Citations

Abstract IntroductionSimulation technology has an established role in teaching technical skills to cardiology fellows, but their impact on teaching trainees to interpret coronary angiographic (CA) images has not been systematically studied. The aim of this randomized controlled study was to test whether structured simulation training in addition to traditional methods would improve CA image interpretation skills in a group of novices to advanced medical trainees.MethodsWe prospectively randomized 105 subjects comprising of medical students (N=20), residents (N=68) and fellows (N=17) from the University of Arizona. Subjects were randomized into a simulation training group which received simulation training in addition to didactic teaching (n=53) and a control training group which received didactic teaching alone (n=52). The change in pre and post-test score (delta score) was analyzed by a two-way ANOVA for education status and training arm.ResultsSubjects improved in their post-test scores with a mean change of 4.6 ± 4.0 points. Subjects in the simulation training arm had a higher delta score compared to control (5.4 ± 4.2 versus 3.8 ± 3.7, p=0.04), with greatest impact for residents (6.6 ± 4.0 versus 3.5 ± 3.4) with a p=0.02 for interaction of training arm and education status.ConclusionsSimulation training complements traditional methods to improve CA interpretation skill, with greatest impact on novice trainees. This highlights the importance of incorporating high-fidelity simulation training early in cardiovascular fellowship curricula.

Introduction: Baseline thrombocytopenia (TP) is a common condition in patients with acute coronary syndrome (ACS) and acute ischemic stroke and has been shown to increase mortality. The effect of baseline TP on cerebrovascular events following initial ACS event is not well studied. Methods: We retrospectively reviewed all patients identified from the institutional NCDR Chest Pain registry database at Mayo Clinic Arizona from Oct 2015 to Sep 2018. Patients were classified into TP (platelet <150) and control (platelet > 150) groups for clinical outcome (stroke/TIA and bleeding events) analysis. P-value < 0.05 is considered significant. Results: Five hundred and thirty-six patients were included for final analysis. Patient demographics and clinical outcomes are shown in Table 1. The rates of dual antiplatelet therapy (DAPT) prescription at discharge (TP vs. control: 68.1% and 75.4%, P=0.197), stroke/TIA (1.3% vs. 2.4%, P=1.000) and recurrent myocardial infarction (11.1% vs. 11.2%, P=1.000) were similar between the two groups. The TP group has more bleeding events compared to control (Figure 1). Conclusions: In patients with ACS, baseline TP does not affect stroke/TIA events but is associated with higher bleeding rate. The results could not be explained by the DAPT or anticoagulation use alone. Further studies are needed to investigate the pathophysiologic correlation of thrombocytopenia, DAPT, and stroke in ACS patients.

Background: Identifying patients at a high risk of mortality post percutaneous coronary intervention (PCI) is of vital clinical importance. We investigated the utility of machine learning algorithms to predict short and intermediate-term risk of all-cause mortality in patients undergoing PCI. Methods: Patient-level demographics, clinical, electrocardiographic ,echocardiographic and angiographic data from January 2006 to December 2017 were extracted from the Mayo Clinic CathPCI registry and clinical records. For patients with multiple PCI events, data collected at the time of the index PCI was used for analysis. Patients who underwent bailout coronary artery bypass graft surgery (CABG) prior to discharge were excluded. 306 variables were incorporated into random forest machine learning model (RF) to predict all-cause mortality at 6 months and 1 year after PCI. Ten-fold cross-validation repeated five times was used to optimize the hyperparameters and estimate its external performance. The National Cardiovascular Data Registry (NCDR) based logistic regression model was used for comparison. The area under receiver operator characteristic curves (AUC) was calculated to assess the ability of the models to predict all-cause mortality. Results: A total of 17356 unique patients were included for the final analysis after excluding 165 patients who underwent CABG surgery during the index hospitalization. The mean age was 66.9 ± 12.5 years;71% were male. Indications for PCI were ST-elevation myocardial infarction (9.4%), non-ST elevation myocardial infarction (12.9%), unstable angina (17.7%), and stable angina (52.8%) in the cohort. In-hospital, 6-month & 1 year mortality rates were 1.9%,4.2% & 5.8% respectively. The RF model was superior to the NCDR model in predicting inhospital, 6-month, 1 year mortality (p<0.0001) ( Figure 1 ). Conclusion: Machine learning is superior to NCDR model in predicting short and intermediate risk of all-cause mortality post PCI.

Percutaneous transendocardial injections of therapeutic agents into the myocardium may not always be effective. We used an animal model for assessing the efficacy of the injections using linoleic acid as a testing agent. Efficacious delivery into the myocardium of a beating heart was indicated by rapidly developed local myocardial necrosis and wall motion abnormalities using echocardiography. We employed this experimental model to test our innovative technology, an acoustically active injection catheter. The Doppler ultrasound‐guided acoustically active injection catheter effectively delivers the substance to the myocardium but needs further technical improvements to minimize an unwanted systemic distribution of the agent.

Abstract Context Peripheral artery disease (PAD) is highly prevalent in the general population, affecting up to 25% of patients 55 years of age or older. There is a known association with acute ischemic stroke, but limited large cohort studies exist pertaining to the relationship between PAD severity and incident ischemic stroke. Objectives To evaluate the risk of incident ischemic stroke and mortality along the spectrum of low and elevated ankle brachial index (ABI) measurement. Methods We performed a retrospective extraction of ABI data of all adult patients who underwent lower extremity physiology study for any indication from January 1, 1996 to June 30, 2018 in the Mayo Clinic health system. PAD was categorized into severe, moderate, mild, and borderline based on ABI measurements and poorly compressible arteries (PCA). These were compared with normal ABI measurements. Associations of PAD/PCA with new ischemic stroke events and all cause mortality were analyzed. Hazard ratios (HR) were calculated using multivariable Cox proportional regression with 95% confidence intervals. Results A total of 39,834 unique patients were included with a median follow up duration of 4.59 years. All abnormal ABI groups, except borderline PAD, were associated with increased risk of incident ischemic stroke after multivariate regression compared to normal ABI. A severity-dependent association was observed between PAD and ischemic stroke with moderate (HR, 1.22 [95% CI, 1.10–1.35]) and severe (HR, 1.19 [95% CI, 1.02–1.40]) categories conferring similar risk in comparison to normal ABI. Patients with PCA carried the greatest ischemic stroke risk (HR, 1.30 [95% CI, 1.15–1.46]). Similarly, abnormal ABI groups were associated with a significant risk for all cause mortality in a severity-dependent manner, with severe PAD conferring the greatest risk (HR, 3.07 [95% CI, 2.88–3.27]). Conclusions This study adds to the growing body of evidence that both PAD and PCA are independent risk factors for incident ischemic stroke and all cause mortality. The association of PAD severity and PCA with risk of ischemic stroke may help clinicians with risk stratification and determining treatment intensity.

AbstractBackgroundTranscatheter aortic valve replacement (TAVR) is a reliable method of treating patients with severe aortic stenosis, but is associated with postprocedure conduction defects.ObjectiveThe purpose of this study was to compare clinical outcomes in patients who developed advanced conduction defects post‐TAVR to those who did not.MethodsWe conducted a retrospective chart review of 243 patients who underwent balloon‐expandable TAVR with the Edwards Sapien valve to determine the incidence of advanced conduction defects in our cohort. We compared clinical outcomes including overall mortality, improvement in symptomatology, and improvement in left ventricular ejection fraction.ResultsAmong the 243 patients included in the study, 9.1% (22/243) required permanent pacemaker (PPM); 19.8% (48/243) developed left bundle branch block (LBBB), and 71.2% (173/243) did not develop any permanent advanced conduction defects. Overall 1‐year mortality was similar across all three groups. There was significant improvement in New York Heart Association functional capacity of all groups post‐TAVR, but this was much less in the PPM group (45.5% vs 68.8%, P = .04). Postprocedure from TAVR, patients with LBBB or PM were less likely to have improvement in their ejection fraction (net loss of −0.7% for LBBB and −5.7% for PPM compared to a net gain of 2.3% for no‐LBBB/PM (P = .02).ConclusionPatients who develop LBBB or require PM post‐TAVR with Edwards Sapien valves are less likely to improve New York Heart Association functional capacity and more likely to have no improvement or deterioration of their pre‐TAVR left ventricular ejection fraction.

Abstract Background Coronary artery disease (CAD) and atrial fibrillation (AF) are commonly associated. Co-treatment with multiple anti-thrombotic agents can increase the risk of bleeding. Purpose We sought to evaluate patient-centered outcomes in patients with AF on double therapy with direct oral anticoagulants (DOACs) compared to patients with standard triple therapy, [a vitamin K antagonist (VKA) plus dual antiplatelet therapy]. Methods We performed an extensive systematic review of the literature and meta-analysis of randomized controlled trials reporting outcomes of patients receiving double therapy with DOACs compared to triple therapy with VKAs in patients with AF undergoing percutaneous coronary intervention (PCI). Patient-centered outcomes were the International Society of Thrombosis and Hemostasis (ISTH) major or clinically relevant non-major bleeding (CRNB), all-cause mortality, major adverse cardiovascular events (MACE), myocardial infarction, stent thrombosis, and stroke. Results Four randomized controlled trials (9602 patients) met our inclusion criteria. Compared to VKAs, DOACs were associated with significantly lower ISTH major bleeding/ CRNB (RR - 0.75, 95% CI: 0.67-0.82, p &lt; 0.00001, I2 = 11%). There were no statistically significant differences in the efficacy outcomes, including myocardial infarction (RR- 0.99, 95% CI :0.79-1.25, p = 0.96, I2 = 0%), stent thrombosis (RR - 0.97, 95% CI: 0.6-1.55, p = 0.89, I2 = 0%), ischemic stroke (RR - 0.76, 95% CI: 0.5-1.15, p = 0.19, I2 = 0%), all-cause mortality (RR - 1.06, 95% CI: 0.85-1.31, p = 0.61, I2 = 0%) and MACE (RR - 1.06, 95% CI: 0.91-1.22, p = 0.97, I2 = 0%). Conclusion Compared with triple therapy with VKAS, double therapy with DOACs is associated with a reduced risk of bleeding and is as effective in patients with AF undergoing PCI. Abstract Figure.

Abstract Funding Acknowledgements None Background Cardiac Power Index (CPI) is an integrative hemodynamic measure of cardiac pumping capability and is the product of the simultaneously measured mean arterial pressure (MAP) and cardiac output (CO). In patients with aortic stenosis (AS), MAP is not reflective of mean systolic left ventricular (LV) pressure due to the transvalvular gradient. Non-invasive assessment of mean systolic LV pressure is challenging in severe aortic stenosis. CPI assessed using systemic MAP was previously shown to predict survival post transcatheter aortic valve replacement (TAVR). Purpose We evaluated the utility of a gradient adjusted CPI in predicting survival post TAVR compared to CPI alone Methods A retrospective study was performed including patients undergoing TAVR with 1 year follow-up. Baseline demographics, clinical, and echocardiographic data were abstracted from a cohort of 1,011 patients. CPI was calculated, (CO x MAP)/ (451 x BSA) Watts/m2. Gradient adjusted CPI was calculated using an augmented MAP i) adding aortic valve mean gradient(AVMG) to systolic blood pressure (CPI1); ii) adding aortic valve maximal instantaneous gradient to systolic blood pressure (CPI2) and iii) adding AVMG to MAP (CPI3). Patient survival score was calculated using a step up technique to identify the cut off value for CPI and gradient adjusted CPI to identify, where the maximum difference in mortality occurred. Multivariate cox-regression analysis was performed to adjust for baseline covariates. Receiver operator curves(ROC) for CPI and gradient adjusted CPI were calculated to predict survival post TAVR. Results The mortality rate at 1 yr was 16%. Mean age and AVMG of survivors was 81 +/- 9 yrs and 43 +/-14 mmHg vs 80 +/-9 yrs and 42 +/- 13 mmHg in the deceased group. Proportion of female patients was similar in both groups (p = 0.7). Patients in the deceased group at baseline had a higher prevalence of chronic lung disease, atrial fibrillation, heart failure within 2-weeks of procedure, higher STS-PROM score, lower serum albumin level, higher prevalence of moderate to severe tricuspid regurgitation, higher right ventricular systolic pressure and higher prevalence of dialysis. Both CPI and gradient adjusted CPI were independently associated with survival at 1 year. The area under ROC for CP, CP1, CP2 and CP3 were 0.67 (95% confidence interval [CI] 0.62 - 0.72), 0.65 (95% CI 0.60 – 0.70), 0.66 (95% CI 0.61 – 0.71) and 0.63 (95% CI 0.58 – 0.68) respectively. Conclusion Gradient adjusted CPI did not improve accuracy of predicting post TAVR survival at 1 year compared to CPI alone. Abstract P339 Figure. Area under ROC