bluuebunny/crossref_metadata_2025 huggingface dataset:
P2765Efficacy of venous recanalization by noninvasive pulsed cavitational ultrasound therapy on swine model of acute deep venous thrombosis
Authors: Khider L , Goudot G , Del Giudice C , Mirault T , Bruneval P , Galloula A , Amemiya K , Vion M , Remond M , Tanter M , Pernot M , Messas E
Published: October 2019

Background

Post thrombotic syndrome is a frequent complication of deep venous thrombosis and is associated with high morbidity and hospitalization. Treatments currently available are invasive, involve use of endovenous procedures with stents and balloons, and frequently require general anesthesia. Pulsed cavitational ultrasound therapy (PCUT) emerged recently as a new technique to destroy remotely soft tissue. We recently demonstrated that PCUT was able to recanalize non-invasively in in vitro model of acute venous thrombosis (human blood clot).

Purpose

We aim to test the safety and efficacy of venous recanalization by noninvasive PCUT in vivo swine model of acute venous thrombosis.

Methods

All the experiments were performed on White large X Landrace swine. We induced an acute femoral deep venous thrombosis by using occlusive balloons introduced from jugular and popliteal vein combined with local injection of 50 IU of human thrombin. A 3 cm length occlusive thrombosis was obtained after 2 hours. Swines were divided in three groups: one with PCUT without follow-up (n=11), one with PCUT and follow-up at 14 days (n=8), and a control group also followed for 14 days (n=5). Acutely and during the follow up all swines received curative anticoagulation. To achieve PCUT, a 2.25 MHz transducer centered by a linear probe was used and cavitation was obtained in the center of the vein (Figure). After manual determination of thrombus location, a robotic arm was used to automatically move the transducer along the thrombus. Effectiveness of recanalization was evaluated by echo-Doppler and phlebography. Safety was assessed by Doppler ultrasound of the insonified area (artery, veins and surrounding tissue) and by histological analysis (local femoral vein and artery and lungs for pulmonary embolism).

Results

Among the 24 swines, we obtained 22 occlusive venous thromboses and 2 partial. The median length of the thrombus was 26±4.4 mm with vein diameter of 8.5±1.6 mm. Acutely, thrombosis recanalization was systematically obtained among the 19 swine with PCUT with median treatment duration of 33 minutes with residual diameter of 2.9±0.9 mm. No extravasation of contrast material or hematoma was observed after the therapy. After a 14-day follow-up, 75% of recanalisation remain permeable vs. 0% of vein permeable in the no therapy group (p=0.008). Residual diameter was 2.6±1.2 mm, which correspond to 50% of the venous diameter. No vein or artery damage and no embolism or pulmonary infarction was observed in all pigs.

Figure 1

Conclusion

We have demonstrated in vivo the safety and the efficacy of PCUT for non-invasive venous recanalization, persistent after 2 weeks.

Acknowledgement/Funding

French society of cardiology
P2781How to bridge residual distance to target low-density-lipoprotein cholesterol in stroke patients after initial statin therapy?
Authors: Yan B P Y , Chan C K Y , Lai W H S , To O T L
Published: October 2019

Background

Current guidelines recommend intensive low-density-lipoprotein cholesterol (LDL-C) lowering to target LDL-C <1.8mmol/L after ischemic stroke (IS). Residual distance to LDL-C target can help select further treatment options after initial statin therapy.

Purpose

We aimed to evaluate residual distance to target LDL-C and the proportion of IS patients who are projected to reach target LDL-C by different statin and non-statin lipid lowering strategies.

Methods

We retrospectively analyzed 5,025 patients admitted with IS or transient ischemic attack who survived 1 year from an academic institution in Hong Kong between Jan 2005 and Sep 2017. Patients were divided into (i) high potency (HP-S; rosuvastatin ≥20mg, atorvastatin ≥40mg or simvastatin ≥80mg); (ii) non-high potency (NHP-S; other statin doses) statin users and (iii) no statin therapy. We calculated the mean distance and percentage LDL-C reduction required to reach target LDL-C. We assumed up-titration from NHP-S to HP-S would further reduce LDL-C by 5–15%; addition of ezetimibe 15–25%; up-titrate to HP-S plus ezetimibe 20–40% and combine statin with proprotein convertase subtilsin-kexin type 9 inhibitor (PCSK-9) 40–60%.

Results

Of 5,025 patients (56.3% males, mean age 69.1±11.5 years), 62.4% (3134/5025) had LDL-C ≥1.8mmol/L at 12-months after index stroke with 16.7% (839/5025), 80.9% (4064/5025) and 2.4% (122/5025) of patients on no statin, NHP-S and HP-S, respectively. 58.1% (2362/4064) of NHP-S and 60.7% (74/122) of HP-S users did not reach LDL-C target. Among these patients, the mean LDL-C was 2.5±0.6 and 2.8±1.0mmol/L; mean residual distance to target 0.7±0.6 and 1.0±1.0mmol/L; and mean percentage LDL-C reduction required to reach target LDL-C goal was 23.3±15.1% and 29.5±18.1%, respectively. The proportion of NHP-S users projected to reach target LDL-C is 34.9% (824/2362) by up-titrating/switching to HP-S, 57.2% (n=1352/2362) by addition of ezetimibe, 84.5% (n=1997/2362) by up-titration to HP-S plus ezetimibe and 98.6% (2330/2362) with PCSK-9 inhibitor (Figure 1). The proportion of HP-S users projected to reach target LDL-C is 43.2% (32/74) by addition of ezetimibe and 94.6% (70/74) with PCSK-9 inhibitor (Figure 1).

Conclusion

The use of high-potency statin is low and more than 50% of statin users did not reach target LDL-C at 12-months after index stroke. Combined up-titration to high-potency statin plus addition of ezetimibe is expected to bridge residual distance to target LDL-C in majority of stroke patients.

Acknowledgement/Funding

Supported in part by a research grant from Investigator-Initiated Studies Program of Merck Sharp & Dohme (Asia) Ltd.
P2782Specific air pollution indicators are related to recurrence of ischemic stroke-a nationwide cohort study with surveillance system by time-stratified case-crossover study design
Authors: Li A H , Chan C L , Wu C Y
Published: October 2019

Background and objective

Ischemic stroke (IS) is the 2nd killer in Taiwan. There was no studies of air pollution indicators (API's) in nationwide database, on their relationship to IS recurrence. We aimed to analyze the IS incidences, its recurrence risk related to API's.

Methods

We used LHID 2005 (Longitudinal Health Insurance Database 2005) from National Health Institute Research Database (NHIRD), i.e. the entire original claim data of randomly sampled 1,000,000 beneficiaries in 2005. The national API surveillance database (PM2.5, PM10, CO, SO2, NO,NO2, NOx, O3) was incorporated with it. The IS incidences was computed by obtaining 1st admission for IS (ICD9–433, 434, 435), and the recurrence was on second IS within 30 days of 1st one. To minimize the confounding effect of comorbidities, we used a time-stratified case-crossover study design, proposed by Maclure (1991), for transient effects on acute events' risk; it is characterized by that each subject serves as his or her own control according to fixed individual characteristics, such as age, gender, lifestyle, socio-economic status, genetics and physiological status, etc. The API exposure was analyzed on the re-admission date (lag0), and 1 to 6 day before re-admission (lag1, lag2 ... lag6 etc.).

Results

The IS recurrence-readmission is strongly associated with SO2 peak level 5 days before (lag5 – 95% CI: 1.011–1.023, p=0.004) for patients above 20. Significant association of IS recurrence with PM2.5, SO2 O3, SO2 is noted in different patient groups.

Table 1. Basic demographics of ischemic stroke in Taiwan (2005–2013) Ischemic stroke N % Age, mean ± SD 68.94±12.8 Male 11832 58% Other forms of chronic ischemic heart disease (ICD9–414) 1496 7% Diabetes mellitus (ICD9–250) 6679 32% Essential hypertension (ICD9–401) 9038 44% Disorders of lipoid metabolism (ICD9–272) 4142 20% Heart failure (ICD9–428) 670 3% Hypertensive heart disease (ICD9–402) 2333 11%

Figure 1. Hazard Ratio of specific API's in IS (only shown with statistical significance): those left to line 1.0 with protective effect and vice versa (20–45, 46–64 and 65 above representative meaning for age range).

Conclusion

Specific API's are strongly associated with IS recurrence. We need a prospective cohort study designed on this topic.
P2788First argentine national registry of echocardiograpphic aortic dimensions: body surface area, age and ethnicity are determinants of aortic dimensions
Authors: Carrero C , Constantin I , Benger J , Makhoul S , Baratta S , Cintora F , Lopez M C , Toldo C , Forte E , Recalde L , Ayon M , Schiavone L , Manganiello C F , Asch F M , Bagnati R
Published: October 2019

Background

Transthoracic echocardiography (TTE) remains the screening tool of choice for thoracic aorta (TA) dilatation. Differences in TA diameters (TAD) according to gender (G), age (A) and body surface area (BSA) have been previously reported. However, these reports are limited by a small sample size, different measurement sites or heterogeneous cohorts. There is scarce data on the influence of ethnicitiy on TAD. Moreover, surgery indication for TA aneurysms is still based mainly on absolute TAD with no reference to G, A or BSA.

Purpose

We designed a prospective nationwide multicenter registry to determine the normal range of TAD at all TA segments in healthy adults of both G and their correlations with A, ethnicity and BSA.

Methods

Healthy adult individuals without cardiovascular risk factors, TA aneurysm, aortic valve disease, cardiac surgery or genetic aortopathies were recruited from 53 centers in Argentina. TTEs were acquired and measured following standard protocols based on EACVI/ASE Guidelines. TAD were measured at six levels: annulus, sinuses of Valsalva, sinotubular junction, tubular ascending aorta, aortic arch and proximal descending aorta. Annulus was measured at mid-systole (inner to inner edge method) and all other at end-diastole (leading to leading edge).

Multiple linear regression models were conducted to obtain coefficients of determination (R2) and 95% prediction intervals. We defined upper normal limits (95th percentile) for 4 age categories, both G and analyzed differences according to ethnicity.

Results

The MATEAR registry included 905 healthy adult patients (mean age: 38.3±13 years, 508 women, BSA: 1.8±0.2 m2). 529 (58.4%) were caucasian and 332 (36.6%) native-american, representative of the ethnic composition of Argentine population.

Pooled data showed a positive correlation between all TAD and A or BSA (p<0.001), similar in both G. Women had smaller absolute TAD due to their lower BSA. Nomograms were obtained for 4 age categories to predict TAD from BSA with no need of G distinction. Native americans showed significatly lower absolute and indexed TAD than caucasian (p<0.01) from annulus to isthmus.

TAD differences according to ethnicity

Conclusions

While age and BSA were significant determinants of aortic dimensions at six levels, we have also detected differences in TAD according to ethnicity, suggesting normative values should also be defined for each ethnic group. We propose nomograms of indexed TAD for different age and ethnic groups without G distinction.
P2791Method for detection of blood clots in ventricular assist devices
Authors: Fuchs G , Berg N , Broman L M , Prahl Wittberg L
Published: October 2019

Background

The technical development of modern ventricular assist devices (VAD) shows continued improvement in patient outcome. VADs continue to gain increased use not only as bridge to transplant but also as a destination therapy. However, VAD therapy is associated with complications, among which thromboembolic complications are common. Better management for early detection is paramount to improve patient outcome.

Purpose

The aims of this study were to determine if the VADs under consideration may retain clots, and to assess the feasibility of early clot detection using a non-invasive technique.

Methods

Two different VADs, the HeartMate II (HMII) and HeartMate 3 (HM3) were tested in a mock loop. Clot analogs (2 cm yarn fragments) were introduced into the loop upstream to the pump. Sound and vibration of the pump was measured using two hydrophones and at the inflow and outflow of the VAD (frequency range: 0.1Hz to 180kHz). The acoustic/vibration data was analyzed concerning the spectral content.

Results

The flow at the outflow section contained a low frequency swirling component. This appeared to be the basic flow feature. However, in the presence of clot analogs, the frequency signal was amplified. For the HMII this occurred below 10Hz. Concerning the HM3 this signal was more difficult to analyze due to HM3's non-constant rotational speed. However, by using wavelet filtering, it was possible to detect the low frequency signal in the presence of clot analogs. It was also observed that clot analogs tended to accumulate at certain regions in the respective VAD. In the HM3, clot fragments remained in a stagnation region at the bottom pump. This experimental finding contradicts published washout results based on a passive scalar model.

Conclusions

These mock loop results indicated the feasibility of early detection of blood clots in VADs by analysis of the sound/vibration induced by the clot. The signal “finger-print” needed for detection may also be possible to recover under non-continuous operational rotational speed as in the HM 3.
P2802Second-generation drug-eluting stents versus coronary artery bypass surgery in patients with stable angina and an isolated lesion in the proximal left anterior descending artery
Authors: Matsoukis I , Toutouzas K , Patsa C , Anousakis-Vlachochristou N , Triantafyllou K , Kantzanou M , Drakopoulou M , Tsiamis E , Latsios G , Synetos A , Karanasos A , Petridou E , Tousoulis D
Published: October 2019

Background/Introduction

Both coronary artery bypass grafting surgery (CABG) and percutaneous coronary intervention (PCI), especially with the use of new-generation drug-eluting stents (DES), remain the most common therapeutic options of coronary artery disease, especially when the proximal segment of left anterior descending artery (pLAD) is involved. There are only a small number of studies comparing these approaches in patients with isolated lesions in LAD.

Purpose

We aim to compare the long-term outcomes of PCI with second-generation DES versus CABG surgery with left internal mammary artery, in patients with stable angina and an isolated single vessel pLAD disease.

Methods

The study population consisted of 1010 consecutive patients with stable angina and an isolated pLAD that were treated either with PCI with second generation (zotarolimus or everolimus) DES (631 patients) or with CABG surgery (379 patients). The primary endpoint was the occurrence of any major adverse cardiac event (MACE) namely cardiac death, non-fatal myocardial infarction and target lesion revascularization (using either percutaneous or surgical technique) as a composite index. Other evaluated main clinical outcomes were the components of MACE, patient-related outcome (PRO-a composite index of all-cause mortality, any myocardial infarction, any revascularization), recurrence of stable angina and arrhythmias occurrence.

Results

Lower rates of in-hospital complications (0.3% versus 12.1%, p<0.001) and shorter hospitalization [median, 1 (interquartile-range: 1–4) versus 8 (interquartile-range: 7–11), p<0.001] were recorded in the PCI group compared with the surgery arm. During the follow-up period (mean, 4.6±2.5 years), no statistical difference was observed in respect to MACE between the two study groups (10.1% versus 7.4%, p=0.14). Higher rates of repeat revascularization were detected in patients treated with PCI than those treated with CABG (5.5% versus 2.9%, p=0.05). Concerning other secondary endpoints, cardiac death (2.9% versus 3.2%, p=0.78), myocardial infarction (1.7% versus 1.3%, p=0.60), and PRO (18.9% versus 17.7%, p=0.64) did not differ in a statistically significant manner between the two techniques. Recurrence of stable angina was significantly increased in PCI (15.6% versus 8.4%, p=0.001), whereas arrhythmias occurrence was most common in the surgery group (6.3% versus 11.9%, p=0.002).

Conclusion

PCI with second-generation DES seem to have similar long-term clinical outcomes compared with CABG in patients with isolated LAD disease, highlighting the excellent long-term outcomes of both therapeutic approaches
P2810Clinical outcomes 1 year after filter protection during percutaneous coronary intervention in patients with attenuated plaque identified by intravascular ultrasound
Authors: Hibi K , Kozuma K , Sonoda S , Endo T , Tanaka H , Koshida R , Ishihara T , Kume T , Tanabe K , Morino Y , Ikari Y , Fujii K , Yamanaka T , Kimura K , Isshiki T
Published: October 2019

Background

In the VAMPIRE 3 (VAcuuM asPIration thrombus REemoval 3) trial, we have previously shown that selective use of distal filter protection during percutaneous coronary intervention (PCI) decreased the incidence of no-reflow phenomenon and was associated with fewer in-hospital serious adverse cardiac events than conventional PCI in patients with attenuated plaque ≥5mm. However, whether the early efficacy of distal embolic protection translate into long term clinical benefit is unknown.

Methods

Patients with acute coronary syndrome (ACS) with attenuated plaque ≥5mm were assigned to distal protection (DP) (n=98) or conventional treatment (CT) (n=96). The primary end point of the incidence of no-reflow phenomenon during PCI and the secondary end point of in-hospital serious adverse cardiac events has been reported previously. The rate of a major adverse events, a composite of death from any cause, non-fatal myocardial infarction, or unplanned target vessel revascularization (TVR) at 1 year was the prespecified secondary end point of the trial. All clinical endpoint events were adjudicated by an independent Clinical Event Committee.

Results

Major adverse events at 1 year occurred in 12 patients (12.2%) in the DP group and in 3 patients (3.1%) in the CT group (P=0.029). The difference was driven by a higher risk of TVR (11 [11.2%] vs. 2 [2.1%], p=0.018) in the DP group compared with the CT group. In patients treated with bare metal stents (n=42), major adverse events occurred in 25.0% of the patients in the DP group and in none of the patients in the CT group (P=0.029), whereas in patients treated with drug eluting stents (n=152), rates of major adverse events were similar between the groups (8.1% vs. 3.9%, p=0.32). Rates of cardiac death were not significantly different (1.0% vs. 1.0%, p=1.00). No definite stent thrombosis was observed in either group.

Conclusions

In the VAMPIRE 3 trial of patients with ACS with attenuated plaque ≥5mm, the 1-year rates of major adverse events in the distal protection group were higher than in the conventional treatment group. This effect could be mitigated by the use of drug eluting stents.

Acknowledgement/Funding

This work was supported in part by a grant from Nipro, Boston Scientific Corporation, and Japan Lifeline.
P2825ICD implantation in secondary prevention after an out-of-hospital cardiac arrest. Does age really matter?
Authors: Baldi E , Buratti S , Rordorf R , Vicentini A , Sanzo A , Petracci B , Demarchi A , Cornara S , Astuti M , Frigerio L , Oltrona Visconti L , De Ferrari G M , Savastano S
Published: October 2019

Background

The implantation of an implantable cardioverter defibrillator (ICD) in secondary prevention is a class I indication for patients with an estimated survival more than 1 year with a good functional status. However, in the elderly population, it is often difficult to estimate the expected survival, especially after an acute event such as an out-of-hospital cardiac arrest (OHCA).

Purpose

To evaluate 1-year survival after OHCA of patients older than 80 compared to those younger than 80.

Methods

We considered all the patients who suffered an OHCA in our Province (55ehz748.1135 inhabitants in northern Italy) from October 1st 2014 to November 30th 2017 stratified in two groups accordingly to their age at the moment of OHCA: elderly group (≥80 years old) and non-elderly group (<80 years old).

Results

In the period analysis resuscitation was attempted in 1464 OHCA patients: 632 of the elderly group (mean age of 86.4±4.4 years) and 832 of the non-elderly group (mean age of 63.4±13.8 years). The two groups were different at baseline. In the non-elderly group there were more males (74.5% vs 42.4%, p<0.001), more cases of medical etiology (95.9% vs 91.2%, p<0.001), a higher rate of bystander CPR (39.4% vs 23.4%, p<0.001) and more shockable rhythms at presentation (25.5% vs 7.9%, p<0.001), whilst a home location of the event was more frequent in the elderly group (81.3% vs 77%, p=0.048). No differences were found regarding both the percentage of not witnessed cardiac arrest (27.5% in elderly and 26% in non-elderly, p=0.57) and the time of EMS arrival (11:36 mins in elderly and 11:23 mins in young, p=0.64). Non-elderly patients showed a significantly higher rate of survival both to hospital admission (25.2% vs 6.8%, p<0.001), to hospital discharge (12.1% vs 1.7%, p<0.001) and at 1 year after the event (10.2% vs 1.6%, p<0.001, Figure 1 - left) as compared to older ones. However, when considering only those patients discharged alive we found a non-significant difference in one-year survival (84.2% vs 90.9%, p=0.64, Figure 1 – right).

Conclusions

Elderly patients have a worst prognosis in the acute phase after an OHCA. However, after hospital discharge, older and younger patients showed a similar 1-year survival. This result highlights how age should not be considered alone to decide whether an ICD in secondary prevention could be indicated or not in older OHCA survivors.
P2835Feasibility and safety of same day discharge after radiofrequency catheter ablation for paroxysmal atrial fibrillation
Authors: Rajendra A , Hunter T , Morales G , Osorio J
Published: October 2019

Background

Atrial fibrillation catheter ablation (CA) is the most frequent arrhythmia ablation and accounts for a significant proportion of treatment cost. Same day discharge (SDD) after paroxysmal atrial fibrillation (PAF) ablation is an attractive strategy for both patients and hospitals.

Objective

To understand the eligibility criteria and outcomes for PAF patients who can safely undergo same day discharge after radiofrequency catheter ablation.

Methods

Patients undergoing CA for PAF were evaluated for SDD at a pre-procedure visit to assess the risk of groin, respiratory, cardiac or bleeding complications. Eligibility criteria for SDD were stable anticoagulation and absence of bleeding history, systolic/diastolic heart failure, or interventional procedures within 60 days, with recommended BMI <35. Patient proximity to the hospital was also considered. Anesthesia included propofol with endotracheal intubation and all patients were ablated with a porous tip contact force catheter (STSF). Patients were on bed rest for 6 hours post-procedure, then ambulated intermittently for 1–2 hours. Discharge followed if they were stable with no evidence of vascular access complications or bleeding. A dedicated RN telephoned patients the following morning to ask a series of standard questions designed to elicit evidence of any complications.

Results

52 procedures were identified for SDD, with 7 patients declining. 45 planned SDD procedures for 43 patients occurred 4/17–6/18. Average age was 57±11 years and CHA2DS2-VASc was 1.5±1.1 at procedure. Procedure time was 69±26 min (IQR: 49 - 84 min) with maximum fluoroscopy usage of 0.2 min and 508±149 mL of fluid infused through the catheter. Two patients stayed overnight due a groin bleed and atelectasis with fever, and one chose to stay for comfort. The remaining 42 discharges occurred after 7.2±1.0 hours in recovery, with no SDD-related complications and no required return visits after the follow-up call. There were 3 AF recurrences (6.7%) as of the 10 week visit.

Conclusion

Appropriate low risk patients identified by simple clinical criteria can be safely discharged the same day after CA of PAF. Further evaluation is required for higher risk patients.

Acknowledgement/Funding

The study was funded by Biosense Webster Inc.
P2839The golden age of ablation: results for atypical flutter ablation in the very elderly
Authors: Lozano-Granero C , Moreno J , Matia R , Hernandez-Madrid A , Sanchez-Perez I , Zamorano J L , Franco E
Published: October 2019

Introduction

Atypical flutter ablation (AFL) is a challenging procedure with limited long-term benefits and not exempt from significant risks.

Purpose

To compare the efficacy and safety of this procedure in a population of octogenarian patients over a population of younger patients.

Methods

From 2015 to 2018, all patients in which AFL ablation was attempted were included. Activation and voltage mapping were used to define AFL circuit. Radiofrequency lesions were performed to operator's discretion until AFL termination. Programmed atrial stimulation was repeated to test inducibility, and any sustained induced arrhythmia was ablated. Follow-up included visits with ECG and/or 24h Holter-ECG at 3 and 12 months.

Results

107 patients (55 females) were included, 26 (24%) aged 80 or older (table). Successful ablation of the original circuit was achieved in 96% in both groups (acute success rate, p=0.973), with induction of other AFL circuits in 43% (46% octogenarians, 42% younger, p=0.708), successfully ablated in 88% in both groups (total success rate, p=0.952). No significant difference was detected in the rate of adverse events (8% in octogenarians versus 7% in younger, p=0.962), with a case of cardiac tamponade in the former, successfully resolved. After a mean follow-up of 11±12 months, 52 patients (49%) were free from recurrence, 13 (50%) in the octogenarian group and 39 (48%) in the younger, with an estimated median survival free from atrial arrhythmias of 26 months (95% CI: 4–48) in the octogenarian group and 18 months (95% CI: 5–32) in the younger group (p=0.716). After multivariate analysis, history of prior AF and indexed left atrial volume, but not age, predicted recurrence.

Demographical and clinical variables All patients (n=107) Octogenarians (n=26) No octogenarians (n=81) p-value Age (years) 69±13 83±3 65±11 <0.0001* Cardiomyopathy (%) 54 (50%) 13 (26%) 41 (51%) 0.956 Left ventricular ejection fraction (%) 60±13 57±17 61±11 0.24 Indexed left atrial volume (ml/m2) 45±19 48±14 43±19 0.55 Prior AF history 49 (46%) 7 (27%) 42 (52%) 0.026* Prior ablation procedures 53 (50%) 8 (31%) 45 (56%) 0.028* Prior cardiac surgery 30 (28%) 2 (8%) 28 (35%) 0.008* Left AFL origin (%) 87 (81%) 24 (92%) 63 (78%) 0.098 *Statistically significant difference.

Survival function

Conclusion

AFL ablation was as effective and safe in octogenarian as in younger ones, with a median survival time free from atrial arrhythmias of more than 2 years.
P2843Impact of bipolar vector orientation and inter-electrode spacing on electrograms during human atrial fibrillation
Authors: Linz D , Saha S , Kutieleh R , Kadhim K , Lau D , Baumert M , Sanders P
Published: October 2019

Background

In patients with atrial fibrillation (AF), local atrial bipolar electrograms (EGM) are clinically used to determine peak-to-peak voltage (Vpp), dominant frequency (DF) and Shannon Entropy (ShEn) for electroanatomical substrate characterization and substrate-based ablation. The effect of bipolar vector orientation and inter-electrode spacing on these EGM-derived measures during AF is unclear.

Methods

To quantify the impact of bipolar vector orientation and inter-electrode spacing, bipolar EGM (10,496 and 20,968 atrial sites, respectively) were reconstructed from unipolar EGM recorded with an array of 18 electrodes in 14 patients with persistent AF. We compared Vpp, DF and ShEn between any two adjacent bipolar vectors with a difference of 45 degree. Vpp, DF and ShEn values were ranked into different classes from highest to lowest value. To quantify the effect of inter-electrode spacing, bipolar EGM were constructed from electrodes spaced 4mm, 8mm, and 12mm apart, respectively.

Results

First, bipolar vector orientation significantly impacts Vpp (maximal difference: 1.341±2.169 mV vs. 0.595±0.652 mV; p<0.01) and the percentage of atrial low voltage areas (Vpp<0.05mV) (maximal difference: 62.31% vs. 32.54%). Bipolar vector orientation also influences DF (maximal difference: 8.547±2.971 Hz vs. 6.360±1.077 Hz; p<0.01) and ShEn (maximal difference: 4.898±0.488 vs. 4.120±0.650; p<0.01) measurements. Second, inter-electrode spacing affects Vppincreasing from 0.854±1.299 mV to 1.013±1.302 mV for 4mm, and 12mm, respectively (p<0.01). The percentage of atrial low voltage areas differed between 53.77% and 42.03% for 4mm and 12mm, respectively. Furthermore, inter-electrode spacing alters DF (maximal difference: 7.316±2.239 Hz vs. 7.234±2.124 Hz; p<0.01) and ShEn (maximal difference: 4.364±0.714 vs. 4.514±0.624; p<0.01) measurements.

Conclusions

Bipolar vector orientation and inter-electrode spacing both significantly affect bipolar EGM-derived measures that may result in significant uncertainty around the electroanatomical substrate characterization in AF patients, which should be considered in the development of future mapping catheter tools and algorithms.
P2851Transvenous lead placement in the setting of venous obstruction: outcomes of tunneling technique versus venoplasty
Authors: Yasin O , Kella D , Isath A , Padmanabhan D , Hodge D , Cochuyt J , Mulpuru S , Cha Y , Friedman P
Published: October 2019

Background

Venous stenosis is a well-recognized complication of transvenous leads when patients require lead revisions or device upgrade. In these cases, balloon venoplasty or alternative venous access with subcutaneous tunneling can be performed.

Purpose

Compare the outcomes of venoplasty vs. tunneling in patients requiring additional transvenous lead implantation.

Methods

A single center retrospective cohort study of all patients undergoing lead implantation/revision requiring venoplasty or tunneling from 2005–2017. Chi-squared and Wilcoxon Rank-Sum tests were used to compare categorical and continuous variables.

Results

Ninety five patients met our inclusion criteria (60 venoplasty & 35 tunneling). There was no difference in procedure success rates (p-value=0.98). Tunneling was associated with less fluoroscopy time but higher incidence of acute complications (0% vs. 23%, p-value=0.002) most requiring invasive intervention and/or blood product transfusion. Long term outcomes were comparable and related to lead failure or infection.

Outcomes for tunneling vs. venoplasty Variable Tunneling (n=35) Venoplasty (n=60) p-value Age Y 67 (23–84) 70 (29–91) 0.25 Male (%) 24 (69%) 41 (68%) 0.98 Number of existing leads 2.1 (1–4) 2.4 (0–4) 0.1 Age of oldest lead 7.0 (0–21) 7.2 (0–33) 0.73 Number of new leads 1.2 (1–3) 1.4 (1–3) 0.26 Fluoroscopy time (SD) min 29.2 (21.3) 39.7 (21.5) 0.012 Procedure success (%) 35 (100%) 55 (92%) 0.9 Acute complications (%) 8 (23%)1 0 (0%) 0.0002   Pocket hematoma/bleed 4 (11%)2   Hemothorax 2 (6%)3   Pericarditis 1 (3%)   Lead compromise 1 (3%) Follow up M 18 (0–76) 28 (0–98) N/A Long term lead issues (%) 6 (17%) 10 (17%) 0.95 Long term complication requiring intervention 4 (11%) 8 (13%) N/A Procedure success: functional lead placed as a result of venoplasty or tunneling. 1Two patients required blood products. 2Two patients required invasive intervention. 3One patient required chest tube and the other ICU admission.

Conclusions

Balloon venoplasty is associated with similar rates of success and a less incidence of acute complications when compared subcutaneous tunneling.

Acknowledgement/Funding

NIH T32 Training Grant HL07111-40
P2872Remote management of heart failure patients with the multisensor ICD alert: preliminary results from the Italian pilot experience
Authors: De Ruvo E , Capucci A , Santini L , Pecora D , Favale S , Molon G , Petracci B , Bianchi V , Cipolletta L , Calo' L , Ammirati F , La Greca C , Santobuono V E , Campari M , D'Onofrio A
Published: October 2019

Background

The HeartLogic (Boston Scientific) index combines data from multiple implantable cardioverter-defibrillator (ICD)-based sensors and has proved to be a sensitive and timely predictor of impending heart failure (HF) decompensation.

Objective

To describe a preliminary experience of remote HF management of patients who received a HeartLogic-enabled ICD or cardiac resynchronization therapy ICD (CRT-D) in clinical practice.

Methods

The HeartLogic feature was activated in 101 patients (74 male, 71±10 years, ejection fraction 30±7%). From implantation to activation (blinded phase), the HeartLogic index trend was not available, thus no clinical actions were taken in response to it. After activation (active phase), remote data reviews and patient phone contacts were performed monthly and at the time of HeartLogic alerts (when the index crossed the nominal alert threshold value of 16), to assess the patient decompensation status. In-office visits were performed when deemed necessary.

Results

During the blinded phase, the HeartLogic index crossed the threshold value 24 times (over 24 person-years, 0.99 alerts/pt-year) in 16 patients. HeartLogic alerts preceded all hospitalizations and unplanned in-office visits for HF (sensitivity: 100%, median early warning: 38 days for hospitalizations, 12 days for HF visits). No clinical events were detected during or within 30 days of recovery of 10 HeartLogic alerts (unexplained alert rate: 0.41 per patient-year). Thus, the positive predictive value was 58% (14/24). During the active phase, 44 HeartLogic alerts were reported (over 46 person-years, 0.95 alerts/pt-year) in 30 patients. 26 (59%) HeartLogic alerts were judged clinically meaningful (i.e. associated with worsening of HF and/or influenced the clinician's decision to make changes to the subject's management).

Conclusions

In this first description of the use of HeartLogic in clinical practice, the algorithm demonstrated its ability to detect gradual worsening of HF. The results of the blinded phase of our experience favorably compare with those reported in the validation study. In the active phase, the HeartLogic index provided clinically meaningful information for the remote management of HF patients.
P2876Repeating non-invasive risk stratification tests improves the prediction of outcomes of ICD patients in the EUTrigTreat study
Authors: Vandenberk B , Rover C , Dunnink A , Friede T , Flevari P , Zabel M , Willems R
Published: October 2019

Background

Non-invasive risk stratification of SCD aims to predict the risk by assessing measures of substrate (LVEF), of triggers (PVCs; T-wave alternans, TWA) and of autonomic function (heart rate turbulence, HRT). However, the value of repeating these tests during follow-up is unclear.

Purpose

To study the predictive value of repeated non-invasive risk assessment.

Methods

EUTrigTreat is a prospective trial aimed to improve non-invasive risk stratification in ICD patients. The study protocol included non-invasive testing at baseline and a repeat after 6 to 12 months. The population included ischemic and non-ischemic cardiomyopathies and arrhythmogenic heart disease. Test results were categorized as pathologic (1) versus non-pathologic (0) for LVEF ≤40%, PVCs >400 in 24h, abnormal exercise TWA (Cambridge Heart) and abnormal HRT (TO >0.1% and/or TS ≤2.0ms/RRI). Time dependent Cox regression modelling was performed for mortality, and a Fine-and- Gray competing risk analysis for shocks, including adjustment for independent predictors in the overall study population (mortality: age, LVEF, history of AF, NT-proBNP, NYHA class, eGFR; shocks: LVEF, secondary prevention).

Results

A total of 635 patients were included with a follow-up of 4.3±1.5 years, 96 (15%) received an ICD shock and 108 (17%) died. The table shows the results at baseline and with repeating the tests after 8±1 months.

Worsening of LVEF compared to a stable LVEF >40% and persistent abnormal HRT were independent predictors of mortality. Improvement in HRT was associated with a lower mortality. Worsened results upon TWA testing was associated with a 3 times higher risk of shocks. A persistent low LVEF was an independent predictor of both mortality and ICD shocks.

Baseline 1 (vs. 0) Worsening 0–1 (vs. 0–0) Improvement 1–0 (vs. 1–1) Stable 1–1 (vs. 0–0) HR (CI) HR (CI) HR (CI) HR (CI) Mortality   LVEF (n=315) 1.85 (1.06–3.24) 3.47 (1.13–10.68) 0.88 (0.40–1.94) 2.22 (1.19–4.15)   TWA (n=204) 0.62 (0.28–1.37) 0.80 (0.25–2.59) 0.67 (0.18–2.47) 0.59 (0.20–1.77)   PVC (n=329) 1.26 (0.73–2.16) 0.99 (0.36–2.72) 0.63 (0.26–1.52) 1.38 (0.75–2.55)   HRT (n=163) 2.57 (0.85–7.77) 4.01 (0.39–41.17) 0.10 (0.01–0.81) 8.71 (1.11–68.24) Shocks   LVEF (n=338) 1.73 (0.93–3.22) 0.92 (0.13–6.67) 0.26 (0.06–1.08) 2.02 (1.09–3.76)   TWA (n=256) 0.82 (0.39–1.70) 2.91 (1.04–8.13) 1.31 (0.48–3.59) 1.54 (0.54–4.43)   PVC (n=366) 1.28 (0.70–2.34) 1.48 (0.54–4.09) 0.54 (0.16–1.81) 1.70 (0.86–3.35)   HRT (n=188) 1.12 (0.50–2.50) 0.57 (0.13–2.52) 0.73 (0.20–2.64) 1.06 (0.43–2.61)

Conclusion

Repeating LVEF, TWA and HRT have the potential to improve risk stratification for mortality and shocks in ICD patients.

Acknowledgement/Funding

This research has received funding from European Community's Seventh Framework Program FP7: EUTrigTreat (grant agreement no. HEALTH-F2-2009-241526).
P2880Incidence and clinical relevance of oversensing due to extracardiac signals in subcutaneous implantable cardiac defibrillator (S-ICD)
Authors: Palacios Rubio J , Grande C , Canadas-Godoy V , Perez-Castellano N , Exposito-Pineda C
Published: October 2019

Background

S-ICD is an ICD system completely extrathoracic, composed of a generator in a left infra-axillary position and a parasternal lead. Arrhythmia detection is done by analyzing extracardiac signals registered in a dipole that is several centimeters in length, larger than in a transvenous ICD. Hence, it could potentially be more susceptible to external interference (eg. myopotentials or electromagnetic noise).

Purpose

To assess real-world incidence and clinical relevance of oversensing due to extracardiac signals (OES) in S-ICD.

Methods

Retrospective review of medical reports and remote monitoring system in two Spanish hospitals. Events were assessed by EHRA-certified specialists in cardiac devices. Differences in patients with OES were sought by univariate analysis using parametric or non-parametric methods according to sample characteristics.

Results

117 patients since October 2014 were analyzed. 88 (75,2%) men, age at implant 49,1±13,8 years. Implants were indicated mainly in primary prevention (72; 61,5%), due to ischemic cardiomyopathy (52; 44,4%), NYHA functional class I-II (107; 91,5%). 24 (20,5%) had intraventricular conduction disorders (9 right bundle branch, 2 left, 13 delayed intraventricular conduction). Electrodes implanted mostly left parasternal (107; 91,5%). On implant, gain ×1 in 90 (96,7% cases with data registered; 24 cases not registered), SmartPass activated in every device with such tool available.

Patients were followed-up for 1,9±1,2 years (maximum 4,2). 4 (3,4%) received appropriate shocks, 10 (8,5%) inappropriate: 3 OES, 3 T-wave oversensing, 3 voltage decrease (leading to SmartPass deactivation), 1 lead dysfunction. In 8 cases OES was identified (incidence 3,7 /100 patients/year): in 3 (37,5%) cases inappropriate shocks were delivered. OES occurred 1,9 (interquartile range, IQR, 0,9–2,9) years after implant. No differences in OES were found depending on sex, indication, S-ICD or lead model, lead position, intraventricular conduction disorders, detection vector at implant, number of suitable vectors at screening, tachycardia detection rate or SmartPass automatic deactivation during follow-up

In 5 cases, a cause for OES was identified: 4 myopotentials, 1 interference from electric engine. Cases were managed by changing sensing vector (3), increasing tachycardia detection rate (2), watchful waiting (2, OES source unidentified) or providing instructions to the patient (1). No OES recurrence after 0,8 years (IQR 0,6–1,1).

Example of OES

Conclusions

S-ICD has an incidence of OES of 3,7 cases /100 patients/year. OES can be successfully managed with a conservative approach.
P2881Eligibility for a subcutaneous defibrillator based on standard 12-lead electrocardiogram
Authors: Sakhi R , Theuns D A M J , Cosgun D , Michels M , Schinkel A F L , Kauling R M , Roos-Hesselink J W , Yap S C
Published: October 2019

Background

Currently, the eligibility for a subcutaneous implantable defibrillator (S-ICD) system relies on a pre-implant vector screening based on the automated screening tool (AST).

Objective

To determine 12-lead ECG characteristics associated with eligibility for an S-ICD in a heterogeneous population at risk for sudden cardiac death (SCD). The goal is to determine patient eligibility for S-ICD using the standard 12-lead ECG, thereby avoiding additional AST screening.

Methods

We prospectively evaluated the eligibility for an S-ICD in 254 consecutive patients at risk for SCD. We identified 12-lead ECG parameters which were independently associated with AST passing (≥1 vector) using multivariable logistical regression analysis in our derivation cohort. The final model was tested in a separate validation cohort.

Results

The overall passing rate was 92% in our derivation cohort. Independent 12-lead ECG characteristics associated with AST passing were QRS≤130 ms, absence of QRS/T discordance in lead II and R/T-ratio ≥3.5 in lead II (Table). Eighty-three of 254 patients (33%) fulfilled these three criteria and had a passing rate of 100%. Of the validation cohort, 37 of 60 patients (62%) fulfilled all three criteria and also had a passing rate of 100%. The interobserver agreement for applying the ECG model was 90% (Cohen's Kappa=0.80).

Table 1 Variables Univariable Multivariable OR (95% CI) P-value OR (95% CI) P-value QRS ≤130 ms 9.65 (3.66–25.43) <0.01 8.09 (2.88–22.77) <0.01 QTc ≤450 ms 3.33 (1.18–9.54) 0.02 Absence of T-wave inversion in lead I 2.74 (1.03–7.25) 0.04 Absence of T-wave inversion in lead II 3.65 (1.29–10.33) 0.02 Absence of QRS/T-wave discordance in lead II 5.05 (1.98–12.92) <0.01 4.19 (1.49–11.74) <0.01 Absence of QRS/T-wave discordance in lead aVF 3.95 (1.53–10.19) <0.01 R/T-ratio ≥3.5 in lead II 3.58 (1.27–10.01) 0.02 4.21 (1.27–13.95) 0.02 R/T-ratio ≥3.5 in lead aVF 3.16 (1.18–8.42) 0.02 OR = odds ratio; CI = confidence interval.

Figure 1

Conclusion

Using the standard 12-lead ECG, we developed a simple screening model with a high specificity for S-ICD eligibility. Our results suggest that patients who fulfill the three ECG criteria do not need additional AST-screening. Therefore, we developed a simple flowchart to determine eligibility for an S-ICD that can be easily implemented in daily clinical practice (Figure).
Acuity Is Seasonal in a Tertiary Care Burn Center
Authors: Williams Felicia N , Sljivic Sanja , Chrisco Lori , Nizamani Rabia , Cairns Bruce A , Jones Samuel W
Published: October 2019

Supply and demand dictate resource allocation in large academic institutions. Classic teaching is that burns is a seasonal specialty with winter being the “busiest” time of year. Resident allocation during the winter and summer months, however, is traditionally low due to the holidays and travel peaks. Our objective was to evaluate our acuity—defined as patient complexity—based on seasons, in order to petition for appropriate mid-level provider allocation. We performed a retrospective review of all admissions to an accredited, large academic burn center. All patients admitted between January 1, 2009 and December 31, 2018 were eligible for inclusion. Demographics, length of stay, injury characteristics, and mortality were evaluated. Thirteen thousand four hundred fifty-eight patients were admitted during this study period. Most patients were admitted during the summer. Patients admitted to the intensive care unit were more likely to be admitted in the winter, although this was not statistically significant. Winter admissions had the longest lengths of stay, and the highest incidence of inhalation injury. Female and elderly patients were more likely admitted during the winter. There was a significant difference in mortality between summer and winter seasons. Acuity is seasonal in our large academic burn center and resource allocation should align with the needs of the patients. This data may help large centers petition their institutions for more consistent experienced mid-level providers, specifically during critical seasons.
Everyday Security, Feminism, and the Continuum of Violence
Authors: Wibben Annick T R
Published: October 2019

This article returns to the original forum question “What is Global Security Studies?,” looking at it in relation to the theme of inclusion and exclusion to point out that security studies scholars exclude feminist scholarship on (everyday) security at their own peril. Showcasing the increasing body of feminist security studies scholarship, the article then highlights not only what scholarship might be included in a truly global security studies, but also the important insights (e.g., about the continuum of violence that spans peace- and wartime) that are missed without it. The article ends with a reflection on the need to also include a wider range of approaches as eminently valuable to global security studies.
The First Darwinian: Alfred Russel Wallace and the Meaning of Darwinism
Authors: Hesketh Ian
Published: October 2019

This essay is an initial study of a larger project that seeks to produce a history of the term ‘Darwinism’. While it is generally well-known that Darwinism could refer to a variety of different things in the Victorian period, from a general evolutionary naturalism to the particular theory of natural selection, very little has been written about the history of the term or how it was contested at given times and places. Building on James Moore’s 1991 sketch of the history of Darwinism in the 1860s, this paper specifically seeks to situate Alfred Russel Wallace’s 1889 book Darwinism in the context of a larger struggle over Darwin’s legacy in the 1880s. It is argued that Wallace used his authority as one of the founders of evolution by natural selection to reimagine what he called ‘pure Darwinism’ as a teleological evolutionism, one that integrated the theory of natural selection with an interpretation of spirit phenomena thereby producing a more agreeable and holistic account of life than was previously associated with Darwinian evolution. By considering the reception of Wallace’s Darwinism in the periodical press it will be argued further that Wallace’s interpretation of Darwinism was generally well received, which suggests that our understanding of what Darwinism meant in the late Victorian period needs to be revisited.
History-Dependent Risk Preferences: Evidence from Individual Choices and Implications for the Disposition Effect
Authors: Andrikogiannopoulou Angie , Papakonstantinou Filippos
Published: October 2019

Using trading data from a sports wagering market, we estimate individuals’ dynamic risk preferences within a prospect theory paradigm. This market’s experimental-like features facilitate preference estimation, and our long panel enables us to study whether preferences vary across individuals and depend on earlier outcomes. Our estimates extend support for experimental findings—mild utility curvature, moderate loss aversion, and probability overweighting of extreme outcomes—to a market setting and reveal that preferences are heterogeneous and history dependent. Applying our estimates to a portfolio choice problem, we show prospect theory can better explain the prevalence of the disposition effect than previously thought.

Authors have furnished an Internet Appendix, which is available on the Oxford University Press Web site next to the link to the final published paper online.