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Little is known about the utility of transcatheter aortic valve implantation (TAVI) in patients with cirrhosis of the liver, and their outcomes have not been studied extensively in literature. We performed a retrospective analysis of patients with severe symptomatic aortic stenosis (AS) who underwent transfemoral TAVI with a SAPIEN 3 valve at our institution between April 2015 and December 2018. We identified 32 consecutive patients with evidence of cirrhosis of the liver on imaging (including ultrasound and/or computed tomography) and patients with severe symptomatic AS who underwent transfemoral TAVI with a SAPIEN 3 valve. Among 1,028 patients, 32 had cirrhosis of the liver and 996 constituted the control group without cirrhosis. Mean age in the cirrhosis group was 74.5 years compared with 81.2 years in the control group. Baseline variables were comparable between the groups. Compared with the noncirrhotic group, patients with cirrhosis had a similar 1-year mortality (12% vs 12%, p = 1), a lower 30-day new pacemaker after TAVI rate (6% vs 9%, p = 0.85), a higher 30-day and 1-year readmission rate for heart failure (11% vs 1% and 12% vs 5%, p = 0.12, respectively), and a similar 1-year major adverse cardiac and cerebrovascular event rate (15% vs 14%, p = 0.98). In conclusion, patients with severe AS with concomitant liver cirrhosis who underwent TAVI demonstrated comparable outcomes to their noncirrhotic counterparts.

Pericardiectomy is the recommended treatment for patients with recurrent pericarditis and refractory symptoms despite optimal anti-inflammatory therapy. We present a case of a 40-year-old woman who underwent total pericardiectomy after multiple episodes of pericarditis that was refractory to optimal guideline-derived medical therapy, including anti-inflammatory and biologic agents, who continued to have relapsing symptoms even after pericardiectomy. (Level of Difficulty: Intermediate.), Central Illustration

The presence of human coronavirus HKU1 infection associated with pericardial inflammation is not reported. We are reporting a young woman with systemic lupus erythematosus, who was positive for HKU1 during her pericarditis flare. Diagnostic imaging demonstrated pericardial effusion, edema, and late gadolinium enhancement on cardiac magnetic resonance imaging and echocardiography. She was on multiple anti-inflammatory medications and achieved remission with anakinra. Her management and a brief literature review is also presented.

Background: There has been an explosion in the clinical application of transcatheter aortic valve replacement (TAVR) worldwide. While moderate and severe grades of paravalvular regurgitation (PVR) ...

Progressive conduction system disease affects patients with transthyretin cardiac amyloidosis, often requiring permanent pacing as the His-Purkinje system is affected. We present a case of left bundle branch pacing in a patient with transthyretin cardiac amyloidosis and infra-Hisian conduction disease with a favorable improvement in cardiac function and stable pacing thresholds. (Level of Difficulty: Intermediate.), Graphical abstract, Progressive conduction system disease affects patients with transthyretin cardiac amyloidosis, often requiring permanent pacing as the His-Purkinje…

There are limited data regarding the impact of mitral annular calcium (MAC) on the outcomes of patients who underwent transcatheter aortic valve implantation (TAVI). We performed a retrospective analysis of patients who underwent TAVI in 2018 and divided them into 2 groups based on the presence or absence of MAC, using a validated MAC computed tomography-based scoring system. Among 468 patients who underwent TAVI in 2018, 271 patients (58%) had MAC present compared with 197 patients (42%) without MAC. Compared with patients without MAC, patients in the MAC group were older (81 vs 79, p = 0.012), had a higher body mass index (29.30 vs 28.05, p = 0.031), lower left ventricular end-diastolic diameter (4.47 vs 4.80, plt;0.001), higher mitral valve mean gradient (4.54 vs 3.01, p = 0.031), and a higher Society of Thoracic Surgeons risk score (5.69 vs 4.91, p = 0.127). There was no significant difference in the with versus without MAC groups in the all-cause mortality (at 1 year: 9% vs 6%, p = 0.8; at 2 years: 15% vs 13%, p = 0.47), incidence of myocardial infarction (1% vs 2%, p = 0.417), stroke (1% vs 3%, p = 0.4), and major adverse cardiac and cerebrovascular events (17% vs 19%, p = 0.53) at 1 year. Although the rate of new-onset left bundle branch block was higher in patients with MAC, there was no significant difference between the 2 groups in the rates of complete atrioventricular block (5% vs 3%, p = 0.483) or the need for pacemaker implantation (6% vs 3%, p = 0.168). The post-TAVI peak aortic valve gradient was comparable between the groups with and without MAC (22.52 vs 22.60, p = 0.931). In conclusion, TAVI is a safe alternative for patients with severe aortic stenosis and concomitant MAC, with comparable outcomes to patients without MAC.

Background: Open heart surgery is preferred for patients with multiple valvular issues with conflicting physiology. Case: A 57-year-old female with a past medical history of Type I Diabetes Mellitus complicated by kidney & pancreatic transplant in 1999 s/p failed kidney transplant in 2016 subsequently back on dialysis, aortic stenosis leading to Transcatheter Aortic Valve Replacement (TAVR) in 2016 who presented to the hospital for profound cardiogenic shock and was found to have severe tricuspid regurgitation, severe mitral stenosis secondary to mitral annular calcification with severe concentric hypertrophy of left ventricle. Decision Making: Her conflicting right and left heart physiology due to Tricuspid Regurgitation and Mitral Stenosis was very difficult to manage medically. She was not deemed a candidate for a heart transplant due to a history of a failed kidney transplant. She underwent surgery which included Mitral Valve Replacement, explant TAVR and repeat aortic valve replacement, Tricuspid repair, Left atrial appendage ligation and maze procedure, and CABG x1 with saphenous vein graft to PDA. She stayed on V-V extracorporeal membrane oxygenation (ECMO) post-operatively and was discharged on post-operative Day # 14. Conclusion: Severe tricuspid Regurgitation & coexisting mitral stenosis pose a dilemma for medical management and only feasible option is surgery which could be extremely challenging.

Introduction: Radiation reduction measures were incorporated in the Cleveland Clinic Catheterization laboratories to mitigate the hazards from radiation exposure to patients and personnel during diagnostic and interventional coronary procedures. We report our experience with these improved systems over a 10-year period. Methods: Fluoroscopes were modified in 2013 by reducing the default fluoroscopic pulse rate from 10 to 7.5 pules/s, added default low-dose acquisitions, revised field-of-view dose factors, and instructed operators to use larger fields-of-view with appropriate collimation. A retrospective data analysis of all patients undergoing diagnostic catheterization from 2009 to 2012 (pre-initiative group), and 2013 to 2019 (post-initiative group) was done using Siemens CARE analytics software. The effectiveness of radiation reduction measures was assessed by comparing the total air kerma (K a,r ), and fluoroscopy- and acquisition-mode air kerma in patients in the two groups after propensity matching them based on age, sex, BSA, and total fluoroscopic time. Results: The total fluoroscopic time for the pre-initiative group (N=18,181) was 8.02 seconds while that for the post-initiative group (N=25,868) was 8.05 seconds. After matching 18,181 patients in both the groups (mean age, 64 years; 62% males), a significant reduction (54.4%) in the mean K a,r was observed in the post- in comparison to the pre-initiative group (420.94 mGy vs. 921.21 mGy; p-16 ). Further analysis revealed a reduction in the mean acquisition- (59.3%; 217.33 mGy vs. 533.50 mGy; p-16 ) and fluoroscopy-mode (47.5%; 203.61 mGy vs. 387.71 mGy; p-16 ) air kerma in the post-initiative group. A sub-analysis of patients matched on the basis of their exact fluoroscopy and acquisition times also revealed a significant reduction in K a,r , acquisition- and fluoroscopy-mode air kerma in the post-initiative group relative to the pre-initiative group (43.95%, 44.04%, 43.78% respectively). Conclusions: Optimization of imaging systems can significantly reduce patient radiation exposures which directly affect the radiation exposure of the Cath lab personnel. Similar algorithms can be applied in other labs to achieve a reduction in radiation exposure.

Data comparing outcomes of distal radial (DR) and traditional radial (TR) access of coronary angiography and percutaneous coronary intervention (PCI) are limited. Online databases including Medline and Cochrane Central databases were explored to identify studies that compared DR and TR access for PCI. The primary outcome was the rate of radial artery occlusion (RAO) and access failure. Secondary outcomes included access site hematoma, access site bleeding, access site pain, radial artery spasm, radial artery dissection, and crossover. Unadjusted odds ratios (ORs) with a random-effect model, 95% confidence interval (CI), and p0.05 were used for statistical significance. Metaregression was performed for 16 studies with 9,973 (DR 4,750 and TR 5,523) patients were included. Compared with TR, DR was associated with lower risk of RAO (OR 0.51, 95% CI 0.29 to 0.90, I

Background Regularly updated data on stroke and its pathological types, including data on their incidence, prevalence, mortality, disability, risk factors, and epidemiological trends, are important for evidence-based stroke care planning and resource allocation. The Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) aims to provide a standardised and comprehensive measurement of these metrics at global, regional, and national levels. Methods We applied GBD 2019 analytical tools to calculate stroke incidence, prevalence, mortality, disability-adjusted life-years (DALYs), and the population attributable fraction (PAF) of DALYs (with corresponding 95% uncertainty intervals [UIs]) associated with 19 risk factors, for 204 countries and territories from 1990 to 2019. These estimates were provided for ischaemic stroke, intracerebral haemorrhage, subarachnoid haemorrhage, and all strokes combined, and stratified by sex, age group, and World Bank country income level. Findings In 2019, there were 12·2 million (95% UI 11·0–13·6) incident cases of stroke, 101 million (93·2–111) prevalent cases of stroke, 143 million (133–153) DALYs due to stroke, and 6·55 million (6·00–7·02) deaths from stroke. Globally, stroke remained the second-leading cause of death (11·6% [10·8–12·2] of total deaths) and the third-leading cause of death and disability combined (5·7% [5·1–6·2] of total DALYs) in 2019. From 1990 to 2019, the absolute number of incident strokes increased by 70·0% (67·0–73·0), prevalent strokes increased by 85·0% (83·0–88·0), deaths from stroke increased by 43·0% (31·0–55·0), and DALYs due to stroke increased by 32·0% (22·0–42·0). During the same period, age-standardised rates of stroke incidence decreased by 17·0% (15·0–18·0), mortality decreased by 36·0% (31·0–42·0), prevalence decreased by 6·0% (5·0–7·0), and DALYs decreased by 36·0% (31·0–42·0). However, among people younger than 70 years, prevalence rates increased by 22·0% (21·0–24·0) and incidence rates increased by 15·0% (12·0–18·0). In 2019, the age-standardised stroke-related mortality rate was 3·6 (3·5–3·8) times higher in the World Bank low-income group than in the World Bank high-income group, and the age-standardised stroke-related DALY rate was 3·7 (3·5–3·9) times higher in the low-income group than the high-income group. Ischaemic stroke constituted 62·4% of all incident strokes in 2019 (7·63 million [6·57–8·96]), while intracerebral haemorrhage constituted 27·9% (3·41 million [2·97–3·91]) and subarachnoid haemorrhage constituted 9·7% (1·18 million [1·01–1·39]). In 2019, the five leading risk factors for stroke were high systolic blood pressure (contributing to 79·6 million [67·7–90·8] DALYs or 55·5% [48·2–62·0] of total stroke DALYs), high body-mass index (34·9 million [22·3–48·6] DALYs or 24·3% [15·7–33·2]), high fasting plasma glucose (28·9 million [19·8–41·5] DALYs or 20·2% [13·8–29·1]), ambient particulate matter pollution (28·7 million [23·4–33·4] DALYs or 20·1% [16·6–23·0]), and smoking (25·3 million [22·6–28·2] DALYs or 17·6% [16·4–19·0]). Interpretation The annual number of strokes and deaths due to stroke increased substantially from 1990 to 2019, despite substantial reductions in age-standardised rates, particularly among people older than 70 years. The highest age-standardised stroke-related mortality and DALY rates were in the World Bank low-income group. The fastest-growing risk factor for stroke between 1990 and 2019 was high body-mass index. Without urgent implementation of effective primary prevention strategies, the stroke burden will probably continue to grow across the world, particularly in low-income countries. Funding Bill & Melinda Gates Foundation.

Background Little is known about the hemodynamic performance of Edwards Sapien-3 (S3) valve after Transcatheter Aortic Valve Replacement (TAVR). Doppler velocity index (DVI) is a better indicator of prosthetic valve function as it is independent of valve size and flow, unlike mean gradient and peak velocity which are flow-dependent. Methods In this study, we compare outcomes based on differences in DVI among a consecutive series of patients who underwent S3 TAVR between April 2015 and December 2018. Our institutional review board approved the study and informed consents were obtained from the subjects. Results Among 921 patients who had follow-up echocardiograms within 30 days after TAVR, 60.8% had DVI ≤0.5, while 39.2% had DVI >0.5. The median 30-day DVI was 0.47 with a standard deviation of 0.11 and mean 0.49 and interquartile range 0.41–0.55. The baseline clinical and procedural characteristics were similar between both groups with the exception of less post-dilation (36.8% vs. 47.4%; p=0.001) and greater implantation depth (2.59±1.99 vs. 2.31±1.9mm; p=0.031) with DVI ≤0.5. The rates of aortic valve calcification, pre dilation, pre-TAVR aortic regurgitation (AR) were similar. At baseline, there were no differences between both groups in mean or peak gradients or aortic velocity time integral (VTI). At 1 year, mean gradients were higher with DVI ≤0.5 (12.7±5.6 vs. 11.1±4.6 mmHg; p=0.001). DVI ≤0.5 was associated with higher peak gradients (24.2±10.2 vs. 21.4±8.7 mmHg; p=0.002), and aortic VTI (51.4±13.5 vs. 46.8±12.2 cm; p0.5 group, patients in DVI0.5 were lower (6.6% vs. 10.6%; log-rank p=0.033), however no difference was noted at both 2 years (17.3% vs. 20.1%; log-rank p=0.151), and 3 years after TAVR (30.7% vs. 31.2%; log-rank p=0.333). Conclusions DVI Funding Acknowledgement Type of funding sources: None. Figure 1. All-cause SurvivalFigure 2. Hemodynamic Data

Background New left bundle branch block (LBBB) is a common finding after transcatheter aortic valve replacement (TAVR) that can result in worse outcomes after TAVR. We aim to investigate the impact of new-onset LBBB after TAVR using the SAPIEN-3 (S3) valve. Methods Consecutive patients who underwent transfemoral-TAVR with S3 valve between April 2015 and December 2018 were included. Exclusion criteria included pre-existing LBBB, right bundle branch block, left anterior hemiblock, left posterior hemiblock, wide QRS ≥120 msec, prior permanent pacemaker (PPM), and non-transfemoral access. Results Among 612 patients, 11.4% developed new-onset LBBB upon discharge. Implantation depth was the only predictor of new-onset LBBB (OR 1.294; 95% CI 1.121–1.493; p Conclusion Among our cohort of S3 recipients, new-onset LBBB was associated with higher PPM requirement, worse LVEF, higher LV volumes and increased risk of heart failure hospitalizations. However, it did not affect mortality in the short-to-intermediate post-TAVR period. Funding Acknowledgement Type of funding sources: None. Figure 1. All-cause Survival

Artificial Intelligence (AI) performs human intelligence-dependant tasks using tools such as Machine Learning, and its subtype Deep Learning. AI has incorporated itself in the field of cardiovascular medicine, and increasingly employed to revolutionize diagnosis, treatment, risk prediction, clinical care, and drug discovery. Heart failure has a high prevalence, and mortality rate following hospitalization being 10.4% at 30-days, 22% at 1-year, and 42.3% at 5-years. Early detection of heart failure is of vital importance in shaping the medical, and surgical interventions specific to HF patients. This has been accomplished with the advent of Neural Network (NN) model, the accuracy of which has proven to be 85%. AI can be of tremendous help in analyzing raw image data from cardiac imaging techniques (such as echocardiography, computed tomography, cardiac MRI amongst others) and electrocardiogram recordings through incorporation of an algorithm. The use of decision trees by Rough Sets (RS), and logistic regression (LR) methods utilized to construct decision-making model to diagnose congestive heart failure, and role of AI in early detection of future mortality and destabilization episodes has played a vital role in optimizing cardiovascular disease outcomes. The review highlights the major achievements of AI in recent years that has radically changed nearly all areas of HF prevention, diagnosis, and management.

We sought to evaluate the outcomes of patients with severe mitral stenosis (MS) resulting from mitral annular calcification and assessed the prognostic impact of co-morbidities and frailty in guiding management. Among 6,915 patients with calcific MS who underwent echocardiography between January 2011 and March 2020, a total of 283 patients with severe calcific MS were retrospectively enrolled. We calculated the Charlson co-morbidity index (CCI). Frailty was scored from 0 to 3 points, with 1 point each assigned for reduced hemoglobin, reduced albumin, and inactivity. The primary end point was all-cause death. The mean age was 72 ± 11 years. The mean mitral valve (MV) area was 1.1 ± 0.4 cm2, and the mean transmitral gradient was 12 ± 4 mm Hg. Although 33% of the patients underwent MV intervention, 67% were conservatively managed. During a median follow-up of 360 days, 35% died. Patients who underwent MV intervention had an improved prognosis compared with those who were treated conservatively, even after propensity score matching. On multivariate Cox regression analysis, higher CCI (hazard ratio [HR] 1.20, 95% confidence interval [CI] 1.04 to 1.38, p = 0.011) and frailty score (HR 1.58, 95% CI 1.12 to 2.23, p = 0.01) were predictors of all-cause mortality, and MV intervention (HR 0.45, 95% CI 0.25 to 0.83, p = 0.011) and angiotensin converting enzyme inhibitor/angiotensin receptor blocker use (HR 0.39, 95% CI 0.20 to 0.79, p = 0.009) were associated with an improved prognosis. In conclusion, patients with severe calcific MS were often frail with multiple co-morbidities and were often managed conservatively. Higher CCI and worse frailty were associated with worse prognosis, regardless of the treatment strategy. MV intervention for select patients was associated with improved prognosis.

BACKGROUND Monitored anesthesia care (MAC) has become more widely used during transcatheter aortic valve replacement (TAVR) to avoid the complications of general anesthesia (GA). METHODS We included consecutive patients who underwent transfemoral-TAVR at our institution between January 2012 and April 2017. We compared outcomes with GA versus MAC. RESULTS Of 998 patients, MAC was used in 43.9%. MAC was associated with shorter procedural time (96.9 ± 30.9 vs. 135 ± 64.6 mins; p

Background: The conventional method of implanting balloon-expandable SAPIEN-3 (S3) valve results in a final 70:30 or 80:20 ratio of the valve in the aorta:left ventricular outflow tract with published rates of permanent pacemaker around 10%. We sought to evaluate whether higher implantation of S3 reduces conduction abnormalities including the need for permanent pacemaker. Methods: We included consecutive patients who underwent transfemoral transcatheter aortic valve replacement using S3 between April 2015 and December 2018 and compared outcomes with typical valve deployment strategy to our more contemporary high deployment technique (HDT). We excluded patients with nontransfemoral access or valve-in-valve. Results: Among 1028 patients, HDT was performed in 406 patients (39.5%). Mean implantation depth under the noncoronary cusp was significantly smaller with HDT compared with conventional technique (1.5±1.6 versus 3.2±1.9 mm; P P =0.216). Thirty-day permanent pacemaker rates were lower with HDT (5.5% versus 13.1%; P P P P =0.804), or moderate-to-severe aortic regurgitation (1% versus 2.7%; P =0.081) at 1 year. HDT was associated with slightly higher 1-year mean gradients (13.1±6.2 versus 11.8±4.9 mm Hg; P =0.042) and peak gradients (25±11.9 versus 22.5±9 mm Hg; P =0.026). However, Doppler velocity index was similar (0.47±0.15 versus 0.48±0.13; P =0.772). Conclusions: Our novel technique for balloon-expandable S3 valve positioning consistently achieves higher implantation resulting in substantial reduction in conduction abnormalities and permanent pacemaker requirement after transcatheter aortic valve replacement without compromising procedural safety or valve hemodynamics. Operators should consider this as an important technique to improve patient outcomes.

The coronavirus disease-19 (COVID-19), first appearing in Wuhan, China, and later declared as a pandemic, has caused serious morbidity and mortality worldwide. Severe cases usually present with acute respiratory distress syndrome (ARDS), pneumonia, acute kidney injury (AKI), liver damage, or septic shock. However, with recent advances in severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) research, the virus´s effect on cardiac tissues has become evident. Reportedly, an increased number of COVID-19 patients manifested serious cardiac complications such as heart failure, increased troponin, and N-terminal pro-B-type natriuretic peptide levels (NT-proBNP), cardiomyopathies, and myocarditis. These cardiac complications initially present as chest tightness, chest pain, and heart palpitations. Diagnostic investigations such as telemetry, electrocardiogram (ECG), cardiac biomarkers (troponin, NT-proBNP), and inflammatory markers (D-dimer, fibrinogen, PT, PTT), must be performed according to the patient´s condition. The best available options for treatment are the provision of supportive care, anti-viral therapy, hemodynamic monitoring, IL-6 blockers, statins, thrombolytic, and anti-hypertensive drugs. Cardiovascular disease (CVD) healthcare workers should be well-informed about the evolving research regarding COVID-19 and approach as a multi-disciplinary team to devise effective strategies for challenging situations to reduce cardiac complications.

Background Tuberculosis is a major contributor to the global burden of disease, causing more than a million deaths annually. Given an emphasis on equity in access to diagnosis and treatment of tuberculosis in global health targets, evaluations of differences in tuberculosis burden by sex are crucial. We aimed to assess the levels and trends of the global burden of tuberculosis, with an emphasis on investigating differences in sex by HIV status for 204 countries and territories from 1990 to 2019. Methods We used a Bayesian hierarchical Cause of Death Ensemble model (CODEm) platform to analyse 21 505 site-years of vital registration data, 705 site-years of verbal autopsy data, 825 site-years of sample-based vital registration data, and 680 site-years of mortality surveillance data to estimate mortality due to tuberculosis among HIV-negative individuals. We used a population attributable fraction approach to estimate mortality related to HIV and tuberculosis coinfection. A compartmental meta-regression tool (DisMod-MR 2.1) was then used to synthesise all available data sources, including prevalence surveys, annual case notifications, population-based tuberculin surveys, and tuberculosis cause-specific mortality, to produce estimates of incidence, prevalence, and mortality that were internally consistent. We further estimated the fraction of tuberculosis mortality that is attributable to independent effects of risk factors, including smoking, alcohol use, and diabetes, for HIV-negative individuals. For individuals with HIV and tuberculosis coinfection, we assessed mortality attributable to HIV risk factors including unsafe sex, intimate partner violence (only estimated among females), and injection drug use. We present 95% uncertainty intervals for all estimates. Findings Globally, in 2019, among HIV-negative individuals, there were 1·18 million (95% uncertainty interval 1·08–1·29) deaths due to tuberculosis and 8·50 million (7·45–9·73) incident cases of tuberculosis. Among HIV-positive individuals, there were 217 000 (153 000–279 000) deaths due to tuberculosis and 1·15 million (1·01–1·32) incident cases in 2019. More deaths and incident cases occurred in males than in females among HIV-negative individuals globally in 2019, with 342 000 (234 000–425 000) more deaths and 1·01 million (0·82–1·23) more incident cases in males than in females. Among HIV-positive individuals, 6250 (1820–11 400) more deaths and 81 100 (63 300–100 000) more incident cases occurred among females than among males in 2019. Age-standardised mortality rates among HIV-negative males were more than two times greater in 105 countries and age-standardised incidence rates were more than 1·5 times greater in 74 countries than among HIV-negative females in 2019. The fraction of global tuberculosis deaths among HIV-negative individuals attributable to alcohol use, smoking, and diabetes was 4·27 (3·69–5·02), 6·17 (5·48–7·02), and 1·17 (1·07–1·28) times higher, respectively, among males than among females in 2019. Among individuals with HIV and tuberculosis coinfection, the fraction of mortality attributable to injection drug use was 2·23 (2·03–2·44) times greater among males than females, whereas the fraction due to unsafe sex was 1·06 (1·05–1·08) times greater among females than males. Interpretation As countries refine national tuberculosis programmes and strategies to end the tuberculosis epidemic, the excess burden experienced by males is important. Interventions are needed to actively communicate, especially to men, the importance of early diagnosis and treatment. These interventions should occur in parallel with efforts to minimise excess HIV burden among women in the highest HIV burden countries that are contributing to excess HIV and tuberculosis coinfection burden for females. Placing a focus on tuberculosis burden among HIV-negative males and HIV and tuberculosis coinfection among females might help to diminish the overall burden of tuberculosis. This strategy will be crucial in reaching both equity and burden targets outlined by global health milestones. Funding Bill & Melinda Gates Foundation.

Background: The seasonal trends of idiopathic pericardial effusion (PEff) are not known. Small PEff is usually asymptomatic but moderate to large PEff may lead to cardiac tamponade necessitating pericardial drainage procedures. Seasonal variations of PEff can help identify the association with viral infections that follow a seasonal pattern. Therefore, we sought to characterize the seasonal trends of moderate to large PEff. Methods: We retrospectively identified pericardial effusion patients from January 2015 to December 2019. Moderate to large PEff was defined as PEff requiring either pericardiocentesis or pericardial window. Patients with minimal to small PEff, autoimmune diseases (systemic lupus erythematosus, rheumatoid arthritis, systemic sclerosis), cardiac surgeries/invasive procedures, hemopericardium, chronic pericarditis, malignancy, and metastasis were excluded. Data was acquired from electronic medical records and frequencies, means, percentages, and chi-square test statistics were calculated. Results: Of the 472 patients with PEff, 63% (n=296) were males and 37% (n=176) females. The median age was 61 years. Pericardiocentesis was performed in 65% of patients and 35% had pericardial window. All seasons had similar incidence of PEff (winter 27%, spring 25%, summer 24%, fall 23%, [X 2 =1.81, p=0.612]). The incidence also remained same across all the quarters of the year (Q1 25%, Q2 25%, Q3 26%, Q4 24%, [X2=0.119, p=0.990). The incidence of pericardiocentesis and pericardial window in winter (27% vs 27.5), Spring (22% vs 31%), summer (26% vs 20%), fall (25% vs 20%) showed no difference (X2=6.40, p=0.094). Conclusion: The incidence of moderate to large acute idiopathic pericardial effusion is consistent across all seasons and quarters. Similarly, no significant seasonality was associated with pericardiocentesis and pericardial window procedures.

Background: Chilli-pepper (CP) is well known for its anti-inflammatory, antioxidant, anticancer, and blood glucose regulation effects. However, the impact of CP on all-cause and cardiovascular mortality is not clear. Methods: A comprehensive search was performed using Ovid, Cochrane, Medline, Embase, and Scopus. We screened the studies from inception till January 16, 2020, and reported the outcomes of our interest after consumption of CP (Figure1a). The inclusion criteria were: all observational and randomized controlled trials reporting the outcomes of interest, and pediatric, animal studies, letters/case reports, reviews, abstracts, and book chapters were excluded. All-cause mortality was studied as the primary endpoint. Cardiovascular, cerebrovascular, and cancer-related deaths were studied as secondary outcomes. Results: From 4729 studies screened, four studies including 570,762 subjects met the inclusion criteria. Random-effects pooled analysis showed that there was a 25% reduction in the relative risk of all-cause mortality for regular CP consumers, compared to non-consumers (relative risk (RR): 0.75; 95% confidence intervals (CI): 0.64-0.88, p = 0.0004, Figure1b). Furthermore, there were a 26% and 23% reduction in the RR of death due to cardiovascular causes (RR: 0.74; 95% CI: 0.62-0.88, p=0.0006, Figure1c) and cancer (RR: 0.77; 95% CI: 0.71-0.84, p=0.0001, Figure 1d), respectively. However, there were no statistically significant differences in cerebrovascular accidents (RR: 0.76; 95% CI: 0.36-1.60, p=0.47). Conclusion: In a contemporary meta-analysis of 570,762 subjects, regular CP consumption was associated with a significant reduction in all-cause, cardiovascular, and cancer-related mortalities. Future studies are needed to better understand the potential mechanisms of the mortality benefits of CP consumption.

Introduction: New permanent pacemaker (PPM) requirement has been linked with left ventricular dysfunction after TAVR. Objective: We sought to study the impact of new PPM on echocardiographic outcomes after TAVR with SAPIEN-3 (S3) valve. Methods: We included consecutive patients who underwent TAVR with S3 valve at the Cleveland Clinic between April 2015 and December 2018. Patients with prior PPM were excluded. Echocardiograms were reviewed to determine left ventricular ejection fraction (LVEF), left ventricular end diastolic volume index (LVEDVi), left ventricular end systolic volume index (LVESVi), left ventricular dimension during diastole (LVDd), posterior wall thickness during diastole (PWTd), interventricular septum during diastole (IVSd), right ventricular systolic pressure (RVSP), inferior vena cava (IVC) diameter and tricuspid regurgitation (TR) grade. Results: Among 886 patients, the rate of 30-day PPM was 10.2%. Baseline LVEF was similar between new PPM and no PPM (55.4 ± 12.7% vs. 57.2 ± 11.2%; p = 0.188). There were no differences in the other studied echocardiographic parameters at baseline. Among patients with new PPM, LVEF was lower at both 30 days (54.4 ± 11.3% vs. 58.4 ± 10.1%; p = 0.001) and 1 year (54.2 ± 12% vs. 59.1 ± 11.3%; p = 0.009) compared to no PPM with Δ LVEF -0.9% vs. +1.4%; p = 0.023. There were no differences in LVEDVi (52 ± 20.8 vs. 48.3 ± 17.6; p = 0.186) at 1 year. LVESVi was higher with new PPM (24.8 ± 16.1 vs. 20.2 ± 10.9; p = 0.038). However, Δ LVESVi was similar between the 2 groups (-1.6 vs. -2.6; p = 0.517). There were no differences in RVSP (38.9 ± 14.1 vs. 40 ± 14; p = 0.58). LVIDd, PWTd, IVSd and IVC diameter also did not show variations whether patients were paced or not. Moderate to severe TR rates were similar as well (17.7% vs. 21.5%; p = 0.407). Conclusion: Among S3 TAVR recipients, new pacing requirement had a detrimental impact on LVEF at both 30 days and 1 year. However, it did not seem to affect the other studied echocardiographic outcomes after TAVR.

Introduction: Coronary artery disease (CAD) is a main cause of mortality in kidney transplant (KT) patients. Preoperative cardiovascular risk assessment is a crucial step before clearance for KT. Hypothesis: We seek to compare long term outcomes in patients who underwent PCI prior to KT as compared to those who did not need PCI. Methods: We identified patients who underwent KT from January 2008 to November 2019 at our institution and had coronary catheterization prior to KT. Results: We included 272 patients, of whom 54 (19.9%) underwent percutaneous coronary intervention (PCI), while the remaining 218 patients did not need PCI. The median age in the PCI group was 57.4 (46.9 - 61.2) years, while it was 53.9 (44.6 - 61) years in the control group. Baseline characteristics including gender, race, hypertension, diabetes, smoking, and hyperlipidemia were comparable in both groups. The median time to KT was 2.4 (1 - 5) years in the PCI group vs. 1.2 (0.6 - 3.3) years in the control group (p=0.001). Among patients who underwent PCI, 51.1% had single-vessel disease and 40.4% had multi-vessel disease on the coronary angiograms as compared with 15.4% and 11.8% in the control group (p Conclusion: Patients with CAD can be safely treated with PCI prior to kidney transplant and have comparable outcomes as compared to those who do not require PCI.

Introduction: Pre-existing atrial fibrillation has been linked with poor outcomes among patients undergoing transcatheter aortic valve replacement (TAVR). Objective: We sought to study the impact of baseline atrial fibrillation/flutter (AF) on outcomes after TAVR with SAPIEN-3 (S3) valve. Methods: All consecutive patients with severe symptomatic aortic stenosis who underwent TAVR with S3 valve at the Cleveland Clinic between April 2015 and December 2018 were included. Results: We included 1028 consecutive patients. Overall, the mean age of our study population was 81 ± 8.9 years, 58.8% were males, 95.8% were Caucasians. Pre-existing AF was present in 432 patients (42%). STS risk score was higher with AF compared to no AF (6.7 ± 3.8% vs. 5.4 ± 3.4%; p < 0.001). Baseline left ventricular ejection fraction (LVEF) was lower with AF (54% vs. 58%; p < 0.001). The rates of 30-day permanent pacemaker (PPM) implantation were similar between AF and no AF (11.4% vs. 9.4%; p = 0.326), as were the rates of new-onset left bundle branch block (LBBB) at discharge (9.6% vs. 9.4%; p = 0.901). There was also no difference in stroke rates at 30 days between the 2 groups (1.6% vs. 1%; p = 0.385). Post-TAVR mild or greater aortic regurgitation (AR) was higher with AF compared to no AF (21.5% vs. 16%; p = 0.022). LVEF was lower with AF at both 30 days (56% vs. 58.5%; p < 0.001) and 1 year (56% vs. 59%; p < 0.001). However, the change in LVEF (Δ) after TAVR was similar between AF and no AF (+1.1% vs. +1.4%; p = 0.624). At 2 years, all-cause death was higher with AF (22.9% vs. 12.8%; log-rank p = 0.011). There was no mortality difference between persistent versus paroxysmal AF (log-rank p = 0.714). Conclusions: Among our S3 TAVR patients, AF did not affect PPM, new-onset LBBB or stroke rates after the procedure. AF was associated with higher mild or greater AR at 30 days, as well as lower LVEF at both 30 days and 1 year compared to no AF. There was significantly higher all-cause mortality in the AF group at 2 years after TAVR.

The coronavirus disease-19 (COVID-19) pandemic has forced hospitals to prioritize COVID-19 patients, restrict resources, and cancel all non-urgent elective cardiac procedures. Clinical visits have only been facilitated for emergency purposes. Fewer patients have been admitted to the hospital for both ST-segment elevation myocardial infarctions (STEMI) and non-ST segment elevation myocardial infarctions (NSTEMI) and a profound decrease in heart failure services has been reported. A similar reduction in the patient presentation is seen for ischemic heart disease, decompensated heart failure, and endocarditis. Cardiovascular services, including catheterization, primary percutaneous coronary intervention (PPCI), cardiac investigations such as electrocardiograms (ECGs), exercise tolerance test (ETT), dobutamine stress test, computed tomography (CT) angiography, transesophageal echocardiography (TOE) have been reported to have declined and performed on a priority basis. The long-term implications of this decline have been discussed with major concerns of severe cardiac complications and vulnerabilities in cardiac patients. The pandemic has also had psychological impacts on patients causing them to avoid seeking medical help. This review discusses the effects of the COVID-19 pandemic on the provision of various cardiology services and aims to provide strategies to restore cardiovascular services including structural changes in the hospital to make up for the reduced staff personnel, the use of personal protective equipment in healthcare workers, and provides alternatives for high-risk cardiac imaging, cardiac interventions, and procedures. Implementation of the triage system, risk assessment scores, and telemedicine services in patients and their adaptation to the cardiovascular department have been discussed.

Papillary fibroelastomas represent the second most common benign cardiac tumour, secondary only to cardiac myxoma. A majority of patients are asymptomatic on presentation. The most common clinical manifestations include stroke, transient ischaemic attack, myocardial infarction and angina. Echocardiography remains the primary imaging modality for identification of these tumours. The majority of papillary fibroelastomas arise from the valves. Simple surgical excision is the mainstay of treatment, carrying an excellent prognosis. We present an unusual case of cardiac papillary fibroelastoma originating from the coumadin ridge (CR) in a 70-year-old woman. The patient exhibited increasing paroxysms of her atrial fibrillation and was pursuing a MAZE procedure. Preoperatively, a transesophageal echocardiogram revealed a 0.7×1 cm intracardiac mass that had echocardiographic appearance of a fibroelastoma. Surgical resection and MAZE procedures were performed. The gross specimen and histopathology findings were consistent with papillary fibroelastoma. This case reports the seventh documented case of fibroelastoma originating from the CR.

Pericardial cysts are considered rare incidental findings, which are generally asymptomatic in nature. Occasionally, patients may represent with chest discomfort, dyspnea, or palpitations. Pericarditis related to a ruptured pericardial cyst has not been previously reported in the literature. Here, we report the case of a 62-year-old man who developed acute pericarditis as a result of a ruptured enlarging pericardial cyst.

Melanoma is a highly aggressive disease with the risk of developing metastasis to virtually all organs including the heart, which can manifest as arrhythmia, right ventricular obstruction, heart failure, or pericardial effusion. Only a few reports are found in the literature of metastatic melanoma, causing ventricular arrhythmia. Prior to the advent of contemporary therapies, cardiac metastases implied a very poor prognosis. The use of immune checkpoint inhibitors and targeted therapy has greatly improved survival outcomes of metastatic melanoma. Aggressive therapy of cardiac metastasis including cardiac surgery can yield good outcomes. We present a case of a 57-year old gentleman with metastatic melanoma and cardiac involvement who initially presented as a ventricular arrhythmia and was successfully treated with immune checkpoint inhibitors and targeted therapy.

Coronary subclavian steal syndrome (CSSS) is a rare cause of angina. It occurs in patients with prior coronary artery bypass grafting and, specifically, a left internal mammary artery (LIMA) to left anterior descending artery (LAD) graft and co-existent significant subclavian artery stenosis. In this context, there is retrograde blood flow through the LIMA to LAD graft to supply the subclavian artery beyond the significant stenosis. This potentially occurs at the cost of compromising coronary artery perfusion dependent on the LIMA graft. In this review, we present a case of a middle-aged female who suffered from CSSS and review the literature for the contemporary diagnosis and management of this condition.

Background Congestive heart failure (CHF) is the most common cause of hospitalization in the US for people older than 65 years of age. It has the highest 30-day re-hospitalization rate among medical and surgical conditions, accounting for up to 26.9% of the total readmission rates. We conducted a quality improvement project at our hospital with the objective to reduce the 30-day all-cause readmissions of patients with CHF by improving the transition of care and setting up scheduled follow-up appointments within two weeks of patient discharge. Method Retrospective data were collected to understand the pattern of admission for CHF during November 2017. Data on 30-day readmission post-discharge was also collected to understand readmission rates. Similarly, all patients who were admitted with acute CHF exacerbation to our hospital during the month of November 2018 were included in our intervention cohort. The 30-day readmission rates of these patients post-intervention were calculated and compared to the initial cohort. Results As part of our study, we ensured that 58% of the enrolled patients had a follow-up appointment scheduled within two weeks of discharge compared to only 30% in 2017. Also, 56% of the enrolled patients kept their follow-up appointments compared to 37% in 2017. The 30-day readmission rate of CHF patients was reduced in half after the implementation of our project, with a 14% readmission rate for our study patients compared to 28% in 2017. Conclusion Patient education and measures to augment post-discharge follow-up appointments can lead to substantial reductions in the readmission rates of heart failure (HF) patients.