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Background The coronavirus disease 2019 (COVID-19) pandemic has impacted many aspects of ST-segment elevation myocardial infarction (STEMI) care, including timely access to primary percutaneous coronary intervention (PPCI). Objectives The goal of the NACMI (North American COVID-19 and STEMI) registry is to describe demographic characteristics, management strategies, and outcomes of COVID-19 patients with STEMI. Methods A prospective, ongoing observational registry was created under the guidance of 3 cardiology societies. STEMI patients with confirmed COVID+ (group 1) or suspected (person under investigation [PUI]) (group 2) COVID-19 infection were included. A group of age- and sex-matched STEMI patients (matched to COVID+ patients in a 2:1 ratio) treated in the pre-COVID era (2015 to 2019) serves as the control group for comparison of treatment strategies and outcomes (group 3). The primary outcome was a composite of in-hospital death, stroke, recurrent myocardial infarction, or repeat unplanned revascularization. Results As of December 6, 2020, 1,185 patients were included in the NACMI registry (230 COVID+ patients, 495 PUIs, and 460 control patients). COVID+ patients were more likely to have minority ethnicity (Hispanic 23%, Black 24%) and had a higher prevalence of diabetes mellitus (46%) (all p, Central Illustration

Purpose Medical school simulations are often designed for a limited number of students to maximize engagement and learning. To ensure that all first-year medical students who wished to join had an opportunity to participate, we designed a novel method for larger groups. Patients and methods We devised a low technology "Orchestra Leader's" chart approach to prominently display students' roles, chosen by lottery. During simulation, the chart was mounted on an intravenous pole and served as a group organizational tool. A course instructor prompted students using the chart to accomplish the course objectives in a logical order. Real-life cardiologists and gastroenterologists provided the students with expert subspecialty consultation. We analyzed 125 anonymous student evaluation ratings for 3 years (2017-2019) with a range of 8 to 19 students per laboratory session. Results Our 2017-2019 larger group sessions were all rated as excellent (1.26, Mean, SD ±.510) on the Likert scale where 1.0 is excellent and 5.0 is poor. There were no statistically significant differences in overall ratings among the 2017, 2018 and 2019 sessions. The subspecialists were uniformly rated as excellent. Verbatim free-text responses demonstrated resounding student appreciation for the role assignment by lottery method. Conclusion We designed a novel, "Orchestra Leader's" chart approach for accommodating larger groups in a multidisciplinary simulation laboratory using role assignment by lottery, roles depicted on an organizational chart, and expert instructor prompting. Our consistently excellent ratings suggest that our methods are useful for achieving well-rated larger group simulation laboratories.

The coronavirus disease 2019 (COVID-19) pandemic has prompted unprecedented physical and emotional challenges in the lives of our health care community. Fellows-in-training (FITs) are at the frontlines of the medical response, balancing programmatic changes to meet urgent patient care demands with

Background Coronary fistula are rare and often present in early adulthood with symptoms of right heart overload from left to right shunting or ischaemia in the distal coronary bed due to coronary steal. Case summary A 73-year-old lady with prior history of supraventricular tachycardia, dyslipidemia and a right coronary artery (RCA) to coronary sinus (CS) fistula, presented with progressive angina. She did not have evidence of ischaemia in the RCA territory on nuclear imaging, and cardiac computed tomography (CT) did not show coronary artery disease but revealed a significantly dilated CS and coronary venous tree. She was found to have CS ostial stenosis and, under transesophageal echocardiographic guidance, underwent successful balloon angioplasty of the CS ostium, with decompression of the coronary venous circulation and resolution of her angina. Discussion Coronary fistula draining to the CS are rare, and association with CS ostial stenosis has been reported very infrequently. CS ostial stenosis can cause elevated coronary venous pressure, leading to decreased global coronary perfusion and symptoms of angina or heart failure. Previous case reports of coronary fistula and CS ostial stenosis were treated with either medical therapy or surgery, and our case is the first to our knowledge to report successful percutaneous treatment.

A young woman with mandibuloacral dysplasia, a syndrome on the progeria spectrum with accelerated vascular calcification and calcific valve stenosis, presented with symptomatic severe aortic stenosis. She underwent transcatheter aortic valve replacement with a balloon-expandable valve, and her exertional symptoms improved significantly. (Level of Difficulty: Intermediate.), Central Illustration

Women continue to be underrepresented in cardiovascular studies, while heart disease remains a major cause of mortality and morbidity in women as in men. In this review, we explore the differences in presentation, characteristics, and treatment of women presenting for coronary intervention for stable coronary disease or acute coronary syndromes. Recent, large meta-analyses of clinical trials have shown that the sex differences in outcomes after non-ST-elevation acute coronary syndrome are attenuated after thorough adjustment for baseline comorbidities, but worse outcomes and more complications are still seen in women after percutaneous coronary intervention. Young women presenting for coronary angiogram are particularly at risk. Biologic factors, differences in presentation, and care disparities all contribute to worse outcomes after MI and PCI in women compared to men; both health behaviors and healthcare system behaviors should and can be modified to improve morbidity and survival in women with heart disease.

Objective To evaluate the impact of COVID‐19 pandemic migitation measures on of ST‐elevation myocardial infarction (STEMI) care. Background We previously reported a 38% decline in cardiac catheterization activations during the early phase of the COVID‐19 pandemic mitigation measures. This study extends our early observations using a larger sample of STEMI programs representative of different US regions with the inclusion of more contemporary data. Methods Data from 18 hospitals or healthcare systems in the US from January 2019 to April 2020 were collecting including number activations for STEMI, the number of activations leading to angiography and primary percutaneous coronary intervention (PPCI), and average door to balloon (D2B) times. Two periods, January 2019–February 2020 and March–April 2020, were defined to represent periods before (BC) and after (AC) initiation of pandemic mitigation measures, respectively. A generalized estimating equations approach was used to estimate the change in response variables at AC from BC. Results Compared to BC, the AC period was characterized by a marked reduction in the number of activations for STEMI (29%, 95% CI:18–38, p

Purpose Medical school simulations are often designed for a limited number of students to maximize engagement and learning. To ensure that all first-year medical students who wished to join had an opportunity to participate, we designed a novel method for larger groups. Patients and Methods We devised a low technology “Orchestra Leader’s” chart approach to prominently display students’ roles, chosen by lottery. During simulation, the chart was mounted on an intravenous pole and served as a group organizational tool. A course instructor prompted students using the chart to accomplish the course objectives in a logical order. Real-life cardiologists and gastroenterologists provided the students with expert subspecialty consultation. We analyzed 125 anonymous student evaluation ratings for 3 years (2017–2019) with a range of 8 to 19 students per laboratory session. Results Our 2017–2019 larger group sessions were all rated as excellent (1.26, Mean, SD ±.510) on the Likert scale where 1.0 is excellent and 5.0 is poor. There were no statistically significant differences in overall ratings among the 2017, 2018 and 2019 sessions. The subspecialists were uniformly rated as excellent. Verbatim free-text responses demonstrated resounding student appreciation for the role assignment by lottery method. Conclusion We designed a novel, “Orchestra Leader’s” chart approach for accommodating larger groups in a multidisciplinary simulation laboratory using role assignment by lottery, roles depicted on an organizational chart, and expert instructor prompting. Our consistently excellent ratings suggest that our methods are useful for achieving well-rated larger group simulation laboratories.

Background Patient‐reported outcome metrics ( PRO s) quantify important outcomes in clinical trials and can be sensitive measures of patient experience in clinical practice. Currently, there is no validated disease‐specific PRO for adults with congenital heart disease ( ACHD ). Methods and Results We conducted a preliminary psychometric validation of a novel ACHD PRO . ACHD patients were recruited prospectively from 2 institutions and completed a series of questionnaires, a physician health assessment, and a 6‐minute walk test. Participants returned to complete the same questionnaires and assessment 3 months±2 weeks later. We tested the internal consistency and test–retest reliability by comparing responses among clinically stable patients at the 2 study visits. We assessed convergent and divergent validity by comparison of ACHD PRO responses to existing validated questionnaires. We assessed responsiveness by comparison with patient‐reported clinical change. One hundred three patients completed 1 study visit and 81 completed both. The ACHD PRO demonstrated good internal consistency in each of its 5 domains (Cronbach's α: 0.87; 0.74; 0.74; 0.90; and 0.89, respectively) and in the overall summary score (0.92). Test–retest reliability was good with an intraclass correlation ≥0.73 for all domains and 0.78 for the Summary Score. The ACHD PRO accurately assessed domain concepts based on comparison with validated standards. Preliminary estimates of responsiveness suggest sensitivity to clinical status. Conclusions These studies provide initial support for the validity and reliability of the ACHD PRO . Further studies are needed to assess its sensitivity to changes in clinical status.

Coronary computed tomography (CT) angiography is often performed in adults with coarctation of the aorta (CoA) for anatomic assessment. As this population ages, assessment of atherosclerotic cardiovascular disease burden is important. Thus, quantitative and qualitative coronary artery calcium (CAC) scores were assessed for patients with CoA ≥16 years of age, who were seen at a referral center. CoA patients had either coronary CT angiography or chest CT with interpretable coronary information performed for clinical indications (follow-up, preoperative, or for symptoms) from 2004 to 2017. Qualitative CAC was determined based on low-dose CT and lung cancer screening protocols. Quantitative CAC scores were compared with an age- and gender-matched control cohort of patients chosen from an emergency department database of patients who received coronary CT angiography for chest pain evaluation. Atherosclerotic cardiovascular disease 10-year predicted risk scores were calculated for both cohorts. Out of 131 patients with CoA (mean age 46.1 ± 15.3 years), 22 patients (17%) had multivessel atherosclerotic disease on qualitative assessment. In the subgroup of patients ≥40 years, those with CoA were more likely to have a quantitative CAC score ≥400 compared with those without CoA (14% vs 4%, p = 0.02). Median atherosclerotic cardiovascular disease risk score was 8% (interquartile range 2% to 12%) for CoA patients ≥40 years, and 5% (interquartile range 2% to 9%) for patient without CoA ≥40 years. In conclusion, we determined that CoA patients have subclinical atherosclerosis identifiable on CT in high rates when compared with patients without CoA. Atherosclerotic cardiovascular disease should be assessed in these patients for prevention and treatment.

Background: Thienopyridine plus aspirin beyond 1 year after coronary stenting reduces myocardial infarction (MI) risk and increases bleeding risk in comparison with aspirin alone. The hazard associated with late thienopyridine discontinuation and risk factors for MI after discontinuation are poorly defined. Methods: In the DAPT Study (Dual Antiplatelet Therapy), after percutaneous coronary intervention and 12 months of thienopyridine (clopidogrel or prasugrel) plus aspirin, eligible patients remained on aspirin and were randomly assigned to continued thienopyridine versus placebo for 18 months. At 30 months, patients stopped the study drug and were observed for 3 months. Cumulative incidence of MI was assessed over 3 months after randomization (months 12–15) and 3 months after study drug discontinuation (months 30–33). The MI hazard for each of these periods was assessed across randomized treatment arms and by DAPT score values Results: Among the 11 648 randomly assigned patients, the monthly cumulative incidence of MI was lower with continued thienopyridine versus placebo at 12 to 15 months (0.12% versus 0.37%, P P =0.02, in patients not treated with paclitaxel-eluting stents), and higher at 30 to 33 months (0.30% versus 0.15%, P =0.013, in all patients; in patients without paclitaxel-eluting stents, 0.18% versus 0.17%, P =0.91). The majority of MIs in both time periods (74% and 76%) were not related to stent thrombosis. After multivariable adjustment, treatment arm independently predicted MI at months 12 to 15 ( P P =0.011). During months 12 to 15, patients with DAPT scores P P =0.012, for scoresP =0.064). Conclusions: Discontinuing thienopyridine after either 12 or 30 months is associated with an early increase in MI risk, mainly unrelated to stent thrombosis; the magnitude of risk is highest in the earlier time frame, and lower in patients not treated with paclitaxel-eluting stents. Although higher DAPT scores identify patients with greater absolute ischemic benefit (relative to bleeding harm) with continued thienopyridine therapy, discontinuation at 12 months increases MI hazard regardless of DAPT score group. Clinical Trial Registration: URL: http://www.clinicaltrials.gov . Unique identifier: NCT00977938.

Aims We sought to identify factors associated with major adverse events (MAE) after cardiac catheterization in adolescents and adults with congenital heart disease (CHD), and create the first model to individualize risk discussions in this growing population. Methods and results Improving Pediatric and Adult Congenital Treatment (IMPACT), a National Cardiovascular Data Registry, contains congenital catheterization data from over 87 hospitals in the United States. Demographics, pre-procedure, and procedural variables were collected for patients over age 10. Multivariable logistic regression was used to identify significant predictors of MAE, a composite of death, urgent surgery or procedure due to a catheterization complication, transfusion, embolic stroke, tamponade, extracorporeal membrane oxygenation or ventricular assist device placement, and device embolization, malposition or thrombosis requiring surgical intervention. A risk score was built based on the effect sizes of each predictor and validated in a split sample. A MAE occurred in 686 (2.5%) of the 27 293 index procedures meeting inclusion criteria. The independent multivariate predictors of MAE were older age, pre-procedural anticoagulation use, renal disease, lower haemoglobin, lower oxygen saturation, non-elective procedure, higher index procedure risk and having had no prior cardiac procedures. Being underweight or overweight had borderline significance and was added to the model. The C-statistic for the model was robust at 0.787 in the derivation and 0.773 in the validation cohort. Conclusion The factors predicting adverse events after cardiac catheterization in adolescents and adults with CHD are different than in the general population. Validation of this model in other national or multi-institutional datasets is the next step.

Cardiovascular disease is the most common cause of pregnancy-related mortality in countries with medium or higher human development index (HDI).1 2 In parallel, medical advancements in the treatment of cardiovascular disease have allowed for more women with structural and congenital heart disease to survive and reach childbearing age, and the number of pregnancies in women with congenital and acquired valvular or ischaemic heart disease is increasing.1 Women with valvular heart disease (VHD) are important to identify as the haemodynamic burden of pregnancy may be particularly difficult for them to tolerate. Starting in the first trimester, as early as 6-week to 8-week gestation, the plasma volume increases (in part due to activation of the renin-angiotensin system) as does the cardiac output, peaking in the second trimester; heart rate continues to increase into the third trimester.3 These shifts lead to an increased risk of heart failure symptoms and arrhythmias in pregnant women with VHD. Given the rapid rise in systemic vascular resistance and significant fluid shifts shortly after delivery, the early post-partum phase is also a time when women with VHD must be followed closely. In this issue, Ducas and colleagues attempt to clarify both the maternal and fetal outcomes of pregnancies in women with significant VHD from countries with medium or higher HDI by performing a systemic review and meta-analysis.4 Sufficiently robust data to assess both maternal and fetal outcomes were found only for women with mitral stenosis (MS) and aortic stenosis (AS). As expected, the rate of adverse maternal events was highest in pregnant women with severe MS and AS; however maternal and fetal adverse events were also common in women with moderate MS and AS. The outcomes of interest included all-cause maternal mortality up to 6 weeks post-partum, stillbirth (after 20 weeks of gestational age) …

The risk of major adverse cardiac and cerebrovascular events (MACCE) in subjects who interrupt temporarily or permanently thienopyridine therapy in the first 6 months after percutaneous coronary intervention (PCI) remains uncertain. In the dual antiplatelet therapy (DAPT) study subjects were enrolled within 72 hours of PCI and treated with aspirin and a thienopyridine for 12 months before being randomized to continued thienopyridine versus placebo. This analysis focuses on the 12-month period before randomization. Thienopyridine interruptions of greater than 24 hours, occurring in the first 6 months after PCI were evaluated. The incidence of MACCE and moderate or severe bleeding occurring within 12 months after PCI were compared between subjects with and without interruptions. Among 23,002 subjects, the incidence of interruption of thienopyridine was 5.1% (n = 1,173). Compared with subjects who adhered to treatment, subjects with an interruption had a higher incidence of MACCE (6.1% vs 4.3%, p = 0.005), death (2.2% vs 1.4%, p = 0.02), myocardial infarction (3.8% vs 2.7%, p = 0.03), and bleeding (3.1% vs 2.2%, p = 0.04) at 12 months. After adjusting for baseline characteristics, interruptions were associated with MACCE (adjusted odds ratio 1.3, 95% confidence interval 1.0, 1.7, p = 0.04) and had a borderline association with subsequent bleeding (adjusted odds ratio 1.4, 95% confidence interval 1.0, 2.0, p = 0.05). In conclusion, interruption of thienopyridine in the first 6 months after PCI occurs not infrequently and is associated with an increased risk of MACCE and subsequent bleeding between the time of interruption and 12 months after PCI.

Background: Studies demonstrate that women physicians are less likely than men to be full professors. Comprehensive evidence examining whether sex differences in faculty rank exist in academic cardiology, adjusting for experience and research productivity, is lacking. Therefore, we evaluated for sex differences in faculty rank among a comprehensive, contemporary cohort of US cardiologists after adjustment for several factors that impact academic advancement, including measures of clinical experience and research productivity. Methods: We identified all US cardiologists with medical school faculty appointments in 2014 by using the American Association of Medical Colleges faculty roster and linked this list to a comprehensive physician database from Doximity, a professional networking website for doctors. Data on physician age, sex, years since residency, cardiology subspecialty, publications, National Institutes of Health grants, and registered clinical trials were available for all academic cardiologists. We estimated sex differences in full professorship, adjusting for these factors and medical school–specific fixed effects in a multivariable regression model. Results: Among 3810 cardiologists with faculty appointments in 2014 (13.3% of all US cardiologists), 630 (16.5%) were women. Women faculty were younger than men (mean age, 48.3 years versus 53.5 years, P P P =0.77), and were less likely to have a registered clinical trial (percentage with at least 1 clinical trial, 8.9% versus 11.1%; P =0.10). Among 3180 men, 973 (30.6%) were full professors in comparison with 100 (15.9%) of 630 women. In adjusted analyses, women were less likely to be full professors than men (adjusted odds ratio, 0.63; 95% confidence interval, 0.43–0.94; P =0.02; adjusted proportions, 22.7% versus 26.7%; absolute difference, –4.0%; 95% confidence interval, –7.5% to –0.7%). Conclusions: Among cardiology faculty at US medical schools, women were less likely than men to be full professors after accounting for several factors known to influence faculty rank.

The population of adults with tetralogy of Fallot (TOF) is growing, and it is not known how the changes in age distribution, treatment strategies, and prevalence of co-morbidities impact their interaction with the health care system. We sought to analyze the frequency and reasons for hospital admissions over the past decade. We extracted serial cross-sectional data from the United States Nationwide Inpatient Sample on hospitalizations including the diagnostic code for TOF from 2000 to 2011. From 2000 to 2011, there were 20,545 admissions for subjects with TOF, with a steady increase in annual number. The most common primary admission diagnoses were heart failure (HF; 17%), arrhythmias (atrial 10% and ventricular 6%), pneumonia (9%), and device complications (7%). The rates of co-morbidities increased significantly, particularly diabetes (4.5% to 8.1%), obesity (2.1% to 6.5%), hypertension, and renal disease. The number of pulmonic valve replacements increased (6.8% to 11.3% of TOF admissions, p0.001), with an increase in median age at surgery from 16 to 19 years old (p = 0.036). The cost per TOF admission was more than double that of noncongenital HF admissions and rose significantly, reaching $21,800 ± 46,000 in 2011. In conclusion, hospitalized patients with TOF have become significantly more medically complex and are growing in number. The increase in the prevalence of obesity, hypertension, and diabetes in this young population supports the need for prevention efforts focused on modifiable risk factors, in addition to HF and arrhythmia treatment. The increase in cost of care calls for further analysis of areas in which efficiency can be increased to ensure high quality of care and lifelong follow-up of patients with TOF.

Background— There is a lack of objective data on the symptoms characterizing disease activity among adults with congenital heart disease (ACHD). The purpose of this study was to elicit the most important symptoms from patients across the spectrum of ACHD and to examine whether reported symptoms were similar across the spectrum of ACHD as a foundation for creating a patient-reported outcome measure(s). Methods and Results— We constructed a 39-item survey using input from physicians specializing in ACHD to assess the symptoms patients associate with disease activity. Patients (n=124) prospectively completed this survey, and the results were analyzed based on underlying anatomy and disease complexity. A confirmatory cohort of patients (n=40) was then recruited prospectively to confirm the validity of the initial data. When grouped based on underlying anatomy, significant differences in disease-related symptom rankings were found for only 6 of 39 symptoms. Six symptoms were identified which were of particular significance to patients, regardless of underlying anatomy. Patients with anatomy of great complexity experienced greater overall symptom severity than those with anatomy of low or moderate complexity, attributable exclusively to higher ranking of 5 symptoms. The second patient cohort had symptom experiences similar to those of the initial cohort, differing in only 5 of 39 symptoms. Conclusions— This study identified 6 symptoms relevant to patients across the spectrum of ACHD and remarkable homogeneity of patient experience, suggesting that a single disease-specific patient-reported outcome can be created for quality and outcome assessments.

There are several congenital diagnoses, most with a wide spectrum of defects, that lead to univentricular physiology (Table 28.1). They can be broadly defined into three categories based on the morphology (right, left, or indeterminate) of the predominant ventricle. The defects most likely to lead to single ventricle repair include hypoplastic left heart syndrome (HLHS), tricuspid atresia, double inlet left ventricle, and defects with a straddling atrioventricular valve (such as an unbalanced atrioventricular canal defect). Less often, pulmonary atresia with intact ventricular septum (with a small RV or RV-dependent coronary circulation), double outlet right ventricle, and Ebstein anomaly may require single ventricle repair. The most common type of univentricular heart at birth is HLHS, with an estimated incidence of 0.2–0.4 per 1000 live births [1, 2] followed by tricuspid atresia (TA) (0.06–0.08 per 1000 live births). In adults, TA is more common than HLHS, as the latter carries a higher pediatric mortality. Incidence is likely to increase, especially in developed countries, as in utero and neonatal interventional options become more available. The incidence of some univentricular subtypes (HLHS in particular) is higher in siblings than in the general population and is thus thought to have a strong genetic component.

ObjectiveThe prevalence of heart failure (HF) among adult patients with congenital heart disease (ACHD) is rising. Right ventricle (RV) exercise reserve and its relationship to outcomes have not been characterised. We aim to evaluate the prognostic impact of impaired RV reserve in an ACHD population referred for cardiopulmonary exercise testing (CPET).MethodsThis retrospective study evaluates patients with ACHD who underwent CPET (n=147) with first-pass radionuclide ventriculography at a single tertiary care centre. RV reserve was categorised as normal, mild to moderately or severely impaired. The primary composite clinical outcome included clinical right HF, arrhythmia, transplantation or death.ResultsPatients were median age 41±13 years, 50% were female and median follow-up was 1.1 (IQR: 0.7–2.0) years. Exercise RV reserve was impaired in 103 patients (70%), of whom 32% were asymptomatic. Resting RV systolic function poorly predicted RV reserve, with 52% of patients with severe impairment having a qualitatively normal echocardiographic assessment. The severely impaired reserve group had lower peak oxygen consumption (VO2)(17.2 vs 22.5 mL/kg/min, p2, age, sex, RV pathology, QRS duration, New York Heart Association class, resting RV ejection fraction and RV dilation by echocardiography or MRI (HR 3.7, 95% CI 1.1 to 13.0, p=0.039).ConclusionImpaired RV reserve, occurred in asymptomatic patients, was not well predicted by resting systolic function assessment, and strongly predicted adverse cardiovascular outcomes.

We aimed to evaluate atherosclerotic cardiovascular disease (ASCVD) risk estimates and guideline-based statin use for primary prevention of ASCVD in adults with congenital heart disease (ACHD). This was a case-controlled, retrospective study of 248 cases and 744 age- and gender-matched controls at a tertiary care referral center. ASCVD risk scores were calculated and used to assess indication for statin treatment for primary prevention per the 2013 American College of Cardiology and American Heart Association guideline on assessment of cardiovascular risk. There were no differences in average 10-year ASCVD risk scores between ACHD cases (4.6% ± 6.6%) and matched controls (5.1% ± 6.7%, p = 0.32). ACHD cases had lower total cholesterol (183 ± 38 vs 192.6 ± 35.3 mg/dL, p 0.001) and were less likely to smoke (8.1% vs 14.6%, p = 0.008), yet had lower high density lipoprotein (52.6 ± 17.2 vs 55.3 ± 17.1 mg/dL, p = 0.03) and higher hypertension rates (38.7% vs 28.5%, p = 0.003). However, only 42.3% ACHD cases with a primary prevention statin indication were appropriately prescribed therapy as compared with 59.0% of controls (p = 0.04). In conclusion, ACHD cases have a similar 10-year ASCVD risk score than age- and gender-matched peers, but ACHD cases are less likely than their peers to be prescribed statin therapy for primary prevention per guideline-based recommendations.

Introduction: Cognitive errors are commonly made by patients during medical visits, traditionally thought to be due to gaps in communication and a complicated subject matter; use of diagrams and post-visit summaries has had a modest effect in improving in patient understanding and recall. We hypothesize that those cognitive errors can also be understood by using the behavioral economics framework of “System 1” mindset, in which patients are reliant on intuition and vulnerable to heuristics, as opposed to “System 2” mindset, which is reflective, slow and detailed-oriented, and that patient-reported outcome measures (PROMs) can shift patients to a “System 2” mindset. Methods: In this pilot, patients from a tertiary center adult congenital heart disease clinic were given Frederick’s Cognitive Reflection Test (CRT; score of 0 to 3, with low scores associated with System 1 mindset) prior to a routine clinical visit. They were randomly assigned to complete the PROMIS and Kansas City Cardiomyopathy Questionnaire either before or after the CRT. The primary endpoint was the mean CRT score in all patients; the secondary endpoint was a comparison of the effect of PROMs. Kruskal-Wallis test was used to compare ordinal variables. Results: Patients (N=47) had a mean age of 48, 93% were native English speakers and all had completed high school (93% at least started college). The median CRT score was 0 (IQR 0-1; 74% had a score of 0), and the mean score was 0.45 (SD 0.85), which is lower than any previously published results in control populations (mean scores 0.57 to 2.18 in 35 studies with 3428 respondents). CRT scores were numerically but not statistically higher in the group who completed the PROMs first (32% vs 20% had a score >0, mean 0.5 vs. 0.4, p=0.46). Patients randomized to PROMs first reported more often that they remembered to ask the physician the questions they had (94.7% vs. 86.7%) and were less nervous during the visit (15.8% vs. 46.7%). Conclusions: The finding that patients are in an intuitive state of mind prior to routine clinic visits, reliant on heuristics and vulnerable to biases, offers an important new framework in which to devise interventions to improve patient participation in their medical visits, recall of information, and decision-making. PROM are a promising candidate for intervention that will be further studied.

Transcatheter pulmonary valve replacement (TPVR) was approved in 2015. Real world practice, including patient selection, outcomes and complications, in patients who may not meet the trial instructions for use, is not well known. Demographics, procedural characteristics and outcomes were collected

Endocarditis of the Melody (Medtronic, Minneapolis, MN) transcatheter pulmonary valve (TPV) has emerged as a potentially serious complication, challenging to diagnose and treat. A 53-year-old male with Tetralogy of Fallot and pulmonary atresia, right ventricle to pulmonary artery conduit in

Endovascular interventions for cardiovascular pathology are becoming increasingly relevant to cardiothoracic surgery. This study assessed the perceived prevalence and efficacy of endovascular skills training and identified differences among training paradigms.Trainee responses to questions in the 2016 In-Service Training Examination survey regarding endovascular training were analyzed based on the four different cardiothoracic surgery training pathways: traditional 2- and 3-year thoracic, integrated 6-year, and combined 4+3 general and thoracic residency programs.The duration of endovascular training was substantially different among programs, at a median of 17 weeks for integrated 6-year, 8.5 weeks for 3-year, 6 weeks for 4+3, and 4 weeks for 2-year residency (p0.0001). After adjusting for year of training and program type, the duration of endovascular rotations was significantly associated with self-assessed comfort with catheter-based skills (p0.0001). Eighty-two percent of residents rotated with trainees from other specialties, and 58% experienced competition for cases. Residents reported greater exposure to transcatheter aortic valve replacement than to thoracic endovascular aortic repair, cardiac catheterization, percutaneous closure of atrial septal defect, and transcatheter mitral valve surgery (p0.0001). A significant proportion of responders reported feeling uncomfortable performing key steps of transcatheter aortic valve replacement (52%) or thoracic endovascular aortic repair (49%).Considerable heterogeneity exists in endovascular training among cardiothoracic surgery training pathways, with a significant number of residents having minimal to no exposure to these emerging techniques. These findings highlight the need for a standardized curriculum to improve endovascular exposure and training.

During medical visits, the stakes are high for many patients, who are put in a position to make, or to begin to make, important health-related decisions. But in such visits, patients often make cognitive errors. Traditionally, those errors are thought to result from poor communication with physicians; complicated subject matter; and patient anxiety. To date, measures to improve patient understanding and recall have had only modest effects. This paper argues that an understanding of those cognitive errors can be improved by reference to a behavioral science framework, which distinguishes between a “System 1” mindset, in which patients are reliant on intuition and vulnerable to biases and imperfectly reliable heuristics, and a “System 2” mindset, which is reflective, slow, deliberative, and detailed-oriented. To support that argument, we present the results of a randomized-assignment experiment that shows that patients perform very poorly on the Cognitive Reflection Test and thus are overwhelmingly in a System 1 state prior to a physician visit. Assigning patients the task of completing patient-reported outcomes measures immediately prior to the visit had a small numerical, but not statistically significant, shift towards a reflective frame of mind. We describe hypotheses to explain poor performance by patients, which may be due to anxiety, a bandwidth tax, or a scarcity effect, and outline further direction for study. Understanding the behavioral sources of errors on the part of patients in their interactions with physicians and in their decision-making is necessary to implement measures improve shared decision-making, patient experience, and (perhaps above all) clinical outcomes.

Ventricular arrhythmias remain a challenge in the care of adults with congenital heart disease (ACHD). This Heart review1 outlines the current frameworks for arrhythmia management while drawing our attention to the knowledge gaps and opportunities to better inform ourselves about the development, presence and treatment of ventricular arrhythmias in ACHD. The development of evidence-based guidelines in ACHD is particularly difficult for several reasons. Randomised controlled trials (RCTs) provide the foundation of data for most other cardiac guidelines; however, heterogeneity of diagnoses and physiological variations leads to relatively small populations in ACHD, which require long recruitment periods. Today, individuals also emerge from childhood surgery with a different footprint than those in prior decades, further complicating the interpretation, and relevance of past RCTs. Therefore, thorough observational studies have been crucial to the development of ACHD guidelines, and with consensus statements inform much of the ACHD literature. As highlighted in this review, some recommendations mirror those in general cardiology, such as the management of acute ventricular arrhythmias, while drawing attention to the physiological differences in certain congenital diagnoses (such as lower resting blood pressure or hypoxia, possible meso-position or dextro-position of the heart) and the haemodynamic reserve and stability of some young patients despite ventricular tachycardia (VT). Similar to general guidelines, implantable cardioverter-defibrillators (ICDs) have …

The treatment of hypertension in coarctation of the aorta (CoA) is ideally managed by early surgical or transcatheter repair to reduce the risk of irreversible aortopathy and refractory hypertension, in addition to other associated sequelae including premature coronary artery disease; stroke; aortic aneurysm, dissection, and rupture; infective endocarditis; and heart failure. The choice of surgical or transcatheter repair is dependent on individual patient considerations. Medical therapy for hypertension due to CoA parallels treatment of essential hypertension with beta blockers, angiotensin-converting enzyme inhibitors, and angiotensin receptor blockers as first-line agents.

Cardiac computed tomography angiogram (cCTA) is often performed in adults with coarctation of the aorta (CoA). As the population ages, assessment of atherosclerotic cardiovascular disease (ASCVD) burden is important. CoA patients ≥16 years of age seen at a referral center with cCTA or chest