Smyth, Philip

Introduction: Complex congenital heart disease (CHD) patients with atrial arrhythmias have higher rates of morbidity and mortality compared to less complex CHD patients. This study aims to identify echocardiographic predictors of thromboembolism (TE) and major bleeding in patients with Tetralogy of Fallot (ToF) or Pulmonary Atresia with Intact Ventricular Septum (PA-IVS) and atrial fibrillation or flutter (AF). Methods: This cohort study included patients with ToF or PA-IVS who had a diagnosis of AF who underwent a TTE across three sites. Outcomes were incidence rate of major bleeding or TE, calculated using univariable and multivariable cox regression with interaction for anticoagulant choice and fractional area change (FAC). The HAS-BLED score was augmented with major predictors of bleeding, and receiver operator curves compared. Results: We included 300 patients (287 ToF [95.7%], 13 PA-IVS [4.3%]), mean age 45.6 years. Most received warfarin (227 [79.4%]), 40 (13%) used DOACs, and 5 (1.6%) used enoxaparin. TTE predictors of TE included large LVOT diameter ≥3cm (HR 8.92, p=0.002), small LVOT VTI (p=0.014), FAC <30% (HR 7.08, p=0.026) and moderate RV dysfunction (HR 10.75, p=0.026). Predictors of major bleeding included moderate tricuspid regurgitation (HR 2.40, p=0.022), right atrial pressure (1.12, p<0.001), severe RA enlargement (HR 2.30, p=0.048), RV mid diameter (HR 1.06, p=0.005), RV end diastolic area (HR 1.04, p=0.021), RV end systolic area (HR 1.05, p=0.016) elevated RVSP and FAC ≤45% (HR 0.37, p=0.016). Among warfarin users, impaired RV function (FAC ≤45%) was linked to reduced major bleeding events (HR 0.27, p=0.025). There was a nonsignificant trend towards higher bleeding in DOAC users with FAC >45% (HR 3.87, p=0.284), but significantly higher bleeding in DOAC users with FAC ≤45% (HR 12.41, p=0.008) vs. warfarin users with normal RV function (table 1). We developed an augmented HAS-BLED score: the standard score plus one point for moderate-to-severe pulmonic or tricuspid regurgitation and one for FAC ≤45%. This outperformed the standard HAS-BLED in predicting major bleeding (AUC 0.67 augmented vs. 0.57 un-augmented, p=0.008) (figure 1). Conclusion: Echocardiographic evidence of right heart disease is a strong predictor of major bleeding in patients with ToF or PA-IVS. FAC is a useful tool to determine excess major bleeding risk, particularly in DOAC users. Augmenting HAS-BLED with right heart parameters improves diagnostic accuracy.

Cardiogenic shock is the most common cause of mortality in patients with acute myocardial infarction with an increase in incidence over the last 15-years. Recent classification systems of cardiogenic shock (CS) have improved categorization of patients into subsets of acuity and begun to integrate phenotypes and etiologies in addition to risk modifiers. Early revascularization with PCI or CABG has been the most important advance in the management of AMI-CS patients with improvements in survival. Despite this initial progress, mortality remains high at approximately 40%, with a significant proportion of patients dying of neurological causes, especially in the cohort with cardiac arrest and multi-organ dysfunction despite cardiac recovery. Mechanical circulatory support devices are an attractive strategy to ameliorate the cardio-metabolic spiral but have thus far failed to show survival benefits in randomized trials during revascularization of AMI-CS patients with IABP and ECMO use, although many aspects of their use have yet to be studied, including their role as part of an escalation or bridging strategy along the continuum of CS care. Randomized trials in Impella percutaneous LVAD use are pending. Cardiac arrest patients represent an important cohort with specific challenges of care and familiarity with management including the use of mechanical CPR devices, temperature optimization, MCS use and pharmacotherapy issues are critical to successful outcomes.