bluuebunny/crossref_metadata_2025 huggingface dataset:
P5617Repeatability of instantaneous wave-free ratio in comparison with fractional flow reserve
Authors: Horie T , Hoshino M , Hirano H , Kanno Y , Ohya H , Sumino Y , Hada M , Yamaguchi M , Kanaji Y , Sugiyama T , Yonetsu T , Kakuta T
Published: October 2019

Background

Instantaneous wave-free ratio (iFR) has been recently introduced as an adenosine free alternative for fractional flow reserve (FFR) to assess the functional significance of epicardial coronary stenosis. Little is known, however, regarding the repeatability and stability of iFR in comparison with FFR.

Purpose

The aim of this study was to evaluate the repeatability of iFR and compare it to that of FFR.

Methods

Patients with stable coronary artery disease who underwent physiological assessment twice within 90 days were enrolled. Repeated measurements were performed at diagnostic and therapeutic catheterization in about 70% of studied population. The remaining patients were measured twice for non-culprit lesion assessment at primary PCI and subsequent non-culprit and ischemia-documented lesion PCI. The calculation of iFRmatlab from DICOM pressure tracing data of resting state was performed using a fully automated off-line software algorithm in a blind fashion. FFR values were also measured by a fully automated algorithm in the same core laboratory by using hyperemic pressure tracing data. The repeatability of the two indices were evaluated and compared. The inter-rater agreement between iFRmatlab and FFR values of two measurements was assessed by κ coefficient. The pressure rate product during each assessment was also documented and evaluated.

Results

Ninety-three lesions from 92 patients were included in the study. The time interval between the two assessments was 38.4±19.0 days. iFRmatlab and FFR both showed significant correlation within the two assessments (iFRmatlab: r=0.75, 95% confidence interval, 0.64 to 0.83; mean difference, −0.006 [−0.18 to −0.01], FFR: r=0.86, 95% confidence interval, 0.79 to 0.90; mean difference, 0.004 [−0.07 to 0.03]). The inter-rater agreement of functional ischemia for iFRmatlab and FFR were κ=0.449 and κ=0.732, respectively. Although the prevalence of functional ischemia during the first and second assessment were consistent for both indices (iFRmatlab: 70.0%/67.7%, FFR: 86.0%/ 86.0%), significant difference was observed in the prevalence of clinical disagreement on the diagnosis of functional ischemia (FFR=0.80, iFR=0.89 used as cut-off values, respectively) between the first and second assessment among the two indices (iFRmatlab: 6.5%, FFR: 23.7%, p=0.002). iFRmatlab was significantly associated with pressure rate product during the examination compared to FFR (iFRmatlab: r= −0.25, 95% confidence interval, −0.43 to −0.04, P=0.018, FFR: r=−0.08, 95% confidence interval, −0.28 to −0.13, p=0.467).

Conclusion

Our results suggested that iFRmatlab showed lower repeatability and reliability for decision making compared to FFR. The instability of iFRmatlab potentially derives at least in part from its association with heart rate and blood pressure product.
P5622Clinical significance of late-acquired malapposition observed by serial optical coherence tomography after second-generation drug eluting stents
Authors: Nakamura T , Yonetsu T , Nakao M , Nakagama S , Niida T , Matsuda Y , Hirasawa K , Hatano Y , Sasaoka T , Umemoto T , Lee T
Published: October 2019

Background

Previous studies have demonstrated that the presence of late-acquired stent malapposition after stent implantation may be a risk of late and very late stent thrombosis and myocardial infarction, which is however still controversial.

Purpose

We sought to investigate the incidence and prognosis of late acquired stent malapposion after second-generation drug eluting stents (2G-DES) implantation.

Methods

A total of 199 lesions in 139 patients who underwent optical coherence tomography (OCT) at both immediately after implantation (Baseline) and 6–12 months after 2G-DES implantation (follow-up) were investigated. We excluded lesions with stent failure before follow-up examination. We evaluated presence or absence of malapposed strut at 1mm interval of OCT images and stents with one or more cross-sections with >30% malapposed strut was defined as stents with malapposition (MP), otherwise well-apposed (WA). We divided the lesions into 4 groups according to the presence of malapposition at baseline and follow-up; WA and WA, persistent well-apposed; MP and WA, resoloved malapposition; WA and MP, late acquired malapposition (LAMP); and MP and MP, persistent malapposition. We compared the target lesion failure (TLF) rate after follow-up examination among 4 groups with Kaplan–Meier analysis.

Results

Median follow-up period was 469 (IQR 71–1416) days. follow-up OCT examination was performed at median 9 months (IQR 7.6–10.5). There were no significant differences in patient's and procedural characteristics among the 4 groups. TLF rate in LAMP group was 12.0% and Kaplan–Meier analysis showed no significant differences among the 4 groups in TLF rate.

TLF-free suvival curves (Kaplan-Meier)

Conclusion

LAMP was observed by OCT at 6–12 months in 12.0% of lesions after 2G-DES implantation, which was not associated with TLF at 5 years.
P5627Automated detection of calcified plaques in coronary optical coherence tomography images using image segmentation based on machine learning
Authors: Gangl C , Roth C , Dalos D , Delle-Karth G , Neunteufl T , Berger R
Published: October 2019

Background and aim

Automated image recognition based on machine learning methods was proven to be feasible in several medical imaging applications recently. Beside image classification methods to categorize input images for example into healthy or suspicious, image segmentation allows accurate localization of pathologies and thereby facilitates a wide area of applications. Because of the unique composition of every machine learning problem the applicability of image segmentation methods for detecting coronary pathologies in optical coherence tomography images remains unclear. Furthermore, the prediction accuracy of deep learning methods usually depends on vast amounts of training data which are often not available for particular medical questions. Therefore special strategies need to be applied to achieve satisfying results with smaller training datasets. We aimed to investigate the applicability of machine learning methods for plaque detection in coronary OCT images, especially considering the challenge of a small training dataset.

Methods

Originating from a dataset of 104 OCT frames containing calcified plaques, we performed image preprocessing using a custom build OCT image processing software to crop the luminal part as well as the areas outside the circular OCT signal to reduce entropy. Furthermore, plaques were identified and marked by an experienced OCT analyst, drawing plaque-enclosing polygonal masks using the same software. We also performed common image augmentation strategies, primarily applying rotation and zoom operations. Subsequently, we split the samples randomly into training, validation and test datasets (80:10:10%). To train the segmentation model, we fed the training and validation samples into an U-Net Convolutional Neuronal Network implementation with domain-specific adaptions using the RMSprop optimizer based on the publicly available PyTorch library.

Results

After 50 training epochs, we could achieve a prediction accuracy of 74.4% with the current configuration measured by the Sørensen–Dice coefficient comparing the similarity of the predicted plaque masks with the ground truth samples (figure 1 illustrates an exemplary comparison between predicted and ground truth plaque masks).

Exemplary projection of a predicted mask

Conclusion

We were able to show that image segmentation based on machine learning strategies is a feasible way for automated plaque detection in coronary OCT imaging even based on small training datasets. Larger training datasets are necessary to raise prediction accuracy.
P5631The impact of plaque type on strut embedment/protrusion and shear stress distribution in bioresorbable scaffold
Authors: Tenekecioglu E , Torii R , Katagiri Y , Dijkstra J , Modolo R , Pekkan K , Bourantas C , Serruys P W
Published: October 2019

Background and aim

Scaffold design and plaque characteristics influence implantation outcomes and local flow dynamics in treated coronary segments. Our aim is to assess the impact of strut embedment/protrusion of bioresorbable scaffold on local shear stress distribution in different atherosclerotic plaque types.

Method

Fifteen Absorb everolimus-eluting Bioresorbable Vascular Scaffolds were implanted in human epicardial coronary arteries. Optical coherence tomography (OCT) was performed post-scaffold implantation and strut embedment/protrusion were analyzed using a dedicated software. OCT data was fused with angiography to reconstruct three-dimensional coronary anatomy. Blood flow simulation was performed and wall shear stress (WSS) was estimated in each scaffolded surface and the relationship between strut embedment/protrusion and WSS was evaluated.

Results

There were 9083 struts analysed. Ninety-seven percent of the struts (n=8840) were well apposed and 243 (3%) were malapposed. At cross-section level (n=1289), strut embedment was significantly increased in fibroatheromatous plaques (76±48μm) and decreased in fibro-calcific plaques (35±52 μm). Compatible with strut embedment, WSS was significantly higher in lipid-rich fibroatheromatous plaques (1.50±0.81Pa), whereas significantly decreased in fibro-calcified plaques (1.05±0.91Pa). After categorization of WSS as low (<1.0 Pa) and normal/high WSS (≥1.0 Pa), the percent of low-WSS in the plaque subgroups were 30.1%, 31.1%, 25.4% and 36.2% for non-diseased vessel wall, fibrous plaque, fibro-atheromatous plaque and fibro-calcific plaque, respectively (p-overall<0.001).

Table 1. Cross-section level Embedment/Protrusion and WSS according to the plaque type Plaque type Embedment depth (μm) Protrusion distance (μm) WSS (Pa) Non-atherosclerotic intimal thickening/normal vessel wall (n=2275) 47±34*Δ¥ 123±34¶Ξπ 1.44±0.9θ§£ Fibrous (n=4191) 53±40*#& 118±38¶Ψ‡ 1.24±0.78αθ∞ Fibroatheromatous (n=2027) 76±48#ΦΔ 94.6±46Ω†Ψπ 1.50±0.81Σ§α Fibro-calcific (n=590) 35±52&Φ¥ 139±50‡†Ξ 1.05±0.91∞£Σ For embedment: *p=0.09, #p<0.001, &p<0.001, Φp<0.0001, Δp<0.0001, ¥p<0.0001. For protrusion: ¶p=0.74, Ξp<0.0001, πp<0.0001, Ψp<0.0001, ‡p<0.0001, †p<0.0001. For WSS: θp<0.001, §p=0.06, £p<0.0001, αp<0.0001, ∞p<0.0001, Ωp<0.0001. n=total strut number in each plaque type, p-values come from mixed-effects regression analysis.

Conclusion

The composition of the underlying plaque influences strut embedment which seems to have effect on WSS. The struts deeply embedded in lipid-rich fibroatheromas plaques resulted in higher WSS compared to the other plaque types.
P5632Different impact of lesion length on fractional flow reserve in intermediate coronary lesions between each coronary artery
Authors: Shibutani H , Fujii K , Matsumura K , Otagaki M , Morishita S , Bando K , Motohiro M , Umemura S , Sugita H , Tanaka M , Shiojima I
Published: October 2019

Background

Previous studies reported that lesion length was an important geometric parameter in addition to the degree of stenosis in the determinant of functional significance of coronary artery stenosis. Nevertheless, the optimal cutoff value of lesion length for predicting functional significance for each coronary artery has not yet been evaluated, though previous studies revealed that the cutoff value of minimum lumen diameter measured on coronary angiography (CAG) to predict fractional flow reserve (FFR) <0.80 is different for each coronary artery

Purpose

This study evaluated whether the impact of lesion length on functional significance is similar between each coronary artery for lesions with intermediate stenosis.

Methods

Patients with suspected coronary artery disease who had at least one intermediate coronary lesion (luminal diameter stenosis of 70 to 80% by visual estimation on CAG) and underwent FFR measurement for the evaluation of myocardial ischemia were evaluated. Quantitative coronary angiography analysis including percent diameter stenosis and lesion length was performed. FFR was measured as the ratio of the mean distal coronary artery pressure to the mean aortic pressure during maximal hyperemia induced by intravenous infusion of adenosine triphosphate (150 μg /kg/min). The area under the receiver operating characteristics (ROC) curve was estimated for the best cutoff value as a predictor of FFR value of ≤0.80 for each coronary artery.

Results

A total of 221 de novo lesions that underwent FFR measurement were enrolled. The average FFR value was 0.81±0.07. Although lesion length was similar among the lesions with an FFR >0.80 at different locations, the mean lesion length was significantly longer for lesions in the right coronary artery (RCA) with an FFR ≤0.80 than for those in the left anterior descending artery (LAD) and left circumflex artery (13.4±3.4 versus 8.6±3.1 versus 12.0±3.7 mm, p<0.001). ROC analysis demonstrated that the optimal cutoff value of lesion length for predicting an FFR ≤0.80 was 10.0 mm in the LAD (0.56 area under the curve, 48% sensitivity, 76% specificity), whereas 13.1 mm in the RCA (0.84 area under the curve, 67% sensitivity, 93% specificity) (Figure).

ROC analysis of LL for FFR≤0.80

Conclusions

A longer lesion length is required to achieve FFR<0.80 in the RCA than in the other arteries. This may suggest the low possibility of an FFR ≤0.80 when stenosis is focal and short in the RCA with stenosis of 70 to 80% by visual estimation on CAG.
P5639Risk stratification for mortality using electrocardiographic markers based on 24-hour holter recordings: the JANIES-SHD study
Authors: Kinoshita T , Hashimoto K , Yoshioka K , Miwa Y , Yodogawa K , Watanabe E , Nakamura K , Nakagawa M , Nakamura K , Watanabe T , Yusu S , Tachibana M , Nakahara S , Mizumaki K , Ikeda T
Published: October 2019

Background

Recent guidelines have stated that reduced left ventricular ejection fraction (LVEF) is the gold standard marker for identifying patients at risk for cardiac mortality. Although reduced LVEF identifies patients at an increased risk of cardiac arrest, sudden cardiac deaths (SCDs) occur considerably more often in patients with relatively preserved LVEF. Current guidelines on SCD risk stratification do not adequately cover this general population pool. Several noninvasive electrocardiographic (ECG) risk stratifiers that reflect depolarization abnormality, repolarization abnormality, and autonomic imbalance have been evaluated so far. With current therapeutic advances using new medicines or devices, an LVEF is often preserved in patients with structural heart disease (SHD). However, the usefulness of noninvasive ECG markers for risk stratification in such a patient population has not yet been elucidated.

Purpose

This study aimed to assess clinical indices and ECG markers based on 24-hour Holter ECG recordings for predicting cardiac mortality in patients with SHD who have left ventricular dysfunction (LVD) but relatively preserved LVEF.

Methods

In total, 1,829 patients were enrolled into the Japanese Multicenter Observational Prospective Study (JANIES study). In this study, we analyzed data of 719 patients (569 men, age 64±13 years) with SHD including mainly ischemic heart disease (65.8%). As ECG markers based on 24-hour Holter recordings, nonsustained ventricular tachycardia (NSVT), ventricular late potentials, and heart rate turbulence (HRT) were assessed. The primary endpoint was all-cause mortality, and the secondary endpoint was fatal arrhythmic events.

Results

During a mean follow-up of 21±11 months, all-cause mortality was eventually observed in 39 patients (5.4%). Among those patients, 32 patients (82%) suffered from cardiac causes such as heart failure and arrhythmia. Multivariate Cox regression analysis showed that after adjustment for age and LVEF, documented NSVT (hazard ratio=2.82, 95% confidence interval [CI]: 1.38–5.76, P=0.005) and abnormal HRT (hazard ratio=2.31, 95% CI: 1.15–4.65, P=0.02) were significantly associated with the primary endpoint. These two ECG markers also had significant predictive values with the secondary endpoint. The combined assessment documented NSVT and abnormal HRT improved predictive accuracy.

Conclusion

This study demonstrated that combined assessment of documented NSVT and abnormal HRT based on 24-hour Holter ECG recordings are recommended for predicting future serious events in SHD patients who have relatively preserved LVEF.

Acknowledgement/Funding

Grants-in-Aid (21590909, 24591074, and 15K09103 to T.I.) for Scientific Research from the Ministry of Education, Culture, Sports, Science, and Technol
P5645Lifetime sex-specific sudden cardiac death prediction using ECG global electrical heterogeneity: the atherosclerosis risk in communities (ARIC) study
Authors: Howell S , Perez-Alday E , German D , Bender A , Rogovoy N , Haq K , Tereshchenko L
Published: October 2019

Background

Sex-based differences in sudden cardiac death (SCD) exist and screening methods for SCD are inadequate.

Purpose

To develop sex-specific lifetime risk prediction models using electrocardiographic (ECG) global electrical heterogeneity (GEH) and clinical characteristics.

Methods

Participants from the Atherosclerosis Risk in Communities study with analyzable ECGs (n=14,725; age, 54.2±5.8 yrs; 55% female, 74% white) were followed up for 24.4 years (median). Traditional ECG and GEH variables were measured on 12-lead ECGs. A Cox regression model was used to develop a prediction model. In women, the final model included race, age, coronary heart disease (CHD), stroke, hypertension, diabetes, smoking, high-density lipoprotein, albumin, uric acid, education level, heart rate, QTc, sum absolute QRST integral, spatial peak QRS-T angle. In men, the final prediction model included age, race, CHD, stroke, hypertension, diabetes, total cholesterol, physical activity, smoking, serum phosphorus, albumin, chronic kidney disease, spatial area QRS-T angle, area spatial ventricular gradient (SVG) elevation and magnitude, and peak SVG magnitude.

Results

There were a total of 530 SCDs. Our prediction models showed robust prediction of SCD in both sexes [(Harrell's C-statistic women 0.863 (95% CI 0.845–0.882), men 0.786 (95% CI 0.786–0.803)]. In women when ECG and GEH variables were added to clinical variables, the net reclassification improved by 9% (P=0.001) (Table). In men there was no significant reclassification improvement.

Net reclassification Lifetime SCD Risk: Clinical + ECG + GEH Variables Women Men <5% 5–15% >15% Total <5% 5–15% >15% Total SCD Cases <5% 82 14 0 96 103 16 0 119 5–15% 7 59 10 76 12 116 12 140 >15% 0 0 20 20 0 5 74 79 Lifetime SCD Risk: Total 89 73 30 192 115 137 86 338 Clinical Variables Only Non-Cases <5% 6,956 131 2 7,089 4,411 264 0 4,675 5–15% 180 509 42 731 210 1,059 48 1,317 >15% 0 28 84 112 0 56 214 270 Total 7,136 668 128 7,932 4,621 1,379 262 6,262

Conclusions

We were the first to develop sex-specific lifetime SCD prediction models. The addition of ECG GEH to clinical variables improved SCD risk reclassification in women, but not in men. Prediction of SCD was more accurate in women as compared to men.
P5646Risk factor paradox in STEMI-related sudden cardiac arrest
Authors: Karam N , Bataille S , Marijon E , Loyeau A , Tafflet M , Lamhaut L , Pires V , Boche T , Dupas F , Le Bail G , Allonneau A , Juliard J M , Lapostolle F , Lambert Y , Jouven X
Published: October 2019

Background

Cardiovascular risk factors (CVRF) are associated with an increased risk of atherosclerosis and ST-segment elevation myocardial infarction (STEMI). Sudden cardiac arrest (SCA) is currently the most feared complication of STEMI. The impact of CVRF on the rate of SCA is still unknown.

Purpose

To assess the association between CVRF and pre-hospital SCA during acute STEMI.

Methods

Data were taken between 2006 and 2014 from the e-MUST study that enrolls all STEMI managed by EMS in the Greater Paris Area, including those dead before hospital admission. Characteristics of patients who presented SCA were compared to those of patients who did not, and multivariable logistic regression was developed including all variables that differed between the two groups, in order to identify characteristics associated with an increased risk of SCA.

Results

Over the study period, 13,253 STEMI patients were included (median age 60.1 [51.4 - 73.0], 78.1% males). Among them, 7,513 patients (58.1%) had ≥2 CVRF, 3,979 (30.8%) had 1 CVRF, and 1,432 (11.1%) did not present any CVRF. Pre-hospital SCA witnessed by emergency medical services occurred in 749 (5.6%) patients. SCA victims were younger compared to the non-SCA group (58.0 vs. 60.3 years (P<0.001), with a higher proportion of patients without known CVRF (17.2 vs. 10.7%, P<0.001). There was no statistical difference in sex ratio (77.5% vs. 78.2%, P=0.69) and presence of past history of coronary artery disease (18.7% vs. 19.5%, P=0.56). Patients with ≥2 CVRF had the lowest rate of SCA (4.6%), while the highest SCA rate occurred among patients without CVRF (8.9%). On multivariate analysis, the presence of ≥2 CVRF was associated with a twice-lower risk of SCA (OR 0.52, 95% CI 0.41–0.65, P<0.001, when the group without risk factors was taken as a reference group).

Conclusion

The prevalence of CVRF is high among patients presenting STEMI. However, once STEMI has occurred, presence of CVRF is associated with a lower rate of SCA per STEMI, creating a risk factor paradox in STEMI-related SCA.
P5650Improvement in ejection fraction predicts heart failure after catheter ablation for atrial fibrillation in patients with left ventricular systolic dysfunction: from the KPAF registry
Authors: Fujimoto H , Doi N , Hirai K , Naito M , Shizuta S , Kobori A , Inoue K , Kaitani K , Kurotobi T , Morishima I , Satomi K , Yamaji H , Nakazawa Y , Kusano K , Kimura T
Published: October 2019

Introduction

The presence of atrial fibrillation (AF) in patients with reduced left ventricular ejection fraction (LVEF) is associated with increased risks of mortality and hospitalization for heart failure (HF). Although prior studies reported that catheter ablation (CA) for AF in low LVEF patients reduced risks of all-cause mortality and HF hospitalization, the predictors of worsening HF after ablation has not been adequately evaluated.

Purpose

The purpose of this study was to investigate the impact of improvement in LVEF after AF ablation on the incidence of subsequent HF hospitalization in patients with low LVEF.

Methods

The Kansai Plus Atrial Fibrillation (KPAF) Registry is a multicenter registry enrolling 5,013 consecutive patients undergoing first-time ablation for AF. The current study population consisted of 1,031 patients with reduced LVEF of <60%. We divided the study population into 3 groups according to LVEF at follow-up; 678 patients (65.8%) with improved LVEF (≥5 U change in LVEF), 288 patients (27.9%) with unchanged LVEF (−5 U ≤ change in LVEF <5 U) and 65 patients (6.3%) with worsened LVEF (<−5 U change in LVEF).

Results

During the median follow-up of 1067 [879–1226] days, patients improved LVEF had lower rate of HF hospitalization, compared with those with unchanged and worsened LVEF (2.1%, 8.0%, and 21.5%, respectively, P<0.0001). Recurrent atrial tachyarrhythmias were documented in 43.5%, 47.2% and 67.7%, respectively (P=0.0008).

Figure 1

Conclusion

Among patients with reduced LVEF undergoing AF ablation, patients with subsequently improved LVEF in association with maintained sinus rhythm had markedly lower risk of HF hospitalization during follow-up as compared with those with unchanged or worsened LVEF.
P5653Atrial fibrillation in arrhythmogenic right ventricular cardiomyopathy and its association with left atrial volume index
Authors: Baturova M A , Svensson A , Svendsen J H , Bundgaard H , Carlson J , Meurling C , Astrom Aneq M , Platonov P G
Published: October 2019

Background

Recent studies in arrhythmogenic right ventricular cardiomyopathy (ARVC) support atrial involvement in the disease progression and consider atrial fibrillation (AF) as one of the primary manifestations of ARVC. We aimed to assess clinical factors, components of 2010 Task Force criteria (TFC2010) and echocardiographic characteristics of atria associated with AF in the Scandinavian cohort of ARVC patients.

Methods

Study sample comprised of 106 definite ARVC patients by TFC2010 from three tertiary care centers participating in the Nordic ARVC Registry (33% females, median age at ARVC diagnosis 41 years [IQR 30–54 years]). No concomitant diseases were observed in 90 patients (85%) while 16 patients had one or more comorbidities: hypertension (n=6), diabetes mellitus (n=5), coronary artery disease (n=5) or congestive heart failure (n=9). AF was included in the registry protocol as a pre-specified clinical event and verified by processing of the electronic ECG databases which contains all ECG recordings from the involved hospitals catchment areas (earliest ECG from 1988). Left (LA) and right atrial (RA) dimensions were obtained by revisiting cardiac ultrasound examinations performed at the time of ARVC diagnosis. Association between AF and clinical characteristics was assessed using multivariable logistic regression analysis adjusted for age and gender.

Results

AF was diagnosed in 29 patients (27%) at a median age of 53 (IQR 38–63) years, 7 females (24%). Median time from ARVC diagnosis to AF onset was 8 (IQR 2–12) years. AF was univariately associated with right ventricular structural abnormalities meeting the definition of major imaging criterion by 2010TFC, ventricular tachycardia (VT) with superior axis (major criterion) and LA volume index. Significantly associated variables were included in a multivariate model, in which LA volume index (OR=1.07, 95% CI 1.01–1.14, p=0.021) and superior axis VT (OR=7.45, 95% CI 1.82–30.55, p=0.005) remained independently associated with AF. In receiver operating characteristic (ROC) curve analysis, LA volume index was significantly associated with AF (AUC=0.703, p=0.005) and with superior axis VT (AUC=0.703, p=0.021). AF was not associated with either RA volume index (univariate OR=1.03, 95% CI 0.99–1.06, p=0.203) or left ventricular ejection fraction (OR=0.97, 95% CI 0.92–1.03, p=0.299).

Conclusion

In patients with ARVC,AF is primarily associated with LA structural abnormalities without indication of RA involvement and is strongly associated with ventricular arrhythmias thus indicating parallel development of atrial and ventricular arrhythmic substrate.
P5656Heart failure clinical phenotypes and outcomes in patients with atrial fibrillation: an analysis from the eurobservational research programme in atrial fibrillation long-term general registry
Authors: Proietti M , Laroche C , Tello-Montoliu A , Lenarczyk R , Dan G A , Maggioni A P , Lip G Y H , Boriani G
Published: October 2019

Introduction

Heart failure (HF) is a well-known risk factor for atrial fibrillation (AF). Moreover, HF is associated with worse clinical outcomes in patients with known AF. Recently, phenotypes of HF have been redefined according to the level of ejection fraction (EF). New data are needed to understand if a differential risk for outcomes exists according to the new phenotypes' definitions.

Purpose

To evaluate the risk of major adverse outcomes in patients with AF and HF according to HF clinical phenotypes.

Methods

We performed a subgroup analysis of AF patients enrolled in the EORP-AF Long-Term General Registry with a history of HF at baseline, available EF and follow-up data. Patients were categorized as follows: i) EF<40%, i.e. HF reduced EF [HFrEF]; ii) EF 40–49%, i.e. HF mid-range EF [HFmrEF]; iii) EF ≥50%, i.e. HF preserved EF [HFpEF]. Any thromboembolic event (TE)/acute coronary syndrome (ACS)/cardiovascular (CV) death, CV death and all-cause death were recorded.

Results

A total of 3409 patients were included in this analysis: of these, 907 (26.6%) had HFrEF, 779 (22.9%) had HFmrEF and 1723 (50.5%) had HFpEF. An increasing proportion with CHA2DS2-VASc ≥2 was found across the three groups: 90.4% in HFrEF, 94.6% in HFmrEF and 97.3% in HFpEF (p<0.001), while lower proportions of HAS-BLED ≥3 were seen (28.0% in HFrEF, 26.3% in HFmrEF and 23.6% in HFpEF, p=0.035). At discharge patients with HFpEF were less likely treated with antiplatelet drugs (22.0%) compared to other classes and were less prescribed with vitamin K antagonists (VKA) (57.0%) and with any oral anticoagulant (OAC) (85.7%). No differences were found in terms of non-vitamin K antagonist oral anticoagulant use. At 1-year follow-up, a progressively lower rate for all study outcomes (all p<0.001), with an increasing cumulative survival, was found across the three groups, with patients with HFpEF having better survival (all p<0.0001 for Kaplan-Meier curves). After full adjustment, Cox regression analysis showed that compared to HFrEF, HFmrEF and HFpEF were associated with risk of all study outcomes (Table).

Cox Regression Analysis HR (95% CI) Any TE/ACS/CV Death CV Death All-Cause Death HFmrEF 0.65 (0.49–0.86) 0.53 (0.38–0.74) 0.55 (0.41–0.74) HFpEF 0.50 (0.39–0.64) 0.42 (0.31–0.56) 0.45 (0.35–0.59) ACS = Acute Coronary Syndrome; CI = Confidence Interval; CV = Cardiovascular; EF = Ejection Fraction; HF = Heart Failure; HR = Hazard Ratio.

Conclusions

In this cohort of AF patients with HF, HFpEF was the most common phenotype, being associated with a profile related to an increased thromboembolic risk. Compared to HFrEF, both HFmrEF and HFpEF were associated with a lower risk of all major adverse outcomes in AF patients.
P5664Trends in incidence and mortality from atrial fibrillation across europe, 1990 - 2017
Authors: Al-Khayatt B , Salciccioli J , Marshall D , Shalhoub J , Sikkel M
Published: October 2019

Background

Atrial fibrillation (AF) is one of the most common arrhythmias found in the general population, carrying risk of associated cardiovascular and cerebrovascular complications, and presenting a significant global health burden. Better understanding of its epidemiology may have public health implications.

Purpose

To describe trends in AF incidence and mortality throughout Europe from 1990 to 2017.

Methods

We performed a temporal analysis of data deposited in the Global Burden of Disease Study Database for countries across the European Union. We extracted age-standardised incidence and age-standardised death rates from the database and graphically inspected the data, as well as summarised the changes in trends using percentage change from the beginning of the observation period (1990) to the end of the observation period (2017).

Results

A total of 24 member states were included. In 1990, the overall median male incidence and mortality from AF were 81.4 cases per 100,000 and 5.0 deaths per 100,000 respectively. The corresponding female median incidence and mortality in 1990 were 66.3 cases per 100,000 and 7.3 deaths per 100,000 respectively. Mortality rates in 2017 were highest in Sweden and Germany. There was an increasing trend in all countries between 1990 and 2017 for both incidence and mortality. For men, the countries with the greatest percentage increases in incidence were Slovenia (+77%) and Poland (+71%). For women, the greatest increases in AF incidence were in Poland (+58%) and Estonia (+48%). The greatest percentage increases in AF related mortality were, in men, Estonia (+195%) and Sweden (+145%), and, in women, Greece (+151%) and Bulgaria (+147%).

Conclusion

AF represents a significant health burden in an aging population; general increases in incidence rates may suggest improvement in detection throughout Europe. However, AF associated mortality is more pronounced in Western Europe.
P5667A clinical risk score for predicting incident atrial fibrillation in Asians: derivation in 7,220,654 Taiwan subjects with 438,930 incident atrial fibrillation
Authors: Chao T F , Chen S A
Published: October 2019

Background

The patient number of atrial fibrillation (AF) is continuously increasing all over the world. No risk score for predicting incident AF has been specifically developed using a nationwide dataset for Asians. Our aim was to investigate risk factors for incident AF in Asians and to combine them to develop a clinical risk scheme.

Method

From January 1st 2000 to December 31st 2000, 7,220,654 subjects aged >40 years without past history of cardiac arrhythmia were identified from the Taiwan National Health Insurance Research Database. Cox regression analysis was performed to identify significant clinical predictors of incident AF which were then incorporated together to develop a scoring scheme.

Results

During a follow up of 16 years, 438,930 patients experienced incident AF. The significant predictors and the calculation rule of the scoring scheme are shown in Figure A. The score ranged from −3 to 25, and the risk of incident AF ranged from 0.06%/year for patients with a score −3 to 7.99%/year for those with a score >19. The AUC in the prediction of 1-year risk of incident AF was 0.86 and was 0.75 for 16-year risk of AF (Figure B), which was higher than that of CHADS2, CHA2DS2-VASc and C2HEST scores.

Conclusion

A clinical risk score has been developed based on a large nationwide database which could be used to identify patients at a high risk of incident AF.
P5671Risk factors associated with recurrence of syncopal episodes in patients admitted to a syncope care unit
Authors: Camiletti A , Ferreira De Souza O F S , Bronchtein A I C B , Oliveira Junior N A O J , Pinheiro M V T P , Abufaiad B A , Rangel R A L R , Nascimento E M , Pereira B B , Oliveira G M M
Published: October 2019

Introduction

Recurrent syncope takes a serious toll on quality of life, being compared to chronic diseases, particularly on the elderly.

Objectives

Identify recurrence predictors in patients treated attended at syncope units (SU).

Method

Study involving patients attended at SUs in the emergency care units of 11 hospitals over the period from May 2015 to July 2017. The SUs were provided around-the-clock dedicated phone support by specialists and a set of standardized protocols (SP) for diagnostic guidance and risk stratification based on current guidelines. In our statistical analysis, we implemented the parametric model for logistic regression (LR) and the non-parametric classification tree (CART) model. All 45 SP variables were included and subsequently selected through the use of elastic net regularization. In the LR, we considered significances of 5 and 10% for the recurrence outcome. These final variables were used to develop the classification trees (CART).

Results

We observed 1189, the majority of them (57.4%) were woman and the average age was 59 years old, with a wide range of variation (14–103). Cardiovascular and neurological diseases, as well as diabetes were more prevalent in men. The cause of syncopal episodes were diagnosticated in 81.1% of the patients, being reflex syncope the most common finding (59.4%). Episodes of recurrence were reported by 45.8%, with women representing 62.9% of this group, and 54.7% of them were younger than 59. In describing symptoms, 18.0% reported trauma associated with syncope, 38.2% showed no trigger incidents and 27.0% showed no prodromal symptoms. Women showed more prodromal symptoms, particularly dizziness, blurry vision, nausea and excessive sweating. In the variable analysis process, the LR highlighted: gender, diastolic blood pressure (DBP) and the incidence of: excessive sweating, blurry vision, palpitations, neurological diseases, changes in the conduction system detected by electrocardiogram and pacemakers (PM) as risk factors for recurrence. The CART classified the most relevant among these factors: age, DBP, sweating, blurry vision, neurological diseases and PM. Following the CART, it was detected that in female patients with signs of excessive sweating and normal DBP, the chance of recurrence was 59.6%, and when DBP ≤60 mmHg, that probability rose to 94.4%. In male patients with neurological diseases, the probability was 59%, but the chance of recurrence rose to 80% in patients with PM, even without concurrent neurological diseases.

Conclusion

The SUs and use of the SP allowed for the identification of high-risk patients and factors associated with higher probability of recurrence, improving overall approach towards syncope treatment.

Acknowledgement/Funding

OWN FINANCIAL SUPPORT
P5676Implementing a syncope pathway
Authors: Saurer G , Mezler-Andelberg M , Weihs W
Published: October 2019

Background

Syncope is a common presenting symptom in emergency departments (0.8–2.4%) and is associated with high health care costs. In up to 40% of cases, etiology remains unidentified after initial evaluation.

Purpose

To assess the increase in diagnostic yield and the time to diagnosis by implementing a structured pathway in syncope evaluation according ESC- Guidelines in a secondary hospital.

Methods

In the study, we compared 2 groups of patients with T-LOC. We evaluated the diagnostic yield and the time to diagnosis. The first group comprised all patients with T-LOC referred to the emergency department (ED) of the hospital from January to March 2016. The work-up was done according to existing clinical practice.

After implementation of a structured pathway in syncope evaluation according to ESC-Guidelines, we reevaluated the diagnostic yield and the time to diagnosis in all patients referred to ED with T-LOC from July to September 2017. The implementation consisted of an initial evaluation (careful history taking with a checklist, physical examination, ECG, orthostatic challenge test carried out by nurses), risk assessment and instructing the medical staff.

Results

There were 169 vs. 85 patients presenting with suspected T-LOC in the ED. 130 (77%) vs. 65 (76.5%) were classified as having a syncope. The diagnostic yield in the syncope patients was 60% vs. 80% (p=0.013). The rate of correct diagnosis within 14 days increased from 55 to 80%.

Conclusion

By implementing a structured pathway and educating the staff, we succeeded in increasing diagnostic yield from 60 to 80%. This could be achieved in a reduced referral to diagnosis time.
P5682Cardiac resynchronization therapy with a single left ventricular septal pacing electrode: acute hemodynamic and electrophysiological effects
Authors: Salden F , Luermans J G , Westra S W , Cornelussen R , Ghosh S , Prinzen F W , Vernooy K
Published: October 2019

Background

Cardiac resynchronization therapy (CRT) is usually performed with a right (RV) and left ventricular (LV) lead. In a previous patient study, pacing the interventricular septum permanently on the LV endocardial side (LV septum) proved feasible in patients with sinus node dysfunction.

Objective

To investigate the effects of LV septal pacing as compared to conventional biventricular (BiV) pacing with respect to acute hemodynamic and electrophysiological effects in CRT indicated heart failure patients.

Methods

Temporary LV septal pacing (transarterial approach) and pacing in the conventional BiV mode using the implanted leads was performed in 26 patients (QRS duration 163±17 ms, 23 left bundle branch block patients) undergoing CRT implantation. Acute hemodynamic response (relative to baseline AAI pacing) was assessed by LVdP/dtmax. Multi-electrode body-surface mapping, what has been used previously to characterize electrical dyssynchrony in CRT patients, was evaluated using the standard deviation of activation times (SDAT) (figure, right panel).

Results

LV septal pacing resulted in a significant LV dP/dtmax increase, that was comparable to conventional BiV pacing (figure, left panel). Combined RV and LV septal pacing did not provide an additional increase. LV septal pacing resulted in a significantly larger reduction in SDAT than RV plus LV septal pacing and conventional BiV pacing (figure, middle panel).

Conclusions

LV septal pacing results in acute hemodynamic improvement and electrical resynchronization that is at least as good as conventional BiV pacing. These results suggest that LV septal pacing with a single ventricular lead may serve as an alternative to conventional BiV pacing for cardiac resynchronization.

Acknowledgement/Funding

Medtronic is a subsidising party.
P5685Abnormal anatomy of the coronary sinus in congenitally corrected transposition of the great arteries (double discordance): a pitfall for transvenous cardiac resynchronization therapy?
Authors: Houyel L , Arribard N , Mostefa Kara M , Bessieres B , Bonnet D
Published: October 2019

Background

Congenitally corrected transposition of the great arteries (ccTGA) or double discordance is a rare congenital heart defect associating discordant atrioventricular and ventriculoarterial connections. Late prognosis depends on the progressive failure of the systemic right ventricle (RV). A possible cause for systemic RV dysfunction could be ventricular asynchrony. Cardiac resynchronization therapy (CRT) may thus be indicated in some cases. However, the cardiologists may experience some problems with the coronary sinus (CS) when implanting a 3-lead CRT transvenous system in these patients.

Aim of the study

To evaluate the anatomy of the CS and cardiac veins in specimens with ccTGA, in order to assess the feasibility of transvenous CRT.

Material and methods

Among the anatomic collection of the French Centre of Reference for complex CHD, 51 heart specimens had ccTGA with 2 ventricles. There were 33 post-natal and 18 fetal hearts. Hearts were reviewed with special attention paid to the course and drainage of the CS and cardiac veins. Segmental anatomy, location of the ventricular septal defect (VSD), status of the pulmonary outflow tract and anomalies of the atrioventricular valves were reviewed.

Results

Segmental anatomy was {S,L,L} in 46/51 hearts, {S,L,D} in 2 and {I,D,D} in 3. There was a VSD in 40 (outlet in 25, inlet in 11, both in 2, muscular in 2), pulmonary atresia in 13, subpulmonary stenosis in 6, abnormal tricuspid valve in 20/48 including Ebstein anomaly in 6, straddling in 9 (3 had replacement). The CS was always located behind the morphologically left atrium (LA). However, its anatomy was normal, with normal drainage into the morphologically right atrium, in only 25/51 (49% of cases). The CS was of reduced length with normal orifice in 17. Orifice was atretic with normal size CS in 2, and CS was completely absent in 6 with direct drainage of coronary veins into the LA. At least 1 available vein was found in all cases with patent CS orifice.

Conclusion

CS in ccTGA is always located behind the morphologically LA. However, its anatomy is abnormal in half of cases. The most frequent anomalies are reduced length (33%) and absent CS or atretic orifice (15.5%). The anatomy of CS should therefore be assessed by imaging techniques (multislice CT imaging or CS venography) before considering transvenous CRT in these patients.
P5692Catheter ablation of ventricular tachyarrhythmias in ischemic patients may contribute to better survival: a new clinical challenge
Authors: Garkina S , Tatarskii R , Mikhaylov E , Lebedeva V , Lyubimtseva T , Kamenev A , Orshanskaya V , Osadchiy A , Gureev S , Lebedev D
Published: October 2019

Background

Ventricular arrhythmias contribute to significant escalation of mortality rate in patients with ischemic cardiomyopathy (ICM). Risk of sudden cardiac death (SCD) could be reduced after implantation of a cardioverter-defibrillator (ICD), yet at the same time more frequent shock episodes are associated with poor life quality and higher hospitalization rate. Radiofrequency (RF) ablation of triggering ventricular premature beats or substrate-based catheter treatment are considered to be effective in patients with ICM but prognosis remains controversial.

Objective

To evaluate role of catheter treatment of ventricular tachyarrhythmias (VTA) and its effect on survival in patients with ischemic cardiomyopathy.

Methods

We enrolled 72 consecutive patients (mean age 64±13 years, 63 male) with prior myocardial infarction (more than 40 days ago) and documented ventricular tachycardia (VT) episodes, including 12 patients which underwent emergency electrical storm ablation. Considering number of VT recurrence episodes after catheter treatment all patients were divided into two groups. First group consisted of 27 patients (37%) with recurrent sustained VT (mean age 62±10 years) while second group included 45 patients (63%) without VT recurrence (mean age 63±12 years). During follow up most of VT episodes were registered in 13±9 years after acute myocardial infarction. Catheter treatment included mapping during hemodynamically tolerated clinically relevant VT and then ablation of VT triggers with subsequent homogenization of the scar. Patients with “fast” VT underwent primary scar homogenization.

Results

Effectiveness of clinically relevant VT ablation in patients with ICM was 63%. During follow-up period all patients were alive and remained relatively stable. Long-term effectiveness of ES elimination was 100% while freedom from clinically significant VTA was up to 79% due to repeated ablation procedures. We also observed improvement of NYHA functional class in 80% of patients.

Conclusion

Catheter ablation of VTA may be effective treatment both in acute period and long term follow up. It also may be effective in improvement of heart failure NYHA functional class in some patients and contributes to better survival in patients with ICM.
P5696The first results from multicentre study of noninvasive epi-endocardial panoramic mapping of ventricular arrhythmias
Authors: Chmelevsky M , Zubarev S , Budanova M , Potyagaylo D , Uecer E , Parreira L , Treshkur T , Fredersdorf S , Adragao P , Lebedev D
Published: October 2019

Background

A noninvasive epi-endocardial panoramic mapping is a promising ECG Imaging technology alternative to catheter-based invasive methods. Some unstable ventricular arrhythmias arising from complex anatomic sites render mapping and ablation difficulties with conventional approach.

Objective

To assess the use of a noninvasive panoramic mapping for diagnosis and localization of ventricular arrhythmias.

Methods

35 patients (20 male, median (25–75%) age – 35 (12–60) years) with polymorphic premature ventricular contractions (PVCs) and 3–5 different QRS morphologies (1500–19000 per day) or monomorphic ventricular tachycardia (VT) were enrolled in the study. Up to 224 body surface electrodes were connected to the noninvasive epi-endocardial electrophysiological system for multichannel ECG recording followed by computed tomography of the heart and torso. The body-surface ECG data were processed using inverse-problem solution software in combination with realistic 3D anatomical models of the heart and torso. The earliest site of activation were determined on isopotential maps for each QRS morphology. On the same day patients underwent catheter ablation of one or two dominant PVC morphologies using 3D electroanatomical mapping system. The site of successful catheter ablation served as final confirmation. Afterwards, electroanatomical maps were exported from Carto 3 system and compared with noninvasive maps using custom written Python-based software.

Results

In total 47 similar PVC morphologies in 30 patients were mapped using noninvasive and invasive electroanatomical mapping systems, 34 (72%) PVCs were correctly diagnosed and 13 (28%) did not accurately correspond with sites of radiofrequency ablation. In 2 patients with four PVC morphologies an early activation zones were determined as a breakthrough from epi and endocardial surface using noninvasive activation maps.

Conclusion

Non invasive epi-endocardial panoramic mapping technology is a novel diagnostic method which can be used as an additional pre-procedural tool for topical diagnosis of polymorphic PVCs.