Singh, Swaiman

Environmental degradation due to industrial groundwater contamination is an emerging cardiovascular disease (CVD) risk factor. Our study examines the elevated CVD prevalence, including heart failure (HF) risk factors, in rural Punjab, India, near which a private distillery was linked to long-term groundwater contamination and environmental degradation. Our team primarily focused on CVD prevalence and its associations with environmental toxins. We also explored the role of socio-economic disparities on health outcomes. A cross-sectional study of 4,885 residents in three villages adjacent to the distillery (Mahianwala Kala, Ratol Rohi, Mansoorwaal Kalan) was conducted from October 2022 to August 2023. Health camps with follow-up door-to-door surveys by trained medical personnel collected medical histories, environmental exposure details, and socio-demographic data. Key outcomes included both communicable and non-communicable diseases, such as hypertension, ischemic heart disease, heart failure, and cancer. Logistic regression assessed associations between CVD prevalence, socio-economic status, and pollution exposure, with groundwater testing for heavy metals and chemical oxygen demand (COD). The cohort demonstrated a high CVD burden, with 39% having hypertension (exceeding national averages by more than 50%), 34% having diagnosed CVD, and 21.3% of households reporting an immediate family history of myocardial infarction. Adjusted models highlighted elevated odds of heart disease (OR 1.42; 95% CI 1.31–1.51) and stroke (OR 1.29; 95% CI 1.16–1.38), with higher clustering in low-income families. Concurrent systemic toxicity was also evident, as 60.5% reported dermatological conditions, 10.5% familial cancer, 20.8% with no history of smoking cited COPD-related dyspnea. We also observed elevated miscarriage rates and developmental disabilities in the studied population. Groundwater analysis confirmed contamination with cyanide (0.3 mg/L), lead (0.16 mg/L), and COD (320 mg/L), correlating with self-reported water discoloration and irregularities in taste. Families with polluted water access had a 1.5-fold increased CVD risk. Industrial contamination was linked to higher cardiovascular morbidity and multi-organ health effects in our study's cohort in rural India. The link was exacerbated by socio-economic inequities. These findings highlight the role of environmental degradation in rise in CVD, particularly in low-resource settings.

Subclavian artery stenosis is a rare but clinically significant cause of vertebrobasilar insufficiency and upper extremity ischemia. Management is challenging, especially in the presence of heavily calcified lesions. Intravascular lithotripsy (IVL) is an emerging adjunctive therapy for calcified lesions, primarily studied in coronary and lower extremity vessels, but its application in subclavian interventions is underexplored. A 78-year-old female with a history of hypertension, diabetes, hyperlipidemia, and peripheral artery disease presented with recurrent dizziness and nausea. Carotid duplex demonstrated moderate left internal carotid stenosis and retrograde flow in the left vertebral artery, consistent with subclavian steal syndrome. Subsequent angiography revealed 90% eccentric, calcified stenosis of the proximal left subclavian artery. Given the lesion’s heavy calcification, the patient underwent percutaneous intervention with a Serranator scoring balloon, followed by IVL using an 8x30 mm peripheral balloon (2 rounds, 30 pulses each). This resulted in significant lesion modification and relief of balloon waist. A 7x27 mm Express LD bare-metal stent was then deployed with excellent angiographic results and residual stenosis <10%. IVUS confirmed adequate stent expansion. The procedure was performed via right femoral access with no complications. Post-procedure, the patient reported complete resolution of dizziness and no further symptoms of vertebrobasilar insufficiency. She was discharged on dual antiplatelet therapy for 30 days, followed by aspirin monotherapy. At 1-month follow-up, she remained asymptomatic with a patent stent and no evidence of restenosis. This case highlights the utility of IVL in treating severely calcified subclavian artery stenosis. Traditional balloon angioplasty and stenting in such lesions are associated with suboptimal expansion, risk of dissection, and restenosis. IVL offers a safe and effective means of calcium modification, facilitating optimal stent deployment. To our knowledge, reports of IVL use in subclavian arteries are scarce, and this case adds to the growing body of evidence supporting its application in complex peripheral vascular interventions. IVL is a valuable adjunct in the endovascular management of heavily calcified subclavian artery stenosis, enabling successful stent placement and symptomatic relief. Further studies are warranted to define its role in this vascular territory.

Introduction: Acute Coronary Syndrome (ACS) is a major global health issue, with smoking as a significant modifiable risk factor. Smoking cessation reduces recurrent coronary events, making it crucial in ACS management. Current protocols recommend smoking cessation education during hospitalization and referral to smoking cessation or outpatient cardiac rehabilitation programs, where nicotine replacement therapy (NRT) and bupropion are available. NRT, including patches, gum, and lozenges, helps alleviate withdrawal symptoms by providing a controlled nicotine dose. Hypothesis: We hypothesize that cautious initiation of NRT during hospitalization benefits ACS patients, with the benefits outweighing the risks. This study seeks to provide clarity and contribute to evidence-based guidelines for ACS management. Methods: In this retrospective cohort study, data were gathered from the TriNetX database. The study compared two cohorts: 122,198 patients who received NRT and were hospitalized for acute myocardial infarction (AMI) or unstable angina (UA), and 160,387 patients who did not receive NRT but were admitted for the same conditions. The follow-up period began on the day of the index event and continued for 30 days. Cardiovascular outcomes were compared between propensity score-matched patients with and without NRT. Results: Patients receiving NRT had a reduced risk of several cardiovascular outcomes compared to those who did not receive NRT, including atrial fibrillation and flutter (RR [95% CI]=0.822[0.792-0.854, p<0.01]) and ventricular fibrillation and flutter (RR [95% CI]=0.715[0.654-0.781, p<0.01]). The risk of death was also reduced (RR [95% CI]=0.701[0.678-0.726, p<0.01]). Hospital readmissions were less frequent in the NRT group (RR [95% CI]= 0.960[0.955-0.965, p<0.01]). Additionally, the risk of cardiac arrest was lower (RR [95% CI]= 0.698[0.660-0.738, p<0.01]), and supraventricular tachycardia (SVT) was less common (RR [95% CI]= 0.883[0.827-0.942, p<0.01]). These results highlight the potential benefits of NRT in reducing the risk of various cardiac events following AMI or UA. Conclusions: The cautious initiation of NRT during hospitalization can benefit ACS patients where the benefits outweigh the risks. This study aims to provide clarity and contribute to evidence-based guidelines for ACS management.

Background: Heart transplantation (HTx) is a life-saving procedure for patients with end-stage heart disease. Sarcoid myocarditis (SM) is a rare condition characterized by granulomatous inflammation of the myocardium. The mainstay of therapy is immunosuppression but the incidence of cardiac sarcoidosis leading to advanced heart failure is increasing. HTx is a valid option in such cases however post-HTx outcomes in sarcoid population have been poorly investigated. Methods: A retrospective analysis of the National Inpatient Sample (NIS) from 2016 to 2021 was conducted. Outcomes compared between sarcoid and non-sarcoid HTx groups were mortality, length of stay (LOS), hospital charges, transplant rejection and graft failure. Mann-Whitney U test was utilized to compare differences between non-parametric variables, while multivariable logistic regression was applied to adjust for confounders. Results: During our study period a total of 17,635 patients underwent HTx out of which 235 (0.013%) had HTx due to sarcoid myocarditis. Multivariable analysis revealed a comparable mortality between sarcoid and non-sarcoid HTx (Adjusted Mortality: aOR 1.35; CI 0.40-4.56; p=0.61). Median length of stay in sarcoid myocarditis group was 29[IQR19-55] vs 28[IQR16-50] p=0.57. Total hospitalization charges were also comparable 956,893[IQR 649,498-1,451,199] vs 800,898[IQR 533,047-1,349,074], p=0.18. There was no significant increase in transplant rejection (aOR 1.43; CI 0.64-3.20; p=0.37) or graft failure (aOR 1.92; CI 0.55- 6.70; p=0.30) in the sarcoid myocarditis group (Table 1, Table 2). Conclusion: Sarcoid myocarditis patients undergoing HTx showed comparable mortality, LOS, total hospital charges, transplant rejection, or graft failure rates to patients undergoing HTx for other causes.While these findings suggest that SM, while rare, does not adversely affect transplant outcomes, we strongly advocate for more studies to adjust for limitations.

Axillary artery intra-aortic balloon pump (axIABP) placement has been implemented as a bridging solution before heart transplantation. This study evaluates complications associated with axIABP support and describes an approach to minimize adverse events. We previously described a percutaneous approach for axIABP placement. However, patients receiving axIABP between September 1, 2017, and September 26, 2019 (n = 32) demonstrated a high rate of balloon pump malfunction (8/32; 25%) and other complications (totaling 15/32; 47%). Sixty-four patients were sequentially treated under a revised protocol. Compared to the initial cohort, no significant differences in demographics were noted. A significant reduction in rate of balloon malfunction (8/32, 25% vs. 1/64, 2%; p < 0.001) and total complications (15/32, 47% vs. 10/64, 16%; p = 0.0025) during the period of support were noted after intervention. Subsequent analysis of total complications per device size (40 vs. ≤ 34 ml balloon) revealed significantly reduced complications in patients with smaller devices (40% vs. 13%, respectively; p = 0.0022). This study provides guidelines to limit complications in patients supported with axIABP, facilitating a protracted period of bridging support.

Introduction: Patients with coronary artery disease (CAD) not amenable to revascularization are reported to have a 3-year mortality >14%. Advances in treatment modalities including medical management, rotational atherectomy, balloon lithotripsy, and drug-eluting stents work for focal disease but poorly treat diffuse CAD. In a porcine model of in-stent restenosis, we here evaluated whether a pro-angiogenic platelet-derived exosome product (PEP) could be delivered into the perivascular space to foster collateral vessel formation. Methods/Results: Cobalt chromium stents were placed and were oversized by 1 mm in the left anterior descending (LAD) and posterior descending arteries (PDA) of sus scrofa domesticus pigs. In-stent restenosis was angiographically visualized at the 2-month timepoint, with hemodynamic significance documented with fractional flow reserve (FFR) of <0.8. To document feasibility of PEP delivery into the perivascular space, exosomes were labeled with a far-red fluorescent tag and delivered into the perivascular bed. Here, the Bullfrog® micro-infusion catheter was positioned either in the great cardiac vein or the middle cardiac vein and PEP was delivered with the microneedle pointed towards the LAD or the PDA. Biodistribution demonstrated exosome retention and uptake around cardiac veins. Using the Bullfrog® technique, PEP was delivered in the perivascular space adjacent to areas of significant coronary stenosis. Initial results 1-month post-treatment demonstrated improved FFR of treated stenotic vessels (from 0.68 to 0.85), while untreated vessels demonstrate no change from previous FFR measurement (from 0.79 to 0.78). Conclusions: Here, exosome-mediated angiogenesis in the perivascular space improved coronary blood flow, distal to areas of stenosis. In patients with diffuse CAD, delivery of biotherapy in cardiac veins running anatomically parallel to stenosed epicardial arteries provides a novel therapeutic opportunity to supplement the existing armamentarium of therapies available for in-stent restenosis.

Coronary angiography is the gold standard for the diagnosis and treatment of epicardial coronary artery disease. Further, it is an essential tool for conduction of translational cardiac research on large animal models, in the development of novel cardiac therapies. While in humans coronary angiography has an exceedingly low mortality rate; in pigs, procedural mortality has been reported as high as 15%, likely due to unsuitable variations in angiographic techniques. Porcine models are used due to the resemblance of cardiac function and anatomy to humans. However, procedural guidelines delineating proper equipment to be used for angiography in this model has yet to be systematically assessed. Aims: To evaluate clinically common catheters for their utility in the safe engagement of the coronary vessels in pigs. Establish optimal workflow and fluoroscopy views for safe coronary artery engagement and angiography. Method/Results: Percutaneous superficial femoral artery access was acquired via ultrasound guidance and subsequent cardiac catheterization was performed in sus domesticus weighing 35-50 kg. Catheters that were tested included the JL 2.5, JL3.0, JR 3.0, AR1, AL1, MPA1, Champ1, 3DRC, hockey stick and RCB (5-7 french) operated over a standard .035 J tip wire. AP views were optimum to engage both the left and right coronary vessels. Only AR1, 3DRC, and hockey stick catheters successfully engaged the RCA, while all catheters tested could successfully engage the LCA. AR1 was noted to be the best for RCA engagement and AL1 for Left system engagement. AR1 was also the most succesful in engagement of both LM and RCA in same pig. AL1 provided the most stable engagement for Left coronary system. AR1/JL were better for LAD intervensions. AL1 is best for LCX intervensions Conclusion: We present a systematic description of percutaneous coronary angiographic procedures highlighting that AL for the LCA and AR for the RCA are the best choice of catheters for fastest and safest engagement of the coronary arteries limiting both radiation time and contrast use. While variations in anatomy can mandate changes in angiographic angles and catheter techniques, AP visualization and use of AL and AR catheters provided the most consistent and effective approach for porcine angiography.

For patients in cardiogenic shock, percutaneous mechanical circulatory support devices (MCSD) have emerged as critical tool to improve hemodynamics and optimize end-organ perfusion; successfully bridging patients to recovery, decision or transplantation. The most commonly utilized MCSD is the femoral intra-aortic balloon pump (IABP). However, femoral access hampers the patient's mobility, quality of life, and capacity to participate in rehabilitation. The advent of the axillary artery approach has served to circumvent limitations associated with the femoral artery approach. However, optimum anatomical placement of IABP within the axillary artery (axIABP) is a topic of debate considering its proximity to the brachial plexus. Here, we report our experince with percutaneous access of the third poriton of the axillary artery which showed promising results with minimal device related complications or adverse events. Methods/Results: Between 2017-2023, a total of 89 patients in cardiogenic shock underwent percutaneous axIABP placement at the Mayo Clinic, MN. All demographic, clinical, and periprocedural data were obtained from hospital chart review and recorded in a database under IRB approval. Indications for axIABP support was determined by multidisciplinary assessment. Complications encountered in the cohort included infection at site 6.7% (n=6), device malfunction [rupture, fracture, leak] 8.98%(n=8), and balloon migration 5.61% (n=5). One patient developed local erythema, 4 (4.49%) patients developed significant vascular complications, including access site bleeding in two patients 2.24%, arterial thrombosis in three patients 3.37%, and self-limited intracranial bleeding in one patient 1.12%. Of note, no nerve injury or damage was observed in the entire patient cohort. Conclusion: Our study highlights the feasibility of percutaneous axIABP in the third portion of the axillary artery, while assessing safety profile and ease of removal. Notably in our review, we did not encounter any brachial nerve damage. Ultrasound was pivotal in identifying and avoiding nerves and nerve bundles during initial access. In conclusion, this approach of axIABP insertion is feasible and can be leveraged for delivery of future innovation in MCSD