Citations

Background: Patients with D-transposition of the great arteries and atrial switch have a high incidence of atrial arrhythmias. We sought to analyze the arrhythmia substrate, ablation strategies, and outcomes for catheter ablation in this population. Methods: An in-depth analysis of all clinical and procedural data in patients with D-transposition of the great arteries, atrial baffles, and atrial arrhythmia ablation was performed. Results: A cohort of 32 patients (72% male, mean age 38±7 years) underwent ablation for non-AV nodal reentrant tachycardia atrial arrhythmias, and 4 patients underwent AV nodal reentrant tachycardia ablation. Cavotricuspid isthmus flutter (CTI-flutter) was the most common arrhythmia, encountered in 75% of patients, followed by scar-related intraatrial reentrant tachycardia (non-CTI intraatrial reentrant tachycardia, 53%) and focal atrial tachycardia (focal atrial tachycardia, 6%). Among the 32 patients, 26 underwent 31 procedures at our institution. For patients with prior outside intervention, the index ablation at our institution revealed CTI-dependent flutter in 3/5 cases. However, redo ablation after an index ablation with demonstrated bidirectional CTI block revealed different/new arrhythmia substrates (80% non-CTI intraatrial reentrant tachycardia, 40% focal atrial tachycardia). Achieving bidirectional block across the CTI often required ablating on both sides of the baffle (retroaortic access, 81%; using a baffle leak, 11.5%; or transbaffle puncture, 7.7%). Combined approaches were necessary in 19% to reach the critical tissue. Acute procedural success was 81%, and recurrence was documented in 58% of patients. Despite recurrence, clinical arrhythmia burden was significantly reduced post-ablation ( P <0.001), with rare episodes, amenable to antiarrhythmic therapy. Redo ablation was required in 5 (19%) patients and uncovered new arrhythmia substrates. AV nodal reentrant tachycardia ablation also required transbaffle approaches in 3/4 patients. Conclusions: CTI-dependent flutter was the most common arrhythmia in patients with Dextro-Transposition of the Great Arteries and atrial switch. Transbaffle approaches were often necessary, and, provided that bidirectional CTI block was achieved at the index ablation, late recurrence was due to different arrhythmia mechanisms. Despite recurrence, ablation was associated with significant clinical improvement.

Abstract Aims Limited US outcome data exist among patients with myocardial injury and types 1 and 2 myocardial infarction (MI) evaluated with high-sensitivity cardiac troponin (hs-cTn). Methods and results This is an observational US cohort study of emergency department (ED) patients undergoing hs-cTnT measurement. Cases with ≥1 hs-cTnT increase &gt;99th percentile were adjudicated following the Fourth Universal Definition of MI. Post-discharge major adverse cardiovascular events (MACE) included death, MI, heart failure (HF) hospitalization, stroke or transient ischaemic attack, and new-onset atrial fibrillation or flutter during 2 years follow-up. Among 2002 patients, 857 (43%) had ≥1 hs-cTnT &gt;99th percentile. Among these, 702 (81.9%) had myocardial injury, 64 (7.5%) had type 1 MI, and 91 (10.6%) had type 2 MI. Compared with patients without myocardial injury, type 2 MI [8.4 vs. 50%; adjusted hazard ratio (HR) 2.31, 95% confidence interval (CI) 1.49–3.58] and myocardial injury (8.4 vs. 47%; adjusted HR 3.13, 95% CI 2.39–4.09) had a higher risk of MACE, in large part because of death and HF hospitalizations. Compared with patients with type 1 MI, type 2 MI (23 vs. 50%; adjusted HR 2.24; 95% CI 1.23–4.10) and myocardial injury (23 vs. 47%; adjusted HR 2.02; 95% CI 1.20–3.40) also have a higher risk of MACE. Conclusion Among unselected US ED patients undergoing hs-cTnT measurement, most increases are due to myocardial injury, and type 2 MI is more frequent than type 1 MI. Patients with myocardial injury and type 2 MI have morbid outcomes, in large part due to death and HF.

Background The aim of this study was to establish prognostic hemodynamic parameters in patients with mitral stenosis secondary to mitral annular calcification. Methods and Results A retrospective cohort of 105 patients undergoing transseptal catheterization for hemodynamic evaluation of mitral annular calcification–related mitral stenosis between 2004 and 2020 was studied. Mitral valve gradient (MVG) and mitral valve area (MVA; calculated by the Gorlin formula) were measured using direct left atrial and left ventricular pressures. The median age of the patients was 70.3 years (58.4–76.7 years), and 53.3% were women. The median MVA was 1.7 cm 2 (1.3–2.3 cm 2 ) and MVG was 7.3 mm Hg (5.3–10.3 mm Hg); left ventricular end‐diastolic pressure was 17.6±28.3 mm Hg. During a median of 2.1 years (0.7–4.5 years), there were 63 deaths; 1‐ and 5‐year survival were 76% and 40%, respectively. There was no association between left ventricular end‐diastolic pressure and survival. After adjusting for age and comorbidities, both MVA (hazard ratio [HR], 0.50 per cm 2 ; 95% CI, 0.34–0.73) and MVG (HR, 1.1 per mm Hg; 95% CI, 1.05–1.20) were independent predictors of death. Atrial fibrillation was also independently associated with mortality. When added to a combined model, MVA remained associated with death (HR, 0.51 per cm 2 ; 95% CI, 0.33–0.79) while MVG was not. Conclusions In patients with mitral annular calcification–related mitral stenosis, survival was poor. MVA and MVG were independently associated with death, but MVA was a better predictor of outcomes.

Purpose: The goal of this study was to compare outcomes of Descemet stripping endothelial keratoplasty (DSEK) in eyes with glaucoma and abnormal anatomy to eyes with Fuchs endothelial corneal dystrophy (FECD). Methods: In a retrospective interventional series of all cases of DSEK between April 1, 2006, and November 30, 2015, recipient diagnosis, preoperative glaucoma status, concurrent surgical procedures, and graft outcomes were recorded. Graft survival, risk of rejection, and subsequent glaucoma surgery were estimated by using Kaplan–Meier analysis with risk factors determined by proportional hazard models. Results: Of 703 DSEKs in 666 eyes (509 subjects), the main recipient diagnoses were FECD (n = 496), pseudophakic corneal edema (n = 112), and failed graft (n = 83). Glaucoma was present in 150 cases before DSEK. Overall graft survival was 85%, 75%, and 71% at 5, 10, and 12 years, respectively, and for FECD without glaucoma was 95%, 89%, and 87% at 5, 10, and 12 years, respectively. Independent risk factors for graft failure included recipient diagnoses of pseudophakic corneal edema (HR = 8.3, P < 0.001), failed graft (HR = 6.4, P < 0.001), and preoperative medical glaucoma (HR = 7.1, P < 0.001) or surgical glaucoma (HR = 12.3, P < 0.001). Preoperative glaucoma treated by previous surgery resulted in graft survival of 28% at 10 years. Preoperative glaucoma was associated with an increased risk of graft rejection (HR = 6.8, P < 0.001) and subsequent glaucoma surgery (HR > 17.4, P < 0.001). Conclusions: Preoperative glaucoma increases the risk of graft failure, graft rejection, and needing subsequent glaucoma surgery in the first decade after DSEK. With previous glaucoma surgery, DSEK graft survival was more favorable compared with published reports of Descemet membrane endothelial keratoplasty.

Background: There are good data to support using a single high-sensitivity cardiac troponin T (hs-cTnT) below the limit of detection of 5 ng/L to exclude acute myocardial infarction. Per the US Food and Drug Administration, hs-cTnT can only report to the limit of quantitation of 6 ng/L, a threshold for which there are limited data. Our goal was to determine whether a single hs-cTnT below the limit of quantitation of 6 ng/L is a safe strategy to identify patients at low risk for acute myocardial injury and infarction. Methods: The efficacy (proportion identified as low risk based on baseline hs-cTnT<6 ng/L) of identifying low-risk patients was examined in a multicenter (n=22 sites) US cohort study of emergency department patients undergoing at least 1 hs-cTnT (CV Data Mart Biomarker cohort). We then determined the performance of a single hs-cTnT<6 ng/L (biomarker alone) to exclude acute myocardial injury (subsequent hs-cTnT >99th percentile in those with an initial hs-cTnT<6 ng/L). The clinically intended rule-out strategy combining a nonischemic ECG with a baseline hs-cTnT<6 ng/L was subsequently tested in an adjudicated cohort in which the diagnostic performance for ruling out acute myocardial infarction and safety (myocardial infarction or death at 30 days) were evaluated. Results: A total of 85 610 patients were evaluated in the CV Data Mart Biomarker cohort, among which 24 646 (29%) had a baseline hs-cTnT<6 ng/L. Women were more likely than men to have hs-cTnT<6 ng/L (38% versus 20%, P <0.0001). Among 11 962 patients with baseline hs-cTnT<6 ng/L and serial measurements, only 1.2% developed acute myocardial injury, resulting in a negative predictive value of 98.8% (95% CI, 98.6–99.0) and sensitivity of 99.6% (95% CI, 99.5–99.6). In the adjudicated cohort, a nonischemic ECG with hs-cTnT<6 ng/L identified 33% of patients (610/1849) as low risk and resulted in a negative predictive value and sensitivity of 100% and a 30-day rate of 0.2% for myocardial infarction or death. Conclusions: A single hs-cTnT below the limit of quantitation of 6 ng/L is a safe and rapid method to identify a substantial number of patients at very low risk for acute myocardial injury and infarction.

AbstractBackgroundLike other chronic, inflammatory skin disorders, hidradenitis suppurativa (HS) is increasingly recognized to be associated with various medical disorders.ObjectiveUsing the Rochester Epidemiology Project (REP), we sought to conduct the first American population‐based study examining the association between HS and various comorbid conditions.MethodsFrom the REP database, we identified patients diagnosed with HS from 2003 through 2018 who were residents of Olmsted County, Minnesota, USA, along with age‐ and gender‐matched controls. The frequency of a wide variety of comorbid conditions was compared between the groups.ResultsA total of 1160 patients with HS were identified during the study period. Compared with age‐ and gender‐matched controls, patients with HS had a significantly higher frequency of several medical conditions, including depression, anxiety, hyperlipidemia, acne conglobata, dissecting cellulitis, pilonidal cysts, polycystic ovary syndrome, diabetes, chronic kidney disease, psoriasis, atopic dermatitis, obesity, and disordered substance use, among others.LimitationsOur study was limited by its retrospective design.ConclusionsProviders caring for patients with HS should consider these results, along with those of similar studies, and obtain a thorough history, comprehensive physical examination, and, potentially, laboratory testing and referral to other specialists.

Background: Left ventricular hypertrophy (LVH) is considered a marker of stage B heart failure according to the ACC/AHA classification. Current guidelines recommend beta-blocker (BB) therapy for treatment but randomized control trials suggest that Angiotensin Receptor Blocker (ARB) therapy may be superior. Purpose: To compare survival among cohorts of LVH patients classified according to use of BB, ARB or neither (NONE) class of medications. Methods: A retrospective analysis of hypertension patients seen in the outpatient clinics was done. LVH was defined using the most stringent electrocardiogram (ECG) criteria whereas patients with minimal and moderate voltage criteria were excluded. Using hypertension medications from the year 2009 outpatient visits notes, 869 LVH patients were classified into BB (604), ARB (115) and NONE (150) cohort groups. Cox proportional hazard models were built. Results: Survival at 5 years was 85.2% with 17 deaths and 98 censored patients, (unadjusted hazard ratio HR 0.53, p=0.03) in the ARB cohort and 75.5 % with 148 deaths, 456 censored patients (HR 0.91, p=0.61) in the BB group compared to 74.0% in the NONE cohort with 39 deaths and 111 censored patients. After adjusting for age, sex, atrial fibrillation/flutter, heart failure, chronic kidney disease (CKD), coronary artery disease (CAD), acute myocardial infarction, stroke, obesity, diabetes, sleep apnea and pulmonary hypertension, HR was 0.40, p=0.006 for ARB and HR=0.80, p=0.278 for BB compared to the NONE group. At baseline, there was no significant difference in age, sex, and the prevalence in heart failure, stroke, obesity, sleep apnea, and pulmonary hypertension in all three groups although the BB group had significantly highest prevalence of atrial fibrillation/flutter, CAD, CKD and the lowest prevalence of diabetes. Conclusion: There was a significant mortality reduction benefit to hypertension patients with ECG diagnosed LVH treated with ARB which was not seen in similar patients on BB when compared to those treated with none of both medication classes. This effect persisted even after adjusting for cardiovascular comorbidities.

Abstract Background: There is an urgent need to improve clinical trial (CT) enrollment of breast cancer (BC) patients (pts), especially from unrepresented minorities. In this regard, our study aims to better understand the characteristics and factors associated with CT enrollment to inform strategies to enhance CT accrual rates. Method: We included 1,308,767 female pts from the National Cancer Data Base diagnosed from 2010 to 2017 with known ER, PR, and HER2 status. Demographic, socioeconomic, Charlson-Deyo Score (CDS) and BC specific data were compared between CT versus non-CT enrolled pts for initial therapy. Comparisons were assessed by Chi-square test. Logistic regression was utilized to determine associations between characteristics and CT enrollment. Odds ratios (OR) and p-values are reported for each group. Results: A total of 1797 pts (0.14%) were enrolled in CT for initial BC therapy. Focusing on the CT group, majority of pts were non-Hispanic White (W;(78.2%), followed by non-Hispanic black (AA;12.2%); Hispanic (H; 5.6%); and non-Hispanic Asian (A; 4%). Most pts (29.3%) were in 50-59 age quartile. TNBC pts formed 22% of CT pts and non-TNBC were 78%. Most pts were from academic centers (54%), followed by comprehensive community cancer (CCC; 23.5%), community cancer (3.9%) and integrated network cancer (INC; 5.6%) programs. Most had private insurance (70%) versus government insurance (27%) and others (3%). Stage IV pts were only 10% of the CT group while most pts (41%) had Stage II BC. CDS of 0 was noted in 90% pts while 1.3% pts had CDS of 2 or more. Most CT pts traveled &lt; 50 miles from treatment center (88.5%), and only 1.2% CT pts traveled 200 or more miles. Most CT pts resided in areas with highest literacy rate (30%) while 15% were from areas with lowest literacy rate. In multivariable model, non-white pts were less likely than Whites to be enrolled in CT (OR 0.81, p&lt;0.05). The odds of CT enrollment in 40-49, 50-59 and 60-69 age quartiles were 3.5, 2.7 and 2.3 times respectively that of pts 70 years or older (p&lt;0.001). TNBC pts were 1.9 times more likely to be enrolled in CT than non-TNBC pts (p&lt;0.001). Academic center pts were 3 times more likely (p&lt;0.001) while INC program pts were less likely than CCC pts to be enrolled (OR 0.7, p=0.006). Pts with government insurance and other insurance were less likely to enroll in CT (OR 0.74, and 0.55, p &lt;0.001 and p=0.003, respectively) compared to private insurance. The odds of a patient with stage II, III, IV BC enrolling in CT was about 2, 3.5 and 4 times higher than a stage I pt (p -&lt;0.001). Pts with CDS 1 (OR 0.8, p=0.025) or 2 or more (OR 0.5, p=0.002) were less likely than CDS 0 pts to be enrolled. Pts who traveled 50-99 or 100-199 miles from the treatment center conducting CT, were 1.9 (p&lt;0.001) and 1.5 times (p&lt;0.05) more likely to be enrolled while those with &gt; 200 miles were less likely (OR 0.75, p=0.442). The group of pts who belonged to a residential area with the highest literacy rate (&lt;6.3% of no high school diploma) were 1.4 times more likely to accrue in CT (p&lt;0.001) than those with high school diploma rate between 6.3 and 10.8%. Compared to metro areas, pts from rural areas were less likely to be enrolled (OR 0.5, p=0.04) as was a lower median income &lt; $40,227 (OR 0.77, p= 0.016).Conclusion: CT enrollment is poor for initial therapy of BC treatment. We identify several modifiable factors including sociodemographics which are associated with BC pts not getting treated on CT. There are other factors that are non-modifiable, e.g., disease stage but may point to the need for more CT development in these areas. Addressing these disparities would lead to improved CT enrollment and overall advancement in BC management landscape. Citation Format: Pooja P Advani, Aaron Spaulding, Alexander Hochwald, Mizba Baksh, David Hodge, Saranya Chumsri, Shanada Monestime, Sikander Ailawadhi. Clinical trial enrollment for initial therapy of breast cancer: Exploring factors associated with poor accrual and significant disparities [abstract]. In: Proceedings of the 2021 San Antonio Breast Cancer Symposium; 2021 Dec 7-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2022;82(4 Suppl):Abstract nr P2-11-15.

Purpose: Outpatient visits and surgeries for nonurgent indications in ophthalmology have intermittently been restricted during the COVID-19 pandemic. Telemedicine services have rapidly gained acceptance during this period, and could improve patient access for routine oculoplastic evaluations in the future. The objective of this study is to investigate interobserver and intraobserver reliability of eyelid and brow position assessment and surgical plan when comparing photography-based and face-to-face evaluation. Methods: This was an observational study conducted at a single academic center. Thirty randomly selected patients who had completed an in-office evaluation for chief complaint of “drooping eyelids” between June 2019 and March 2020 were included. Virtual assessment of brow position, dermatochalasis, blepharoptosis, and margin-reflex distance 1 was performed by 2 oculoplastic surgeons based on external photographs, and a surgical plan was formulated. Fraction of agreement and Cohen’s κ were determined to evaluate reliability of the virtual assessment compared to face-to-face examination. Results: For 60 eyes from 30 study subjects, diagnostic reliability for observer A was near perfect for brow ptosis, substantial for blepharoptosis and moderate for dermatochalasis (κ = 0.86, 0.67, and 0.57, respectively); for observer B, reliability was moderate for brow and blepharoptosis and substantial for dermatochalasis (0.47, 0.59, and 0.79). Fraction of agreement for blepharoptosis was 94% in eyes where the eyelid margin was visible, and 66% in eyes where the eyelid margin was obscured by overhanging skin. Virtual margin-reflex distance 1 measurements were highly correlated with those obtained face to face (r = 0.77, p < 0.01). Fraction of agreement for surgical plan after virtual examination by observer A/B, respectively, was 100%/94% for brow lift, 90%/87% for blepharoptosis repair and 83%/83% for functional upper blepharoplasty. Conclusions: Virtual evaluation of upper eyelid and brow malposition can be performed with acceptable reliability. Co-existing dermatochalasis or brow ptosis may require special photographic technique or video examination to ensure an appropriate diagnosis. A photography-based preliminary surgical plan offers a viable alternative to face-to-face encounters.