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Background: Balloon Tipped Temporary Pacemakers (BTTP) are the most used temporary pacemakers; however, they are associated with a risk of dislodgement and thromboembolism. Recently, Temporary Permanent Pacemakers (TPPM) have been increasingly used. Evidence of outcomes with TPPM compared to BTTP remains scarce. Methods: Retrospective, chart review study evaluating all patients who underwent temporary pacemaker placement between 2014 and 2022 (N = 126) in the cardiac catheterization laboratory (CCL) at a level 1 trauma center. Primary outcome of this study is to evaluate the safety profile of TPPM versus BTTP. Secondary objectives include patient ambulation and healthcare utilization in patients with temporary pacemakers. Results: Both groups had similar baseline characteristics distribution including gender, race, and age at temporary pacemaker insertion (p >.05). Subclavian vein was the most common site of access for the TPPM cohort (89.0%) versus the femoral vein in the BTTP group (65.1%). Ambulation was only possible in the TPPM group (55.6%, p <.001). Lead dislodgement, venous thromboembolism, local hematoma, and access site infections were less frequently encountered in the TPPM group (OR = 0.23 [95% CI (0.10‐0.67), p <.001]). Within the subgroup of patients with TPPM, 36.6% of the patients were monitored outside the ICU setting. There was no significant difference in the pacemaker‐related adverse events among patients with TPPM based on their in‐hospital setting. Conclusion: TPPM is associated with a more favorable safety profile compared to BTTP. They are also associated with earlier patient ambulation and reduced healthcare utilization. [ABSTRACT FROM AUTHOR]

Introduction: An arteriovenous fistula (AVF) in patients with end‐stage kidney disease (ESKD) can influence flow states. We sought to evaluate if assessment of aortic stenosis (AS) by transthoracic echocardiographic (TTE) differs in the presence of AVF compared to other dialysis accesses in patients on dialysis. Methods: We identified consecutive ESKD patients on dialysis and concomitant AS from a single center between January 2000 and March 2021. We analyzed TTE parameters of AS severity (velocities, gradients, aortic valve area [AVA]) and hemodynamics (cardiac output [CO], valvuloarterial impedance [Zva]) and compared AS parameters in patients with AVF versus other dialysis access. Results: The cohort included 94 patients with co‐prevalent ESKD and AS; mean age 66 years, 71% male; 43% Black, 24% severe AS. Dialysis access: 53% AVF, 47% others. In the overall cohort, no significant differences were noted between AVF versus non‐AVF in AVA/CO/Zva, but with notable subgroup differences. In mild AS, CO was significantly higher in AVF versus non‐AVF (6.3 vs. 5.2 L/min; p =.04). In severe AS, Zva was higher in the AVF versus non‐AVF (4.6 vs. 3.6 mm Hg/mL/m2). With increasing AS severity in the AVF group, CO decreased, coupled with increase in Zva, likely counterbalancing the net hemodynamic impact of the AVF. Conclusion: Among ESKD patients with AS, TTE parameters of flow states and AS severity differed in those with AVF versus other dialysis accesses and varied with progression in severity of AS. Future longitudinal assessment of hemodynamic parameters in a larger cohort of co‐prevalent ESRD and AS would be valuable. [ABSTRACT FROM AUTHOR]

Purpose: In this review, we examine the intersection of cardiovascular disease (CVD), race/ethnicity, and homelessness/unstable housing—a key social determinant of cardiovascular health. Homelessness has deep roots reflecting structural racism in housing, educational, and economic policies, leading to disproportional representation of Black, Native American, and Hispanic people among the U.S. homeless population. Recent Findings: Increasingly rigorous observational studies detail the disproportionate incidence, prevalence, and mortality of CVD among people experiencing homelessness. Studies of hospital admissions document concerning disparities in procedural CVD care. We summarize current evidence about CVD among people experiencing homelessness. We conducted a new structured review of 27 articles about CVD and homelessness to determine if and how they collected and reported on race/ethnicity and racism. We searched for evidence-based interventions to improve CVD for people experiencing homelessness. Summary: A recent systematic review and additional articles addressing CVD and homelessness found no interventions targeting the intersections of these topics or any that specifically addressed race/ethnicity. We found that 16 of 27 reviewed studies (59%) collected any data on race/ethnicity, but only 5 (19%) reported CVD-specific outcomes by race/ethnicity. We summarize clinical evidence based on expert opinion that, while practical, lacks rigor and does not consider the intersectional impact of race/ethnicity, homelessness, and other factors on people experiencing CVD. Therefore, we conclude that more research and innovation are needed using community-engaged approaches to develop evidence to support improved CVD prevention and management among people experiencing homelessness who identify as Black, Native American, Hispanic, or other people of color. [ABSTRACT FROM AUTHOR]

Background: The prevalence of advanced chronic kidney disease (CKD) is higher in Black than in White Americans. We evaluated CKD progression in Black and White participants and the contribution of biological risk factors. We included the study of lung function (measured by forced vital capacity [FVC]), which is part of the emerging notion of interorgan cross-talk with the kidneys to racial differences in CKD progression.Methods: This longitudinal study included 2175 Black and 2207 White adult Coronary Artery Risk Development in Young Adults (CARDIA) participants. Estimated glomerular filtration rate (eGFR) and urinary albumin-to-creatinine ratio (UACR) were measured at study year 10 (age 27– 41y) and every five years for 20 years. The outcome was CKD progression through no CKD, low, moderate, high, or very high-risk categories based on eGFR and UACR in combination. The association between race and CKD progression as well as the contribution of risk factors to racial differences were assessed in multivariable-adjusted Cox models.Results: Black participants had higher CKD transition probabilities than White participants and more prevalent risk factors during the 20-year period studied. Hazard ratios for CKD transition for Black (vs White participants) were 1.38 from No CKD into ≥ low risk, 2.25 from ≤ low risk into ≥ moderate risk, and 4.49 from ≤ moderate risk into ≥ high risk. Racial differences in CKD progression from No CKD into ≥ low risk were primarily explained by FVC (54.8%), hypertension (30.9%), and obesity (20.8%). In contrast, racial differences were less explained in more severe transitions.Conclusion: Black participants had a higher risk of CKD progression, and this discrepancy may be partly explained by FVC and conventional risk factors. [ABSTRACT FROM AUTHOR]

Background: A hemodynamically significant arteriovenous fistula (AVF) in end‐stage kidney disease (ESKD) causes a high flow state, resulting in pathologic cardiovascular remodeling, and deserves timely clinical recognition. Case: A 55‐year‐old woman with history of ESKD with deceased donor kidney transplant with failing graft function and baseline creatinine of 2.8 mg/dl presented to the clinic with nocturnal cough, orthopnea, dyspnea on exertion and pedal edema. Physical exam was notable for large, aneurysmal right brachial AVF. Transthoracic echocardiography (TTE) revealed left ventricular (LV) enlargement and hypertrophy and elevated cardiac output (CO) of 10 L/min, raising a clinical concern for high‐output heart failure. Decision making: A non‐invasive assessment of the hemodynamic significance of the AVF was performed using a TTE. During temporary occlusion of the AVF, it was determined that about 27% of the resting CO was attributed to the AVF, suggesting hemodynamic significance. Nicoladoni‐Israel‐Branham sign was negative as there was no change in patient's heart rate, but this was potentially attributed to beta‐blockade and chronic loading conditions. She underwent AVF banding and 2‐month later her presenting symptoms resolved, and a TTE showed a decrease in resting CO of 7.6 L/min with normalization of LV size. Conclusion: This case highlights several teaching points. Firstly, in patients with ESKD, a large AVF can contribute to a high CO state resulting in maladaptive cardiovascular remodeling. Secondly, TTE evaluation of the hemodynamic contribution of an AVF can be performed with the application of the Nicoladoni‐Israel‐Branham sign. Finally, some experts recommend pre‐emptive banding or ligation of AVF after successful kidney transplantation as this has been shown to have symptomatic and cardiovascular benefits. [ABSTRACT FROM AUTHOR]

Aortic stenosis with concomitant chronic kidney disease (CKD) represents a clinical challenge. Aortic stenosis is more prevalent and progresses more rapidly and unpredictably in CKD, and the presence of CKD is associated with worse short-term and long-term outcomes after aortic valve replacement. Because patients with advanced CKD and end-stage kidney disease have been excluded from randomized trials, clinicians need to make complex management decisions in this population that are based on retrospective and observational evidence. This statement summarizes the epidemiological and pathophysiological characteristics of aortic stenosis in the context of CKD, evaluates the nuances and prognostic information provided by noninvasive cardiovascular imaging with echocardiography and advanced imaging techniques, and outlines the special risks in this population. Furthermore, this statement provides a critical review of the existing literature pertaining to clinical outcomes of surgical versus transcatheter aortic valve replacement in this high-risk population to help guide clinical decision making in the choice of aortic valve replacement and specific prosthesis. Finally, this statement provides an approach to the perioperative management of these patients, with special attention to a multidisciplinary heart-kidney collaborative team-based approach. [ABSTRACT FROM AUTHOR]

Background: Infective endocarditis rarely causes mitral valve stenosis. When present, it has the potential to cause severe hemodynamic decompensation and death. There are only 15 reported cases in the literature of mitral prosthetic valve bacterial endocarditis causing stenosis by obstruction. This case is even more unusual due to the mechanism by which functional mitral stenosis occurred.Case Presentation: We report a case of a 23-year-old white woman with a history of intravenous drug abuse who presented with acute heart failure. Transthoracic echocardiography failed to show valvular vegetation, but high clinical suspicion led to transesophageal imaging that demonstrated infiltrative prosthetic valve endocarditis causing severe mitral stenosis. Despite extensive efforts from a multidisciplinary team, she died as a result of her critical illness.Conclusions: The discussion of this case highlights endocarditis physiology, the notable absence of stenosis in modified Duke criteria, and the utility of transesophageal echocardiography in clinching a diagnosis. It advances our knowledge of how endocarditis manifests, and serves as a valuable lesson for clinicians treating similar patients who present with stenosis but no regurgitation on transthoracic imaging, as a decision to forego a transesophageal echocardiography could cause this serious complication of endocarditis to be missed. [ABSTRACT FROM AUTHOR]

Background: Reperfusion after coronary occlusion (myocardial infarction, MI), as in Wellens' syndrome, is often represented on ECG as T-wave inversion in the leads overlying the affected myocardial wall(s). As an extension of this logic, reperfusion of the posterior wall should manifest on right precordial leads (which are opposite the posterior wall) as enlarged T-waves.Objective: We sought to determine whether T-wave amplitude (TWa) in leads V2 and V3 after reperfusion in posterior MI (PMI) is greater than in patients without PMI.Methods: Review of ECGs from patients with ST elevation MI of the left circumflex or right coronary artery with post-procedure thrombolysis in MI (TIMI) flow >0 between 2007 and 2009. Blinded experts reviewed admission ECGs to determine the presence of PMI and measure TWa before and after reperfusion. Maximum TWa in V2 and V3 and the difference between maximum and admission V2 and V3 TWa were compared between those with and without PMI.Results: Of 72 patients, 48 had PMI. Values expressed are medians and IQRs. Maximum TWa after reperfusion was greater in PMI than in non-PMI in V2 (5.00 mm (3.5 to 8.25) vs 3.9 mm (2.75 to 5.5), p=0.04), but not in V3 (4.0 mm (2 to 5.5) vs 3.0 mm (1.75 to 4), p=0.09). The increase in TWa in V2 and V3 after reperfusion was greater in PMI compared with non-PMI: (V2, 3.4 mm (2 to 5.25) vs 1.25 mm (-0.25 to 2), p=0.0005; V3, 2 mm (-0.5 to 3.25) vs 0.25 mm (-1 to 1.75), p=0.03).Conclusions: Reperfusion of the posterior wall results in higher right precordial TWa, and an even greater increase in TWa, as measured in leads V2 and V3. This observation has important implications for emergency physicians to accurately identify recent posterior infarction in patients who may be symptom free on presentation but at risk of reocclusion. [ABSTRACT FROM AUTHOR]

Background: ST elevation (STE) on the electrocardiogram (ECG) may be due to acute myocardial infarction (AMI) or other nonischemic pathologies such as left ventricular aneurysm (LVA). The objective of this study was to validate 2 previously derived ECG rules to distinguish AMI from LVA. The first rule states that if the sum of T-wave amplitudes in leads V1 to V4 divided by the sum of QRS amplitudes in leads V1 to V4 is greater than 0.22, then acute ST-segment elevation MI is predicted. The second rule states that if any 1 lead (V1-V4) has a T-wave amplitude to QRS amplitude ratio greater than or equal to 0.36, then acute ST-segment elevation MI is predicted.Methods: This was a retrospective analysis of patients with AMI (n = 59) and LVA (n = 16) who presented with ischemic symptoms and STE on the ECG. For each ECG, the T-wave amplitude and QRS amplitude in leads V1 to V4 were measured. These measurements were applied to the 2 ECG rules; and sensitivity, specificity, and accuracy in predicting AMI vs LVA were calculated.Results: For rule 1 (sum of ratios in V1-V4), sensitivity was 91.5%, specificity was 68.8%, and accuracy was 86.7% in predicting AMI. For rule 2 (maximum ratio in V1-V4), sensitivity was 91.5%, specificity was 81.3%, and accuracy was 89.3% in predicting AMI.Conclusions: When patients present to the emergency department with ischemic symptoms and the differential diagnosis for STE on the ECG is AMI vs LVA, these 2 ECG rules may be helpful in differentiating these 2 pathologies. Both rules are highly sensitive and accurate in predicting AMI vs LVA. [ABSTRACT FROM AUTHOR]