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Cachexia is often seen in patients with heart failure (HF). This study aimed to examine the association between cachexia and clinical outcomes in patients hospitalized for HF. We extracted all adult cases with a primary diagnosis of HF that were discharged between January and November, identified in the Nationwide Readmissions Database for 2016 through 2019. Exclusion criteria included cases with missing data or a diagnosis of acquired immunodeficiency syndrome, advanced liver disease, end-stage renal disease, chronic lung disease, or malignancy. Appropriate weighting was used to obtain national estimates. Primary outcomes were inpatient mortality, length of stay, and 30-day readmission in patients with HF with cachexia compared with patients with no cachexia. Multivariable logistic regression was used to estimate the association between cachexia and clinical outcomes. Survey procedures were applied using Statistical Analysis Software 9.4. The final analysis included 2,360,307 HF-related hospitalizations. Cachexia was present in about 7% of the study population. A greater percentage of patients with cachexia were female and older than patients without cachexia (52% vs 47% female, the mean age of 77 vs 72 years, respectively). However, after adjusting for demographics and co-morbidities, including coronary artery disease and atrial fibrillation, patients with cardiac cachexia had higher inpatient mortality (odds ratio 3.01, 95% confidence interval 2.88 to 3.15, p0.001), prolonged hospital stays (9 vs 5 days, p0.0001), and greater all-cause 30-day readmissions (23% vs 21%, p0.0001). HF-related cachexia is associated with increased inpatient mortality, greater resource use, and additional healthcare costs.

Objectives Oral steroids are routinely administered in the United States for prophylaxis of iodinated contrast media hypersensitivity (ICMH). We studied the impact of short-term steroid use in diabetic patients with ICMH undergoing nonemergent coronary angiography. Methods We retrospectively analyzed records of diabetic patients with and without ICMH who underwent nonemergent coronary angiography at our center. Primary study endpoint was 30-day major adverse cardiac events (MACE) and secondary endpoints were pre- and postprocedure fasting blood glucose (FBG), highest in hospital blood glucose, pre- and postprocedure systolic blood pressure (SBP), and use of intravenous insulin and antihypertensive medications. Results A total of 88 diabetics with ICMH (study group) and 76 diabetics without ICMH (control group) undergoing angiography were enrolled. Demographics and hemoglobin A1c values were similar in both groups. Preprocedural FBG was significantly higher in the study group. The study group had significantly higher post angiography FBG (239.93 + 96.88 mg/dl vs. 156.6 + 59.88 mg/dl) and greater use of intravenous (IV) insulin (67.27% vs. 32.43%). Further, those who received steroids had significantly higher systolic SBP postprocedure (146.16 + 25.35 mmHg vs. 130.8 + 21.59 mmHg), a higher incidence of severe hypertension and use of IV antihypertensive medications (80.95% vs. 19.05%) periprocedurally. There were no differences in 30-day MACE between groups. Conclusion Short-term steroid use for ICMH results in a significant increase in surrogate markers for adverse clinical events after coronary procedures. Study findings highlight the need for better periprocedural management of these patients and to limit steroid prophylaxis to those with only true ICMH.

Introduction: The Emory risk score has been developed to predict new pacemaker implantation in patients undergoing TAVR procedures. There is limited data on assessing risk of early versus late pacemaker implantation in these patients. Hypothesis: The Emory risk score is similar for patients with both early and late pacemaker implantation in TAVR patients. Methods: A single center observational study was performed at our tertiary care center. All patients who underwent pacemaker implantation after TAVR procedures were included. Patients were categorized as early or late if they had pacemaker implantation within the same admission versus implantation post discharge. Standard statistical tests were used for analysis with two-sided p value Results: A total of 97 patients were studied between January 2017 to April 2020. The mean age was 77.5 ± 7 years and females were 41.2%. At baseline patients with early implantation of pacemakers (n=66) had a higher proportion of underlying RBBB (45.2% vs 23.3%, p=0.43), higher valve size as well as a higher incidence of valve oversizing > 146% (43.9 % vs 19.4 %, p =0.23)when compared to patients with late pacemakers(n=31). There was no difference between patient characteristics, baseline comorbidities, pre procedural ECG parameters as well as use of beta blocking agents. Late pacemaker implantations were associated with a overall lower Emory Risk score (1.06±1.41 vs 1.70±1.35, p =0.037). Conclusions: The Emory Risk score is significantly different for early and late pacemaker implantation. Further studies are needed evaluate risk of late pacemaker implantation.

The endocannabinoid system plays an important role in the intake of palatable food. For example, endocannabinoid signaling in the upper small-intestinal epithelium is increased (i) in rats after tasting dietary fats, which promotes intake of fats, and (ii) in a mouse model of diet-induced obesity, which promotes overeating via impaired nutrient-induced gut–brain satiation signaling. We now utilized a combination of genetic, pharmacological, and behavioral approaches to identify roles for cannabinoid CB1Rs in upper small-intestinal epithelium in preferences for a western-style diet (WD, high-fat/sucrose) versus a standard rodent diet (SD, low-fat/no sucrose). Mice were maintained on SD in automated feeding chambers. During testing, mice were given simultaneous access to SD and WD, and intakes were recorded. Mice displayed large preferences for the WD, which were inhibited by systemic pretreatment with the cannabinoid CB1R antagonist/inverse agonist, AM251, for up to 3 h. We next used our novel intestinal epithelium-specific conditional cannabinoid CB1R-deficient mice (IntCB1−/−) to investigate if intestinal CB1Rs are necessary for WD preferences. Similar to AM251 treatment, preferences for WD were largely absent in IntCB1−/− mice when compared to control mice for up to 6 h. Together, these data suggest that CB1Rs in the murine intestinal epithelium are required for acute WD preferences.

Introduction: Stroke after transcatheter aortic valve replacement (TAVR) is a significant cause of morbidity and mortality. It increases the risk of mortality threefold, within one year of TAVR. It is also associated with significant disability and increased health care costs. A validated risk prediction tool for stroke one year after TAVR may be useful in risk stratification to guide decisions at the point of clinical care and in research. The objective of this study was to assess the calibration and discriminative ability of the R 2 CHA 2 DS 2 VASc, CHA 2 DS 2 VASc, R 2 CHADS 2 , and CHADS 2 scores for predicting stroke within one year of TAVR. Methods: This was a retrospective cohort study using data from a midwestern academic center TAVR program. Patients who underwent TAVR from 2012 to the first quarter of 2018 who had one-year follow-up data were included in the study. The model discrimination and calibration were assessed using the area under the receiver operating characteristic curve (c-statistic) and the Hosmer-Lemeshow test respectively. Results: Six hundred and sixty four patients met the inclusion criteria and 3.4% had stroke within one year of undergoing TAVR. They had a median age of 81 years and a mean STS score of 6.3. The R 2 CHA 2 DS 2 VASc, CHA 2 DS 2 VASc, R 2 CHADS 2 , and CHADS 2 scores had c-statistics of 0.591, 0.596, 0.607, and 0.622, respectively. The Hosmer-Lemeshow χ 2 p-values were 0.762, 0.422, 0.463 and 0.146 respectively. Conclusion: The CHADS 2 score had the best discriminative ability for stroke prediction one year after TAVR. All the four scores were well calibrated.

Background The ACC/AHA guidelines recommend low-dose dobutamine challenge for hemodynamic assessment of the severity of AS in patients with low flow, low gradient aortic stenosis with reduced ejection fraction (EF) (LFLG-AS; stage D2). Inherent pitfalls of echocardiography could result in inaccurate aortic valve areas (AVA), which have downstream prognostic implications. Data on the safety and efficacy of coronary pressure wire and fluid-filled catheter use for low dose dobutamine infusion is sparse. Methods We retrospectively analyzed 39 consecutive patients with EF on echocardiography who underwent simultaneous right and left heart catheterization . Hemodynamic assessments were performed at baseline and at every increment in the dobutamine infusion rate (The infusion was continued until maximal dose of dobutamine or a mean AV gradient > 40 mm Hg was attained. The occurrence of sustained ventricular arrhythmias , symptomatic hypotension or intolerable symptoms leading to cessation of infusion was recorded. Transient ischemic attacks (TIAs) or clinically apparent strokes periprocedurally or up to 30 days after the procedure were recorded. Results Dobutamine challenge confirmed true AS in 26 patients (67%) and pseudosevere AS in 34%. No sustained arrhythmias, hypotension or cessation of infusion from intolerable symptoms were observed. No clinical strokes or TIAs were observed up to 30 days after procedure in any of these patients. Conclusions Hemodynamic assessment of AS using a pressure wire with dobutamine challenge is a safe and effective tool in identifying truly severe AS in patients with LFLG-AS with reduced EF.

Graphical abstract, Highlights • Traumatic RV pseudoaneurysm is a rare diagnosis. • Optimal management of RV pseudoaneurysm remains unknown. • The authors describe a novel percutaneous treatment approach for RV pseudoaneurysm.

Objective: The aim of this paper was to study the association between body mass index (BMI) and coronary sinus (CS) brain natriuretic peptide (BNP) levels in patients with heart failure and reduced systolic function (HFrEF). Background: There is an inverse relationship between systemic venous BNP (V-BNP) levels and BMI in patients with HFrEF. It is unclear whether this finding is due to decreased production or due to an increased metabolism of BNP. Since CS-BNP levels reflect BNP production, we hypothesized that assessing the correlation of CS-BNP levels with BMI would provide insight into the mechanism of this inverse relationship of V-BNP and BMI. Methods: We prospectively enrolled 54 subjects with HFrEF who were to undergo cardiac resynchronization device implantation. CS-BNP, V-BNP, and arterial BNP (A-BNP) levels were measured during the implant procedure. Subjects were divided into 2 groups based on their BMI (group 1: BMI Results: The mean age of the overall study group was 64 ± 10 years. Average BMI for group 1 was 25.8 ± 2.8 and 36.8 ± 4.6 for group 2 (p < 0.03). A history of hypertension was present in 55% (n = 26) of the subjects, while diabetes was reported in 31% (n = 15). Serum creatinine was 1.0 ± 0.2 mg/dL and TSH 2.1 ± 1.4 mIU/L. 79% of the subjects were receiving β-blockers, while 94% were receiving angiotensin-converting enzyme inhibitors or angiotensin receptor blockers. The mean CS-BNP, V-BNP, and A-BNP levels in group 2 were significantly lower than in group 1 (286.2 ± 170.5 vs. 417.5 ± 247.5 pg/mL, p = 0.04; 126.6 ± 32.5 vs. 228 ± 96.4 pg/mL, p = 0.01; and 151.9 ± 28.6 vs. 242 ± 88.8 pg/mL, p = 0.04, respectively). Univariate analysis and multivariate regression adjusted for age, diabetes mellitus, sex, glomerular filtration rate, and left atrial size confirmed BMI as an independent predictor of CS-BNP levels (β = -0.372, p = 0. 03) in our study. Conclusions: In this study, we demonstrate an inverse relationship between CS-BNP levels and BMI in patients with HFrEF. These findings suggest that the previously established inverse relationship between V-BNP and BMI is due to a decreased cardiac production of BNP in obese patients rather than from increased peripheral metabolism.

Stroke after transcatheter aortic valve replacement (TAVR) increases the risk of 1-year mortality 3-fold. A tool for predicting 1-year stroke after TAVR is lacking. The purpose of this study was to develop a new risk score for predicting 1-year stroke after TAVR and compare its performance with

BACKGROUND Over the last decade, there has been a significant increase in the use of percutaneous left ventricular assist devices(p-LVADs). p-LVADs are being increasingly used during complex coronary interventions and for acute cardiogenic shock. These large bore percutaneous devices have a higher risk of vascular complications. We examined the vascular complication rates from the use of p-LVAD in a national database. METHODS We conducted a secondary analysis of the National In-patient Sample (NIS) dataset from 2005 till 2015. We used the ICD-9-CM procedure codes 37.68 and 37.62 for p-LVAD placement regardless of indications. We investigated common vascular complications, defining them by the validated ICD 9 CM codes. χ2 test and t test were used for categorical and continuous variables, respectively for comparison. RESULTS A total of 31,263 p-LVAD placements were identified during the period studied. A majority of patients were male (72.68%) and 64.44% were white. The overall incidence of vascular complications was 13.53%, out of which 56% required surgical treatment. Acute limb thromboembolism and bleeding requiring transfusion accounted for 27.6% and 21.8% of all vascular complications. Occurrence of a vascular complication was associated with significantly higher in-hospital mortality (37.77% vs. 29.95%, p

Ventricular free wall rupture (VFWR) is a rare entity and is mostly related to post myocardial infarction (MI) complications usually involving left ventricle. In traumatic chest injuries, the right ventricle (RV) is more commonly involved due to its anatomic and structural vulnerability, as in our case. Survival, although rare, has almost always been secondary to urgent surgical repair, which is the current standard of care for such cases. However, extremely tenuous hemodynamic parameters preclude urgent surgical interventions in most of these cases. Surgical repair was considered to have prohibitive risk in our case also due to multiple comorbidities. Our case offers a unique perspective into the feasibility and safety of percutaneous closure of VFWR with devices such as Amplatzer Vascular Plug (AVP) II under transesophageal echocardiography (TEE) and angiographic guidance in patients who survive VFWR. The lack of randomized evidence to standardize the duration and regimen of antiplatelet therapy following placement of these devices is to be noted.

OBJECTIVES To assess the prognostic significance of high vs. low grade coronary artery ectasia (CAE) and the impact of antithrombotic or anticoagulant therapy on adverse cardiac outcomes. BACKGROUND There is paucity of knowledge on the impact of angiographic characteristics in CAE or that of antithrombotic or anticoagulant therapy on outcomes. METHODS AND RESULTS In this retrospective study, we reviewed angiograms and medical records of all cases of confirmed CAE (2001-2011). Extent of CAE was categorized using the Markis classification. Types 1 and 2 were categorized as high-grade and types 3 and 4 as low-grade CAE. Angiographic flow was recorded as normal or sluggish (

Percutaneous coronary intervention (PCI) followed by transcatheter aortic valve replacement (TAVR) is an alternative to surgery in patients with severe aortic stenosis (AS) and coronary artery disease (CAD). In many, the coronary arteries are severely calcified and best treated with rotational atherectomy (RA). However, RA is not routinely performed in severe AS patients due to safety concerns. There is a paucity of data on the safety of RA in severe AS patients with calcific CAD.We retrospectively analyzed the medical records of 29 patients with severe AS who underwent elective RA-facilitated PCI at our center between January 1, 2011 and December 31, 2015.Twenty-nine patients (mean age, 79.8 ± 8.8 years) were enrolled. Mean aortic valve area was 0.71 ± 0.20 cm², mean aortic valve gradient was 40.32 ± 9.88 mm Hg. All PCIs were successful (mean diameter stenosis, 86.3 ± 7.6%; mean burr size, 1.62 ± 0.19 mm). Nineteen patients (65.5%) required temporary pacemaker. Eight patients (27.6%) required vasopressors during PCI. There was a significant reduction in systolic blood pressure (SBP), diastolic blood pressure (DBP), mean arterial pressure (MAP), and heart rate (HR) during RA, but without clinical events. No procedure was aborted and there were no deaths or clinical myocardial infarctions.RA-facilitated PCI can be safely performed in elderly patients with severe AS and severely calcified CAD with low risk of complications. There was a significant but transient drop in SBP, DBP, MAP, and HR during RA. However, this was not associated with clinically significant adverse events.

Ankle-brachial index (ABI) is conventionally derived as the ratio of higher of the 2 systolic ankle blood pressures to the higher brachial pressure (HABI method). Alternatively, ABI may be derived using the lower of the 2 systolic ankle pressures (LABI method). The objective of this study was to assess the utility and difference between 2 techniques in predicting peripheral artery disease (PAD). Participants who underwent both ABI measurement and arteriography from July 2005 to June 2010 were reviewed. Angiographic disease burden was scored semiquantitatively (0=50%, 1=50% to 75%, and 2=75% stenosis of any lower extremity arterial segment), and PAD by angiography was defined as50% stenosis of any 1 lower extremity arterial segment. A combined PAD disease score was calculated for each leg. A total of 130 patients were enrolled (260 limbs). The ABI was0.9 (abnormal) in 68% of patients by HABI method and in 84% by LABI. LABI method had higher sensitivity and overall accuracy to detect PAD compared with the HABI method. Regression analysis showed that an abnormal ABI detected by LABI method is more likely to predict angiographic PAD and total PAD burden compared with HABI. Moreover, abnormal ABI by LABI method had higher sensitivity and accuracy to detect PAD in patients with diabetes and below knee PAD compared with the HABI method. In conclusion, ABI determined by the LABI method has higher sensitivity and is a better predictor of PAD compared with the conventional (HABI) method.

This study assessed the safety of intravenous adenosine infusion during fractional flow reserve (FFR) evaluation of intermediate coronary lesions in severe aortic stenosis (AS). In severe AS, the extent of underlying coronary artery disease (CAD) can be an important determinant for deciding between surgical aortic valve replacement (SAVR) and transcatheter aortic valve replacement (TAVR). Hemodynamic assessment of coronary lesion severity using FFR may reduce the extent of revascularization needed and make TAVR more feasible in higher-risk patients (compared with coronary artery bypass surgery with SAVR).We retrospectively analyzed the demographic, clinical, and hemodynamic parameters of 72 patients with severe AS who underwent FFR procedure with intravenous adenosine infusion for hemodynamic assessment of intermediate coronary artery lesions. Severe AS patients were elderly, predominantly male, and had a high prevalence of peripheral arterial disease, prior myocardial infarction, left ventricular hypertrophy, and chronic kidney disease. Mean aortic valve area in these patients was 0.71 ± 0.24 cm². No patient with severe AS required discontinuation of the adenosine and all patients tolerated the infusion well. We observed a statistically significant reduction in systolic blood pressure (SBP), diastolic blood pressure (DBP), mean arterial pressure (MAP), and heart rate (HR) during adenosine infusion compared with the baseline values. However, no clinically significant adverse events occurred.In elderly patients with severe AS, adenosine infusion is safe and well tolerated during FFR evaluation of intermediate coronary lesions. There was a significantly greater drop in SBP, DBP, MAP, and HR with adenosine infusion as compared with baseline values. This, however, was not associated with clinically significant adverse events.

Usually 25% of the myocardium is replaced by amyloid deposition for symptoms to appear with congestive heart failure being the most common presentation of cardiac amyloidosis. In the clinical workup of patients with diastolic heart failure and myocardial hypertrophy, cardiac amyloidosis is an important differential diagnosis. Once congestive heart failure occurs, the median survival is less than six months in untreated patients, and is the most common cause of death. 2

The effect of dual antiplatelet therapy (DAPT) or oral anticoagulation on long term incidence of acute coronary syndromes (ACS) in patients with coronary artery ectasia (CAE) and no significant occlusive CAD is not well known. We retrospectively analyzed 317 consecutive cases of CAE. CAE patients

Steroid prophylaxis prior to coronary angiography is routine in patients with contrast allergy (CA). We aimed to assess the impact of steroid use in diabetic patients with CA undergoing elective angiography. We retrospectively analyzed records of diabetics with and without CA who underwent

Though percutaneous closure of atrial septal defect (ASD) or patent foramen (PFO) has been available for several years, it has remained controversial due to lack of strong outcomes data and lack of uniform acceptance by the neurology community. We sought to determine nationwide trends in the use of

Pseudoaneurysm formation has been reported in degenerated coronary artery saphenous vein bypass grafts, as well as in native coronary arteries after interventional procedures or blunt trauma. In contrast, pseudoaneurysm formation arising from the anastomotic site of native coronary vessels soon after coronary artery bypass grafting is rare, and neither the clinical presentation of this phenomenon nor its treatment is well described. We present the case of a 63-year-old man, a recent coronary artery bypass grafting patient, who presented with acute coronary syndrome due to a large and expanding pseudoaneurysm of the saphenous vein-to-ramus intermedius artery graft anastomosis. After several attempts, we successfully treated the pseudoaneurysm by means of percutaneous coil embolization. To our knowledge, this is the first report of acute coronary syndrome secondary to a pseudoaneurysm at the coronary artery–saphenous vein graft anastomosis. In addition, this appears to be the first report of the percutaneous treatment of such a pseudoaneurysm by means of coil embolization.

This paper concerns validation of the PATHOGENA version of electron-activated reactors designed to purify contaminated water to make it potable. The basic design of PATHOGENA is a 100-gallon plastic tank batch reactor which houses a vapor-ion plasma (VIP) generator and 1-micron ion-separator (ION-SEP) porous water filter. While the VIP generator splits ambient air into aggressive water treatment agents in the form of charged ions, free electrons, hydroxyl and peroxyl radicals using UV radiation, the ION-SEP filter is designed to eliminate broad-spectrum bacteria and other microbes. The validation process was started with creation of water quality database from: (a) contaminated surface water; (b) EPA/West Virginia Water Quality Standards, and (c) Vienna City Council drinking water. The PATHOGENA purifier was then run 14 days/month from April-September 2014 and samples analyzed for chemical and bacteriological quality. When the results were matched against previous data, PATHOGENA compared favorably with both EPA/West Virginia water quality standards and Vienna City drinking water (R2 = 0.99; p

Background: Current guidelines discourage aortic stenosis (AS) evaluation by direct pressure measurement if echocardiography (echo) is adequate. However several studies show sizable differences between echo and catheterization (cath) lab measurements. Dobutamine Challenge is recommended for

Background: Clinical presentation, natural history of coronary artery ectasia (CAE) and prognostic implications of its anatomic classification of are not well known. Methods: We retrospectively analyzed 376 consecutive cases of CAE and angiographically categorized them using the Markis

Background: Percutaneous coronary intervention (PCI) followed by transcatheter valve replacement is an alternative for patients with severe aortic stenosis (SAS) and coronary artery disease (CAD). In many, the coronaries are calcific and best treated with rotational or orbital atherectomy (RA or OA

Background: Current guidelines discourage aortic stenosis (AS) evaluation by direct pressure measurement if echocardiography (echo) is adequate. However several studies show sizable discrepancies between echo and catheterization (cath) lab measurements. We wanted to investigate the impact of both

Current guidelines discourage aortic stenosis (AS) evaluation by direct pressure measurement if echocardiography (echo) is adequate. However several studies show sizable differences between echo and catheterization (cath) lab measurements. Low flow/ low gradient (LF/LG) severe aortic stenosis (AS)

Current guidelines discourage aortic stenosis (AS) evaluation by direct pressure measurement if echocardiography (echo) is adequate. However several studies show sizable differences between echo and catheterization (cath) lab measurements. Low flow/ low gradient (LF/LG) severe aortic stenosis (AS)

Background: Fluoroscopic radiation has been implicated in reducing the sex ratio (M:F) by potentially damaging the Y chromosome. We examined the effects of exposure to fluoroscopic radiation on gender of offspring of cardiologists across the world.