bluuebunny/crossref_metadata_2025 huggingface dataset:
P6472Novel cardiac imaging prognostic markers of clinical outcome in patients with bicuspid aortic valve and chronic aortic regurgitation
Authors: Kockova R , Linkova H , Hlubocka Z , Praveckova A , Polednova A , Sukupova L , Benes J , Blaha M , Honsova E , Penicka M
Published: October 2019

Background

Patients with chronic aortic regurgitation (AR) can have a substantial myocardial damage despite being asymptomatic. Early surgical strategy might be beneficial. Bicuspid aortic valve (BAV) is a congenital heart disease present in almost 30% of these patients.

Purpose

Identify novel imaging predictors of early disease progression.

Methods

Prospective three-centre study of patients with chronic AR of at least moderate to severe (3+) grade and BAV morphology. Patients without currently recognised indication for surgical treatment were enrolled. Baseline examination included echocardiography (ECHO) with 3-dimensional (3D) vena contracta area and magnetic resonance (MR) with regurgitant fraction measured from flow sequence. All imaging studies were analysed in CoreLab. The primary endpoint was defined as a combination of cardiovascular death, surgical treatment or hospitalization for heart failure.

Results

A total of 83 patients with BAV and at least 3+ AR were enrolled during 2015–2018. Median follow-up was 759±455 days, primary composite endpoint occurred in 13 patients who met criteria for surgical treatment, no patient died or was hospitalized for heart failure. Baseline parameters were compared between two groups: patients with and without endpoint. Clinical and laboratory data did not differ between the two groups. Left ventricular (LV) ejection fraction was normal in all patients. LV diameters and volumes were significantly larger in patients with primary endpoint. This was most pronounced in MR measured indexed volumes in end-diastole and end-systole, P=0.003 and P=0.003. Non-invasive markers of diffuse myocardial fibrosis (native T1 relaxation time and global longitudinal strain, P=0.614 and P=0.137 respectively) were not different. Novel markers of AR severity were significantly increased in surgically treated patients: 3D vena contracta 0.26±0.10 cm2 versus 0.38±0.11 cm2 (P<0.001), MR regurgitant fraction 33.9±15.4 versus 50.2±12.2% (P=0.001). Both 3D vena contracta with cutoff value ≥0.4 cm2 (sensitivity=85%, specificity=84%, area under the curve=0.85) and MR regurgitant fraction with cutoff value ≥34% (sensitivity=94%, specificity=58%, area under the curve=0.76) showed high accuracy to identify patients who require early surgical intervention. Adding 3D vena contracta and MR regurgitant fraction to indexed LV end-systolic volumetric parameters significantly increases the predictive value for early disease progression with p=0.001 and p=0.006 (Likelihood-ratio test).

3D vena contracta predictive value

Conclusions

Novel imaging parameters of AR severity such as 3D vena contracta and MR derived regurgitant fraction predict early disease progression in patients with BAV and at least 3+ chronic AR. These values significantly increase the predictive value of traditional parameters based on LV size measures.
P6476Surgery does not appear to improve survival in patients with endocarditis and substance use disorder
Authors: Abdollah H , Brogly S B , Payne D , Lajkosz K , Coverdale N S , Gomes T , Hamilton A
Published: October 2019

Background

Cohort studies of surgery compared with medical treatment (MT) on endocarditis mortality are conflicting. We conducted a population-based study to estimate associations between treatment and mortality.

Methods

1,381 patients with substance use disorder (SUD) and 5,053 without (NSUD) hospitalized for endocarditis were included. Treatment was modeled as a time-dependent variable: patients who underwent surgery after admission were classified as MT until surgery occurred and surgically treated thereafter. Patients without surgery were classified as MT. Adjusted hazard ratios (aHR) between treatment and death (in-hospital, 30 days, one, two, five years) by SUD status were estimated.

Results

Among SUD patients, there was a trend towards reduction in in-hospital death with surgery vs. MT (aHR 0.61 [95% CI: 0.35–1.04]), but no difference at 30 days (aHR 0.79 [95% CI: 0.42–1.48]). Mortality was higher in SUD patients who underwent surgery compared with MT at one (aHR 1.30 [95% CI: 0.95–1.76]), two (aHR 1.27 [95% CI: 0.97–1.65]), and five years (aHR 1.37 [95% CI: 1.09–1.72]). In NSUD patients, in-hospital mortality (aHR 0.93 [95% CI 0.76–1.16]) did not differ, but 30 day mortality (aHR 1.36 [95% CI 1.04–1.77]) was higher with surgery versus MT, and lower at one (aHR 0.87 [95% CI: 0.73–1.03]), two (aHR 0.75 [95% CI: 0.64–0.88]), and five years (aHR 0.70 [95% CI: 0.61–0.81]).

Kaplan-Meier Survival Curves of Patients

Interpretation

Surgery compared with MT conferred no long-term survival benefit in SUD patients. In NSUD patients, surgery was associated with an initial increased risk of early death followed by a lower risk after one year.

Acknowledgement/Funding

Grant from Department of Surgery, Queen's University
P6477Preoperative renal injury and multi-elevated biomarkers are associated with adverse outcomes in patients with severe aortic stenosis undergoing surgical valve replacement
Authors: Spampinato R , Bochen R , Stoeger G , Sieg F , Noack T , Etz C , Borger M A
Published: October 2019

Background

The presence of early stages of renal injury (AKI) and biomarkers has been associated with adverse outcomes in cardiac surgery.

Purpose

We aimed to determine whether preoperative AKI is associated with long-term all-cause mortality in patients with severe aortic stenosis (AS) undergoing surgical aortic valve replacement (SAVR) and if the combination of AKI with multi-elevated biomarkers (Amino-terminal pro-B-type natriuretic peptide, BNP; high-sensitivity cardiac troponin T, hsTNT; and C reactive protein, CRP) has a better prognostic utility.

Method

From a prospective registry of patients with AS referred for SAVR, 560 participants (68±8.8 years; 329 men) were retrospectively included when echocardiograms, serum creatinine and biomarkers were available within 30-days before surgery. Kaplan-Meier (KM) curves for all-cause mortality were created for groups of patients based on the presence of AKI, defined as a stage I or more according to the Acute Kidney Injury Network classification. To further describe the utility of multi-elevated biomarkers, 4 groups were created and the KM-curves and c-statistics evaluated. Mean follow-up was 737±410 days and 30 (5.4%) patients died.

Results

Patients with preoperative AKI (n=68) were significantly older (70±7.6 vs. 67±8.9 years, p=0.02), more likely to have hypertension, diabetes, a worse functional class (NYHA III-IV: 59% vs. 36%, p<0.001), worse glomerular filtration rate (60±20 vs. 81±26, p<0.001), an elevation of multiple biomarkers (hsTNT, BNP, and CRP), and a higher logistic-EuroScore (3.8±2.8 vs. 3.0±2.2, p=0.04). But there were no differences in the incidence of coronary artery disease, LVEF (57±10 vs. 59±11%), aortic valve area index, or in surgical characteristics. Those patients with AKI exhibited higher 3-year all-cause mortality (11.7% vs. 5.7%, p=0.04). Interestingly, the combination of AKI with 3 elevated biomarkers was associated with a more than fourfold increase in 3-year all-cause mortality (47.5% vs. 4.3%, p<0.0001), and the c-statistics (AUC 0.599 vs 0.710, p<0.001) suggested a better prediction for long-term death.

Figure 1

Conclusions

This study demonstrates an adverse association of preoperative AKI with survival following SAVR, which was accentuated when combined with multi-elevated biomarkers, suggesting the need for less invasive strategies and/or closer postoperative follow–up in such patients.
P6478Resting and exercise pulmonary artery systolic pressure to rule out later development of pulmonary arterial hypertension in systemic sclerosis
Authors: Gargani L , Codullo V , Argiento P , Moreo A , Pieri F , Mori F , Epis O , Moggi-Pignone A , Montecucco C , Valentini G , Matucci-Cerinic M , Sicari R , Ghio S , Bossone E , D'Alto M
Published: October 2019

Background

Patients with systemic sclerosis (SSc) are at risk of developing pulmonary arterial hypertension (PAH), which is often diagnosed late when the benefits of vasoactive therapies are limited. The concept of exercise pulmonary hypertension as a possible transitional phase anticipating resting PAH has been assessed in several pathologies, but has not been endorsed by the latest European Guidelines, because not supported by sufficient data.

Purpose

To evaluate whether PASP values at rest and at peak exercise, estimated at echocardiography, could be predictors of further development of PAH.

Methods

Four hundred and twenty-nine SSc patients without a previous diagnosis of PAH, enrolled at 4 referral Centres, underwent standard exercise Doppler echocardiography with PASP estimation at rest and at peak stress. Patients were then followed-up to assess the development of PAH, as diagnosed by a complete diagnostic work-up including right heart catheterization. PAH was defined by pre-capillary pulmonary hypertension (mean pulmonary artery pressure ≥25 mmHg with pulmonary arterial wedge pressure ≤15 mmHg), without significant interstitial lung disease and/or left heart disease.

Results

During the median follow-up of 75 months (IQR 29–114), 16 patients developed PAH. A combined cut-off of ≥24 mmHg as resting PASP and ≥40 as peak PASP was identified as the best predictor of further development of PAH (see Figure). Both resting PASP and peak PASP were predictors of PAH at univariate analysis (resting PASP OR 1.13, 95% C.I. 1.07–1.19, p<0.0001; peak PASP OR 1.13, 95% C.I. 1.07–1.18, p<0.0001). At multivariate analysis, only peak PASP was independently associated to PAH development (OR 1.13, 95% C.I. 1.04–1.18, p<0.001). Only one patient among those with resting PASP <24 mmHg and peak PASP <40 mmHg (34.7% of the total population) developed PAH during the follow-up (after 10 years from normal exercise Doppler echocardiography).

Kaplan-Meier curves

Conclusions

Exercise increase in PASP is an independent predictor of later development of PAH in SSc. An increase in exercise PASP is frequent and is not necessarily associated with a later development of PAH, whereas the very high negative predictive value of a normal PASP both at rest and at peak exercise can be used in the clinical practice to confidently rule out about one third of patients.

Acknowledgement/Funding

Italian Ministry of Health (Ricerca Finalizzata 2011-2012)
P6486Flow state, gradients and anatomopathological valvular calcification: influence in aortic stenosis surgical outcomes
Authors: Museli J T , Zambruno L , Coria N , Giunta G , Salmo J F , Vigliano C , Guevara E
Published: October 2019

Introduction

Aortic stenosis (AS) patients are heterogeneous. The relationship between stenosis severity, transvalvular flow state and gradients is conflictive and non-linear.

Objective

To evaluate the relationship between transvalvular flow state and gradients with the anatomopathological aortic valve characteristics and perioperative morbimortality among patients (pt) submitted to aortic valve replacement (AVR).

Methods

We analyzed 516 pt with symptomatic severe AS (effective valve area <1 cm2) with preserved left ventricular ejection fraction (>50%) submitted to AVR. Perioperative mortality and a combined endpoint (death, low cardiac output syndrome and acute renal injury) were analyzed dividing the population by transvalvular flow (35 ml/m2) and mean gradient (40 mmHg), both measured by echocardiography. A morphologic evaluation of 383 operatively excised native cardiac valves was performed. Valvular thickening and calcification were categorized in mild, moderate and severe.

Results

Male subjects represented 52.9% (283 pt). Mean age were 69±11.5 years. Pt showed a mean ejection fraction of 61±4.8%, the peak gradient was 86.2±24 mmHg, and mean gradient was 53±18 mmHg.

Cardiac low output syndrome (normal flow (NF) – 14%, low flow (LF) – 23%; p<0,02), IABP (NF 1,8%, LF 6%, p<0,02) and perioperative mortality (NF 2,7%, LF 7%, p<0,02) were more frequent in low flow pt (185 – 35%).

Bicuspid valves represented 24.5% of the whole population. Bicuspid patients were younger 64±9 vs 73±12 years (p<0.05) and had more moderate–severe calcification (MSC) 93.4% vs 75.6% (p<0.05).

No difference was found in moderate -severe thickening (MSTh) and MSC when analyzing the population by flow (35 ml/m2). On the contrary, low gradient pt (<40mmHg) had lower MSC and MSTh. (Table)

Finally, 4 groups were considered: normal flow–high gradient NFHG (52.2%), normal flow–low gradient NFLG (12%), low flow–high gradient LFHG (25.5%) and low flow–low gradient LFLG (10.1%). A trend toward more perioperative events was seen in the LF-LG group despite less calcified and thickened valves. (Figure)

Table 1 Normal Flow Low Flow P value Normal gradient Low gradient P value M-S thickening 143 (58.1%) 80 (58.3%) NS 186 (62.4%) 37 (43.5%) 0.0018 M-S calcification 195 (79.2%) 119 (86.8%) NS 263 (88.2%) 51 (60%) <0.05 Bicuspid valve 62 (25%) 32 (23%) NS 62 (25.2%) 32 (23.3%) NS M-S: Moderate-Severe.

Figure 1

Conclusions

In our population of severe symptomatic AS with preserved ejection fraction submitted to AVR, low gradient pts had less calcified and thickened valves. LFLG pts presented a trend towards more perioperative events despite having less valvular calcification.
P6495Role of vascular smooth muscles cells in naked mole rats during ageing (Heterocephalus glaber)
Authors: Mgrditchian-Griffo T , Faulkes C G F , Thornton S T , Shanahan C S , Hayward R H , Li Z L , Cruickshank K C , Regnault V R , Lacolley P L
Published: October 2019

Vascular stiffening and a prothrombotic state consistently increase with age. We have shown previously that Vascular Smooth Muscle Cells (VSMCs) have a major role in both vascular stiffening and thrombin generation in the vascular wall in a context of hypertension (Arterioscler Thromb Vasc Biol 2015). Naked mole rats (NMRs) are the longest-lived rodent species, have a maximum lifespan exceeding 30 years, living approximately ten times longer than a similarly sized mouse, and do not develop arterial stiffening with age (AJP, 2014).

The objective was to analyze arterial composition as well as phenotypic VSMC changes from primary cultures in NMRs at 2- and 10-year old.

We used Thoracic aortas of young (2-year-old) and adult (10-year-old) NMRs for the study of arterial wall as well as for the preparation of VSMCs' primary cultures.

Our results showed no difference in elastin/collagen ratio and no intimal thickening in NMRs at 10-years-old compared to 2-years-old (n=4 in each group). Primary cultures showed positive alpha-actin staining without VSMC morphological changes up to 6 passages using standard conditions (20% fetal bovine serum). Smoothelin and myosin-heavy chain are similar at both ages. VSMCs density was identical in 2- and 10-years-old NMRs, whereas cell hypertrophy was observed in older animals.

Focal adhesions assessed by vinculin staining were unchanged between the two groups. There was no increase in plasma thrombin generation and at the surface of VSMCs up to 10 years of age associated with no increase in fibrinogen and factor VIII, both known to increase normally with age in humans.

Our findings showed an absence of canonical signs of normal vascular ageing in NMRs that are normally present in rodent and humans. The retaining of a VSMC phenotype and focal adhesion distribution support previous data observed in ageing. These results reinforce the current concept of VSMCs as emergent cells in the process of ageing.
P6500Genetics links abdominal and thoracic aorta aneurysm
Authors: Ijpma A S , Heijsman D , Roos-Hesselink J W , Verhagen H J M , Ter Raa S , Majoor-Krakauer D
Published: October 2019

Introduction

Familial disease, with a genetic cause, occurs in at least 20–30% of the families of patients with an aortic aneurysm. In these families there is an increased risk for relatives. Therefor family screening is recommended around the age of 50–60 years for first degree relatives of patients with an abdominal aneurysm (AAA) and relatives of patients with thoracic aorta aneurysms (TAA). However current guidelines do not specify the extend of aorta screening for relatives of patients with AAA and patients with TAA. Current practice is that first degree relatives of AAA patients are offered abdominal echo screening for AAA and relatives of TAA patients cardiologic echo for TAAA. Although co- occurrence of AAA with TAAA in rare genetic disease is well known, for other familial aneurysm disease, the frequency of the co-occurrence of AAA and TAAA has not been established.

Purpose

To improve family screening for familial aneurysm, and identify the role of underlying genetic defects.

Methods

To determine the genetics of AAA, whole exome sequencing and CT family screening of the complete aorta was performed in 391 families with familial aneurysm. These families are nested in a patient cohort ascertained form unselected consecutively diagnosed AAA patients visiting the Vascular Surgery Clinic at the our MC.

Results

In 391 families, 360 relatives had a dilated aorta. The spectrum of aortic features in the relatives included 210 (58%) relatives with AAA, 102 (28%) relatives with TAA. Co-occurrence of AAA and TAA was noted in 41 (11%) relatives. In addition 66 (18%) and 79 (22%) had a dilation in the arteria iliaca communis sinistra resp. dextra. In 18 families pathogenic mutations in 11 aneurysm genes were detected.

Conclusion

To reduce underdiagnoses of relatives of AAA patients, CT screening of the total aorta and the iliac arteries is the method of choice, and should replace echo screening of specific parts of the aorta in relatives. Updating the guidelines for family screening for aortic aneurysms is needed to improve early detection and treatment of family members with aorta dilatations.

Acknowledgement/Funding

Stichting Lijf en Leven
P6502Association between diabetes mellitus and abdominal aortic aneurysm: a mendelian randomization study
Authors: Chen Q.-C , Yao C , Wang S.-M
Published: October 2019

Background

It is generally acknowledged that those with diabetes mellitus (DM) have at least a 10-fold risk for cardiovascular disease (CVD). However, patients with DM have been shown with a lower incidence of abdominal aortic aneurysm (AAA) in epidemiological data. Related research has illustrated that the aortic may be protected in the hyperglycemic microenvironment while the causality of this relationship is still uncertain.

Purpose

Here, we undertake a two sample Mendelian randomization (MR) study to evaluate whether DM genetically influences the risk of AAA.

Methods

We analyzed the genetic summary data from the DIAGRAM (Diabetes Genetics Replication And Meta-analysis) consortium and MRC-IEU (Integrative Epidemiology Unit) consortium. Base on the result from GIAGRAM consortium (26488 DM cases and 83964 controls), 25 single nucleotide polymorphisms (SNPs) associated with DM as the instrumental variables in MR study. Then, for each of the 25 SNPs associated with DM, we retrieved their summary data from MRC-IEU Consortium (263 cases and 462747controls). Inverse-variance weighting (IVW) was conducted to obtain the associations of DM with AAA and several sensitivity analyses were also performed to assess the potential violation of MR assumptions.

Results

DM was not significantly associated with risk of AAA (odds ratio [OR], 1.ehz746.1092; 95% confidence interval [CI], 0.9998–1.0002; P, 0.9622). Weighted median (OR, 1.0002; 95% CI, 0.9999–1.0005; P, 0.1992) and MR Egger analysis (OR, 1.0003; 95% CI, 0.9995–1.0012; P, 0.4071) suggested similar effect estimates of DM on AAA. With the large P value for the intercept, the result of MR-Egger regression method indicated no evidence for the presence of horizontal pleiotropy (Egger regression intercept, 3.9e-05, P, 0.384). In a leave-one-out analysis, no single SNP was observed with strong driving effect of DM on AAA.

Conclusions

Through 25 genetically identified SNPs in this two sample MR study, DM is not associated the risk of AAA this large study using two-sample MR, which did not support the result from previous epidemiological data. In conclusions, this large MR study provides evidence to suggest that DM may not be causally associated with AAA.
P6504NETosis is associated with the severity of aortic stenosis
Authors: Kopytek M , Kolasa-Trela R , Zabczyk M , Undas A , Natorska J
Published: October 2019

Background

High hemodynamic forces similar to those observed in aortic stenosis (AS) can trigger neutrophil extracellular traps (NETs) formation.

Purpose

An involvement of NETosis in the AS pathogenesis is unknown.

Methods

We enrolled 25 patients, median age 64.9 [range, 58–69] years with isolated severe AS (transvalvular pressure gradient, PGmean: 53.6±11.3 mm Hg, PGmax: 85.1±17.6 mmHg), after aortic valve replacement and 15 healthy sex/age-matched controls. Autopsy-derived aortic valves from 5 healthy donors served as negative control. Transverse valve sections were taken from the mid and commissural areas of the leaflet and cryosectioned by a Leica CM 1520 cryostat. Valvular expression of citrullinated histone H3 (citH3), together with myeloperoxidase (MPO), and neutrophil elastase (NE) as NETs biomarkers and macrophages (CD68) were evaluated by single- and double- immunostaining. Plasma concentrations of citH3 and interleukin 6 (IL-6) were also determined.

Results

All stenotic and healthy valves expressed citH3 in the leaflets' endothelial and sub-endothelial layers at the aortic side. The in loco expression of citH3-positive cells was higher in AS patients compared with controls (42.3±8.7% vs. 7.2±4.8%, p<0.05) and correlated with disease severity measured as aortic valve area (AVA; r=−0.84, p<0.0001), as well as PGmean (r=0.62, p<0.001), and PGmax (r=0.52, p>0.05). Double-staining revealed that within stenotic leaflets 28.3±8.4% of cells were citH3/MPO- and 25.2±7.1% citH3/NE-positive. None of control valves showed MPO or NE-positivity. Moreover, 6.6±1.9% of valvular cells (17.2±5.4% of citH3-positive cells) showed citH3/CD68 double-positivity and were identified as macrophages. Plasma levels of citH3 were 59% higher in AS patients then in controls (p<0.05), and the concentrations of citH3 correlated with IL-6 levels (r=0.44, p<0.05) and AVA (r=−0.48, p<0.05).

Conclusions

The presence of NETs in stenotic valves and association with AS severity might suggest novel mechanisms involved in the disease progression. This work was supported by the grant from the Polish National Science Center (DEC-2017/01/X/NZ5/02006 to R.K-T.).

Acknowledgement/Funding

This work was supported by the grant from the Polish National Science Center (DEC-2017/01/X/NZ5/02006 to R.K-T.).
P6518Radial artery dilatation to improve access and lower complication rates during coronary angiography (RADIAL): a randomized controlled trial
Authors: Doubell J , Kyriakakis C , Weich H , Herbst P , Pecoraro A , Moses J , Griffiths B , Snyman H W , Kabwe L , Du Toit R , Joubert L , Hassan K , Doubell A
Published: October 2019

Background

Transradial catheterization has become the preferred access site for coronary angiography. The transradial approach is however not without challenges and complications. Cannulation is technically challenging and may require multiple cannulation attempts or access may fail. Local access site complications may occur postprocedurally.

Purpose

To explore the use of prolonged occlusion flow mediated dilatation (PO-FMD) to dilate the radial artery prior to cannulation to reduce puncture attempts, increase cannulation success and reduce access site complications in transradial coronary angiography.

Methods

1156 patients undergoing transradial coronary angiography were randomized into PO-FMD and sham PO-FMD groups. PO-FMD was achieved by a 10 minute inflation of a blood pressure cuff on the arm to above systolic pressure, followed by deflation with resultant radial artery dilation. In the sham PO-FMD group the cuff was not inflated. The operators were blinded to the intervention.

Results

580 patients were randomized to the sham PO-FMD group and 576 to the PO-FMD group. The number of puncture attempts were reduced with the use of PO-FMD, with a median number of attempts of 1 in the PO-FMD group and 2 in the sham PO-FMD group (p<0.001). Cannulation failure was reduced with PO-FMD FMD with cannulation failure rates of 2.7% in the PO-FMD group and 5.8% in the sham PO-FMD group (p=0.01). Radial artery pulsation loss (RAPL) was reduced with PO-FMD with 1.4% in the PO-FMD group and 3.8% in the sham PO-FMD group (p=0.02).

Conclusion

PO-FMD decreases puncture attempts, reduces cannulation failure rates and decreases RAPL during transradial coronary angiography.
P6520Outcomes of the trans radial approach PCI in a single tertiary center over a decade of adoption and
Authors: Perl L , Bental T , Greenberg G , Vaknin-Assa H , Assali A , Kornowski R
Published: October 2019

Background/Introduction

The trans-radial approach (TRA) has been increasingly adopted for the use of percutaneous coronary interventions (PCI), with reported clinical benefits. Little is known regarding the change in outcomes over time.

Purpose

To assess the temporal trends of TRA PCI in a single tertiary center over a decade.

Methods

From a database of 21,763 consecutive PCI's, we analyzed 15,429 patients in 2 periods – 2008 to 2012 (period 1) and 2013 to 2017 (period 2). We examined the proportions of use of TRA, the influence on in-hospital outcomes and adjusted long-term effects.

Results

The rate of TRA rose from 15.9% in period 1 to 69.1% in period 2, including in specific situations such as acute coronary syndrome, chronic total occlusion, bifurcation, calcified lesions and unprotected left main PCI. In-hospital rates of bleeding were lower for TRA vs. TFA (1.8% vs. 5.1%, overall, p<0.001), as were rates of additional bleeding events in the following 12 months (1.3% vs. 2.4%, p<0.001). Following multivariate analysis, use of TRA was associated with a lower 30-day and 4-year rate of the composite outcomes of death, myocardial infarction, target vessel revascularization or coronary artery bypass surgery [at 4 years, HR-0.86 (95% CI 0.77–0.96 p=0.007) during period 1 and HR-0.62 (95% CI 0.55–0.7 p<0.0001) during period 2, figure 1]. Interaction analysis showed a stronger effect at the latter period (HR-0.69, 95% CI 0.59–0.81, p<0.001).

Figure 1

Conclusions

Over a decade of follow-up, TRA has gained acceptance for different PCI scenarios, including complex patients- a course which is associated with consistent short and long-term clinical benefits.
P6522Overcoming anatomic challenges to transradial access in STEMI patients
Authors: Campos I , Galvao Braga C , Costa J , Quina Rodrigues C , Costa Oliveira C , Medeiros P , Marques Pires C , Vieira C , Marques J
Published: October 2019

Background

Transradial access is associated with fewer access-related complications, earlier discharge and lower mortality, being the preferred route to perform coronary angiogram and interventions due to its safety and cost effectiveness in STEMI patients. However, the radial artery is smaller, more superficial and thinner than the femoral artery and a percentage of patients ranging from 14% to 27% have a radial artery that is smaller than a 6-French introducer, which sometimes makes angioplasty difficult.

Purpose

This study reports our initial experience with the 5F straight (STR) flush catheter, which can be used as a “child” type rapid exchange catheter inside the 6F guiding catheter, creating a distal tip transition, facilitating angioplasty in transradial coronary interventions when the radial artery is small, tortuous or as severe spasm that impedes advancement of guiding catheter after successful angiography with 5F catheter.

Methods

We analysed, retrospectively, 1510 STEMI patients (pts) admitted in our catheterization laboratory, from August of 2010 to October 2017. Of these patients, 95 (6.3%) pts with problems in advancing a 6F guiding catheter, were submitted to this technique and a direct crossover to a femoral approach was performed in 36 pts (2.4%). This technique consists in the use of longer 5F STR flush catheter in order to overcome the larger distal tip of the 6F guiding catheter through the radial access, employing a 5-in-6 F technique.

Results

In 89 of 95 patients (93.7%), this new technique was successful, with a mean reperfusion time since arrival to the catheterization laboratory of 24.5±9.9 minutes. Of the pts submitted to this technique the majority were female 51 (57.3%) and the mean age was 67±14.3 years. Angioplasties were performed in the left main (2; 2.3%), left anterior descending (36; 40.4%), left circumflex artery (8; 9.0%), right coronary artery (40; 44.9%), right posterior descending artery (1; 1.1%) and obtuse marginal branch (2; 2.3%). No complications in arterial access were seen. Throughout these years of study, the need for crossover to femoral approach has decreased with the learning of this technique. The time until reperfusion since catheterization laboratory arrival was 29.3±9.5 minutes when there was a crossover, being statistically higher than with the radial procedure with the STR technique (p<0.017).

Conclusion

This new technique may be a simple and useful approach to perform primary PCI through transradial access in patients with small diameter radial arteries, allowing a reduction of crossover to femoral access, which translates into a lower risk of vascular complications and shorter reperfusion time, that may influence the prognosis of STEMI patients.
P6525Impact of acute arrhythmias on in-hospital mortality in patients undergoing angioplasty
Authors: Karrthik A , Gad M , Ahuja K , Bazarbashi N , Abderrehman K , Ahmed H
Published: October 2019

Introduction

Arrhythmia is one of the most common complications in patients undergoing percutaneous coronary interventions (PCI). Prior attempts to address these arrhythmias “aggressively” did not show improvement in survival. This study aims to investigate the impact of acute arrhythmias on in-hospital mortality in patients undergoing angioplasty in the United States.

Methods

Data about patients undergoing PCI between January 2010 and December 2014 on the Nationwide Readmission Database (NRD) was queried from the Healthcare Cost and Utilization Project (HCUP). All patients undergoing PCI were identified with the appropriate ICD-9 procedure codes. Binominal logistic regression testing was utilized to perform a multivariate analysis and different patient baseline characteristics were adjusted for including age, gender, LOS, diabetes mellitus, hypertension, renal failure, and cancer diagnosis. Odds Ratio (OR) of in-hospital mortality following acute arrhythmia were reported alongside 95% Confidence Intervals (CI).

Results

A total of 2,712,078 patients underwent PCI during hospitalization from January 2010 to December 2014. Out of those, 56,985 (2.1%) patients died while hospitalized. Most of the patients who died were older (mean age 70.73±12.9) and males (59.3%). After adjusting for age, female gender, hypertension, diabetes, heart failure, anemia, malignancy, psychiatric disorder, and longer length of stay; ventricular and supraventricular arrhythmias were found to be predictors of in-hospital mortality. Atrial fibrillation had an OR of 1.588 (95% CI: 1.551–1.626), ventricular tachycardia an OR of 2.191 (95% CI: 2.133–2.250), and ventricular fibrillation an OR of 4.143 (95% CI: 4.031–4.258).

Conclusions

Ventricular and supraventricular arrhythmias are independent predictors of in-hospital mortality following angioplasty. Further studies are warranted to evaluate the optimal management for patients with acute arrhythmia following PCI.
P6532Trimetazidine and nicorandil decrease the increment of serum creatinine in patients with normal or slightly decreased renal function after undergoing elective percutaneous coronary intervention
Authors: Li X , Wang X , Liu D , Zhang M , Liu M , An F
Published: October 2019

Background

Contrast-induced nephropathy (CIN) is a serious complication of percutaneous coronary intervention which can cause serious adverse outcomes. There is still no effective treatment for it.

Aims

To evaluate and compare the protective effect of trimetazidine and nicorandil on renal function in patients undergoing percutaneous coronary intervention.with estimated glomerular filtration (eGFR) >60 ml/min/1.7 m2.

Method

161 patients who met the inclusion criteria were recruited and divided into control group (n=41), trimetazidine group (n=40), nicorandil group (n=40) and trimetazidine combined with nicorandil group (n=40). Both TMZ and nicorandil were administered orally 72 hours before and 48 hours after the procedure. All patients in the four groups were given intravenous saline (0.9%) at a rate of 1 ml/kg/h 6 hours before and 12 hours after the procedure. Serum creatinine (SCr), GFR were measured before and 48 hours after the procedure. An increase of 44mmol/L (0.5mg/dL) in SCr or 25% higher than basal levels at 48 hours after administered iodinated CM was diagnosed as CIN.

Results

(1) The baseline characteristics of the four groups were similar. (2) The SCr levels increased in control group (baseline 73.07±15.69 VS. after PCI 91.71±23.10 mmol/L), TMZ group (baseline 71.90±17.30 VS. after PCI 82.00±17.19 mmol/L), nicorandil group (baseline 72.23±15.95 VS. after PCI 81.45±18.30 mmol/L)and TMZ plus nicorandil group (baseline 71.13±13.50 VS. after PCI 73.35±12.64 mmol/L) at 48 hours after the procedure, all p values <0.05. (3) The increment of SCr after PCI in control group (ΔScr=18.63±9.21 mmol/L) is higher than TMZ group (ΔScr=10.10±5.62 mmol/L) and nicorandil group (ΔScr=9.23±5.60mmol/L), and is higher than TMZ plus nicorandil group (ΔScr=2.23±1.42 mmol/L), all p values <0.001. There was no statistical difference of increment of SCr between TMZ group and nicorandil group. (4) Contrast-induced nephropathy developed in 14.6% (6/41) in control group, 2.5% (1/40) in TMZ group and 2.5% (1/40) in nicorandil group (p<0.05), none in TMZ plus nicorandil group.

Conclusions

TMZ and nicorandil exerted similar protective effect on renal function by decreasing SCr level and CIN incidence after PCI. The efficacy of TMZ combined with nicorandil on renal protection was greater than TMZ or nicorandil alone.
P6537Screening for Atrial Fibrillation in Native Americans using iPhone ECG
Authors: Stavrakis S , Elkholey K , Lofgren M , Freedman B
Published: October 2019

Background

Atrial fibrillation (AF) is a major risk factor for stroke. Screening for silent AF, with subsequent initiation of anticoagulation in at-risk individuals, may decrease the risk of stroke. Native Americans (NA) have a high prevalence of diabetes and higher incidence of stroke than whites and blacks. Indigenous Australians, and Maori in New Zealand develop AF on average 10–20 years earlier than Europeans and Asians living in the same country. We hypothesized that screening for AF using a single time point, 30-second iPhone-based ECG recording will result in identification of silent AF in a significant number of NA compared to routine care, and that the age profile of those detected may be younger than non-NA.

Purpose

To determine the prevalence of AF, and incidence of unknown AF in NA seen at a tribal clinic using opportunistic screening with a single-lead iPhone-based ECG device (Kardia Mobile).

Methods

A database study was carried out in NA patients aged ≥50 followed to determine the prevalence of AF. Consecutive patients aged ≥50 with no prior history of AF were approached when attending the AST clinic for a primary care visit for opportunistic screening. Following consent, a 30-second ECG was recorded. A cardiologist overread all tracings to confirm the diagnosis of AF. Those confirmed to have AF were referred to a cardiologist for further management.

Results

The AF prevalence in 2952 NA patients aged ≥50 (1256 male, 1696 female), was 2.2%. Prevalence increased significantly with age (age 50–59, 0.9%; age 60–69, 2.6%; age 70–79, 3.6%; age ≥80, 7.8%; p for trend <0.0001). There were significant sex differences in AF prevalence (males 3.6% vs. females 1.2% p<0.0001). The mean age of those with AF was significantly older than for those without AF (69±10 vs, 63±6 respectively, p<0.0001). In the first month following study commencement in Jan 2019, 157 eligible patients without AF were approached and 142 (90%) agreed to receive screening for AF. The mean age of those enrolled was 62±8 years (66% women), and mean CHA2DS2-VASc score was 2.3±1.4.The age and sex distribution of those screened was similar to the overall clinic population without AF. Two of 142 patients (1.4%; age 59 and 61, respectively) screened were diagnosed with AF and were referred to a cardiologist. Enrollment is planned to reach 1500 patients by August 2019.

Conclusions

Opportunistic screening for AF using iPhone ECG in NA is feasible and well accepted by the patients when attending a tribal clinic. Our preliminary data suggest that NA, like other first nation peoples, may develop AF at a younger age compared to non-NA populations and would be likely to benefit from AF screening. In light of the high prevalence of risk factors for development of AF in NA, this novel approach for AF screening in tribal clinics has the potential to improve health outcomes among a large number of individuals.
P6547The energy cost of His bundle pacing can be curtailed
Authors: Zanon F , Marcantoni L , Pastore G , Baracca E , Picariello C , Lanza D , Maddalozzo A , Giatti S , Carraro M , Roncon L , Barbetta A , Di Gregorio F
Published: October 2019

Introduction

His bundle pacing (HBP) allows physiological ventricular activation and prevents the electrical and mechanical desynchronization generally induced by myocardial stimulation, which can increase the risk of atrial fibrillation and heart failure. On the other hand, reliable HBP capture often requires higher energy than conventional myocardial pacing. This reduces the expected life of the stimulator and might limit the diffusion of HBP in the clinical practice.

Purpose

Decreasing HBP current drain by careful management of stimulation safety margin and pulse duration.

Methods

In 28 patients undergoing DDD pacing with HBP, a third lead was implanted in RV apex to provide back-up pacing on demand. HBP and apical leads were connected, respectively, to the V1 and V2 channels of a 3-chamber stimulator. When HBP was effective, apical sensing occurred within the VV delay and prevented V2 stimulation. In contrast, in case of HBP failure, V2 sensing was missing and apical back-up pacing was promptly delivered at the end of the VV delay. The availability of a back-up pulse on demand allowed reducing the HBP safety margin with no risk. Furthermore, the individual HBP strength-duration curve was derived in the aim of optimizing the Hisian pulse parameters, which are the major determinants of the device current drain.

Results

Correct back-up inhibition by successful HBP and stimulation in the event of capture loss was achieved in all the patients. The latency from Hisian pacing to apical sensing averaged 96±14 ms. According to the pacemaker counters, no back-up pulse was delivered in daily life in 59% of patients. In the remaining, the prevalence of back-up stimulation never exceeded 15% of paced ventricular cycles. The high HBP threshold was essentially due to an increased rheobase (1.2±0.6 V), while the chronaxie ranged from 0.30 to 0.53 ms in 71% of patients (median 0.44 ms), exceeding 0.6 ms only in 29% of the cases. An average current saving of 5.4±3.0 μA was obtained at the expense of a mild reduction in HBP safety margin (from 1.6±0.2 to 1.4±0.1 times).

HBP and apical back-up

Conclusions

Back-up stimulation on demand is a reliable option to decrease HBP current drain and prolong the stimulator service life with full safety. In most of the cases, significant saving can be achieved by pulse shortening, as the chronaxie time is in the same range as with myocardial stimulation and longer pulses are not required. A pulse duration exceeding 0.6 ms is indicated in less than 1/3 of the implants.
P6550Right ventricular apical pacing vs. non-right ventricular apical pacing induced tricuspid regurgitation: implication of 3D echocardiographic location of leads
Authors: Yu Juan Y , Chen Y , Wu M , Zhen Z , Yao Q
Published: October 2019

Background

Pacemaker, device leads have been reported to cause tricuspid regurgitation (TR) of variable degrees. It is different between RVA pacing and None-RVA pacing in device-related TR. Few articles indicate this area. Objectives: We sought to evaluate (1) TR degree in patients with right ventricular apical (RVA) pacing vs. none-RVA pacing; (2) the relationship of lead-position between RVA vs. none-RVA pacing associated with TR undergo 3-dimensional echocardiography (3DE).

Methods

Conventional echocardiography performed in 458 patients after pacemaker implantation. In addition, 284 patients with pre-pacemaker implantation echocardiography available were included to evaluate the development of significant TR prospectively.

Results

RVA pacing patients had a higher frequency of significant TR (degree≥2) compared to none-RVA pacing (63% vs. 42%, p-value <0.01). For RVA pacing, the lead was more likely to position at the anterior, posterior and septal compared to none-RVA pacing (51% vs. 33%, p-value <0.01). Importantly, leads were more likely to be positioned in the central portion with none-RVA pacing compared to RVA pacing (30% vs. 13%, p-value <0.01). Among 284 patients with pre-& post-implantation echocardiography, RVA pacing is associated with the development of significant TR compared to none-RVA pacing (59% vs. 41%, P=0.012).

Factors Associated with Significant TR Univariate p-value Multivariate p-value Age 1.035 (1.016–1.055) <0.01 1.025 (1.005–1.047) 0.02 Duration 1.003 (1.001–1.006) 0.02 1.001 (0.998–1.004) 0.62 Male 0678 (0.468–0.980) 0.04 0.657 (0.436–0.991) 0.05 Pre-AF 2.623 (1.740–3.955) <0.01 1.162 (0.588–2.295) 0.67 Post-AF 3.529 (2.329–5.346) <0.01 2.671 (1.566–4.556) <0.01 DDDR 0.428 (0.236–0.777) 0.01 0.724 (0.336–1.563) 0.41 RVA 2.451 (1.673–3.589) <0.01 1.962 (1.266–3.042) <0.01

3D TTE view of the device leads in TVs

Conclusions

The study demonstrates that RVA pacing is more likely to develop significant TR compared to none-RVA pacing. Significantly, this study is the first details to demonstrate that lead impingement is one of the possible mechanisms that could explain the higher frequency of TR in RVA pacing compared to none-RVA pacing by 3DE.

Acknowledgement/Funding

This manuscript is partially supported by the Summit Grant from the University of Hong Kong and Queen Mary Hospital.
P6553Contemporary pacemakers and oncologic radiotherapy courses: a real-time, wireless-enabled observation
Authors: Di Girolamo E , Furia N , Faustino M , Appignani M , Marini M , Genovesi D , Di Carlo C , Delana A , Barbareschi A , Falco M D
Published: October 2019

Background

The effects of high dose oncologic radiotherapy on cardiac pacemakers (PMs), at even less than 6MV power, are unpredictable, depending on multiple factors. Normal PM function may be impaired during photon exposure, with potentially life-threatening consequences in PM-dependent patients, and, unlike in magnetic resonance imaging setting, both manufacturer statements and guidelines discourage direct exposure.

Purpose

To evaluate transient PM malfunctions by direct exposure to doses up to 10 Gy during radiotherapy course, actually not recommended or considered even unsafe, 17 wireless-telemetry-enabled PMs obtained after upgrade or extraction of the system, with sufficient residual battery charge for the purpose of the study (at least 1 year to elective replacement indicator, E.R.I.) were evaluated in a real-time in-vitro session.

Methods

All PMs underwent baseline interrogation. Single chamber devices were programmed in VVI/40 mode while dual or triple chamber devices were programmed in DDD/40 mode. Rate adaptive function was disabled to avoid the “run-away” phenomenon during exposure. A centering computed tomography was performed to build the corresponding treatment plan and the PMs were blinded randomized to receive either 2, 5 or 10 Gy exposure by a low photon-energy linear accelerator (6MV) in a homemade water phantom (600 MU/min). The effective dose received by the PMs was assessed by an in-vivo dosimetry. During radiotherapy course, the devices were observed in a real-time session using manufacturer specific equipment, and PM function (pacing and sensing, programmed parameters) was recorder by a videocamera in the bunker before (5 minutes), throughout, and after (5 minutes) the entire radiation exposure.

Results

During radiotherapy course, non of the PMs reported spontaneous changes in parameter settings. 13 PMs (76.5%) recorded non clinically relevant minor transient electromagnetic sensing interferences. No atrial and/or ventricular oversensing nor base-rate-pacing inhibition were observed. Only 4 PMs (23.5%) reported neither transient malfunction nor minor noise, withstanding direct radiation exposure. Transient oversensing-related malfunctions were observed regardless of either 2, 5 or 10 Gy exposure.

Conclusions

Minor, non clinically relevant electromagnetic sensing interferences were observed in most of the PMs during direct exposure. Nevertheless, to avoid potentially life-threatening PM malfunctions, magnet application on the PM pocket site or reprogramming in the asynchronous mode are still suggested in PM-dependent patients ongoing even low energy radiotherapy exposure.

Acknowledgement/Funding

None
P6561Diagnostic yield of implantable loop recorders: a comparison of arrhythmia nurse specialists versus clinicians
Authors: Lee J D , Eftekari H , Paul G , Zhupaj A , Panikker S , Dhanjal T , Yusuf S , Hayat S , Osman F
Published: October 2019

Background

Implantable loop recorders (ILR) are recommended in guidelines to determine symptom-rhythm correlation. Arrhythmia Nurse Specialists (ANS) play a critical role in the assessment of such patients. Their effectiveness at risk stratification for ILR implantation is unknown. The ESC 2018 Syncope guidelines recommend more research in this field.

Aim

To evaluate the diagnostic yield of consecutive ILR implants at a tertiary centre over a 2year period and compare ANS versus Clinicians.

Methods

A retrospective study of all patients undergoing ILR implant between April 2016 and April 2018. Data collected included baseline patient demographics, referral source and management changes made by ILR findings.

Results

305 patients had an ILR; median age was 71yrs (interquartile range 52–81), 55% male. Median follow-up time was 15months. Referrals were from general cardiology (GC) = 98 (32%), electrophysiology (EP) = 105 (34%), and ANS-led syncope clinic = 102 (34%). Indications for ILR implant were syncope = 203 (65.9%), palpitation = 21 (6.9%), pre-syncope = 16 (5.2%), cryptogenic stroke = 35 (11.5%) and others 7 (8.9%) (falls, channelopathies). Of the entire cohort, 102 (34.0%) experienced arrhythmias recorded on the ILR that resulted in a change of management. This included: pacemaker implant = 49 (16.1%), complex-device implant = 7 (2.3%), AF=28 (9.2%), SVT=14 (4.6%), VT=1 (0.3%). Of those with a syncope indication (n=203), findings on ILR altered management in 73patients (36.0%) over a median follow-up of 18months; a pacing indication in this syncope group was present in 44 (21.9%) patients (median time to diagnosis: 2.7 months) with 24 receiving a pacemaker indication within 3 months of ILR insertion. ANS had a higher pacemaker implant rate. Overall, an ILR resulted in a diagnostic yield of 34.1% (n=104). Specialist nurse referral resulted in an overall greater trend towards change of management in 38.2% of patients compared with GC (32.7%) and EP (31.0%) (p=0.593 nurse vs. consultant).

Conclusion

The overall diagnostic yield of ILR insertion was 34% in our study. ANS had a trend towards a greater diagnostic yield compared with clinicians, and significantly more pacemaker indications. Our data suggests that ANS patient selection for ILR insertion are at least comparable to clinicians.