bluuebunny/crossref_metadata_2025 huggingface dataset:
P1856Percutaneous mitral edge-to-edge valvuloplasty in end-stage heart failure as a bridge to heart transplant: a case series from a single tertiary referral center
Authors: Montalto C , Crimi G , Mandurino-Mirizzi A , Frassica R , Gazzoli F , Covi R , Moschella M , Ghio S , Magrini G , Raineri C , Pelenghi S , Ferrario M , De Ferrari G M , Oltrona-Visconti L
Published: October 2019

Background

Improved outcomes after percutaneous edge-to-edge mitral valvuloplasthy with MitraClip implantation were recently observed in patients with heart failure (HF) and functional severe mitral regurgitation (MR). Nonetheless, its efficacy in end-stage heart failure (HF) are lacking.

Purpose

Our aim was to investigate feasibility, preliminary efficacy on hemodynamics and follow-up of MitraClip implantation in a cohort of patients with very advanced HF.

Methods

Patients were retrospectively included in the present analysis if already in HT list, unsuitable for HT despite optimal medical and device therapy, or if implantation was a “bridge-to-candidacy”.

Results

Baseline and procedural characteristics are listed in Table 1; MR etiology was predominantly functional (n=7). No major complications were observed in the peri-operative period. At 6-month follow-up, invasive hemodynamics was available for 8 patients. A significant increase in cardiac index was observed (Least Square Mean Difference, LSMD = +0.47 L/min/m2; p=0.03; Figure 1), in conjunction with a numerical reduction in pulmonary vascular resistance (LSMD = −1.02 WU; p=0.3), a trend towards lower mean pulmonary arterial pressure (LSMD = −6.5 mmHg; p=0.053) and lower ejection fraction (LSMD = −6.5%; p=0.053). At a median follow-up of 772 days (IQR 156–1,578), all three patients unsuitable for HT at baseline could be eligible to HT list and one of them received LVAD. Moreover, two patients were transplanted, four experienced unplanned rehospitalization for HF, and one died of non-cardiac cause.

Table 1. Baseline clinical evaluation (n=10) Age (y) 53.67±8.43 HF Etiology – post ischemic 4 (40) Male sex 6 (60) HF Etiology – no CAD 4 (40) Body Surface Area (m2) 1.76±0.22 HF Etiology – other 2 (20) Chronic Resynchronization Therapy 5 (50) Euroscore II 6.00±2.74 Baseline MR grade (+) 4 (40) STS mortality 1.71±2.65 Residual MR grade (+) 1.71±0.49 Clips implanted (number) 1.78±0.67 Data are expressed as mean ± SD or count (valid %). MR scored on a scale from 0+ to 4+. STS, Society of Thoracic Surgeons.

Figure 1

Conclusions

Percutaneous edge-to-edge mitral valvuloplasty with MitraClip appears safe and effective in end-stage patients, impacts on clinical decision-making and therefore might be considered as a “bridge” towards a more definite strategy.

Acknowledgement/Funding

None
P1888Autoantiboides to Muscarinic M2 cholinoceptors in patients with paroxysmal atrial fibrillation
Authors: Mironova E S , Mironova N A , Mironov N Y U , Layovich L Y U , Golitsyn S P , Zykov K A , Sharf T V , Efremov E E , Azmuko A A , Molokoedov A V
Published: October 2019

Introduction

Atrial fibrillation (AFib) is the most frequenly encountered arrhythmia. In the majority of cases AFib occurs in patients with cardiovascular diseases such as arterial hypertension (AH). In 10–15% of cases AFib occurs in the absense of comorbidities in structurally normal heart. It is reffered to as “lone AFib” and the cause of this arrhythmia remains unknown. Activation of cardiac M2-actylcholinoreceptors (M2-CR) leads to decrease in duration of atrial refractory periods that may contribute to development of AFib. Autoantibodies against M2-CR has cholinomimetic properties, but role of these autoantibodies in development and maintenance of AFib has not been studied.

Purpose

To assess autoantibodies against M2-CR in patients with paroxysmal lone AFib, in patients with AFib and AH and healthy people.

Methods

100 patints with lone Afib, 100 patients with Afib and AH and 25 healthy people were included. Patients underwent clinical blood and urinlysis, assessment of biochemistry blood panel, 12-lead ECG, 24-hour Holter monitoring, echocardiography and stress-testing (treadmill or stress-echocardiography). Assesment of IgM and IgG autoantibodies to M2-CR was performed by indirect immunoenzyme assay. The following peptide molecules were used as epitopes for detection of autoantibodies: M1-amino acid sequence YTVIGYWPLGVVCDL (83–98) of the first extracellular loop of M2-CR; M2-sequence VRTVEDGECYIQFFSNAAVTFGTAI (168–192) of the second extracellular loop of M2-CR; M3-sequence NTFCAPCIPNTV (410–421) of the third extracellular loop of M2-CR, M4-short sequence VEDGECYIQFFS (171–182) of the second extracellular loop of M2-CR; M1+M4-chimeric molecule formed by sequences of the first and the second extacellular loops of M2-CR connected by disulfide bound YTVIGYWPLGVVCDL+VEDGECTIQFFS (83–98+171–182).

Results

IgG to M2-CR were found in 32% of patients with AFib and in 12% of healthy subjects (p<0,05). IgM to M2-CR were found in 25% of patients with AFib and in 32% of healthy subjects (p<0,05). In patients with lone AFib prevalence of IgG to M2-CR were greater than in patients with AFib and AH (39% vs 25%; p<0,05). Patients with lone AFib and AFib and AH had higher prevalence of IgG to all amino-acid sequences and difference was statistically significant for M2, M4, M1+M4 epitopes (see fig.).

Prevalence of IgG to M2-CR epitopes

Conclusion

Higher prevalence of IgG to M2-CR in patients with AFib than in healthy subjects may suppose an active role of autoimmune processes in arrhythmogenesis.
P1904Oral anticoagulation in patients undergoing elective cardioversion of atrial fibrillation. Real-life experience from Finland
Authors: Itainen-Stromberg S , Hekkala A.-M , Aro A , Vasankari T , Airaksinen J , Lehto M
Published: October 2019

Background

Non-vitamin K antagonist oral anticoagulants (NOACs) are increasingly used in patients with atrial fibrillation (AF) undergoing elective cardioversion (ECV). The real-life data evaluating the safety and efficacy of ECV in patients receiving NOACs is sparse.

Purpose

The aim was to investigate the use of NOACs and warfarin in ECV in a real-life setting and to assess how the chosen regimen affected the delay to ECV and rate of complications.

Methods

Consecutive AF patients undergoing ECVs in a large city in Finland between January 2015 and December 2016 were studied. Data on patient characteristics, delays to cardioversion, anticoagulation treatment, acute (<30 days) complications and regimen changes within one year were evaluated.

Results

Nine hundred patients (59.2% men; mean age, 68.0±10.0) underwent 992 ECVs, of which 596 (60.0%) were performed using NOACs and 396 (40.0%) using warfarin. The mean CHA2DS2-VASc score was 2.5 (±1.6). In patients without previous anticoagulation treatment, NOACs were associated with a shorter mean time to cardioversion than warfarin (51 vs. 68 days, respectively; P<0.001). Furthermore, patients receiving NOAC had fewer postponements of scheduled elective cardioversion compared with warfarin (12.6% vs. 37.4%, respectively, P<0.001). The most common reason for visit cancellation was an imbalance of warfarin therapy and labile INR values. Six thromboembolic events (0.6%) occurred: 4 (0.7%) in NOAC-treated patients and 2 (0.5%) in warfarin-treated patients. All patients who experienced a stroke or TIA had adequate anticoagulation therapy for at least 3 weeks preceding the cardioversion, and both patients in the warfarin group had an INR value >2 when thromboembolic complications occurred. Clinically relevant bleeding events occurred in 3 patients (0.5%) receiving NOACs and 7 patients (1.8%) receiving warfarin. Anticoagulation treatment was altered for 99 patients (11.0%) during the study period, with the majority (88.2%) of changes from warfarin to NOACs.

Conclusion

In this real-life study, the rates of thromboembolic and bleeding complications were low in AF patients undergoing ECV. Patients receiving NOAC therapy had a shorter time to cardioversion and fewer postponements of scheduled elective cardioversion compared with warfarin. Furthermore, patients receiving NOAC therapy had less anticoagulation treatment changes than patients on warfarin.

Acknowledgement/Funding

Finnish Foundation for Cardiovascular Research, Helsinki University Hospital District research fund, Boehringer-Ingelhem, Finnish Medical Foundation
P1906Modified frailty as a novel factor to predict the effectiveness of electrical cardioversion of atrial fibrillation in the elderly population
Authors: Mlynarska A , Mlynarski R , Marcisz C , Golba K S
Published: October 2019

Electrical cardioversion is one of the recognized methods of treatment of atrial fibrillation (AF)/maintenance of sinus rhythm. There are no factors that allow to predict the response to electrical cardioversion in the elderly population. Frailty is a common geriatric syndrome that embodies an elevated risk of catastrophic declines in health and function among older adults – we hypothesized that frailty can be a factor to predict the effectiveness electrical cardioversion.

Methods

199 consecutive patients over 60 years (average age 71.41±6.99; 40.2% W) with AF hospitalized due to electrical cardioversion. The follow-up period for maintenance of sinus rhythm was 180±14 days. The Tilburg Frailty Indicator was used to examine the frailty before cardioversion. A global score of 5 points or more let us to respond the frailty syndrome.

Results

174 patients out of 199 (87.4%) were found to have electrical cardioversion be effective. Frailty was recognized in 68 out of the 199 (34.17%). There was 66.2% (45/68) effectiveness in the frailty-affected group, whereas there was 99.2% (130/131) in the robust group; p=0.ehz748.0653. 87.9% patients have maintenance sinus rhythm after 6 months; in the frailty affected group it was 75% vs 94.6% in robust group; p=0.ehz748.0653. In the logistic regression, frailty (OR: 0.41, 95% CI: 0.2870–0.0,5851; p<0.0001) was emerged as an independent predictor of effectiveness of electrical cardioversion. The ROC curves for frailty in the effectiveness electrical cardioversion are presented in the figure below – left panel. The area under the curve is 0.856 (95% CI - 0.799–0.902). The cutoff value for a frailty recognition was 4 (p<0.0001). Similarly, in the logistic regression, frailty (OR: 0.65, 95% CI: 0.5010–0.8330; p=0.0003) was also emerged as an independent predictor of maintenance sinus rhythm. The ROC curves for frailty in the maintenance of sinus rhythm are presented in the figure – right panel. The area under the curve is 0.718 (95% CI - 0.650–0.779). The cutoff value for a frailty recognition in this case was also 4 (p<0.0001).

ROC curves

Conclusion

Frailty is a novel, independent factor that can be used to predict the effectiveness of electrical cardioversion and maintenance of sinus rhythm in the elderly population. Modifying the level of recognition in the Tilburg Frailty Indicator to a 4, improve the prediction of effectiveness of electrical cardioversion as well as maintenance of sinus rhythm.
P1911The impact of pulmonary vein morphology and orientation on the outcomes of cryoballoon ablation in patients with paroxysmal atrial fibrillation
Authors: Chichkova T Y U , Mamchur S E , Kachurina E N
Published: October 2019

Background

Circumferential contact of cryoballoon and pulmonary vein (PV) ostium is an important factor for pulmonary vein isolation (PVI). PV ostium shape and orientation can make challenges for PV occlusion.

Purpose

We aimed to assess the impact of pulmonary vein morphology and orientation on cryoablation outcomes in patients with paroxysmal AF.

Material and methods

The single-center prospective study included 122 patients (males: 46.7% (57), mean age 57 (53; 62) with drug-refractory paroxysmal AF. The mean AF duration was 4 years (2; 4). A multislice cardiac computed tomography (MSCT) was performed prior to CBA in order to evaluate the PV anatomy (maximal and minimal ostium diameters, ovality of PV ostium, angle of PV orientation in the frontal and axial plane (Figure1)). The presence of typical anatomy (4 separate ostia of PVs) was inclusion criteria. Procedures were performed with 28-mm second generation balloon. A procedural endpoint was the achievement of PVI. Outcomes of PVI were defined as freedom from any AF episodes documented by ECG from the end of blanking period to 12 months.

Results

PVI was achieved in 97.5% of PVs (476/488). Freedom from AF was 78.7%. Difficult occlusion of right inferior PV was observed in 12 patients and associated with a more horizontal PV orientation in the frontal plane: −15.2±6.20 versus −26.5±6.3°, p<0.001. A total of 11 (9%) patients experienced transient phrenic nerve injury (PNI) during ablation of right superior PV (RSPV). PNI was associated with the maximum and minimum diameter of the RSPV 20.0–24.0 mm (OR=13,2; 95% CI: 3.4–51; p<0.05) and 17.5–20.0 mm (OR=12.5; 95% CI: 4.7–41.9; p<0.05), respectively. Patients with AF recurrence had significantly larger maximum and minimum diameters of left superior PV (LSPV): 18.8 versus 17.5 mm, p=0.048, and 13.4 versus 12.5 mm, p=0.05, respectively. Ovality of PV ostium was larger in the recurrence group: 0.36 versus 0.18, p=0.05.

Figure 1. Evaluation of PV orientation

Conclusions

Evaluation of PV morphology and orientation can be used to predict CBA results. AF recurrence was associated with larger diameters and ovality of LSPV ostium. More horizontal RIPV orientation was associated with difficult PV occlusion. RSPV morphology can affect safety of procedure.
P1920Long-term outcomes of pulmonary vein isolation using second-generation cryoballoon during atrial fibrillation ablation: A single-center large-scale study
Authors: Canpolat U , Kocyigit D , Yalcin M U , Coteli C , Sener Y Z , Oksul M , Gurses K M , Evranos B , Yorgun H , Aytemir K
Published: October 2019

Background

Currently available second-generation cryoballoon (CB2) is accepted as an effective and safe tool for pulmonary vein isolation (PVI). Although much more data exists about 1-year outcomes of CB2 ablation, data on long-term outcomes are scarce. Objective: We aimed to assess the long-term outcomes of PVI using CB2 in a large-scale symptomatic AF population at our tertiary referral center.

Methods

In this non-randomized prospective observational study, a total of 486 patients with paroxysmal (71%) or persistent (29%) AF who underwent index PVI using CB2 at our hospital between January 2013 and June 2017 were enrolled. Atrial tachyarrhythmia (ATa) free survival was defined as absence of AF, atrial flutter or atrial tachycardia recurrence >30 s following 3-months blanking period. Predictors of recurrence were evaluated by univariate and multivariate Cox proportional hazards regression models.

Results

Acute procedural success rate was 99.8% (1898/1902 PVs). Mean procedural and fluoroscopy time were 64.9±9.2 and 12.1±2.6, respectively. At median 39 (IQR: 26–56) months follow-up, ATa free survival was 78.6% after a single procedure (280/345 [81.2%] for paroxysmal AF vs 102/141 [72.3%] for persistent AF, p=0.019) and 84.4% after a mean 1.48±0.42 ablations.Cox regression analysis showed that left atrium diameter, duration of AF history and early ATa recurrence were found as the independent predictors of late recurrence. PNP was observed in 17 (3.5%) patients.

Figure 1

Conclusions

Second-generation CB based PVI is effective to maintain sinus rhythm in a significant proportion of paroxysmal and early persistent AF patients with an acceptable complication rates at long-term follow-up.
P1928Global telemedicine initiatives for combating ami
Authors: Mehta S , Botelho R , Niklitzchek S , Fernandez F , Cade J , Prudente M , Dusilek C , Hamdan N , Hurtado E , Lacativa M , Ceschim M , Torres M A , Vieira D , Pisana L , Quintero S
Published: October 2019

Background

Major disparities exist between developed and developing countries in Acute Myocardial Infarction (AMI) outcomes. Telemedicine has emerged as a powerful, cost-efficient, and scalable tool for population-based AMI management. We propose efficient telemedicine protocols as frontline AMI strategies for resource-constrained developing countries.

Purpose

To create a global template of using telemedicine protocols for treating AMI.

Methods

A hub and spoke strategy was utilized for Latin America Telemedicine Infarct Network (LATIN) to expand access in Brazil, Colombia, Mexico, and Argentina. Small clinics and primary care health centers in remote areas were strategically connected with 24/7 primary PCI facilities. Experts at 4 remote sites provided urgent EKG diagnosis and tele-consultation that triggered ambulance dispatch and implementation of standardized AMI protocols.

Results

784,947 patients were screened for AMI at 350 LATIN centers (Brazil 143, Colombia 118, Mexico 82, Argentina 7). With this expanded geographic reach, 8,448 (1.08%) patients were diagnosed with STEMI and 3,911 (46.3%) urgently reperfused, including 3,049 (78%) with Primary PCI. Time to Telemedicine Diagnosis (TTD) was 3 min, tele-accuracy 98.9%, D2B 51 min, and in-hospital mortality 5.2%. Major reasons for non-treatment were insurance denials, lack of ICU beds and chest pain >12 hours.

Conclusions

LATIN demonstrates the feasibility of a population-based and telemedicine guided AMI strategy that can hugely expand access. Telemedicine has important public health implications as a global approach to AMI care in developing countries.
P1932Predictors of DAPT use in patients beyond 1 year post myocardial infarction: Insights from the TIGRIS observational study
Authors: Russo J J , Yan A T , Pocock S J , Brieger D , Owen R , Andersson Sundell K , Granger C B , Cohen M G , Yasuda S , Nicolau J C , Brandrup-Wognsen G , Westermann D , Simon T , Goodman S G
Published: October 2019

Background

International guidelines vary in their recommendations for dual antiplatelet therapy (DAPT) use beyond 1 year post-myocardial infarction (MI).

Purpose

To identify predictors of DAPT use in patients ≥1 year post-MI prior to the publication of the DAPT score and the 2017 European Society of Cardiology (ESC) guidelines for DAPT in coronary artery disease.

Methods

TIGRIS (NCT01866904) was a prospective, multi-center (369 centers in 25 countries), observational study of patients 1 to 3 years post-MI between June 2013 and November 2014. We performed a multivariable logistic regression analysis to identify independent predictors of DAPT use at 396 days post-MI (365 + 31 days overrun period to allow intended DAPT discontinuation at 1 year). Patients on oral anticoagulation were excluded.

Results

Of 8464 patients enrolled (mean age 66 years, women 24%, ST-elevation MI 53%), 40% were on DAPT at 396 days post-MI (Figure). In the subset of patients on DAPT at 396 days post-MI, aspirin was combined with clopidogrel in 84%, prasugrel in 12%, and other antiplatelet agents in 4%. DAPT use at 396 days post-MI was independently associated with geographic region, age, PCI for the index MI, and a history of multivessel disease or angina (Table). Several variables included in the DAPT score and ESC guideline recommendations (diabetes, second prior MI, hypertension, peripheral artery disease, heart failure, smoking, and renal insufficiency) were not independent predictors of DAPT use at 396 days.

Independent predictors of DAPT @396 days Variable at enrolment Patients Odds ratio (95% CI) P-value Region: Europe 3813 Reference group 0.01 North America 923 1.65 (0.56, 4.86) Latin America 1084 2.55 (1.19, 5.47) Asia and Australia 2644 3.01 (1.42, 6.36) Age <65 years 3274 1.15 (1.04, 1.28) 0.005 PCI for index MI 6925 2.08 (1.82, 2.38) <0.0001 Multi-vessel disease 5598 1.37 (1.24, 1.52) <0.0001 History of angina 829 1.46 (1.24, 1.71) <0.0001

DAPT use at 396 days post-MI by region

Conclusion

During the study period, DAPT use ≥1 year post-MI was prevalent and appeared to be influenced by regional practices. Further research is needed to determine whether the DAPT score and the 2017 ESC guidelines for dual antiplatelet therapy have changed long-term DAPT use practices.

Acknowledgement/Funding

AstraZeneca AB, Södertälje, Sweden
P1933Comparing treatment recommendations for the DAPT and PRECISE-DAPT scores after percutaneous coronary intervention
Authors: Boudreau R , Fu A , Barry Q , Perry-Nguyen D , Tran U , Simmard T , Le May M , Labinaz M , Dick A , Glover C , Froeschl M , Hibbert B , Chong A Y , So D
Published: October 2019

Background

Dual antiplatelet therapy (DAPT), with aspirin and a P2Y12 inhibitor, is the standard therapy for patients following PCI. Duration of treatment with DAPT has been controversial despite large studies. Current guidelines recommend treatment duration be individualized based on risk of ischemia and bleeding. To facilitate treatment decisions, risk assessment tools, including the DAPT and PRECISE-DAPT scores, have been developed.

Purpose

As components of these scores differ, the variability of recommendation remains unknown. We set to evaluate inter-tool concordance in treatment recommendation in a cohort of patients after PCI.

Methods

Using data from our local PCI registry, we calculated the PRECISE-DAPT at baseline following PCI and the DAPT after 1 year of treatment for 311 consecutive patients with complete data for both scores to be calculated. Based on their DAPT and PRECISE-DAPT scores, patients were grouped into concordant for long-term treatment (DAPT ≥2 and PRECISE-DAPT <25) or concordant for shortened treatment (DAPT <2 and PRECISE- DAPT ≥25). All other patients were considered discordant. We then performed a concordance analysis using Cohen's kappa to measure degree of agreement.

Results

Among the 311 patients, mean age was 63.4 (SD 11.6); 245 (79%) were men, 93 (29.9%) had history of a prior MI, 130 (41.8%) were current smokers, 32 (10.3%) had a history of CHF or LVEF <30%, 82 (26.3%) had diabetes and 196 (63.0%) were previously diagnosed with hypertension. Index event consisted of a STEMI in 101 (32.4%), NSTEMI in 93 (29.9%), unstable angina in 27 (8.7%), stable angina in 67 (21.5%) and the remaining 23 (7.4%) had other indications for PCI. Mean DAPT score was 1.52 (SD 1.37). Mean PRECISE-DAPT was 17.65 (SD 12.73). The DAPT recommended long-term treatment for 162 (52.1%) and shortened treatment for 149 (47.9%). The PRECISE-DAPT recommended long-term treatment for 245 (78.9%) and shortened treatment for 66 (21.2%). The overall proportion of agreement between the two risk scores was 56.6% with a Cohen's kappa index of 0.110 (95% CI, 0.017 to 0.204). See Table.

Concordance Analysis PRECISE-DAPT Score Recommendation Long Term (N=245) Shortened (N=66) DAPT Score Recommendation Long Term (N=162) 136 (43.7%) 26 (8.4%) Concordant for Long Term Treatment Shortened (N=149) 109 (35%) 40 (12.8%) Concordant for Shortened Treatment

Conclusion

Comparison of the DAPT score and the PRECISE-DAPT score showed concordance in treatment recommendation in only 56.6% of patients. Given the poor agreement between these tools, prospective concurrent evaluations and correlation to outcomes will be required in future studies.
P1946Hypertension prevalence, awareness, treatment and control and 10-year estimated CVD risk in East and West Africa: pooled analysis of data from 4 African countries
Authors: Samson O , Muhihi A , Mohamed S , Ameh S , Ochimana C , Oluwasanu B , Bolarinwa A O , Sewankambo N , Danaei G
Published: October 2019

Background

Though the prevalence of hypertension is rising in Sub-Saharan Africa, few studies have characterized the epidemiology and management of hypertension across many heterogeneous communities. We assessed prevalence, awareness, treatment and control of hypertension and estimated the 10-year cardiovascular risk across six sites in East and West Africa.

Methods

Between June and August 2018, we conducted household-based surveys in 6 rural, semi-urban and urban settings in Kenya, Nigeria, Tanzania and Uganda to enroll community-dwelling adults (aged >18 years) collect data including age, gender, smoking, anthropometric measures, health insurance, utilization of health care facilities. We defined hypertension as systolic blood pressure of at least 140 mm Hg, or diastolic blood pressure of at least 90 mm Hg, or self-reported antihypertensive medication use. We used country specific Globorisk prediction equations to estimate 10-year CVD risk.

Results

A total 3,150 participants with a mean age of 40 years (SD 15), 61% of whom were women, 8% had ever smoked, and 33% were overweight/obese. About 23.7% (95% CI 22.2, 25.2) of the entire sample had hypertension, of whom 60.6% (56.8, 64.3) were diagnosed. Among diagnosed, 61.7% (57.2, 66.1) were taking antihypertensives, and 27.7% (22.7, 33.1) had controlled BP. The prevalence of hypertension was 38.6% in Ikire-Nigeria, 25.1% Ukonga-Tanzania, 23.3% in Oyo-Nigeria, 21.6% in Okpok-Nigeria, 20.4% in Soroti-Uganda, and 9.7% in Viwandani-Kenya. The overall median estimated 10-yr CVD risk was low 4.6% IQR (2.3, 9.6) and 8.6% had 10-yr CVD risk >10%. (Figure 1)

Conclusion

Among African adults aged >18 years, nearly a quarter have hypertension, three in 5 being treated, and fewer than three in ten had BP under control. The low number of people in control is ubiquitous in all sites and warrants greater prevention strategies, better screening and more effective and affordable treatment options than what is currently available.
P1951Serial left ventricular global longitudinal strain and mortality in patients with Takotsubo cardiomyopathy
Authors: Isaza N , Alashi A , Faulx J , Popovic Z B , Menon V , Faulx M , Griffin B P , Desai M Y
Published: October 2019

Background

Recent studies on Takotsubo cardiomyopathy (TC) have challenged the common conception that it is a relatively benign condition with functional recovery observed in the majority of cases. However, it is important to recognize that overt functional recovery might not reflect the true regional recovery, which might have an adverse impact on survival.

Objective

We sought to assess baseline and follow-up left ventricular function characteristics and their impact on longer-term mortality in patients presenting with documented Takotsubo cardiomyopathy (TC) at a tertiary centre.

Methods

339 patients (66±14 years, 88% women) presented to our centre between 2006 and 2018 with acute anginal symptoms and were subsequently diagnosed with TC following clinical and angiographic evaluation. All patients returned for a follow-up evaluation including transthoracic echocardiography (TTE). Baseline and follow-up (3–6 months after TC diagnosis) LV ejection fraction (LVEF) and LV global longitudinal strain (LV-GLS using velocity vector imaging) were recorded on TTE. The primary endpoint was longer-term mortality.

Results

Hypertension, dyslipidaemia, and diabetes were present in 71%, 56%, and 26% of patients. Baseline mean troponin I peak, LVEF and LV-GLS were 0.9±7 ng/ml, 36±9%, and 11±3%; respectively. 94% had baseline LVEF<50%, 272 (80%) had apical ballooning, and 94% had LV-GLS worse than −18%. No patient had angiographically obstructive coronary artery disease. At 3–6 months follow-up, mean LVEF, and LV-GLS improved to 57±9% and 16±3%, respectively. 87% of patients had LVEF >50%, but in 70% LV-GLS remained worse than −18%. After 3.3±3 years, 72 patients (21%) died. On multivariable Cox survival analysis (adjusted for age, gender, baseline troponin peak and follow up LVEF), follow up LV-GLS was independently associated with longer-term mortality (hazard ratio 1.12 [95% confidence interval 1.05, 1.20], p<0.001). Significantly more patients with follow up LV-GLS worse than −18% died vs. those with LV-GLS better than −18% (57/237 [24%] vs. 15/102 [15%], log-rank statistic p-value 0.01, Kaplan-Meier figure 1).

Kaplan-Meier curve of freedom from death

Conclusions

In this large single-centre study of patients with documented TC (majority women), 87% recovered LVEF at 3–6 months, but in 70% LV-GLS remained worse than −18%, which was independently associated with higher longer-term mortality.
P1954Prognostic value of the CHADS2 score for adverse cardiovascular events in acute myocardial infarction patients without atrial fibrillation: J-MINUET Substudy
Authors: Motozato K , Sakamoto K , Tsujita K , Nakao K , Ozaki Y , Kimura K , Ako J , Noguchi T , Suwa S , Fujimoto K , Nakama Y , Nishimura K , Miyamoto Y , Ogawa H , Ishihara M
Published: October 2019

Background

The CHADS2score has mainly been used to predict the likelihood of cerebrovascular accidents in patients with atrial fibrillation. However, increasing attention is being paid to this scoring system for risk stratification of patients with coronary artery disease. We investigated the value of the CHADS2 score in predicting cardiovascular events in Japanese acute myocardial infarction (AMI) patients without atrial fibrillation.

Methods

To elucidate the prognostic value of CHADS2score in AMI patients, we analysed data of the Japanese registry of acute Myocardial INfarction diagnosed by Universal dEfiniTion (J-MINUET). This was a prospective and multicenter registry consisting of 3,283 AMI patients, who were hospitalized within 48-hours of onset from July 2012 to March 2014. We calculated the CHADS2 scores for 3,044 patients without clinical evidence of atrial fibrillation. The presence of heart failure was substituted by Killip classification>2 on admission. Clinical follow-up data was obtained for 3 years. In addition to the in-hospital mortality,we evaluated cardiovascular events, defined as all cause deathor non-fatal MI during 3-year follow up periods.

Results

In this study, enrolled patients were classified into low- (point 0–1), intermediate- (point 2–3), and high-score (point 4–6) groups by calculating CHADS2 score. Overall patients with low, intermediate and high score were divided into 1,395, 1,393 and 256 patients, respectively. In-hospital mortality among low, intermediate, and high score groups were 2.8%, 7.4% and 14.8%, respectively (P<0.001). The incidence of cardiovascular eventsamong low, intermediate, and high score groups were 7.8%, 16.3%, 29.3%, respectively (P<0.001). Kaplan-Meier analysis showed a significant difference between the groups (Figure). The event rates were significantly higher in both high score and intermediate score group than in low score group (P<0.001). Multivariate Cox hazard analysis identified CHADS2 score (per 1 point) as an independent predictor of cardiovascular events in addition to chronic kidney disease and lower body mass index. (hazard ratio, 1.344; 95% CI, 1.239–1.459; P<0.001). Among the factors constituting CHADS2 score, heart failure and age were identified as independent predictors for in-hospital mortality. With respect to the cardiovascular event during 3 years, heart failure, age, and previous stroke were revealed as significant independent predictors.

Conclusion

This large cohort study indicated that the CHADS2 score is useful for the prediction of in-hospital mortality and the cardiovascular events during 3-year follow up in Japanese AMI patients without atrial fibrillation.
P1960Endothelial progenitor cells are associated with cardiovascular outcome in patients with peripheral artery disease
Authors: Pesau G , Hoebaus C , Zierfuss B , Koppensteiner R , Schernthaner G H
Published: October 2019

Background and introduction

Endothelial dysfunction and associated cells are an important cornerstone in the development and progression of peripheral artery disease (PAD). Endothelial progenitor cells (EPC) are released from the bone marrow and have exhibited the potential for cardiovascular repair. Higher EPC levels have been linked to longer event-free survival in coronary artery disease. Similar evaluation of EPC on mortality in PAD is lacking.

Purpose

The current study aimed to evaluate the possible association between EPC levels and mortality in PAD patients.

Methods

EPC were measured in 367 PAD patients (age 69.22±10.3, 66.5% male, Fontaine stage I-II) by flow cytometry using the cell surface marker CD34+ and CD309+. Patients were followed for seven years to assess all cause and cardiovascular mortality. Patients were categorized into quartiles according to EPC levels for further analyses. Statistics included Kaplan-Meier and Cox regression.

Results

89 patients died over the observation period. ICD-codes indicated a cardiovascular cause in 58 patients. The group with the highest count of EPC showed a trend towards higher all-cause mortality (p=0.070) and a significant association with cardiovascular mortality (p=0.002). Multivariable adjustment for age, c-reactive protein, systolic blood pressure, renal function (creatinine and urinary albumin), low density lipoprotein cholesterol, HbA1c, and smoking status revealed the EPC quartile to be an independent risk factor for cardiovascular mortality (p=0.016).

Conclusion

Increased levels of CD34+CD309+ cells are independently associated with long-term cardiovascular mortality in PAD patients.
P1967Impact of strut thickness, of number of crown and connectors on clinical outcomes on patients treated with second generation DES
Authors: Gatti P , Iannaccone M , Barbero U , Bassignana A , Gallo D , De Benedictis M , Helft G , Morbiducci U , D'Oronzo B , D'Ascenzo F , Giustetto C
Published: October 2019

Introduction

In new generation drug eluting stents (DESs) era, the impact of stent geometry on freedom from recurrent events has been poorly explored. Impact of struts thickness, number of crowns and connectors on clinical outcomes was evaluated in the present study.

Methods

Randomized controlled trials comparing last generation DESs were selected. The primary endpoint was the rate of target lesion revascularization (TLR), while secondary was Definite Stent Thrombosis (ST).

Results

53 studies with 52006 patients were included. A struts thickness ≤81 nm was associated with a lower incidence of TLR (2.9%: 2.4–3.4 vs. 3.6%: 3.0–4.3) and ST (0.8%: 0.6–1.1 vs. 1.3%: 0.9–1.8). A mean number of connectors >2.5 was also associated with a lower incidence of TLR (3.2%: 2.8–3.6 vs. 3.5%: 2.9–4.2) and ST (1.0%:0.8–1.3 vs. 1.3%: 0.9–1.7 vs for ST). On the other hand, stents with average number of crowns <7.5 did not perform better than stents with higher average number of crowns.

Conclusions

The findings of the study support that lower struts thickness and higher numbers of connectors have a positive clinical outcome reducing stent thrombosis and target lesion revascularizations, while the average number of stent crowns plays a secondary role.
P2240CTA derived plaque characteristics and cardiac events in deferred lesions by invasive FFR
Authors: Motoyama S , Sarai M , Kawai H , Miyajima K , Muramatsu T , Takahashi H , Naruse H , Ishii J , Ozaki Y
Published: October 2019

Background

Fractional flow reserve (FFR) based strategy for coronary artery disease (CAD) is widely accepted. However, cardiac events could occur at deferred lesions after FFR. We previous reported that CT derived high risk plaque (HRP) and residual stenosis were the independent predictors of cardiac events.

Purpose

The purpose of this study was to investigate if plaque characteristics on CTA could predict cardiac events in deferred lesions after FFR.

Methods

We included 211 vessels of 193 patients who were deferred revascularization after CTA and invasive FFR. The presence of HRP and the stenosis grading on CTA were analyzed.

Results

Median follow-up period after CTA was 623 days (IQR 302–945). HRP and obstructive stenosis were detected in 58 (27.5%) and 87 (41.2%) lesions, respectively. Cardiac events were occurred in 10 lesions at 440±167 days in average (range: 150–770 days). Multivaliate cox hazard regression analysis revealed that HRP (HR8.01, p=0.0032) and obstructive stenosis with ≥70% (HR 34.93, p<0.0001) were the independent predictors of cardiac events after adjusted for age, sex, and FFR≤0.8. Of 21 lesions with both HRP and obstructive stenosis, 29% lesions resulted in cardiac events in 2 years.

Conclusions

Even in the deferred lesions by invasive FFR, lesions with HRP and obstructive stenosis showed high rate of cardiac events. These lesions should be treated with intensive medical therapy to prevent cardiac events.
P2246Maternal and foetal outcomes of anticoagulation in pregnant women with preconception venous thromboembolism
Authors: Soegaard M , Skjoth F , Nielsen P B , Beyer-Westendorf J , Larsen T B
Published: October 2019

Background

Anticoagulation is essential to prevent recurrent venous thromboembolism (VTE) during pregnancy in women with a history of preconception VTE. However, information on the safety of anticoagulant drugs in this setting is limited.

Purpose

To investigate the risk of maternal and foetal adverse outcomes associated with anticoagulant exposure during pregnancy.

Methods

Nationwide cohort of all pregnant women in Denmark with preconception VTE, 2000–2017. We linked individual-level data from nationwide registries on anticoagulant exposure, maternal and foetal outcomes.

Results

Among 5,099 pregnancies in 3,246 women with preconception VTE (mean age 31 years, 41% nulliparous), 36.4% were exposed to anticoagulants during first trimester (66.4% low-molecular-weight heparin (LMWH), 31.9% VKA, and 1.8% NOAC (Table). No maternal deaths occurred. Maternal outcomes were comparable among LMWH and unexposed women, whereas recurrent VTE and foetal loss was more prevalent in VKA and NOAC exposed women. Foetal risk was lowest in unexposed and LMWH exposed, whereas preterm birth was prevalent in VKA and NOAC exposed.

Table 1. Maternal and foetal outcomes in pregnant women with preconception VTE according to first trimester anticoagulant exposure Maternal outcomes No anticoagulants LMWH VKA NOAC Total pregnancies/singleton foetuses, N 3,244/2,722 1231/1,124 591/442 33 /26 Recurrent VTE, % (N) 2.7 (89) 3.3 (41) 6.4 (38) – (<5) Antenatal bleeding, % (N) 2.3 (73) 2.7 (33) 1.5 (9) 0 Preeclampsia, % (N) 3.0 (98) 2.1 (26) 4.4 (26) – (<5) Foetal loss, % (N) 13.4 (436) 6.6 (81) 22.2 (131) 21.2 (7) Foetal outcomes in live singleton births, except stillbirth   Stillbirth, % (N) 0.6 (17) 0.6 (7) – (<5) 0   Mean gestational age, days/birthweight, gram 246/3,458 246/3,471 238/3,212 243/3,138   Preterm birth (<37 weeks), % (N) 41.1 (1,111) 38.3 (428) 63.2 (277) 57.7 (15)   Very preterm birth (<28 weeks), % (N) 0.9 (24) 1.3 (14) 2.7 (12) 0   Small for gestational age, % (N) 4.2 (109) 4.5 (49) 4.8 (20) – (<5)   Mean 5-minute Apgar score, (sd) 9.8 (0.8) 9.8 (0.7) 9.8 (1.0) 9.7 (1.0)   Congenital defects 8.4 (226) 9.0 (100) 10.0 (44) – (<5) Counts are supressed in cells with <5 observations to prevent disclosure of potentially identifiable information.

Conclusion

Our findings are reassuring and in support of the recommendation of LMWH for pregnant women with prior VTE. Few women were exposed to NOAC during pregnancy, and the safety of NOACs cannot be substantiated with the current level of evidence.

Acknowledgement/Funding

The Obel Family Foundation partly funded this research by an unrestricted grant.
P2261The impact of a short-term cardiac rehabilitation program on activities of daily living in elderly patients with chronic heart failure
Authors: Paneroni M , Scalvini S , Simonelli C , Rivadossi F , Pavesi C , Rainoldi F , Lovagnini M , La Rovere M T , Ambrosetti M , Pedretti R
Published: October 2019

Introduction

A high proportion of elderly patients with Chronic Heart Failure (CHF) experience dyspnea and fatigue during the activities of daily living (ADLs).

Purpose

We aimed to determine 1) the VO2 peak of some basic ADLs comparing it to VO2 peak at CardioPulmonary Exercise Test (CPET) and 2) the effects of 3-week inpatient cardiac rehabilitation program on ADLs' performance.

Methods

At entry and at the end of a 20-day cardiac rehabilitation program patients performed an ADL-test consisting of five task-related ADL activities and two time-related ADL activities while wearing a metabolimeter mobile device (K5, Cosmed). Task-related activities were: 1) to put on and take off socks, shoes and jacket (ADL 1); 2) to fold eight towels (ADL 2); 3) to put 6 bottles on a shelve (ADL 3); 4) to make a bed (ADL 4); 5) to go up and down 1-floor stairs (ADL 5). Time-related ADL activities were: 1) to sweep the floor for 4 minutes (ADL 6) and 2) to walk for six minute (6MWT). Metabolic load, oxygen uptake, ventilation, heart rate and symptom of dyspnea were computed for each ADL. During the program, patients performed a CPET.

Results

Fifty-six CHF patients [89% men; age 72±6 years; Ejection Fraction (EF) 38±12%; 66% with EF<40%] were enrolled. At entry, the least demanding ADL [expressed as proportion of peak oxygen uptake (VO2 peak) reached at CPET] was ADL 3 with 53,14±18.53%, while the most challenging was the 6MWT with 116.81±34.48%. Forty-two (75%) patients reached the VO2peak of CPET during 6MWT. After rehabilitation, there was a significant decrease in the time required to perform the task-related activities (ADL 1–5) [from 382.25±114.90 to 354.48±116.92 seconds, p=0.0175] and a significant increase in the distance covered during 6MWT [from 421.35±81.64 to 448.84±89.69 meters, p=0.000]. Moreover, following rehabilitation a significant decrease of heart rate in ADL1, ADL 3 and ADL 5 and a significant decrease of dyspnea in ADL 5, ADL 6 and 6MWT was recorded.

Conclusion

A comprehensive cardiac rehabilitation program can improve ADL performance due to the change of some physiological variables during effort. Further studies about the role of dedicated rehabilitation program (i.e. occupational rehab) are necessary.
P2268Incidence and prognostic impact of sepsis in patients with acute myocardial infarction complicated by cardiogenic shock - Results of the CULPRIT-SHOCK study and registry
Authors: Zeymer U , Desch S , Akin I , Ouarrak T , De Waha S , Thiele H
Published: October 2019

Background

Patients with acute myocardial infarction (AMI) complicated by cardiogenic shock (CS) have a high mortality. It has been proposed that one component is a systemic inflammatory response to shock. Some of these patients even develop sepsis. Therefore,we analyzed a large cohort of patients with AMI and CS and sought to determine the incidence of sepsis and its impact on outcome.

Methods

The CULPRIT-SHOCKtrial and registry included 1009 patients with AMI complicated by CStreated with early PCI. In the trial 686 patients were randomized to immediate multivessel PCI or culprit lesion only PCI. In the current subanalysis patients were compared in those developing sepsis during the ICU phase to thosewithout sepsis.

Results

From the total of 1009 patients 103 (10%) developed sepsis. The baseline characteristics and 30-day outcomes are shown in the table.

Sepsis (n=103) No sepsis (n=906) p-value Age (yrs) 68 68 0.8 Women 22.3% 25.3% 0.5 Diabetes 34.3% 29.7% 0.3 GFR <60 ml/min 5.8% 6.4% 0.8 CPR 54.4% 54.2% 0.8 Lactat >5 mmol/l 54.2% 50.8% 0.6 Mechanical support device 35.0% 29.1% 0.2 Bleeding 28.2% 18.8% 0.02 Need for renal replacement therapy 37.9% 9.6% <0.0001 Mortality 54.4% 45.7% 0.08

Conclusion

About 10% of patients with AMI complicated by CSdevelop sepsis. Sepsis is associated with a higher incidence of the need for renal replacement therapy, bleeding and and a trend towards higher mortality. Therefore,further research is needed to improve outcome of these very high risk patients.
P2275Left-sided deviation and fibrous-fatty infiltration of the right bundle branch in the elderly: implication for transcatheter aortic valve implantation (TAVI) procedure
Authors: Cabrera J A , Porta-Sanchez A , Nunez Pernas D , Rubio J M , Navarro F , Salvador-Montanes O , Macias Y , Nevado-Medina J , Sanchez-Quintana D
Published: October 2019

Introduction

Permanent and irreversible damage to the conduction tissue is one of the most common complications of TAVI. Detailed knowledge of the anatomy of the atrioventricular (AV) bundle is crucial to minimize the potential for injury to the His bundle branch block or complete AV block.

Purpose

Preexisting anatomic location and damage of the right bundle branch (RBB) may have important unrecognized clinical implications.

Methods

The myocardial arrangement and the presence of fibrous and fatty tissue infiltration of the AV conduction axis and right bundle branch were examined by dissection techniques and histological sections in 57 structurally normal human heart specimens (48 males, 77±7 years).

Results

The AV conduction axis enters the AV component of the membranous septum and is encircled by the fibrous tissue of the central fibrous body. The AV bundle is divided in a non-branching portion and a branching portion. After a short distance of the non-branching component along the septal crest, the RBB arises at the end of the branching portion of the conduction axis and is located superficially in the muscular ventricular septum. The RBB takes off from the bundle at the level of origin of the superior fascicle of the left bundle, passing then through the thickness of the ventricular septum to emerge beneath the medial papillary muscle of the tricuspid valve. In 22 hearts (49%) in which we found to have a relatively left-sided deviation of the AV bundle in relation to the interventricular membranous septum the RBB runs intramyocardial along the muscular interventricular septum. In the remaining 51% of the hearts the RBB runs subendocardially in the crest of the interventricular muscular septum. We found connective tissue and fatty infiltration along the right bundle branch in 23 hearts (40%) from its origin to its distal part. A significant correlation was found between age and the presence of RBB fibrosis (85% of hearts from individuals with age >80 years). These 2 conditions may make the RBB very vulnerable to self-expanding aortic valves during or after TAVI (figure).

RBB and its critical region

Conclusions

The presence of an intramyocardial location of the RBB with a lef-sided deviation and the fibro-fatty infiltration found in the mayority of senescent hearts are relevant anatomic determinants that may increase the risk of complete AV block following a TAVI procedure.