bluuebunny/crossref_metadata_2025 huggingface dataset:
P6515Balloon pulmonary angioplasty in patients with chronic thromboembolic pulmonary hypertension: a systematic review and meta-analysis
Authors: Denas G , Zoppellaro G , Badawy M R , Squizzato A , Tarantini G , Pengo V
Published: October 2019

Introduction

Balloon pulmonary angioplasty (BPA) is a percutaneous treatment option for patients with chronic thromboembolic pulmonary hypertension (CTEPH) judged inoperable or with persistent symptoms after surgery.

Purpose

We performed a systematic review of the literature to better understand the effectiveness and safety of balloon pulmonary angioplasty.

Methods

PubMed and EMBASE were searched for studies reporting BPA results in patients with CTEPH. Differences in clinical and hemodynamic parameters including 6-minute walking distance, NYHA class, mean PAP, pulmonary vascular resistance, and cardiac output, before and after the procedure were analyzed. Weighted mean proportion and 95% confidence intervals (CIs) of adverse events were calculated.

Results

Of the 1084 potentially eligible studies, 13 were included in the final analysis, yielding on overall cohort of 676 patients. BPA was associated with a reduction in mean pulmonary artery pressure (median: from 43 to 30 mmHg), reduction in pulmonary vascular resistance (median: from 10.22 to 5.00 Woods Units), increase in cardiac index (median: from 2.45 to 2.72 l/min/m2), and improvement of 6-minute walking distance (median: from 328 to 442 meters). Estimated peri-procedural mortality was 2.2% of patients (95% CI 0.7–4.4) with a low risk of publication bias. Mortality rate tends to be higher in older studies and this is consistent with the progressive experience gathered by operators. Reperfusion and pulmonary vessel injuries occurred in 9.5% (95% CI 2.7–19.6) and 2.5% (95% CI 0.8–5.0) of the total BPA sessions, respectively, with on overall high risk of publication bias.

Haemodynamic parameters and 6-minute wal

Conclusions

Our findings suggest that BPA in CTEPH patients is an effective and safe treatment option in inoperable patients or patients with persistent-recurrent symptoms after surgery. Balloon pulmonary angioplasty might be considered as a second line-treatment in patients with chronic thromboembolic pulmonary hypertension not amenable for surgery.
P6516The association between prior coronary artery bypass graft surgery and outcome after percutaneous coronary intervention (PCI): an observational study of 123,780 patients
Authors: Beirne A , Rathod K , Jain A , Mathur A , Wragg A , Smith E J , Jones D A , Kalra S , Malik I , Redwood S , MacCarthy P , Bogle R , Firoozi S , Dalby M
Published: October 2019

Background

Limited information exists regarding procedural success and clinical outcomes in patients with previous CABG undergoing percutaneous coronary intervention (PCI). We sought to compare outcomes in patients undergoing PCI with or without previous coronary artery bypass grafts (CABG).

Methods

This was an observational cohort study of 123,780 consecutive PCI procedures from the Pan-London (United Kingdom) PCI registry, from January 2005 to December 2015. The primary end-point was all-cause mortality at a median follow-up of 3.0 years (interquartile range 1.2–4.6 years).

Results

12,641 (10.2%) patients had a history of previous CABG, of whom 29.3% (n=3,703) underwent PCI to native vessels and 70.7% (n=8,938) to bypass grafts. There were significant differences in the demographic, clinical, and procedural characteristics of these groups. The risk of mortality during follow-up was significantly higher in patients with prior CABG (23.2%) (p=0.0005) compared to patients with no history of prior CABG (12.1%) and was seen for patients who underwent either native vessel (20.1%) or bypass graft PCI (24.2%, p<0.0001). However, after adjustment for baseline characteristics, there was no significant difference in outcomes seen between the groups when PCI was performed in native vessels in patients with previous CABG (HR 1.02, 95% CI 0.77–1.34; P=0.89) but a significant increase in mortality among patients with PCI to bypass grafts (HR 1.33 95% CI 1.03–1.71, P=0.026). This was seen after multivariate adjustment and propensity matching.

Figure 1. Kaplan-Meier Curves

Conclusion

Patients with prior CABG are older, with a greater comorbid burden and more complex procedural characteristics, but after adjustment for these differences clinical outcomes are similar to patients undergoing PCI without prior CABG. In these patients, native vessel PCI was associated with better outcomes compared to the treatment of vein grafts.
P6528Impact of chronic kidney disease on clinical outcomes in patients with unprotected left main coronary artery disease: insights from a large-sized all-comers registry
Authors: Kim D W , Her S H
Published: October 2019

Aims

Clinical outcomes according to the status of renal insufficiency were not fully evaluated in patients with significant left main coronary artery disease (LMCAD).

Methods and results

The current study analyzed 4894 patients with unprotected LMCAD enrolled in the multicenter IRIS-MAIN registry. Renal insufficiency was graded according to the baseline renal function (eGFR). The primary clinical outcome was major adverse cardiocerebrovascular event (MACCE), defined as a composite of death, myocardial infarction, stroke, and any revascularization. At baseline, 3824 (78%) had preserved renal function (eGFR ≥60 ml min–1 1.73m–2), 838 (17%) had moderate renal dysfunction (eGFR of ≥30 and <60), and 232 (5%) had severe renal dysfunction (eGFR <30). At 2 years, the rates of MACCE were significantly higher in patients with lower levels of eGRF (9.1% in eGRF ≥60, 16.0% in eGFR of ≥30 and <60, and 36.2% in eGRF <30, respectively, P<0.001). After multivariable adjustment, as compared with patients with eGFR ≥60, the hazard ratios (HR) for MACCE proportionally increased for patients with eGFR of ≥30 and <60 (HR 1.46, 95% CI 1.18–1.79) and for those with eGFR <30 (HR 3.39, 95% CI 2.61–4.40). The adjusted risks for MACCE was similar between percutaneous coronary intervention (PCI) and coronary-artery bypass grafting (CABG) in patients with preserved and moderate renal dysfunction. However, in patients with severe renal dysfunction, PCI was associated with a significantly higher risk of MACCE compared to CABG (38.5% vs. 24.7%, HR 1.80, 95% CI 1.03–3.13, P=0.04).

Crude and Adjusted Risk of Primary Composite Outcome After PCI and CABG, According to the Status of Baseline Renal Function Patient Groups 2-Year Event Rate, n (%) Crude Risk Adjusted Risk* Revascularization type HR 95% CI P value HR 95% CI P value PCI CABG (reference) All patients 306/2825 (10.8) 144/1453 (9.9) 1.160 0.952–1.414 0.141 1.265 1.036–1.546 0.021 Subgroups by baseline eGFR   Preserved renal function (eGFR >60) 190/2289 (8.3) 89/1098 (8.1) 1.080 0.840–1.389 0.549 1.125 0.874–1.449 0.360   Moderate renal dysfunction (eGFR ≥30 and <60) 71/419 (169%) 37/282 (13.1%) 1.394 0.936–2.074 0.102 1.276 0.854–1.909 0.234   Severe renal dysfunction (eGFR <30) 45/117 (38.5%) 18/73 (24.7%) 1.997 1.154–3.458 0.014 1.798 1.032–3.130 0.038

Conclusions

The degree of renal insufficiency was proportionately associated with worse clinical outcomes in patients with LMCAD. In patients with severe renal dysfunction of eGFR of <30, PCI was associated with a higher risk of MACCE as compared with CABG.

Acknowledgement/Funding

This work was supported by a grant from the CardioVascular Research Foundation, Seoul, Korea (2015-09).
P6529Safety of emergency pretreatment regimen for contrast allergy before percutaneous coronary intervention for ST-elevation myocardial infarction
Authors: Jha K , Berger A , Blankenship J
Published: October 2019

Background

Primary percutaneous coronary intervention (PPCI) is the best treatment for ST-elevation myocardial infarction (STEMI). However, patients with prior contrast reactions may not receive PCI due to concern over a recurrent contrast reaction.

Purpose

To determine the clinical efficacy of emergency pretreatment regimens for contrast allergy in STEMI patients undergoing PPCI.

Methods

We retrospectively identified all individuals with a history of contrast allergy who presented with STEMI, were pretreated for contrast allergy, and underwent PPCI at our medical center between January 2005 to May 2018. Emergency pretreatment regimen included a combination of intravenous (IV) steroid, IV famotidine and IV diphenhydramine administered immediately before PCI. Laboratory records, inpatient notes, and discharge summaries were reviewed to confirm the severity of the original contrast allergy and identify any allergic breakthrough reaction after pretreatment with an emergency regimen. Reactions were characterized as mild, moderate, severe, or of unknown severity.

Results

During the study period 15,712 individuals underwent PCI, of which 176 patients presented with STEMI, had confirmed contrast allergy, and were pretreated before undergoing PCI. No patient with a history of contrast allergy underwent PPCI without pre-treatment. Mean age was 64 years, with 52% males, and all individuals were white. The majority had hypertension (77%), 67% had dyslipidemia, 29% had diabetes mellitus, and 20% patients had a prior history of MI. Intravenous steroids used in the emergency regimen included methylprednisone (n=100), hydrocortisone (n=70), and dexamethasone (n=6). The original allergic response to ICM was mild in 59% patients, moderate in 15%, severe in 20% and of unknown severity in 13% patients. Of the 176 patients only 10 (5.6%) developed a breakthrough reaction. Most of which were mild; none was fatal. Median length of hospital stays was three days and nine patients (10.8%) passed away within 30 days of hospital admission.

Conclusions

Patients with prior contrast allergy presenting with STEMI can safely undergo PPCI after emergency pretreatment. Breakthrough reactions are infrequent and mild.
P6531Evidence-practice gap in the preprocedural risk assessment for contrast-induced acute kidney injury
Authors: Shoji S , Sawano M , Shiraishi Y , Ikemura N , Noma S , Suzuki M , Numasawa Y , Fukuda K , Kohsaka S
Published: October 2019

Background

Contrast-induced acute kidney injury (CI-AKI) is one of the frequently encountered and costly complications after percutaneous coronary intervention (PCI). Clinical practice guidelines strongly recommend that PCI patients should universally undergo preprocedural assessment for the risk of CI-AKI, and the contrast volume (CV) should be minimized to an achievable level, particularly among the high AKI risk patients. However, data on the CV use based on the comprehensive preprocedural risk assessment is still lacking.

Purpose

Our study aimed to 1) assess the impact of CV increase with the incidence of AKI among high AKI risk patients, and 2) retrospectively evaluate the used CV based on the preprocedural comprehensive risk assessment for patients undergoing PCI within multicenter longitudinal registry.

Methods

Between 2009 and 2018, 22,373 patients underwent PCI in 14 participating facilities, and consecutive patient data was registered. AKI was defined as a >0.3mg/dl absolute or >1.5-fold relative increase in post-PCI creatinine or new initiation of dialysis, based on the Acute Kidney Injury Network criteria. The post-procedural creatinine was defined as the highest value within 30 days after the indexed procedure. Congruent with the National Cardiovascular Data Registry (NCDR) definition, if more than 1 post-procedural creatinine level was measured, the highest value was used for determining AKI. We divided the patients into four groups according to quartile of NCDR AKI risk scores.

Results

Mean age of the patients were 68.7±11.1 years, and 79.1% were male. Mean CV use was 161.4±74.8ml. The incidence of CI-AKI was 8.9%, and was particularly high among high AKI risk patients (21.1%); CV (per 1ml linear increase) was directly associated with the occurrence of AKI (OR: 1.002 per unit in CV; 95% CI: 1.001–1.003; P<0.001) in these patients. CV during PCI decreased with the progression of chronic kidney disease (CKD), but it did not alter by the overall NCDR AKI risk score (Figure). After multivariable adjustment, CV was predicted by stage of CKD (−13.68ml; 95% CI: −12.05 to −15.30ml; P<0.001), but not by the value of pre-procedure prediction score (NCDR AKI risk score, P=0.575).

CV according to CKD/NCDR AKI risk score

Conclusions

Higher CV was directly associated with the occurrence of AKI among higher AKI risk patients. However, CV use was largely influenced by the stage of renal disease, and not with overall patient risk presented by contemporary risk scores. Our results have identified an important evidence-practice gap and emphasizes the importance of total preprocedural assessment to minimize CV and prevent subsequent AKI.

Acknowledgement/Funding

KAKENHI (16KK0186, 16H05215, 25460630, 25460777), Bayer, Daiichi Sankyo, Bristol-Myers Squibb, Teikoku Seiyaku, Sumitomo Dainippon, AstraZeneka, Pfizer
P6548Left bundle branch area pacing in patients with atrioventricular block
Authors: Su L , Huang W J , Wu S J
Published: October 2019

Background

The application of His bundle pacing (HBP) on patients with distal AV block should be of concern.Left bundle branch Aera pacing (LBBA pacing), pacing immediately beyond the site of block will be considered.

Purpose

To access the clinical benefits and safety of LBBA pacing in patients with atrioventricular (AV) block.

Methods

One hundred and thiry nine patients diagnosed with AVB were included. The Select Secure lead (model 3830; Medtronic) was used. Characteristics of LBB capture are summarized as following: 1) The paced QRS morphology of RBBB pattern during unipolar tip pacing; 2) Usually, LBB potential could be recorded; 3) If higher output pacing shortened the times abruptly and the times remain constant. Pacing parameters (threshold, R-wave amplitude and impedance) and Echocardiographic measurements were assessed during follow-up.

Results

All patients were success achieved LBBA pacing. The detailed baseline characteristic and follow-up were shown in the Table. Threshold, R-wave amplitude and impedance remained stable during follow -up. Echocardiographic measurements showed that LBB pacing did not affect the cardiac function. There was no LV septum penetration and dislodgment.

Conclusion

LBBA pacing had ideal pacing parameters and preserve cardiac function and may be an excellent alternative to HBP or RVP.

Acknowledgement/Funding

Key R&D Program of Zhejiang (2019C03012), Major Project of the Science and Technology of Wenzhou (ZS2017010)
P6566Noninvasive Panoramic Mapping of Phase Singularities with Signal Complexity Analysis in Patients with Persistent Atrial Fibrillation
Authors: Chmelevsky M , Budanova M , Zubarev S , Potyagaylo D , Sohns C , Lemes C , Kivelitz D , Metzner A , Kuck K H
Published: October 2019

Background

An assessment of positive outcome probability of ablation therapy based on the comprehensive signal complexity analysis is a promising working hypothesis while electrocardiographic imaging (ECGI) can detect and visualize zones of phase singularities (PS) associated with stable sources of atrial fibrillation (AF).

Methods

Ten consecutive patients with persistent AF (three female, median (min–max) – 63.5 (45–75) years) underwent ECGI using “Amycard 01C EP lab” system with cardiac MRI (1.5-T Magnetom Avanto) followed by pulmonary vein isolation. Each T-Q segment with a length >800 ms during AF was processed to find PS. Sites with rotations around stable pivot points were considered as PS and then marked and visualized on the reconstructed anatomical 3D atrial model. Finally, a signal complexity cluster analysis was performed to define and depict phase-aggregation zones.

Results

ECGI analysis identified a total number of 410 PS, with 196 (47.8%) occurring in the LA and 214 (52.2%) in the RA. The median (25–75% IQR) number of revealed PS per patient was n=20 (14–30) for RA and n=20 (11–22) for the LA. The majority of the PS in the LA was located on the inferior wall n=66 (min-max 1–17). In eight patients, comprehensive signal complexity analysis revealed stability of phase-clustered zones over time. The mean number (min-max) of PS in a clustered area was 10 (6–15). In two patients, PS were distributed disordered on the entire LA and RA surface.

Distribution of phase singularities

Conclusions

This is the first clinical study demonstrating signal complexity analysis capability of clustering noninvasively mapped PS and relating them to specific atrial anatomical regions. Thereby obtained clusters may be a potential zones of conduction block, and could contribute to a better understanding of the temporal AF complexity.
P6577Isolated systolic hypertension versus combined systolic-diastolic hypertension as predictors of atrial fibrillation: data from a 8-year-follow-up study
Authors: Konstantinidis D , Tsioufis C , Dimitriadis K , Kasiakogias A , Liatakis I , Koutra E , Leontsinis I , Kouremeti M , Iliakis P , Vogiatzakis N , Karaminas N , Thomopoulos K , Tousoulis D
Published: October 2019

Background/Introduction

Isolated systolic hypertension (ISH) and combined systolic-diastolic hypertension (CH) are related with increased cardiovascular risk.

Purpose

The aim of the present study was to compare the predictive role of ISH and CH for the incidence of atrial fibrillation (AF) in a cohort of essential hypertensive patients.

Methods

We followed up 1605 essential hypertensives with office systolic blood pressure (BP)≥140 mmHg [mean age 58.1 years, 842 males, office BP=153/92 mmHg] for a mean period of 8 years. All subjects had at least one annual visit and at baseline underwent echocardiographic study and blood sampling for estimation of metabolic profile. Patients with baseline ISH exhibited office systolic BP ≥140 mmHg and office diastolic BP <90 mmHg, while those with CH had office systolic BP ≥140 mmHg and office diastolic BP ≥90 mmHg. Moreover, new-onset AF was defined as hospitalization for AF or compatible electrocardiographic tracings.

Results

The incidence of new-onset AF over the follow-up period was 3.4% (n=55). Patients with ISH (n=510) compared to those with CH (n=1095) were older (65±10 vs 55±11 years, p<0.0001), had at baseline lower waist circumference (95.5±12 vs 98±12 cm, p<0.0001), office systolic BP (149±10 vs 155±13 mmHg, p<0.0001), office diastolic BP (80±5 vs 98±7 mmHg, p<0.0001), while did not differ regarding left ventricular mass index and lipid levels (p=NS for all). Univariate Cox regression analysis revealed that baseline ISH (hazard ratio=4.612, p=0.013) and CH (hazard ratio=1.794, p=0.036) predicted new-onset AF. However, in multivariate Cox regression model, age (hazard ratio=1.078, p<0.001), left ventricular mass index (hazard ratio 1.012, p=0.014), left atrium diameter (hazard ratio=1.102, p<0.001) and ISH (hazard ratio=1.551, p=0.035) but not CH turned out to be independent predictors of new-onset AF episodes.

Conclusions

In essential hypertensive patients, ISH but not CH exhibits independent prognostic value for AF. These findings support that ISH constitutes a hypertensive phenotype of particularly increased arrhythmia risk needing careful evaluation and treatment.
P6578Development of the novel program to diagnose atrial fibrillation using automated blood pressure monitor
Authors: Ishizawa M , Noma T , Ishikawa S , Matsunaga K , Kawakami R , Miyake Y , Ishikawa K , Tsuji T , Murakami K , Minamino T
Published: October 2019

Background

Atrial fibrillation (AF) is often asymptomatic and contributes to an increased risk of strokes. The development of proper screening device of AF is unmet medical needs worldwide. Recently, we had reported that multiple measurements using Omron automated blood pressure (BP) monitor with irregular heartbeat detection showed high sensitivity and specificity for AF detection in general cardiac patients, however, this method had limitations in discriminating between AF and other arrhythmias.

Purpose

The aim of this study is to develop a novel program that can accurately diagnose AF by discriminating it from other arrhythmias using the pressure pulse waveform data outputted from Omron automated BP monitor.

Methods

In our previous clinical research, BP measurements were performed 3 times each for 303 general cardiac patients (mean age: 72.2 years, 69.8% male) with recording the real-time single lead ECG, and a total of 909 pressure pulse waveforms were obtained. Among them, 840 pressure pulse waveforms from 280 patients (include 40 AF patients) used for further analysis. We developed a program to analyze and visualize uniquely the characteristics of AF waveform through the autocorrelation-based waveform processing system produced by Melody International Ltd, Kagawa, Japan. All visualized results were judged and classified into Sinus, Non-AF and AF by two individuals blinded to the results. For each patient who obtained 3 results, a two by two contingency table was created and sensitivity, specificity, and accuracy for diagnosing AF were calculated.

Results

Among 840 pressure pulse waveforms, only 21 (2 Sinus and 19 Non-AF) out of 720 Sinus and Non-AF waveforms were judged as AF, and 7 out of 120 AF waveforms were judged as Non-AF. None of AF waveforms was absolutely misjudged as Sinus. In analysis for each patient, when one or more AF judgements were found in 3 waveforms, the diagnosis of AF has sensitivity and specificity of 100% and 95.8%, respectively. When two or more AF judgements were found in 3 waveforms, the diagnosis of AF has sensitivity and specificity of 100% and 97.9%, respectively. In this rule, the diagnostic accuracy of AF reached up to 98.8%, and no sinus patients were misjudged as AF.

Conclusion

The novel program, which applied autocorrelation methods uniquely to analysis of the pressure pulse waveforms recorded by automated BP monitor, showed high sensitivity and high specificity for AF diagnosis in general cardiac patients. This program is expected to be useful for early diagnosis for asymptomatic AF patients.

Acknowledgement/Funding

The present research is supported by a grant through the SCOPE from the Ministry of Internal Affairs and Communications, Japan.
P6579Genetic profile and predictors of positive genetic test in Brugada syndrome
Authors: Faria B , Ribeiro S , Calvo L , Miltenberger-Miltenyi G , Oliveira M , Hafe P , Dias G , Cardoso F , Sanfins V , Lourenco A
Published: October 2019

Introduction

Brugada syndrome (BS) is a channelopathy with autosomal dominant transmission, incomplete penetrance and variable expression. There are 18 different gene mutations described in association with this syndrome, however 70% of patients remain without identifiable genetic cause. Genetic testing is appropriated for patients with clinical diagnosis but it is also a very important tool in familiar screening.

Aim

We aim to characterize genetic profile of patients with clinical diagnosis of BS and identify differences between patients with and without causative mutation.

Methods

We included patients followed by the arrhythmology department of our hospital with diagnosis of BS and that have performed genetic test (or patients who were identified through familiar screening and with negative genetic test in the index case). Patients identified through familiar screening with positive genetic test but no spontaneous electrocardiographic pattern, still awaiting pharmacologic provocative test at the time of enrolment – no clinical diagnosis - were excluded. Genetic test was considered positive when we found a pathogenic or probably pathogenic mutation. Mutations in PKP, SLMAP, CACNA, CACNB, SCN10A and CLASP genes considered of uncertain clinical relevance were not included as positive genetic test. We analysed differences between subset of patients with and without causative mutation regarding clinical and electrocardiographic variables. We performed multivariate analysis to find predictors of positive genetic test.

Results

From our 173 patients, 140 met the inclusion criteria and none exclusion criteria so they were enrolled. Patients were 61% male with mean age of 50±15 years old. Mean follow-up was 26±28 months; 24,4% of index cases were positive for causative mutation, 6,8% patients with pathogenic mutation in SCN5A gene and 17,6% with probably pathogenic mutation in SCN5A.

We haven't found significant differences between the 2 groups (negative and positive genetic test) in any clinical variable included. Regarding electrocardiographic variables, patients in whom a mutation was identified had longer PR interval (192±36 vs 170±28, p=0.001), longer QRS (121±19 VS 111±18 p=0.017), particularly when QRS>110ms (p=0,002), and longer QT (398±25 VS 370±45 p=0.015) In multivariate analysis, PR interval (p=0.032) and QRS>110ms (p=0,041) were independent predictors for positive genetic test.

Conclusion

In our BS population, there were no clinical differences between patients with and without causative mutation, also concerning events rate. Patients with positive genetic test have significantly longer PR interval and QRS>110ms than in patients with genetic test negative. Those results can be interpreted in relation to sodium channel disfunction in patients with SCN5A mutation.
P6586Brugada syndrome risk stratification - Evaluation of clinical and ECG risk markers in a multicenter international primary prevention cohort
Authors: Honarbakhsh S , Providencia R , Garcia-Hernandez J , Martin C A , Hunter R J , Lim W Y , Kirkby C , Sharifzadehgan A , Waldmann C , Marijon E , Munoz-Esparza C , Lacunza J , Gimeno-Blanes J R , Lambiase P D
Published: October 2019

Background

Risk stratification for sudden cardiac death (SCD) in Brugada syndrome (BrS) is a significant challenge.

Purpose

To evaluate the importance of clinical and ECG factors in the likelihood of developing significant ventricular arrhythmias (VAs)/SCD in BrS patients.

Methods

VA occurrence during follow-up were assessed and the role of 16 proposed clinical or ECG risk markers evaluated in a multicenter international study of BrS patients and no history of cardiac arrest. Markers with predictive power were identified and incorporated into a risk score model.

Results

Across 15 international centers, 1084 patients were included. During a follow-up of 5.3 years (IQR 2.7–9.0 years)- 110 patients had VA occurrence (10.1%) with an annual event rate of 1.7% (95% CI 1.4–2.0). Of the 16 proposed risk factors, diagnosis by family screening of sudden cardiac death (HR 4.65; p<0.001), probable arrhythmia related syncope (HR 3.88, p<0.001), type 1 spontaneous ECG (HR 3.56; p<0.001), Early Repolarisation (HR 3.15; p<0.001) and type 1 Brugada pattern in peripheral leads (HR 2.42; p<0.001) were associated with a higher VA occurrence risk during follow-up. These 5 variables were incorporated into a risk score model whereby each variable was allocated a point score based on the variable's predictive strength. The total points obtained from the model for a patient could then be translated into the predicted VA occurrence risk during follow-up (Figure 1). The model showed a sensitivity of 63.5% (95% CI 50.0–76.9) and specificity of 84.2% (95% CI 81.1–87.1) in predicting VA occurrence at 5-years follow-up. The model showed a greater discriminative power compared to an existing model (AUC 0.83 vs. 0.71; p<0.001).

Figure 1

Conclusions

This multicenter study with longest reported follow-up to date identified 5 risk markers for VA occurrence. Utilizing these markers in a risk score model can aid BrS risk stratification to enable individualized risk prediction and ICD prescription.
P6587The experience of a French specialized inherited arrhythmia center in the management of long QT syndrome patients
Authors: Probst V , Minier M , Mabo P , Clerici G , Babuty D , Mansourati J , Kyndt F , Thollet A , Sacher F , Gourraud J B
Published: October 2019

Introduction

Congenital long QT syndrome (LQTS) is a hereditary disease characterized by prolonged QTc interval and risk of ventricular tachyarrhythmias, which may lead to syncope, cardiac arrest, or sudden death in young people.

Objective

The aim of this study is to report the experience of the French referral center of inherited arrhythmia of the University Hospital of Nantes.

Methods

Consecutive patients affected with lonq QT syndrome were recruited in a multicentric prospective registry in France (15 centers) between 1997 and 2018. Clinical data and 12-lead ECG were collected. Genetic screening was performed using dHPLC-DNA sequencing, HRM or targeted sequencing for at least KCNQ1, KCNH2 and SCN5A.

Results

In this study, we enrolled a total of 741 patients affected by LQTS according to the Schwartz score (447 (60%) females, 404 (55%) index cases). Mean age at diagnosis was 33±21 years. In this cohort, 343 patients (46%) were symptomatic: 66 patients experienced resuscitated sudden cardiac death (SCD, 9%), 211 (28%) syncope and 66 (9%) ventricular arrhythmias. One hundred and two patients (14%) had history of familial SCD. At baseline, heart rate was 69±19 bpm, PR 149±39 mm, QRS 86±16 mm and QTc 479±62 mm.

Three hundred and eighty-six patients (52%) were treated with beta-blockers and 88 patients (12%) were implanted with an ICD.

Genetic screening was performed in 668 (90%) patients. Genetic screening for the 3 major genes of LQTS was positive for 411 patients (62%): 165 variants (25%) in KCNQ1, 178 variants (27%) in KCNH2, 68 variants (10%) in SCN5A. Moreover, we found variants in minor genes of LQTS for 22 patients (3%).

During a mean follow-up of 6.2±5.2 years, 64 patients (9%) underwent arrhythmic events (7 SCD (1%), 8 appropriate ICD therapy (1%) and 49 ventricular arrhythmias (7%). The rate of arrhythmic event was 1.39%/y. Mean age at the first event was 41.7±21.5 years. Sixteen patients (2%) died of non-arrhythmic causes.

Conclusion

Care in a specialized inherited arrhythmia center is associated with a low incidence of arrhythmic event (1.39%/y) in patients affected with LQTS.
P6597Long-term impact of catheter ablation on growth differentiation factor-15 and neutrophil-lymphocyte ratio in paroxysmal atrial fibrillation
Authors: Bin Waleed K , Xia Y L , Gao L J , Xiaomeng Y , Tse G , Yves D G , Wang L L , Shuling W , Wang J , Bo Z , Li Y C
Published: October 2019

Background

There is increasing evidence that inflammatory biomarkers growth differentiation factor 15 (GDF-15) and neutrophil-lymphocyte ratio (NLR) appear to be associated with stroke and adverse cardiovascular events in patients with atrial fibrillation (AF). However, long-term impact of catheter ablation (CA) on GDF-15 and NLR is still unknown.

Objective

To evaluate the long-term change in GDF-15 and NLR after CA in paroxysmal AF patients.

Methods

A total of 58 paroxysmal AF patients were consecutively enrolled to perform CA. The inflammatory biomarkers GDF-15 and NLR were measured at baseline and 6-months postablation.

Results

All patients except one could complete 6-Months follow up. Fifty (87.7%) patients maintained sinus rhythm (SR group) and seven (12.3%) patients sustained AF recurrence (AFR group). No significant difference was noted in clinical and procedural characteristics between two groups (p>0.05), except mean fluoroscopy time (minutes 22±11.7 vs. 13±5.3, p=0.001) significantly longer in AFR than SR group. The GDF-15 (pg/ml 195±57 vs. 216±88, p=0.398), and NLR (% 1.8 (1.3–3) vs. 2.6 (1.4–3.4), p=0.395) were comparable at baseline in both SR and AFR groups respectively. At 6-months postablation, GDF-15 (pg/ml 133±41 vs. 195±57, p<0.001), and NLR (% 1.6 (1.1–2) vs. 1.8 (1.3–3), p=0.004) were significant deceased compared to baseline levels in SR group. However, GDF-15 (pg/ml 139±86 vs. 216±88, p=0.064), and NLR (% 1.6 (1.2–3) vs. 2.6 (1.4–3.4), p=0.398) biomarkers remained comparable to baseline level in AFR group (p>0.05)

Conclusion

Inflammatory biomarkers; GDF-15 and NLR significantly decreased at long-term on successful maintenance of sinus rhythm by CA in paroxysmal AF patients.

Acknowledgement/Funding

None
P6598MicroRNA 21 and Hypoxia Inducible Factor 1 synchronize the impact of B lymphocytes on cardiac function after acute myocardial infarction
Authors: Sun Y , Pinto C , Loyer X , Duval V , Alayrac P , Gomez I , Vilar J , Lemitre M , Levoye A , Ait-Oufella H , Mallat Z , Silvestre J
Published: October 2019

Background

Myocardial infarction (MI) is a severe ischemic disease responsible for heart failure and sudden death. Mature B lymphocytes have been shown to exacerbate tissue injury and deterioration of cardiac function after MI. However, the cellular and molecular mechanisms governing B cell deleterious effects in the ischemic milieu remain to be defined.

Purpose

In this study, we speculate that endogenous activation of the miR21/HIFα-related pathways mediates the effect of B lymphocytes on post-ischemic cardiac remodeling.

Methods

Acute MI was induced by permanent ligation of the left anterior descending artery in mice. Cardiac function and remodeling was determined by echocardiography and immunohistochemistry. Inflammatory cell number and phenotype were defined by FACS analysis. To evaluate the role of HIFα isoforms in B cells, we generated mice with B cell lineage specific (Cd79aCre/+) conditional deletion of HIF1α (HIF1αflox/flox), HIF2α (HIF2αflox/flox), or both isoforms (HIF1α-HIF2αflox/flox).

Results

Acute MI increased miR21 levels in B cells. miR21 deficient mice showed reduced B cell numbers in the spleen, blood and subsequently in the injured cardiac tissue. Transplantation of bone marrow derived cells isolated from miR21-deficient mice (miR21−/−) improved cardiac function and remodeling when compared to administration of wild-type (WT) bone marrow cells. Similarly, in Rag1−/− immunodeficient mice with acute MI, re-supplementation with miR21−/− B lymphocytes restored cardiac repair and function when compared to injection of WT B cells. miR21 abrogated PTEN contents and subsequently enhanced HIF1α levels in cultured B cells. B cell deletion of HIF1α, but not that of HIF2α, reduced B cell accumulation and improved cardiac function after MI. Mice, which were equally deficient in HIF1α and HIF2α, also exhibited abrogation of adverse ventricular remodeling and showed recovery of cardiac function after MI. Toll like receptor agonist, CpG, fostered the release of the monocyte chemo-attractant protein, Ccl7, in cultured WT B cells but not in miR21- or HIF1α- deficient B cells. Ccl7 circulating levels were also reduced in miR21−/− and Cd79aCre/+/HIF1α flox/flox animals after acute MI. Ccl7 down-regulation hampered Ly6Chigh monocyte infiltration in the ischemic myocardium, leading to decreased infarct size and interstitial fibrosis, supporting cardiac repair.

Conclusion

This work reveals a novel function for miR21/HIF1α related pathways in B lymphocyte dependent effect on cardiac function and remodeling in the setting of acute MI.
54Role of the gut microbiome for the cholesterol lowering effect of atorvastatin
Authors: Zimmermann F , Schmidt D , Escher U , Jasina A , Roessler J , Heimesaat M M , Gast M , Poller W , Kratzer A , Giral Arnal H , Schumann P , Leistner D M , Landmesser U , Haghikia A
Published: October 2019

Background and aims

Statins show interindividual differences in the extent of low-density lipoprotein cholesterol (LDL-C) reduction. The mechanisms of this interindividual variation are not fully understood. Here, we examined the potential role of the gut microbiome for the LDL-C lowering property of atorvastatin.

Methods

Mice (C57BL/6) with either intact (conventional mice, CONV, n=24) or with antiobiotic depleted gut microbiome (gnotobiotic, n=16), were put on standard chow diet (SCD) (n=11) or high fat diet (HFD) (n=29) for 6 weeks. During the last 4 weeks atorvastatin (Ator, 10mg/kg body weight/day) or control vehicle was orally applied via gavage. Blood levels of LDL-C and glucose and body weight after 6 weeks of treatment were compared between the groups. Expression of genes involved in hepatic and intestinal cholesterol-metabolism were examined. Faeces of CONV mice were analyzed for alteration of the gut microbiota profile upon atorvastatin treatment using 16S rRNA qPCR.

Results

HFD fed mice with intact gut microbiome showed significantly increased blood LDL-C levels as compared to SCD (HFD: 36.8±1.4 mg/dl vs. SCD: 22.0±1.8 mg/dl; P<0.01). Bodyweight gain or blood glucose levels after HFD were not significantly different between CONV and gnotobiotic mice. While in CONV mice atorvastatin significantly reduced LDL-C levels after HFD, in gnotobiotic mice the LDL-C lowering effect of atorvastatin was attenuated (CONV+HFD+Ator: 31.0±1.8 mg/dl vs. gnotobiotic mice+HFD+Ator: 46.4±3 mg/dl; P<0.01). The expression of genes involved in hepatic cholesterol synthesis was not significantly altered in gnotobiotic mice as compared to CONV mice. In CONV mice HFD decreased the relative abundance of the bacterial phyla Bacteroidetes and increased the abundance of Firmicutes as compared to SCD. The ratio between Firmicutes to Bacteroidetes was shifted towards control conditions upon atorvastatin treatment.

Conclusions

The results of this study suggest a regulatory impact of atorvastatin on the gut-microbial profile and, in turn, a crucial role of the gut-microbiome for the LDL-C lowering effect of atorvastatin independent of its regulation of hepatic cholesterol synthesis. Our findings provide novel insight into potential microbiota-related mechanisms causing interindividual variation in LDL-C lowering effects of statins.

Acknowledgement/Funding

German Heart Research Foundation
79Experience from heart or heart/lung transplantation from a single centre for adult congenital heart disease: too little, too late?
Authors: Meras Colunga P , Riesgo Gil F , Khan U , Pires A , Smith J , Kempny A , Simon A , Gatzoulis M A
Published: October 2019

Introduction

Heart failure is the leading cause of death in adults with congenital heart disease (ACHD). Heart or heart and lung transplantation (H/HLTx) can be effective therapy for these patients, but unfavourable anatomy, end-organ damage, pulmonary vascular disease, HLA sensitization and lack of robust selection criteria currently limit its application.

Methods

Consecutive ACHD patients >16 years of age who were considered for H/HLTx at our tertiary centre between 2006 and 2018 constitute our study population. Baseline characteristics and outcome, including H/HLTx and death were obtained for all from designated databases, medical records and the UK Office for National Statistics.

Results

Of a total of more than 9,000 active ACHD patients, 130 (53.1% male, mean age 42.2, IQR 32.6–50.2 years) fulfilled inclusion criteria with a broad spectrum of underlying ACHD and considerable mortality across all anatomic subgroups [Table 1].

82% of patients had previous cardiac surgery (55.5% with ≥2 sternotomies or thoracotomies). Cardinal presenting features were poor functional capacity, low cardiac output, cyanosis and/or end-organ disease; “only” 47% had moderate or severe dysfunction of the systemic and 37% of the subpulmonary ventricle. Frequent comorbidities were atrial arrhythmia 68.7%, PH 30.4%, CKD 23.5%, liver dysfunction or cirrhosis 11.3%; 36.8% of patients had an ICD and 16.5% a CRT, whereas 79.8% were on diuretics, 70.5% MRA, 51.6% beta blockers, 32.6% ACEI, 18.9% ARB, 10.5% Digoxin and 29.5% on pulmonary vasodilators. HLA antibodies were positive in 47.3% (high sensitization >90% in 13.2%).

There was high overall mortality with 35.4% of patients dying over a median of 2.7 years (IQR 1.1–4.9). Only 13.6% from our cohort were transplanted, with a survival of 76.5% at a mean of 5.9 years from H/HLTx.

ACHD subgroup % of total % transplanted Mortality (%) Median follow-up (years) Univentricular heart 25.4 6.1 30.3 2.5 Systemic RV 21.5 7.4 35.7 2.6 Shunts with PAH / Eissenmenger 13.9 5.9 27.8 3 Tetralogy of Fallot with Pulmonary atresia 12.3 14.3 50 3.5 Left sided valvar disease, CoA, Marfan 10.8 14.3 50 0.6 CHD associated with cardiomyopathy 9.2 50 33.3 5.3 Other 6.9 22.2 22.2 2.2 RV: right ventricle; PAH: Pulmonary arterial hypertension; CoA: aortic coarctation.

Survival in end-stage heart failure

Conclusion

Of the small number of patients with heterogenous ACHD considered for H/HLTx in our contemporary practice, there was high overall mortality, whereas only a fraction of patients was actually transplanted. Better patient selection and timing are clearly warranted so that more ACHD patients benefit from this effective therapy.

Acknowledgement/Funding

None
95TAVI performed without systematic intensive care unit admission: an update of a single center experience
Authors: Akodad M A , Aldhaheri E A , Macia J C M , Gandet T G , Schmutz L S , Marin G M , Rivalland F R , Robert G R , Targosz F T , Maupas E M , Albat B A , Cayla G C , Leclercq F L
Published: October 2019

Background

Systematic admission to the intensive care unit (ICU) was considered as a standard of care after transcatheter aortic valve implantation (TAVI). However, regarding to improvements in procedural results, our team pointed out feasibility and safety of TAVI without ICU admission in selected patients referred in our center in 2015

Purpose

The aim of this study was to evaluate the evolution of our practice after the first study to confirm the feasibility and safety of TAVI without ICU in a large population of patients.

Methods

We evaluate prospectively 451 consecutive patients undergoing TAVI between January 2017 and december 2017. The same “low-risk” criteria were applied to this cohort of patients to allow admission to conventional cardiology unit: stable clinical state, transfemoral access, no right bundle branch block at baseline, left ventricular ejection fraction >40% and no complications occurring during the procedure. Any new conduction disturbance was considered as indication for ICU.

Results

The mean age was 81.8±7.5 years and the mean logistic Euroscore was 9.1±3.3%. The balloon-expandable Sapien 3 was used in 181 patients (40.1%) and the transfemoral route was the main vascular approach (n=412, 91.3%). According to the predefined criteria, 289 patients (64.1%) were considered at “high-risk”. In-hospital major complications occurred in 52 patients (11.5%) including 3 deaths (0.7%), 6 major vascular complications (1.3%), 1 stroke (0.2%), 7 heart failures (1.5%), 2 tamponades (0.4%), 2 ventricular perforations (0.4%) and 31 high-degree conduction disorders (6.9%) including 26 patients undergoing immediate pacemaker implantation allowing a non-ICU decision. All complications occurred in the “high-risk” group (figure) and the negative predictive value of the “low-risk” criteria to predict complications was 100%. In multivariate analysis, right bundle branch block (p<0.ehz747.00241), first degree atrioventricular block (p=0.02), low LVEF (p=0.01) were found as pre procedural predictive factors of adverse events.

ICU and non-ICU admission after TAVI

Conclusion

Our results confirm that with a rigorous selection of patients and using simple criteria, TAVI can be routinely performed without ICU admission in nearly 40% of patients with a stable proportion of patients not referred to ICU between 2015 and 2017.
124Impact of intimal tracking for recanalization of CTO lesions on long-term clinical outcomes
Authors: Kano S , Nasu K , Habara M , Shimura T , Yamamoto M , Adachi Y , Konishi H , Kodama A , Koshida R , Kinoshita Y , Tsuchikane E , Terashima M , Matsubara T , Suzuki T
Published: October 2019

Background

For recanalization of coronary chronic total occlusion (CTO) lesions, subintimal guidewire tracking in both antegrade and retrograde approaches are commonly used.

Purpose

This study aimed to assess the impact of subintimal tracking on long-term clinical outcomes after recanalization of CTO lesions.

Methods

Between January 2009 and December 2016, 474 CTO lesions (434patients) were successfully recanalized in our center. After guidewire crossing in a CTO lesion, those lesions were divided into intimal tracking group (84.6%, n=401) and subintimal tracking group (15.4%, n=73) according to intravascular ultrasound (IVUS) findings. Long-term clinical outcomes including death, target lesion revascularization (TLR), target vessel revascularization (TVR) were compared between the two groups. In addition, the rate of re-occlusion after successful revascularization was also evaluated.

Results

The median follow-up period was 4.7 years (interquartile range, 2.8–6.1). There was no significant difference of the rate of cardiac death between the two groups (intimal tracking vs. subintimal tracking: 7.0% vs. 4.1%; hazard ratio, 0.61; 95% confidence interval [CI], 0.19 to 2.00; p=0.41), TLR (14.3% vs. 16.2%; hazard ratio, 1.34; 95% CI, 0.71 to 2.53; p=0.37), and TVR (17.5% vs. 20.3%; hazard ratio, 1.27; 95% CI, 0.72 to 2.23; p=0.42). However, the rate of re-occlusion was significantly higher in the subintimal tracking group than intimal tracking group at 3-years re-occlusion (4.2% vs. 14.5%; log-rank test, p=0.002, Figure). In the multivariate COX regression, subintimal guidewire tracking was an independent predictor of re-occlusion after CTO recanalization (HR: 5.40; 95% CI: 2.11–13.80; p<0.001).

Figure 1

Conclusions

Subintimal guidewire tracking for recanalization of coronary CTO was associated with significantly higher incidence of target lesion re-occlusion during long-term follow-up period.
193Qualifying event proximity, cardiovascular risk, and benefit of empagliflozin in patients with type 2 diabetes and stable atherosclerosis in the EMPA-REG OUTCOME trial
Authors: Udell J , Zinman B , Wanner C , Von Eynatten M , George J T , Zwiener I , Lund S S , Hantel S , Fitchett D
Published: October 2019

Background

In type 2 diabetes, the temporal proximity of an atherosclerotic cardiovascular (CV) event can impact prognosis, but whether timing influences sodium glucose co-transporter 2 inhibitor effects is unknown. We explored the association of time from last qualifying CV event before randomisation (myocardial infarction [MI], stroke, coronary artery disease or peripheral arterial disease) with CV outcomes and benefit of empagliflozin (EMPA) in EMPA-REG OUTCOME.

Methods

Patients (pts) were randomised to EMPA 10 mg, 25 mg or placebo and followed for 3.1 years (median). Risk of major adverse CV events (3P MACE: CV death, MI, stroke), CV death or hospitalisation for heart failure (HHF) were evaluated using Cox regression in subgroups of ≤1/>1 year since last qualifying CV event. Qualifying event stratification was possible in 6796 (97%) pts.

Results

In the overall population, N=6796 (4547 EMPA and 2249 placebo pts), median (Q1, Q3) time from last CV event was 3.8 (1.5–7.6) years. Overall, 1214 (EMPA 841; placebo 373) and 5582 (EMPA 3706; placebo 1876) pts had a last qualifying CV event ≤1 and >1 year, respectively. Pts with more recent events had similar risk for CV outcomes compared with pts >1 year from qualifying event (Figure). Moreover, the benefit of EMPA on CV outcomes was consistent between pts enrolled ≤1 or >1 year from the qualifying CV event (all p-interaction >0.05; Figure).

Conclusion

Although most pts had a qualifying CV event >1 year before randomisation in EMPA-REG OUTCOME, the benefits of EMPA appear to extend to pts with more recent CV events.

Acknowledgement/Funding

Boehringer Ingelheim & Eli Lilly and Company Diabetes Alliance