Impact of TAVR on patients with severe aortic stenosis and liver cirrhosis.

We sought to assess the impact of transcatheter aortic valve replacement (TAVR) on patients that have both severe aortic stenosis (SAS) and liver cirrhosis on mortality at 365 days after index event. We identified 19,210 patients that met inclusion criteria using the TriNetX database, consisting of data from 58 large healthcare organizations collected between 1 January 2010 and 24 February 2022. Of those patients, 1,283 (3.2%) had SAS with liver cirrhosis that had a TAVR, and 19,210 (96.8%) had SAS with liver cirrhosis that did not have a TAVR. We analyzed the data to compare all-cause mortality at 365 days using the TriNetX web platform. In addition, we conducted propensity score matching (PSM) to reduce the effects of confounders between the two groups. Patients with SAS and liver cirrhosis that had a TAVR were older (72.4 ± 9.7 vs. 68.0 ± 11.8, P < 0.001), and they had higher rates of heart failure (71.2 vs. 34.5%, P < 0.001), coronary artery disease (72.0 vs. 31.2%, P < 0.001), diabetes (52.5 vs. 41.2%, P < 0.001), and chronic kidney disease (43.8 vs. 30.1%, P < 0.001) compared with patients with SAS and liver cirrhosis without TAVR. PSM created two well-matched cohorts of 1,269 patients each. The TAVR group had a lower mortality rate compared with the no TAVR group (22.5 vs. 34.8%, P < 0.0001) at 365 days. This was confirmed using a log-rank test. Given these data, it appears that there is a mortality benefit associated with TAVR in patients with SAS and liver cirrhosis.NEW & NOTEWORTHY Risk calculators used to predict unfavorable surgical outcomes could flag a patient as ineligible for transcatheter aortic valve replacement (TAVR) based on the presence of liver cirrhosis. Our data analysis suggests that performing a TAVR to treat severe aortic stenosis in patients with liver cirrhosis could decrease their mortality risk as opposed to not performing a TAVR. Careful consideration should be given to this patient population to ensure the best quality of life and long-term outcome.

Convolution Neural Network Algorithm for Shockable Arrhythmia Classification Within a Digitally Connected Automated External Defibrillator.

Background Diagnosis of shockable rhythms leading to defibrillation remains integral to improving out-of-hospital cardiac arrest outcomes. New machine learning techniques have emerged to diagnose arrhythmias on ECGs. In out-of-hospital cardiac arrest, an algorithm within an automated external defibrillator is the major determinant to deliver defibrillation. This study developed and validated the performance of a convolution neural network (CNN) to diagnose shockable arrhythmias within a novel, miniaturized automated external defibrillator. Methods and Results There were 26 464 single-lead ECGs that comprised the study data set. ECGs of 7-s duration were retrospectively adjudicated by 3 physician readers (N=18 total readers). After exclusions (N=1582), ECGs were divided into training (N=23 156), validation (N=721), and test data sets (N=1005). CNN performance to diagnose shockable and nonshockable rhythms was reported with area under the receiver operating characteristic curve analysis, F1, and sensitivity and specificity calculations. The duration for the CNN to output was reported with the algorithm running within the automated external defibrillator. Internal and external validation analyses included CNN performance among arrhythmias, often mistaken for shockable rhythms, and performance among ECGs modified with noise to mimic artifacts. The CNN algorithm achieved an area under the receiver operating characteristic curve of 0.995 (95% CI, 0.990-1.0), sensitivity of 98%, and specificity of 100% to diagnose shockable rhythms. The F1 scores were 0.990 and 0.995 for shockable and nonshockable rhythms, respectively. After input of a 7-s ECG, the CNN generated an output in 383±29 ms (total time of 7.383 s). The CNN outperformed adjudicators in classifying atrial arrhythmias as nonshockable (specificity of 99.3%-98.1%) and was robust against noise artifacts (area under the receiver operating characteristic curve range, 0.871-0.999). Conclusions We demonstrate high diagnostic performance of a CNN algorithm for shockable and nonshockable rhythm arrhythmia classifications within a digitally connected automated external defibrillator. Registration URL: https://clinicaltrials.gov/ct2/show/NCT03662802; Unique identifier: NCT03662802.

Double-Valve Heart Disease and Glomerulonephritis Consequent to Abiotrophia defectiva Endocarditis.

Abiotrophia defectiva, a nutritionally deficient streptococcus, is a rare cause of infective endocarditis. It has been associated with hemophagocytic syndrome. We present the first case of A. defectiva infective endocarditis that led to antineutrophil cytoplasmic antibody-associated glomerulonephritis. The patient was a 55-year-old man whose endocarditis affected the mitral and aortic valves. His course was complicated by atrial fibrillation, stroke, and glomerulonephritis. He was successfully treated with antibiotics and dual valve replacement.

Coronary Artery Involvement in Segmental Arterial Mediolysis: A Case Report.

Segmental arterial mediolysis (SAM) is an increasingly recognized disorder affecting small- to medium-sized muscular arteries. A patient with SAM involving the visceral arteries who was also found to have multivessel coronary artery involvement is described. The patient underwent a battery of biochemical, imaging, and genetic tests to exclude other vasculitides and connective tissue disorders. The aim is to shed light on the potential for SAM to affect the coronary arteries and recommend screening of the coronary arteries of patients with SAM. © RSNA, 2019.

Association between loop diuretic dose administered in first 24 hours of heart failure admissions and length of hospital stay.

Background: Heart failure remains one of the highest disease burdens in the USA and worldwide. Heart failure guidelines recommend starting with a higher or equal to home dose of loop diuretics in acute decompensated heart failure admissions. To date, no study has been published assessing the effect of first 24 h loop diuretic dose on length of hospital stay. Objective: We hypothesize that the higher the first 24 h loop diuretic dose to home dose ratio, the shorter the length of hospital stay will be. Design/Methods: Retrospective chart review was conducted in a community teaching hospital and included patients discharged between February, 2015 and April, 2016, with a primary diagnosis of acute decompensated heart failure. The primary outcome was the length of hospital stay. The study population was divided into three groups based on the hospital to home dose ratio. Results: Among the 609 patients included in the data analysis, there was no statistically significant difference in length of hospital stay among the study groups. Inpatient mortality and incidence of acute kidney injury were highest in the group that received a first-24-hours hospital dose that was less than their home dose. Percentage of weight loss and 30-day readmission were not statistically significantly different among the groups. Conclusion: There was no association between the dose ratio and length of hospital stay in each group. Additional randomized controlled trials need to be conducted to provide more evidence and guidance for dosing loop diuretics in acute decompensated heart failure admissions.

Exercise-induced syncope in a sedentary woman.

Vasovagal (neurocardiogenic) syncope, a subtype of reflex syncope, has many well-known triggers. However, we found no previous report of vasovagal exercise-induced syncope in a sedentary person. We present the case of a 35-year-old sedentary woman who experienced vasovagal syncope as she underwent an exercise stress test. Results of evaluations, including resting and stress electrocardiography and echocardiography, were normal. Her presentation is highly unusual: syncope has typically not been associated with exercise except in young athletes, people with structural heart abnormalities, or people with a prolonged QT syndrome. To our knowledge, this is the first report of vasovagal syncope associated with exercise in a sedentary patient who had normal cardiac and electrophysiologic function. We suggest possible physiologic mechanisms and diagnostic strategies.