bluuebunny/crossref_metadata_2025 huggingface dataset:
P1826Computational fluid dynamic analysis of acute aortic dissection
Authors: Numata S , Keiichi I , Yamazaki S , Kanda K , Yaku H
Published: October 2019

Background

Mechanism of acute aortic dissection still is not well understood. It is very difficult to predict where, when, and how acute aortic dissection occurs. This time we focused on blood flow velocity (FV), wall shear stress (WSS), and oscillatory shear index (OSI) which is three dimensional fluctuations of WSS inside ascending aorta. It is well recognized that a higher or lower WSS may cause intimal dysfunction, which could result in the progression of atherosclerosis. Furthermore, because of the non-slip boundary mechanical equilibrium of forces, WSS will separate the inner and outer layers of the aorta. This sheer force could stress the medial tissue and result in degeneration. OSI has been reported as important hemodynamic parameter that is highly associated with the progression of atherosclerosis by inducing radical oxygen production of the endothelial cells. Therefore, OSI may be more closely associated with the degeneration of the media in comparison with WSS. This time FV, WSS, and OSI was evaluated using computational fluid dynamics to identify the location of acute aortic dissection entry.

Method

Using computed tomography data of three patients (Case A, B, C) who had acute aortic dissection, each three pre-dissection aorta model was made. Computer simulation images of four dimensional pulsatile blood flow was made and pulsatile cardiac flow from one cardiac cycle was simulated. A three-dimensional movie was made to evaluate FV, WSS, and OSI. One normal size aorta was evaluated as a control.

Results

In control, blood flow inside ascending aorta was laminar, on the contrary, spiral flow was observed in three dissection cases. FV was slightly higher in dissection case (control: 0.56m/s, A: 0.77m/s, B: 1.05m/s, C: 0.35m/s). Maximum WSS in ascending aorta was 3.24Pa in control. In dissection cases, there was patchy high (A: 18.6Pa, B: 25.6Pa, C: 4.0Pa,) WSS lesion in ascending aorta. In case A and B, these patchy high lesions are close to the entry site. In all three dissection case, OSI was high around entry site.

Figure 1

Conclusion

According to our computer simulation, patchy high WSS and high OSI lesion is related with acute dissection entry site at the ascending aorta.

Acknowledgement/Funding

None
P1827Maximum systolic flow deceleration rate in the false lumen by 4D-flow MRI is associated with aortic dilatation in patients with chronic descending aorta dissection
Authors: Ruiz Munoz A , Guala A , Dux-Santoy L , Teixido-Tura G , Sao-Aviles A , Granato C , Lopez-Sainz A , Servato M L , La Mura L , Galian L , Casas G , Gonzalez-Alujas T , Ferreira I , Evangelista A , Rodriguez-Palomares J F
Published: October 2019

Introduction

Patent false lumen (FL) in aortic dissection has been associated with poor prognosis mainly due to aortic expansion. Although morphologic variables have been related to aortic dilatation as expression of high pressure in the FL, they do not reflect flow characteristics. We propose the maximum systolic flow deceleration rate (MSDR) in the FL, quantified by 4Dflow, assuming that flow should be strongly decelerated during systole under high pressure.

Methods

Twenty-nine patients with a patent FL after aortic dissection (no Marfan syndrome) and with a follow-up of at least 3 years underwent a contrast-enhanced 4D-flow MR. FL acceleration was calculated during the cardiac cycle in a sub-volume of the descending aorta (5 cm around the level of the pulmonary bifurcation). MSDR was determined as the maximum minus the minimum acceleration in systole over the corresponding time interval (Figure 1a). Aortic growth rate (GR) was defined as the difference between final and initial aortic diameters obtained by angio-CT over the period of follow-up. Population was divided into tertiles based on GR.

Results

Demographic, clinical variables or basal aortic diameter did not show differences among GR groups (Table 1). MSDR was statistically different in patients with a GR <1mm/year (group 1) compared to fast-dilating patients (groups 2, 3) (Figure 1c). MSDR showed a positive linear correlation with GR resulting in a Pearson's correlation of 0.481 (p=0.008) (Figure 1b).

Table 1. Demographic and other variables Tertile 1 Tertile 2 Tertile 3 p-value Age (year) 63.4 (±13.5) 62.5 (±13.6) 64.6 (±6.7) 0.902 BSA (m2) 2.0 (±0.2) 1.8 (±0.2) 1.9 (±0.1) 0.213 Men 6 (86%) 4 (57%) 4 (100%) 0.210 Hypertension 4 (66%) 5 (71%) 4 (100%) 0.438 Atherosclerosis 1 (17%) 1 (14%) 0 (0%) 0.699 Initial diameter 45.0 (±7.69) 36.0 (±4.2) 37.0 (±6.5) 0.078 Final diameter 49.5 (±6.74) 44.9 (±5.7) 59.2 (±9.8) 0.049* Follow-up (year) 11.8 (±8.79) 7.9 (±3.3) 8.1 (±4.0) 0.921 Aortic GR (mm/year) 0.3 (±0.3) 1.2 (±0.3) 2.6 (±1.0) 0.001* MSDR (cm/s3) 1212 (±468) 2411 (±1034) 2558 (±1098) 0.005* Values are mean (±SD) or n (%).

Conclusion

MSDR of flow in the FL derived from 4D-flow RM is related to GR of dissected descending aorta. It is useful to discriminate mild vs. significant aorta enlargement and identify patients who may benefit from earlier therapy.
P1828Aortic calcification detected by computed tomography and aortic vulnerable plaques: aortic angioscopy study
Authors: Kojima K , Ebuchi Y , Migita S , Morikawa T , Mineki T , Tamaki T , Akutsu N , Murata N , Kitano D , Sudo M , Fukamachi D , Takayama T , Hiro T , Hirayama A , Okumura Y
Published: October 2019

Background

Aortic calcification is associated with atherosclerotic risk factors and an increased risk of death and cardiovascular disease. However, the relationships aortic calcification and aortic plaque instability are not yet elucidated. Recently, some reports showed non-obstructive aortic angioscopy seemed to visualize atherosclerotic changes of aortic wall more clearly compared with computed tomography (CT). The purpose of this study was to evaluate whether aortic calcification is associated with aortic vulnerable plaques in patients with cardiovascular disease.

Methods

We investigated 60 consecutive patients with confirmed or suspected coronary artery disease who underwent both aortic angioscopy and CT. The AC volume (ACV) was measured using the volume-rendering method by extracting the area >130 HU within the whole aorta. ACV index (ACVI) was defined as ACV divided by the body surface area. We evaluated the number of ruptured plaque (RP), ulceration and fissure by aortic angioscopy in the whole aorta. We excluded 4 hemodialysis patients. All patients were divided into the median value of ACVI.

Results

The mean age of patients was 68±10. The median of ACVI was 10.7 ml/m2 [3.9–22.7]. High ACVI patients had significantly greater number of RP, ulceration and atheromatous plaques detected by aortic angioscopy compared with those of low ACVI (2.2±2.7 vs 0.8±1.1, p=0.033, 1.6±1.2 vs 0.9±1.0, p=0.041, 4.0±3.1 vs 1.9±1.8, p=0.009, respectively). Furthermore, the patients without aortic calcification did not have RP at all. In a multivariate model, the number of the atheromatous plaques was independently associated with high ACVI (odds ratio 1.57, 95% confidence interval 1.07–2.69, p=0.018)

Conclusions

Aortic calcification detected by CT was related to aortic vulnerable plaques in patients with cardiovascular disease.
P1829Accumulation of advanced glycoxidation end products (AGEs) is associated with the severity of aortic stenosis in patients with concomitant type 2 diabetes
Authors: Kopytek M , Zabczyk M , Undas A , Natorska J
Published: October 2019

Background

Accumulation of advanced glycoxidation end products (AGEs) leads to chronic inflammation, glycation of proteins and tissue damage, particularly in patients with diabetes mellitus (DM).

Purpose

To evaluate whether increased valvular accumulation of AGEs in patients with aortic stenosis (AS) and concomitant diabetes (AS-DM) is associated with enhanced valvular inflammation, increased oxidative stress and AS progression.

Methods

We enrolled 50 patients (28 women), aged 67.2±7.9 years with severe AS (transvalvular gradients: PGmean=52.9±13.4 mmHg, PGmax=84.9±18.7 mmHg), including 30 subjects with type 2 DM (glycaemia 6.3±1.9 mM/l, glycated haemoglobin [HbA1c] 6.9±1.4%), who underwent aortic valve replacement. Valvular expression of AGEs, AGE receptors (RAGE), interleukin-6 (IL-6), prothrombin (FII), C-reactive protein (CRP), and reactive oxygen species (ROS) were evaluated ex vivo by single/double-immunostaining. The percentage of immuno-positive areas was analyzed for each valve.

Results

There were no differences with regard to age and AS severity between AS and AS-DM patients. Subjects with AS-DM had elevated valvular expression of both AGE and RAGE (41.3±15.2% and 17.6±7.1%, respectively) as compared to non-DM (9.4±3.9% and 3.4±2.4%, respectively; all p<0.001). In AS-DM patients AGE/RAGE showed co-expression in 51.5% of areas. The percentage of ROS-, CRP-, and IL-6-positive areas was elevated within AS-DM compared to AS valves (10.9±2.4%, 6±0.3%, and 5.7±1.4% vs 4.8±1.7%, 2.5±0.1%, and 1.6±0.9%, respectively; all p<0.05). Valvular expression of FII was elevated in AS-DM patients compared to those with AS (17.3±2.5% vs. 11±2%, p<0.05). In AS-DM patients the percentage of valvular AGE-positive areas correlated with HbA1c (r=0.44, p<0.05) and blood glucose levels (r=0.57, p<0,05). The amount of valvular RAGE correlated with HbA1c (r=0.63, p=0.009) but not with blood glucose levels. In AS-DM patients we found positive associations between the amount of valvular AGE and IL-6 with disease severity measured as aortic valve area (AVA; r=−0.83, p<0.0001; r=−0.64, p<0.001, respectively) and PGmax (r=0.54, p<0.05; r=0.52, p<0.05, respectively) but not with PGmean. There were no associations between PGmax/PGmean and HbA1c levels in the whole AS-DM group. However, patients with HbA1c >6.5% (n=19) or ≤6.5% (n=11) were characterized by higher PGmax and PGmean compared to those with HbA1c ≤6.5% (93.3±8.9 mmHg vs 67.5±7.2 mmHg and 63.6±6.5 mmHg vs 52±77 mmHg, respectively, all p<0.05).

Conclusions

Patients with AS-DM compared to those with AS demonstrate enhanced valvular AGEs accumulation and increased RAGE expression along with accelerated inflammation and oxidative stress. The accumulation of valvular AGE correlated with both hyperglycaemia and AS severity.

Acknowledgement/Funding

This work was supported by the grant from the Polish National Science Center (UMO-2015/19/B/NZ5/00647 to J.N).
P1830The Relationship between Spontaneous Ruptured Aortic Plaques/Injuries and Cardiovascular
Authors: Komatsu S , Takahashi S , Yutani C , Kodama K
Published: October 2019

Background

Non-obstructive general angioscopy has enabled to demonstrate high incidence of various types of spontaneous ruptured aortic plaques/injuries (SRAPIs).

Purpose

The aim of the study is to clarify the relationship between SRAPI and cardiovascular risk factors.

Methods

A total of 439 consecutive patients who had or suspected coronary artery disease were performed angioscopy and were screened SRAPI from ascending aorta to iliac artery. The incidence and the number of SRAPI were analyzed. Association between the total number of total SRAP and patients' characteristics were analyzed.

Results

The total number of SRAPI detected was 2211, 10 [4,22](median [IQR]) per patient.

The numbers of high incidence of representative SRAPI, such as erosion, intramural bleeding, puff-chandelier rupture, puff rupture, fissure, flap, bleeding from fissure, and subintimal bleeding were 327, 313, 268, 262, 224, 167, 120, and 91, respectively. Stepwise multiple linear regression analysis indicated that age, smoking, HbA1c, and coronary heart disease significantly affected the numbers of overall SRAPI (Table).

Conclusions

SRAPIs were associated with cardiovascular risk factors.
P1832Myocardial injury assessed by T1 mapping after on-pump and off-pump coronary artery bypass grafting. a pre-specified analysis of mass V trial
Authors: Dallazen A R , Hueb W , Rezende P C , Boros G A B , Ribas F F , Nomura C H , Rochitte C E , Morais T , Lima E G , Martins E B , Carvalho G F , Ribeiro M O L , Serrano Junior C V , Ramires J A F , Kalil Filho R
Published: October 2019

Background

Myocardial structural damage may occur during coronary artery bypass grafting (CABG) surgery and is identified by the significant release of cardiac biomarkers. However, the evidence of these structural myocardial changes after CABG by current imaging methods remains unknown. To evaluate myocardial structure, we used the T1 mapping of cardiac magnetic resonance (CMR) before and after on-pump and off-pump CABG.

Methods

Patients with multivessel coronary artery disease and preserved ventricular function were included and underwent on or off-pump CABG. CMR and T1 mapping were performed using the MOLLI technique (modified Look-Locker inversion-recovery). Values of native T1 and extracellular volume fraction (ECV) were compared before and after on and off-pump procedures.

Results

Of 110 eligible patients, 34 were excluded due to the presence of new late enhancement or edema. Of 76 patients remained, 32 (42%) underwent on-pump (Group A) and 44 (58%) off-pump CABG (Group B). All baseline characteristics were similar between groups, besides the Syntax Score that was higher in Group A (25 × 21, p=0.002). For group A, native T1 before and after procedures was 1013 ms (998–1043) and 1004 ms (793–1048), p=0.19, and ECV was 26.4 (23.9–27.6) and 31.2 (27.6–33.9), p<0.001. For group B, native T1 before and after procedures was 1015 ms (970–1044) and 992 ms (867–1051), p=0.003, and ECV 27.5 (25.3–29.9) and 30.3 (26.5–34.3), p=0.02. The comparison of native T1 difference before and after procedures between groups A and B was not significant (Delta T1 −9.8 (−102 to 51.8) × −25.4 (−119 to 51,2), p=0.87. However, the difference of ECV between groups was statistically significant (ECV Delta 3.8 (2.2 to 7.1) × 1.3 (−1.1 to 4.9), p=0.039, respectively, for groups A and B.

Figure 1

Conclusion

In this sample, T1 mapping identified significant myocardial structural changes in both surgical revascularization procedures. Additionally, a marked myocardial injury generated by ECV changes were observed after on-pump CABG.
P1835Application of SYNTAX score I, II and residual SYNTAX as predictors of long-term clinical outcomes after coronary artery bypass grafting
Authors: Martins E B , Hueb W , Lima E G , Rezende P C , Garzillo C L , Carvalho G F , Carvalho F P C , Linhares Filho J P P , Batista D V , Silva R R , Boros G A B , Azevedo D F C , Serrano Junior C V , Ramires J A F , Kalil Filho R
Published: October 2019

Background

The evaluation of coronary disease by SYNTAX score I (SSI) is used to grade coronary complexity. Following SSI, two other scores were developed: SYNTAX score II (SSII) and residual SYNTAX score (rSS). Nevertheless, there is still a lack of evidence about the prognostic significance of these scores among patients undergoing CABG.

Purpose

Our aim was to evaluate the relation of the SSI, SSII and rSS score with outcomes in a long-term follow-up after elective CABG.

Methods

This is a single center, registry-based study. Baseline SSI was calculated from patients undergoing CABG by interventional cardiologists. SSI results were considered as usual: <23, 23–32 and >32. SSII and rSRR were then calculated and categorized in tertiles: <21.4, 21.4–29.4 and >29.4 for SSII and 0, 1–5 and >5 for rSS. Primary outcome was a composite of overall death, myocardial infarction, additional revascularization, or stroke (MACCE).

Results

Data were obtained from 559 patients. Median follow-up was 6 years (IQR: 4.9–9.8) and 170 events were documented. The Kaplan-Meier curves (figure 1) showed significant differences of MACCE in higher SSI, SSII and rSS (p=0.039, 0.033, <0.001 respectively). After multivariate adjustment, rSS, ejection fraction (EF) and age were found to be independent predictors of MACCE (p<0.001, 0.034 and 0.006, respectively).

Figure 1

Conclusion

In this sample SSI, II and residual were associated with the occurrence of events. However, just the rSS remained an independent predictor of MACCE together with age and EF.
P1836Constrictive pericarditis after open heart surgery: a 20-year case controlled study
Authors: Moreyra A E , Yang Y , Zinonos S , Cosgrove N M , Cabrera J , Kostis W J , Shindler D M , Kostis J B
Published: October 2019

Background

Constrictive pericarditis (CoPe) after open-heart surgery (OHS) is a rare complication. Information on the incidence, determinants, and prognosis of this condition has been scarcely reported.

Purpose

To investigate the long term prognosis of CoPe after OHS.

Methods

Using the Myocardial Infarction Data Acquisition System database, we analyzed records of 144,902 patients that had OHS in New Jersey hospitals between 1995 and 2015. CoPe was identified in 79 patients after discharge. Differences in proportions were analyzed using chi square. Cases and controls were matched for demographics and comorbidities. Cox proportional hazard models were used to evaluate outcome risks. Log-rank test was used to assess differences in the Kaplan-Meier survival curves.

Results

Patients with CoPe were more likely to have history of valve disease (HVD) (p<0.0001), atrial fibrillation (AF) (p=0.0006) and chronic kidney disease (CKD) (p=0.012). Significant predictors of CoPe were AF (HR 1.62, 95% CI 1.02–2.59), CKD (HR 2.70, 95% CI 1.53–4.76), diabetes (HR 1.73, 95% CI 1.08–2.80) and HVD (HR 3.11, 95% CI 1.88–5.15). Patients with CoPe compared to matched controls had a higher 10-year mortality (p<0.0001). This became a statistically significant difference at 6 years after surgery (Figure).

Survival Curve

Conclusion

Constrictive pericarditis is a rare complication of OHS and occurs more frequently in patients with AF, CKD, diabetes and HVD. It is associated with an unfavorable long-term prognosis. The data highlight the need for strategies to help prevent this complication.

Acknowledgement/Funding

Robert Wood Johnson Foundation
P1840Mid-term results of bioprosthetic aortic valve replacement with the Trifecta valve: A word of caution
Authors: Werner P , Russo M , Seewald M , Coti I , Haberl T , Laufer G , Kocher A , Andreas M
Published: October 2019

Background

Structural valve deterioration (SVD) with associated bioprosthetic valve dysfunction remains an unsolved problem, exposing patients to the risk of aortic valve re-intervention after surgical aortic valve replacement (SAVR). Several strategies have been proposed to improve prosthesis design for optimal performance. The leaflets of the Trifecta valve are mounted on the outside of the prosthetic stent to achieve a larger orifice area. Although favourable early clinical outcomes have been reported, long-term durability still needs to be assessed.

Purpose

The aim of the current study was to assess the mid-term overall mortality and re-intervention rate in patients who received a Trifecta valve with a follow-up >5 years.

Methods

Patients who underwent SAVR at our centre between 2011 and 2012 were identified in the internal, prospective database. All patients with implantation of a Trifecta valve in aortic position were included. Primary endpoints were freedom from overall mortality and from re-operation at latest follow-up (FU). Additionally, assessment of echocardiographic parameters at baseline and follow-up was performed.

Results

Seventy-six patients (age 77.3±9.5 years, BMI 28.6±5.8, 68% male) were included in the study. EuroScore II was 7.2% (± 7.7) while mean STS-Mortality score was 2.4±1.1%. Of all procedures, 53% were isolated aortic valve replacements, whereas concomitant procedures were performed in 47% of cases (37% CABG, 12% mitral surgery, 8% tricuspid surgery). Baseline echocardiographic assessment showed a mean pressure gradient (MPG) of 51±21 mmHG, a peak pressure gradient (PPG) of 78±36 mmHG and a peak velocity (Vmax) of 4.2±1.1 m/s.

Thirty-day mortality was 7%. Freedom from overall mortality at 1 year and 5 years was 84% and 73%, respectively. Freedom from death and freedom from re-operation at latest FU (6.7±0.5 years) was 68% and 90%, respectively. In a composite endpoint analysis, freedom from death or re-intervention at latest follow up was 60%. A total of 7 patients underwent aortic valve re-interventions (re-replacements n=5, valve-in-valve n=2). Indications for re-interventions were SVD (n=5), NSVD (n=1, pannus ingrowth) and endocarditis (n=1). One case of re-stenosis occurred in a patient who was deemed not feasible for aortic valve re-intervention and died.

Kaplan Meier analysis

Conclusion(s)

To our knowledge, this patient cohort presents with the lowest rate of freedom from re-operation (90%, 6.7±0.5 years) after SAVR with the Trifecta valve. A relatively high number of SVD and NSVD has been observed, which might be attributable to the specific leaflet mounting or the deformable valve frame of the first generation. Current results call for further investigation with prospective echocardiographic follow-up in this patient group.

Acknowledgement/Funding

None
P184511 years of transcatheter aortic valve implantation in a single centre and outcomes for all 1004 patient cases completed
Authors: Brennan P F , Wilson S J , Alkhalil M , Santos A , McNiece A , Johnston N G , Jeganathan R , Owens C G , Manoharan G , Spence M S
Published: October 2019

Background

Long-term outcome data after TAVI is of key importance as indications have extended from high risk patients to intermediate risk alongside contemporary study of low risk patients.

Purpose

We report our complete 11 y experience of TAVI.

Methods

All patients (n=1004) treated with TAVI in our institution between Feb 2008 & Nov 2018 were included. Data was collected prospectively and all death certificates were reviewed. Independent predictors of mortality were determined by multivariable cox proportional hazard modelling. Annular sizing was performed via echocardiography +/or angiography until Aug 2012 after which time cardiac CT was used.

Results

Patients were 53% female & had mean age 81.9±6.6 y, logistic EuroScore 18.5%. 89% were NYHA >2, and 26.7% had a left ventricular ejection fraction (LVEF) of <50%. TAVI was performed for severe degenerative aortic valve disease (93.5%), while valve-in-valve (2.4%) bicuspid (2.1%) & rheumatic (2%) made up the remainder. Self-expanding valves were implanted in 73% cases. 98% cases were performed under local anaesthesia. A percutaneous transfemoral approach was used in 92% cases. For the first 6 y 19% procedures were performed for urgent inpatients, rising to 42% over the last 5 y. The mean time to discharge was 5.5 d, overall, & 60% cases were discharged within 72 h in the last 5 y. Mortality, for those at risk, was 3.2%, 12.8%, 53% & 88% at 30 d, 1 y, 5 y & 10 y. The median time to death was 2.6 y. Non-cardiac death accounted for 62% deaths, with sepsis being the main cause (55%). The main cause of cardiac death was heart failure (HF (53%)). Independent clinical predictors of death were increased age, atrial fibrillation, pulmonary disease & LVEF <50%. Use of a 2nd generation valve was associated with better survival at 5 y (p<0.001).

30 d new permanent pacemaker and stroke incidence were 13.7% and 2% respectively. 30 d readmission occurred in 13% patients. Independent clinical predictors of 1 y HF (7%) readmission were NYHA Class >2 and LVEF <50%. Endocarditis was seen in 1.6% during a mean follow-up 2,593 patient y. Mean aortic gradients at 1 y, 5 y & 10 y were 9.7mmHg, 8.4mmHg & 10.53mmHg. One patient had severe trans-aortic regurgitation during the follow-up. A 2nd TAVI procedure was performed in 5 patients with clinically significant paravalvular regurgitation, all within 30 d.

Figure 1. A. Survival. B. Predictors death

Conclusion

This comprehensive evaluation of all patients treated with this innovative technology provides reassurance regarding the long-term clinical efficacy of TAVI & gives insight into the evolution of our programme with time.
P1864Primary predictor of esophageal injury after catheter ablation of atrial fibrillation
Authors: Ito M , Kanazawa H K , Kaneko S K , Kanemaru Y K , Kiyama T K , Arima Y A , Takashio S T , Yamamoto E Y , Kaikita K K , Fujisue K F , Sueta D S , Usuku H U , Suzuki T S , Sakamoto K S , Tsujita K T
Published: October 2019

Background

It has been demonstrated that the short distance between the esophagus and the posterior left atrium (LA) is closely associated with the occurrence of esophageal injury (EI) after catheter ablation of atrial fibrillation (AF). Meanwhile, it has not been fully elucidated whether esophageal temperature monitoring sufficiently prevent EI.

Objectives

The purpose of this study was to examine the usefulness of esophageal temperature monitoring for avoiding EI. Further we analyzed the relation between the incidence of EI and the distance between the esophagus and the posterior LA measured on the contrast computed tomography (CT).

Methods

Among 403 patients who underwent catheter ablation of AF, upper gastrointestinal tract endoscopy was performed the next day after ablation to examine for EI. The incidence of EI was compared between 95 patients who used esophageal temperature probe (ETP) (ETP Group) and 308 patients who did not used ETP (Non-ETP Group) during ablation. The shortest distance between esophagus and posterior LA measured on contrast CT (SD-CT) was also compared between the ETP and Non-ETP Groups.

Results

In all patients, EI was found in 35 patients (8.6%). The SD-CT in patients with EI was significantly lower than that in patients without EI (2.3±0.6 vs 4.1±0.8 mm, p<0.001).

No differences were observed between the two groups in terms of age, body mass index, LA diameter, esophageal course, total number of radiofrequency (RF) energy applications, total amount of RF energy applications, or the location of SD-CT. Also, EI occurred at nealy the same frequency between the ETP Group and Non-ETP Group (8/95 patients; 8.4% vs 27/308 patients; 8.8%, p=0.553). The severity diagnosed as moderate (erosion) in 3 patients and mild (erythema) in 5 patients of ETP Group, and as severe (ulcer) in 23 patients and mild (erythema) in 4 patients of Non-ETP Group. There was no significant difference in the SD-CT between the ETP Group and Non-ETP Group (3.96±0.98 vs 4.19±1.01 mm, p=0.54). However, the SD-CT in patients with EI was significantly shorter than the SD-CT in patients without EI, both in the ETP Group (2.3±0.6 vs 4.1±0.9 mm, p<0.001) and in the Non-ETP Group (2.5±0.2 vs 4.2±0.9 mm, p=0.017), respectively. Multiple regression analysis revealed that only SD-CT significantly correlated with EI. The area under a receiver operating characteristic curve using ST-CT as a predictive marker in EI patients was 0.971 (p<0.001). When the cut-off value of EI was set at 2.9mm, the sensitivity and specificity for EI diagnosis were 96.6% and 87.5%.

Conclusions

The incidence of EI was significantly correlated with SD-CT. Esophageal temperature monitoring did not reduce EI, however, the use of monitoring alleviated the severity of EI, especially in patients with short SD-CT.

Acknowledgement/Funding

None
P1867Diagnostic value of fragmented QRS complex and early repolarization pattern in detecting myocardial fibrosis and inflammatory
Authors: Gordeeva M , Karlina V , Parmon E , Shlyakhto E
Published: October 2019

Myocardial fibrosis (MF) and inflammatory (MI) play a significant role in pathogenesis of arrhythmias, heart failure and sudden cardiac death. Endomyocardial biopsy (EMB) and cardiac magnetic resonance with late gadolinium enhancement (CMRI-LGE) are used to detect this structural abnormalities. These methods are very informative but not a screening. ECG patterns: fragmented QRS complex (fQRS) and early repolarization (ERP) can be used as markers of MF and MI.

Purpose

To analyze the relationship between structural changes of myocardium, determined using by CMRI-LGE and EMB and fQRS and ERP.

Materials and methods

We analyzed results of CMRI-LG, EMB and 12-lead ECG in 46 patients (28 male, median age – 47.3±12.7). We used the criteria by Das M., 2006 to identify FQRS and the criteria by Macfarlane P.W., 2015 to identify ERP.

Results

Based on the results of CMRI-LGE and EMB all patients were divided into 3 groups: 1st – 20 patients (70% male, median age 56 (48.5; 58.5)) with acute inflammatory (more then 14 leucocytes per mm2) and myocardial fibrosis (detecting by EMB and/or CMRI-LGE); 2nd group – 20 patients (65% male, median age 37 (28.0; 49.5)) with myocardial fibrosis without inflammatory changes; 3rd group – 6 patients without fibrosis or inflammatory. In the 1st group fQRS were detected in 7 (35%) patients, ERP – 6 (30%). In the 2nd group fQRS were detected in 5 (25%) patients, ERP – 6 (0%). In the 3rd group fQRS were not detected in 7 (35%) patients, ERP – 6 (30%).

We assessed sensitivity and specificity of fQRS and ERP in detected MF and MI by comparing with CMRI-LGE and EMB (table 1).

Sensitivity and specificity ECG patterns Myocardial fibrosis Myocardial inflammatory ECG pattern Method Sensitivity Specificity ECG pattern Method Sensitivity Specificity FQRS EMB 76.9% 39.4% FQRS EMB 53.8% 63.6% MRI 83.3% 56.0% MRI 30.8% 84.0% ERP EMB 42.9% 30.8% ERP EMB 85.7% 66.7% MRI 50.0% 41.9% MRI 33.3% 81.3% FQRS, fragmented QRS; ERP, early repolarization pattern; EMB, endomyocardial biopsy; MRI, cardiac magnetic resonance with late gadolinium enhancement.

Conclusions

FQRS have significant sensitivity (83.3%) and specificity (56%) for detecting MF. And ERP has significant sensitivity (85.7%) and specificity (66.7%) for detecting MI. This ECG patterns could be discussed as screening markers of structural myocardial abnormalities.
P1872Canadian electrophysiology labs registry report update 2011–2018
Authors: Kaoutskaia A , Shurrab M , Amit G , Parkash R , Exner D , Toal S , Sterns L , Sarrazin J F , Glover B , Chauhan V , Sultan O , Nair G , Deyell M W , Macle L , Crystal E
Published: October 2019

Background

Interventional cardiac electrophysiology (EP) is rapidly evolving; a nationwide registry was established and re-administered since 2011 to conduct a periodic review of resource allocation across Canada.

Methods

The registry collects annual data on EP lab infrastructure, imaging, tools, human resources, procedural volumes, and wait times. Leading physicians from each EP lab were contacted electronically.

Results

All Canadian EP centres were identified (n=30); 50% and 45% of active centres participated in the last 2 instalments of the registry. Since 2011, data has been consistently obtained from 11 university-affiliated centres. Table 1 reports trends in procedural volumes and operators. Figure 1 depicts the ablations done per operator. The mean wait time to see an electrophysiologist for an initial non-urgent consult is 23 weeks. The wait time between an EP consult and ablation date is 17.8 weeks for simple ablation, 15.9 weeks for VT ablation, and 30.1 weeks for AF ablation. On average centres have 2 (range: 1–4) rooms equipped for ablations; each centre uses the EP lab an average of 7 shifts per week. While diagnostic studies and radiofrequency ablations are performed in all centres, point-by-point cryoablation is available in 85% and cryoballoon in 77% of the centres; 38% of the respondents use circular ablation techniques.

Trends in procedural volumes + operators 2015–2016 2013–2014 2011–2012 Procedures per operator 117±70 120±68 113±42 Procedures per centre 498±299 477±245 446±237 Ratio of staff to trainees 2.0:1 1.6:1 1.5:1 Full time physicians per centre 4.1 (0–7) 4.1 (1–7) 3.5 (0–7) Nurses trained specifically for EP 4.6 (0–10) 4.4 (0–10) n/a Ablation procedures volume:   AV Reciprocal Tachycardia 12% 10% 11%   AV Nodal Re-entry Tachycardia 18% 19% 23%   Atrial Fibrillation/Atypical Flutter 33% 35% 30%   Typical Flutter 20% 14% 19%   Ventricular Tachycardia 8% 8% 10%   Total annual ablations in all respondent centres 5478 5243 4908 Mean ± standard deviation. Staff (full-time + part-time prorated to 0.5).

Annual ablation volumes per operator

Conclusion

This initiative provides contemporary data on invasive EP practices. The results show feasibility in data collection which will serve as a reference for decisions regarding resource planning.
P1876Atrial fibrillation related symptoms and cardiovascular outcomes
Authors: Krisai P , Blum S , Aeschbacher S , Beer J H , Moschovitis G , Witassek F , Kobza R , Rodondi N , Mahmood A , Meyer-Zuern C , Kuehne M , Osswald S , Conen D
Published: October 2019

Background

Comprehensive information on the impact of atrial fibrillation (AF)-related symptoms and quality of life (QoL) on adverse outcomes is sparse.

Purpose

We aimed to investigate whether AF-related symptoms and/or QoL are associated with cardiovascular outcomes in a large cohort of AF patients.

Methods

A total of 3902 participants with documented AF from two nationwide prospective cohort studies in Switzerland were included. Information on AF-related symptoms was assessed yearly by standardized questionnaires, QoL was quantified using a visual analog scale (0–100, with higher scores indicating better QoL). The primary endpoint was a composite of stroke and systemic embolism. The secondary endpoint was a composite of cardiovascular death, hospitalization for heart failure and myocardial infarction. We assessed associations using multivariable, time-updated Cox proportional-hazards models including age, sex, study cohort, history of heart failure, hypertension, diabetes, prior stroke, prior myocardial infarction, vascular disease and prior catheter ablation for AF as covariates.

Results

Mean age was 72 years, and 72% were male. The median QoL score was 75 points, and 2572 (66%) participants had AF-related symptoms. Symptomatic individuals were younger (71 vs 75 years) and had more often paroxysmal AF (29 vs 23%) (p for both <0.001). The most frequent symptoms were palpitations (42%), dyspnea (25%) and fatigue (18%). In multivariable, time-updated models, the hazard ratio (HR) was 1.24 (95% confidence intervals (CI) 0.72; 2.11, p=0.43) for the primary endpoint and HR 0.83 (95% CI 0.65; 1.06, p=0.14) for the secondary endpoint in symptomatic vs non-symptomatic individuals. There was a significant, inverse association for a 5-point increase in the QoL score with both the primary (HR 0.94 (95% CI 0.88; 0.99), p=0.04) and secondary (HR 0.91 (95% CI 0.88; 0.93), p<0.0001) endpoints.

Conclusions

AF-related symptoms are not associated with adverse cardiovascular events in AF patients. In contrast, QoL is inversely associated with to adverse cardiovascular outcomes.
P1882Association between acute hepatitis B flare and long-term clinical outcomes in patients with atrial fibrillation
Authors: Im S I , Park H S
Published: October 2019

Background

Relationship between AF and inflammation was shown in previous studies. However, there was limited data about the association between the acute hepatitis B flare (AVHF-B) and AF in the long-term follow-up.

Purpose

The aim of this study was to evaluate the association of AVHF-B and long-term clinical outcomes in patients with AF.

Methods

Our University echocardiography, electrocardiogram (ECG) and hepatitis B database were reviewed from 2008 to 2017 to identify patients with AF and AVHF-B. Patients were followed for a mean 26.4±0.9 months and were divided into two groups according to the absence or presence of AVHF-B with AF.

Results

Among 280 patients with AF, 100 (35.7%) patients had AVHF-B. Total any event rates were significantly higher in patients with AVHF-B compared to those without AVHF-B (P<0.001). Arrhythmias including AF, atrial tachycardia,APC, VT, and VPC also occurred in 54 (19.3%) patients, with a significantly higher incidence in patients with AVHF-B than in those without AVHF-B (P<0.001). In univariate analysis, CHA2DS2 VASc, Left atrial diameter (LAD), E/E' (the peak mitral flow velocity of the early rapid filling wave/early diastolic mitral annulus velocity) and AVHF-B were significantly associated with arrhythmic events and total any events including thromboembolic events, arrhythmic events, re-hospitalizations and mortality. In multivariate analysis, AVHF-B was independent risk factors for arrhythmic events (P=0.031) at the long-term follow-up.

Conclusion

The patients with AVHF-B were associated with higher arrhythmic events and total any events, suggesting more intensive medical therapy with close clinical follow-up will be required.

Acknowledgement/Funding

None
P1887Development and validation of a novel premature ventricular contraction detector in an insertable cardiac monitor
Authors: Rajagopal G , Sarkar S , Reiland J , Koehler J , Lustgarten D L
Published: October 2019

Background

High premature ventricular contraction (PVC) burden may increase the risk of cardiac arrhythmias, PVC-induced cardiomyopathy and heart failure.

Purpose

We developed and validated an algorithm for continuous long-term monitoring of PVC burden in implantable loop recorders or insertable cardiac monitors (ICM).

Methods

The PVC algorithm uses long-short-long RR interval sequence and similarity and differences in r-wave morphology for three consecutive beats to detect the occurrence of a single PVC beat. Various threshold combinations were used for long-short-long RR interval sequence and degree of difference and similarity of R-wave morphology to be able to detect various types of PVCs including monomorphic, polymorphic, bigeminal, trigeminal, and interpolated PVCs. For example, a high degree of difference in R-wave morphology only required the short interval to be less than the longer interval by a smaller amount. The algorithm was designed with the intention to achieve minimum over reporting of PVC burden, i.e. maximum specificity. The algorithm was developed and validated using ECG strips stored in an ICM from real world patients. Gross, patient average and generalized estimating equation (GEE) estimates for sensitivity, specificity, positive and negative predictive value are reported.

Results

The PVC detection algorithm was developed using 87 2-minute ECG strips recorded by an ICM containing 2129 single PVC beats and 12,402 non-PVC beats to obtain a gross sensitivity and specificity of 75.9% and 98.8%. The validation data cohort consisted of 787 ICM recorded ECG strips 7–10 minutes in duration from 134 patients, providing over 460,000 beats of which 439,106 (94%) were normal beats, 8398 (2%) single PVC beats and 16,634 (4%) noisy beats. Couplets and triplets were excluded. Table 1 shows the performance results of the PVC detection algorithm in this validation set.

Performance of PVC detector Gross Patient average GEE (95% CI) Sensitivity 75.2% 69.9% 72.5% (65.8–78.3) Specificity 99.6% 99.4% 99.4% (99.2–99.6) Positive Predictive Value (PPV) 75.9% 40.6% 40.6% (33.6–48.0) Negative Predictive Value (NPV) 99.5% 99.6% 99.6% (99.3–99.7)

Conclusions

The PVC detection algorithm was able to achieve a high specificity, which ensures that 99.6% of the normal events are not incorrectly identified as PVCs, while detecting 75% of PVCs on a continuous long-term basis in insertable cardiac monitors. The accuracy of PVC burden estimates during continuous monitoring using this algorithm needs further validation using Holter studies.

Acknowledgement/Funding

Medtronic Plc
P1890Pioglitazone inhibits diabetes-induced atrial mitochondrial oxidative stress and improves mitochondrial biogenesis, dynamics and function through the PGC-1 signaling pathway
Authors: Liu T , Zhang Z , Zhang X , Meng L , Gong M , Li J , Qiu J , Suo Y , Liang X , Wang X , Jiang N , Tse G , Li G , Zhao Y
Published: October 2019

Background

Oxidative stress contributes to adverse atrial remodeling in diabetes mellitus. This can be prevented by the PPAR-γ agonist pioglitazone through its anti-oxidant and anti-inflammatory effects.

Purpose

In this study, the molecular mechanisms underlying these effects were investigated.

Methods

Rabbits were randomly divided into control (C), diabetic (DM), and pioglitazone-treated DM (Pio) groups. Echocardiographic, hemodynamic, electrophysiological, intracellular Ca2+ properties were measured. Serum PPAR-γ levels, serum and tissue oxidative stress and inflammatory markers, mitochondrial morphology, reactive oxygen species (ROS) production rate, respiratory function, and mitochondrial membrane potential (MMP) levels were measured. Protein expression of pro-fibrotic marker transforming growth factor β1 (TGF-β1), and the mitochondrial proteins (PGC-1α, fission and fusion-related proteins) were measured.

Results

Compared with controls, the DM group demonstrated larger left atrial diameter and fibrosis area associated with a higher incidence of inducible AF. Lower serum PPAR-γ level was associated with lower PGC-1α, higher NF-κB and higher TGF-β1 expression. Mn-SOD protein was not different but lower mitochondrial fission- and fusion-related proteins were detected. Mitochondrial swelling, higher mitochondrial ROS, lower respiratory control rate, lower MMP and higher intracellular Ca2+ transients were observed. In the Pio group, reversal of structural remodeling and lower inducible AF incidence were associated with higher PPAR-γ and PGC-1α. NF-κB and TGF-β1 were lower and biogenesis, fission and fusion-related protein were higher. Mitochondrial structure and function, and intracellular Ca2+ transients were improved. In HL-1 cell line, transfected with PGC-1α siRNA blunted the effect of pioglitazone on Mn-SOD protein expression and MMP collapse in H2O2-treated cells.

Conclusion

Diabetes mellitus induces adverse atrial structural and electrophysiological remodeling, abnormal Ca2+ handling and mitochondrial damage and dysfunction. Pioglitazone prevented these abnormalities through the PPAR-γ/PGC-1α pathway.

Acknowledgement/Funding

National Natural Science Foundation of China (No 81570298, 81270245, 30900618 to T.L.)
P1891CD8+CD28null T lymphocytes are associated with the development of atrial fibrillation after elective cardiac surgery
Authors: Kazem N , Sulzgruber P , Thaler B , Koller L , Pilz A , Fleck T , Laufer G , Steinlechner B , Wojta J , Niessner A
Published: October 2019

Background

Post-operative atrial fibrillation (POAF) is assumed as a complex and multifactorial interaction of different pathogenic factors. Data suggests an inflammatory process as a main trigger of this specific type of atrial fibrillation. CD8+ T lymphocytes that lack the surface protein CD28 were found to be crucially involved in chronic inflammatory processes within the cardiovascular system. Of utmost interest, these so called CD8+CD28null T cells are known to present with auto-aggressive behavior and deleterious cytotoxic effects on human tissue. Therefore, the impact of cellular immunity on the development of POAF was sought to assess.

Methods

To elucidate the impact of cellular immunity on the development of POAF, we prospectively enrolled 129 patients undergoing elective cardiac valve and/or coronary-artery-bypass-graft surgery. Fluorescein-activated cell sorting (FACS) was performed to investigate lymphocyte subsets. Patients were stratified in two subgroups according to patients developing POAF (n=60) and individuals free of POAF (n=69). Binary logistic regression analysis was performed to assess the impact of cellular immunity on the development of POAF.

Results

Comparing patients developing POAF to individuals free of POAF the fraction of CD8+ lymphocytes was significantly higher in individuals developing POAF (30.5% [POAF] vs. 25.7% [non-POAF]; p=0.021) Interestingly, the fraction of CD8+CD28nullT-lymphocytes was significantly higher in the POAF sub-group (66.7% [POAF] vs. 61.6% [non-POAF]; p=0.043). Binary logistic regression further proved that the fraction of CD8+CD28null T cells was a strong prognosticator for the development of POAF with a crude odds ratio per one standard deviation of 3.45 (95% CI 1.11–10.70; p=0.032). The prognostic potential remained stable after adjustment for potential confounders (age, male gender and type of surgery) within the multivariate model with an adjusted odds ratio per one standard deviation of 3.21 (95% CI 1.01–10.18; p=0.048).

Conclusion

We found that cytotoxic CD8+CD28null T lymphocytes proved to be a strong and independent predictor for the development of POAF after elective cardiac surgery. Our results potentially indicate an auto-immune impact of this preexisting, highly cytotoxic T cell subset in the pathogenesis of POAF.

Acknowledgement/Funding

Verein zur Förderung der Forschung – Atherosclerosis Thrombosis and Vascular Biology (Vienna, Austria)
P1892Asymmetric and symmetric dimethylarginine in atrial fibrillation progression and recurrence
Authors: Buettner P , Schwedhelm E , Hindricks G , Boeger R H , Thiele H , Kornej J
Published: October 2019

Background

Asymmetric and symmetric dimethylarginine (ADMA and SDMA) are post-translationally modified amino-acids that inhibit nitric oxide (NO) production and have been associated with cardiovascular events and death. Recently, an association of ADMA with atrial fibrillation (AF) incidence and prevalence has been described. In this study we analyzed the association of ADMA and SDMA with the progression and recurrence of AF.

Methods

In total, 254 patients (64±11 years, 67% males, BMI 29±8 kg/m2, 53% paroxysmal AF, 27% low voltage areas (LVA)) undergoing first AF ablation were included into analyses. LVA were determined using high-density maps and defined as <0.5 mV. AF progression was defined as paroxysmal AF (PAF) with/without LVA and continuous AF (CAF) with/without LVA. AF recurrences were defined as any atrial arrhythmia occurring after ablation 3 to 18 months. Blood plasma samples were collected before catheter ablation and at follow-up. ADMA and SDMA were measured in plasma samples by liquid chromatography-tandem mass spectrometry (LC-MS/MS).

Results

While no differences were detected for ADMA, the SDMA plasma concentrations were significantly higher in AF patients with CAF and LVA (n=50, median 0.587 μmol/L; inter quartile range (IQR) 0.514–0.689 μmol/L, p=0.029) compared to PAF without LVA (n=90, 0.532; IQR 0.467–0.640 μmol/L), PAF with LVA (n=12, 0.494; IQR 0.444–0.615 μmol/L) and CAF without LVA (n=86, 0.537; IQR 0.465–0.633) μmol/L. There were 28 patients with available follow-up data and 18 patients (64%) had sinus rhythm. These patients had significantly lower SDMA plasma concentrations (0.458; IQR 0.405–0.517 vs. 0.507; IQR 0.449–0.604 μmol/L; p<0.001) at follow-up, while baseline SDMA levels were similar compared with patients with AF recurrence (p=0.944). Furthermore, patients without recurrence had significantly lower ADMA plasma concentrations (0.466; IQR 0.422–0.520 vs. 0.545; IQR 0.456–0.608 μmol/L, p<0.03) at follow-up, while baseline ADMA levels were similar independent on rhythm outcome (p=0.759).

Conclusion

Increased SDMA levels correlated with AF progression phenotypes characterized by persistent AF and the presence of LVA. In patients without arrhythmia recurrences ADMA and SDMA levels decreased.