Franczak, Stephanie

Objectives: To determine the frequency with which emergency medical services (EMS) clinicians recognize patients enrolled in hospice and describe their prehospital management. Methods: Observational cohort study of patients enrolled in hospice who were transported by EMS within a health system between May 5, 2018, and June 4, 2023. Two physicians reviewed each encounter to determine whether interventions were comfort-focused (hospice philosophy) or life-sustaining care. Interrater reliability was 100% (k = 1.0). Descriptive statistics are provided. Results: EMS clinicians identified hospice enrollment in 51% ( n = 46) of 88 encounters. Most patients (90%, n = 79) received comfort-focused care. Life-sustaining care was provided to four patients identified as hospice-enrolled and included cardiopulmonary resuscitation, an advanced airway, and vasopressors ( n = 1, 25%); spinal immobilization ( n = 2, 50%), and naloxone ( n = 1, 25%). Conclusion: Most patients received care consistent with the philosophy of hospice. However, EMS clinicians may have only identified half of patients enrolled in hospice. This demonstrates an opportunity to improve recognition of patients’ care preferences, starting in the out-of-hospital setting.

Background: Subaortic membrane (SAM) is a fibromuscular ridge beneath the aortic valve that causes fixed left ventricular outflow tract (LVOT) obstruction. Surgical resection is the standard treatment for symptomatic patients or those with high gradients; however, recurrence occurs in up to 14% of adults within 5 years. While radiofrequency ablation (RFA) is well-established in arrhythmia management, its role in treating SAM has not been previously described. Case Information: 53-year-old man with HTN, BMI 51.7, and well-controlled OSA presented with worsening exertional dyspnea and fatigue in April 2024. He had prior surgical SAM resection in 2018, complicated by third-degree AV block requiring pacemaker implantation. Follow-up echocardiography revealed SAM recurrence with peak LVOT gradient of 52 mmHg. Given elevated surgical risk, a novel catheter-based RFA approach was pursued. In July 2024, the patient underwent catheter-based RFA under general anesthesia. A ThermoCool SmartTouch SF catheter was advanced retroaortically across the aortic valve toward the subaortic ridge, guided by CARTO 3 with CartoSound. A semi-circular lesion set was delivered to the septum inferior to the membrane. Two steam pops occurred during ablation in this area. Serial transthoracic echocardiograms at 3 and 8 months demonstrated sustained LVOT gradient reduction, from 52 mmHg pre-ablation to 49 mmHg and 38 mmHg, respectively. Left ventricular ejection fraction (EF) remained stable at 61%, with no new wall motion abnormalities or pericardial effusion. The patient reported marked improvement in symptoms and normalization of daily activity tolerance. No procedural complications or hospital readmissions occurred. Decision-Making: Given the patient’s high surgical risk and recurrent symptoms, the multidisciplinary team determined that repeat sternotomy carried elevated morbidity. RFA offered a targeted, minimally invasive solution that leveraged electrophysiology tools and preserved structural integrity while maximizing safety. Conclusions: This first-in-human case illustrates the feasibility of intracardiac RFA for recurrent SAM. The patient experienced sustained LVOT gradient reduction, preserved EF, and marked symptomatic improvement. This novel approach may offer a viable option for select patients with recurrent subaortic obstruction and prior sternotomy, warranting further investigation to define lesion durability, depth of tissue effect, and conduction system safety.