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Introduction: Graves’ disease (GD) is known to cause menstrual changes and has been linked to infertility in women. This can be due to the increased production of androstenedione and testosterone induced by the excess thyroid hormone. However, screening for sex hormone levels in all women diagnosed with GD to identify patients more likely to have infertility is not cost-effective and not clinically indicated. AI-augmented ECG can identify the signature of female with an AUC of 0.97. In this model, AI- ECG gives a probability number between 0-100% of being female, with higher numbers indicating high probability of being female. Hypothesis: We hypothesized that this inexpensive AI ECG tool is reflective of hormonal levels and the resulting changes in menstrual cycle and fertility associated with GD in women. Methods: Patients diagnosed with GD (2009-2019) at our institution were included. Three intervals were identified: 1) Before GD: >2 months before GD diagnosis 2) During GD: within 2 months before GD and before attaining euthyroidism 3) After GD: after attaining euthyroidism. The matched-pairs t-test was used to compare probability of being a female; patients acted as their own controls. A subset analysis was done on females <45 years at GD diagnosis to study the association between female probability during GD and menstrual changes (defined as shorter, lighter, or newly irregular menstrual cycles). Results: 154 females with ECGs both before and during GD were identified. AI ECG female probability decreased with GD diagnosis (85% vs. 77%, P<.001). On the other hand, 137 females with GD had ECGs during and after GD. Female probability increased after attaining euthyroidism (76% vs 83%, P=.005). Moreover, 72 females <45 years were identified; 30 (42%) developed menstrual changes and had significantly lower AI-ECG female probability [77 (58-94)% vs 98 (92-100)%, P<.001] Conclusions: AI-enabled ECG signature of female gender in women was altered by GD and was associated with menstrual changes, likely reflecting changes in sex hormone levels. Future studies to confirm its role in screening for infertility in women with GD are needed.

Background: Although genetic testing (GT) in dilated cardiomyopathy (DCM) enables molecular diagnosis, family screening and provides prognostic information, it is underutilized. Our hypothesis was that systemic intervention (INT) in the heart failure (HF) clinic could increase the frequency of GT for DCM. Methods: Eligible DCM patients in a 17-month period before and after the INT were compared for frequency of genetic counseling and GT uptake. The INT comprised of the following: 1. Pre-emptive cardiovascular genomics e-consult (with a specialist in genetic DCM) for all new HF patients that could be canceled by the treating physician if the patient was considered ineligible or was uninterested. If eligible and patient was willing, 2. They were shown a video in person on genetic testing for DCM prepared by a genetics counselor 3. A trained HF clinic nurse provided answers to questions and completed the test requisition 4. Educational material was provided to the patient 5. Results were reviewed electronically and communicated to the patient via letter or phone call by the physician completing the e-consult. Clinical genetics consultation was available throughout the study period. Standard commercially available cardiomyopathy gene panels were used for GT. Results: There were 162 eligible DCM patients before and 194 after the INT. DCM patients were more likely to undergo genetic counseling post-INT versus (vs) pre-INT (33.5% vs 14.8%, OR 2.9, 95% CI 1.7-4.8, P <.0001). Similarly, DCM patients were more likely to undergo GT post-INT vs pre-INT (27.3% vs 13%, OR 2.5, 95% CI 1.4-4.3, P =.001). Consequently, the total number of patients who were diagnosed to have likely pathogenic or pathogenic DCM-related genetic variants increased from 2 pre-INT to 6 post-INT. These variants were detected in the following genes: FLNC (n=2), TTN (n=2), DES , LMNA , PLN and TNNT2 . Conclusion: An intervention that was pre-emptive, easily accessible and available to the healthcare provider was successful in raising the rates of genetic counseling and testing in DCM patients seen in the HF clinic. Whether such low-cost interventions will enhance cascade screening and provide an opportunity for precision medicine remains to be determined.

Introduction: The predictive value of left atrial (LA) volume and reservoir function (ResF) post-atrial fibrillation (AF) ablation has been scarcely studied. Hypothesis: Abnormal LA volume and ResF post-ablation are associated with adverse cardiovascular events. Methods: We analyzed LA maximum (LAVImax) and minimum (LAVImin) volume index, and 2 measures of ResF, emptying fraction (LAEF) and expansion index (LAEI), prospectively measured at 3-month post-procedure in patients in sinus rhythm who underwent AF ablation between 2007-2016. Composite endpoint (CE) at follow up was all-cause mortality, cardiac hospitalization (heart failure or acute ischemic event) and stroke. Results: 792 patients were studied ( age 60±10 years, 25% women ; Table 1) . Over 7.5 years [IQR 3.0-9.7], 96 (12%) patients experienced CE, which was more prevalent in patients with enlarged LA and reduced ResF. Impaired LA volumes and ResF were each independently associated with CE ( Fig.1 ), even after adjustment for clinical, demographic and echo characteristics (Model A, Fig.2 ) (LAVImax ≥35 ml/m 2 : HR 2.15 [95% CI, 1.35-3.43], p=0.001; LAVImin≥20.5 ml/m 2 : HR 2.88 [1.77-4.69], p<0.0001; LAEF<39%: HR 2.00 [1.31-3.05], p=0.001; LAEI<65%: HR 1.95 [1.27-3.01], p=0.003). ResF measures (LAEF and LAEI) were incremental to LAVImax (all p<0.05), but not LAVImin (all p>0.05; Fig.2 ). In patients with normal LA (LAVImax <35 ml/m 2 ; n=408), increased LAVImin (≥20.5 ml/m 2 ) remained associated with CE (HR 3.11 [1.45-6.67], p=0.004) and cardiac hospitalization (HR 5.81 [1.87-18.01], p=0.002). These findings were independent of AF recurrence. Conclusions: In these patients, enlarged LA and impaired ResF at 3-month post-ablation were strongly associated with adverse cardiovascular outcomes, regardless of AF recurrence. Measures of LA ResF were incremental to LAVImax. Notably, LAVImin showed the strongest associations and even identified a high-risk subgroup among patients with non-dilated LA.

ABSTRACT Objective: To study the applicability of on-table extubation (OTE) protocol following congenital cardiac surgery in a low-resource setting and its impact on the length of intensive care unit (ICU) stay, hospital stay, hospitalization cost, parental anxiety, and nurse anxiety. Materials and Methods: In this prospective, nonrandomized, observational single-center study, we included all children above 1 year of age undergoing congenital cardiac surgery. We evaluated them for the feasibility of OTE using a prespecified protocol following separation from cardiopulmonary bypass. The data were prospectively collected on 60 children more than 1 year of age, belonging to the Risk Adjustment for Congenital Heart Surgery 1, 2, 3, and 4 groups and divided into two groups: those who underwent successful OTE and those who were ventilated for any duration postoperatively (30 children in each group). Duration of hospital stay, ICU stay, and total hospital cost were collected. Anxiety levels of the primary caregiver (nurse) in the ICU and the mother were assessed immediately after the arrival of the child in the ICU using the State Trait Anxiety Inventory (STAI). Results: Children who were extubated immediately following congenital cardiac surgery had significantly shorter ICU stay (median 20 [19, 22] h vs. 22 [20, 43] h [ P < 0.05]). Patients extubated on table had a significant reduction in hospital cost {median Rs. 161,000 (138,330; 211,900), approximately USD 1970 ( P < 0.05)} when compared to children who were ventilated postoperatively {median Rs. 201,422 (151,211; 211,900) , approximately USD 2464}. The anxiety level in mothers was significantly less when their child was extubated in the operating room (STAI 36.5 ± 5.4 vs. 47.4 ± 7.4, P < 0.001). However, for the same subset of patients, anxiety level was significantly higher in the ICU nurse (STAI 46.0 ± 5.6 vs. 37.8 ± 4.1, P < 0.05). Conclusion: OTE following congenital cardiac surgery is associated with a shorter duration of ICU stay and hospital stay. It also reduces the total hospital cost and the anxiety level in mothers of children undergoing congenital heart surgery. However, the primary bedside caregiver during the child’s ICU stay had increased anxiety managing patients with OTE.

Background: Cardiac amyloidosis (CA) is associated with sinus node dysfunction (SND) and conduction system disease (CSD) yet data on pacing indications and outcomes is scarce. Methods: Retrospective review of patients (pts) with CA who had device implantation due to pacing indication at our institution. Results: At total of 51 (mean age 67.2±9.2 years, 90.2% male) pts with immunoglobulin light chain (n=27, 52.9%), hereditary transthyretin (n=7, 13.7%) and wild-type transthyretin (n=17, 33.3%) CA were included. Indication for pacing was exercise intolerance (n=16, 31.4%), syncope (n=16, 31.4%), congestive heart failure (n=5, 9.8%) and palpitation (n=2, 3.9%) with SND (n=23, 45.1%), CSD (17=33.3%) and uncontrolled atrial fibrillation (n=11, 21.6%). 16 (31.4%) pts received defibrillators (ICD) for primary prevention, of whom 8 (15.7%) had left ventricular ejection fraction (LVEF) ≤35%. Atrial (P wave: 1.7±1.2mV, threshold: 1.1±0.5mV/0.5±0.2ms) and right ventricular (RV) (R wave: 7.9±3.8mV, threshold: 0.8±0.4mV/0.4±0.1ms) lead parameters were satisfactory at implantation. During follow-up (mean 36.6±33.6 months), 26 (51%) pts reported symptomatic improvement (SI). Syncope was the only predictor of SI (OR 16.4, 95%CI 1.8-145.2, p=0.01) while exercise intolerance was not (OR 0.09, 95%CI 0.02-0.44, p=0.003). First-time life-threatening ventricular arrhythmias (VA) occurred in 6 (11.8%) pts, 3 (5.9%) had ICD implanted for LVEF ≤35%, 3 (5.9%) without ICD and LVEF ≥35%. Syncope was not predictive of first-time VA. RV lead noise led to inappropriate ICD shocks in 1 patient. Atrial lead sensing failure occurred in 6 (11.8%) and loss of capture in 5 (9.8%). Conclusion: Device implantation in patients with cardiac amyloidosis is safe but atrial lead failure is common. Syncope usually improves with pacing whereas other factors should be considered in those presented with exercise intolerance. Selection of pts who need pacing for prophylactic ICD implantation is challenging as neither left ventricular ejection fraction nor syncope are predictive of arrhythmic events.

Objective The aim of this study was to assess the diagnostic utility of cerebrospinal fluid (CSF) myelin oligodendrocyte glycoprotein antibodies (MOG‐IgG) testing. Methods We retrospectively identified patients for CSF MOG‐IgG testing from January 1, 1996, to May 1, 2023, at Mayo Clinic and other medical centers that sent CSF MOG‐IgG for testing including: controls, 282; serum MOG‐IgG positive MOG antibody‐associated disease (MOGAD), 74; serum MOG‐IgG negative high‐risk phenotypes, 73; serum false positive MOG‐IgG with alternative diagnoses, 18. A live cell‐based assay assessed CSF MOG‐IgG positivity (IgG‐binding‐index [IBI], ≥2.5) using multiple anti‐human secondary antibodies and end‐titers were calculated if sufficient sample volume. Correlation of CSF MOG‐IgG IBI and titer was assessed. Results The pan‐IgG Fc‐specific secondary was optimal, yielding CSF MOG‐IgG sensitivity of 90% and specificity of 98% (Youden's index 0.88). CSF MOG‐IgG was positive in: 4/282 (1.4%) controls; 66/74 (89%) serum MOG‐IgG positive MOGAD patients; and 9/73 (12%) serum MOG‐IgG negative patients with high‐risk phenotypes. Serum negative but CSF positive MOG‐IgG accounted for 9/83 (11%) MOGAD patients, and all fulfilled 2023 MOGAD diagnostic criteria. Subgroup analysis of serum MOG‐IgG low‐positives revealed CSF MOG‐IgG positivity more in MOGAD (13/16[81%]) than other diseases with false positive serum MOG‐IgG (3/15[20%]) ( p = 0.01). CSF MOG‐IgG IBI and CSF MOG‐IgG titer (both available in 29 samples) were correlated (Spearman's r = 0.64, p < 0.001). Interpretation CSF MOG‐IgG testing has diagnostic utility in patients with a suspicious phenotype but negative serum MOG‐IgG, and those with low positive serum MOG‐IgG results and diagnostic uncertainty. These findings support a role for CSF MOG‐IgG testing in the appropriate clinical setting. ANN NEUROL 2024;96:34–45