bluuebunny/crossref_metadata_2025 huggingface dataset:
P3562Efficient selection of patients with aldosterone-producing adenoma using the ACTH stimulation test
Authors: Kita T , Furukoji E , Sakae T , Kitamura K
Published: October 2019

Adrenal venous sampling (AVS) is the gold standard test for distinguishing between unilateral and bilateral primary aldosteronism (PA), however, AVS requires advanced and time consuming technique. The needs for AVS has been increasing due to increased utilization of screening for PA. Efficient selection of unilateral PA, such as aldosterone-producing adenoma (APA), before AVS is useful to avoid undesirable AVS in bilateral PA, such as idiopathic hyperaldosteronism. In this study, 40 patients who underwent all three confirmatory tests including the captopril-challenge test, furosemide upright test and adrenocorticotropin (ACTH) stimulation test (AST), and who were diagnosed as having PA by AVS were recruited. Subjects were diagnosed as having unilateral aldosterone excess (n=22) or bilateral aldosterone excess (n=18) by AVS. All patients with unilateral PA underwent operation and were finally diagnosed with APA. Major differences were detected in serum potassium level, basal plasma aldosterone concentration (PAC), presence of adrenal tumor, and AST results between the two groups. The PAC/cortisol ratio at 120 min in the AST showed the highest diagnostic capability for distinguishing the subtype of PA according to a receiver operating characteristic (ROC) curve analysis (area under the ROC curve was 0.956). At a cut-off value of 1.20 for the PAC/cortisol ratio at 120 min on AST, the sensitivity was 95.5% and the specificity was 88.9%. Sufficiently high sensitivity demonstrated indicates that the PAC/cortisol ratio at 120 min in the AST is useful for selecting patients with PA who are suitable for AVS.
P3578Determinants of visual-functional mismatches as assessed by coronary angiography and 3-D angiography-based quantitative flow ratio
Authors: Sugiyama T , Kanno Y , Hamaya R , Hoshino M , Usui E , Kanaji Y , Yamaguchi M , Hada M , Ohya H , Sumino Y , Hirano H , Yuki H , Horie T , Yonetsu T , Kakuta T
Published: October 2019

Background

Quantitative flow ratio (QFR) is a novel three-dimensional quantitative coronary angiography (QCA)-based computational index that can estimate fractional flow reserve (FFR) without pharmacologically induced hyperemia or the use of a pressure wire.

Purpose

We aimed to evaluate the determinants of visual-functional mismatches between conventional two-dimensional QCA and QFR.

Methods

A total of 504 de novo intermediate-to-severe lesions from 504 patients with stable angina who underwent angiographical and physiological assessments were analyzed. All lesions were divided into four groups based on the significance of visual (QCA-diameter stenosis [DS] >50% and ≤50%) and functional (QFR <0.80 and ≥0.80) stenosis severity. Patient characteristics, angiographic findings, QFR computations, and physiological indices were compared among the four groups.

Results

Among 504 lesions, 153 lesions (30.4%) showed concordantly negative (DS ≤50% and QFR >0.80) and 170 lesions (33.7%) showed concordantly positive (DS >50% and QFR ≤0.80) visual and functional assessments. Among 181 lesions (35.9%) with discordant results, 75 lesions (14.9%) showed a mismatch (DS >50% and QFR >0.80) and 106 lesions (21.0%) showed a reverse mismatch (DS ≤50% and QFR ≤0.80), respectively. Reverse mismatch was associated with smaller reference diameter (odds ratio [OR] 0.561; P=0.036), greater DS (OR 1.039, P=0.013), lower coronary flow reserve (CFR) (OR 0.571, P<0.001, non-diabetes mellitus (OR 2.141, P=0.013) and lower ejection fraction (OR 0.961, P=0.011). Mismatch was associated with smaller DS (OR 0.914, P<0.001), shorter lesion length (OR 0.894, P=0.001), higher CFR (OR 1,633, P<0.001), and lower estimated glomerular filtration rate (OR, 0.968, P=0.001). Lesion location and the index of microcirculatory resistance was not associated with the prevalence of reverse mismatch or mismatch.

Conclusions

There was a high prevalence of visual-functional mismatches between QCA-DS and QFR, and CFR was an important functional factor of mismatches. Our results suggested the difference between predictors of reported visual-functional mismatches of QCA/FFR and those of QCA/QFR.
P3638Triglyceride deposite cardiomyovasculopathy latency in population with coronary artery disease
Authors: Nakano Y , Onishi T , Niwa T , Takashima H , Shimoda M , Ohashi H , Ando H , Waseda K , Amano T
Published: October 2019

Background

Triglyceride deposit cardiomyovasculopathy (TGCV) is a novel clinical concept found among Japanese cardiac transplant recipients in 2008 that the abnormal intracellular triglyceride (TG) metabolism results in the ectopic accumulation of TG in vascular smooth muscle cells and cardiomyocytes, leading to diffuse narrowing coronary artery disease (CAD) and heart failure. TGCV is estimated to affect almost forty to fifty-thousand people in Japan, but there is no real-world date about the prevalence or latency.

Purpose

To evaluate TGCV latency in population with CAD, especially requiring urgent coronary angiography as Study 1, and chronic hemodialysis as Study 2.

Methods

This is multicenter retrospective estimation consisting of two studies.

Study 1) From 2012 to 2017, consecutive 400 patients of unstable angina or acute myocardial infarction who underwent urgent coronary angiography (CAG) and following iodine-123-β-methyliodophenyl-pentadecanoic acid (BMIPP) scintigraphy, a tracer for the diagnosis of TGCV, were enrolled.

Study 2) From 2011 to 2017, 88 chronic hemodialysis patients who underwent planed CAG and BMIPP scintigraphy for detection of ischemic heart disease were enrolled.

TGCV was diagnosed based on the latest diagnostic criteria for TGCV. The criteria include two major items (2 points each: BMIPP scintigraphy Wash-Out Rare <10%, Diffuse narrowing coronary arteries) and two minor items (1 point each: Jordans' anomaly in peripheral blood smear, Diabetes). Four points or more and three points indicated definite and probable TGCV, respectively. Only Items other than Jordans' anomaly were available for the diagnosis of TGCV because of retrospective nature. We evaluated the latent rate of definite and probable TGCV.

Results

Study 1) Figure (left) demonstrates the result of Study 1. Definitive TGCV patients were 14 patients, accounting for 3.5% of total 400 patients, and probable TGCV patients were 39 patients, accounting for 9.8% of all. Total 53 definitive and probable TGCV patients accounted for 13.3% of all. Annual average latency were 3.6±1.7% as definitive, 10.0±5.5% as probable and 13.6±6.6% as definitive and probable TGCV, respectively.

Study 2) Figure (right) demonstrates the result of Study 2. Definitive TGCV patients were 17 patients, accounting for 19.3% of total 88 hemodialysis patients, and probable TGCV patients were 22 patients, accounting for 25.0% of all. Total 39 definitive and probable TGCV patients accounted for 44.3% of all. Annual average latency of definitive TGCV was 19.3±13.4%. Of the 17 definitive TGCV patients, 9 patients were hemodialysis patients with diabetes.

Figure 1

Conclusions

TGCV might be latent with a probability of 3.6±1.7% per year in patients with unstable angina or acute myocardial infarction, and with a probability of 19.3±13.4% per year in chronic hemodialysis patients suspected of ischemic heart disease.
P3650Prognostic impact of post procedural aortic valve insufficiency on long-term risk for surgical aortic valve repair in patients undergoing balloon valvuloplasty for congenital aortic valve stenosis
Authors: Pavlovic A S , Djordjevic S A , Mehmedbegovic Z , Stefanovic I , Kalanj J , Topalovic M , Ostric Pavlovic I , Zivkovic V , Ilic S , Milovanovic V , Vulicevic I , Bisenic D , Vukomanovic G , Parezanovic V , Djukic M
Published: October 2019

Background

Limited evidence is available regarding the prognostic impact of post procedural aortic valve insufficiency (AVI) on long-term outcome in patients with congenital aortic valve stenosis treated with balloon aortic valvuloplasty (BAV).

Purpose

To assess the prognostic impact of immediate post procedural AVI on long-term outcome in patients undergoing BAV for congenital aortic valve stenosis.

Methods

We analyzed 89 patients (median age 4 years, range 6 days to 25 years), undergoing BAV during 2004–2017, from a prospective registry of a tertiary university center, with a median follow-up period of 4 years. Patients were classified into two groups based on presence of immediate post procedural AVI grade more than “+1/4” as assessed by echocardiography. Kaplan Meier cumulative mortality curves for groups above vs. bellow post procedural AVI grade “+1/4” were compared with log-rank test. Cox regression model was used to assess the risk for surgical aortic valve repair (SAVR) in long-term follow up with patients without worsening of AVI after BAV serving as the reference group.

Results

During follow up, SAVR was performed in 20% (n=18) of patients. Patients with immediate post procedural AVI grade more than “+1/4” after BAV had significantly higher long-term risk for SAVR compared to those without AVI worsening (72% vs. 18%, log-rank p<0.001). When adjusted for other significant aortic valve repair predictors, such as bicuspid aortic valve, neonatal age, residual aortic valve peak gradient >35 mm Hg, the presence of AVI grade more than “+1/4” immediately after BAV was independently associated with 6-fold (HR=5.60, 95% CI 2.03–15.42, p=0.001) increased risk for SAVR.

Kaplan-Meier freedom from SAVR curves

Conclusion

The presence of post procedural AVI grade more than “+1/4” in patients undergoing BAV for congenital aortic valve stenosis is independently associated with the increased risk for SAVR in long-term follow up.
P3669Impact of the endocarditis team on management strategies and mortality: the Dutch experience
Authors: Van Der Spoel T , Van Heusden H , Liesdek O , Boel E , Arends J , Suyker W , Chamuleau S
Published: October 2019

Background

Infective endocarditis (IE) was associated with poor survival. In 2015, the European Society of Cardiology (ESC) introduced the multidisciplinary IE team to improve diagnostics, treatment and outcome in patients with IE.

Purpose

This study evaluated the clinical implementation of the IE team in the Netherlands.

Methods

Retrospective cohort of all IE patients diagnosed between 2012–2016 in a tertiary single center. Clinical characteristics, data on imaging techniques, surgical procedures, IE-related complications and all-cause mortality were collected. Differences before and after installation of the IE team in 2015 were analyzed.

Results

Overall, 257 IE patients were included with a minimal follow-up of 1 year. No significant differences in baseline characteristics or imaging method were observed. The annual incidence of IE gradually increased over time from 36 cases in 2012 to 50 cases in 2016. This was caused by an increase in native IE cases. No difference in mortality was observed before and after 2015 (22% vs. 26%, P=0.43).

After 2015, a reduction in hospitalization duration was observed (37 vs. 32 days; P=0.09) and median time to surgery had significantly decreased (18 vs. 8 days; P=0.01). Although an increase in congestive heart failure and valvulair abscess were observed a downtrend in acute renal failure (25% vs. 16%, P=0.08) was observed. Multivariate analysis demonstrated that age, COPD, diminished LV function and surgery were important predictors for mortality but not the IE team.

Conclusion(s)

The introduction of a multidisciplinary IE team led to earlier surgical intervention and was associated with a reduction in hospital duration but not an important predictor for mortality. These results are important in view of designing novel clinical trials.
P3677Heritable veno-oclusive pulmonary disease in iberian romani patients: the difficulty of genetic counseling and its impact in the perpetuation of the disease
Authors: Perez Olivares Delgado C , Tenorio J , Aurtenetxe A , Cristo M J , Navas P , Hernandez I , Moreno A , Bedate P , Martinez A , Palomino J , Arribas F , Escribano P
Published: October 2019

Pulmonary veno-oclussive disease (PVOD) is a rare form of pulmonary hypertension of poor prognosis and difficult diagnosis. A founder mutation in EIF2KA4 gene has been described in Iberian Romani patients with familial PVOD.

Aims

genetically and clinically characterize a cohort of Iberian Romani patients with familial PVOD. To perform the family screening, analyze the phenotype and socio-cultural determinants which may influence on disease's course and spreading.

Methods

Patients with familial PVOD were included from November 2011 until February 2019. Clinical and survival data were obtained from the Spanish National Registry of PAH. Genetic analysis of EIF2KA4 was performed in patients and relatives.

Results

13 index cases were included, all of them Iberian Romani, carrying the founder mutation (p.Pro1115Leu) in EIF2KA4. Genetic screening revealed 74 of healthy heterozygotes and 13 homozygotes: among them 10 affected and 3 unaffected at baseline assessment (7, 28 and 37 years old). More than half of their family members, including one complete family, refused genetic screening. The survival free of transplant or death was 77.3% and 52.4%, at 1 and 3 years, respectively.

Baseline characteristics Total n=23 Age, years (SD) 23.6 (11.8) Male sex, % 52.2 Functional class NYHA III-IV, % 85 Pulmonary vascular resistance, UW (SD) 10 (5.4) DLCO, % 31.1 6MWT, meters (SD) 352.4 (160) Lung transplant, % 47.8 Survival free of transplant 3 years, % 52.4 DLCO, diffusing capacity for carbon monoxide; 6MWT, 6-minute walk test.

Conclusions

Patients were seriously ill from a young age. They have early pregnancy and high number of children. The high frequency of endogamy in the Romani population is likely to have an important impact on the transmission of PVOD, as it would favor the appearance of new homozygous carriers. Currently, our major concern is the low range of family members that accepted to be studied, more than 50% of family members rejected genetic studies and counseling.
P3705Impact of subclinical atrial fibrillation detected by cardiac implantable electronic devices on the risk of future embolic stroke events from Far East
Authors: Nakano M , Kondo Y , Nakano M , Kajiyama T , Hayashi T , Ito R , Takahira H , Kobayashi Y
Published: October 2019

Background

Atrial fibrillation (AF) is the most common type of arrhythmia. AF-related stroke tends to be more severe, and the mortality rate is higher compared with stroke without AF. The definition of AF in patients with cardiac implantable electronic devices (CIEDs) is not clear and the appropriate treatment guideline for patients with AF episode has not established yet. Recent CIEDs have led to an improvement in the early detection of AF episodes, especially in patients who are asymptomatic. Previous studies showed that atrial high-rate episodes (AHREs) detected by CIEDs are associated with embolic stroke events. However, little is known about the incidence of AF and stroke events in Japanese patients with CIEDs who have no prior AF and take no anticoagulant.

Objective

The purpose of this study was to identify the incidence of embolic stroke events in patients with and without AF events detected by CIEDs and examine the risk factors of embolic stroke events.

Methods

We retrospectively analyzed the database of our hospital. Every 6 months, AF events were checked by CIEDs. AF30 was defined as AF episodes lasting for ≥30 seconds detected by CIEDs. We examined the characteristics and incidence of embolic stroke events and investigated the relationship between AF30 and the incidence of embolic stroke events.

Results

We enrolled 348 consecutive patients who had no prior AF and took no anticoagulant in this study (follow-up period, 65±58 months; age, 70±16 years; male sex; 64%; defibrillator, 55%). The mean CHADS2 score and CHA2DS2-VASc score were 1.8±1.1 points and 2.8±1.5 points, respectively. The mean HAS-BLED score was 1.7±1.2 points. During the follow-up, 23 of 348 patients (6.6%) had embolic stroke events. Thirteen patients (4.1%/year) and 10 patients (0.63%/year) had embolic stroke events with and without AF30, respectively. The comparison of characteristics among patients with and without embolic stroke events was shown in Table. In multivariate logistic regression analysis, independent predictors for embolic stroke events were new-onset episode of AF30 (odd ratio [OR] 5.3, 95% confidence interval [CI] 2.2–13, P=0.0003) and an enlarged left atrium ≥40mm (OR 3.1, 95% CI 1.2–7.9, P=0.016).

Conclusions

Embolic stroke events were common in Japanese patients with CIEDs. AF30 and enlarged left atrium were risk factors of embolic stroke events in this population. Therefore, when physicians detect new-onset AF in patients with CIEDs, they should consider a comprehensive assessment of the risk and benefit of prescribing an anticoagulant.
P3708Prognostic significance of electrocardiographic changes after subarachnoid hemorrhage
Authors: Yuba T , Kimura Y , Mukaida T , Aoyama T , Hirano H , Gen S , Ohashi K , Hattori A , Takayama A , Yui Y , Kuroki N , Abe D , Suzuki K
Published: October 2019

Background and purpose

Many reports have examined electrocardiographic (ECG) changes after subarachnoid hemorrhage from long ago; however, there are few reports on the prognosis of patients who have an ECG abnormality. Therefore, in this study, the prognoses of patients with subarachnoid hemorrhage showing abnormal ECG findings were retrospectively analyzed.

Methods

Over 30 months from January 2014 to June 2016, 199 patients (mean age, 61.1±17.0 years; 46.7% male) admitted with a subarachnoid hemorrhage (SAH) were enrolled. To assess the mechanism underlying abnormal ECG in the SAH, predictor variables, such as demographics (age, sex, and body surface area), hemodynamics (heart rate and systolic blood pressure), blood biochemical results, neurological assessments (Glasgow Coma Scale), and computed tomography (CT) severity classification (World Federation of Neurosurgical Societies classification) were recorded. The subarachnoid hemorrhage was classified into either the cerebral aneurysm rupture group (N=132) or traumatic subarachnoid hemorrhage group (N=67) and analyzed.

Results

In the cerebral aneurysm rupture group, the QT prolongation was significantly increased compared with the traumatic subarachnoid hemorrhage group (424.8±87.7 ms vs. 400.5±95.8 ms, P<0.05). There was a correlation between consciousness level (Glasgow Coma Scale) on admission and QT prolongation, and significant QT prolongation was observed in critical patients (Pearson's correlation coefficient test P=0.04). ST changes correlated with CT classification severity (WFNS classification), and the most severe group (WFNS Grade 5) showed significant ST changes. On admission, the cerebral aneurysm rupture group and 97.0% in the traumatic subarachnoid hemorrhage group.

Conclusions

Significantly prolonged QT and ST changes are noted in patients with severe aneurysmal subarachnoid hemorrhage. The cause of the ECG abnormality in subarachnoid hemorrhage patients is not yet understood. A small number of experimental animal models have shown that electrocardiogram abnormalities associated with subarachnoid hemorrhage develop in the brain stem, and an autonomic nerve abnormality may also be involved.

A D-dimer is positively correlated with both aneurysm trauma and traumatic subarachnoid hemorrhage and may be used for auxiliary diagnosis of a subarachnoid hemorrhage.
P3713Positive troponin levels and electrocardiographic findings in acute ischemic stroke
Authors: Zareba N D C , Urdapilleta M , Sandoval C E , Garcia Zamora S S , Ameriso S F , Herrera Paz J J
Published: October 2019

Background

Troponin elevation and ECG changes are frequent findings in patients with acute ischemic stroke (AIS). The pathophysiology of these findings is still debated.

Purpose

To assesss the prevalence of electrocardiographic (ECG) changes and troponin elevation in AIS and to determine if these findings correlate with stroke severity.

Methods

Observational, retrospective study among AIS patients admitted to our stroke unit between October 2016 and December 2018. ECG was performed at admission and 24 hours later. Troponin levels were obtained after 6 hours of stroke symptoms onset. The NIH Stroke Scale (NIHSS) was performed by stroke neurologists.

Results

We included 744 consecutive patients (58% male), aged 66.8 years ±16.6 SD. Main vascular risk factors were hypertension (62%), dyslipidemia (49%), type 2 diabetes (18%), smoking (16%) and coronary artery disease (CAD) (17%). Twelve patients (1.6%) died during the hospitalization. Almost a half of patients (48.7%) had abnormal ECG. The most frequent ECG findings were: long QTc (26%), pathologic Q wave (18%), atrial fibrillation (AF) (9.4%), T wave inversion (5%), left-bundle bunch block (LBBB) (4%) and ST segment depression (2%). Patients who had a history of CAD had abnormal ECG findings more frequently than those who had not. (71% vs 44%, p<0.001).

Thirteen percent of patients had positive troponin levels and 6% presented severe strokes (defined as a NIHSS >15). In the univariate analysis, positive troponin was associated with ST segment depression (p=0.01), T wave inversion (p<0.01), LBBB (p<0.01) and AF (p<0.01). Patients with severe strokes had more frequent ECG abnormalities (p=0.002) and positive troponin levels (p<0.001). LBBB and AF were also associated with severe stroke (p=0.002 and p<0.0001 respectively).

Conclusions

ECG changes are prevalent in acute stroke. T wave inversion, ST segment depression, AF and LBBB are associated with high troponin levels, potentially suggesting underlying CAD. High troponin levels, LBBB and AF are associated with severe stroke. Patients with acute stroke may have underlying cardiovascular disease and may benefit from cardiologic evaluation.
P3717More fresh thrombi in cardio embolic than vascular related acute vessel syndromes
Authors: Meuwissen M , Remmers M J M , Pertiwi K R , Scholzel B E , Versteylen R J , De Boer O , Sturm M F A M , Van Den Hoef T P , Ijsselmuiden A J J , Van Norden A G W , De Jong T E A M , Haans H A W , Aarts R A H M , Vos L D , Van Der Wal A C
Published: October 2019

Background

Acute thrombotic occlusion may lead to major life threatening syndromes such as ST elevation myocardial infarction (STEMI) or stroke. In the majority, the underlying pathophysiology may be related to local vascular factors or thrombotic emboli. Thrombus composition might be indicative of underlying etiology and affect therapeutic considerations. Comparison of thrombi of patients suffering from both these acute syndromes has not been made yet. In this study, we compared the “age” of thrombi of patients with STEMI and acute large vessel occlusion related stroke (LVOS).

Methods and results

A total of 126 consecutive patients underwent thrombectomy for either STEMI (n=51) or LVO (n=75). All STEMI patients had vascular related occlusions. Causes of LVOS were classified according to the TOAST criteria; i.e. large artery atherosclerosis (LAA), cardio embolic (CE), other determined and embolic stroke of unknown source. Aspirated material was histopathological ordered as fresh (<1 day old), lytic (1–5 days old) or organized (>5 days old). In general, thrombi of patients with LVOS were fresher compared to thrombi of STEMI patients (p=0,04). This difference is can be attributed mainly to CE patients, which had significantly younger thrombi (p=0.001). Thrombi of LAA had comparable age with thrombi of STEMI (Figure).

Conclusion

Thrombi of cardio embolic stroke are fresher compared to that of thrombi of atherosclerotic related stroke. The latter have thrombi with comparable age of that with thrombi of ST elevation myocardial infarction. These findings may have therapeutic implications in anti-thrombotic therapies.
P3724Impact of chronic kidney disease on efficacy and safety of interventional left atrial appendage closure – results from the prospective multicenter LAARGE registry
Authors: Fastner C , Brachmann J , Lewalter T , Zeymer U , Sievert H , Nienaber C A , Weiss C , Ince H , Maier J , Achenbach S , Sigusch H H , Hochadel M , Schneider S , Senges J , Akin I
Published: October 2019

Background

The interventional left atrial appendage closure (LAAC) is an effective and safe alternative to standard oral anticoagulation (OAC) for stroke prevention in atrial fibrillation (AF) patients with contraindications for long-term OAC. Chronic kidney disease (CKD) has a high prevalence among AF patients, and was shown to increase the number of peri-procedural complications in cardiac interventions.

Purpose

This subanalysis of the LAARGE registry aimed to investigate CKD's impact on outcomes after LAAC.

Methods

This prospective, real-world LAAC registry included 625 patients with documented renal function from 37 German centers between April 2014 and January 2016. CKD was defined by an eGFR <60 mL/min/1.73 m2. Procedure was conducted with different LAAC devices considering the relevant recommendations. Baseline characteristics, procedural data, intra-hospital and one-year follow-up outcome were registered for CKD and non-CKD patients stratified by the different CKD stages.

Results

CKD patients (n=300; 48.0%) had a more pronounced cardiovascular risk profile, a higher stroke (CHA2DS2-VASc score 4.9±1.5 vs. 4.2±1.5; p<0.001) and bleeding risk (HAS-BLED score 4.3±1.0 vs. 3.5±1.0; p<0.001), and had experienced more prior bleedings (83.7 vs. 76.3%; p=0.022). Implantation success was similarly high between both groups (97.9%; p=n.s.). In CKD patients, MACCE during one-year follow-up was more frequent (18.1 vs. 6.8%; p<0.001) mainly being triggered by all-cause deaths, but in-hospital MACCE was not (0.3 vs. 0.3%; p=n.s.). Kaplan-Meier estimation showed a lower one-year survival among CKD patients (82.4 vs. 94.4%; p<0.001) without significant accentuation in patients with advanced CKD (i.e., <30 mL/min/1.73 m2; p=n.s. to other CKD patients). While annual rate of device associated complications (2.6 vs. 2.8%; p=n.s.) and strokes (0 vs. 1.0%; p=n.s.) was comparable during follow-up, annual severe bleeding rate was higher in CKD patients (2.6 vs. 0.3%; p=0.027) which was 71.4 and 94.4% less than expected from the HAS-BLED score (p<0.01 for the comparison to the estimated risks, but no significant interaction between groups).

Conclusions

Despite an increased cardiovascular risk profile of CKD patients, device implantation was safe, and annual stroke rate was statistically indifferent to non-CKD patients across all CKD stages after LAAC. Moreover, a substantial reduction of annual stroke and major bleeding risk was observed, as compared to the estimated annual risk.

Acknowledgement/Funding

Stiftung Institut für Herzinfarktforschung, Ludwigshafen, Germany
P3728Impact of residual leaks and device-associated thrombus after left atrial appendage occlusion: long-term transesophageal follow-up and clinical outcome
Authors: Staubach S , Moertl M , Strohm H , Krollmann C , Mudra H
Published: October 2019

Background

Standardized transesophageal echocardiography (TEE) data regarding peri-device leaks and thrombus formation after left atrial appendage occlusion (LAAO) are sparse. Criteria to quantify residual leaks seem to appear highly arbitrarily. We therefore examined patients by long-term TEE follow-up after LAAO in a standardized Echo protocol.

Methods

Our patients were prospectively examined by questionnaires and TEE 6 weeks post-procedurally and ≥12 months after LAAO. TEE was performed according to the Munich consensus document, including multiple TEE views (2D and 3D) and an adequate, lower Nyquist limit (20–30cm/s) to detect low velocity flow. The severity of the leaks were graded as follows: >5mm severe, 3–5mm moderate and 1–2mm mild. Antithrombotic regime was administered according to the PROTECT-AF protocol for the Watchman device in the first 60 patients, and dual antiplatelet therapy for 1–3 months thereafter as well as for the Amplatzer device.

Results

In total, 107 LAAO were performed in our institution in patients with a mean age of 77 years. Mean CHA2DS2-VASc score was 4.3±1.3, mean HAS-BLED score 2.7±0.9. Mean clinical follow-up duration was 52.8 months, mean TEE follow-up 43.1 months. The overall annual stroke rate was 1.49%. None of the patients with a post-procedural stroke showed an intracardial thrombus by TEE after six weeks, during the event and in long-term FU. In long-term TEE follow-up 46% (n=18/39) had a mild to moderate residual leak and 2.6% (n=1/39) a severe leak >5mm.Two of the patients with a permanently existing leak sustained an ischemic stroke: in the first patient with a peri-device leak of 3mm the stroke occurred 80 months post-procedurally, in the second one with a growing leak from 3 to 6,5mm 25 months post-procedurally, both classified most likely as a cardioembolic stroke. One patient without a leak in long-term TEE FU suffered a stroke 5 years after LAAO (p=0.61). In all three patients antithrombotic regime during the event consisted of ASS alone.Device-associated thrombus was observed in 1.9% (n=2/107) six weeks after the procedure and increased to 15.4% (n=6 out of 39 TEE studies) in long-term FU, all appeared immobile. None of those patients suffered a thromboembolic event.

Conclusions

In long-term follow up, residual, mostly mild to moderate leaks and device-associated thrombi after LAAO seem to occur occasionally. However, patients with a residual leak or immobile thrombus do not appear to have a higher risk for thromboembolism so far.
P3735Incidence of bicuspid aortic valve in 16,185 neonates by echocardiographic screening in a single institution: is it really congenial?
Authors: Waki K , Ueda K , Satoh K , Ogino K , Hayashi T , Arakaki Y
Published: October 2019

Background

Bicuspid aortic valve (BAV) has been reported to be the most common congenital heart disease with an incidence of 1 to 2% in the general population; however, its incidence in neonates is still unclear because most of the reported incidence data are based on surgical or autopsy cases in adults.

Purpose

To elucidate the true incidence of congenital isolated BAV in neonates by echocardiographic screening in a population-based study.

Methods

We examined a total of 16,185 full-term neonates (male, 48.9%) born in our institution during either of the following two periods: September 1986 to February 2008 and October 2014 to September 2017. Mean gestational age (range) was 39.4 (36 to 42) weeks, and mean birth weight (range) was 3075 (2268 to 4622) g. On the second day after birth, we performed echocardiography and colour-Doppler flow mapping in all subjects. BAV was classified into two types on the basis of morphologicfindings in the parasternal short axis view of the aortic valve: BAV with raphe harbouring two cusps and commissures, showing a congenital fusion of two underdeveloped cusps, and BAV without raphe, showing a fish mouth appearance in systolic images. BAV associated with other congenital heart diseases such as coarctation of the aorta was excluded from this study.

Results

BAV was identified in 14 neonates (0.09%), an incidence of 0.9 in 1,000 live births. Of the 14 BAV neonates, five had BAV with raphe, whereas nine had BAV without raphe. Of the five BAV neonates with raphe, four had fusion of the right and noncoronary cusps, whereas one had that of the right and left coronary cusps. No aortic regurgitation was detected except trivial one in only one neonate, and no significant valvar stenosis was detected.

Conclusion

The incidence of BAV in neonates was much lower than previously reported incidence data. An acquired fusion of the cusps may develop in later life, and eventually may result in increased incidence of functional BAV.
P3747Does pulmonary vein isolation have similar results for treating AF in Chagas disease?
Authors: Macedo P , Rueda P , Serafim L , Oliveira E , Santos S , Henz B , Leite L
Published: October 2019

Background

AF is reported in up to 20% of patients with Chagas, a prevalent disease in Latin-America. PV isolation (PVI) in the cornerstone of AF ablation. However, in Chagas cardiopathy (ChC), microvascular and autonomic abnormalities, atrial fibrosis and sinoatrial dysfunction are possible mechanisms of AF. Therefore, the results of PVI may be different in this subgroup.

Objectives

To describe long-term results of AF ablation in pts with Chagas versus non-Chagas disease (ChC x NonCh) and evaluate risk factors for post-ablation recurrence.

Methods

This is a prospective, single-center study that included pts with nonvalvular AF who underwent PVI between 2013 and 2016. All procedures were guided by eletroanatomic mapping and intracardiac echocardiogram. Categorical variables were analyzed using chi-square test and numerical variables with t-student test. Binary logistic regression was performed to identify independent predictors of recurrence of any sustained atrial tachyarrhythmias.

Results

Ablation was performed in 160 pts (54±15 yo, 59% male): 42 pts with ChC (26%, 62±8 yo) and 118 NonChC (74%, 53±15 yo; p<0,001)). There was no difference in AF type (38x34% paroxysmal, 42x43% persistent, and 19x23% long-term persistent, p=NS) and left atrium diameter (38±5 vs 40±8mm, p=NS). In ChC the mean CHADSVASC score was higher (2.4 vs 1.4, p<0,001) and LVEF was lower (52±18% vs 64±8%, p=0.02). After a follow-up of 31±14 mo and 1.1 ablation per group, recurrence of AF/AT was higher in ChC (33% vs 14%, p=0.03) although more pts with Chagas were on AAD (71 vs 31%, p<0,001). During follow-up, occurrence of embolic events and cardiac or all-cause mortality were not different between groups (0% vs 1.7%, p=NS and 2.4 vs 1.7% p=NS; for ChC vs and NonChC, respectively).

At multivariate analysis, long-term persistent AF, hypertension and Chagas disease (HR= 2.21, 3.36 and 3.16, respectively) were independent predictors of recurrence.

Conclusions

Chagas disease is an independent predictor of recurrence after PVI. Further studies should address which strategy is more appropriate to this group of patients.
P3761Correlation between CHA2DS2-VASc score and left atrial size in patients with atrial fibrillation: an upto 15-year prospective follow-up study
Authors: Lin T T L , Lin L Y , Tsai C T T
Published: October 2019

Background

Left atrial (LA) size represents atrial fibrillation (AF) burden and a predictor of AF-related stroke. CHA2DS2-VASc score is also a well-established predictor of AF-related stroke. It is unknown whether these two factors are correlated and complimentary to each other, or one of them is a major determinant of stroke risk for AF patients.

Methods

A total of 708 patients from the National Taiwan University AF Registry were followed upto 15 years. LA size was measured by M-mode of echocardiography and the CHA2DS2-VASc score was calculated as measures of stroke risk. Primary endpoints during follow-up were defined as ischemic strokes or transient ischemic accidents.

Results

Both LA size and CHA2DS2-VASc score were associated with the risk of stroke in univariate analyses (c statistic 0.662 [0.601 to 0.723] for CHA2DS2-VASc score and 0.595 [0.516 to 0.674] for LA size). There was a positive correlation between LA size and CHA2DS2-VASc score (r=0.17, P<0.0001). Patients with higher CHA2DS2-VASc scores had a higher mean LA size (P<0.01 for trend). When combining LA size and CHA2DS2-VASc score in the multivariate Cox model, only CHA2DS2-VASc score remained statistically significant to predict the thromboembolic endpoint (hazard ratio 1.39 [1.20–1.63]; P<0.001).

Mode of anlysis Harzard ratio (95% confidence interval) P value Univariate analysis*   CHADS2-VASc score 1.42 (1.22–1.66) <0.001   Left Atrial Size 1.30 (1.04–1.62) 0.019 Multivariate analysis*   CHADS2-VASc score 1.39 (1.20–1.63) <0.001   Left atrial size 1.20 (0.96–1.48) 0.106

Conclusion

There is a positive correlation between echocardiographic LA size and CHA2DS2-VASc score. LA size is not an independent predictor of AF-related stroke, but provides a diagnostic value to predict stroke risk through its association with CHA2DS2-VASc score. Calculation of CHA2DS2-VASc score may replace measurement of echocardiographic LA size when evaluating the risk of AF-related stroke.
P3767Progressive left atrial remodeling associates with cholesterol efflux capacity of HDL in atrial fibrillation patients
Authors: Takano A , Iwata H , Miyosawa K , Funamizu T , Hayashi H , Tabuchi H , Sekita G , Daida H
Published: October 2019

Background

The clinical significance of high-density lipoprotein (HDL) function, represented by cholesterol efflux capacity (CEC), in addition to serum HDL cholesterol (HDL-C) levels, has been recognized in the pathogenesis and prognosis in patients with atherosclerotic cardiovascular diseases. However, the roles of HDL in the development and the progression of atrial fibrillation (AF), has been rarely evaluated. In this study, we thus hypothesized that the compromised HDL function may be associated with the progression of pathological structural remodeling in left atrium (LA).

Objective

We explored the association between CEC of HDL and the left atrial dimension (LAD), a maker of structural remodeling in the LA, in patients with AF and control.

Methods

This is a single center case-control study including consecutive 260 AF patients (AF group) and 34 paroxysmal supraventricular tachycardia (PSVT) patients (PSVT group, served as a control group), who underwent catheter ablation from July 2017 to December 2018. Blood samples were collected before catheter ablation procedure. CEC of HDL was measured by using ex vivo radiotracer system that involved incubation of [3H] cholesterol-loaded J774.1 murine macrophage-like cells with apoB-depleted serum.

Results

Serum HDL-C level was lower in AF group compared to those of PSVT group (55.3±15.3mg/dl vs 61.7±13.3mg/dl: p=0.024). As a marker of HDL function, CEC of HDL was significantly lower in patients with AF group compared to those in PSVT patients (4.74±0.84% vs 5.20±0.99%: p=0.005, Fig 1). In all patients including both groups, CEC of HDL was inversely correlated with LAD (r=−0.25; p<0.001, Fig 2), indicating the inverse association between HDL function and the progression of structural remodeling in AF. Moreover, multivariate logistic regression analysis adjusted by age, gender, body mass index, ejection fraction, and HDL-C demonstrated that increase in CEC of HDL was associated with the lower risk to be highest quartiles of LAD (>42mm), even adjusted by serum HDL-C levels (odds ratio of 1-SD elevation in CEC of HDL for LAD>42mm: 0.63; 95% confidence interval: 0.40–0.97, p=0.037), which implicated the link between HDL function and progression of left atrial structural remodeling.

Conclusion

Findings in this study may suggest that compromised HDL functionality is associated with the pathogenesis of left atrial structural remodeling in AF patients.
P3774Prediction of left atrial appendage thrombosis in nonvalvular atrial fibrillation by means of predictors not related to CHA2DS2-VASc score
Authors: Gizatulina T , Khorkova N Y , Belokurova A V , Kharats V E , Martyanova L U
Published: October 2019

Background

Nonvalvular atrial fibrillation (AF) is the most common sustained cardiac dysrhythmia and the most frequent cause of cardio-embolic stroke. It is well known that left atrial appendage thrombi (LAAT) are the source of most embolic strokes in patients with AF, and can be easily identified by transesophageal echocardiography (TEE).

Purpose

To determine additional LAAT predictors not included in the CHA2DS2-VASc score in patients with nonvalvular AF.

Methods

Retrospective study enrolled 636 patients with nonvalvular AF (400 males) aged 24–84 years (mean age 57.8±9.1), admitted to our Research Center in 2014–2017 for catheter ablation or electrical cardioversion. All patients had scheduled transthoracic echocardiography (TTE), as well as TEE performed to exclude LAAT. Four forms of cardiac geometry were revealed with the help of TTE according to Recommendations of ASE and EACI: normal geometry, concentric remodeling, eccentric hypertrophy and concentric hypertrophy.

Results

According to TEE results, LAAT (6.6%) was detected in 42 patients from 636. Patients with LAAT more often had persistent and permanent AF (assigned as “AF stability”), had bigger sizes and volumes of left and right cardiac chambers, lower left ventricular ejection fraction, more expressed LV hypertrophy and lower blood flow velocity in the LA appendage compared to patients without LAAT. Remodeling types also varied: less LAAT patients had normal cardiac geometry and more LAAT patients had LV eccentric hypertrophy. To analyze factors associated with AF, we used a multivariable logistic regression model, involving the potential independent, clinically relevant variables and echocardiographic parameters. Logistic regression analysis identified the latter three as independent predictors for LAAT (Table 1). According to ROC-analysis the quality of the received model was assessed as good: AUC=0.763 (p<0.01), sensitivity – 75.8%, specificity – 72.2%.

Table 1 Predictors B Wald statistics χ2 P OR 95% CI AF stability 0.913 4.143 0.042 2.491 1.034–6.000 LA diameter, mm 0.149 8.684 0.003 1.160 1.051–1.281 Eccentric hypertrophy 1.440 7.411 0.006 4.222 1.497–11.908 Constant −10.613 24.088 0.000

Conclusion

From risk factors, not included in the CHA2DS2-VASc score, in addition to such predictable values as AF stability and left atrial diameter, such predictor as eccentric left ventricular hypertrophy was revealed, which in our study was associated with more than a 4-fold increase in the risk of LAAT.
P3782Frailty to predict unplanned hospitalizations, stroke, bleeding and death in atrial fibrillation
Authors: Meyre P , Gugganig R , Aeschbacher S , Leong D P , Blum S , Coslovsky M , Beer J H , Moschovitis G , Mueller D , Rodondi N , Stempfel S , Mueller C , Kuehne M , Conen D , Osswald S
Published: October 2019

Aim

We investigated the prevalence of frailty, and the relationships between frailty and the risk of adverse clinical outcomes in patients with atrial fibrillation (AF).

Methods

Patients with known AF were enrolled in a nation-wide observational cohort study in Switzerland. Information on medical history, medication, lifestyle factors and clinical measurements were obtained. The primary outcome was unplanned hospitalizations, secondary outcomes were all-cause mortality, bleeding and stroke. The frailty index (FI) was measured using a cumulative deficit approach according to previously published criteria. Participants were divided into three groups (non-frail, pre-frail and frail) according to their FI at study entry. The association between frailty and clinical outcomes was assessed using multivariable adjusted Cox proportional hazard models.

Results

We included 2369 patients with a mean age of 73±8 years (27.3% female). The prevalence of frailty and pre-frailty was 10.6% and 60.7%, respectively. Frailty was associated with unplanned hospitalization (adjusted hazard ratio [HR] 3.59; 95% confidence interval [95% CI], 2.78–4.63; p<0.001), all-cause mortality (adjusted HR 16.72; 95% CI 7.75–36.05; p<0.001), bleeding (adjusted HR 2.46; 95% CI 1.61–3.77; p<0.001), and stroke (adjusted HR 3.29; 95% CI 1.29–8.39; p=0.01) (Figure). Similarly, pre-frailty was significantly associated with unplanned hospitalization (adjusted HR 1.82; 95% CI 1.49–2.22; p<0.001), all-cause mortality (adjusted HR 5.07; 95% CI 2.43–10.59; p<0.001) and bleeding (adjusted HR 1.53; 95% CI 1.11–2.13; p=0.01), but not with stroke.

Cumulative incidence of adverse events

Conclusion

In our cohort, more than two thirds of AF patients were either pre-frail or frail. These patients have a high risk of unplanned hospitalizations and other adverse outcomes, indicating that frailty is a powerful tool to predict adverse clinical outcomes in AF patients.

Acknowledgement/Funding

Swiss National Science Foundation; Foundation for Cardiovascular Research Basel; University of Basel
P3799Experimental model of interatrial block by Bachmann bundle conduction block
Authors: Guerra Ramos J M , Vilahur G , Bayes De Luna A , Casani L , Cabrera J A , Martinez-Selles M , Mendieta G , Baranchuk A , Badimon L , Sanchez-Quintana D
Published: October 2019

Background

The recognition of advanced IAB is becoming an important clinical landmark due to its association with atrial fibrillation, the so-called Bayes' syndrome. The electrocardiographic (ECG) criteria of interatrial block (IAB) have been established. A P-wave duration ≥120 ms is considered partial IAB and if there is a biphasic P-wave in the inferior leads advanced IAB. The pathophysiology of this ECG finding has been largely discussed. IAB has been explained as the result of the retrograde activation of left atrium due to complete block in the Bachmann bundle (BB).

Purpose

To assess the ECG changes resulting of blocking BB conduction in an experimental healthy animal model. Additionally, to compare the pattern of activation of the left atrium before and after the block.

Methods

Six open-chest anesthetized healthy adult swine were studied. A twelve-lead ECG was continuously recorded. The BB was epicardially accessed at the traversus sinus of the pericardium. At that level, monopolar electrosurgical energy (3 animals) and radiofrequency energy (3 animals) (Boston Scientific Blazer™ II XP, 8 mm tip) was applied until extensive tissue disruption was present and permanent P-wave changes observed. An electroanatomical map CARTO® XP (Biosense Webster Inc) of the right and left atrium was performed in two animals before and after energy deployment. Finally, animals were sacrificed, and tissue samples collected for anatomopathological examination.

Results

After energy application, all animals showed a significant prolongation of P-wave duration from 59±11 msec to 115±13 msec (p<0.001) with appearance of a biphasic P-wave pattern in the inferior leads. The CARTO® maps showed a change in left atrial activation, cranio-caudal at baseline and caudo-cranial at the end of the procedure. (Figure) The histological analysis showed transmural lesions at the level of the BB in all the specimens.

ECG/CARTO maps: Baseline and after block

Conclusion

IAB ECG pattern, accompanied by a marked change in the activation of the left atrium, develops after blocking the conduction at the level of the BB in an experimental healthy animal model. These results confirm the association of IAB and BB conduction block and suggest that IAB represents an independent entity.

Acknowledgement/Funding

Fundaciό Privada Daniel Bravo Andreu
P3812The economic burden of heart failure in Denmark from 1998 to 2016
Authors: Bundgaard J S , Mogensen U M , Christensen S , Ploug U M , Roerth R , Ibsen R , Kjellberg J , Koeber L
Published: October 2019

Background

Heart failure (HF) imposes a large burden on the individual as well as society and the aim of this study was to investigate the economic burden attributed to direct and indirect costs of patients with HF before, at, and after time of diagnosis.

Methods

Using Danish nationwide registries we identified all patients >18 years with a first-time diagnosis of HF from 1998–2016 and matched them 1:1 with a control group from the background population on age, gender, marital status, and educational level. The economic analysis of the total costs after diagnosis was based on direct costs including hospitalization, procedures, medication, and indirect costs including social welfare and lost productivity to estimate the annual cost of HF.

Results

We included a total of 176,067 HF patients with a median age of 76 years, and 55% were male. Patients with HF incurred an average of €17,039 in sum of total annual direct (€11,926) and indirect (€5,113) health-care costs peaking at year of diagnosis compared to €5,936 in the control group with the majorityattributable to inpatient admissions. The total annual net costs including social transfer after index HF were €11,957 higher in patients with HF compared to controls and the economic consequences increased markedly 2 years prior to the diagnosis of HF (Figure 1).

Conclusion

Patients with HF impose significantly higher total annual health-care costs compared to a matched control group with findings evident more than 2 years prior to HF diagnosis

Acknowledgement/Funding

Novartis