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Abstract Background Cichlid fishes have undergone rapid, expansive evolutionary radiations that are manifested in the diversification of their trophic morphologies, tooth patterning and coloration. Understanding the molecular mechanisms that underlie the cichlids' unique patterns of evolution requires a thorough examination of genes that pattern the neural crest, from which these diverse phenotypes are derived. Among those genes, the homeobox-containing Dlx gene family is of particular interest since it is involved in the patterning of the brain, jaws and teeth. Results In this study, we characterized the dlx genes of an African cichlid fish, Astatotilapia burtoni, to provide a baseline to later allow cross-species comparison within Cichlidae. We identified seven dlx paralogs (dlx1a, -2a, -4a, -3b, -4b, -5a and -6a), whose orthologies were validated with molecular phylogenetic trees. The intergenic regions of three dlx gene clusters (dlx1a-2a, dlx3b-4b, and dlx5a-6a) were amplified with long PCR. Intensive cross-species comparison revealed a number of conserved non-coding elements (CNEs) that are shared with other percomorph fishes. This analysis highlighted additional lineage-specific gains/losses of CNEs in different teleost fish lineages and a novel CNE that had previously not been identified. Our gene expression analyses revealed overlapping but distinct expression of dlx orthologs in the developing brain and pharyngeal arches. Notably, four of the seven A. burtoni dlx genes, dlx2a, dlx3b, dlx4a and dlx5a, were expressed in the developing pharyngeal teeth. Conclusion This comparative study of the dlx genes of A. burtoni has deepened our knowledge of the diversity of the Dlx gene family, in terms of gene repertoire, expression patterns and non-coding elements. We have identified possible cichlid lineage-specific changes, including losses of a subset of dlx expression domains in the pharyngeal teeth, which will be the targets of future functional studies.

Background: Perclose ProGlide (PPG) Suture-Mediated Closure System™ is safe and can reduce time to hemostasis following procedures requiring arterial access., Aims: We aimed to compare PPG to figure of 8 suture in patients who underwent interventional catheter procedures requiring large bore venous access (LBVA) (≥13 French)., Methods: In this physician-initiated, randomized, single-center study [clinicaltrials.gov ID: NCT04632641], single-stick venous access was obtained under ultrasound guidance. Eligible patients were randomized 1:1, and 100 subjects received allocated treatment to either PPG (n = 47) or figure of 8 suture (n = 53). No femoral arterial access was used in any patient. Primary outcomes were time to achieve hemostasis (TTH) and time to ambulation (TTA). Secondary outcomes were time to discharge (TTD) and vascular-related complications and mortality. Wilcoxon rank-sum test was used to compare TTH, TTA, and TTD., Results: TTH (minutes) was significantly lower in PPG versus figure of 8 suture [median, (Q1, Q3)] [7 (2,10) vs. 11 (10,15) respectively, p < 0.001]. TTA (minutes) was significantly lower in PPG compared to figure of 8 suture [322 (246,452) vs. 403 (353, 633) respectively, p = 0.005]. TTD (minutes) was not significantly different between the PPG and figure of 8 suture arms [1257 (1081, 1544) vs. 1338 (1171,1435), p = 0.650]. There was no difference in minor bleeding or access site hematomas between both arms. No other vascular complications or mortality were reported., Conclusion: PPG use had lower TTH and TTA than figure of 8 suture in a population of patients receiving LBVA procedures. This may encourage same-day discharge in these patients., (© 2024 The Author(s). Catheterization and Cardiovascular Interventions published by Wiley Periodicals LLC.)

Main Conclusion: Biofortification of legumes using diverse techniques such as plant breeding, agronomic practices, genetic modification, and nano-technological approaches presents a sustainable strategy to address micronutrient deficiencies of underprivileged populations. The widespread issue of chronic malnutrition, commonly referred to as "hidden hunger," arises from the consumption of poor-quality food, leading to various health and cognitive impairments. Biofortified food crops have been a sustainable solution to address micronutrient deficiencies. This review highlights multiple biofortification techniques, such as plant breeding, agronomic practices, genetic modification, and nano-technological approaches, aimed at enhancing the nutrient content of commonly consumed crops. Emphasizing the biofortification of legumes, this review employs bibliometric analysis to examine research trends from 2000 to 2023. It identifies key authors, influential journals, contributing countries, publication trends, and prevalent keywords in this field. The review highlights the progress in developing biofortified crops and their potential to improve global nutrition and help underprivileged populations., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Background: We aimed to elucidate clinical implications of genetic variant interpretation in assessing disease severity and progression in thoracic aortic aneurysm and dissection (TAAD) patients., Methods: Consecutive TAAD patients with aortic root and/or ascending aortic aneurysms seen between 2011 and 2020 were included. Serial echocardiography, family history of TAAD, and management information were retrospectively collected and analyzed. Patients were classified into gene-positive (Gen-P), variants of uncertain significance, and gene-negative (Gen-N) groups., Results: A total of 407 patients were included: mean age 53.7 ± 15.4 years, 64.4% men, and 38% with reported family history of TAAD. Thirty-seven (9.1%) were Gen-P; 147 (36.1%) had a variant of uncertain significance. The maximal aneurysm diameter was 4.78 mm larger in Gen-P than the other groups (P < .001). In 162 unoperated TAAD patients with serial echocardiographic measurements, aneurysms enlarged at a significantly higher rate in the Gen-P (1.36 mm/year, 95% CI: 0.77-1.95) than variants of uncertain significance and Gen-N groups (0.83 mm/year vs 0.89 mm/year, respectively; P < .001). Aneurysms were 20% more likely to require surgical intervention for every millimeter increase in diameter. When considered on an individual basis, the highest growth rates were found in the variants of uncertain significance group., Conclusions: While aneurysms linked to variants of uncertain significance demonstrate average growth rates comparable to those in Gen-N, close follow-up and genetic counseling in the variants of uncertain significance group are recommended for assessment of pathogenicity on a case-by-case basis. Early familial gene testing in TAAD is important to develop individualized preventive and therapeutic criteria., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Hypertrophic cardiomyopathy is the most common inherited cardiac disease, exhibiting diverse phenotypes. Obstructive hypertrophic cardiomyopathy occurs in about two-thirds of cases and carries a worse prognosis. Mavacamten use in heart transplant recipients is limited. This paper reports a recipient who developed severe symptomatic obstructive hypertrophic cardiomyopathy phenotype/phenocopy and was initiated on mavacamten., Competing Interests: Dr Abood’s time was supported by the Colton Scholarship, which played no role in this case or this manuscript, including the decision to submit it for publication. The authors have reported that they have no relationships relevant to the contents of this paper to disclose., (© 2024 The Authors.)

Aims: In clinical trials, mavacamten reduced left ventricular outflow tract obstruction (LVOTO) and improved symptoms in patients with symptomatic obstructive hypertrophic cardiomyopathy (oHCM). We aimed to share our real-world experience with the efficacy and safety of mavacamten in this patient population., Methods and Results: This retrospective, single-centre study included patients with symptomatic oHCM from March 2023 to November 2023. Inclusion criteria were oHCM, age >18 years, significant LVOTO (gradient >50 mmHg at rest or with Valsalva), New York Heart Association (NYHA) class ≥II despite maximally tolerated medical therapy, and left ventricular ejection fraction (LVEF) >55%. Patients were evaluated by echocardiography, NYHA class, electrocardiography and Holter monitor on each monthly visit for 3 months. A total of 31 patients were included in this study. The mean (SD) age was 58 (16.5) years, and 14 (45%) were female. Mean provoked left ventricular outflow tract gradient (LVOTG) reduced by -49.4 mmHg (P < 0.001) at 4 weeks, -59.2 mmHg (P < 0.001) at 8 weeks, and -60.8 mmHg (P < 0.001) at 12 weeks. Twenty-six of the 31 patients (83.8%) achieved an LVOTG ≤30 mmHg at Week 12. No major side effects were reported. Sixty-seven percent experienced ≥2 NYHA class improvements, LVEF remained above 55% and no dose titration was made., Conclusions: Our real-world experience aligns with established mavacamten trial outcomes. Continuous vigilance and longitudinal investigations are needed to further assess potential long-term impacts., (© 2024 The Author(s). ESC Heart Failure published by John Wiley & Sons Ltd on behalf of European Society of Cardiology.)

Background: Vasospastic angina usually presents with intermittent episodes of chest pain. It can rarely be associated with the perception of phantom odors., Case Summary: A 69-year-old woman presented for evaluation of intermittent shortness of breath and chest pain. She reported that she often experienced an abnormal smell sensation just prior to the event. The patient had abnormal smell sensation and shortness of breath at the initiation of exercise stress echocardiography with transient electrocardiographic changes and new regional wall motion abnormalities. Subsequent invasive coronary angiography showed no obstructive epicardial coronary artery disease. The patient was started on calcium channel blocker therapy with resolution of symptoms., Conclusion: Phantom odor perception has been rarely reported as an angina-equivalent symptom. Clinicians should have a high index of suspicion in patients presenting with atypical anginal symptoms., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (© 2024 Zubair, Suma, Masood, Jan, Bajwa and Haddadian.)

Background: Patients with hypertrophic cardiomyopathy (HCM) have been shown to exhibit abnormal diastolic vessel flow; however, flow pattern profiles and their possible association with different grades of diastolic dysfunction have not been studied. Color Doppler two-dimensional echocardiography permits visualization of the septal perforator arteries, and pulsed-wave Doppler allows recording of diastolic septal artery flow (SAF). Through routine visualization of the septal perforator arteries and acquisition of SAF, we noticed 3 patterns of SAF in patients with HCM. In this study, we aimed to assess the feasibility of the acquisition of SAF and to describe types of SAF in an HCM cohort and their associations with diastolic function., Methods: We reviewed two-dimensional echocardiograms and the electronic records of 108 patients with HCM in whom septal artery color and spectral Doppler had been performed. The peak diastolic and end-diastolic velocities, diastolic slope, diastolic flow time-velocity integral, and systolic flow reversal of the septal perforator arteries were recorded with pulsed-wave Doppler. Echocardiographic and clinical characteristics were analyzed., Results: A reproducible pulsed-wave Doppler tracing was recorded in 54% of patients with HCM. Three distinct patterns of SAF were identified: type 1-smooth, linear holodiastolic velocity decrease; type 2-with presence of an atrial dip; and type 3-biphasic velocity decrease with an early, rapid diastolic slope and a mid-to-late gentle slope. These 3 SAFs correlated with different grades of diastolic dysfunction., Conclusion: Septal artery flow could be detected in more than 50% of patients with HCM. Three distinct types of SAF were identified, correlating with different grades of diastolic dysfunction. These 3 types of SAF can provide additional information about left ventricular end-diastolic pressure and diastolic function in patients with HCM in whom diastolic function may be difficult to determine., Competing Interests: Conflicts of Interest None., (Copyright © 2023 American Society of Echocardiography. Published by Elsevier Inc. All rights reserved.)

The age-based trends in-hospital outcomes in patients with percutaneous left atrial appendage occlusion (LAAO) are unknown. Using the National Readmission Database from 2016 to 2019, patients who underwent LAAO were divided into 2 age groups: 60 to 79 and ≥80 years. The primary objective was to evaluate the age-based trends in the outcomes related to LAAO. The secondary objectives were to evaluate the mean cost and total cumulative cost of readmissions in both age groups in 2019. We identified 58,818 patients who underwent LAAO, of whom 36,964 (63%) were aged 60 to 79 years, and 21,854 (37%) were ≥80 years. The hospital mortality, pericardial complications, acute kidney injury, and in-hospital cardiac arrest did not change over time. The risk-adjusted postoperative stroke and bleeding requiring blood transfusion decreased in patients aged ≥80 years (p trend 0.03 for both outcomes). The length of stay decreased, and early discharge rates increased over time in both the unadjusted and risk-adjusted models in both age groups. The risk-adjusted 90-day readmission rates also decreased in patients aged ≥80 years. The inflation-adjusted cost did not change over time on the unadjusted and adjusted analyses. The total cumulative all-cause 90-readmission cost for both groups in 2019 was $31.7 million. Most outcomes after LAAO either improved or did not change from 2016 to 2019. Hospital mortality has remained <0.5% consistently since 2016. The risk-adjusted postoperative stroke, bleeding, and 90-day readmission rates improved in elderly vulnerable patients aged ≥80 years. The inflation-adjusted cost did not improve despite the decreasing length of stay and improving early discharge rates., Competing Interests: Declaration of Competing Interest The authors have no competing interests to declare., (Copyright © 2023 Elsevier Inc. All rights reserved.)

There are no national data on age-based outcomes of septal reduction therapy. Using the National Inpatient Sample, we included all adult patients who underwent septal myectomy (SM) or alcohol septal ablation (ASA) from 2005 to 2019. The primary objective was to evaluate the in-hospital mortality and new permanent pacemaker (PPM) placement after SM and ASA in 3 age groups. In total, 9,564 patients underwent SM and 5,084 underwent ASA. Compared with the age group 18 to 39 years, the odds of in-hospital mortality after SM were similar in age group 40 to 64 years and 4.46 times higher than in age group ≥65 years; the higher mortality in the older group was explained by higher co-morbidity burden on the risk-adjusted analysis. Furthermore, compared with age group 18 to 39 years, the odds of new PPM placement after SM were higher in the age groups 40 to 64 years and ≥65 years, despite the risk adjustment (adjusted odds ratio [AOR] 3.17, 95% confidence interval [CI] 1.33 to 7.58 and AOR 4.39, 95% CI 1.78 to 10.8, respectively). The odds of in-hospital mortality after ASA were similar in age groups 65 to 79 years and 18 to 64 years. However, the odds of in-hospital mortality were higher in the age group ≥80 years than in the age group 18 to 64 years, although this difference were not present after risk adjustment. The odds of new PPM after ASA were higher for the age groups 65 to 79 years and ≥80 years than age group 18 to 64 years, despite the risk adjustment (AOR 1.78, 95% CI 1.22 to 2.60 and AOR 3.10, 95% CI 2.09 to 6.57, respectively). Finally, we also estimated these absolute risks in different age groups. In conclusion, this national data will inform health care providers to better understand the aged-based risks of outcomes after septal reduction therapy., Competing Interests: Declaration of Competing Interest The authors have no competing interests to declare., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: Pressure-strain loop analysis is a novel echocardiographic technique to calculate myocardial work indices that has not been applied to patients with apical hypertrophic cardiomyopathy (ApHCM). We hypothesized that myocardial work indices differ between patients with ApHCM and those with non-ApHCM. This study aimed to (1) evaluate myocardial work indices in patients with ApHCM compared with those with non-ApHCM, (2) describe associations with relevant clinical variables, and (3) examine associations with significant late gadolinium enhancement (LGE) on cardiac magnetic resonance imaging., Methods: We retrospectively identified 48 patients with ApHCM and 69 with non-ApHCM who had measurements of global longitudinal strain (GLS), global work index (GWI), global constructive work (GCW), global wasted work, and global work efficiency. We evaluated available cardiac magnetic resonance imaging data on 34 patients with ApHCM and 51 with non-ApHCM. Multivariable regression models correcting for traditional cardiac risk factors were used to evaluate the associations of myocardial work indices with relevant clinical variables., Results: Median GLS (-11% vs -18%, P < .001), GWI (966 mm Hg% vs 1803 mm Hg%, P < .001), and GCW (1,050 mm Hg% vs 1,988 mm Hg%, P < .001) were significantly impaired in patients with ApHCM compared with those with non-ApHCM. Increasing N-terminal pro b-type natriuretic peptide, abnormal ultrasensitive troponin, and increasing maximal left ventricular wall thickness were significantly associated with reduced GWI and GCW in patients with ApHCM (P < .05). Global constructive work had only modest accuracy (area under the curve [AUC] = 0.70) to predict LGE in patients with ApHCM. However, in patients with non-ApHCM, GLS was the strongest predictor of LGE (AUC = 0.91), with a -17% cutoff yielding 81% sensitivity and 80% specificity., Conclusion: Myocardial work indices are significantly impaired in patients with ApHCM compared to those with non-ApHCM and correlate with important clinical variables. Global longitudinal strain, GWI, and GCW are more strongly predictive of fibrosis in patients with non-ApHCM than ApHCM., (Copyright © 2023 American Society of Echocardiography. Published by Elsevier Inc. All rights reserved.)

We aimed to evaluate longitudinal trends of racial and ethnic disparities in the utilization of diagnostic angiograms, percutaneous coronary intervention (PCI), and coronary artery bypass graft surgery (CABG) for non-ST elevation myocardial infarction (NSTEMI) and ST elevation myocardial infarction (STEMI). We retrospectively analyzed the National Inpatient Sample (2005-2019). The 15-year period was divided into 5, 3-year periods. Our study included 9 million adult patients (NSTEMI, 72%; STEMI, 28%). No improvement in utilization of these procedures was seen in period 5 (2017-2019) vs period 1 (2005-2007) for both NSTEMI and STEMI in non-White patients vs White patients (P > 0.05 for all comparisons), excepting in CABG for STEMI in Black patients vs White patients (difference in CABG rate: period 1, 2.6%; period 5, 1.4%; P = 0.03). Reducing disparities in PCI for NSTEMI and both PCI and CABG for STEMI in Black patients vs White patients was associated with improved outcomes., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Purpose: Dual antiplatelet therapy is standard for patients undergoing percutaneous coronary intervention (PCI) with stents. Traditionally, patients swallow the loading dose of a P2Y12 inhibitor before or during PCI. Time to achieve adequate platelet inhibition after swallowing the loading dose varies significantly. Chewed tablets may allow more rapid inhibition of platelet aggregation. However, data for this strategy in patients with stable ischemic heart disease or non-ST-elevation acute coronary syndrome (NSTE-ACS) are less robust., Methods: In this single-center prospective trial, 112 P2Y12-naïve patients with stable ischemic heart disease or NSTE-ACS on aspirin therapy and who received ticagrelor after coronary angiography but before PCI were randomized to chewing (n=55) or swallowing (n=57) the ticagrelor loading dose (180 mg). Baseline variables were compared using 2-sample t -test and chi-squared/Fisher's exact tests as appropriate, with alpha set at 0.05. P2Y12 reaction units (PRU) were compared at baseline, 1 hour, and 4 hours using Wilcoxon rank-sum test. Patients then received standard ticagrelor dosing., Results: After exclusions, P2Y12 PRU in the chewed and swallowed groups at baseline, 1 hour, and 4 hours after ticagrelor loading dose were 243 vs 256 (P=0.75), 143 vs 210 (P=0.09), and 28 vs 25 (P=0.89), respectively. No differences were found in major adverse cardiac events (MACE) or major bleeding at 30 days and 1 year., Conclusions: In patients with stable ischemic heart disease or NSTE-ACS, chewing rather than swallowing ticagrelor may lead to slightly faster inhibition of platelet aggregation at 1 hour with no increase in MACE or major bleeding., Competing Interests: Conflicts of Interest None., (© 2023 Advocate Aurora Health, Inc.)

Background:  Although uncomplicated Type B aortic dissection (uTBAD) is traditionally treated with optimal medical therapy (OMT) as per guidelines, recent studies, performed primarily in interventional radiology or surgical operating rooms, suggest superiority of thoracic endovascular aortic repair (TEVAR) over OMT due to recent advancements in endovascular technologies. We report a large, single-center, case control study of TEVAR versus OMT in this population, undertaken solely in a cardiac catheterization laboratory (CCL) with a cardiologist and surgeon. We aimed to determine if TEVAR for uTBAD results in better outcomes compared with OMT., Methods:  This was a retrospective chart review of all patients with uTBAD during the last 13 years, with 46 cases (TEVAR group) and 56 controls (OMT group)., Results:  In the TEVAR group, the procedure duration of 2.5 hours resulted in 100% procedural success for stent placement, with 63% undergoing protective left subclavian artery bypass, 0% mortality or stroke, and a lower readmission rate (1 vs. 2%; p  = 0.04 in early TEVAR cases), but a longer length of stay (12.9 vs. 8.5 days: p  = 0.006). The risk of all-cause long-term mortality was markedly reduced in the TEVAR group (RR = 0.38; p  = 0.01), irrespective of early (<14 days) versus late intervention. On follow-up computed tomography imaging, the false lumen stabilized or decreased in 85% of cases, irrespective of intervention timing., Conclusion:  TEVAR performed solely in the CCL is safe and effective, with lower all-cause mortality than OMT. These data, in collaboration with previous data on TEVAR in different settings, call for consideration of an update of practice guidelines., Competing Interests: The authors declare no conflict of interest related to this article., (The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/).)

Manganese deficiency critically impairs the function and stability of photosystem II (PSII) and negatively impacts crop growth and yield. However, the response mechanisms of carbon and nitrogen metabolism to Mn deficiency in different genotypes of maize and the differences in Mn deficiency tolerance are unclear. Herein, three different genotypes of maize seedlings (sensitive genotype: Mo17, tolerant genotype: B73, and B73 × Mo17) were exposed to Mn deficiency treatment for 16 days using liquid culture with different concentrations of MnSO 4 [0.00, 2.23, 11.65, and 22.30 mg/L (control)]. We found that complete Mn deficiency significantly reduced maize seedling biomass; negatively affected the photosynthetic and chlorophyll fluorescence parameters; and depressed nitrate reductase, glutamine synthetase, and glutamate synthase activity. This resulted in reduced leaf and root nitrogen uptake, with Mo17 being most severely inhibited. B73 and B73 × Mo17 maintained higher sucrose phosphate synthase and sucrose synthase activities and lower neutral convertase activity compared to Mo17, which resulted in higher accumulation of soluble sugars and sucrose and maintenance of the osmoregulation capacity of leaves, which helped mitigate damage caused by Mn deficiency. The findings revealed the physiological regulation mechanism of carbon and nitrogen metabolism in different genotypes of maize seedlings that resist Mn deficiency stress, providing a theoretical basis for developing high yield and quality.

Background Although sex disparities in the diagnostic evaluation and revascularization of patients with acute myocardial infarction are well documented, no study has evaluated longitudinal trends in these disparities. Methods and Results Using the National Inpatient Sample from 2005 to 2019, 9 259 932 patients with acute myocardial infarction were identified. We divided 15 years into five 3-year periods. The primary objective was to evaluate sex-based trends in the use of diagnostic angiography, percutaneous coronary intervention, and coronary artery bypass graft (CABG) among patients with non-ST-segment-elevation myocardial infarction and ST-segment-elevation myocardial infarction (STEMI) over 15 years. The secondary objective was to evaluate sex disparities in mortality, length of stay, and cost. For non-ST-segment-elevation myocardial infarction, we saw a small reduction in sex disparity in the use of all diagnostic angiography in period 5 versus period 1 (4% versus 5.3%; P <0.01), no change in sex disparity in percutaneous coronary intervention use in period 5 versus period 1 (5.6% versus 5%; P =0.16), and a widening sex disparity in CABG in period 5 versus period 1 (5.4% versus 4.4%; P <0.01). However, we noted decreasing sex disparities in the use of diagnostic angiography, percutaneous coronary intervention, and CABG for ST-segment-elevation myocardial infarction in mostly all periods compared with period 1 ( P <0.05, all comparisons), but differences still existed in period 5. Risk-adjusted in-hospital mortality was higher after CABG for non-ST-segment-elevation myocardial infarction and after percutaneous coronary intervention and CABG for ST-segment-elevation myocardial infarction in women than men. Conclusions Despite variable trends in sex disparities in diagnostic and revascularization procedures for acute myocardial infarction, disparities still exist.

The regional differences in the use of septal reduction therapies and the associated outcomes in patients with Hypertrophic obstructive cardiomyopathy (HOCM) are unknown. The primary objective of our study was to evaluate the regional disparities in the use of septal reduction therapies, including septal myectomy and alcohol septal ablation, in patients with HOCM. The secondary objective was to analyze the regional differences in the outcomes in these patients. Patients with HOCM had 87% higher risk-adjusted odds of getting septal myectomy (adjusted odds ratio 1.87, p = 0.03) and 37% lower risk-adjusted odds of getting alcohol septal ablation (adjusted odds ratio 0.63, p = 0.03) in the Midwest than in the Northeast. The in-hospital mortality rate was higher for patients who underwent septal myectomy in the South versus the Northeast on the unadjusted analysis. These differences persisted despite the adjustment for demographic and clinical characteristics. Additional adjustment for hospital volume partially explained these disparities, but the adjustment for both hospital volume and hospital teaching status completely explained these disparities. The risk-adjusted in-hospital mortality in patients who underwent alcohol septal ablation was similar in the South versus other regions. In conclusion, regional disparities may exist in the use of septal myectomy and alcohol septal ablation, and patients with HOCM should be referred to high-volume teaching hospitals for septal myectomy for better outcomes, which may also eliminate the extra burden of hospital mortality in the South., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Purpose: To evaluate the effectiveness and safety of atherectomy versus plain balloon angioplasty (POBA) for treatment of critical limb ischemia (CLI) due to tibioperoneal arterial disease (TPAD)., Materials and Methods: Patients enrolled in the Vascular Quality Initiative registry who had CLI (Rutherford Class 4-6) and underwent atherectomy versus POBA alone for isolated TPAD were retrospectively identified. Of eligible patients, a cohort of 2,908 patients was propensity matched 1:1 by clinical and angiographic characteristics. The atherectomy group comprised 1,454 patients with 2,183 arteries treated, and the POBA group comprised 1,454 patients with 2,141 arteries treated. The primary study endpoint was major ipsilateral limb amputation. Secondary endpoints were minor ipsilateral amputations, any ipsilateral amputation, primary patency, target vessel reintervention (TVR), and wound healing at 12 months., Results: The median follow-up period was 507 days, the mean patient age was 69 years ± 11.7, and the mean occluded length was 6.9 cm ± 6.5. There was a trend toward higher technical success rates with atherectomy than with POBA (92.9% vs 91.0%, respectively; P = .06). The rates of major adverse events during the procedure were not significantly different. The 12-month major amputation rate was similar in the atherectomy and POBA groups (4.5% vs 4.6%, respectively; P = .92; odds ratio, 0.97; 95% CI, 0.68-1.37). There was no difference in 12-month TVR (17.9% vs 17.8%; P = .97) or primary patency (56.4% vs 54.5%; P = .64) between the atherectomy and POBA groups., Conclusions: In a large national registry, treatment of CLI from TPAD using atherectomy versus POBA showed no significant differences in procedural adverse events, major amputations, TVR, or vessel patency at 12 months., (Copyright © 2022 SIR. Published by Elsevier Inc. All rights reserved.)

Background: Hypertensive crisis is a life-threatening condition, further classified as hypertensive emergency and hypertensive urgency based on the presence or absence of acute or progressive end-organ damage, respectively. Readmissions in hypertensive emergency have been studied before. We aimed to analyze 30-day readmissions using recent data and more specific ICD-10-CM coding in patients with hypertensive crisis., Methods: In a retrospective study using the National Readmission Database 2018, we collected data on 129,239 patients admitted with the principal diagnosis of hypertensive crisis. The primary outcome was the all-cause 30-day readmission rate. Secondary outcomes were common causes of readmission, in-hospital mortality, resource utilization, and independent predictors of readmission. We also compared outcomes between patients with hypertensive urgency and hypertensive emergency., Results: Among 128,942 patients discharged alive, 13,768 (10.68%) were readmitted within 30 days; the most common cause of readmission was hypertensive crisis (19%). In-hospital mortality for readmissions (1.5%) was higher than for index admissions (0.2%, P < 0.01). Mean length of stay for readmissions was 4.5 days. The mean hospital cost associated with readmissions was $10,950, and total hospital costs were $151 million. Age <65 years and female sex were independent predictors of higher readmission rates. Subgroup analysis revealed a higher readmission rate for hypertensive emergency than hypertensive urgency (11.7% vs. 10%, P < 0.01)., Conclusions: All-cause 30-day readmission rates are high in patients admitted with hypertensive crisis, especially patients with hypertensive emergency. Higher in-hospital mortality and resource utilization are associated with readmission in these patients., (© The Author(s) 2022. Published by Oxford University Press on behalf of American Journal of Hypertension, Ltd. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Objective: Small, older studies have suggested that the use of atherectomy devices has become common in peripheral vascular interventions (PVIs) despite the paucity of strong clinical guidelines. We analyzed the 10-year trends in the use of atherectomy for PVIs across the United States and identified the main predictors of atherectomy use., Methods: Using the Vascular Quality Initiative registry, we identified all patients who had undergone endovascular PVIs for occlusive lower extremity arterial disease from 2010 to 2019. Procedures in which an atherectomy device had been used as the primary or secondary device were classified as the atherectomy group. We calculated the frequency of atherectomy use over time and across geographic regions. Using regression modeling, we identified the factors that were independently associated with atherectomy use., Results: A total of 205,377 PVIs had been performed for 152,693 unique patients. During the 10-year period, 16.6% of the PVI procedures had used atherectomy, increasing from 8.5% in 2010 to 19.7% in 2019 (P trend  < .0001). Across 17 geographic regions, we found a significant difference in the prevalence of atherectomy use, ranging from 8.2% to 29%. The strongest predictor of atherectomy use was performance of PVI in an office setting (odds ratio [OR], 10.08; 95% confidence interval [CI], 9.17-11.09) or ambulatory center (OR, 4.0; 95% CI, 3.65-4.39) vs a hospital setting. The presence of severe (OR, 2.6; 95% CI, 2.4-2.85) or moderate (OR, 1.5; 95% CI, 1.4-1.69) lesion calcification was also predictive of atherectomy use. Other predictive factors included elective status, insurance provider, lesion length, prior PVI, claudication symptoms, and diabetes mellitus., Conclusions: Atherectomy use in PVI significantly increased from 2010 to 2019. We found wide regional variability in the use of atherectomy that seemed to be driven more strongly by nonclinical factors., (Copyright © 2022 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Objectives: The aim of the study is to evaluate current trends and long-term durability of both drug-eluting stents (DES) and drug-coated balloons (DCB) in the treatment of peripheral artery disease (PAD)., Background: PAD affects more than 200 million people worldwide. Endovascular treatment of critical PAD has advanced in recent years. DES and DCB have demonstrated superiority compared to balloon angioplasty or bare metal stenting. The current literature lacks any long-term, direct comparison., Methods: A retrospective analysis was completed on patients who had femoral-popliteal interventions from June 2014 to June 2018 with either DCB or DES. Patient medical data and lesion characteristics were retrieved using the Vascular Quality Initiative database. Outcomes were analyzed through December 2019. Primary endpoint of time to clinical event-driven target lesion reintervention (TLR) and secondary endpoint of all-cause mortality were examined., Results: Four hundred eighty-three patients with a total of 563 interventions met the inclusion criteria. Three hundred fifty-nine DCB and 204 DES were performed. Of the DCBs, 132 required bailout stenting at the time of procedure. The mean time for TLR in the DES group was 1,277 days (SD 546), compared to 904 days (SD 330.1) for DCB. For patients requiring TLR, DES remained patent significantly longer (373 days longer on average) ( p < 0.001). For all-cause mortality there was no significant difference at 50 months between DCB and DES ( p = 0.06)., Conclusions: In patients who required TLR, DES had a significantly longer length of time to reintervention vs DCB (average 373 days), although no difference in mortality was observed., Competing Interests: The authors declare that they have no conflicts of interest regarding the publication of this paper., (Copyright © 2022 Nathan Marzlin et al.)

Objective: Despite the widespread use of inferior vena cava filters (IVCFs), no large controlled trials have examined the IVCF retrieval rates and clinical events for patients without retrieved IVCFs. We hypothesized that IVCF retrieval success would decrease as the time from placement increased and that the clinical event rates would be more prevalent for those without a retrieved IVCF. We evaluated retrieval success as a function of time and compared the rates of venous thromboembolism and mortality between patients who had undergone IVCF retrieval within 12 months vs patients with unsuccessful IVCF retrieval., Methods: All patients who had undergone IVCF placement between 2011 and 2017 with available follow-up data at eight community hospitals were enrolled in our retrospective cohort study. The procedure dates, incidence of subsequent deep vein thrombosis (DVT) and pulmonary embolism, and mortality dates were collected. Patients were classified as having a nonretrieved IVCF if their IVCF had not been retrieved after ≥12 months of follow-up., Results: Of 1709 patients who had undergone IVCF placement, IVCF retrieval was successful for 770. We found a significant (P = .018) decrease in retrieval success as the time from IVCF insertion increased. After a mean of 36 ± 16 months, the incidence of subsequent DVT was lower in the retrieved group than in the nonretrieved group (8.1% vs 11.9%; P = .05; hazard ratio, 0.65; 95% confidence interval, 0.42-1.00). Mortality was lower for those with retrieved than for those without retrieved IVCFs (8.8% vs 28.8%; P < .001; hazard ratio, 0.5; 95% confidence interval, 0.35-0.7). No significant difference was found in the rate of pulmonary embolism., Conclusions: IVCF nonretrieval was more likely for older patients with a greater prevalence of comorbid conditions. Increased rates of subsequent DVT and mortality were observed for patients without IVCF retrieval. Finally, the likelihood of successful IVCF retrieval decreased with increased time from IVCF placement., (Copyright © 2022 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Purpose: The COVID-19 pandemic posed unprecedented demands on health care. This study aimed to characterize COVID-19 inpatients and examine trends and risk factors associated with hospitalization duration, intensive care unit (ICU) admission, and in-hospital mortality., Methods: This retrospective study analyzed patients with SARS-CoV-2 infection hospitalized at an integrated health system between February 2, 2020, and December 12, 2020. Patient characteristics and clinical outcomes were obtained from medical records. Backward stepwise logistic regression analyses were used to identify independent risk factors of ICU admission and in-hospital mortality. Cox proportional hazards models were used to evaluate relationships between ICU admission and in-hospital mortality., Results: Overall, 9647 patients were analyzed. Mean age was 64.6 ± 18 years. A linear decrease was observed for hospitalization duration (0.13 days/week, R 2 =0.71; P<0.0001), ICU admissions (0.35%/week, R 2 =0.44; P<0.001), and hospital mortality (0.16%/week, R 2 =0.31; P<0.01). Bacterial co-infections, male sex, history of chronic lung and heart disease, diabetes, and Hispanic ethnicity were identified as independent predictors of ICU admission (P<0.001). ICU admission and age of ≥65 years were the strongest independent risk factors associated with in-hospital mortality (P<0.001). The in-hospital mortality rate was 8.3% (27.4% in ICU patients, 2.6% in non-ICU patients; P<0.001)., Conclusions: Results indicate that, over the pandemic's first 10 months, COVID-19 carried a heavy burden of morbidity and mortality in older patients (>65 years), males, Hispanics, and those with bacterial co-infections and chronic comorbidities. Although disease severity has steadily declined following administration of COVID-19 vaccines along with improved understanding of effective COVID-19 interventions, these study findings reflect a "natural history" for this novel infectious disease in the U.S. Midwest., Competing Interests: Conflicts of Interest None., (© 2022 Aurora Health Care, Inc.)

Objective: To describe our institution's experience with the AngioVac system., Background: Intracardiac and intravascular masses previously required surgical excision, but now, there are a number of minimally invasive options. With the advent of vacuum aspiration, more specifically the AngioVac System (AngioDynamics, NY, USA), there exists a system with both low mortality and minor complications. However, the number of retrospective studies remains limited. Outcome data for high-risk patients are also limited., Methods: Data were collected and analyzed in patients who underwent AngioVac therapy at our tertiary care center from January 2014 to December 2020., Results: Our results demonstrated a 93.3% intraoperative success rate and a 100% intraoperative survival rate. However, a number of complications, including but not limited to hematomas, anemia, and hypotension, occurred, as described below., Conclusions: Our experiences demonstrated good outcomes and continue to support the usefulness of the AngioVac System. The data also support the use of AngioVac as a treatment option for the debulking or removal of right heart masses in critically ill patients., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2021 Aashish Katapadi et al.)

This project sought to evaluate if business card distribution improved the utility of Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) surveys by serving as a feedback mechanism for trainees. Between fall 2018 and spring 2019, patient encounters for 6 cardiovascular disease fellows were tracked over two 60-day periods. Six weeks were allowed for HCAHPS surveys to be returned. Business cards were subsequently deployed and encounters similarly tracked. During the control-group monitoring period, 721 patient encounters were logged and 80 (11.1%) surveys were returned. Qualitative feedback, in the form of free-response comments, was provided in 41 (51.3%) surveys. Business cards were then deployed and encounters similarly tracked. During the business card period, 508 patient encounters occurred and 97 (19.1%) surveys were returned. Qualitative feedback was provided in 52 (53.6%) surveys. No fellow-specific feedback was returned in either group. Business card use by trainees was associated with an improved rate of survey return, from 11.1% to 19.1%, but no effect on feedback to fellows or patient satisfaction scores was found. HCAHPS surveys were not useful in providing trainees with feedback. Immediate verbal feedback from patients via ancillary staff was observed. A method of relaying communication from patients to ancillary staff and medical education programs is needed., Competing Interests: Conflict of interest None., (© 2021 Aurora Health Care, Inc.)

Integrated, data-driven criteria are necessary to evaluate delivery outcomes in pregnancies affected by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) during the ongoing COVID-19 pandemic. This study analyzed maternal demographics, clinical characteristics, treatments, and delivery outcomes of 85 ethnically diverse, adult pregnant women who tested positive for SARS-CoV-2 at the time of delivery. Median maternal and gestational ages were 27 years (interquartile range [IQR]: 23-31) and 39 weeks (IQR: 37.3-40.0), respectively. Of the 85 SARS-CoV-2-positive participants, 67 (79%) had no COVID-19 symptoms at the time of routine COVID-19 admission testing, 14 (16%) reported mild COVID-19 symptoms, and 4 (5%) presented severe COVID-19 symptoms that required hospitalization. Patients in the severe COVID-19 group had significantly longer hospitalizations than those with nonsevere COVID-19 (7 [IQR: 4.5-9.5] vs 2 [IQR: 2-3] days; P<0.01). Neonatal outcomes included 100% live births with a median 1-minute Apgar score of 8 and 15% preterm births. No neonatal deaths or vertical transmissions were reported, and all neonatal intensive care unit admissions were related to prematurity. Overall, maternal symptom prevalence and peripartum complication rates were low, suggesting a generally good prognosis for pregnant women with SARS-CoV-2 infections at the time of delivery., Competing Interests: Conflict of interest None., (© 2021 Aurora Health Care, Inc.)

Aortic thrombus is a rarely identified source of distal embolization. A conservative approach with anticoagulation alone carries a significant risk of embolization. Various open surgical approaches have been suggested as therapeutic options, but all of them carry a significant morbidity and mortality risk in this population subgroup. Contemporary endovascular approaches aimed at exclusion of the floating thrombus are now increasingly performed, and have significantly lower periprocedural complications compared with an open surgical approach.

Multiple lentigines syndrome is an autosomal dominant inherited condition with variable expressivity that is also known as LEOPARD syndrome. LEOPARD stands for lentigines, electrocardiographic conduction defects, ocular hypertelorism, pulmonary valve stenosis, abnormalities of genitalia, retardation of growth, and deafness. LEOPARD syndrome most frequently develops secondary to a missense mutation of protein-tyrosine phosphatase nonreceptor type 11 gene, which encodes tyrosine phosphatase. The missense mutation p.Tyr279Cys can either occur as a de novo mutation or affect multiple family members. Although hypertrophic cardiomyopathy is not part of the LEOPARD acronym, it is the most frequent cardiac anomaly observed in this syndrome. The recognition of increased left or right ventricular wall thickness in patients with LEOPARD syndrome may have significant impact on their clinical course similar to classic hypertrophic cardiomyopathy, which may require septal reduction procedures for relief of left or right ventricular outflow tract obstruction or implantable cardioverter-defibrillator placement for sudden cardiac death prevention. We describe a case series of a family with diffuse lentigines and hypertrophic cardiomyopathy in which the son carries the protein-tyrosine phosphatase nonreceptor type 11 (p.Tyr279Cys) gene mutation and both the son and daughter underwent left ventricular myectomy at an early age. In conclusion, our case series of a family with LEOPARD syndrome illustrates the importance of recognizing hypertrophic cardiomyopathy as part of this syndrome., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Importance: Malignant arrhythmic mitral valve prolapse (MVP) phenotype poses a substantial risk of sudden cardiac death (SCD), and an estimated 26 000 individuals in the United States are at risk of SCD per year. Thus, identifying risk-stratification strategies for SCD is imperative., Observations: Patients with MVP have a heterogenous clinical spectrum, ranging from a benign course to a devastating complication such as SCD. Some of the high-risk markers of MVP, which are identified electrocardiographically, include inverted or biphasic T waves, QT dispersion, QT prolongation, and premature ventricular contractions originating from the left ventricular outflow tract and papillary muscles. Morphofunctional characteristics of SCD are leaflet thickness of 5 mm or greater, mitral annulus disjunction, paradoxical systolic increase of the mitral annulus diameter, increased tissue Doppler velocity of the mitral annulus, and higher mechanical dispersion on echocardiography and fibrosis identified by late gadolinium enhancement on cardiac magnetic resonance imaging., Conclusions and Relevance: Findings from this review suggest that SCD can occur earlier in the course of MVP from complex arrhythmias that are triggered by the repeated tugging and traction of the chordopapillary muscle unit and basal mid-myocardium, even before macrofibrosis can be identified in these regions by late gadolinium enhancement on cardiac magnetic resonance imaging. Some of the newer markers identified by speckle-tracking Doppler, such as mechanical dispersion, myocardial work index, and postsystolic shortening, need further validation in a larger population.

Background: Prior studies have neither described methods for crossing a severely stenotic aortic valve (AV) in light of modern imaging modalities (echocardiography, computed tomography, fluoroscopy) nor characterized a successful crossing. This study aimed to fill that gap., Methods: Time to cross the valve (TTCV) was measured prospectively in 35 consecutive patients undergoing transcatheter AV replacement and used to define two groups (≤60 seconds or >60 seconds). TTCV was analyzed as a function of 20 imaging variables. The AV was crossed systematically with a pigtail catheter parked in the non-coronary cusp, AL-1 catheter above the AV, and a straight wire for crossing, in 20° left anterior oblique view, as the operator adjusted catheter-to-catheter (CTC; AL-1 to pigtail) and catheter-to-wire (CTW; pigtail to wire) with each failed pass., Results: Mean TTCV was 39.5 ± 59 seconds. Of all the imaging variables, only lower AV peak velocity (3.9 ± 0.69 m/s vs 4.28 ± 0.35 m/s; P<.05) and larger aortic annulus perimeter (77 ± 5.7 mm vs 65 ± 23 mm; P<.05) were significantly different in the <60 group (n = 29; TTCV, 21 ± 12 seconds) vs the >60 group (n = 6; TTCV, 157 ± 52 seconds). The successful pass was characterized by a CTC of 1.67 ± 0.78 cm and CTW of 0.2 ± 0.36 cm. These distances increased in horizontal hearts (CTC and CTW were 0.76 cm) to higher in normally oriented hearts (CTC, 1.63 cm; CTW, 0.5 cm) to even higher in vertical hearts (CTC, 2.9 cm; CTW, 0.56 cm)., Conclusion: Although lower peak jet velocity was associated with rapid AV crossing, the major insight from these data is characterization of a successful pass, which can facilitate clinical practice.

Right-sided aortic arch is a rare anomaly (incidence 0.05%), commonly associated with an aberrant subclavian artery (35% of cases) with a Kommerell diverticulum at the origin. This aberrant artery passes posterior to the esophagus and can cause compression syndrome. We present such a case, treated with a hybrid endovascular repair. ( Level of Difficulty: Advanced. )., (© 2020 The Authors.)

Objectives: Cardiogenic shock carries high mortality despite advancements in therapeutic interventions. Impella (Abiomed) is a mechanical circulatory support device that is being increasingly used in cardiogenic shock patients. Impella is also utilized in high-risk patients undergoing percutaneous coronary intervention (PCI). We review the trend of Impella use at a single tertiary-care center, retrospectively analyze the outcomes, and discuss the increasing use of this device in the United States., Methods: This a retrospective, observational study of Impella use for two indications, cardiogenic shock and high-risk PCI, at a tertiary-care center. The primary endpoint was the yearly implant rate of Impella and the secondary endpoint was periprocedural complications and major adverse cardiovascular events at 30 days., Results: Forty-four Impella devices were implanted between 2008 and June of 2017. The rate of Impella implantation has significantly increased since its introduction in our facility in 2008. The most common complication was acute renal dysfunction (23%) followed by vascular complications (20%). Mortality at 30 days was 75% in the cardiogenic shock group and 11% in the high-risk PCI group., Conclusion: The use of the Impella device as a mechanical circulatory support has increased since its introduction, although its acceptance rate remains low. Despite its theoretical hemodynamic advantage, the outcome in cardiogenic shock patients remains poor.

Epicardial hematoma can manifest immediately or within a few minutes to hours after coronary intervention. Review of angiogram after the diagnosis of hematoma, in our case, showed deep distal positioning of a non-polymer jacketed wire, which is the most likely cause of the adverse outcome. Multimodality imaging is critical for diagnosis and management of such cases.