bluuebunny/crossref_metadata_2025 huggingface dataset:
P1816Aortic root morphology in bicuspid aortic valve is related to the type of BAV
Authors: Masi P , Milleron O , Paul J F , Arnoult F , Ould Ouali N , Tchitchinadze M , Lansac E , Jondeau G
Published: October 2019

Background

Dilatation of the ascending aorta associated with bicuspid aortic valve (BAV) is common and has been associated with an increased risk of aortic dissection. However, the causal links between BAV types, aortic valve dysfunction and aorta phenotype are still poorly understood. Our hypothesis is that aortic root dilatation in BAV is an anatomic modification related to the BAV type.

Purpose

To assess whether the morphology and orientation of the aortic root can be predicted by the type of BAV.

Methods

86 patients with BAV without significant valvulopathy (aortic regurgitation <2 and no more than mild stenosis with mean gradient <10mmHg) referred for aortic aneurysm assessment and who had benefited from TTE and CT were studied.

Definitions

Typical BAVs have a horizontal valve opening (type I L-R and type 0 anteroposterior) while atypical BAVs have a vertical valve opening (type I N-R and type 0 lateral) (Figure). Asymmetry of the root is evaluated in type I BAV using the normalized diameter ND = sinus to commissure diameter/mean of the 3 sinus to commissure diameters.

We compared, in the typical (n=64) and atypical (n=22) BAVs, using CT, the asymmetry of the root using the normalized diameter, the orientation of the bicuspid aortic valve opening and the orientation of the largest diameter of the aortic root using the sagittal plane as a reference (Figure).

Results

Patients with typical and atypical BAVs were comparable for age, sex, weight, height, aortic root surface area and maximum aortic root diameter.

Aortic root asymmetric modifications were related to the type of BAV with: – a predominant non coronary sinus dilatation in type I L-R (Non coronary sinus to commissure normalized diameter = 1.02 in Type I l-R vs 0.98 in type I R-N; p=0.0004). – a predominant left coronary sinus dilatation in type I L-N (left coronary sinus to commissure normalized diameter = 1.07 in type I R-N vs 1.01 in type I L-R; p<0.0001). – a significantly larger anteroposterior diameter in type 0 typical BAVs (45mm vs 40mm p=0.02) and a significantly larger lateral diameter in type 0 atypical BAVs (48mm vs 39mm p=0.0003). The orientation of the aortic valve opening is correlated with the type of BAV: Using the sagittal plan as a reference, this angle is 144,9° for the typical BAVs vs 56,6° for the atypical BAVs p<0.0001 (Figure). The orientation of the maximal aortic diameter is correlated with the type of BAV: Using the sagittal plan as a reference, this angle is 64.3° for the typical BAVs and 143,1° for the atypical BAVs p<0.0001 (Figure 1).

Figure 1

Conclusion

The morphology and orientation of the aortic root in BAVs are strongly correlated with the type of BAV, suggesting anatomical modifications rather than aortopathy.
P1822Pocket-size mobile echocardiographic device screening for thoracic aortic aneurysm in asymptomatic hypertensive patients
Authors: Lee A P , Yang F , Fan Y T , Wong M C , Wong R H
Published: October 2019

Background

Patients with hypertension may develop thoracic aortic aneurysm (TAA) that can be asymptomatic but potentially life-threatening. We sought to assess the prevalence of asymptomatic TAA among hypertensive patients and define the effectiveness of a TAA point-of-care screening program using pocket-size mobile echocardiographic (PME) devices.

Methods

We prospectively performed transthoracic echocardiography for TAA screening using a PME device on 1529 hypertensive patients (age, 62y [30y to 85y], 824 men) who attended our hypertension specialist clinic between June 2016 and July 2018. Measurement of the dimensions of the aortic sinus, sinotubular junction, ascending aorta, aortic arch, and descending thoracic aorta were obtained through multiple standard echo views.

Results

The prevalence of TAA (defined as maximum aortic diameter of ≥4.5cm and/or >50% diameter of the adjacent aorta) in our study population was 7.3% (111/1529), with distal ascending aorta as the most frequent location (Figure). Multiple logistic regression analysis identified male gender, older age, and presence of heart valve disease as independent factors associated with TAA (all p<0.05).

Figure 1

Conclusions

Asymptomatic TAA is common among asymptomatic hypertensive patients. Point-of-care use of PME device is effective in detecting TAA in a clinic setting. Such approach may be useful for early detection of TAA among at-risk patients allowing aggressive blood pressure control and early surgical intervention to prevent catastrophic complications such as aortic dissection or rupture.

Acknowledgement/Funding

Health and Medical Research Fund of the Hong Kong Government
P1837HFpEF reverses in more than a quarter of patients after thoracoscopic AF ablation
Authors: Kougioumtzoglou A M , Neefs J , Wesselink R , Terpstra M M , Van Den Berg N W E , Berger W R , Meulendijks E R , Krul S P J , Piersma F R , De Jong J S S G , Van Boven W J P , Driessen A H G , De Groot J R
Published: October 2019

Purpose

To evaluate the proportion of patients in whom parameters that define the diagnosis of HFpEF and HFmrEF persist versus normalize upon elimination of AF.

Background

Atrial fibrillation (AF) and heart failure with preserved or mid-range ejection fraction (HFpEF or HFmrEF) concur in many patients. Distinction between these two diagnoses remains challenging as one can cause or exacerbate the other. Adequate patient selection for invasive AF treatment is crucial to improve rhythm outcome.

Methods

Patients underwent thoracoscopic ablation, consisting of pulmonary vein isolation (PVI) alone or PVI with additional lines in the case of persistent AF. Patients were prospectively followed-up. HFmrEF or HFpEF was defined as left ventricular ejection fraction (LVEF) ≥40% or ≥50% respectively and N-terminal prohormone of brain natriuretic peptide (NT-proBNP) levels >125 pg/ml. Patients who remained free from AF, or any atrial tachycardia of more than 30 seconds, at 6 months postoperatively, were included in this study. Patients with AF recurrences during this period were excluded. The primary outcome was the change of NT-proBNP at 6 month follow-up.

Results

From 2008 to 2017, 92 patients undergoing thoracoscopic AF ablation fulfilled the aforementioned criteria and were included. Of these patients, mean age was 61±8 years and 66 (72%) were male. Median NT-proBNP was 366 pg/ml (128–2916) and mean LVEF was 53±7%. Thirty (35%) patients had a LVEF of 40–49%. Six months after elimination of AF, NT-proBNP was <125 pg/ml (Figure 1A: median 87 (50–122) vs 459 (137 – 2916) pg/ml at baseline; p<0.001) in 26 patients (28%), whereas in the remaining patients NT-proBNP was unchanged (Figure 1B: median 298 (126–1568) vs. 318 (128–2387) pg/ml at baseline; p=0.011).

Figure 1. NT-proBNP alterations after thoracoscopic AF ablation from baseline to 6 month follow-up. A. Patients with normalization of NT-proBNP. B. Patients with unchanged high levels of NT-proBNP.

Conclusion

In 28% of patients the diagnostic criteria of HFpEF/HFmrEF are caused by AF and normalize upon elimination of AF with thoracoscopic ablation.
P1869A novel risk score to predict mortality in patients with atrial fibrillation: the BLACCK (AF) death risk score
Authors: Samaras A , Kartas A , Fotos G , Vasdeki D , Dividis G , Paschou E , Tsoukra P , Forozidou E , Kotsi E , Goulas I , Karvounis H , Giannakoulas G , Tzikas A
Published: October 2019

Background

Prior risk stratification schemes for atrial fibrillation (AF) have extensively focused on stroke as the principal outcome. However, an accurate estimation of the risk of death in patients with AF has received disproportional attention.

Purpose

The aim of this study was to develop and validate a risk score for predicting mortality in patients with AF who underwent a hospitalization for cardiac reasons.

Methods

The new risk score was developed and internally validated in 887 patients with AF, who were followed up for a median of 2 years. The outcome measure was all-cause mortality. Biomarker samples, echocardiographic data and renal function values were obtained at the date closest to hospital discharge. A Cox-model that determined the variables that significantly contributed to the prediction of all-cause mortality, was adapted to a risk points system through weighting of the model coefficients. The model was internally validated by bootstrapping, assessing both discrimination and calibration.

Results

311 all-cause deaths were reported during 1755 person-years of follow-up (incidence rate 17.7 events per 100 person-years). The most important predictors of death were N-terminal pro B-type natriuretic peptide (NT-proBNP), high-sensitivity troponin-T (hs-TnT), left atrial area indexed to body surface area (LAAi), prior cardiac arrest, kidney impairment, congestive heart failure and age, and were included in the BLACCK (AF) death risk score. The score was well-calibrated (observed probabilities adjusted to predicted probabilities) and showed good discriminative ability [c-index 0.87 (95% CI 0.85–0.90)]. The internal validation of the score reported minimal over-fitting (optimism-corrected c-index of 0.85). The 1, 2 and 3-year risk of death derived by the score's total points may be calculated immediately through the nomogram (Figure 1).

BLACCK (AF) risk score nomogram

Conclusions

We developed a simple, well-calibrated and internally validated novel risk score for predicting 1, 2 and 3-year risk of death in patients with AF after a hospitalization for cardiac reasons. The BLACCK (AF) death risk score included both cardiac biomarkers and clinical information, performed well and may assist physicians in decision-making when treating patients with AF.
P1874Novel predictors of atrial fibrillation progression
Authors: Tarzimanova A I , Podzolkov V I , Pisarev M V , Gataulin R G
Published: October 2019

Objective

To identify predictors of progression of atrial fibrillation (AF) in patients with hypertension, coronary heart disease (CHD) and chronic heart failure (CHF) with recurrent AF.

Materials and methods

The study included 312 patients with recurrent AF. The patients were divided into 3 groups according to the leading underlying condition: essential hypertension (n=136), CHD (n=112), and CHF (n=64). The average follow-up duration was 60±3 months. “Progression” of AF was defined as development of persistent or permanent AF.

Results

During the 5-year prospective follow-up in all the groups of patients with recurrent AF, progression of arrhythmia from paroxysmal or persistent to permanent form was noted. The rate of AF progression in patients with CHF was significantly higher, and its percentage was 59%. The progression percentage after 5 years was 46% (p=0.002) in patients with hypertension and 51% (p=0.008) in patients with CHD. AF progression in patients with hypertension correlated significantly with left ventricular hypertrophy (OR 1.25; 95% CI, 1.03 to 1.52) and increased vascular wall stiffness (OR 2.3; 95% CI, 1.95 to 2.65). Independent predictors of arrhythmia worsening in patients with CHD were history of myocardial infarction (OR 1.23; 95% CI, 0.9 to 1.5), irreversible left ventricular (LV) hypokinesis (OR 1.41; 95% CI, 1.1 to 1.7), and increased plasma N-terminal pro–A-type natriuretic peptide (NT-proANP) (OR 1.16; 95% CI, 0.8 to 1.4). Reduced LV ejection fraction (EF) (OR 0.84; 95% CI, 0.7 to 0.89) and increased plasma N-terminal pro–B-type natriuretic peptide (NT-proBNP) (NT-proBNP) (OR 2.3; 95% CI, 1.93 to 2.67) were independent predictors of AF progression from persistent to permanent form in patients with heart failure with reduced ejection fraction.

Conclusions

Progression of AF is related to the underlying cardiovascular disease. Early vascular aging syndrome and LV hypertrophy are the main factors of AF progression in patients with hypertension. Previous myocardial infarction with irreversible hypokinesis is associated with AF progression in patients with CHD. Reduced LVEF and increased plasma BNP predict AF progression in patients with CHF.
P1881High-sensitivity cardiac troponin T in patients with acute atrial fibrillation
Authors: Arbucci R , Haseeb S , Campos R , Trivi M , Costabel J P
Published: October 2019

Background

Atrial Fibrillation (AF) is the most common sustained cardiac arrhythmia encountered in clinical practice and confers a significant burden to morbidity and mortality. High-sensitivity cardiac troponin T (hs-cTnT) levels have provided a significant contribution in the early diagnosis of cardiovascular events; however, the significance of hs-cTnT elevation in the setting of acute AF is not clearly understood.

Purpose

The aim of this study was to evaluate the factors associated with hs-cTnT elevation and its prognostic implication in patients with acute AF.

Methods

This single-center prospective study included 406 consecutive patients who presented to the emergency department (ED) with acute AF. Acute AF was defined as a rapid, irregular, and chaotic atrial activity of <48 hours' duration including both the first symptomatic onset of chronic or persistent AF, and episodes of paroxysmal AF. The association between hs-cTnT and outcomes were evaluated using multivariate analyses.

Results

The mean age of the population was 67.3±12.2 and 74% were male. The median time from the onset of symptoms to ED consultation was 230 minutes (interquartile range: 123–450 minutes). The median hs-cTnT value was 12 ng/L, with 39% of patients with values above the 99 thpercentile. AF was reverted to sinus rhythm in 76% of the patients (83% attempted cardioversion). At one-year, AF recurrence was observed in 38% of the patients and major adverse cardiovascular events (MACE) (death, myocardial infarction, acute coronary syndrome or stroke) were observed in 6% of the patients. After adjusting for demographic and clinical characteristics in multivariate analysis, hs-cTnT elevation was associated with increasing age and left atrial area (p=0.001). Hs-cTnT levels were not associated with 1-year AF recurrence (p=0.132) or with AF reversion (p=0.869). Hs-cTnT levels were significantly higher in patients who experienced MACE at 1-year (12 ng/L vs 24 ng/L, p=0.001) and hs-cTnT was a predictor of MACE on multivariate analysis (OR 3.486, 95% CI 1.256–5.379, p=0.009).

Variable Result AF rate 110 (90–118) Atrial area, cm2 22 (19–27) Cardioversion attemped 82.5%

Conclusions

Hs-cTnT elevation accounted for a large proportion of patients with acute AF. Elevated levels of hs-cTnT were not associated with AF reversion or with 1-year AF recurrence, however hs-cTnT was highly predictive of MACE at 1-year.
P1908Left common pulmonary vein in atrial fibrillation ablation with cryoballoon. A meta-analysis
Authors: Gionti V , Negro M C , Longobardi M , Storti C
Published: October 2019

Background

Conflicting results regarding the impact of left common pulmonary (LCPV) vein on clinical outcome of atrial fibrillation (AF) ablation with cryoballoon technology have been reported. In the present study, we sought to investigate the performance of the 28 mm cryoballoon advance (CB-A) on left common pulmonary vein (LCPV) in terms of post procedural outcome.

Methods

We systematically searched on PubMed and Cochrane library for the articles that compared the recurrence rate of AF after cryoballoon ablation between patients with four separate and distinct pulmonary vein ostia and with LCPV.

Results

A total of 5 studies with 1052 patients met our predefined inclusion criteria. Recurrence of AF after CB-A ablation was similar in both groups (Log OR 0.45; 95% CI: −0.03, 0.94; I=48%, p=0.08), Fig 1.

Figure 1

Conclusion

LCPV doesn't affect clinical outcome of AF ablation with cryoballoon technology.
P1919The assessment of the application and the efficacy of pulmonary vein isolation with cryoballoon for non-paroxysmal atrial fibrillation
Authors: Nitta G , Inaba O , Kato S , Kono T , Ikenouchi T , Murata K , Matsuda J , Kanoh M , Inamura Y , Takamiya T , Negi K , Sato A , Yamato T , Matsumura Y , Nitta J
Published: October 2019

Background

Pulmonary vein isolation (PVI) using second generation cryoballoon (CB) ablation has become an established treatment for paroxysmal atrial fibrillation (PAF) patients. On the other hand, PVI with radiofrequency (RF) has been an established treatment for non-PAF patients, in addition to PAF patients.

Purpose

The data on second generation CB ablation for non-PAF patients is limited. We assessed the application of PVI with CB for non-PAF patients and compared the outcomes of success rate, radiational time, and procedural time.

Methods

A total of 2632 AF patients (age 64±10; 1873 males) underwent initial PVI from September 2014 to June 2018. Second-generation CB was employed to 1587 patients (CB-PAF: 80%, CB-non-PAF: 20%) and RF using irrigation-tip catheter was employed to other 1045 patients (RF-PAF: 40%, RF-non-PAF: 60%). In CB group, PV touch-up ablation with RF was needed for 113 patients (7%) (CB-PAF: 6%, CB-non-PAF: 13%; p<0.001). After PVI, additional ablation for non-PV foci was undergone after the induction by using ISP infusion and rapid atrial pacing.

Results

AF free survival rate was almost equivalent in both non-PAF group (2-years Kaplan-Meir event rate, CB-non-PAF 66.3%, RF-non-PAF 69.8%; log-rank p=0.297). There was significantly difference in procedural time (CB-non-PAF 132±56min, RF-non-PAF: 189±52min, p<0.001), and radiation time (CB-non-PAF: 47±40min, RF-non-PAF: 75±31min, p<0.001). The percentage of patients with non-PV foci was significantly higher in CB group (CB-non-PAF 41%, RF-non-PAF 54%, p<0.001), and after excluding the patients with non-PV foci, AF free survival rate was almost equivalent in both group (2-years Kaplan-Meier event rate, CB-non-PAF 75.4%, RF-non-PAF 78.8%; log-rank p=0.577). On the other hand, in patients in CB, AF free survival rate was significantly superior in PAF group (2-years Kaplan-Meir event rate, CB-PAF 83.3%, CB-non-PAF 65.2%; log-rank p<0.001). There was significantly difference in procedural time (CB-PAF: 117±47min, CB-non-PAF: 132±56min, p<0.001), and radiation time (CB-PAF: 38±22min, CB-non-PAF: 46±27min, p<0.001). The percentage of patients with non-PV foci was significantly higher in non-PAF group (CB-PAF 30%, CB-non-PAF 41%, p<0.001), and after excluding the patients with non-PV foci, AF free survival rate was also significantly superior in PAF group (2-years Kaplan-Meier event rate, CB-PAF 85.1%, CB-non-PAF 69.8%; log-rank p<0.001).

Conclusions

For non-PAF patients with PV triggers, PVI with CB might be non-inferior to PVI with RF. Our study showed the efficacy of CB in terms of the shortening of procedural time, and the reduction of radiational exposure. PVI with CB for non-PAF patients was inferior to that for PAF patients.
P1956Geriatric nutritional risk index as predictor for long-term survival and cardiovascular or limb events in peripheral arterial disease patients
Authors: Matsuo Y , Kumakura H , Shirakura T , Ichikawa K , Funada R , Yagi H , Iwasaki T , Ichikawa S , Kurabayashi M
Published: October 2019

Background

The geriatric nutritional risk index (GNRI) is a simple tool to assess the nutritional risk and associated with mortality. However, there are no reports focusing GNRI in peripheral artery disease (PAD) patients.

Purpose

The purpose of this study was to examine the effects of GNRI for long-term survival, cardiovascular and limb events in PAD patients.

Methods

A prospective cohort study was performed in 1219 PAD patients. Baseline GNRI was calculated from serum albumin level and body-mass-index. The patients were divided into four groups by GNRI level (G1: >98; G2: 92–98; G3: 82–91; G4: <82). The endpoints were overall survival (OS) and freedom from major adverse cardiovascular and limb events (MACE and MACLE).

Results

The median follow-up was 73 months. There were 626 deaths (51.4%) during follow-up. The rate of cardiovascular death among dead was 51.3%. The OS rates markedly depended on GNRI level (p<0.01). The 5-year OS rates were G1: 80.8%, G2: 62.0%, G3: 40.0%, G4: 23.3%, respectively. In multivariate analyses, GNRI, age, low ankle brachial pressure index (ABI), low estimated glomerular filtration rate (eGFR), and high C-reactive protein (CRP) levels were independent factors associated with OS (<0.05). GNRI, age, low ABI, diabetes mellitus, coronary artery disease, lower eGFR and higher CRP levels were associated with MACE and MACLE (p<0.05, respectively). Besides, statins improved OS, MACE, and MACLE (<0.01, respectively).

Conclusions

GNRI was an independent predictor for OS, MACE, and MACLE in PAD patients. Furthermore,statins improved OS, MACE and MACLE in patients with PAD.
P1962Impact of Dual Antiplatelet Therapy duration on clinical outcome after stent implantation for coronary bifurcation lesions: results from the Euro Bifurcation Club - P2BiTO - registry
Authors: Di Serafino L , Gamra H , Cirillo P , Zimarino M , Amat-Santos I J , Barbato E , Briguori C , Chieffo A , Ergilis A , Gil R J , Kedev S A , Petrov I , Radico F , Nakamura S , Stankovic G
Published: October 2019

Background

Duration of Dual Antiplatelet Therapy (DAPT) following Acute Coronary Syndromes (ACS) or Stable Coronary Artery Disease (SCAD) treated with coronary stenting is still debated. Although current guidelines consider several “clinical” criteria to decide for short DAPT (<6 months), standard DAPT (12 months) and prolonged DAPT (>12 months), the relationship between DAPT duration, treatment of bifurcations and its impact on clinical outcome has been poorly investigated in real world registries.

Purpose

We evaluated the impact of DAPT duration on clinical outcomes in consecutive all-comers patients treated with stenting of coronary artery bifurcation lesions included in the Euro Bifurcation Club -P2BiTO - registry.

Methods

Data on 5036 consecutive patients who underwent PCI on coronary bifurcation at 17 major coronary intervention centres between January 2012 and December 2014 were collected. The primary endpoint of the study was the cumulative occurrence of Major Adverse Cardiac Events (MACCE), defined as a composite of overall-death death, non-fatal myocardial infarction (MI), target vessel revascularization (TVR) and stroke during the follow-up; the secondary endpoints were the single occurrence of any of the above mentioned events.

Results

Data on DAPT duration was available for 3992 patients (79%). Patients were divided into 3 groups: Group 1) DAPT <6-months (n=720); Group 2) DAPT >6-months but <12-month (n=1602); Group 3) DAPT >12-months (n=1670). Follow up was completed in 3935 (98%) patients with a median of 20 months (C.I.=12–28). At 24 months after the index procedure, MACCE occurred more frequently in the DAPT <6-month group (Group 1) as compared with both Group 2 and 3 (respectively, 102 (14%) versus 154 (10%) and 164 (10%), HR: 0.72 (0.64–0.82), p<0.001). This difference remains after adjustment for clinical and angiographic characteristics (HR: 0.66 (0.58–0.77), p<0.001). On the contrary, no significant difference was found between Group 2 and Group 3 patients. At the Kaplan-Meier analysis (Figure 1), freedom from MACCE survival was significantly lower in patients receiving DAPT for less than 6 months (Log-Rank: 29.5, p<0.001).

Figure 1. Kaplan-Meier curves

Conclusions

In the P2BiTO registry, short DAPT duration of less than 6 months was associated with a significantly higher risk of MACCE compared to longer DAPT in a real-world registry of patients treated for coronary artery bifurcation stenosis.
P2237National trends in coronary artery disease imaging
Authors: Weir-Mccall J R , Roditi G , Williams M C , Rudd J H F , Newby D E , Nicol E D
Published: October 2019

Background

The 2010 National Institute of Clinical Excellence (NICE) Clinical Guideline 95 (CG95) recommended coronary computed tomographic angiography (CTA) for low-intermediate risk patients with stable chest pain. The indications for CTA broadened substantially in the 2016 update, which recommended CTA for all patients with possible angina and diagnostic uncertainty.

Purpose

To examine trends in the use of imaging for the investigation of coronary artery disease (CAD) in England in the years before and after the 2016 CG95 guideline update.

Methods

Numbers of invasive coronary angiography (ICA), single positron emission tomography (SPECT), stress echocardiography (SE), CTA, and positron emission tomography (PET) scans performed from 2012–2018 were extracted from a national database of imaging procedures performed in England. Per capita average annual growth was calculated at a national and healthcare provider level, and comparisons were made before and after the 2016 CG95 update. Healthcare providers with greater than median CTA growth were compared to those with less than median growth to ascertain the impact of CTA on other forms of CAD investigation. Total healthcare provider costs for imaging were calculated using NHS tariff costs.

Results

From 2012–2018, 1,792,655 imaging examinations were performed for the investigation of CAD, with an overall annualized growth rate of 4%. Average annual growth (per 100,000 population per year) from 2012–2018 was 1±31% for ICA, 28±39% for CTA, −11±22% for SPECT, 0±1% for PET, 1±2% for SE and 5±16% for MRI. Following the 2016 CG95 update, there was an increase in the year-to-year average annual growth of CTA scans performed (53±79 versus 2±53 tests/100,000/yr, p<0.001) compared with a fall in the rate of ICA use (−13±48 versus +5±36 tests/100,000/yr, p=0.03). SPECT underwent a consistent fall in utilisation over the study period, with an average annual growth rate of −4%, with no difference before or after the 2016 CG95 update (P>0.1). Rates of change in the utilization of SE, PET, and MRI did not change following the introduction of the 2016 CG95 update. Regions with an above median average annual growth in CTA exhibited a greater decline in SPECT use (−19±28 versus −4±11 tests/100,000/yr, p=0.037) than regions with a below median growth in CTA use, with no difference in the average annual growth of ICA, SE, PET or MRI (p>0.1 for all; Figure 1). Per capita healthcare costs remained stable throughout the study period, with no significant change following CG95 (p>0.1).

Figure 1. CTA, SPECT and ICA growth rate

Conclusion

There is a clear and consistent trend towards increased imaging for the diagnosis and management of CAD. The 2016 NICE CG95 update resulted in a rise in the use of CTA, and a fall in ICA. Importantly, rates of ICA utilization fell despite a rise in CTA usage. Centres with the greatest growth in CTA had the greatest fall in SPECT utilisation and consequently, overall imaging costs were unchanged.
P2434Digital zoom decreases radiation exposure dose up to 30% in percutaneous coronary intervention
Authors: Umemoto N , Hasegawa K , Iio Y , Inoue I , Sumi T , Sugiura T , Taniguchi T , Asai T , Yamada M , Ishii H , Murohara T , Shimizu K
Published: October 2019

Background

Interventional cardiology is gaining greater popularity worldwide with each passing year. Reduction of exposure dose is a very imminent and an important issue in cardiology procedure. Although a newer radiation reduction technique, device and procedure are very valuable and expected, we should consider about therapy technique, radiation technique, devices, and the way to protection. Digital zoom digitally enlarges images in real time by up to 2.5-fold at lower doses than those used with traditional field of view changes. In our phantom examination the average dose reduction of digital zoom was 27%.

Methods and results

This study is designated as single-center, retrospective, not-randomized, observation study. 2101 eligible cases were collected. We assigned the cases of PCI without the use of Digital zoom to the Conventional group and those involving the use of Digital zoom to the Digital zoom group. There were 806 patients in the Conventional group and 1195 in the Digital zoom group. Because we had begun using Digital zoom from January 2015 onwards, all patients in the Conventional group had undergone PCI from January 2013 to December 2014 and all patients in the Digital zoom group had undergone PCI from January 2015 to December 2016. In addition, we calculated the RAK/minute and DAP/minute for an accurate assessment. To minimize the difference of characteristics between two groups, propensity score including all baseline variables was performed. Furthermore, Predictors of radiation exposure were investigated using multivariable least square methods. Inter group differences were observed in DAP, RAK, DAP/min, and RAK/min (Digital zoom group vs conventional group: DAP, 16000 cGy cm2 [from 1st quartile to 3rd quartile; 10300–24400] vs 20700 [13400–29500], p<0.001; DAP/min, 557 cGy cm2/min [392–737] vs 782 [571–1010], p<0.01; RAK, 1590 Gy [990–2410] vs 1850 [1220–2720], p<0.01; RAK/min, 54.7 Gy/min [38.5–73.2] vs 71.2 [51.5–93.0], p<0.01). Even after propensity score matching, intergroup differences in DAP (810 cases), DAP/min (811 cases), RAK (746 cases), and RAK/min (744 cases) persisted. Furthermore, the least squares method showed that Digital zoom is an important predictor of DAP (β=0.17, p<0.01) and RAK (β=0.12, p<0.01).

Conclusion

Digital zoom is an old and cost-free technique, but one of most powerful reduction of exposure method. Propensity score adjustment and least square methods show that digital zoom is one of independent effective method.
P2445Prognostic values of left ventricular reservoir functional indices measured by three dimensional speckle tracking analysis
Authors: Tsujiuchi M , Ebato M , Wada D , Nagumo S , Maezawa H , Yamauchi T , Suzuki H
Published: October 2019

Background

Left atrial functional indices measured by two dimensional echocardiography (2DE) have prognostic significance for major cardiovascular events (MACE). Retrospective analysis using propensity score matching to assess the prognostic values of left atrial reservoir function measured by three dimensional speckle tracking analysis (3DSTA) was performed.

Methods

Two hundred sixty-four patients (Male 60%, 65±15yo) who underwent both clinically indicated 2DE and 3DSTA for various underlying heart diseases from January 4, 2013 to February 28, 2016 were followed to record MACE. Patients with significant mitral valve disease, history of pulmonary vein isolation and persistent atrial fibrillation were excluded. Maximum and minimum left atrial volume (LAVImax and LAVImin), left atrial emptying fraction (LAEmpF), peak global LA area ratio (LAAC), circumferential strain (LACS) and longitudinal strain (LALS) were measured using 3DSTA. Standard indices including peak global LVLS (2DLVLS) and left ventricular ejection fraction (LVEF) and LA volume index were also assessed by 2DE. Cutoff line for LA reservoir functional indices and 2DLVLS was determined using ROC analysis. Average treatment effect for the treated (ATT), Average treatment effect (ATE) for each index were calculated after propensity score matching for clinical indices (age, sex, coronary artery disease, hypertension, diabetes, eGFR <45 ml/min/1.73m2, LVEF <40%)

Results

During a mean follow-up of 547±435 days, MACE developed in 30 patients (7 cardiac death 6 stroke, 1 nonfatal MI, 22 admission for heart failure). Age, coronary artery disease (CAD), diabetes mellitus (DM), chronic kidney disease (CKD: eGFR< 45ml/min/1.73m2), LVEF, 2DLVLS, LAVImax and LAVImin by 2DE and all LA indices by 3DSTA had significant prognostic value by univariate analysis. LAEmpF and LALS by 3DSTA had higher ATT, ATE and Log rank χ2 than other LA indices and 2DLVLS. The model added LALS or LAEmpF by 3DSTA had higher prognostic value (LALS <10.6%: AUC; 0.82, HR; 5.57 CI: 2.32–14.06, LAEmpF <33.0%: AUC; 0.82, HR; 6.59 CI; 2.60–20.18) than LA volume indices by 2DE and also tended to be better than 2DLVLS (LVLS <6.04%: AUC; 0.77, HR; 5.37 CI; 2.06–13.73).

propensity score matching

Conclusion

LALS and LAEmpF by 3DSTA showed additive prognostic value for MACE.
P2447Defining the values of left ventricular ejection fraction, volumes and strain by 2-dimensional echocardiography in subjects with normal cardiac geometry - a single center study
Authors: Jadav R , Nhola L , Thaden J , Herrmann J , Pellikka P , Pislaru S , Villarraga H
Published: October 2019

Background

Left ventricular ejection fraction (LVEF), end diastolic, end systolic volumes (EDV, ESV) and global longitudinal strain (GLS) are very important parameters that are frequently reported in cardiology. Normal cardiac geometry was not considered in articles that published normal values. It is important to know normal parameters for population studies. Our hypothesis is to analyze how EF, volumes and GLS may vary by age groups, gender and BMI in a population with normal cardiac geometry.

Purpose

To define the values in EF, volumes and GLS measurements in a healthy population with normal cardiac geometry stratified by age groups, gender and body mass index (BMI).

Methods

This is a single center retrospective study conducted from 2008 to 2018. We selected 4557 subjects (2605 females, 1952 males) >18 years with ≤ mild valvular heart disease, who underwent 2D-echocardiography (2DE) at Mayo clinic, Rochester. All selected subjects had normal LV geometry (i.e., LV mass index≤88g/m2 in females and ≤102g/m2 in males and relative wall thickness ≤0.42 measured by 2DE) and without any cardiovascular risk factors or structural or functional abnormality determined by 2DE. Based on age groups, gender and BMI, we assessed the variability in volumes indexed to body surface area, EF and GLS by Mean ± SD and two sample t-test.

Results

Mean age was 54±15 years (females = 53±15, males = 56±16), body surface area was 1.9 m2±0.2 (females = 1.8±0.2, males = 2.1±0.2), LV GLS −20.7% ±2 SD (females = −21.2±2, males= −20.2±1.9) ranging −16.1 to −27.6 in both genders (Figure); LVEF by Biplane volume method 62.6% ± 4 SD (females = 63±4.3, males=62±4.5). The end diastolic volume 63.6±11.7 cc/m2 (female = 59.9±10.3, males = 68.1±11.8) and end systolic volume 23.9 cc/m2±5.4 (female = 22.3±4.8, males = 25.9±5.5). LV GLS, Biplane EF values were higher in females and EDV and ESV values were higher in males. LV GLS values decreased with age in females (P<0.0001). While EF increased with age in both genders (P<0.0001), EDV and ESV values decreased with age (P<0.0001). When each gender is sub-divided based on their BMI (<25 and ≥25), GLS, EDV and ESV values were higher in population with BMI <25 (P<0.0001).

Normal geometry variables

Conclusion

To our knowledge, this is the biggest single center study to evaluate LV GLS values, LV EF, ED, ES volumes. These results can be used as reference values in a normal population.

Acknowledgement/Funding

None
P2464Reduction in left atrial reservoir strain is an independent predictor of atrial fibrillation in patients with arterial hypertension and preclinical diastolic disfunction
Authors: Chilingaryan A L , Tunyan L G , Adamyan K G
Published: October 2019

Left atrial (LA) dimensions, wall composition and function strongly depend on left ventricular (LV) diastolic function and impaired in patients with preclinical diastolic disfunction (PDD), which increases the likelihood of atrial fibrillation (AF) occurrence. LA longitudinal strain (LALS) is a sensitive parameter of subclinical myocardial changes and its reduction might be predictive for AF.

Methods

168 patients (90 female) 68±9 years with arterial hypertension in sinus rhythm with preserved systolic function (LVEF>50%) and PDD and without renal or valvular disease and 45 age and sex matched healthy controls were followed up for 2 years. PDD was diagnosed at stress echocardiography (SE) if E/e' ≥13, transmittal E wave deceleration time reduction >50ms, systolic pulmonary artery pressure (sPAP) >30 mmHg, and patients remained asymptomatic. LALS was measured by speckle tracking echocardiography as average value of two basal segments in 4 chamber view along with LA end-systolic volume index (LAVi), LA EF, LV mass index (LVMi), and LVLS. 72 hours Holter monitoring was performed every 6 months.

Results

Patients with PDD had larger LAVi, less LALS, higher LVLS and bigger LVMi compared with controls (LAVi 30.5±4.9 ml/m2 vs 23.1±4.8 ml/m2, p<0.001; LALS 34.7±6.9% vs 45±4.3%, p<0.001; LVLS –17.4±2.4% vs –20.8±2.1%, p<0.002; LVMi 81.8±12.3 g/m2 vs 68±9.2 g/m2, p<0.001). AF was registered in 42 (25%) patients with PDD. LAVi, LVLS and LVMi did not significantly differ in PDD patients with or without incidents of AF however LALS was significantly less in patients with AF (26.8±7.5% vs 37.2±8.1%, p<0.01). Multivariate analysis defined LALS as an independent predictor of AF development (OR=2.4; 95% CI=2.41–5.96; p<0.01) with the cut-off value of 28.9%.

Conclusion

LA peak reservoir LS is an independent predictor of AF development in patients with PDD.
P2472Two-dimensional speckle tracking echocardiography in heart transplant patients: five year follow-up of right and left ventricular function
Authors: Lozano Jimenez S , Monivas Palomero V , Goirigolzarri Artaza J , Navarro Rico S , Borrego Hernandez A , Cavero Gibanel M A , Gomez Bueno M , Segovia Cubero J , Alonso Pulpon L A , Mingo Santos S
Published: October 2019

Background

Evolution of left and right ventricular (LV and RV) function after heart transplantation (HT) has not been well described. Our objective was to evaluate the normal evolution of echocardiographic parameters of both ventricles and to explore if there is a link between the decrease of strain values and acute rejection (AR) or coronary allograft vasculopathy (CAV)

Methods

We followed 29 HT recipients with serial echocardiograms performed between 2011 and 2018, with a median follow-up of 5 years. LV global longitudinal strain (LV GLS) was analyzed by speckle tracking in 12 LV segments in 4 and 2 chamber views, and RV free wall longitudinal strain (RV free Wall LS) was measured in 4 chamber view. Acute rejection was diagnosed by EMB following our HT protocol. We take into consideration only moderate or severe rejection episodes (grade ≥2R).The presence of CAV was studied by coronariography or IVUS one year post-HT.

Results

As shown in the table below, LVEF was preserved from the begining of the follow up while LV GLS reached the normality in the 6th month, and both remained in normal ranges untill the 5th year. Regarding RV function, TAPSE was impaired in the early post-HT period and increased progressively and reached normality 1 year after HT. RV lateral wall LS rose during follow-up as well, reaching normal values 6 months after HT. Nevertheless, we noticed an impairment in this parameter at 5 years (−20.1±2.7, p=0.001), although it remained within normal ranges compared to guidelines reference parameters. We did not find any correlation between any parameter evaluated and the presence of AR or CAV at five years of follow-up.

LV and RV function parameters LVEF LV GLS TAPSE FAC RV free wall LS Basal (14 days) 63.0±7.9 −17.2±3.6 12.1±2.9* 43.7±9.8 −19.3±4.2 3 months 65.0±8.6 −17.7±2.8 14.8±3.4* 45.3±8.2 −22.0±4.6 6 months 65.8±9.6 −18.7±3.4 16.1±3.6 44.6±9.6 −24.6±4.9* 1 year 63.5±8.1 −18.1±2.2 17.1±4.1 44.0±8.1 −26.7±7.1* 2 years 63.8±6.8 −18.3±9.0 19.4±3.7 45.3±7.9 −27.6±6.3* 5 years 64.4±7.3 −18.1±3.3 17.9±3.9 46.6±12.1 −20.1±2.8 P (Anova) 0.85 0.85 <0.001 0.82 <0.001

Conclusion

As we show in this series of HT recipients with uneventful postoperative course, all LV and RV function parameters showed normal values 1 year after HT and manteined them during long-term follow-up. The presence of AR or CAV did not have any influence in ventricular function.
P2476Non-invasive left ventricular stiffness measurements for assessing diastolic myocardial properties after orthotopic heart transplantation
Authors: Petrescu A M , Bezy S B , Santos P S , Cvijic M S , Orlowska M O , Van Keer J V K , Bogaert J B , Droogne W D , Van Cleemput J V C , D'hooge J D , Voigt J U V
Published: October 2019

Background

After orthotopic heart transplantation (HTx), allografts undergo characteristic alterations including myocardial fibrosis. These histologic changes contribute to functional impairment, especially to increased passive myocardial stiffness (MS), which is an important pathophysiological determinant of left ventricular diastolic dysfunction (DF). However, the transplanted heart is affected by many factors that make the interpretation of diastolic echocardiographic parameters difficult. Echocardiographic shear wave (SW) elastography is an emerging approach for measuring MS in vivo. Natural SWs occur after mechanical excitation of the myocardium, e.g. after mitral (MVC), and their propagation velocity is directly related to MS, thus providing an opportunity to assess stiffness at end-diastole (ED).

Purpose

The aim was to evaluate the relationship between MS and diffuse myocardial fibrosis as mechanism of DF in HTx patients.

Methods

We prospectively enrolled 33 patients (10.3±6.3 years after HTx) that underwent right heart catheterization (all) and CMR (n=18) during their annual check-up. We performed SW elastography in parasternal long axis views of the LV using a fully programmable experimental scanner (HD-PULSE) equipped with a clinical phased array transducer (Samsung Medison P2–5AC) at 1100±250 frames per second. Tissue acceleration maps were extracted from an anatomical M-mode line along the midline of the LV septum. The ED SW propagation velocity was measured as the slope in the M-mode image (Figure A). Right heart catheterization was performed on the same day. HTx patients were assumed to have diastolic dysfunction (DDF) if the pulmonary capillary wedge pressure (PCWP) exceeded 18mmHg (n=9). All other patients were assumed to have normal diastolic function (NDF, n=24). Native T1 and extracellular volume (ECV) were measured to evaluate diffuse myocardial fibrosis.

Results

Positive correlations were found between SW velocities at ED and PCWP (r=0.61, p<0.001; Figure B), between SW velocities at ED and T1 (r=0.80, p<0.001; Figure D), and between SW velocities at ED and ECV (r=0.66, p=0.004). SW propagation velocities at ED were significantly higher in DDF than in NDF (8.05±1.85 vs. 3.77±1.02 m/s; p<0.001; Figure C), and corresponded to the T1 values (as illustrated in Figure D).

Conclusions

End-diastolic shear wave velocity – as a measurement of passive myocardial stiffness – showed a good correlation with CMR defined myocardial fibrosis. High PCWPs were consistent with the increase in SW velocities, reflecting the fibrous changes in the ventricle. These findings thus suggest that cardiac shear wave elastography has the potential to become a powerful tool for the assessment of diastolic myocardial properties in cardiac transplant recipients.
P2494Cardiovascular disease burden attributed to high blood pressure in Chinese adults with type 2 diabetes
Authors: Bragg F , Halsey J , Guo Y , Chen Y , Bian Z , Clarke R , Li L , Chen Z
Published: October 2019

Background

Cardiovascular diseases (CVD) are the most common cause of death among people with diabetes, reflecting in part co-existence with other CVD risk factors, including high blood pressure. However, controversy persists about the nature of the relationship of blood pressure with risk of CVD in individuals with diabetes, and about the associated disease burden.

Methods

We analysed data from 26,315 men and women aged 30–79 years with type 2 diabetes but no prior history of CVD, who were recruited into the China Kadoorie Biobank in 2004–2008 from 10 diverse areas in China. During ∼10 years' follow-up 1,190 major coronary events (MCE), 4,362 ischaemic stroke (IS), 469 intra-cerebral haemorrhage (ICH) events and 4,503 deaths (including 1,807 CVD deaths) were recorded. Usual systolic (SBP) and diastolic (DBP) blood pressure and uncontrolled hypertension were related to risks of incident CVD and all-cause mortality, after adjustment for relevant confounders.

Results

Overall, 75.7% of participants had prior doctor-diagnosed (24.8%) or screen-detected (67.7%) hypertension, compared with 54.3% among those without diabetes. The age-adjusted prevalence of hypertension was higher among men and in rural areas. Among those with previously diagnosed hypertension, 39.3% reported use of anti-hypertensive medications (on average, 1 agent) and 8.5% had controlled hypertension (<130/80 mmHg). Usual SBP was continuously and positively associated with the risk of CVD, with no evidence of a threshold throughout the range examined (120–180 mmHg). Each 10 mmHg higher SBP was associated with a 27% higher risk for CVD death (HR 1.27, 95% CI 1.25–1.30). Strong positive associations were also seen for MCE (1.16, 1.12–1.21), IS (1.15, 1.13–1.18), and ICH (1.46, 1.34–1.60). Overall, uncontrolled hypertension accounts for an estimated 39% (32–45%), 30% (21–38%), 24% (20–28%) and 48% (34–58%) of CVD deaths, MCE, IS and ICH, respectively, among Chinese adults with diabetes.

Conclusion

Hypertension is common but frequently undetected and uncontrolled among adults with type 2 diabetes in China. Effective diagnosis and management of hypertension among individuals with diabetes would be expected to achieve substantial reductions in CVD morbidity and mortality.

Acknowledgement/Funding

Wellcome Trust, MRC, BHF, CR-UK, Kadoorie Foundation, MoST, NSFC
P2495Poor cardiorespiratory fitness in adolescence predicts cardiomyopathy risk in mid-life
Authors: Robertson J , Schaufelberger M , Lindgren M , Adiels M , Aberg M , Rosengren A
Published: October 2019

Background

Cardiorespiratory fitness and physical activity have well–known cardio–protective effects. Along with reports on declining levels of physical activity globally, heart failure caused by cardiomyopathy is increasing among young people. Still, it is unknown whether poor fitness in adolescence can be associated with cardiomyopathy in adulthood.

Purpose

To study a possible link between cardiorespiratory fitness in adolescence and being diagnosed with cardiomyopathy in adulthood.

Methods

A nationwide register-based prospective cohort study of 1,668,893 young men (mean age 18.3 years, SD 0.7), enlisting for compulsory military service 1969–2005. Body mass index (BMI) and blood pressure were registered at baseline, along with test results for fitness. Values were trichotomized and about 13.5% were classified as having poor cardiorespiratory fitness. Cardiomyopathy diagnoses were identified from the National Hospital Register and Cause of Death Register, during an up to 46-year follow-up, and divided into categories: 1) dilated, 2) hypertrophic, 3) alcohol/drug-induced, and 4) other. Hazard ratios (HR) were calculated with Cox proportional hazards models.

Results

During follow-up (median 27 years; interquartile interval 19–35 years), 4,477 cases of cardiomyopathy were registered, of which 2,631 (59%) were dilated, 673 (15%) were hypertrophic, and 480 (11%) were alcohol/drug-induced. Poor cardiorespiratory fitness was strongly associated with elevated risk of both dilated (HR 1.59, 95% confidence interval (CI) 1.38–1.83) and alcohol/drug–induced cardiomyopathy (HR 2.32, 95% CI 1.68–3.20), adjusted for BMI, age at conscription, conscription year, test center, and baseline comorbidities (diabetes, hypertension, congenital heart disease).

Conclusion

The present study shows that poor cardiorespiratory fitness in adolescence may be associated with both dilated and alcohol/drug–induced cardiomyopathy in adulthood. This strengthens the evidence of fitness as a cardio–protective factor, and brings further support to the importance of interventions promoting physical activity already in childhood.

Acknowledgement/Funding

The Swedish Research Council, The Swedish Heart and Lung Foundation