EMBASE, COCHRANE, and Scopus and SPORTDiscus databases from January 1, 2000, to October 21, 2021 to identify randomized controlled trials that evaluated the impact of exercise training on OSA severity. Pre-exercise and postexercise training data on the primary and secondary objectives were extracted. Results A total of 11 randomized controlled trials (533 study participants) were identified based on the inclusion criteria. The mean pre-exercise and postexercise reduction in apnea hypopnea index was −6.94 event per hour (95% confidence interval [CI]: −10.74 to −3.13, I2 = 84%). The mean changes in oxygen desaturation index and body mass index were −5.32 events per hour (95% CI: −9.65 to −0.99, I2 = 73%) and −1.21 kg·m−2 (95% CI: −1.80 to −0.62, I2 = 49%) respectively. Conclusion In adult patients with OSA, exercise training was associated with statistically significant reduction in OSA severity.

Background: Identifying patients at a high risk of mortality post percutaneous coronary intervention (PCI) is of vital clinical importance. We investigated the utility of machine learning algorithms to predict short and intermediate-term risk of all-cause mortality in patients undergoing PCI. Methods: Patient-level demographics, clinical, electrocardiographic ,echocardiographic and angiographic data from January 2006 to December 2017 were extracted from the Mayo Clinic CathPCI registry and clinical records. For patients with multiple PCI events, data collected at the time of the index PCI was used for analysis. Patients who underwent bailout coronary artery bypass graft surgery (CABG) prior to discharge were excluded. 306 variables were incorporated into random forest machine learning model (RF) to predict all-cause mortality at 6 months and 1 year after PCI. Ten-fold cross-validation repeated five times was used to optimize the hyperparameters and estimate its external performance. The National Cardiovascular Data Registry (NCDR) based logistic regression model was used for comparison. The area under receiver operator characteristic curves (AUC) was calculated to assess the ability of the models to predict all-cause mortality. Results: A total of 17356 unique patients were included for the final analysis after excluding 165 patients who underwent CABG surgery during the index hospitalization. The mean age was 66.9 ± 12.5 years;71% were male. Indications for PCI were ST-elevation myocardial infarction (9.4%), non-ST elevation myocardial infarction (12.9%), unstable angina (17.7%), and stable angina (52.8%) in the cohort. In-hospital, 6-month & 1 year mortality rates were 1.9%,4.2% & 5.8% respectively. The RF model was superior to the NCDR model in predicting inhospital, 6-month, 1 year mortality (p<0.0001) ( Figure 1 ). Conclusion: Machine learning is superior to NCDR model in predicting short and intermediate risk of all-cause mortality post PCI.

AbstractIntroductionThe right ventricle (RV) strain measured by speckle tracking (RVS) is an echocardiographic parameter used to assess RV function. We compared RVS to RV fractional area change (FAC%), tricuspid annular plane systolic excursion (TAPSE) and Doppler tissue imaging‐derived peak systolic velocity (Sʹ) in the assessment of right ventricular (RV) systolic function measured using cardiac magnetic resonance imaging (MRI).MethodsWe enrolled consecutive patients who underwent cardiac MRI between Jan 2012 and Dec 2017 and a transthoracic echocardiogram (TTE) within 1 month of the MRI with no interval event. Baseline clinical characteristics and MRI parameters were extracted from chart review. Echocardiographic parameters were measured prospectively. TTE parameters including RVS, TAPSE, Sʹ, and FAC% were tested for accuracy to identify impaired RV EF (EF < 45% & <30%) using receiver operator curves.ResultsThe study cohort included 500 patients with mean age 55 years ± 18 and peak tricuspid regurgitation velocity 2.7 ± 1.4 m/s. The area under ROC for RVS was 0.69 (95% CI 0.63–0.75) and 0.78 (95% CI 0.70–0.88) to predict RVEF < 45% & RVEF < 30%, respectively. The RV FAC% had second highest accuracy of predicting RVEF among all the TTE parameters tested in study.ConclusionRight ventricular strain is the most accurate echocardiographic method to detect impaired right ventricular systolic function when using MRI as the gold standard.

Abstract Introduction Insomnia is a novel and modifiable risk factor for incident cardiovascular disease (CVD). However, identification of early markers of subclinical CVD in diagnosed insomnia is understudied. Our aim for this ongoing study is to contrast markers of cardiovascular structure and function between people with insomnia and good-sleeping controls. Methods Persons with insomnia (met ICSD-III criteria) and good sleeping controls (&lt;8 Insomnia Severity Index, mean 8-night SOL and WASO&lt;31min) were recruited from the community. Twenty-two adults (21-39y; 55% women) with no history of CVD, diabetes, inflammatory conditions, significant hypertension, or current sleep-disordered breathing (WatchPat200, Itamar Medical) were enrolled and underwent fasting cardiovascular testing. Testing included: Central augmented aortic pressure (AP) and carotid-femoral pulse wave velocity (cfPWV) for vascular stiffness; brachial artery flow mediated dilation (FMD) to assess endothelial function; and 2D echocardiography to assess ejection fraction (EF%), left ventricular global longitudinal strain (LVGLS), left atrial volume index (LAVI), mitral valve E/e’ ratio (E/e’), and lateral e’. ANCOVA models, adjusting for age, comparing persons with insomnia (n=6) to good sleeping controls (n=16) on each cardiovascular measure were conducted. Results AP (range:-5,10mmHg), cfPWV (range: 4.8-7.6m/s), EF% (range:55.0-72.0%), LVGLS (range:-26,-19%) LAVI (range:14.1-26.7mL/m2), E/e’ (range:3.2-7.8), and lateral e’ (range:0.09-0.22cm/sec) were all within normal ranges according to age and sex normative standards. Mean FMD was 8.8% (SD=4.3, range:4.3-19.8%). Age adjusted ANCOVA models indicated that the insomnia group had significantly worse cardiovascular function than good sleeping controls on cfPWV (M=6.8±0.3 vs. M=5.7±0.2; p=0.004), EF% (M=60.0±1.7 vs. M=65.2±1.0; p=0.017), LVGLS (M=-21.6±0.6 vs. M=-24.3±0.4; p=0.001), and lateral e’ (M=0.12±0.01 vs. M=0.18±0.01; p=0.003). No group differences were found for AP, FMD, LAVI, and E/e’. Conclusion Among relatively healthy young adults, people with insomnia had greater arterial stiffness and worse left ventricular systolic and diastolic functioning. Support American Academy of Sleep Medicine Foundation Focused Projects Award for Junior Investigators 179-FP-18

Abstract Funding Acknowledgements None Background Cardiac Power Index (CPI) is an integrative hemodynamic measure of cardiac pumping capability and is the product of the simultaneously measured mean arterial pressure (MAP) and cardiac output (CO). In patients with aortic stenosis (AS), MAP is not reflective of mean systolic left ventricular (LV) pressure due to the transvalvular gradient. Non-invasive assessment of mean systolic LV pressure is challenging in severe aortic stenosis. CPI assessed using systemic MAP was previously shown to predict survival post transcatheter aortic valve replacement (TAVR). Purpose We evaluated the utility of a gradient adjusted CPI in predicting survival post TAVR compared to CPI alone Methods A retrospective study was performed including patients undergoing TAVR with 1 year follow-up. Baseline demographics, clinical, and echocardiographic data were abstracted from a cohort of 1,011 patients. CPI was calculated, (CO x MAP)/ (451 x BSA) Watts/m2. Gradient adjusted CPI was calculated using an augmented MAP i) adding aortic valve mean gradient(AVMG) to systolic blood pressure (CPI1); ii) adding aortic valve maximal instantaneous gradient to systolic blood pressure (CPI2) and iii) adding AVMG to MAP (CPI3). Patient survival score was calculated using a step up technique to identify the cut off value for CPI and gradient adjusted CPI to identify, where the maximum difference in mortality occurred. Multivariate cox-regression analysis was performed to adjust for baseline covariates. Receiver operator curves(ROC) for CPI and gradient adjusted CPI were calculated to predict survival post TAVR. Results The mortality rate at 1 yr was 16%. Mean age and AVMG of survivors was 81 +/- 9 yrs and 43 +/-14 mmHg vs 80 +/-9 yrs and 42 +/- 13 mmHg in the deceased group. Proportion of female patients was similar in both groups (p = 0.7). Patients in the deceased group at baseline had a higher prevalence of chronic lung disease, atrial fibrillation, heart failure within 2-weeks of procedure, higher STS-PROM score, lower serum albumin level, higher prevalence of moderate to severe tricuspid regurgitation, higher right ventricular systolic pressure and higher prevalence of dialysis. Both CPI and gradient adjusted CPI were independently associated with survival at 1 year. The area under ROC for CP, CP1, CP2 and CP3 were 0.67 (95% confidence interval [CI] 0.62 - 0.72), 0.65 (95% CI 0.60 – 0.70), 0.66 (95% CI 0.61 – 0.71) and 0.63 (95% CI 0.58 – 0.68) respectively. Conclusion Gradient adjusted CPI did not improve accuracy of predicting post TAVR survival at 1 year compared to CPI alone. Abstract P339 Figure. Area under ROC

Abstract Introduction Systolic right ventricular (RV) function has prognostic significance both in acquired and congenital heart diseases. However accurate assessment of RV ejection fraction (EF) with transthoracic echocardiography (TTE) remains challenging due to the complex geometric shape of the RV. Magnetic resonance imaging (MRI) remains the gold standard modality for assessment of RV function; however the cost and availability limits the regular use of MRI in clinical practice. The RV strain measured by speckle tracking (RVS) is a novel method of assessing RV EF. Purpose The purpose of the study was to assess the accuracy of RVS compared RV fractional area change (FAC%), tricuspid annular peak systolic excursion (TAPSE) and Doppler tissue imaging-derived isovolumic acceleration and peak systolic velocity (S') at the lateral tricuspid annulus in the assessment of impaired RV EF. Methods We retrospectively identified patients who had a cardiac MRI between 2012- 2017 and only included patients with a TTE within 1 month of the MRI for our final analysis. Baseline characteristics, TTE and MRI parameters were extracted from chart review. RV strain was measured retrospectively using ECHOINSIGHT software. Four TTE parameters including RVS, TAPSE, S' and FAC% were tested for accuracy to identify impaired RV EF (defined as EF<45%) using receiver operator curves. Results The study cohort included 500 patients with mean age 55 yr ± 18 and right ventricular systolic pressure 33.7±13.6 mmHg. The proportion of female gender, diabetes, hypertension and obstructive sleep apnea were 38%, 15.6%, 43% & 19.8% respectively. The area under ROC for TAPSE, S', FAC% and RVS were 0.58 (95% confidence interval [CI] 0.51–0.65, p=0.03), 0.59 (95% CI 0.52–0.66, p=0.03), 0.67 (95% CI 0.61–0.73, p=0.03) and 0.70 (0.64–0.76, p=0.03) for assessing RV EF <45%. Conclusion Right ventricular strain most accurately detected impaired right ventricular ejection fraction as obtained by MRI. Acknowledgement/Funding None