bluuebunny/crossref_metadata_2025 huggingface dataset:
P3637Relationship between serial measurements of NT-proBNP and cardiovascular events in patients with acute coronary syndrome
Authors: Jang J Y , Ahn J H , Bae J S , Kang M G , Kim K , Park H W , Koh J S , Park Y , Hwang S J , Kwak C H , Hwang J Y , Jeong Y H
Published: October 2019

Background

Increased level of natriuretic peptides has been known as an important predictors of adverse cardiovascular (CV) outcomes in patients with acute coronary syndrome (ACS). We sought to evaluate clinical implication of N-terminal pro-brain natriuretic peptide (NT-proBNP) measured at initial and follow-up periods.

Methods

Serial NT-proBNP levels (on-admission and one-month post-PCI) were measured in ACS patients undergoing PCI (n=2,290). High NT-proBNP levels were determined according to the predefined age-specific criteria. Patients were stratified into 4 groups according to NT-proBNP levels (on-admission & one-month): (1) normal-normal group (n=1234, 53.9%); (2) high–normal group (n=257, 11.2%); (3) normal-high group (n=376, 16.4%); and (4) high-high group (n=423, 18.5%). Clinical events were defined as all-cause death and MACE (a composite of CV death, non-fatal MI, and ischemic stroke).

Results

With a median follow-up of 35.9 (IQR: 16.8, 54.5) months, all-cause death and MACE were occurred in 4.1% and 7.2%, respectively. NT-proBNP on-admission vs. at one-month did not differ significantly (median 391.6 [IQR: 143.9, 1402.3] vs. median 619.1 [IQR 240.1, 1616.1]; p=0.622), but the prevalence of high NT-proBNP was increased over time (25.3% to 34.9%; p<0.001). The rates of all-cause death and MACE significantly increased only in the high-high group compared with other groups (log-rank test, all p values <0.001, Figure). After adjustment, the high-high group remained significantly risky in terms with the occurrence of all-cause death (HR, 2.99; 95% CI, 1.65 to 5.41; p<0.001) and MACE (HR, 1.96; 95% CI, 1.28 to 3.01; p=0.002).

Figure 1

Conclusion

Serial measurements of NT-proBNP at on-admission and follow-up can help to stratify the risks of all-cause death and adverse CV events following PCI in ACS patients. About two-fifths of patients having high NT-proBNP level during hospitalization can be classified into the low-risk group for all-cause death and adverse CV events.

Acknowledgement/Funding

None
P3648Plasma glutamate are increased in non-smoker patients with vasospastic angina pectoris and associated with plasma cystine and antioxidant capacity
Authors: Fujibayashi K , Oda M , Wakasa M , Takano S , Kuzume Y , Saeki Y , Sawaguchi J , Fujita W , Saito R , Kawai Y , Kajinami K
Published: October 2019

Background

Endothelial dysfunction of the coronary arteries caused by oxidative stress plays an important role in the pathogenesis of vasospastic angina pectoris (VSAP). Glutamate, a non-essential amino acid, exerts endothelial dysfunction by oxidative stress production through N-methyl-D-aspartate receptor activation. Besides oxidative stress, decrease of antioxidant may be responsible for endothelial dysfunction. Glutathione (GSH), an important antioxidant, is synthesized from imported cystine through the cystine/glutamate antiporter system (XC-) in association with the export of glutamate. Glutamate also competitively inhibits cystine import into the endothelial cells through the XC-leading to GSH depletion. Thus the extracellular glutamate and cystine are crucial for the intracellular redox status. However, it remains unclear whether glutamate and/or cystine are implicated in the pathogenesis of VSAP. As smoking induces powerful oxidant stresses in the whole body, we investigated plasma glutamate, cystine, oxidative stress markers and antioxidant capacity in non-smoker patients with VSAP.

Methods and results

Sixty-two consecutive non-smoker patients suspected having VSAP were performed coronary angiograms (CAG). Forty-nine patients who did not show any significant coronary stenosis (<50%) were performed the intracoronary acetylcholine provocation test. Patients were categorized into the VSAP-positive group (n=27) and the VSAP-negative group (n=22) on the basis of test results. Blood samples were collected from the femoral sheath before the CAG. Plasma glutamate, cystine, nitrotyrosine (NT), reactive oxygen metabolites (d-ROMs) and biological antioxidant potential (BAP) were measured. The levels of plasma glutamate and cystine in the VSAP-positive group were significantly higher than those in the VSAP-negative group (59.8±25.7 vs 43.5±18.7 nmol/L, p=0.0054, and 35.3±14.2 nmol/L vs 25.2±9.1 nmol/L, p=0.0018, respectively). The levels of plasma glutamate showed significant and positive association with the levels of plasma cystine (r=0.40, p=0.005). There were no significant differences in the levels of NT and d-ROMs as oxidative stress markers, and BAP as an antioxidant capacity between the two groups, respectively. However, the levels of plasma glutamate showed significant and negative association with BAP values (r=−0.3, p=0.038).

Conclusions

Plasma levels of glutamate were increased in non-smoker patients with VSAP and positively associated with plasma cystine levels and negatively associated with antioxidant capacity, suggesting that plasma glutamate modulate plasma cystine levels and antioxidant capacity through the XC- inhibition, and could be a novel risk factor of VSAP.
P3655Right ventricular volume off-loading following atrial septal defect closure or pulmonary valve replacement: impact on tricuspid regurgitation and mid-term remodeling
Authors: Martin Garcia A C , Dimopoulos K , Boutsikou M , Kempny A , Alonso-Gonzalez R , Swan L , Uebing A , Babu-Narayan S V , Martin-Garcia A , Sanchez-Fernandez P L , Castro Garay J C , Li W , Shore D F , Gatzoulis M A
Published: October 2019

Introduction

Cardiac surgery or catheter intervention is nowadays commonly performed to abolish volume loading of the right ventricle (RV) in adults with congenital heart disease (ACHD).

Purpose

Little is known, however, of their impact on the preexisting tricuspid regurgitation (TR) following such procedures (atrial septal defect [ASD] closure and pulmonary valve replacement [PVR]), which was the aim of our study.

Methods

Demographics, clinical and echocardiographic characteristics were analyzed from 162 consecutive patients undergoing such interventions between July 2005 and December 2014, who had at least mild preoperative TR.

Results

Mean age at intervention was 42±16 years (38.3% male); 101 patients underwent ASD closure, whereas 61 patients PVR. Only 11.1% receiving concomitant tricuspid valve surgery (repair). There was significant overall improvement in severity of TR, from 38 (23.5%) patients having moderate or severe TR preoperatively to only 11 (6.8%) and 20 (12.3%) at 6 and 12 months of follow-up, respectively (p<0.05) (Figure 1) (Table 1). Improvement in TR was observed in patients who did not have concomitant TV repair, from 15.3% to 6.9% and 11,8%, 6 and 12 months, respectively (p<0.05).

Echocardiographic data Echo 1 (baseline) Echo 2 (6 months) Echo 3 (12 months) p-value† ‡Echo 1 ‡Echo 2 ‡Echo 3 TR grade (none = 1, mild = 2, moderate = 3, severe = 4) 2.3±0.6 1.6±0.6 1.7±0.8 <0.0001 A B B End-diastolic tricuspid annulus diameter (cm) 4.3±0.6 3.6±0.6 3.5±0.5 <0.0001 A B B Systolic tenting area (cm2) 0.7±0.5 0.5±0.2 0.5±0.3 <0.0001 A B B Coaptation distance (cm) 0.6±0.2 0.4±0.2 0.4±0.2 <0.0001 A B B End-diastolic area (cm2) 30.3±7.5 21.7±6.0 20.6±6.0 <0.0001 A B C Fractional area change (%) 39.4±8.4 39.0±8.0 39.9±8.1 0.58 A A A RV mid diameter (cm) 4.2±0.7 3.3±0.7 3.2±0.6 <0.0001 A B B RVOT end-diastolic proximal diameter (cm) 4.4±0.6 3.8±0.6 3.6±0.5 <0.0001 A B C TAPSE (cm) 2.1±0.6 1.4±0.5 1.4±0.4 <0.0001 A B B Lateral TDi S (cm/s) 12.4±3.3 8.8±3.0 9.2±3.0 <0.0001 A B B Systolic pulmonary artery pressure (mmHg) 42.4±13.4 34.8±10.1 35.1±11.6 <0.0001 A B B LVEF (normal = 1, mild LV dysfunction = 2, moderate = 3, severe = 4) 1.0±0.2 1.0±0.2 1.0±0.2 0.80 A A A RA area (cm2) 26.1±9.6 19.5±6.6 19.2±6.7 <0.0001 A B B *One-way ANOVA comparison. ‡Tukey pairwise comparison between Echos 1, 2 and 3: means that do not share a letter are significantly different (i.e. p<0.05).

Figure 1

Conclusions

ASD closure or PVR are commonly associated with significant reduction of preoperative functional tricuspid regurgitation event amongst patients who did not undergo concomitant tricuspid valve surgery.
P3660Investigating the role of neutrophils and NETs in staphylococcus aureus endocarditis
Authors: Meyers S , Liesenborghs L , Lox M , De Meyer S F , Vanassche T , Verhamme P , Martinod K
Published: October 2019

Background/Introduction

Infective endocarditis (IE) remains one of the deadliest cardiac diseases. Despite optimal antibiotic and surgical treatment, still one in three patients do not survive Staphylococcus aureus (S. aureus) IE. In order to cause this disease, bacteria need to first overcome shear stress and adhere to cardiac valves. Secondly, they need be able to progress into a complex lesion. Previously, we have shown that S. aureus adheres to cardiac valves via platelets and von Willebrand factor. However, the process of progression from initial bacterial adhesion to a complex vegetation, particularly how bacteria bypass the immune system and thrive in the host environment, remains unclear.

Purpose

We aimed to determine the role of neutrophils and neutrophil extracellular traps (NETs) in IE progression using a novel mouse model.

Methods

We intravenously injected mice with S. aureus and locally stimulated the endothelium with histamine, resulting in IE lesions that originate on inflamed heart valves. After three days we determined the development of IE on the aortic valves with Gram staining and echocardiography. We investigated the presence of NETs in 14 mice by immunostaining for citrullinated histone H3 (H3Cit), extracellular DNA, and myeloperoxidase. Of these 14 mice, 9 developed endocarditis. In a separate set of experiments, we investigated the role of neutrophils in IE development by injecting a neutrophil-depleting or control antibody 24h before surgery.

Results

Echocardiography revealed real IE lesions attached on inflamed aortic valves. Mice with endocarditis had significantly (P=0.005) more detectable H3Cit (9/9) than those without (1/5). More specifically, four mice had H3Cit+ neutrophils within thrombi, indicating early NETosis. Seven mice had an extracellular H3Cit staining pattern within the thrombus. These extracellular H3Cit-positive regions were associated with DNA and myeloperoxidase, indicating the presence of a network of NETs. When we depleted neutrophils, mice developed significantly more endocarditis (7/16 vs. 1/15, P=0.03).

Conclusion

Endocarditis lesions contained NETs or neutrophils undergoing NETosis, and neutrophil depletion led to increased IE incidence. Further investigating these two players in IE could potentially provide new strategies to combat this deadly disease.

Acknowledgement/Funding

FWO SB
P3661Two-fold increase in incidence of infective endocarditis in the period 1997–2016: a Danish nationwide study
Authors: Dalsgaard Jensen A , Ostergaard L , Eske Bruun N , Voldstedlund M , Torp-Pedersen C , Gislason G , Koeber L , Loldrup Fosboel E
Published: October 2019

Background

Infective Endocarditis (IE) is a disease with high mortality. Previous studies have shown considerable differences and contradicting trends in overall incidence and mortality why data from an unselected nationwide cohort is needed.

Purpose

We investigated temporal trends in the incidence rate and in-hospital mortality of IE in Denmark in the period of 1997–2016.

Methods

We included cases of first-time IE (1997–2016) using Danish nationwide registries. Crude incidence rates were given for each calendar year. Further, incidence rates were reported for subgroups of age and sex. For the analysis of patient characteristics and in-hospital mortality, the study cohort was grouped into four 5-year intervals (1997–2001, 2002–2006, 2007–2011, 2012–2016). Multivariable adjusted Cox proportional hazard model was used to compare in-hospital mortality between groups.

Results

A total of 8,147 patients with IE were identified in the period of 1997–2016. The median age and proportion of males increased from 64.3 years (P25-P75: 48–75.5) and 59.1% to 71.8 years (P25-P75: 62.1–79.9) and 67.1% in 1997–2001 and 2012–2016, respectively. The overall incidence rate (Figure 1) increased from 4.68/100.000-person-years (PY) (CI95: 4.17–5.26) to 8.23/100.000 PY (CI95: 7.53–8.99) in 1997 and 2016, respectively. Male incidence increased from 5.35/100.000 PY (CI95: 4.59–6.23) to 11.03/100.000 PY (CI95: 9.9–12.29) and female incidence increased from 4.03/100.000 PY (CI95: 3.38–4.8) to 5.44/100.000 PY (CI95: 4.67–6.35) in 1997 and 2016 respectively. Incidence rates increased more than seven-fold for the oldest age group (≥80 years) from 1997 to 2016 (6.95/100.000 PY [CI95: 5.32–9.08] to 51.19/100.000 PY [CI95: 43.41–60.38], respectively). In-hospital mortality was significantly lower for patients with IE in the period of 2011–2016 compared with 1997–2001 HR: 0.8 (CI95: 0.69–0.92).

Figure 1

Conclusion

Infective endocarditis incidences are increasing mostly among men and elderly patients. In order to prevent this disease as best as possible, we need more knowledge on causes for this increasing incidence.
P3667Diagnostic value of cardiac CT scan in patients with suspected infective endocarditis
Authors: Simoni A S S , Di Biceglie M D B , Alessandrini M A , Resseguier N R , Casalta A C C , Pradier J P , Casalta J P C , Gouriet F G , Riberi A R , Raoult D R , Drancourt M D , Collart F C , Jacquier A J , Habib G H
Published: October 2019

Background

Infective endocarditis (IE) is a severe disease requiring early diagnosis and treatment. Although echocardiography (ECHO) is the key diagnostic method, CT-scan (CT) has recently been added as a new ESC diagnostic criterion. However, published data are scarce and included few patients

Purpose

To assess the additional value of CT over ECHO for the diagnosis of IE

Methods

Between 2014 and 2017, 246 pts with suspected IE underwent both ECHO and CT. Using the expert consensus of the Endocarditis Team after a 3-month follow-up as gold standard, 222 IE were confirmed (112 native [NVE] and 110 prosthetic [PVE]) and 24 were rejected.

The primary end-point was the comparison between ECHO and cardiac CT (CCT) findings.

The secondary end-point was the change in diagnostic criteria sensitivity and specificity associated with the addition of CT results.

Results

1. Among the 110 cases of definite PVE,

– Vegetations were found in 49 (44%) pts by ECHO and 45 (40%) by CCT (agreement in 71 [64%] pts).

– Periannular lesions were found in 33 (30%) pts by ECHO and 46 (41%) by CCT (agreement in 86 [77%] pts).

– CCT found a new cardiac lesion missed by ECHO in 10 (9%) pts.

2. Among the 112 cases of definite NVE,

– Vegetations were found in 84 (76%) pts by ECHO and 90 (81%) by CCT (agreement in 84 [76%] pts).

– Periannular lesions were found in 34 (30%) pts by ECHO and 29 (26%) by CCT (agreement in 58 [52%] pts).

– CCT found a new cardiac lesion missed by ECHO in 3 (3%) pts.

3. Including CT findings as major and minor criteria increased the sensitivity of Duke criteria from 60 to 70% in 124 suspected PVE, and from 73 to 80% in 122 suspected NVE, without significant decrease in specificity.

Conclusions

1. This study is the largest prospective study assessing the value of CT in the diagnosis of IE.

2. Adding CT findings significantly increases the sensitivity of Duke criteria, both in NVE and PVE.

3. Our results support the use of ESC criteria including CT rather than Duke criteria.
P3672Effects of inhaled nitrite in addition to sildenafil in thalassemia patients with pulmonary hypertension
Authors: Sasiprapha T , Pussadhamma B , Sibmooh N , Chuncharunee S , Sritara P , Yingchoncharoen T
Published: October 2019

Background

Pulmonary hypertension is the major morbidity and mortality in patients with thalassemia. Recent studies have found that inhaled nebulized nitrite can significantly decrease pulmonary pressure in immediate response, but data are needed to determine its clinical benefits.

Methods

We conducted a multicenter, randomized, double-blind, placebo-controlled trial including thalassemia patients with symptomatic pulmonary hypertension, diagnosed by right heart catheterization and were currently treated with sildenafil. Patients continued the optimum dose of sildenafil and were randomly assigned into 2 groups; the treatment group and the control group. The treatment group was given 30 mg of inhaled nebulized nitrite twice a day for 3 months while the control group was given inhaled normal saline. The outcomes were the improvement of clinical and echocardiographic parameters at 1 and 3 months.

Results

A total of 12 patients were recruited, 5 were assigned to the treatment group and 7 to the control group. The median of sildenafil in both group were 60 mg/day. Treatment with the inhaled nebulized nitrite in addition to sildenafil significantly reduced the mean pulmonary artery pressure at 3 months when compared to placebo (median −7.30 mmHg in treatment group vs +2.30 mmHg in control group, P=0.016). In the treatment group, the median 6-minute walk distance was significantly increased from 380 m to 427 m. at 1 month (P=0.043) but there was no significant difference in the median change of 6-minute walk distance when compared to control group at 3 months (+48 m. in treatment group vs +17.5 m. in control group, P=0.286). No significant difference in NT-proBNP change between the two groups was detected. There were no hypotension or other major adverse effects in the treatment group.

Clinical and Echoparemeters Outcome

Conclusions

The addition of inhaled nebulized nitrite to sildenafil can decrease mean pulmonary pressure and has a tendency to improve six minutes walk distance in thalassemia patients with pulmonary hypertension.

Acknowledgement/Funding

Cooley's anemia foundation, Mahidol university research funding
P3678Pulmonary artery ablation during open mitral valve surgery for pulmonary artery hypertension: a prospective randomized study
Authors: Bogachev-Prokophiev A V , Zalesov A , Afanasyev A V , Sharifulin R M , Ovcharov M A , Karaskov A M
Published: October 2019

Purpose

Recent investigations of pulmonary artery (PA) ablation into the treatment of idiopathic pulmonary artery hypertension (PAH) have suggested improvement of functional capacity, and hemodynamics. We investigated the impact of PA ablation in patients with PAH due to left heart disease (Dana Point, 2008) scheduled for open-heart mitral valve surgery.

Methods

Fifty patients aged 52±10 with mitral valve disease complicated severe PAH (mean PAP >40mm Hg) were randomly assigned to mitral valve surgery with or without PA ablation procedure. Eligible criteria: positive reactive test with nitric oxide inhalation (decrease of mean PAP more than 10 mm Hg without decrease of cardiac output). There were no between group differences in preoperative characteristics.

Surgical procedure

After bypass is establishedthe fibrous fold of pericardiumand the ligamentum arteriosum are dissected out, and the branches of the right and left pulmonary artery are mobilized well out into the hilum of the lungs bilaterally. PA ablation was performed epicardially at the bifurcation of the main PA, and 10 mm distal to the right and left PA's using AtriCure Isolator®multifunctional pen.

Serial assessment of echocardiography, right heart catheterization (catheter Swan-Ganz), and 6-min walk test (6MWT) were performed during hospital stay. The primary endpoints were the change of meanpulmonary artery pressure (PAP)and 6MWT. The secondary endpoints were hospital mortality, freedom from PADN-related complication: PA perforation, PA dissection, and PA thrombosis (MDCT assessment).

Results

There were no early deaths. No procedure-related complications were observed.

On first day after surgery patients from ablation group showed significant reduction of mean PAP (from 50.6±5.3to 34.6±9.9 mm Hg, p<0.001), and significant improvement of 6MWT at discharge (from 229±34 m to 475±21 m, p<0.001). On first day after surgery patients from control group also showed significant reduction of mean PAP (from 51.3±6.3to 47.2±8.5 mm Hg, p=0.011), and significant improvement of 6MWT at discharge (from 249±32 m to 335±18 m, p<0.001). Nevertheless, there was significant between group difference in mean PAP on first day after surgery (34.6±9.9 mm Hg, vs 47.2±8.5 mm Hg, p=0.005). Moreover there was significant differences in 6MWT at discharge (475±21 m vs 335±18 m, p=0.002) with benefit to ablation group.

Epicardial pulmonary artery ablation

Conclusions

We report for the first time the effect and superiority of PA ablation on functional capacity and hemodynamics in patients with mitral valve disease complicated PAH. Epicardial PA ablation for the treatment PAH can be effectively and safely performed during open heart surgery.

Acknowledgement/Funding

None
P3685Can 3D echocardiography give a contribute to the diagnosis of Arrhythmogenic Right Ventricular Cardiomyopathy (ARVC)?
Authors: Mazzanti A , Addetia K , Maragna R , Yamat M , Pagan E , Monti L , Bagnardi V , Priori S G
Published: October 2019

Background

The diagnosis of ARVC is based on the structural assessment of the heart with 2D echocardiography (2DE) and cardiovascular MRI (CMR) to detect the presence of global and segmental right ventricular (RV) abnormalities. Little is known about the diagnostic value of 3D echocardiography (3DE) in ARVC. The aim of this study was to assess whether a combination of 2DE and 3DE could replace 2DE and CMR combination with similar diagnostic accuracy in patients with suspected ARVC.

Methods

Thirty-nine subjects (59% males, 47±15 years, 41% with desmosomal mutations) with suspected or confirmed diagnosis of ARVC underwent evaluation of the RV with the use of CMR, 2DE, 3DE.

3DE and CMR were independently used to obtain RV volumes, ejection fraction and presence of segmental RV abnormalities. These studies were blindly classified as meeting none, minor, or major criteria for ARVC in accordance with the 2010 TFC. Kappa statistics were used to assess the concordance between 2DE-CMR and 2DE-3DE diagnostic approaches.

Results

Using the 2DE-CMR approach, patients were classified as follows: 5 not affected, 8 with possible, 9 with borderline and 17 with definite ARVC diagnosis. The evaluation of TFC criteria with the 2DE-3DE approach yielded a high degree of concordance with the standard of care (2DE-CMR approach, K=0.93 with 95% CI: 0.84–1.0). There was complete agreement between the 2DE-CMR and 2DE-3DE approaches for individuals with definite ARVC diagnosis (n=17) and in individuals not affected by ARVC (n=5). Two patients with possible and borderline ARVC diagnosis using the 2DE-CMR approach were confirmed as definite ARVC with 2DE-3DE approach.

Contribution of 3D echo to ARVC

Conclusions

The use of 2D and 3D echocardiography allows bedside evaluation of patients with suspected ARVC, which is diagnostically comparable to that obtained using the traditional combination of 2DE-CMR. This information is particularly relevant for patients who cannot undergo CMR such as patients with ICD.
P3706Atrial fibrillation with CHA2DS2-VASC =0. Really no need for anticoagulation?
Authors: Cosmi D , Mariottoni B , Cosmi F
Published: October 2019

Background

Based on the ESC guidelines on Atrial Fibrillation, oral anticoagulation is recommended in male patients with CHA2DS2-VASC score ≥1, in females if CHA2DS2-VASC is ≥2. In our research, we evaluated if there are patients at risk of significant thromboembolic events among those whose CHA2DS2-VASC score is apparently = 0, that could benefit of anticoagulant therapy.

Methods

Over the last 12 years, 20,154 outpatients were evaluated in our clinics. We found the presence of non valvular atrial fibrillation in 3.043 (15.1%) patients. In 176 (5.7%) of them the CHA2DS2-VASC was = 0. None of them, as suggested in the guidelines, received oral anticoagulants or antiplatelet drugs. In these patients, we evaluated the presence of other two important cardiovascular risk factors, not included in CHA2DS2-VASC score: cigarette smoking and hypercholesterolemia.

Results

Smoking patients were 70, of whom heavy smokers (≥20 cigarettes/day) were 32. Patients with LDL cholesterol>115 mg/dl were 55. During one year follow-up, 3 of 176 patients (1.7%) with CHA2DS2-VASC score = 0 had a stroke. These patients were all heavy smokers and one of them also had high LDL values; they didn't show significant carotid stenosis or carotid dissection. None of the patients was found to have thrombophilic disorders.

Transthoracic echocardiogram was performed, resulting negative for patent foramen ovale, ventricular dysfunction, or masses.

All patients underwent 24 hours blood pressure monitoring, and it was found that all of them had masked hypertension; lower extremity arterial evaluation revealed mild, asymptomatic peripheral arterial disease, with ABI <0.9. No events occurred in patients with elevated LDL, not heavy smokers.

The risk of stroke in the population of heavy smokers, even if CHA2DS2-VASC score was apparently = 0, was 9.3%, with a clear indication for anticoagulation.

Conclusions

In heavy smokers patients with atrial fibrillation, CHA2DS2-VASC score could apparently be =0, when they are only clinically evaluated. In fact, these patients often have asymptomatic peripheral arterial disease of the lower limbs and masked hypertension.

Our research highlights how in some subgroups of patients there could be some “hidden” risk factors, that we should keep in mind and closely search for when evaluating the risk of cardioembolic stroke, that remains high.
P3715Impact of sleep-disordered breathing on short-term functional outcomes in ischemic stroke patients: a cardiopulmonary coupling analysis using holter-monitoring
Authors: Kang D O , Kim C K , Park Y , Jang W Y , Kim W , Choi J Y , Choi C U , Na J O
Published: October 2019

Background

Sleep-disordered breathing (SDB) assessed by conventional polysomnography is reported to have close association with worsened clinical outcomes in patients with ischemic stroke. The cardiopulmonary coupling (CPC) analysis using Holter-monitoring is an easily assessable method to evaluate SDB. However, its prognostic impact needs to be investigated.

Purpose

The present study investigated the prognostic impact of SDB defined by CPC analysis using Holter-monitoring at early stage of ischemic stroke on the functional disability at 3-month follow-up.

Methods

Total 692 patients with acute ischemic stroke who underwent Holter-monitoring were enrolled. The CPC analysis was conducted and SDB was defined as the presence of narrow-band (NB) coupling during sleep time. We investigated the association between SDB and functional disability at 3-month measured by modified Rankin scale (mRS).

Result

The NB coupling was present in 216 (31.2%) of 692 patients with mean age of 64.2±12.8 years. The NB group showed significantly higher proportion of severe functional disability (mRS ≥3; 45.3% vs. 12.3%, p<0.001) and persistent disability (ΔmRS≤0; 42.6% vs. 56.4%, p<0.001) after 3-month. In multivariate analysis, the presence of NB coupling was an independent predictor of higher risk of both severe and persistent functional disability (HR: 3.97; 95% CI: 2.37–6.64; p<0.001; and HR 1.92; 95% CI: 1.34–2.77; p<0.001, respectively). The results were consistent after propensity-score matched analysis with 175 patient pairs (C-statistics=0.759).

Parameters of functional disability Overall population (n=692) PSM population (n=350) no NB (n=476) NB (n=216) OR (95% CI) p-value no NB (n=175) NB (n=175) OR (95% CI) p-value Initial NIHSS ≥5 89 (18.6) 81 (37.5) <0.001 52 (29.7) 52 (29.7) >0.999 Discharge mRS ≥3 146 (30.6) 126 (58.3) <0.001 90 (51.4) 89 (50.8) 0.915 3-month mRS ≥3 59 (12.3) 98 (45.3) 5.86 (4.00–8.60) <0.001 38 (21.7) 72 (41.1) 2.52 (1.57–4.02) <0.001 3-month ΔmRS ≤0 (persisent disability) 203 (42.6) 122 (56.4) 1.74 (1.26–2.41) 0.001 77 (44.0) 100 (57.1) 1.69 (1.11–2.58) 0.014 Data are expressed as n (%). mRS = modified Rankin's scale; NB = narrow-band; NIHSS = National Institutes of Health Stroke Scale; OR = odds ratio; PSM = propensity-score matched.

Functional disabilities after 3-month

Conclusion

SDB assessed by CPC analysis at early phase of ischemic stroke was able to predict both greater and persistent functional disability at 3-month. The CPC analysis using Holter-monitoring is a useful modality for predicting functional disabilities in acute ischemic stroke.
P3719Myocardial injury during TAVI with self-expanding prosthesis is not associated with patient-prosthesis features, hemodynamics or clinical outcome
Authors: Johnsen M S , Kelly I E , Askevold E T , Hoffmann P , Opdahl A , Al-Ani A , Von Lueder T G
Published: October 2019

Background

Transcatheter aortic valve implantation (TAVI) has been associated with increases in markers of myocardial injury but underlying mechanisms as well as relevance for prosthesis hemodynamics, cardiac function and clinical outcome remain unclear.

Purpose

To study the trajectory of high-sensitivity troponin T (hs-TnT) during TAVI and elucidate putative associations with demographics, anatomical and procedural features, as well as clinical and echocardiographic outcome.

Methods

This prospective real-world registry study included all patients (n=275) undergoing transfemoral TAVI using a self-expanding or balloon-mounted system at a large tertiary university hospital over the most recent three-year period. Plasma levels of hs-TnT (reference level 0–14 ng/l) at 24 hours (h) before TAVI and at 9h, 18h, 30h, 42h and 72h after TAVI were analyzed. Patients with ongoing myocardial ischemia and acute coronary syndrome were excluded. We studied the association between hs-TnT values and patient characteristics, echocardiographic and CT findings at baseline as well as procedural features including the use of pre- and postdilatation. Moreover, we studied the association between hs-TnT and and echocardiography and clinical outcome at 1 year after TAVI.

Results

In this real-world TAVI cohort (median age 83.2±0.2 years; 48.7% women; 5.2±0.2 comorbidities; eGFR 58.0±6.0 ml/min/1.73m2; mean±standard error), 100% of patients exhibited significant elevations of hs-TnT at approximately 9-fold (207.0±11.0) compared to baseline (23±0.2 ng/L, median±SE). Peak hs-TnT values were reached at 9 h post-TAVI (207±11 ng/L) with subsequent gradual decline (figure). Myocardial injury was confirmed by elevated creatin kinase (CK) and CKMB isozyme. No significant association was found between peak hs-TnT, delta hs-TnT (peak minus baseline values) or area under the curve (AUC) of hs-TnT on the one hand, and patient demographics including renal dysfunction, comorbidity, age and gender on the other side. Moreover, no significant association between hs-TnT and anatomical features, prosthesis sizing, or use of pre- and postdilatation was found. No association between hs-TnT during TAVI and NYHA functional class, transvalvular pressure gradient, cardiac function or survival at 1 year was found. In subjects with at least one year of follow-up after TAVI (n=138), NYHA functional class (1.7 vs 2.7) and NT-proBNP plasma levels (1126±316 vs 1581±563 ng/L) were significantly lower compared to pre-TAVI.

Conclusions

Modest transient elevations of hs-TnT occur in all patients undergoing TAVI and are consistent with subtle myocardial injury. The lack of significant association between the extent of myocardial injury during TAVI and clinical and hemodynamic outcome as well as all-cause mortality is reassuring for current real-world practice.
P3720Cerebral near-infrared spectroscopy monitoring during transcatheter aortic valve implantation
Authors: Seppelt P C , Mas S , Lotz G , Meybohm P , Zacharowski K , Fichtlscherer S , Zeiher A M , Vasa-Nicotera M
Published: October 2019

Introduction

Stroke and transient ischemic attack (TIA) are important periprocedural cerebrovascular complications of transcatheter aortic valve implantation (TAVI). Regional cerebral O2 saturation is an indicator for cerebral perfusion and can be measured in real-time and noninvasively by near-infrared spectroscopy (NIRS). In this pilot study we evaluated the feasibility and utility of NIRS during TAVI.

Methods

Regional cerebral O2 saturation (rScO2, bihemispheric) was measured by near-infrared spectroscopy during 32 transfemoral TAVI procedures (female 56.3%, mean age 81.8 years). All patients received conscious sedation and O2-supplement if peripheral oxygen saturation (SpO2) was below 95%. Baseline rScO2 was measured at the beginning of the procedure, as well as before, during and 5min after rapid pacing for valve deployment.

Results

Mean preoperative mini mental state examination score was 26.5 points (theoretically max. 30 points, >24 points no severe cognitive impairment). Two-third of the patients (n=21) required oxygen supply (mean 4.0 l/min) during the TAVI procedure. Mean baseline rScO2 was 59.3% with no differences between both cerebral hemispheres (left 60.3% vs. right 58.7% p=0.23). Compared to baseline rScO2 and rScO2 assessed immediately before rapid passing, rScO2 dropped significantly during rapid pacing (59.3% vs. 51.8%, p<0.01 and 60.9% vs. 51.8%, p<0.01 respectively). Five minutes after rapid pacing rScO2 values had normalized again (post rapid pacing 60.9% vs. 51.8% during rapid pacing, p<0.01; baseline 59.3% vs. post rapid pacing 60.9%, p=0.51). Intraprocedural cerebrovascular events were observed in two cases. One patient developed a left-sided hemiplegia (stroke, later verified by cerebral CT scan) and one patient a transient tremor of the left upper extremity (TIA, new hemorrhagic or ischemic event ruled out by cerebral CT scan). In both cases we observed an abnormal sudden rScO2 decrement by the corresponding right hemispheric NIRS sensor (left-right hemisphere sensor: 60% vs. 44% and 63% vs. 48% respectively).

Conclusion

Regional cerebral O2 saturation, an indicator for cerebral perfusion, decreases significantly during rapid pacing of TAVI procedure. Furthermore, rScO2 measurement by NIRS may be helpful to detect cerebrovascular complications early during TAVI procedure.
P3722Platelet reactivity changes following transcatheter aortic valve implantation
Authors: Ostojic Z , Samardzic J , Reskovic Luksic V , Pavasovic S , Skoric B , Separovic Hanzevacki J , Milicic D , Bulum J
Published: October 2019

Introduction

Although recent studies described changes in platelet reactivity (PR) in days following transcatheter aortic valve implantation (TAVI), precise time course and duration of these changes have not been fully investigated.

Purpose

To investigate PR changes during and after TAVI.

Methods

Study included 42 consecutive patients with severe and symptomatic aortic stenosis undergoing TAVI procedure in our institution. Patients' clinical characteristics were collected from medical records. All patients who did not have chronic dual antiplatelet therapy received loading dose of aspirin and clopidogrel (300 mg) one day before the procedure followed by their standard maintenance doses for next three months. PR was measured in six time points: just before induction of anaesthesia (T1), after heparin administration (T2), at the end of procedure (T3), and on 3rd, 6th and 30th postoperative day (T4–6). PR was measured using impedance aggregometer (Multiplate® analyzer, Roche, Munich, Germany) in response to three platelet aggregation agonists: arachidonic acid (ASPItest), ADP (ADPtest) and thrombin receptor activating peptide-6 (TRAPtest).

Results

Mean patient age was 82.1 years with majority of patients being male 57.1% (N=24). Mean valve area and mean transvalvular gradient prior to procedure were 0.71±0.21 cm2 and 49.1±18.7 mmHg, respectively. All patients underwent successful TAVI procedure using either self-expandable (N=25, 59.5%) or balloon-expandable valve. Two patients (4.7%) underwent transapical TAVI, while transfemoral approach was used in all other patients. Mean postimplantation gradient was 10.2±7.1 mmHg.

Mean PR on T1 was 24.3±23.1 U for ASPItest, 41.6±26.5 U for ADPtest and 90.1±33.3 U for TRAPtest. There was no significant difference in PR on T2. However, on T3, ignificant reduction of PR in all 3 tests was observed (ASPI 9.4±10.1 U (p=0.001), ADP 23.1±15.0 U (p<0.001) and TRAP 64.5±27.3 U (p<0.001)). Lowest PR values for all tests were reached on T4, after which incline in PR has been observed. On T5, value of ASPItest reached levels not significantly different to those on T1 (15.1±17.2 U, p=0.13), while ADPtest and TRAPtest remained significantly lower (27.3±18.5 U, p=0.007 and 68.6±33.2 U, p=0.003, respectively). All PR values returned to initial levels on T6 (figure 1).

Conclusions

Our results show that successful TAVI procedure induces transient decrease in PR regardless of the platelet activation pathway. These findings add new knowledge in understanding complexed relations in intravascular milieu following TAVI. Further research on a larger number of patients is needed to confirm and asses clinical significance of these results.

Acknowledgement/Funding

Croatian Science Foundation
P3736Predictors of access site complication in transfemoral transcatheter aortic valve implantation
Authors: Potratz M , Kramer N , Mohemed K , Scholtz S , Scholtz W , Rudolph V , Bleiziffer S , Rudolph T K
Published: October 2019

Background

Transcatheter aortic valve implantation (TAVI) is an increasing common treatment option for patients (pts) with symptomatic severe aortic stenosis (AS). Despite its proven effectiveness and decreasing complication rate, vascular access site complications still occur in 5–7% of the cases and are associated with increased mortality and morbidity.

Purpose

The aim of this study was to analyze pts with vascular complications during TAVI procedure to better understand underlying mechanisms and aid future risk stratification.

Methods

From our ongoing single center TAVI registry encompassing over 1600 pts, we recruited 200 pts with vascular complications. By using propensity score 1:2 matching 400 controls without vascular complications were identified. Matching was done for peripheral vascular disease, age, gender, sheath size and BMI using the nearest neighbor algorithm. In the femoral artery, a localized, upward calcium scoring over 10 cm starting from the bifurcation was conducted in all pts using the 3mensio structural heart software ver. 8.0 (Pie Medical Imaging BV). Comparison between groups was done using the t-test. Multiple regression analysis was used to identify risk factors independently associated with vascular complication.

Results

Using VARC-2 definitions 22 (11%) pts classified as major and 178 (89%) as minor vascular complications. Patients with vascular complications had a significantly longer duration of hospitalization 17.1 days vs. 14.4 days (p=0.001), were more often on oral anticoagulation in 22.3% vs. 15.1%, (p=0.03) and had low preprocedural hemoglobin (11.8 vs. 12.1 (p=0.03). Vascular complications resulted in significantly higher 30 day mortality (7.4% vs. 3.2%, p=0.02). Detailed analysis of the femoro-iliacal vessels showed a higher percentage of kinking (50.5% vs. 33%, p = <0.001) in pts with vascular complications, however the calcium score was not significantly different (269.57 vs. 267.18, p=0.94). Of interest, pts with major vascular complications had a significantly higher calcium score as compared to controls (500.3 vs. 267.2, p=0.002). Major complications also translated in an even higher mortality after 30 days (18.2% vs. 3.2% (p = <0.001) and hospitalization time (days): 27.7 vs. 14.5 (p = <0.001) Multiple regression analysis identified vascular kinking (p = <0.001) and oral anticoagulation (p=0.04) at admission to be independent risk factors for vascular complication in the overall cohort whereas calcium score was only predictive for major vascular complications (p=0.04)

Conclusion

This study confirms that vascular complications during TAVI are associated with increased 30 day mortality and longer hospitalization. Patient dependent factors are the main predictors for vascular complications and should be considered thoroughly.
P3743A routine nursing questionnaire adds predictive value to conventional risk scores for TAVI (Transcatheter Aortic Valve Implantation) outcome
Authors: Gharibeh S X , Zweiker D , Binder J , Toth-Gayor G , Schmidt A , Zirlik A , Zweiker R
Published: October 2019

Background

Previous studies indicate that frailty is associated with poor outcome following TAVI.

Purpose

This study aimed to investigate whether a questionnaire routinely administered by nurses might serve as a surrogate for frailty and predict outcome in TAVI patients in addition to conventional risk scores.

Methods

This is a retrospective single-centre study performed at a university clinic with a high volume of TAVI. We included 461 consecutive patients (age 82±6 years, 60.5% female) scheduled for TAVI between 2012 and 2016. Based on seven questions addressing levels of patients' self-dependence assessed by nurses on admission, TAVI patients were divided into a “frail” group (at least one answer indicating limited self-dependence) and a self-dependent group (all other patients). We sought to assess (1) prevalence of frail TAVI patients, and (2) impact of frailty on two-year mortality assessed by Cox regression in addition to established risk scores.

Results

The prevalence of frail TAVI patients was 40.3%. Frail patients had significantly higher two-year mortality than self-dependent (non-frail) patients (25.3% vs 14.9%, p=0.014, Figure). In multivariate analysis stratified for age and left-ventricular function, body mass index (BMI), atrial fibrillation (AF) and frailty were significant predictors of increased two-year mortality (BMI, per kg/m2: HR 0.95 [95% CI 0.90–0.99], p=0.028; AF: HR 2.07 [1.35–3.18], p=0.001; frailty: HR 1.81 [1.18–2.76], p=0.006).

In addition to the Society of Thoracic Surgeons (STS) risk of mortality score, both AF and frailty significantly predicted increased two-year mortality (AF: HR 2.02 [1.32–3.09], p=0.001; frailty: HR 1.55 [1.01–2.38], p=0.045).

Conclusion

This study shows that a routine nurses' questionnaire covering levels of self-dependence serves as risk indicator for long-term mortality after TAVI. This unconventional geriatric assessment adds predictive power for two-year-mortality to a conventional risk score (such as STS) and might be used to stratify patients for greatest benefit from TAVI.
P3746Temporal patterns of premature atrial contractions predict atrial fibrillation occurrence in bradycardia patients continuously monitored through pacemaker diagnostics
Authors: Boriani G , Botto G L , Pieragnoli P , Ricci R P , Biffi M , Marini M , Sagone A , Avella A , Pignalberi C , Ziacchi M , Ricciardi G , Tartaglione E , Grammatico A , Gasparini M
Published: October 2019

Background

The frequency of premature atrial complexes (PACs) has been indirectly related with atrial fibrillation (AF) occurrence and adverse outcomes.

Objective

To evaluate whether temporal patterns of PACs are directly associated with AF onset in pacemaker patients with continuous monitoring of the atrial rhythm.

Methods

Overall, 193 pacemaker patients (49% female, 72±9 years old), enrolled in a national registry, were analyzed. Frequency of daily PACs was measured in a 14-day initial observation period, during which patients were in sinus rhythm. In the following period, temporal occurrence and frequency of daily PACs and eventual onset of AF were derived by pacemaker diagnostics.

Results

In the run-in period, median PACs frequency was 614 PACs/day (interquartile range=70–3056). Subsequently, in a median follow-up of 6 months, AF occurred in 109 patients, in particular in 37/96 (38.5%) patients with a PAC rate<614 PACs/day and in 72/97 (74.2%) patients with PAC rate≥614 PACs/day (p<0.001). In patients with AF occurrence, the number of daily PACs, normalized by dividing for the average of PACs in 10 preceding days, progressively increased in the 5–6 days preceding AF (Figure). Cox Model predictive analysis showed that the risk of AF was significantly higher in patients with a relative increase of the daily PACs higher than 30% compared with PACs average number in 10 preceding days (hazard ratio (95% confidence interval) = 3.67 (2.40–5.59), p<0.001).

PACs changes daily trend before AF

Conclusion

PACs frequency increases in the 5–6 days preceding AF onset. A relative increase of the daily PACs is significantly associated with the risk of AF occurrence.
P3751The reinnrevation with pulmonary vein isolation associated cardiac autonomic dysfunction
Authors: Kodama T , Kikuchi T K , Yoneyama A
Published: October 2019

Background

It is well-known that cardiac autonomic nerve is impaired after Pulmonary vein isolation (PVI) for atrial fibrillation (Af), but the the long-term change in cardiac autonomic function is unclear.

Objective

We followed the long-term cardiac autonomic nervous function after PVI and clarified its recoverability.

Subjects

Of 136 patients who received 1st session PVI from 2013 to 2017, 49 patients [Male: 86%, 62±11y, Diabetes meritus: 16%, radiofrequency (RF) ablation: 59%, cryoballoontechnique (Cryo): 41%, left atrial diameter: 37.2±4.5mm, LVEF: 67.4±9.7%, BNP: 103±108pg/dl]who satisfied the Inclusion criteria (No history of cardiac surgery, no recurrence of Afafter PVI for more than 1 year, with Holter ECG record of sinus rhythm before PVI and every 3 months after PVI for 1 year or more.

Method

Heart rate variability (HRV) parameters for each period (before PVI and after PVI 0–3 months, 3–6 months, 6–9 months, 9–12 months) were obtained from each Holter ECG records using MemCalcsystem. We defined the HRV before PVI as 100% and examined the rate of change for each HRV (see Figure) after PVI retrospectively.

Result

All of HRV indicators after PVI had been decreased significantly at 0–3 months after PVI (from 21.7% to maximum of 77.9% down). Figure is a series of indexes from front to back in order of decreasing HRV at 0–3 months after PVI, and the frequency domain index concentrates on the front. These decreased HRVs gradually recovered through 12 months after PVI (shown in figure left), but this change is more responsive in the frequency domain index than in the time-domain index, and after 3–6 months, all indices has already showed a significant rise compared with 0–3 months after PVI. In any of the indices, this increase over time did not receive interaction due to the difference in the procedure (RF, Cryo).

Conclusion

HRV decreased by PVI showed a significant rise over time, mainly in the frequency domain, at 3–6th month after PVI, suggesting the existence of reinnervation of cardiac autonomic nerve at this period.