bluuebunny/crossref_metadata_2025 huggingface dataset:
P6509Plasma trimethylamine n-oxide level is associated with neoatherosclerosis in patients with very late stent thrombosis
Authors: Tan Y , Yan H B
Published: October 2019

Background

Trimethylamine N-oxide (TMAO) has been demonstrated to promote the pathogenesis of atherosclerosis. It is unknown whether plasma TMAO is associated with neoatherosclerosis, an important underlying mechanism of very late stent thrombosis (VLST). We investigated the relationship between the culprit plaque morphology and plasma TMAO concentration in patients with ST-segment elevation myocardial infarction caused by VLST.

Methods

Optical coherence tomography (OCT) was used to evaluate the culprit lesion morphology. Thirty consecutive patients with VLST were enrolled; 17 patients were identified as neoatherosclerosis and 13 without neoatherosclerosis. Patients with neoatheroslcerosis were further divided into two subgroups, including 11 patients with plaque rupture and 6 without plaque rupture, respectively.

Results

The plasma TMAO levels were significantly higher in patients with VLST than in healthy individuals (3.64 μM [2.08–4.58] vs. 1.47 μM [0.89–2.75], p<0.001). Within VLST patients, plasma TMAO levels were significantly higher in patients with neoatherosclerosis than in those without neoathersclerosis (4.35 μM [3.43–5.37] vs. 2.02 μM [1.30–3.59]; p<0.001). The logistic analysis revealed that plasma TMAO was a predictor of neoatherosclerosis (odds ratio: 3.35, 95% confidence interval: 1.40–8.03; p=0.007). In addition, patients with neoatherosclerosis with plaque rupture had significantly elevated plasma TMAO concentration than those without plaque rupture (5.29 μM [4.35–7.21] vs. 3.63 μM [3.02–3.92]; p=0.012). The area under receiver operating characteristic curve for patients with neoatherosclerosis versus those without neoatherosclerosis was 0.87, the corresponding sensitivity and specificity was 0.77 and 0.88, respectively.

The comparison of plasma TMAO level

Conclusions

High plasma TMAO was associated with neoatherosclerosis and plaque rupture in patients with VLST.

Acknowledgement/Funding

This study was supported by the Chinese Academy of Medical Sciences Innovation Fund for Medical Sciences (2016-I2M-1-009)
P6511CABG was associated with higher risk of periprocedural stroke than PCI in patients with complex coronary artery disease
Authors: Watanabe H , Shiomi H S , Kimura T K
Published: October 2019

Background

Periprocedural stroke was believed to occur more frequently after coronary artery bypass grafting (CABG) than percutaneous coronary intervention (PCI). However, few clinical data have endorsed it.

Methods

The CREDO-Kyoto registry Cohort-1 and Cohort-2 are large-scale registries enrolling consecutive patients undergoing first coronary revascularization in the BMS era (2000–2002) for Cohort-1, or in the DES era (2005–2007) for Cohort-2 in Japan. Using the pooled individual patient-level data, the current study population consisted of 7774 patients who received PCI (PCI group) and 4392 patients who received CABG (CABG group).

Results

The cumulative 30-day incidence of stroke was significantly lower in the PCI group than in the CABG group (0.5% versus 1.7%, P<0.0001). Even after adjusting for baseline characteristics, the excess 30-day risk of the PCI group relative to the CABG group for stroke remained significant (hazard ratio [HR]: 0.34, 95% confidence interval [CI]: 0.23–0.52, P<0.0001). Similarly, the cumulative 10-year incidence of stroke was significantly lower in the PCI group than in the CABG group (13.2% versus 14.8%, P=0.046). However, after adjusting for confoundings, the excess 10-year risk of the PCI group relative to the CABG group for stroke was not higher than that of CABG (hazard ratio [HR]: 0.84, 95% confidence interval [CI]: 0.68–1.04, P=0.11).

Conclusions

CABG was associated with higher risk of periprocedural stroke than PCI in patients with complex coronary artery disease. However, the risk of stroke during 10-year follow-up was similar between the groups.
P65217.5-Fr sheathless guides versus 7-Fr glidesheath slender sheath/7-Fr guiding catheter combination for acute myocardial infarction: a propensity-matched analysis
Authors: Isawa T , Horie K , Taguri M , Ootomo T
Published: October 2019

Purpose

To investigate the differences between a 7.5-Fr sheathless guides and a 7-Fr Glidesheath slender sheath (GSS) /7-Fr guiding catheter combination regarding access-site complications and process time metrics in percutaneous coronary intervention (PCI) for acute myocardial infarction (AMI).

Methods

We enrolled 609 patients undergoing PCI for AMI at our hospital using either a 7.5-Fr sheathless guides or a 7-Fr GSS/7-Fr guiding catheter combination; 1:1 propensity score matching was performed. A propensity score was estimated using a multivariate logistic regression model. Variables included were age, gender, weight, hypertension, diabetes, smoking, statin, estimated glomerular filtration rate, end-procedural activated clotting time, oral anticoagulants, SYNTAX score I, previous PCI, history of MI, Killip class, prior ipsilateral transradial intervention, and radial artery diameter.

Results

A total of 336 subjects were included in the propensity-matched sample. Compared with the GSS group, the sheathless group had significantly less frequent severe radial spasm (Sheathless: 0.6% vs. GSS: 4.8%, p=0.037) and Bleeding Academic Research Consortium type 2, 3, or 5 bleeding events (Sheathless: 12.5% vs. GSS: 21.4%, p=0.041).

Procedure outcomes Variables Total population Propensity-matched population Sheathless (n=368) Glidesheath (n=241) OR (95% CI) p Sheathless (n=168) Glidesheath (n=168) OR (95% CI) p Primary outcomes   RAO at 30 days 10 (2.7) 3 (1.2) 0.45 (0.08–1.77) 0.26 4 (2.4) 1 (0.6) 0.25 (0.03–2.22) 0.37   Severe radial spasm (grade 3 or 4) 5 (1.4) 12 (5.0) 3.78 (1.22–13.87) 0.011 1 (0.6) 8 (4.8) 8.35 (1.03–67.52) 0.037   BARC type 2, 3, or 5 bleeding within 30 days 40 (10.9) 45 (18.7) 1.87 (1.15–3.05) 0.008 21 (12.5) 36 (21.4) 1.91 (1.06–3.43) 0.041   Procedural success 361 (98.6) 238 (98.8) 1.10 (0.21–7.14) 0.54 167 (99.4) 166 (98.8) 0.50 (0.05–5.53) 1.0 Secondary outcomes   Coronary ostial dissection 7 (1.9) 3 (1.2) 0.65 (0.11–2.87) 0.75 4 (2.4) 3 (1.8) 0.75 (0.16–3.38) 1.0   MACCEs within 30 days 4 (1.1) 7 (2.9) 2.70 (0.68–12.73) 0.12 4 (2.4) 0 (0) n/a 0.12   Puncture to balloon time, min 26.0 (21.0–35.0) 27.0 (20.0–38.0) n/a 0.52 26.5 (21.0–37.0) 27.0 (20.0–38.0) n/a 0.77 Data are presented as median (interquartile range) or n (%), unless otherwise indicated. Bleeding Academic Research Consortium; CI, confidence interval; MACCEs, major adverse cardiac and cerebrovascular events; OR, odds ratio; RAO, radial artery occlusion. MACCEs include all-cause death, myocardial infarction, target-vessel revascularization, and cerebrovascular accident.

Conclusions

These data demonstrate a clear advantage of sheathless guides over GSS/guiding catheter combination for decreased risk of severe radial spasm and bleeding.
P6539Automated detection of atrial fibrillationb based on vocal features analysis
Authors: Golovchiner G , Abelow A , Swissa M , Morelli O , Beker A
Published: October 2019

Background

Early identification of atrial fibrillation (AF) has been a long-standing clinical challenge and an unmet need. AF may be present without the patient being aware of any symptoms, leading to a delay in or failure of diagnosis. ESC guidelines recommend opportunistically screening patients >65 years of age using pulse palpation or an ECG rhythm strip, however these methods have limited effectivity. Analysis of natural speech signals has been used as a monitoring tool for various medical conditions and has recently been reported to enable estimation of heart rate. In this study we evaluated the efficacy of vocal features analysis in the detection of AF and in discriminating between sinus rhythm (SR) and episodes of AF.

Methods

In this prospective multicenter study, patients with persistent AF admitted for cardioversion were enrolled. A total of 86 patients in 2 centers were included. Prior to cardioversion, the patients spoke specific vowels and words according to a pre-specified protocol; an ECG tracing was simultaneously recorded. Following successful cardioversion and recovery from sedation, these recordings were repeated in SR. The recordings of the first 34 patients were used to develop an algorithm of AF detection based on analysis of acoustic features in SR and AF conditions. The algorithm was then validated in all of the patients (n=86) in the following manner: 25% of SR recordings were used to train the algorithm while the remaining 75% of SR and 100% of AF data from every patient were tested with the algorithm to distinguish between AF and SR.

Results

A total of 513 recordings from 86 patients were analyzed. Classification of the recordings as AF or SR was performed using varying cutoff values of the separation parameter. The resulting curve showing the specificity and sensitivity of the developed algorithm for distinguishing AF from SR is presented. Two specific examples of working points are a specificity of 92% and sensitivity of 83%, and a specificity of 82% and sensitivity of 92%.

Conclusions

This study demonstrates the feasibility of detecting AF and discriminating it from SR using analysis of acoustic features extracted from spoken vowels. The potential use of this method for wider population screening should be further evaluated.
P6552Is it possible to recognize free-wall implantation of leadless pacemakers from an ECG?
Authors: Kajiyama T , Kondo Y , Nakano M A , Nakano M I , Hayashi T , Ito R , Takahira H , Kobayashi Y
Published: October 2019

Background

Leadless pacemaker (Micra, Medtronic, US) is a effective treatment for bradycardia and eliminates any malfunctions related to intravenous leads. However, some cases exhibit pericardial effusion, presumably associated to device implantation to right ventricular free-wall.

Objectives

The present study was carried out to find ECG features during ventricular pacing by Micra, which enabled to distinguish free-wall implantation from septal implantation without imaging modalities.

Methods

Consecutive 21 patients who received implantation of Micra in our facility were enrolled. Location of device in the right ventricle was evaluated using echocardiography or computed tomography in order to determine whether the device was implanted on the septum or the freewall. The difference of 12-lead ECG during ventricular pacing from Micra were analyzed between the septum group and the free wall group.

Results

According to the imaging investigation, body of Micra was clearly identifiable in 17 patients. The locations of device were classified into septum in 11 patients, free-wall in 4 patients, and indeterminate but apex in 2 patients. Further analysis regarding ECG was performed exclusively between the septum group and the free-wall group. In lead V1, peak deflection index (PDI) was significantly larger in free-wall group than septum group (0.64±0.06 vs. 0.45±0.10, P=0.005), whereas there was no difference of QRS duration, transitional zone and QRS pattern.

PDI of V1 and Location of LPM

Conclusion

PDI of V1 could be useful to predict implantation of Micra to free-wall and may potentially stratify the risk of postprocedural pericardial effusion.
P6557Permanent atrial fibrillation development in patients with DDD pacemaker -Rrisk factors and association with mortality in long-term
Authors: Debski M , Ulman M , Zabek A , Boczar K , Haberka K , Kuniewicz M , Lelakowski J , Malecka B
Published: October 2019

Background

In patients undergoing permanent DDD cardiac pacing, the maintenance of atrial contractility is important to ensure adequate ventricular filling and to guarantee an optimal ventricular ejection capacity. Atrial fibrillation (AF) is a major risk factor for thromboembolic events and is associated with increased cardiovascular and all-cause mortality.

Purpose

To analyse the risk factors for development of permanent AF in patients with DDD pacemaker and determine its association with all-cause mortality in long-term follow-up.

Methods

Retrospectively collected records comprised all consecutive patients who underwent primary DDD pacemaker implantation at single-centre between 1984–2014. Patients who were lost to follow-up after hospital discharge were excluded from analysis. Follow-up was completed on 31st August 2016. Definition of permanent AF was the occurence of AF which persisted until the end of follow-up. Data on patients' survival status and deceased patients' dates of death were collected from the national death registration system. Information of death date was available as of 31st August 2016. The endpoint was all-cause mortality.

Results

We included a total of 3771 patients and 24,432 patient-years of follow-up and exluded 157 (4%) patients who were lost to follow-up after hospital discharge. Mean follow-up was 78±62 months (max. 370 months), 1761 (47%) were female. Paroxysmal AF prior to DDD pacemaker implantation was detected in 1276 patients (34%). During entire follow-up 717 (19%) patients developed permanent AF in a mean period of 55±50 months. Analysis of risk factors for development of permanent AF is presented in Figure. Cox proportional hazards model with time-dependent covariate showed that development of permanent AF significantly increased mortality during follow-up (HR = 1.885, 95% CI, 1.654–2.148, P<0.001; with adjustment for age at implantation and sex: HR = 1.475, 95% CI, 1.294–1.682, P<0.001).

Permanent AF risk factors

Conclusions

Female sex protected against permanent AF development, whereas age at implantation, history of paroxysmal AF and apical position of RV lead increased the risk. Permanent AF was significantly increasing the all-cause mortality, even after adjustment for age at implant and gender.

Acknowledgement/Funding

None
P6564Prediction of the progression from paroxysmal to persistent or permanent atrial fibrillation using different scores. Is AF progression mainly atrial aging?
Authors: Fauchier L , Martins R , Bisson A , Bodin A , Clementy N , Pierre B , Babuty D
Published: October 2019

Reliable prediction of atrial fibrillation (AF) progression from paroxysmal to non-paroxysmal form of AF could help in optimizing follow-up and decision-making regarding the rate and rhythm control management. The HATCH score and others have been proposed to identify AF patients likely to progress to sustained forms of AF, but external validation is limited. We aimed at evaluating these scores in a large series of AF patients and to identify possible factors leading to persistent/permanent AF.

Methods

All patients with AF seen over a period of 10 years were identified in a database and followed up for AF progression and mortality. Predictors of outcomes were identified using Cox regression model. The values of HATCH, CHA2DS2-VASc, ALARMEc, APPLE, MB-LATER scores and CHARLSON comorbidity index were evaluated with C statistics for prediction of AF progression.

Results

Among 8962 patients (71±14 years), 4991, 476 and 3495 had paroxysmal, persistent AF, and permanent AF, respectively. During a follow-up of 927±1084 days, 404 paroxysmal AF patients progressed to persistent or permanent AF (yearly rate of 3.0%). Progression was associated with a trend toward increased cardiovascular mortality. Independent predictors of AF progression were heart failure (hazard ratio (HR) 2.07; 95% CI 1.50–2.85, p<0.0001), valvular disease (HR=1.87, 95% CI=1.35–2.58, p=0.0002) and the use of digoxin (HR=2.39, 95% CI=1.75–3.29, p<0.001). Conversely, a history of stroke was associated with a lower rate of progression (HR=0.50, 95% CI=0.28–0.88, p=0.02). Overall, most of the score, particularly the HATCH score, were modest predictors of progression (table). The best score was actually the CHARLSON comorbidity index. The predictive values of all scores were better on patients not treated with antiarrhythmic agent.

C-statistics for AF progression All patients (n=4,991) p value* HATCH 0.576 (0.562–0.590) <0.0001 CHA2DS2-VASc 0.532 (0.503–0.560) <0.0001 ALARMEc 0.634 (0.607–0.660) 0.03 APPLE 0.631 (0.605–0.658) 0.03 MB-LATER 0.612 (0.587–0.638) 0.001 CHARLSON 0.667 (0.640–0.693) – *DeLong test vs CHARLSON comorbidity index.

Conclusion

Most of scores have a modest predictive value to identify the risk of evolution to permanent AF. Among them, the CHARLSON comorbidity index had the best predictive value and outperformed other tools. This suggests that AF progression may actually reflect global aging both at the individual and local atrial level.
P6575Evaluation of arrhythmias using an insertable cardiac monitor in patients with hypertrophic cardiomyopathy
Authors: Magnusson P , Morner S
Published: October 2019

Background

Hypertrophic cardiomyopathy (HCM) is a heterogeneous disease associated with arrhythmias. Life-threatening ventricular tachycardia (VT) or fibrillation is the main cause of sudden cardiac death (SCD) in HCM, even though bradycardia does occur. An implantable cardioverter-defibrillator effectively prevents SCD. Non-sustained VT is a risk factor for SCD and part of current risk stratification. Furthermore, atrial fibrillation (AF) is believed to be common in HCM and increases the risk of stroke. Notably, novel oral anticoagulant (NOAC) is recommended in HCM with AF, even in the absence of other risk factors. Routinely, arrhythmias are evaluated by 24–48 hours of ambulatory monitoring occasionally. Thus, the true burden of arrhythmia is unknown but may be elucidated by an insertable cardiac monitor (ICM).

Purpose

The purpose of this study was to ascertain the incidence of NSVT, AF, and significant bradycardia in unselected HCM patients by use of an ICM.

Methods

In total, 30 adults with HCM had an ICM Confirm Rx implanted subcutaneously at the level of the fourth rib on the left side. None had a cardiac device implanted previously since they were considered to be at low risk for SCD according to ESC risk score. The application for monitoring was installed in the patients' phone which also allowed for patient activation in case of symptoms. The ICM was programmed as follows: VT ≥160 beats per minute (bpm) during ≥8 intervals, AF ≥2minute of duration, and bradycardia ≤40 bpm or pause ≥3.0 s. Clin Trial Reg: NCT03259113.

Results

In total, 29 patients, mean age 51.2±12.3 years, 24 (82.8%) males, completed the monitoring and 1 had the phone disconnected the vast majority of time and was excluded for analyses. During a follow-up of 14–18 months, 9 patients (31.0%) had AF and were started on NOAC and potential dose-adjustment of beta-blocker. One of these patients had syncope due to rapidly conducted AF. One of the patients with AF also had episodes of atrial flutter. At least one episode of NSVT was detected in 6 patients (20.7%). In 11 patients (37.9%), sino-atrial block/sinus arrest were seen, typically 30–40 bpm. In 9 patients (31.0%) no significant arrhythmia were detected.

Conclusion

In this first study of ICM in HCM, evaluation of arrhythmia burden in low risk patients with HCM, yielded 31.0% AF, 20.7% NSVT, and 37.9% sino-atrial block/arrest.

Acknowledgement/Funding

Abbott
P6580Prevalence and clinical significance of latent Brugada syndrome in juvenile lone atrial fibrillation
Authors: Fathy E , Gaido L , Quaranta S , Anselmino M , Giustetto C , Kamal Salama M , Ghaleb R , Salh A , Gaita F
Published: October 2019

Introduction

Brugada syndrome (BrS) cause about 20% of sudden cardiac death (SCD) in young healthy adults. Nearly 20% of Brugada patients develop supraventricular arrhythmias, mostly atrial fibrillation (AF). But whether lone AF may be the first clinical manifestation in young patients with latent BrS remains unclear.

Purpose

To estimate the prevalence and clinical significance of latent Brugada ECG pattern in young population (age ≤45 years) with lone AF.

Methods

A total of 78 patients with lone atrial fibrillation (mean age 35±7) were selected from 111 young patients with juvenile atrial fibrillation (age ≤45 years) between January 2015 and November 2017. All patients were clinically evaluated. Moreover 12 lead-24H Holter ECG and pharmacological class 1C antiarrhythmic drug (AAD) test were done for high suspicious cases of Brugada ECG. The diagnosis of Brugada ECG pattern was established according to the second consensus report criteria 2005 and since 2013, according to HRS/EHRA/APHRS expert consensus statement.

Results

According to the study protocol, we considered two groups of patients, group 1: 13 patients (16.7%; mean age 37±8) were diagnosed with type 1 Brugada ECG pattern (3 during class 1C AADs therapy and 10 induced by class 1C AAD test), group 2: 65 patients (83%; mean age 35±7) diagnosed as lone AF without type 1 Brugada ECG. The clinical characteristics of the two groups are described in table 1. Regarding to group 1, two patients had positive electrophysiological study with subsequent ICD implantation and genetic test for SCN5A mutation was positive in 3 patients.

Table 1. G1, G2 clinical characteristics Patients characteristics Group 1 (n=13) Group 2 (n=65) P value Mean age (years) 37±8 35±7 0.42 Gender (Male %) 7 (54%) 54 (83%) 0.02 Family history of BrS 2 (15%) 0 (0%) 0.03 Family history of SCD 1 (8%) 1 (1.5%) 0.20 Syncope 4 (31%) 5 (8%) 0.02 Sick Sinus Syndrome 1 (8%) 7 (11%) 0.70 Paroxysmal AF 12 (92%) 54 (83%) 0.40 Suspected basal ECG for BrS 13 (100%) 28 (43%) <0.01 Statistical test is considered significant when p value <0.05.

Conclusions

Up to our knowledge this study is the first one that estimate the prevalence of latent BrS in juvenile lone AF patients. Young patients with lone AF had a high prevalence of latent BrS. Syncope, family history of SCD and family history of BrS are significant indicators of the presence of latent BrS in young patients with lone atrial fibrillation.
P6591Arrhythmogenic effects of non-steroidal anti-inflammatory drugs (NSAID)
Authors: Frommeyer G , Baeumer S , Ellermann C , Eckardt L
Published: October 2019

Background

Clinical and experimental data suggest potential deleterious effects of non-steroidal anti-inflammatory drugs (NSAID) in cardiac disease. The aim of the present study was to characterize potential direct arrhythmogenic effects of ibuprofen or indometacin on cardiac electrophysiology.

Methods and results

In 13 isolated rabbit hearts, indometacin was administered in increasing concentrations (10, 30 and 50μM) after obtaining baseline data. In further 13 hearts, ibuprofen was infused (10, 30 and 50μM). Eight endo- and epicardial monophasic action potentials and a simultaneously recorded 12-lead ECG showed a significant decrease of QT-interval in indometacin- (50μM: −60ms, p<0.05) and ibuprofen-treated hearts (50μM: −81ms, p<0.01). This was accompanied by a similar decrease of action potential duration (APD). Effective refractory period (ERP) was also reduced by indometacin (−24ms, p<0.05) and ibuprofen (−22ms, p<0.05) while spatial dispersion of repolarisation remained stable with both drugs.

Programmed ventricular stimulation and burst stimulation were employed for provocation of ventricular arrhythmias. In the indomethacin group 7 episodes of ventricular arrhythmias were inducible at baseline. The incidence was increased to 22 (10μM), 37 (30μM) and 51 (50μM) with higher concentrations of indometacin. In the ibuprofen group 15 episodes were inducible at baseline. After infusion of 10μM ibuprofen, also 15 episodes of ventricular arrhythmias occurred while 34 episodes were inducible with 30μM ibuprofen.

Conclusion

Infusion of the NSAID ibuprofen and indometacin resulted in a significant abbreviation of myocardial repolarization and a shortening of ventricular refractory periods. This resulted in an enhanced inducibility of ventricular arrhythmias and may contribute to the proposed deleterious effects of NSAID in the presence of cardiac disease.
P6594Granger Causality-based analysis to accurately identify specific electrophenotypes of myocardial fibrillation
Authors: Handa B S , Li X , Qureshi N , Mann I , Kanagaratnam P , Peters N S , Ng F S
Published: October 2019

Background

Clinical identification of fibrillation drivers remains challenging in both atrial and ventricular fibrillation (VF). In this study, we developed novel tools using granger causality (GC) analysis for quantifying the causal relationship between neighbouring fibrillatory signals. We tested whether it was adaptable to low resolution, limited coverage and sequentially acquired data for quantifying global organisation of VF and mapping regions with stable rotational drivers (RDs).

Methods

Eighteen Sprague-Dawley rat hearts were perfused ex vivo for optical mapping studies. VF with differing degrees of organisation was induced with carbenoxolone (10–50μM, n=8), or prior maturation of patchy ventricular fibrosis (n=10) generated by ischaemia-reperfusion. After phase mapping, the data was downsampled to 25% of full resolution to develop validated GC-based tools. The causality pairing index (CPI), a global measure of organisation, quantified propagational effects between all neighboring signals. Low-resolution GC-vector maps localized areas harboring RDs and quantified the prevalence of RDs over time using a novel index called circular interdependence value (CIV). These GC-based tools were then adapted to analyze low-resolution multi-electrode electrograms of sixteen persistent-AF (psAF) patients presenting for a first ablation procedure.

Results

A spectrum of fibrillatory organisation and mechanisms in VF was observed. In rat VF there was a positive correlation between CPI and the number of stable RDs (R2=0.41, p=0.004), and CIV showed a significant difference in driver vs non-driver regions (0.91±0.05 vs 0.35±0.06, p=0.0002). Similarly, in psAF patients, there was a positive correlation between CPI and the number of stable RDs (R2=0.56, p≤0.001). GC vector mapping showed that 8/16 of patients had at least one RD area, and 8/16 had chaotic activity with no RDs.

Conclusion

Mechanisms of myocardial fibrillation occurs along a spectrum between organized activity with discrete areas harboring RDs and disorganised myocardial activation with no RDs. GC maps can be utilised for identifying regions localising RDs with sequential mapping in limited spatial resolution and coverage. In psAF GC-based analysis accurately identified specific fibrillatory mechanisms from low-resolution mapping. GC vector mapping holds potential for development with human fibrillation data as a mapping tool for driver guided ablation.

Acknowledgement/Funding

BHF Programme Grant PG/16/17/32069
P6595The optogenetic defibrillation of ventricular arrhythmia in myocardial infarction rats in vivo
Authors: Wang X I , Cheng Y , Rao P , Wang L
Published: October 2019

Introduction

Optogenetics is a low-invasive, flexible and highly selective intervention that enables electrical excitation with light on myocardium overexpressing light-sensitive proteins. Optical illumination can control the simultaneous exciting of the whole myocardium under the spot, which is more conducive to recovery from electrical disturbance to sinus rhythm.

Purpose

We explored optogenetic defibrillation for different illumination parameters how to affect defibrillation rates and the possible mechanism of continuous illumination defibrillation.

Methods

Systemic delivery via right jugular vein injection of (AAV9-CAG-hChR2(H134R)-mCherry) were performed in juvenile SD rats to achieve the light sensitive protein Channelrhodopsin-2 (ChR2) transfer throughout the whole heart. We intubated and ventilated rats, opened chest and recorded the ECG. After ligation of the left anterior descending coronary artery, ventricular arrhythmia was induced by electrical burst stimulation (10v, 50Hz, 2s). Cardiac epicardium illumination with 470nm blue laser was performed to investigate the effects of optogenetic defibrillation and its underlying mechanism. Every heart accepted 30 pulses of 20ms duration on 8Hz to test the light intensity threshold for 1:1 capture. Different illumination modes of multiple light intensity (2,4,8,10,20 times threshold intensity), pulse duration (20, 50, 200, 500 and 1000ms) and illumination position (RV apex, RV, RVOT, septum, LV) were applied in each attempt for 4 repetitions with 1 s interval.

Results

We demonstrated that ventricular arrhythmias could be terminated by illumination of the right ventricle at 20 times threshold intensity in 1s (figure A) with the successful defibrillation rate of 95±2.673% (mean ±SEM; N=7). Herein, the successful optogenetic defibrillation rate was strongly depending on light intensity (N=5, n=50 episodes, p=0.0118) and duration of illumination (N=5, n=50 episodes, p<0.0001) (figure B.C). Notably when there were higher intensity and longer pulse duration, the higher defibrillation rate appeared. There was no significant difference in the defibrillation rate among different illumination positions (N=5, n=25episodes per position, p=0.1177) (figure D). To explore the underlying mechanism of optogenetic defibrillation, we performed the same illumination mode during sinus rhythm in 2 rats (figure E. F. G). We observed that higher light intensity and longer pulse duration were more conducive to induce an episode of higher frequency focal excitement.

Views of optogenetic defibrillation

Conclusions

We demonstrated that optogenetic defibrillation is a highly effective intervention and the possible mechanism is partly attributed to overdrive suppression. We believe that optogenetic approach is potentially to be translated into more efficient and pain-free clinical termination of ventricular arrhythmia.

Acknowledgement/Funding

The national natural science foundation of China (81772044)
P6600Cardiac electrical biomarker retains memory of myocardial ischaemia not severe enough to cause myonecrosis
Authors: Chattopadhyay S , Adjei F , Kardos A
Published: October 2019

Background

“Cardiac electrical biomarker” (CEB) is a numerical index measured by the Vectraplex ECG (vECG) System with Vectraplex AMI software that detects changes in the cardiac electrical fields from dipolar to multipolar vectors during myocardial ischemia. CEB has been validated with ECG traces derived from patients with acute myocardial infarction. However the threshold of CEB for diagnosis of NSTEMI is varied between studies.

Purpose

To examine the effect of myocardial ischemia during transient coronary occlusion on CEB and the time-course of its recovery.

Method

Seventy-five consecutive patients with normal (without Q waves, ST-T changes, arrhythmias, bundle branch blocks, left ventricular hypertrophy etc) surface ECG (sECG) had CEBs measured from vECGs recorded before, during and 1, 2 and 3 hours after balloon occlusion during elective percutaneous coronary intervention (PCI). HsTnI was measured before and 1, 2 and 3 after the procedure. The balloon was inflated to the clinically indicated pressures till the appearance of symptoms and/or ST changes or to a maximum of 90 seconds. Ischemia induction during balloon occlusion was confirmed by the presence of ST-T changes on sECG and/or TIMI-0 flow on angiogram. Multiple vECGs were recorded at each balloon occlusion. Every vECG used to derive CEBs was adjudicated for quality by 2 observers blinded to the results. vECGs with wandering baseline, transient arrhythmias, bundle branch blocks etc. were discarded. The highest CEBs derived from best traces were analysed. The pre- and post-PCI CEBs, were compared with the maximum CEB during balloon occlusion using Wilcoxon rank and Friedman test.

Results

Fifteen subjects with negative FFR and 2 subjects with totally occluded arteries that could not be revascularised were excluded. Mean duration of balloon occlusion resulting in the highest CEB was 54.1 secs. The maximum CEB was reached in 20, 27 and 11 patients during pre-dilatation, stent deployment and post-dilatation respectively. The CEB increased with balloon inflation (pre-PCI median (interquartile range, IQR) 53.5 (31–105) vs balloon occlusion 202 (108–332), p<0.0001). The CEB during balloon occlusion gradually recovered over 1, 2 and 3 hrs post-PCI (vs 74.5 (35–135), p<0.0001; vs 66 (37–118), p<0.0001; vs 58.5 (29–97), p<0.0001 respectively). The 1hr (p=0.0011) and 2hr (p=0.0352) post-PCI CEB remained higher than pre-PCI CEB and returned to the pre-PCI level at 3h post-PCI (p=0.4433). All except 2 patients had normal 3hr TnI; both being below the threshold for diagnosis of peri-procedural MI.

Figure 1

Conclusion

CEB increases with short transient coronary artery occlusion not severe enough to cause myocardial necrosis and took 3 hours to return to the pre-procedural level suggesting its feature of “ischemic memory”. Thus CEB may have a value in detecting an ischemic episode in patients with chest pain but without a raised hs-Tn.

Acknowledgement/Funding

None
33Can anti-hypertensive thiazide diuretics also reduce fragility fracture risk?
Authors: Sousa J P , Ribeiro J , Puga L , Lourenco C , Goncalves L
Published: October 2019

Introduction

A great deal of fractures are related to osteoporosis. Thiazide diuretics have been associated with reduced age-related bone loss, by decreasing urinary calcium excretion. On the other hand, they can also induce hyponatremia, which is a risk factor for fracture occurrence, potentially jeopardizing hypocalciuric protective effects. Recently, a secondary analysis of the ALLHAT trial found that chlorthalidone may reduce hip and pelvic fractures, when compared to lisinopril.

Purpose

To compare fracture outcomes of hypertensive thiazide users with those of hypertensive patients not treated with thiazides.

Methods

MEDLINE, EMBASE, Cochrane and SCOPUS databases were comprehensively searched, from inception to the first of February of 2019, for cohort studies mentioning thiazide diuretic usage and fracture rates. Literature search, study eligibility, including methodological quality assessment, and data extraction were independently conducted by two investigators. Meta-analysis was performed using generic inverse variance outcome and, due to heterogeneity of the original studies, a random effects model. Confounder-adjusted relative risk (RR) was pooled. Primary outcome was total fracture rate, whereas hip and women-specific fracture risk were regarded as secondary endpoints.

Results

Fourteen eligible studies were identified. Overall, 3,601,779 patients were included and 290,885 incidental fractures were recorded. Prototype patient was middle-aged to old and three studies only enrolled females. Clinical follow-up was documented at a median of five years. Thiazide diuretic users, as compared with non-users, had a significant 11% reduction in total fractures (RR=0.86, 95% confidence interval [CI]=0.82–0.97, p=0.008, i2=77%). Seven studies, encompassing 553,614 patients and 5,005 cases, allowed for estimation of hip fracture risk, with thiazides demonstrating an even larger effect (RR=0.78, 95% CI=0.68–0.89, p=0.0004, i2=45%). Likewise, four studies, incorporating 149,024 patients and 150.998 cases, were able to provide insight into women fracture risk, in whom thiazides seem to exert no significant protective effect (RR=1.00, 95% CI=0.78–1.27, p=0.98, i2=77%).

Conclusion

Thiazide diuretics may convey a decreased risk of fracture, particularly in the potentially lethal hip location. This protective secondary effect of thiazides should be considered in hypertension clinic, with osteoporotic men seeming the best candidates for this therapy.
45Association of types of dietary fats and all-cause and cause-specific mortality: a prospective cohort study and meta-analysis of prospective studies with 1,148,117 participants
Authors: Mazidi M , Mikhailidis D P , Sattar N , Toth P P , Judd S , Blaha M J , Hernandez A V , Banach M
Published: October 2019

Background

The associations between dietary fats with mortality are poorly delineated.

Purpose

Using a large prospective cohort we evaluated the link between total fat, mono-unsaturated (MUFA), polyunsaturated (PUFA) and saturated fatty acid (SFA) consumption and all-cause, coronary heart disease (CHD), stroke, and diabetes (T2D)-associated mortality in a representative sample of US adults. We then added our results to a systematic review and meta-analysis.

Methods

We evaluated 35,080 participants from the National Health and Nutrition Examination Surveys (NHANES) 1988–1999 (19.2 years follow-up) and 1999–2010 (12 years follow-up), with vital status available through December 31, 2011. Cox proportional hazard regression models were used to evaluate the association between baseline quartiles of fat consumption (g/day, 24h recall) and all-cause or cause-specific mortality. For the systematic review, selected databases were searched up to November 2018 and 29 prospective cohorts (n=1,148,117) met inclusion criteria. The DerSimonian-Laird method and generic inverse variance methods were used for random effects meta-analyses.

Results

In fully adjusted models from our prospective study, there was a negative association between total fat (hazard ratio [HR]:0.90, 95% confidence interval [CI]: 0.82, 0.99, Q4 vs. Q1) and PUFA (0.81,95% CI: 0.78–0.84) consumption and all-cause mortality (Figure), whereas SFA were positively associated with mortality (1.08, 95% CI: 1.04–1.11). In the meta-analysis we found a significant negative association between total fat (HR: 0.89, 95% CI: 0.82–0.97, I2:27%), MUFA (0.93, 95% CI: 0.87–0.99, I2:56%) and PUFA (0.86, 95% CI: 0.80–0.93, I2:63%) consumption and all-cause mortality. No significant association was observed between total fat and both CVD and CHD mortality (0.92, 95% CI: 0.79–1.08, I2:46%, and 1.03, 95% CI: 0.99–1.09, I2:42%, respectively), while a positive association between SFA intake and CHD mortality (1.10, 95% CI: 1.01–1.20, I2:52.6%) was observed. Neither MUFA nor PUFA were associated with CVD and CHD mortality. Inverse associations were observed between MUFA (0.80, 95% CI: 0.67–0.96, I2:0%) and PUFA (0.84, 95% CI: 0.80–0.90, I2:0%) intakes and stroke mortality.

All-cause death and total fat intake.

Conclusions

Our results highlight differential associations of total fat, MUFA and PUFA intake with all-cause mortality, but no association of them with CVD and CHD mortalities. SFA intake was significantly associated with higher all-cause mortality inNHANES and with CHD mortality in our meta-analysis. The type of fat intake appears to be associated with important health outcomes.

Acknowledgement/Funding

None
65Utilization of percutaneous left atrial appendage closure in patients with atrial fibrillation in the United States: analysis from national inpatient sample 2016
Authors: Wu L , Ho K
Published: October 2019

Introduction/Background

In recent years, the percutaneous left atrial appendage closure (LAAC) has been gaining its popularity in the US. However its use in the US in recent years has not been well described.

Purpose

To provide an updated cross-sectional survey of performance of percutaneous LAAC in the US at national database level.

Methods

We use ICD-10 disease and procedure code to identify all the percutaneous LAAC performed in 2016 in US from national inpatient sample database. The demographic feature, comorbidity, mean time to procedure, mortality, complication rate, length of stay, total cost were described. Procedure related complication Including any vascular, cardiac, respiratory, neurologic and renal complications defined by AHRQ as patient safety indicators.

Results

There is approximately a total of 7550 percutaneous LAAC performed in the US in 2016. The majority of the patients were elderly (mean age 66.83±0.34), white (80.41%) male (59.04%). The mean Charlson Comorbidity Index score is 1.74, with hypertension (76.75%), diabetes (29.23%) being the most common comorbidity. The mean time to procedure is 1.98±0.11 days. The procedure related mortality is 2.06%, whereas the complication rate is 19.6%. The average length of stay is 10.77 day, with an average total cost of 239.67 thousand dollars.

Baseline characterlistisc and outcomes Total percutaneous LAAC (estimated from sample) 7550 Age, years 66.83±0.34 Male, % 59.04 White, % 80.41 Mean Charlson Comorbidity Index 1.74±0.31 Hypertension, % 76.75 Diabetes, % 29.23 CKD, % 21.42 Mean Time to procedure, days 1.98±0.11 Mortality, % 2.06 Length of Stay, days 10.77±0.25 Any Complication, % 19.6 Total Cost, thousand dollars 239.67±10.01 Values are reported as mean ± SD. Categorical variables are represented as frequency.

Conclusion

A total of 7550 percutaneous LAAC was performed in US in 2016. The procedure related mortality is 2.06%, with an average time to procedure of 1.98 days and a length of stay of 10.77 days.
91Transcatheter valve-in-valve versus redo surgical aortic valve replacement for the management of failed biological prosthesis: early and late outcomes
Authors: Tam D , Dharma C , Wijeysundera H C , Austin P , Ouzounian M , Rocha R V , Fremes S E
Published: October 2019

Background

While the gold standard for the management of failed previous biological prosthesis was redo surgical aortic valve replacement (SAVR), valve-in-valve (ViV) transcatheter AVR (TAVR) has emerged as a less invasive option. Published studies comparing the two techniques have been small and limited to early outcomes. Herein, we compare early mortality, morbidity and late mortality between ViV TAVR and redo SAVR.

Methods

Clinical and administrative databases for Canada's most populous province, Ontario (>13 million patients), were linked to identify patients undergoing ViV and redo SAVR for a failed biological prosthesis. Baseline characteristics were compared and 1:1 propensity score matching (PSM) was performed to account for baseline differences. Standardized mean differences (SMD) were used to assess adequacy of PSM, whereby a SMD<0.10 indicated a good match. Early outcomes were compared in the matched groups using McNemar's test. In accordance to government privacy legislation, outcomes with <6 events, were presented as absolute risk difference (ARD) between ViV and Redo SAVR to prevent patient re-identification. Late mortality was compared between the matched groups using Kaplan-Meier survival curves and a Cox-proportional hazard model.

Results

Records of 558 patients undergoing intervention for a failed biological prosthesis between March 2008 to September 2017 in 11 Ontario institutions were reviewed (ViV = 214, redo SAVR = 344). Patients who underwent ViV were older (78.2±8.2 vs 69.1±11.4, p<0.001, SMD=0.92) and had more hypertension, diabetes, ischemic heart disease, atrial fibrillation, congestive heart failure compared to redo SAVR before PSM (SMD>0.20). Propensity matching on 24 variables yielded similar groups for comparison (n=133 pairs). Ages were similar between ViV and Redo SAVR (76.0±6.2 vs 76.0±8.7, SMD=0.003) along with all other comorbidities (SMD<0.1). 30-day mortality was significantly lower with ViV compared to Redo SAVR (ARD: −7.4%, 95% confidence interval (95% CI): −12.4%, −2.3%). The rate of permanent pacemaker implantation (ARD: −8.1%, 95% CI: −14.2%, −2.1%), blood transfusions (ARD: −62.2%, 95% CI: −75.2%, −49.1%) and length of stay (LOS) (mean difference: −7.8 days, 95% CI: −11.0, −4.6 days) were also lower with ViV. All-cause mortality at 5 years was similar between ViV and redo SAVR (Figure, p=0.19).

Figure 1

Conclusion

ViV TAVR was associated with lower early mortality, risk of permanent pacemaker implantation, any blood transfusion, and hospital LOS compared to redo SAVR in the largest PSM study to date. While there was no difference in late mortality at 5 years, additional studies with more subjects and longer follow-up are necessary. ViV TAVR may be the preferred approach for the treatment of failed biological prosthesis.
93The high burden of rehospitalisations following transcatheter aortic valve implantation
Authors: Aagaard D T , Fosbol E L , De Backer O , Borgersen E , Gislason G , Torp-Pedersen C T , Sondergaard L , Kober L , Butt J
Published: October 2019

Background

Transcatheter aortic valve implantation (TAVI) is a treatment option for severe symptomatic aortic stenosis in patients at increased surgical risk. Rehospitalisations following surgical aortic valve replacement are a strain on patients and society. However, data on the extent of the burden and cause of hospitalisations following TAVI are sparse.

Purpose

To examine rehospitalisations and factors associated with rehospitalisations in a one-year period following TAVI.

Methods

In this Danish nationwide observational cohort study, we identified all patients who underwent TAVI from January 2008 through June 2016 and were discharged alive by Danish nationwide health- and administrative registries. Subsequent rehospitalisations, defined as a hospital admission for at least one overnight stay, were classified as either cardiovascular or non-cardiovascular according to the discharge diagnosis codes. Factors associated with any rehospitalisation were identified using Cox regression.

Results

In total, 2,390 patients undergoing TAVI were included. The median age was 81 years (25th-75thpercentile 77–85 years of age) and men comprised 52% of the study population. Of all patients undergoing TAVI, 24% were hospitalised during the first 30 days after the procedure, while 54% were hospitalised during the first year. Among patients surviving the first year after the procedure, 25% were admitted to a hospital once, 14% were admitted twice, 8% were admitted three times, and 10% were admitted at least four times. Of all hospitalisations, 34% were due to a cardiovascular cause and 10% died during the one-year follow-up. Factors associated with any hospitalisation were chronic kidney disease (HR 1.72 [95% CI, 1.48–2.00]), peripheral vascular disease (HR 1.36 [95% CI, 1.16–1.59]), atrial fibrillation (HR 1.28 [95% CI 1.14–1.43]), ischemic heart disease (hazard ratio [HR] 1.23 [95% confidence interval [95% CI], 1.09–1.38]), and chronic obstructive pulmonary disease (HR 1.16 [95% CI, 1.02–1.33] (Figure).

Forrest plot

Conclusions

In a nationwide, all-comers cohort of patients undergoing TAVI, 57% of patients were hospitalised at least once during the first-year post-procedure and approximately one-third of all hospitalisations was due to a cardiovascular cause. Focus on patient selection and prevention of readmissions after TAVI is warranted.