bluuebunny/crossref_metadata_2025 huggingface dataset:
P2771A novel doppler index for the diagnosis of post pulmonary embolism impairment syndrome
Authors: Dzikowska-Diduch O , Kostrubiec M , Brodka K , Wyzgal-Chojecka A , Pacho P , Kurnicka K , Lichodziejewska B , Labyk A , Roik M , Pruszczyk P
Published: October 2019

Introduction

Follow-up studies demonstrated that after an episode of acute pulmonary embolism (PE), half of patients report functional limitation. Chronic thromboembolic pulmonary hypertension (CTEPH) is diagnosed in approximately 4%, while others are supposed to have heart failure with preserved ejection fraction (HFpEF) or chronic thromboembolic disease (CTED). Echo can not only assess tricuspidal regurgitation pressure gradient (TRPG) indicating pulmonary hypertension but also with tissue Doppler, E/e' ratio can diagnose left ventricular diastolic dysfunction. We tried to asses if a novel echo index: TRPG to E/e' could be useful in differentiation between CTEPH, CTED and HFpEF.

Material and methods

We analyzed data of consecutive 535 PE survivors (313 F, aged 61±17 yrs). 342/535 (64%) reported significant functional impairment after at least 6 months anticoagulation. All symptomatic subjects underwent detailed diagnostic workup which included standardized echocardiography, lung scintigraphy, pulmonary functional tests, and chest CT, RHC and coronary angiography when appropriate.

Results

Eventually, out of 342 symptomatic PE survivors (220 F, aged 65±15 yrs) CTEPH was diagnosed In 17 cases, CTED in 8 pts and HFpEF in 174 pts and in the remaining other causes were found (i.e. coronary artery disease, anemia, pulmonary disease). Doppler echocardiography showed that TRPG/E/e' was significantly increased in CTEPH and CTED patients when compared to subjects with HFpEF (Table 1).

Echocardiographic doppler assessment HFpEF p CTEPH p CTED p n=174 HFpEF vs CTEPH n=17 CTEPH vs CTED n=8 HFpEF vs CTED TRPG (mmHg) 26.7±8.9 <0.01 59.5±32.0 0.013 34.4±15.1 ns E/e' 11.1±2.9 ns 10.1±32.0 ns 8.9±2.0 ns TRPG / E/e' 2.5±1.0 <0.001 6.0±2.4 <0.01 3.8±1.1 0.013 TRPG, Tricuspidal regurgitation pressure gradient; CTEPH, Chronic thromboembolic pulmonary hypertension; CTED, Chronic thromboembolic disease; HFpEF, Heart failure with preserved ejection fraction.

Conclusion

Our data indicate that echocardiographic index TRPG/(E/e') may be helpful in the differentiation of functional limitation in patients after pulmonary embolism.
P2774Galectin-3, GDF-15, and ST2 in noninvasive assessment of myocardial remodelling in chronic thromboembolic pulmonary hypertension
Authors: Kriechbaum S D , Peters K , Ajnwojner R , Wolter J S , Haas M , Roller F , Keller T , Rolf A , Hamm C W , Mayer E , Guth S , Liebetrau C
Published: October 2019

Background

In chronic thromboembolic pulmonary hypertension (CTEPH), pulmonary artery obstruction leads to impaired pulmonary hemodynamics and secondary right heart failure, which is highly predictive of outcome. Thus, the extent of myocardial -especially right heart- remodelling is an indicator of disease severity.

Purpose

The aim of the present study was to assess growth differentiation factor-15 (GDF-15), galectin-3, and suppression of tumorigenicity 2 (ST2) as non-invasive biomarkers of myocardial remodelling in patients suffering from CTEPH.

Methods

We analysed the serum levels of GDF-15, galectin-3 and ST2 in a cohort of 64 CTEPH patients and in a control group of 25 patients without cardiovascular disease. The biomarker levels were further correlated with clinical, laboratory, and hemodynamic data, including 6-minute walking distance (6-MWD), N-terminal pro-brain natriuretic peptide (NT-proBNP), mean pulmonary artery pressure (meanPAP), pulmonary vascular resistance (PVR), and right atrial pressure (RAP).

Results

The biomarker levels in the control group were: galectin-3: 3.5 ng/l (IQR 2.7–4.0), GDF-15: 92.6 pg/ml (IQR 78.5–129.1), and ST2: 48.65 ng/l (IQR 35.5–57.0). CTEPH patients had higher levels of GDF-15 (196.7 pg/ml; IQR 128.4–302.8; p<0.001) and ST2 (52.6 ng/l; IQR 44.5–71.9; p=0.05) but not galectin-3 (3.4 ng/l; IQR 2.7–4.3; p=0.84). In the CTEPH cohort, patients with a meanPAP >35 mmHg (GDF-15: p=0.01; ST2: p=0.04) and patients with a PVR >500 dyn sec cm–5 (GDF-15: p=0.004; ST2: p=0.002) had significantly increased biomarker levels. For the detection of a meanPAP >35mmHg, ROC analysis revealed an AUC of 0.71 for GDF-15 and 0.67 for ST2. The level of GDF-15 correlated with the level of NT-proBNP (rrs=0.69; p≤0.001) and the RAP (rrs=0.54; p≤0.001) and inversely with the 6-MWD (rrs=−0.47; p≤0.001). The level of ST2 correlated with the level of NT-proBNP (rrs=0.67; p≤0.001) and the RAP (rrs=0.54; p≤0.001) and inversely with the 6-MWD (rrs=-0.31; p=0.02).

Conclusion

Our results demonstrate that GDF-15 and ST2, non-invasive biomarkers of myocardial remodelling, are significantly elevated in patients suffering from CTEPH. The correlation of biomarker levels with established outcome predictors suggests a use as indicators of disease severity.
P2780Accuracy of electronic healthcare records for diagnosis of stroke types in a large community-based prospective cohort study in China
Authors: Turnbull I J , Clarke R , Guo Y , Hacker A , Kartsonaki C , Bian Z , Sansome S , Chen H , Wu H , Xu X , Li L , Chen Z , Chen Y
Published: October 2019

Background and purpose

Reliable assessment of the determinants of major pathological types of stroke is dependent on the accuracy of diagnosis in population-based studies. We evaluated the diagnostic accuracy of stroke types in a large community-based cohort study involving health records collected in China.

Methods

In 2004–08, >0.5 million adults aged 30–79 years were recruited from general populations of 10 diverse areas (5 urban, 5 rural) in China. During an approximate 7-year follow-up, 37,694 stroke cases had been reported by linkage to electronic health records from disease-specific and mortality registries and from national health insurance agencies. For all reported stroke cases, hospital medical records were retrieved systematically and relevant data extracted for subsequent adjudication by specialists using bespoke electronic platforms.

Results

Among all reported incident stroke cases, 80% were ischaemic stroke (IS), 17% were intracerebral haemorrhage (ICH), and 1% were subarachnoid haemorrhage (SAH). To date, medical records have been retrieved for 29,632 cases, with reports of stroke diagnosis verified by public health staff in 27,115 (92%) cases, of which 3,778 (14%) were secondary diagnoses. Evidence of neuroimaging was found in 92% of all verified stroke cases. Of 23,337 primary stroke cases sent for specialist adjudication, a diagnosis of pathological stroke type was confirmed in 19,718 cases with the positive predictive values being 82.4% (95% confidence interval [CI], 82.0% - 82.8%) for IS, 97.8% (97.6 - 97.9) for ICH, and 98.2% (98.1 - 98.3) for SAH. Overall, the strength of association of systolic blood pressure was over 6-fold greater for confirmed than non-confirmed stroke cases and was nearly 3-fold greater for confirmed ICH than IS cases.

Diagnostic accuracy by stroke type Reported Retrieved Verified Adjudicated Confirmed Approximate 95% CI n n % n % n % n PPV, % IS 30,143 25,477 85 23,551 92 20,045 85 16,515 82.4 (82.0–82.8) ICH 6,484 3,486 54 3,079 88 2,919 95 2,854 97.8 (97.6–97.9) SAH 557 397 71 326 82 279 86 274 98.2 (98.1–98.3) Other 510 272 53 159 59 94 59 75 79.8 (79.4–80.2) IS indicates ischaemic stroke; ICH, intracerebral haemorrhage; SAH, subarachnoid haemorrhage; and PPV, positive predictive value.

Conclusions

The overall diagnostic accuracy of pathological stroke types obtained from hospital records in China is comparable to reports from Western populations. Despite advances in electronic healthcare records, reliable classification of stroke types requires clinical adjudication using additional relevant investigations.

Acknowledgement/Funding

Kadoorie Charitable Foundation, UK Wellcome Trust & National Natural Science Foundation and National Key Research and Development Program of China
P2786Current ESC guidelines for normal ascending aortic diameter: prevalence of aortic dilatation increases to 20% in a consecutive coronary CTA population
Authors: Kauhanen P , Saari P , Jaakkola P , Korhonen M , Parkkonen J , Vienonen J , Vanninen R , Liimatainen T , Hedman M
Published: October 2019

Introduction

Epidemiological studies on the prevalence of ascending aortic (AA) dilatation are scanty.

Purpose

To clarify prevalence of AA dilatation according to ESC 2014 guidelines and to study its risk factors.

Methods

This retrospective study included 1000 consecutive patients scheduled for diagnostic coronary artery computer tomography angiography (CCTA) with low to moderate pretest probability for coronary artery disease (CAD). AA diameter was measured at 3 planes; sinus valsalva, sinotubular junction and tubular part. Threshold for AA dilatation was set to >40 mm (ESC 2014). Traditional risk factors for AA dilatation were collected from medical records.

Aortic size index (ASI) was used as a comparative measurement. ASI is defined as the ratio between aortic diameter and body surface area (BSA). The threshold for AA dilatation was set to upper limit of normal distribution exceeding two standard deviations (95%).

Heart-aorta angle (HAA, Figure) was measured as one suggestive risk factor.

Results

Patients' mean age was 52.9±9.8 years, 66.5% were women. The prevalence of AA dilatation in the whole study population was 20.4% according to ESC 2014 guidelines. When patients with hypertension (n=445) or coronary calcifications or stenosis in CCTA (n=375) were excluded, the prevalence of AA dilatation was 14.5% in the population of normotensive patients without CAD (n=380).

According to the normal-distributed ASI values the threshold for normal dimension of sinus valsalva was defined as 23.5 mm/m2 and for tubular part 22.7 mm/m2 for normotensive patients without CAD. Using these thresholds, the prevalence of AA dilatation was 7.8% in the whole population and 7.1% in normotensive patients without CAD.

Smaller HAA was associated to AA dilatation. Median HAA was 125.6° (range: 119.2–131.5°) in patients with dilated AA and 130.1° (123.7–136.4°) in patients with non-dilated AA (p<0.001).

Higher BSA was associated to larger AA dimensions. Risk factors for AA dilatation (according to ESC criteria) were male gender, BAV, hypertension and smoking (p<0.01).

Figure 1

Conclusions

The prevalence of AA dilatation proved to be relatively high in this consecutive CCTA population when using ESC 2014 guidelines. Body size is associated to AA dimensions; thus, it seems reasonable to include BSA in the definition of AA dilatation.

Acknowledgement/Funding

Oiva Vaittinen will grant, Aarne Koskelo Foundation
P2787Gender differences in acute type B aortic dissection
Authors: Chatani R , Murai R , Kawase Y , Tada T , Kadota K
Published: October 2019

Background

The incidence of aortic dissection has been reported to be lower in women; however, women have a poor prognosis. Also, the incidence of false lumen thrombosis has been reported to be different between Europe, the United States, and Japan. We aimed to determine gender differences in long-term prognosis of acute type B aortic dissection.

Methods

We retrospectively reviewed 220 consecutive patients hospitalized for acute type B aortic dissection between January 2012 to December 2017. After exclusion criteria of unknown onset time, >14 days after the onset, in-hospital death, and aortic events requiring additional treatment during hospitalization were applied, 186 patients were analyzed by gender: 133 men and 53 women. The patient background, treatment method, prognosis, and outcome were compared and examined.

Results

Both the proportions of smoking history and patients receiving oxygen therapy during hospitalization were significantly higher in men (59% vs. 22%, p<0.01; 91% vs. 72%, p<0.01, respectively), whereas that of classical aortic dissection was similar between men and women (41% vs. 32%, p=0.36). The avoidance rate of a composite of all deaths and aortic events 2 years after discharge was similar (hazard ratio, 0.99; 95% confidence interval, 0.52 to 1.59; p=0.966).(Picture1)

Picture 1

Conclusion

The long-term prognosis of acute type B aortic dissection treated by medical therapy during hospitalization was equivalent in men and women despite gender differences in several background factors.
P2797Clinical outcomes of an ultra-thin strut sirolimus-eluting stent with biodegradable polymer in all-comers patients undergoing coronary intervention
Authors: Menown I B A , De Silva R , Mitra R , Balachandran K , More R , Spyrou N , Zaman A , Raja Y , Tulwar S , Sinha M , Glover J , Clifford P , Ordoubadi F , Elghamaz A
Published: October 2019

Background

Thin stent struts may be associated with reduced vessel injury and use of biodegradable polymers may further improve long term outcomes. However, data with earlier stents has been inconsistent; thus further studies with newer devices are needed.

Purpose

To evaluate the efficacy and safety of a new ultra-thin (65um) strut cobalt chromium sirolimus-eluting stent with a hybrid design (closed cell at ends and open cells in middle to reduce edge injury and optimise conformability) in all-comers patients undergoing percutaneous coronary intervention (PCI).

Methods

We enrolled 752 patients from 14 sites undergoing PCI into a prospective, non-randomised, multi-centre, open-label, observational registry. Inclusion of patients with complex anatomy (long stent lengths, bifurcations and chronic total occlusions) was encouraged. Clinical follow-up was scheduled at 1, 9, 12 and 24 months. The primary endpoint was incidence of major adverse cardiac events (MACE) - cardiac death, non-fatal myocardial infarction (MI), or target vessel revascularization (TVR) - at 9 months.

Results

Mean patient age was 64.7±12.2 years, 20.7% had diabetes, 58.8% had dyslipidaemia, 40.4% had multi-vessel disease, 22% had previous PCI, 4.7% had previous coronary-artery bypass graft, and 19.6% had a clinical history of previous MI. Mean lesion length was 25.7±17.3 mm. The primary endpoint of cumulative MACE up to 9 months (from 624 patients reaching 9 months follow-up) occurred in 12 patients (1.92%), including 6 (0.96%) cardiac death, 5 (0.80%) MI and 6 (0.96%) clinically indicated TVR. Definite stent thrombosis was reported in 3 patients (0.48%) and probable stent thrombosis in 2 patients (0.32%).

Conclusions

Use of an ultra-thin strut biodegradable polymer sirolimus-eluting stent in all-comers patients undergoing PCI was associated with good clinical efficacy and safety.

Acknowledgement/Funding

Meril Life
P2806A novel sirolimus drug eluting stent for Small-Vessel Disease: results from en-ABL e-registry
Authors: Testa L , Dani S , Desai D , Pandya R , Parekh P , Vasavada A , Bhalani N , Sheth C , Sharma A , Shah D
Published: October 2019

Objective

The aim of the study was to assess the clinical outcome of Abluminus DES in patients with small vessels.

Background

Percutaneous coronary intervention (PCI) of small coronary vessel (≤2.75 mm) associated with more chances of restenosis and repeat revascularization even when drug eluting stent employed.

Methods

A total of 2,500 patients enrolled in en-ABL e-registry which is a prospective, multicentre observational post market registry. Out of 2,500 patients, 1,253 patients had small vessel (SV, ≤2.75 mm) while 1,247 had large vessel (LV, >3mm) disease. The primary endpoint was major adverse cardiac events (MACE) which is composite of cardiac death, target vessel myocardial infraction (TV-MI) and target lesion/vessel revascularization (TLR) at 1 year follow up. The secondary endpoint were stent thrombosis and MACE up to 2 years.

Results

Baseline characteristics were well matched in both groups. In the SV group had higher prevalence of diabetes as compared to large vessel 43.0% vs 25.7%. Total 1,400 lesions treated with 1,612 Abluminus DES and 1,569 lesions treated with 1,675 Abluminus DES in SV and LV groups respectively. The mean diameter of stent was 2.61±0.23 and 3.3±0.3 mm in SV and LV groups respectively. There was a significant difference in MACE in treatment groups (3.7% vs. 1.4%, p=0.004 respectively) at 1 year. No significant differences were observed between SV and LV groups in terms of death/myocardial infarction or stent thrombosis. There were increment of only one TLR and no stent thrombosis reported at 2-year follow-up.

Conclusion

This result suggests the efficacy and safety of novel Abluminus DES in small vessel disease.
P2811Impact of ticagrelor monotherapy on two-year clinical outcomes in patients with long stenting: insights from the Global Leaders trial
Authors: Takahashi K , Chichareon P , Modolo R , Kogame N , Chang C C , Tomaniak M , Hamm C , Steg P G , Stoll H P , Onuma Y , Valgimigli M , Vranckx P , Windecker S , Serruys P W
Published: October 2019

Background/Introduction

Data on the efficacy and safety of different antiplatelet regimens are limited in patients with increasing total stent length (TSL).

Purpose

To evaluate the impact of the experimental strategy (1-month dual antiplatelet therapy [DAPT] followed by 23-month ticagrelor monotherapy) vs. the reference regimen (12-month DAPT followed by 12-month aspirin monotherapy) in patients with increasing TSL.

Methods

The present post-hoc analysis of the Global Leaders trial evaluated the primary endpoint (the composite of the all-cause death and new Q-wave myocardial infarction [MI]) at two years in patients with increasing TSL. In addition, the patient-oriented composite endpoint (POCE) (the composite of all-cause death, any stroke, any MI, and any revascularization) and the net adverse clinical events (NACE) (the composite of POCE and Bleeding Academic Research Consortium [BARC] type 3 or 5 bleeding) were also assessed.

Results

The cohort of 15,450 patients treated with a biolimus-eluting biodegradable polymer stents were included in this analysis. In the longer TSL group (≥46mm), the experimental strategy significantly reduced the risk of the primary endpoint (3.78% vs. 5.68%, hazard ratio (HR): 0.67, 95% confidence interval (CI): 0.49–0.90, p=0.008, P interaction=0.042) as well as POCE (14.57% vs. 18.11%, HR: 0.79, 95% CI: 0.67–0.92, p=0.003, P interaction=0.010) and NACE (16.07% vs. 19.64%, HR: 0.80, 95% CI: 0.69–0.93, p=0.004, P interaction=0.012) at two years. The risk of BARC type 3 or 5 bleeding at two years was similar between the two antiplatelet regimens.

KM in patients with long stenting

Conclusion

Ticagrelor monotherapy significantly reduced the risk of the primary endpoint, POCE and NACE with a similar risk of BARC type 3 or 5 bleeding at two years in patients with the longer TSL.

Acknowledgement/Funding

The Global Leaders trial was supported by unrestricted grants from AstraZeneca, Biosensors, and The Medicines Company. ECRI (European Cardiovascular R
P2822Seasonal variation in in-hospital cardiac arrest and associated mortality
Authors: Tsang J , Sulaiman S , Jahangir A
Published: October 2019

Background

Previous reports have documented seasonal variation in out-of-hospital cardiac arrest (OHCA), with peak incidence in winter months, regardless of geographical region. However, seasonal variation in in-hospital cardiac arrest (IHCA) has not been well studied.

Purpose

To assess seasonal variation in incidence of in-hospital cardiac arrest, as well as gender and mortality differences.

Methods

We queried the 2014 National Inpatient Service (NIS) database for the total numbers of inpatient hospitalizations and in-hospital cardiac arrests for each month, as identified by ICD-9 codes (99.60 and 99.63). The trend for each month was plotted to assess seasonal variations in hospitalizations, IHCA, and mortality.

Seasonal Variations in IHCA

Results

The mean age of the study population was 57.3±0.2 years and 58.9% were female. Out of 29,717,872 total inpatient hospitalizations in 2014, the overall IHCA event for the year was 0.38%. Females were more likely to be hospitalized; however, males were more likely to have IHCA. These gender differences persisted throughout the year. Overall, more hospitalizations and IHCA were seen in the winter compared to the summer, and this trend was seen in both men and women. The highest incidence of in-hospital cardiac events occurred in January and the lowest incidence occurred in June. There was no seasonal variation in mortality in both male and female patients who suffered IHCA.

Conclusion(s)

In this observational study, seasonal variation is present in in-hospital cardiac arrest. Cardiac events are highest in the winter months as compared to the summer months; however, the mechanism of this variation is unknown and warrants further study.

Acknowledgement/Funding

None
P2828Survival after an out-of-hospital cardiac arrest decrease over time in all Utstein categories. The importance of a long follow-up
Authors: Baldi E , Buratti S , Contri E , Canevari S , Molinari S , Pagani M , Lusona B , Mojoli F , Bertona R , Osti R , Palo A , Oltrona Visconti L , De Ferrari G M , Savastano S
Published: October 2019

Background

Survival beyond 1-month after an out-of-hospital cardiac arrest (OHCA) is still considered a challenge for OHCA registries and it is often unexplored. However, a longer follow-up could help to better comprehend the long-term issues of OHCA survivors.

Purpose

Our aim was to evaluate the long-term outcome after OHCA via an Utstein-based cardiac arrest registry with a long follow-up (up to 5 years).

Methods

We enrolled all the people with an OHCA of any aetiology in our Province (about 55ehz748.1138 inhabitants in northern Italy) in whom CPR was attempted. The primary endpoint was the survival at 1 month, and the secondary endpoints were the survival at 6 months and then every year until 5 years after OHCA.

Results

In the first 45 months (October 2014–June 2018) 1774 resuscitation attempts for confirmed OHCAs were enrolled. Baseline characteristics: male 59.7%; mean age of 73.4±16 years; mean EMS response time was 11:31±5:09 mins; home location 78.8%; bystander-witnessed events were 56.1%; EMS witnessed event 15.6%; bystander CPR 39.5%; AED use before EMS arrival 2.5%; medical etiology 93%; first shockable rhythm 18.2% (90.7% VF, 2.5% VT without pulse, 6.8% AED shockable). When considering survival from the event (Figure 1 – left panel), survival was significantly higher for shockable Utstein categories (p<0.001). Considering only those patients discharged alive (Figure 1 – right panel) long term survival was significantly higher (p<0.01) once again for shockable rhythms. Interestingly, in this category survival continued to decrease over time ranging about from 90% in the first year to about 80% at four years.

Figure 1

Conclusions

Our results demonstrated that survival after OHCA can change over the time in all the Utstein categories, so we believe that a longer follow-up should be encouraged by next Utstein style revision.
P2830Clinical and genetic findings in relatives to young sudden cardiac death victims without post-mortem examination (autopsy)
Authors: Kjerrumgaard A , Jacobsen E M , Hansen B L , Winkel B G , Christensen A H , Bundgaard H
Published: October 2019

Background

Guidelines recommend clinical assessment of relatives to young sudden cardiac death (SCD) victims (<50 years) to protect the surviving relatives by pre-symptomatic interventions, in case the SCD was due to an inherited cardiac disorder. The etiology is an inherited cardiac disease in about 50% of young SCD cases. The work-up of relatives is generally guided by findings in the SCD victim. If post-mortem examinations (autopsies) have not been performed the work-up of relatives is challenged. The diagnostic hit-ratio of screening of relatives under these circumstances is unclear.

Purpose

To assess the diagnostic yield of inherited cardiac diseases of cardiac work-up in relatives of SCD victims, where no autopsy had been performed.

Methods

This retrospective study consecutively included families referred to our tertiary referral centre, specialised in hereditary cardiac diseases, during the period 2005 to 2018 due to SCD in the family. No autopsy had been performed in any of the SCD victims. The relatives underwent standard cardiac work-up according to guidelines. Based on the findings in the relatives the families were categorised into: 1) definite diagnosis, 2) borderline diagnosis or 3) undiagnosed.

Results

We assessed 149 relatives (43±16 age, 48% men) to 84 SCD un-autopsied cases (44±11 age, 79% men). In 11 (13%) families a definite diagnosis was established, in 8 (10%) families a borderline diagnosis was found and the remaining 65 (77%) families remained undiagnosed. The most common diagnosis was premature IHD (36%) followed by cardiomyopathies (27%) and channelopathies (27%). A disease-causing mutation was identified in 3 families out of 15 genetically examined families.

Conclusion

Systematic cardiac work-up of relatives to not-autopsied SCD victims, revealed a definite hereditary cardiac disease in 13% of the referred families, and a borderline diagnosis in additionally 10% of the families. Despite a reduced diagnostic yield in family members of non-autopsied SCD victims, work-up of relatives is clearly still justified.
P2840Discrimination between sinus rhythm and atrial fibrillation/flutter: reliability of seven different built-in automatic-diagnostic computer programs in a cohort of >2000 12-lead electrocardiograms
Authors: Diemberger I , Martignani C , Massaro G , Lorenzetti S , De Bie J
Published: October 2019

Introduction

Atrial fibrillation and flutter (AF/AFl) are the more common sustained arrhythmias in the elderly. ESC guidelines underline the need for large-scale screening strategies, especially to improve primary prevention of thromboembolic complications. However, the current gold-standard for identification of AF/AFl is a 12-lead ECG reviewed by an appropriately trained physician. The availability of automatic discrimination between AF/AFl and sinus rhythm (SR) by automatic- diagnostic computer programs (ACP) implemented in current 12-lead ECG recorders is a possible solution to improve this process.

Aim

To assess the reliability and agreement of the main world-wide available ACPs implemented in current 12-lead ECG recorders in discriminating between AF/AFl vs. SR in a large dataset of real-world ECGs.

Methods

We assessed seven ECG interpretation programs from seven different manufacturers (GE 12SL, Glasgow, MEANS, Midmark, Mortara VERITAS, Philips DXL and Schiller). We created a large set of representative ECGs converted from previously recorded digital ECGs acquired with equipment that complied with the requirements of International Electrotechnical Commission standard IEC 60601–2-51:2003 and were representative of those in hospital settings. We excluded ECGs from pacemaker carriers. We used a specific device for playing back ECGs to 12-lead ECG recorders implementing the seven programs. Each statement from automatic diagnosis provided by each device was recorded and combined appropriately for the purpose of this analysis: identification of AF/AFl vs. SR. Gold standard was built by independent re-assessment by three different reviewers.

Results

We collected 2064 10s 12-lead ECGs with SR (1882) or AF/AFl (182) that were analyzed by seven different ACP. ECG's with other arrhythmias were excluded for this analysis (to increase transferability of the results). All seven programs agreed on SR in 1645 (87.4%) and AF/AFl in 139 cases (76.4%) (Figure 1, panel A). In 280 cases (13.6%), at least one program did not agree with the others. After revision by cardiologists 237 were found to be SR and 43 AF/AFl. Sensitivity for AF/AFl ranged between 90%-97% and false positive diagnosis ranged between 3.4% and 0.4%. Notably, the chance of obtaining at least a wrong diagnosis from one device was 280/2064 (13.6%), with a number of possible false AF/AFl greater than real prevalence of AF/AFl (Figure 1, panel B).

Figure 1

Conclusions

Despite a general good reliability of each single ACP for AF/AFl recognition the chance of between-device discordance is not negligible and the risk of false positive automatic diagnosis of AF/AFl should be considered when managing real-world patients especially when deciding to start oral anticoagulation.
P2846Focal impulse and rotor modulation ablation versus pulmonary vein isolation for the treatment of paroxysmal atrial fibrillation (FIRMAP AF study)
Authors: Tilz R , Lenz C L , Sommer P S , Sawan N , Meyer-Saraei R , Shpun S , Sarver A , Heeger C , Hindricks G , Vogler J , Eitel C
Published: October 2019

Background

Based on the assumption of trigger elimination, pulmonary vein isolation (PVI) currently presents the gold standard of atrial fibrillation (AF) ablation. Recently, rapidly spinning rotors or focal impulse formation has been raised as a crucial sustaining mechanism of AF. Ablation of these rotors may potentially obviate the need for trigger elimination with PVI.

Purpose

This study sought to compare the safety and effectiveness of Focal Impulse and Rotor Modulation (FIRM) guided catheter ablation only with the gold standard of pulmonary vein isolation (PVI) in patients with paroxysmal AF.

Methods

This was a post-market, prospective, single-blinded, randomized, multi-center trial. Patients were enrolled at three centers and equally (1:1) randomized between those undergoing conventional RF ablation with PVI (PVI group) vs. those treated with FIRM-guided RF ablation without PVI (FIRM group). Data was collected at enrollment, procedure, and at 7-day, 3-month, 6-month, and 12-month follow-up visits. The study was closed early by the sponsor. At the time of study closure, any pending follow-up visits were waived.

Results

From February 2016 until February 2018, a total of 51 (out of a planned 170) patients (mean age 63±10.6 years, 57% male) were enrolled and randomized. Four patients withdrew from the study prior to treatment, resulting in 23 patients allocated to the FIRM group and 24 in the PVI group. Only 13 patients in the FIRM group and 11 patients in the PVI group completed the 12-month follow-up. Statistical analysis was not completed given the small number of patients.

Single-procedure effectiveness (freedom from AF/atrial tachycardia recurrence after blanking period) was 52.9% (9/17) in the FIRM group and 85.7% (12/14) in the PVI group at 6 months; and 31.3% (5/16) in the FIRM group and 80% (8/10) in the PVI group at 12 months. Repeat procedures were performed in 45.8% (11/24) patients in the FIRM group and 7.4% (2/27) in the PVI group.

The acute safety endpoint [freedom from procedure-related serious adverse events (SAE)] was achieved in 87% (20/23) of FIRM group patients and 100% (24/24) of PVI group patients. Procedure related SAEs occurred in three patients in the FIRM group: 1 femoral artery aneurysm and 2 injection site hematomas. No additional procedure-related SAEs were reported >7 days post-procedure.

Conclusions

These partial study effectiveness results reinforce the importance of PVI in paroxysmal atrial fibrillation patients and suggest that FIRM-guided ablation alone (without PVI) is not an effective strategy for treatment of paroxysmal AF in most patients. Further study is needed to understand the effectiveness of adding FIRM-guided ablation as an adjunct to PVI in this patient group.

Acknowledgement/Funding

Abbot
P2852Risk factors for death and survival after TLE in the groups of eighty- and ninety-year-olds
Authors: Jachec W , Polewczyk A , Segreti L , Bongiorni M G , Kutarski A
Published: October 2019

Background

Despite the fact that the transvenous lead extraction (TLE) is the method of choice of treatment for pacing complications, these procedures are not often performed in the elderly. The prognosis after TLE in these groups of patients is uncertain.

Aim

Evaluation of risk factors for death of patients who underwent TLE over the age 80 and 90 years.

Methods

3368 patients with complete follow-up data (mean age at the time of procedure; 65.38±15.64 years old, 1198 female) who underwent TLE procedures in two high volume experienced European centers. Risk factors for death in patients divided in to three groups depending on the age: below the age of 80 (group A, n=2854) and in groups of eighty-years-old (group B, n=484) and ninety-years old (group C, n=30) were determined using the Cox multivariable model.

The survival of eighty-year-olds and ninety-year-olds was worse compared to younger patients and they did not differ between themselves (Figure 1).

Results

815 deaths occurred during 3.87±2.76 years of follow-up; 611 (21.4%) in group A, 192 (39.7%) in group B (p<0,001) and 12 (40%) in group C (p<0.001) (B, C vs A, χ2 test). Results of multivariable Cox regression analysis are present in Table 1.

Table 1 Group A Group B Group C Age <80 years old Age between 80–90 years old Age ≥90 years old HR (95% CI) HR (95% CI) HR (95% CI) Female (y/n) 1.026; (0.851–1.238) 1.202 (0.874–1.654) 1.332; (0.428–4.146) Age in TLE (year) 1.021; (1.013–1.029) 1.053 (0.996–1.114) 0.997; (0.701–1.418) NYHA class (by one) 1.391; (1.240–1.561) 1.409 (1.134–1.750) 1.312; (0.698–2.466) LVEF (1%) 0.974; (0.967–0.980) 0.993 (0.982–1.005) 1.003; (0.947–1.063) Hypertension (y/n) 1.062; (0.889–1.268) 0.595 (0.428–0.828) 0.679; (0.203–2.271) Diabetes (y/n) 1.384; (1.152–1.662) 1.333 (0.951–1.868) 1.522; (0.398–5.821) Creatinin level (umol/l) 1.045; (1.020–1.070) 1.608 (1.385–1.866) 2.247; (0.704–7.171) Atrial fibrillation (y/n) 1.402; (1.169–1.682) 1.066 (0.783–1.451) 1.278; (0.380–4.296) ICD (y/n) 0.994; (0.825–1.198) 0.942 (0.618–1.437) 1.922; (0.419–8.830) Infectious indications (y/n) 1.137; (0.913–1.415) 1.014 (0.671–1.533) 1.104; (0.298–4.091) Lead related endocarditis 1.511; (1.174–1.945) 1.576 (1.004–2.474) 1.942; (0.385–9.804)

Conclusion

The survival of eighty-year-olds and ninety-year-olds did not differ between themselves in long term follow-up after TLE. There were no specific risk factors affecting the risk of mortality in long-term observation after TLE in nanogenarius
P2855Unexpectedly high rate of lead failure of the Microport (formerly Sorin/Livanova) Beflex and Vega pacemaker electrodes: A single centre experience
Authors: Anwander M , Kueffer T , Branca M , Sweda R , Nozica N , Asatryan B , Lam A , Baldinger S , Haeberlin A , Seiler J , Servatius H , Tanner H , Reichlin T , Roten L , Noti F
Published: October 2019

Introduction

Pacing leads remain the weak link of current pacemaker systems. Various differences in design and material exist among companies. Lead performance is mainly assessed via post-marketing studies of the manufacturing companies. Reliable independent reports are rare. We aimed to study the early and long-term performance of the Microport (formerly Sorin/Livanova) Beflex and Vega leads at our centre, for which a lead survival >99% at 3 years has been reported by the company.

Method

In this single centre, retrospective study we analysed the performance of all right ventricular Microport pacemaker leads implanted at our centre between January 2014 and January 2018. Only first pacemaker implants were considered. Lead failure was defined as any lead issue requiring reintervention during follow-up (dislocation, perforation, electrical abnormalities such as lead noise or excessively high thresholds).

Results

A total of 271 Microport right ventricular pacing leads were implanted (233 Beflex and 38 Vega leads). Mean patient age was 76±13.1 years (66% men). Dual chamber pacemakers were implanted in 162 patients (60%) and single chamber in 109 (40%). Mean threshold at implant was 0.6V/0.5ms (range 0.3–1.2V), mean R wave 13.2 mV (range 1.5–30mV) and mean impedance 816 Ohm (range 469–1639 Ohm). Patients without available follow-up information were excluded (N=18, 6.6%). The remaining 253 patients (93.4%) were analysed. Median follow-up was 1.26 years, IQR [25%=0.91 and 75%=2.24]. We observed a total of 25 lead failures (10%). Lead dislocation occurred in 2 cases (0.8%), lead perforation in 5 cases (2%), electrical abnormalities in 6 cases (2.4%) and excessively high threshold in 12 cases (4.8%; mean voltage 4V, range 2–7.5V; mean pulse width 0.75ms, range 0.35–1ms). Yearly incidence of lead failure per 100 leads was 6.1% (95%-CI [4.09–8.98] with a failure rate of 12.74% at 3 year in Kaplan-Meier analysis (Figure).

Figure 1

Conclusion

We found an unexpectedly high rate of lead failure of the Microport Beflex and Vega pacing leads at our centre. The two main reasons for premature lead failure were excessively high thresholds as well as electrical abnormalities during follow-up. Comparison of lead performance with other centres and against other leads are needed to further assess the magnitude of the problem.
P2858Cardiac implantable device malfunctions during radiotherapy courses up to 10 Gy: a double-center, prospective, randomized, in-vitro evaluation
Authors: Di Girolamo E , Marini M , Faustino M , Furia N , Appignani M , Genovesi D , Di Carlo C , Delana A , Barbareschi A , Falco M D
Published: October 2019

Background

Exposure to radiotherapy in patients with cardiac implantable electronic devices (CIEDs), both pacemakers (PMs) or implantable cardioverter defibrillators (ICDs), seems to be still troubleshooting. Unlike magnetic resonance imaging, high dose photon radiation at even less than 6MV power, notoriously a non-neutron-producing setting, may transiently or permanently affect normal device function. Malfunctions may be harmfull and life-threatening in high risk patients, such as PM-dependent or ICD ones.

Purpose

To evaluate CIED malfunctions by direct exposure to doses more than 2Gy in oncologic radiotherapy, 162 CIEDs (116 PMs and 46 ICDs) from two different centers, with at least 4 months to Elective Replacement Indicator (E.R.I.) were evaluated.

Methods

All CIEDs had a baseline telemetry interrogation. Single chamber devices were programmed in the VVI/40 mode and dual or triple chamber devices were programmed in the DDD/40 mode. Rate adaptive function was disabled. In ICDs, antitachycardia therapies were disabled with the ventricular tachycardia/fibrillation monitor still enabled. To build the corresponding treatment plan a centering Computed Tomography was performed and CIEDs were blinded randomized (4:4:4) to either 2, 5 or 10 Gy direct exposure by a low photon-energy LINAC (6MV) in a water phantom. An in-vivo dosimetry assessed the effective dose received by the CIEDs. All CIEDs had a telemetry-interrogation, using manufacturer specific equipment, immediately after exposure and monthly for a four-month follow-up.

Results

Immediately after exposure, 1 reset to emergency mode was observed in a PM (0.6% overall; 0.9% among PMs)), while 7 PMs reached the E.R.I immediately after exposure (4.3% overall; 6% among PMs). 10 ICDs (6.2% overall; 21.8% among ICDs) reporded multiple ventricular fibrillation detection stored in the device memory. During follow-up, 3 PMs (1.9% overall; 2.6% among PMs) and 1 ICD (0.6% overall; 2.2% among ICDs) reached the E.R.I. and 1 PM (0.6% overall; 0.9% among PMs) switched to emergency mode. All reported events occurred regardless of either 2, 5, or 10 Gy direct exposure. Malfunctions were observed in only older CIEDs.

Conclusions

Our data suggest recent CIEDs withstanding direct oncologic radiotherapy exposure up to 10 Gy, commonly considered not recommended or even unsafe by manufacturer statements and clinical guidelines. Malfunctions occurred in only older devices.

Acknowledgement/Funding

None
P2861Elevated cc chemokine receptor 2 expression and higher migratory activity of monocytes in atrial fibrillation patients with progressive structural remodeling
Authors: Miyosawa K , Iwata H , Takano A , Hayashi H , Funamizu T , Doi S , Tabuchi H , Sekita G , Matsushita S , Amano A , Daida H
Published: October 2019

Background

Inflammation in atrial tissue underlies structural remodeling of left atrium, which is a hallmark of atrial fibrillation (AF). Activated monocytes mediate inflammation; however, the role of monocytes in AF pathogenesis has not been extensively examined. In this study, we thus investigated the association between structural remodeling of left atrium, represented by left atrial dimension (LAD), and characteristics of peripheral monocytes in patients with AF.

Methods

Blood samples were collected from patients undergone catheter ablation between July 2017 and October 2018, including AF patients (n=152) and paroxysmal supraventricular tachycardia (PSVT) patients, which serves as a control non-AF group (n=22). AF patients were further divided into two groups by the median of LAD (normal LAD group: LAD <40 mm, n=77, large LAD group: LAD ≥40 mm, n=75). Peripheral blood mononuclear cells (PBMC) were isolated to analyze monocyte subsets by flow cytometry. In a subset of patients, we further isolated monocytes from PBMC by using magnetic bead-based negative selection method then gene products associated with inflammation or monocyte functions were evaluated. We also examined migratory activity of monocytes toward monocyte chemotactic protein-1, a ligand for CC chemokine receptor 2 (CCR2), using a modified Boyden chamber method. Finally, we performed immunofluorescence staining of monocytes and macrophages in left atrial appendages resected from patients underwent coronary bypass graft surgery (CABG) complicated by AF.

Results

There were no differences in age, body mass index and high-sensitivity C-reactive protein levels among three groups, including non-AF, normal LAD and large LAD groups, except that more female subjects were included in non-AF group. We found that proportions of classical CD14++CD16- and nonclassical CD14+CD16++ monocytes were higher (non-AF: 71.2±7.3% vs. AF: 75.5±8.3%, p<0.05) and lower (non-AF: 16.4±5.9% vs. AF: 13.2±5.5%, p<0.05), respectively, in all AF patients compared with those in non-AF group, while no significant difference was observed between normal and large LAD groups. In monocytes from large LAD group, mRNA levels of CCR2, a receptor to mediate monocyte chemotaxis, were significantly higher compared to those in normal LAD group (Figure A, p<0.05). Furthermore, monocytes isolated from large LAD group exhibited higher migratory capacity compared to normal LAD group (Figure B, p<0.01). Finally, higher monocyte/macrophage infiltrations to left atrial appendages were implicated in patients with large LAD, shown by immunofluorescence staining.

Conclusions

Monocytes in AF patients with enlarged left atrium expressed higher CCR2 mRNA and were more active in chemotaxis to MCP-1, suggesting the proactive roles of activated monocytes in the pathogenesis of arterial remolding in AF.
P2869Role of PDE8 in cAMP dynamics in human atrial fibrillation
Authors: Grammatika Pavlidou N , Pecha S , Reichenspurner H , Christ T , Nikolaev V O , Molina C E
Published: October 2019

Background

Cardiac arrhythmias, such as atrial fibrillation (AF), are often related to remodeling of membrane receptors and alterations in cAMP-dependent regulation of Ca2+ handling mechanisms. For instance, decreased L-type calcium current (ICa,L) density but upregulated RyR2 are major hallmarks of AF. These inhomogeneous AF-associated changes of protein phosphorylation point to a local regulation of PKA activity within these intracellular compartments. Local cAMP compartmentation and the role of phosphodiesterase (PDEs) have ben extensively studied in ventricular myocytes from animals. However, only a few studies have evaluated the contribution of PDEs to the pathophysiology of AF and the reason for the persistent AF-associated hypophosphorylation of the L-type calcium channel (LTCC) is currently unknown. The aim of this study was to investigate whether a change in the expression level of PDE8 in human atrium may affects cAMP nearby LTCC promoting the reduction of the ICa,L observed in persistent AF.

Methods

Atrial myocytes were isolated from tissue of 47 patients in sinus rhythm (SR) and with AF. Cells were then transfect with an adenovirus (Epac1-camps or pm-Epac1-camps) in order to express the (cytosolic or membrane, respectively) FRET-based cAMP sensor and cultured during 48 hours. Föster-resonance energy transfer (FRET) was used to measure cAMP in 232 isolated human atrial myocytes. Ro-20-1724 (10 μM), Cilostamide (1 μM) and PF-04957325 (30 nM) and IBMX (100 μM) were used as PDE4, PDE3, PDE8 and non-selective phosphodiesterases (PDEs) inhibitor respectively.

Results

Effects of PDE4 and especially PDE3 inhibition on cytosolic [cAMP] are reduced in AF. Pharmacological PDE8 inhibition induces only a small increase in basal intracellular [cAMP] in AF but it showed a big synergic effect when PDE4 was inhibit at the same time. By contrast, PDE8 inhibition dramatically increased basal [cAMP] in the subsarcolemmal compartment in AF while PDE3 or PDE4 inhibition had a smaller effect that didn't change between SR and AF.

Conclusions

PDE8 controls basal cytosolic cAMP levels in human atrial myocytes from patients with persistent AF while PDE3 effects tends to be reduced in these patients. Furthermore, PDE8 is the main PDE in controlling cAMP levels at the membrane in persistent AF. Thus, our study may provide a clue for the reported reduction of the ICa,L in persistent AF.
P2883VT/VF treatment in a contemporary population of single chamber ICD recipients: ATP efficacVF
Authors: Angeletti A , Paolisso P , Statuto G , Massaro G , Lorenzetti S , Frisoni J , Martignani C , Ziacchi M , Giacopelli D , Grassini D , Diemberger I , Biffi M
Published: October 2019

Aim of the study

to investigate the efficacy of ATP in consecutive, unselected ICD recipients implanted in 2014–2015.

Methods

All patients had a VT zone as 350 ms and a VF zone as 280 ms programmed, with a detection duration >20 seconds and >8 seconds respectively for VT and VF. Anti-tachycardia pacing (ATP) was available before/during charging in the VF zone, while at least 3 attempts with ATP were programmed in the VT zone. ATP efficacy was assed at the first ventricular arrhythmia episode for each patient. Overall ATP efficacy was also calculated on the burden of treated episodes.

Results

A total of 165 patients (median age 63 [48–72] years, male 79%, primary prevention 80%, ischemic 53%) implanted with a single chamber ICD were followed for a median period of 847 [666–1030] days: 44 (27%) had VT/VF episodes. Among a total of 706 VT/VF episodes, 623 were treated with ATP and/or shock. 7 patients were treated with shock as first delivered therapy (efficacy 100%), whereas 33 were treated with ATP (efficacy 55% of treated patients, 71% of episodes). The median cycle of the treated arrhythmias was 309 [280–324] ms.

Efficacy at first attempt ALL Ischemic NICM Primary Secondary Per patient (first therapy occurrence)   Shock (7/7) 100% (7/7) 100% – (6/6) 100% (1/1) 100%   ATP (18/33) 55% (13/23) 57% (5/10) 50% (13/22) 59% (5/11) 45% Per episode   Shock (14/14) 100% (14/14) 100% – (6/6) 59% (8/8) 100%   ATP (432/609) 71% (245/362) 68% (187/247) 76% (127/201) 63% (305/408) 75%

Conclusion

ATP is quite effective is a contemporary cohort of single chamber ICD recipients in a fast arrhythmia range (average 190–220 bpm) with a long detection. This observation strengthen the value of ATP in ICD selection, and should be balancen when considering an S-ICD.