bluuebunny/crossref_metadata_2025 huggingface dataset:
P2703Impact of subtended myocardial mass on the assessment of functional ischemia as evaluated by FFR and QFR
Authors: Kanno Y , Hoshino M , Sugiyama T , Kanaji Y , Yamaguchi M , Hada M , Ohya H , Sumino Y , Hirano H , Horie T , Yonetsu T , Kakuta T
Published: October 2019

Background

The fractional flow reserve (FFR) becomes a standard practice for revascularization decision-making in evaluating the functional significance of angiographically intermediate epicardial coronary stenosis. The quantitative flow ratio (QFR) is a novel method for rapid computational estimation of FFR without pressure wire and hyperemic induction. FFR has been reported to be associated with not only epicardial stenosis but also subtended myocardial mass (Vsub). In contrast, the relationship between QFR and Vsub has not been clarified.

Purpose

We sought to examine if subtended myocardial mass (Vsub) assessed by coronary computed tomography showed a significant relationship with QFR in comparison with FFR.

Methods and results

We performed a post-hoc analysis of 152 territories (LAD 116, RCA 25 and LCX 11 lesions) with angiographically intermediate-to-severe stenosis in 152 patients who underwent FFR assessment. The median FFR and QFR values were 0.76 (0.64–0.84) and 0.76 (0.72–0.83), respectively. The median diameter stenosis (%DS) and minimum lumen diameter (MLD) were 54.5 (43.9–64.2) and 1.2 (0.9–1.6), respectively. In total, 123 (80.9%) and 29 (19.1%) lesions showed concordant and discordant FFR and QFR functional classifications, respectively. The ability of Vsub/MLD2 to discriminate lesions with FFR≤0.80 and QFR≤0.80 was assessed compared with QCA data. FFR values were associated with Vsub (R=0.37, P<0.001). In contrast, a trend albeit no significant linear relationshipwas detected between QFR and Vsub (R=0.15, P=0.060). The area under the curve (AUC) of Vsub/MLD2 predicting FFR≤0.80 (0.88: 95% confidence interval [CI], 0.83–0.94)was significantly better than that of MLD (0.80: 95% [CI], 0.72–0.88) (P<0.001). On the other hand, the AUC of Vsub/MLD2 predicting QFR≤0.80 (0.82: 95% [CI], 0.75–0.90) was similar to that of MLD (0.80: 95% [CI], 0.72–0.87) (P=0.276). Multivariate analysis showed that the value of Vsub/MLD2 was an independent predictor of FFR≤0.80 (odds ratio [OR]: 1.09, 95% [CI]: 1.03–1.15, P=0.002), whereas it was not an independent predictor of QFR≤0.80.

Conclusions

Subtended cardiac mass volume derived from CT segmentation improved the diagnostic performance of angiography-derived parameters to identify ischemia-producing lesions when FFR used as a reference standard, whereas QFR showed non-significant relationship with subtended cardiac mass.
P2705Hybrid QFR-FFR decision making strategy for revascularization
Authors: Kanno Y , Hoshio M , Sugiyama T , Kanaji Y , Yamaguchi M , Hada M , Ohya H , Sumino Y , Hirano H , Horie T , Yuki H , Yonetsu T , Kakuta T
Published: October 2019

Background

Measurement of the fractional flow reserve (FFR) has become a standard practice for revascularization decision-making in evaluating the functional significance of angiographically intermediate epicardial coronary stenosis. The quantitative flow ratio (QFR) is a novel method for rapid computational estimation of FFR without pressure wire and vasodilator drugs.

Purpose

Nevertheless, the evidence was shown the clinical better outcome of coronary revascularization stratified by FFR, the adoption of FFR remains low. We hypothesized that combined QFR and FFR hybrid strategy could improve the physiological assessment without pressure wire and drugs.

Methods and results

We performed a post-hocanalysis of 549 vessels with angiographically intermediate stenosis in 549 patients who underwent measurement of FFR. The median FFR and QFR values were 0.81 (0.73–0.87) and 0.79 (0.74–0.87), respectively.The ischemic threshold was defined as 0.80 for both QFR and FFR measures. The diagnostic sensitivity, specificity, accuracy, positive predictive value, and negative predictive value of the QFR for predicting an FFR of ≤0.80 were 86.2%, 71.9%, 78.9%, 74.5%, and 84.5%, respectively. The area under the receiver operating characteristic curve using the cut-off threshold of ≤0.80 for the FFR was 0.85 (95% confidence interval [CI], 0.81–0.88) for the QFR.In total, 433 (78.9%) and 116 (21.1%) lesions showed concordant and discordant FFR and QFR functional classifications, respectively. A hybrid QFR-FFR strategy was developed, by allowing deferral when QFR values providing negative predictive value greater than 90% and treat others when QFR values greater than that showing 90% positive predictive value, with adenosine being given only to patients with QFR in between those values. For the FFR cut-off (0.8), an QFR of <0.73 could be used to confirm treatment (PPV of 90.7%), while an QFR value of >0.83 could be used to defer revascularization (NPV of 90.0%). When QFR values fall between 0.73 and 0.84, adenosine is given for hyperemic induction and the FFR cut-off of 0.8 is used to guide revascularization. This hybrid QFR-FFR approach has a 95% agreement with an FFR-only decision making, and 285 lesions (51.9%) would have obviated the need of a pressure wire and adenosine.

Hybrid QFR-FFR strategy

Conclusions

A hybrid QFR-FFR strategy for coronary revascularization could reduce the need of a pressure wire and vasodilator drugs, which may increase the penetration of functional assessment of coronary lesions.
P2728Prognostic impact of left atrial function in patients with cardiac amyloidosis: a cardiac magnetic resonance study
Authors: Morini S , Aquaro G D , Taborchi G , Martone R , Gabriele M , Bartolini S , Vignini E , Vergaro G , Barison A , Emdin M , Olivotto I , Perfetto F , Di Mario C , Cappelli F
Published: October 2019

Background

Left atrial function (AEF) is a parameter of paramount importance that has a prognostic value in a number of heart conditions. Cardiac involvement in both light-chain and transthyretin amyloidosis is the main driver of prognosis and influences treatment strategies. Cardiac magnetic resonance (CMR) provides high quality images of the left and right atria using high temporal resolution steady state free precession (SSFP) cine sequences.

Purpose

The aim of our study was to assess by CMR left atrial function and his correlation with prognosis in patients with cardiac amyloidosis.

Method

We enrolled 80 consecutive patients with diagnosis of cardiac amyloidosis: 38 patients (47%) with light-chain and 42 patients (53%) with transthyretin one. CMR was performed using a 1.5-T scanner. In all subjects, the study of atria was obtained by acquiring cine steady-state free precession (SSFP). Left Atrial function was evaluated by the ratio between the maximum and the minimum LA volume. A median follow up of 937 days was performed and 36 patients (44%) died of cardiac causes. We evaluated cardiac death as endpoint. We split out all the patient in 4 different quartiles depending on left atrial function: in the first quartile patients with AEF≤14% that reflects severe atrial dysfunction, in the second quartile patients with AEF between 14 and 19%, in the third quartile patients with AEF between 19 and 36% and in the last one patients with AEF≥36% that represent patients with normal value of left atrial function.

Results

We found that CMR assessed left atrial function allowed to individuate and stratify the prognosis in patients with cardiac amyloidosis. The most effective parameter to evaluate cardiac death was left atrial function with a cut off ≤14% that could predict cardiac related mortality with the same accuracy in both light-chain and transthyretin amyloidosis patients. Kaplan Meier analysis showed that patients with AEF≤14% had a worse prognosis as compared to patient with AEF≥14% (log rank p. 0001). Furthermore patients with AEF≤14% have a cardiac death risk of 32% at 1 year and 61% at 3 years.

Kaplan Meier analysis

Conclusion

Cardiac magnetic resonance is an imaging modality that allows to individuate with great accuracy left atrial function in patients with various heart conditions and especially cardiac amyloidosis. CMR left atrial function assessment clearly identifies a subgroup of cardiac amyloid patients with an increased risk of death.
P2739Can cardiac mechanics predict outcome in hypoplastic left heart syndrome patients? A speckle tracking echocardiography study
Authors: Borrelli N S , Di Salvo G , Sabatino J , Spada M , Delle Donne G , Josen M , Ibrahim A , Penco M , Ghez O , Fraisse A , Michielon G
Published: October 2019

Introduction

Hypoplastic Left Heart Syndrome (HLHS) still carries a high morbidity and mortality. Right ventricle (RV) dysfunction is one of the most important responsible of a worse outcome. Unfortunately, RV assessment is a challenge. Speckle tracking echocardiography (STE) demonstrated an excellent ability in the estimation of RV function.

Purpose

The aim of our study is to evaluate the ability of STE and standard 2D echo parameters in predicting death and need for heart transplantation (HT) in HLHS patients.

Methods

31 patients with diagnosis of HLHS successfully completed Norwood (n=29) or comprehensive Norwood stage II at our Institution between 2016 and 2018. Survival at 6 months was 93.3%, survival at 18 months was 81.1%. We present our preliminary data on 23 HLHS patients (13 male).

All the studied patients underwent in-hospital interstage stay. Serial echocardiographic assessments were performed in all the included patients (baseline, one month after Norwood, three months after Norwood, one week before bidirectional cavopulmonary anastomosis [BCPA] and two months after BCPA).

From apical view we measured: tricuspid annulus peak systolic excursion (TAPSE), fractional area change (FAC), longitudinal strain (LS) and strain rate (LSR).

Results

After a median follow-up of 2.2 years (1.7–2.6 years), 6 out of 23 patients met the composite endpoint of death/HT.

At pre-Norwood assessment, there was no statistical difference between survivor and death/HT patients.

In death/HT group TAPSE declined at one-month after Norwood procedure. LS decreased significantly at three-months after Norwood. After BCPA, death/HT patients had much lower FAC, TAPSE, LS and LSR than survived patients.

At one-month evaluation, TAPSE ≤5 mm had a good specificity for death/HT (80%) and a moderate sensitivity (70.6%) with an area under the curve (AUC) of 0.80. Still at one-month evaluation, Δ LS ([{baseline LS – one-month post Norwood LS}/ baseline LS] *100) >7.7% showed a 100% sensibility and moderate specificity (76.5%) for death/HT (AUC 0.841).

LS in HLHS patient and LS ROC curve.

Conclusions

HLHS patients with TAPSE ≤5 mm and Δ LS of >7.7% one-month after Norwood had a high likelihood of death or HT. These preliminary data encourage the routine use of TAPSE and LS to monitor cardiac function in HLHS patients and to identify subgroup patients at high risk.
P2759Value of biomarkers (urinary KIM-1, NGAL, albumin, serum Cys C) for predicting renal lesions and prognosis in patients with infective endocarditis
Authors: Pisaryuk A , Povalyaev N , Sorokina M , Teterina M , Balatskiy A , Kotova E , Mal'kov P , Karaulova Y , Efremovtseva M , Ratchina S , Milto A , Safarova A , Kobalava Z
Published: October 2019

Background

Infective endocarditis (IE) is frequently complicated by kidney damage of various pathogenesis. The essential differences in pathophysiological mechanisms of kidney lesions (glomerular and tubular damage, mixed mechanisms) create different therapeutical targets. Nowadays these mechanisms are only possible to differentiate with the use of nephrobiopsy or autopsy. Non-invasive methods to assess the genesis of kidney damage are eagerly wanted. It is possible that kidney biomarkers may be such method.

Materials and methods

209 patients with verified IE (DUKE 2009, 2015), hospitalized and treated in city clinical hospital named after V.V. Vinogradov in Moscow from January 2010 to June 2018, were included in the study. Kidney function was assessed using CKD-EPI formula. Acute kidney injury (AKI) and acute kidney disease (AKD) were diagnosed according to current guidelines (KDIGO 2012) and the work group consensus (ADQI 16 Workgroup 2017). Serum creatinine decrease on ≥26,5 mcmol/L in 48 hours after the hospitalization was counted as early-onset AKI. Patients with serum creatinine elevation on ≥26,5 mcmol/L in 48 hours during the hospitalization were diagnosed with late-onset AKI. Biomarkers were assessed at the admission. Cystatin C level was assessed in serum; neutrophil gelatinase-associated lipocalin (NGAL), kidney injury molecule 1 (KIM-1), albumin levels were assessed in urine.

Results

Kidney damage biomarkers' levels were analyzed in 65 patients with IE. Patients with kidney dysfunction (n=45) comparing to ones without AKI (n=20) had higher mean value of all kidney biomarkers, however, the significant difference was established only for cystatin C. (1.9 vs 1.3 mg/l respectively; p<0.001). Patients with early-onset AKI (n=11) next to patients without AKI had significantly higher cystatin C value at admission (1.9 vs 1.3 mg/l respectively; p=0,0186). In similar manner patients with late-onset had had significantly higher cystatin C value at admission (1.9 vs 1.3 mg/l respectively; p=0,002). Cystatin C appeared to be an independent AKI predictor with threshold value 1.35 mg/l (OR 14.0; 95% CI 1.74–112.2; p=0.013), and also cystatin C was an independent predictor of the in-hospital mortality with threshold 1.87 mg/l (OR 3.16; 95% CI 1.25–7.99; p=0.006). After analysis of patients with AKD it was established that they had significantly higher levels of cystatin C (1.7 vs 1.3 mg/l respectively; p=0.035) and NGAL (19 vs 1.9 ng/ml; p=0.05) in comparison with patients without AKD. Albumin and KIM-1 didn't show significant associations.

Conclusions

The results of a study allow to consider serum cystatin C as AKI marker, AKI predictor and in-hospital mortality predictor in patients with IE, and urinal NGAL and serum cystatin C may be considered as AKD markers.
P2760Prognostic value of 18-fluorodeoxyglucose positron emission tomography/computed tomography in infective endocarditis
Authors: Sovannarith S , Ravis E , Tessonnier L , Philip M , Cammilleri S , Oliver L , Arregle F , Martel H , Renard S , Gouriet F , Casalta J P , Collart F , Drancourt M , Raoult D , Habib G
Published: October 2019

Background

18-Fluorodeoxyglucose Positron emission tomography (18F-FDG PET/CT) has been shown to be useful for the diagnosis of IE, but its prognostic value is unknown.

Objectives

This study sought to assess the prognostic value of 18F-FDG PET/CT in prosthetic (PVE) and native valve endocarditis (NVE).

Methods

We prospectively studied 173 consecutive patients (109 PVE and 64 NVE) with definite IE who underwent a 18F-FDG PET/CT study and were follow-up for one year. Primary end-point was a composite of major cardiac events i.e. death, recurrence of IE, acute cardiac failure, non-scheduled hospitalization for cardiovascular reason, and new embolic event

Results

18F-FDG PET/CT was positive in 98 (57%) patients, 82% (n=88/109) in the PVE and 16% (n=10/64) in the NVE group. At a mean follow of 225±18 days, the primary end-point occurred in 94 (55%) patients, 63 (58%) in the PVE group and 31 (48%) in the NVE group. In the PVE group, positive 18F-FDG PET/CT was significantly associated with higher rate of primary end-point (OR=2.6, IC95%=1.04 to 6.6; p=0.04). Moderate to intense 18F-FDG valvular uptake was also associated with worse outcome (OR=2.1; IC95%=1.1 to 4.0; p=0.03) and to new embolic events, (OR: 8.8; IC95%= 1.1 to 69.5; p=0.02). In the NVE group, 18F-FDG PET/CT was not associated with occurrence of the primary end-point.

Conclusion

In addition to be an accurate diagnostic tool, 18F-FDG PET/CT is predictive of major cardiac events in PVE and to embolic events during the first year following IE episode
P2773Evaluation of the bleeding prediction score VTE-BLEED for predicting recurrent VTE
Authors: Klok F A , Presles E , Tromeur C , Barco S , Konstantinides S V , Couturaud F
Published: October 2019

Introduction

VTE-BLEED is a validated score for identification of patients at a 3 to 5-fold increased risk of major bleeding during extended anticoagulation for venous thromboembolism (VTE; table 1). It is unknown whether VTE-BLEED high-risk patients also have an increased risk for recurrent VTE, which would limit the potential usefulness of the score.

Methods

This was a post-hoc analysis of the randomised double-blind placebo-controlled PADIS-PE trial, in which patients with a first unprovoked pulmonary embolism (PE) initially treated for 6 months were randomised to receive an additional 18-month of warfarin versus placebo. Primary outcome of the current analysis was recurrent VTE during 2-year follow-up after anticoagulant discontinuation, i.e. after the initial 6-month treatment in the placebo arm and after 24 months of anticoagulation in the active treatment arm. This rate, adjusted on study treatment allocation, was compared between patients in the high- versus low-risk VTE-BLEED group.

Results

In complete case analysis (n=308; 82.4% of total population), 89 (28.9%) patients were classified as VTE-BLEED high risk. A total of 44 VTE events occurred after anticoagulant discontinuation during 668 patient-years. The cumulative incidence of recurrent VTE was 16.4% (95% CI 10.0–26.1%; 14 events) and 14.6% (95% CI 10.4–20.3%; 30 events) in the high-risk and low-risk VTE-BLEED groups, respectively, for an adjusted Hazard Ratio of 1.16 (95% CI 0.62–2.19; Figure 1).

Figure 1

Conclusion

In this study, patients with unprovoked PE classified at high risk of major bleeding by VTE-BLEED did not have a higher incidence of recurrent VTE after cessation of anticoagulant therapy, supporting the potential yield of the score for making management decisions on the optimal duration of anticoagulant therapy.
P2778Geographic variability in the decline of the incidence of fatal and non-fatal stroke: a statewide study
Authors: Kostis J B , Cabrera J , Zinonos S , Kostis W J
Published: October 2019

Background/Introduction

There is scant information on the geographic variability in the rate of stroke incidence as it relates to the demographics, comorbidities, risk factors, and insurance type.

Purpose/Methods

County-level data on four modifiable groups of health factors including healthy behaviors, clinical care, physical environment, and socioeconomic conditions were obtained from the Robert Wood Johnson Foundation. The percentage of persons 65 years or older, smokers, physically inactive, obese, diabetics, heavy drinkers, college graduates, low income, unemployed, uninsured heads of single parent households, and residence in areas of violent crime was used in predicting fatal or non-fatal stroke. The counties were lumped into 5 categories based on similarities of the above characteristics. The incidence of fatal and non-fatal stroke was compared among the 5 county clusters using a mixed-effects regression model.

Results

The incidence of fatal and non-fatal stroke was significantly lower (p<0.0001) in cluster 3, where residents had higher income, were better educated, and were less likely to be unemployed, to live in single parent households, to have diabetes, to be obese, to smoke, to be physically inactive, or to live in communities with violent crime. The percentage of persons older than 65, violent crime rate, and obesity were identified as significant predictors of stroke using a mixed-effects regression model.

Conclusions

This study indicates that the incidence of stroke is higher in areas with older population, higher rate of obesity, and in regions with more violent crime. In order to improve health outcomes, preventive measures for stroke should address environmental factors in addition to the known cardiovascular risk factors.

Acknowledgement/Funding

Robert Wood Johnson Foundation
P2783Ascending aorta enlargement in patients referred to coronary artery calcium scoring
Authors: Sosnowski M , Czekaj A , Mlynarski R , Brzoska J , Chromik K , Wojakowski W
Published: October 2019

Background

Coronary artery calcium scoring is a main indication for a non-contrast-enhanced cardiac computed tomography (NCE-CCT). Great arterial vessels evaluation should be a part of CCT-based diagnosing.

Purpose

We aimed at analyzing data regarding great thoracic arterial sizes from a single-center cohort of 7950 patients who had NCE-CCT with a 64 raw scanner within the last decade.

Methods

In 5886 persons complete measurements of great arterial vessels' diameters at the level of the main pulmonary artery bifurcation were reported. The diameter of ascending aorta (AAD) was used to detect its enlargement on basis of absolute size, in relation to age and height (rAAD) and proportion to thoracic descending aorta (DAD) and main pulmonary artery (PAD). Respective criteria were: AAD≥43mm, rAAD>UNL for age/height (3.4+15.55*h+0.18*a), and AAD:DAD or AAD:PAD of 1.35 (range 1.1–1.6), both. Data were compared among patients with normal body mass index (BMI, kg/m2), overweight and obesity.

Results

Overall, increased absolute AAD was diagnosed in 149 persons (2.53%), rAAD>UNL in 358 (6.08%) and abnormal proportions AAD:DAD or AAD:PAD in 370 (13.0%) or 959 (16.3%), resp. Relative AAD was normal in 11 and 7 had normal proportions out of those with abnormal measured AAD. Among 138 patients with concordant absolute and relative increases, in 53 normal proportions were stated. In a cohort of 5737 patients with normal AAD (absolute), rAAD>UNL was found in 220 subjects (3.83%). Among remaining 5517 with normal both absolute and relative AAD, at least one abnormal proportion was found in 985 patients (17.9%). Taking into account BMI, the incidence of abnormal AAD was 0.3% in normal BMI patients (n=1409), 2,5% in overweight (n=2503) and 3.2% in obese (n=1974), while incidence of abnormal rAAD>UNL was 2.7%, 3.0% and 5.5%, resp. Abnormal proportions indicating abnormality within DAD or PAD were found in 1.1% and 3.8% normal BMI pts, in 2.4% and 4.7% overweight pts, and in 2.3% and 8.8% obese pts.

Conclusions

Absolute increase in ascending aorta size is relatively infrequent in patients referred to coronary artery calcium scoring. Use of age-height regression-based criteria increased diagnosis of abnormal ascending aorta size. Mutual proportions analysis among large arterial vessels showed further 5–6 fold increase in detection their abnormalities well before absolute or regression-based criteria are met. Great arterial vessels abnormalities are more frequent in overweight and obsese patients. Use of proportion analysis might be a step towards an individually-oriented medicine.
P2824A new Utstein-based model score to predict survival to hospital admission: the TICINUM score
Authors: Baldi E , Caputo M L , Savastano S , Burkart R , Benvenuti C , Palo A , Oltrona Visconti L , Auricchio A , De Ferrari G M
Published: October 2019

Background

The prediction of the possibility of return of spontaneous circulation (ROSC) in the individual patient is one of the major challenges confronting resuscitation science. The RACA score has been proposed to predict the achievement of a ROSC longer than 20 seconds in field (out-of-hospital, OH). However, no score exists to predict a ROSC sustained until arrival at the emergency department, using the standardized Utstein-based categorization of variables.

Purpose

To create a new Utstein-based score to predict the survival to hospital admission of an OH cardiac arrest (CA) victim.

Methods

We performed a retrospective analysis of all prospectively collected OHCAs occurred between 2015 and 2017 in two regions, one in northern Italy and the other in southern Switzerland. All consecutive patients who suffered an OHCA of any aetiology between 01/01/2015 and 31/12/2017 in whom CPR was attempted were included. We used random effect logistic regression to model survival to hospital admission after an OHCA. We included the same variables used in the RACA score, re-categorized following Utstein recommendations. For model validation, we computed the model area under the ROC curve (AUC ROC) for discrimination. We derived the TICINUM score using the coefficients estimated in the regression model (multiplied by 10 and rounded to the nearest integer). We plotted the score against the probability of hospital ROSC.

Results

1961 patients were included in our analysis (62% males, mean age 73±16 years old). Age, aetiology, witnessed OHCA, site of OHCA, time of EMS arrival and shockable rhythm were independently associated with survival to hospital admission. The model showed a good discrimination (AUC 0.83, 95% CI 0.81–0.85) for predicting survival to hospital admission. The model variables and their odd ratios are presented in Figure 1 (left). The score value is obtained summing a coefficient calculated for each variable. The nomogram of the probability of survival to hospital admission associated to the different score values is presented in the Figure 1 (right).

Figure 1

Conclusion

The TICINUM score is a new score, which allows to predict with good discrimination the probability of survival to hospital admission of an OHCA victim. The simple calculation and the fact that it is Utstein based makes it easily applicable by EMS personnel during an OHCA scenario.
P2848Electrical reconnections after pulmonary vein isolation with or without contact force-guided catheters: a comparison of the proficiency of atrial fibrillation ablation
Authors: Fujimoto Y , Yodogawa K , Iwasaki Y , Hachisuka M , Mimuro R , Maru Y , Oka E , Hayashi H , Yamamoto T , Shimizu W
Published: October 2019

Background

Atrial fibrillation (AF) ablation is the most commonly performed catheter ablation (CA) procedure today. The 2015 ACC/AHA/HRS Advanced Training Statement reported that the success rate of AF ablation is higher in high-volume centers than in low-volume centers. We tested whether the procedure proficiency of each operator was associated with the outcome of AF ablation, and whether the ablation outcome depended on whether contact force (CF)-guided catheters were used or not, in a high-volume center.

Methods

We conducted a retrospective observational study including all AF patients who underwent radiofrequency CA with or without CF support since 2016 at our hospital. The patients who underwent CA at other hospitals or underwent a balloon or surgical ablation in the first session were excluded. Each ipsilateral pulmonary vein (PV) pair was divided into 8 segments. The reconnection numbers and sites of the PV segment were evaluated in the second session. Operators were divided into the experienced group (≥100 AF cases/year, at least every 3 years) and developing group (other than the experienced group), respectively.

Results

Among 728 patients who underwent an initial AF ablation and were followed for 510±306 days, 131 (90 males, 65±10 years) received a second ablation procedure and were analyzed. A total of 260 and 264 PV isolations (PVI) were performed by the experienced and developing group operators in the initial ablation, respectively. Compared to the experienced group, the developing group had a longer procedure time for the PVI (35±15 vs. 28±10 min, p<0.001), higher frequency of reconnections of the PVs (73% vs. 59%, p=0.01) and higher number of reconnection gaps (2.1±2.0 vs. 1.5±2.0, p=0.02), respectively. There were no significantly differences in the number of gaps between the catheters with and without CF (1.6±2.0 vs. 1.4±2.0, p=0.65) in the experienced group, however, in the developing group a smaller total number of gaps (1.5±1.6 vs. 2.4±2.1, p=0.006) and less frequency reconnection gaps of the posterosuperior segment of the right PV (10% vs. 45%, p=0.005) were seen with catheters with CF than without. There was no significant difference in the procedure time for the PVI between catheters with and without CF.

Conclusions

The operator proficiency may predict the outcome after AF ablation even in high-volume centers. It is preferable to perform PVI with a CF-sensing catheter for operators without adequate proficiency.

Acknowledgement/Funding

JSPS KAKENHI Grant Number JP18K15865
P2849Prevalence and significance of sustained pulmonary vein isolation in repeat AF ablation procedures
Authors: Nascimento Matos D J , Cavaco D , Rodrigues G , Carmo J , Carvalho M S , Ferreira A M , Costa F , Carmo P , Morgado F , Mendes M , Adragao P
Published: October 2019

Introduction

Pulmonary vein (PV) reconnection is a common cause of relapse after catheter ablation of atrial fibrillation (AF). However, some patients have AF recurrence despite durable PV isolation. The aim of this study was to assess the PV isolation status at the time of a second catheter ablation (redo) procedure, and its relationship with subsequent AF relapse.

Methods

Consecutive patients with symptomatic drug-resistant AF who underwent redo procedures from January 2006 to December 2017 were identified in a single-center observational registry. Pulmonary vein isolation status was assessed during the electrophysiologic study with a circular mapping catheter. Additional radiofrequency (RF) energy applications were also recorded. AF relapse was defined as symptomatic or documented AF/atrial tachycardia/atrial flutter after a 3-month blanking period.

Results

We identified 240 patients (77 [32%] females, median age 61 [IQR 53–67] years, 85 [35%] with non-paroxysmal AF) undergoing redo procedures during the study period. At the time of redo, 17 (7%) of the patients presented bidirectional conduction block of all PVs. PV reconnection occurred in 157 (65%) of cases in the left superior vein, 142 (59%) in the left inferior vein, 177 (73%) in the right superior vein, and 163 (68%) in the right inferior vein (table). All of the PVs were reconducted in 91 (38%) patients. Additional RF applications were performed in the left atrium (LA) roof, LA posterior wall, cavotricuspid isthmus, mitral isthmus, superior vena cava, coronary sinus, and left atrial appendage ostium, at the operator's discretion (table 1).

Over a median follow-up of 2-years (IQR 1–5), 126 patients (53%) suffered AF recurrence, yielding a mean relapse rate of 17%/year. In multivariate Cox regression analysis, the lack of PV reconnection at the time of redo emerged as an independent predictor of subsequent relapse (HR 1.97, 95% CI 1.12–3.49, p=0.019) even after adjustment for univariate predictors including non-paroxysmal AF, body mass index, female sex, and active smoking.

Conclusion

In patients undergoing redo AF ablation procedures, less than 10% present with complete PV isolation. Despite being relatively infrequent, this finding is independently associated with greater likelihood of subsequent recurrence, suggesting that other mechanisms, not fully addressed by additional RF applications, are at play.
P2863Regional specific remodeling of cGMP pathway in human atrial fibrillation
Authors: Bork N I , Pavlidou N G , Reiter B , Reichenspurner H , Christ T , Nikolaev V O , Molina C E
Published: October 2019

Background

Atrial fibrillation (AF) is accompanied by a profound remodeling of membrane receptors and alterations in cyclic nucleotides-dependent regulation of Ca2+-handling. Thus, while basal ryanodine receptors activity is upregulated, L-type calcium current (ICa,L) density is diminish in AF, due to local microdomain-specific cAMP dynamics. The same seems true for cGMP regulation in AF. In AF cGMP-mediated increase in ICa,L is blunted but NO-mediated attenuation of β-adrenoceptors stimulation-mediated increase is preserved. However, although the role of cGMP in controling atrial function and pathophysiology is controversial, no study has been ever performed in human myocytes to measure cGMP directly.

Methods

We isolated myocytes from the right and/or left atrium of 27 patients in sinus rhythm (SR), and with AF. Cells were then transfected with adenovirus to express the cytosolic FRET-based cGMP sensor red-cGES-DE5 and cultured for 48 hours. Förster resonance energy transfer (FRET) was used to measure cGMP in 61 living human atrial myocytes. We stimulated cells with the C-type natriuretic peptide CNP (100 nM and 1 μM), and the non-selective phosphodiesterases (PDEs) inhibitor IBMX (100 μM). Additionally, PDE specific inhibitors for PDE2 (Bay 60–7550, 100 nM) and PDE3 (Cilostamide, 10 μM) as well as inhibitor of the soluble guanylyl cyclase (ODQ, 50 μM) were used. We also measured PDE2 and PDE3 mRNA levels in atrial tissue samples from both groups of patients using RT-qPCR.

Results

We could show that stimulation with CNP increased cGMP levels in human atrial myocytes. However, in myocytes from patients with AF global cGMP responses to CNP and to IBMX was reduced compared to SR. Additionally, there was a difference in response to CNP and IBMX in patients with AF between the right and the left atria. Whereas in the right atria IBMX could further increase cGMP levels in the cell, in the left atria leaded to a reduction in cGMP levels. RT-qPCR showed a tendency of PDE3 to be reduced in AF. On the other hand, PDE2A gene expression was upregulated in the left atria.

Conclusions

We have shown that PDEs contributes cGMP signaling in the human atria and that they are involved in atrial pathophysiology. Now our data clearly show differences in cGMP regulation in cardiomyocytes isolated from left and right atrium from patients in atrial fibrillation and sinus rhythm. We observe a major role of PDEs, regulating cGMP pathway promoted by the reduced responses in AF, especially PDE2 in the left atria.
P2866Automated ultrasound ablation parameters predict lesion depth in a perfused thigh model
Authors: Marrouche N , Joseph M , Godfrey J , Phillips P , Piazza D , Macnamara F , Harari D
Published: October 2019

Background

The accuracy and safety of lesions created during catheter ablation of cardiac tissue rely on the user's ability to predict the size of lesions that form under variable conditions during treatment. A user-directed robotic system was developed that uses Low-Intensity Collimated Ultrasound (LICU) for cardiac imaging and to produce linear lesions without tissue contact. Molecular absorption of mechanical energy induced in the tissue by LICU causes a temperature rise resulting in thermal tissue necrosis.

Purpose

By varying the speed of the LICU beam as it traces the desired lesion path, while considering the beam intensity, distance from catheter tip to tissue, and relative motion of the target tissue, we demonstrate the capability to deposit lesions of known depth according to a predictive model.

Methods

The LICU catheter was mounted in a servo-controlled, 3 axis stage suspended above a perfused porcine thigh that simulates the thermodynamic properties of the myocardium such as acoustic attenuation, thermal conduction, and specific heat capacity. Therapy was delivered along a linear path while varying the distance to tissue, speed of the beam, and motion of the catheter relative to the tissue in 3 dimensions. Programmed relative motion was representative of typical and extreme motion in humans. Pathological analysis after necropsy was used to quantify lesion depth which was then compared to lesion depth as predicted by a mathematical model from approx. 4–12 mm.

Results

Data from 66 samples were categorized according to typical and extreme motion at 4 different distances (3, 8, 9 and 13 mm). Measured vs predicted lesion depth was well correlated (R = 0.898) with 98.5% of the samples within ±2 mm.

Assessment of LICU lesion depth

Conclusion

Lesion depth using LICU is well controlled in an animal model for the range of distances and relative motion typically encountered in a human subject. The range of acoustic beam speeds and acoustic power density with LICU predictably produces lesions up to 12 mm deep. The LICU thermal model may be useful to create lesions of known depth thus ensuring transmurality of lesions while potentially avoiding unintended extra-cardiac injury.
P2884Complications of cardiac implantable electronic device intervention in patients with left ventricular assist devices
Authors: Kiani S , Black G B , Lloyd M S , Merchant F M , El-Chami M F , Cole R T , Hoskins M H , Westerman S B
Published: October 2019

Background

There are limited data on management of cardiac implantable electronic devices (CIED) in patients with left ventricular assist devices (LVADs). These patients may be at elevated risk of complications after undergoing CIED procedures.

Purpose

In order to better understand these risks, we set out to describe and quantify the complications associated with CIED procedures among patients with LVADs.

Methods

We retrospectively evaluated all patients with LVADs at our institution (n=235) from August 2007 to November 2017 who had any subsequent CIED procedure (initial implant, generator exchange, lead revision or extraction). We identified device-related complications at 30 days and one year from the time of the CIED procedure. Complications were defined as death, stroke, cardiac perforation, pericardial effusion, pneumothorax, lead dislodgment, infection, and any hematoma requiring a direct physician encounter.

Results

Forty-eight CIED interventions were performed on 42 patients after LVAD implant. Mean age was 49.4±15.1 years and 64% were male. Mean duration of LVAD therapy prior to procedure was 396 days. All patients were on warfarin therapy (mean INR 2.33±0.68); in 83% of procedures patients were on at least one anti-platelet agent. All interventions involved placement or revision of an ICD system. Fourteen procedures (29%) were initial implants and 34 (71%) were secondary procedures (19 generator exchanges, 13 lead revisions ± generator exchange and 2 extractions). Seven procedures (14.5%) were complicated by pocket hematoma; all of these were in secondary procedures. Patients with hematomas trended toward higher INR (2.51±0.26 vs 2.31±0.72); this was not statistically significant. Two patients with hematoma developed CIED infection, resulting in a total infection rate of 4.2%. Of those, one developed systemic infection requiring extraction of the system and the other developed a pocket infection managed with pocket washout and prolonged antibiotics. All complications occurred within 30 days of the procedure (Figure 1).

Figure 1. Complication free survival

Conclusion

In this single center study, CIED procedures on patients with preexisting LVAD was associated with a low rate of complications requiring intervention.

Acknowledgement/Funding

Emory University
Decreasing Colectomy Rate for Ulcerative Colitis in the United States Between 2007 and 2016: A Time Trend Analysis
Authors: Barnes Edward L , Jiang Yue , Kappelman Michael D , Long Millie D , Sandler Robert S , Kinlaw Alan C , Herfarth Hans H
Published: October 2019

Background

Improved treatment approaches for ulcerative colitis (UC), including novel medications, might reduce the need for colectomy. We performed a retrospective cohort study of adult patients (age 18–64) with UC in the United States to examine time trends for colectomy and biologic use from 2007 to 2016.

Methods

We estimated quarterly rates for colectomy and biologic use using the IQVIA Legacy PharMetrics Adjudicated Claims Database. We used interrupted time series methods with segmented regression to assess time trends with 95% confidence intervals (CIs) for biologic use and colectomy before and after the emergence of newly available biologic therapies in 2014.

Results

Among 93,930 patients with UC, 2275 (2.4%) underwent colectomy from 2007 to 2016. Biologic use rates increased significantly from 2007 to 2016, from 131 per 1000 person-years in 2007 (95% CI, 121 to 140) to 589 per 1000 person-years in 2016 (95% CI, 575 to 604; P < 0.001). Colectomy rates decreased significantly between 2007 and 2016, from 7.8 per 1000 person-years (95% CI, 7.4 to 8.2) to 4.2 per 1000 person-years in 2016 (95% CI, 3.2 to 5.1; P < 0.001). An interruption in 2014 was associated with a positive trend deflection for biologic use (+72 treatments per 1000 person-years per year (95% CI, 61 to 83) and a negative trend deflection for colectomy (–0.76 per 1000 person-years per year; 95% CI, –1.47 to –0.05).

Conclusions

Among commercially insured patients in the United States from 2007 to 2016, biologic use rates increased, colectomy rates decreased, and both trends were impacted by the interruption in 2014. These findings suggest that new biologic therapies may have contributed to decreased colectomy rates.
GBS type III oligosaccharides containing a minimal protective epitope can be turned into effective vaccines by multivalent presentation
Authors: Carboni F , Angiolini F , Fabbrini M , Brogioni B , Corrado A , Berti F , Adamo R , Margarit I
Published: October 2019

Recent structural studies demonstrated that the epitope recognized by a monoclonal antibody representative of the protective response against the type III Group B Streptococcus polysaccharide was comprised within two of the repeating units that constitute the full-length native structure. Here we took advantage of this discovery to design a novel vaccine based on multivalent presentation of the identified minimal epitope on a carrier protein. We show that highly glycosylated short oligosaccharide conjugates elicit functional immune responses comparable to the full-length native polysaccharide. The obtained results pave the way to the design of well-defined glycoconjugate vaccines based on short synthetic oligosaccharides.
Adverse drug event rates in pediatric pulmonary hypertension: a comparison of real-world data sources
Authors: Geva Alon , Abman Steven H , Manzi Shannon F , Ivy Dunbar D , Mullen Mary P , Griffin John , Lin Chen , Savova Guergana K , Mandl Kenneth D
Published: October 2019

Objective

Real-world data (RWD) are increasingly used for pharmacoepidemiology and regulatory innovation. Our objective was to compare adverse drug event (ADE) rates determined from two RWD sources, electronic health records and administrative claims data, among children treated with drugs for pulmonary hypertension.

Materials and Methods

Textual mentions of medications and signs/symptoms that may represent ADEs were identified in clinical notes using natural language processing. Diagnostic codes for the same signs/symptoms were identified in our electronic data warehouse for the patients with textual evidence of taking pulmonary hypertension-targeted drugs. We compared rates of ADEs identified in clinical notes to those identified from diagnostic code data. In addition, we compared putative ADE rates from clinical notes to those from a healthcare claims dataset from a large, national insurer.

Results

Analysis of clinical notes identified up to 7-fold higher ADE rates than those ascertained from diagnostic codes. However, certain ADEs (eg, hearing loss) were more often identified in diagnostic code data. Similar results were found when ADE rates ascertained from clinical notes and national claims data were compared.

Discussion

While administrative claims and clinical notes are both increasingly used for RWD-based pharmacovigilance, ADE rates substantially differ depending on data source.

Conclusion

Pharmacovigilance based on RWD may lead to discrepant results depending on the data source analyzed. Further work is needed to confirm the validity of identified ADEs, to distinguish them from disease effects, and to understand tradeoffs in sensitivity and specificity between data sources.
Dietary supplementation of a fiber-prebiotic and saccharin-eugenol blend in extruded diets fed to dogs
Authors: Nogueira Juliana Paschoalin De Souza , He Fei , Mangian Heather F , Oba Patricia Massae , De Godoy Maria R C
Published: October 2019

Prebiotics and dietary fibers are nondigestible ingredients that may confer benefits to the host by selectively stimulating beneficial intestinal bacteria and microbial-derived metabolites that support gut and host health. This experiment evaluated the effects of a blend of prebiotics and dietary fibers on apparent total tract digestibility (ATTD) and fecal metabolites related to gastrointestinal health in adult dogs. Four diets containing either 5% cellulose (control; CT), 5% dietary fiber and prebiotic blend (FP), 0.02% saccharin and eugenol (SE), or 5% fiber blend plus 0.02% saccharin and eugenol (FSE) were formulated to meet or exceed the AAFCO (2017) nutritional requirements for adult dogs. Eight adult female beagles (mean age 4.2 ± 1.1 yr; mean BW = 10.8 ± 1.4 kg; mean BCS = 5.8 ± 0.6) were randomly assigned to 1 of the 4 dietary treatments using a replicated 4 × 4 Latin square design. Each experimental period consisted of 14 d (10 d of diet adaptation and 4 d of total and fresh fecal and total urine collection). All animals remained healthy throughout the study, with serum metabolites being within reference ranges for adult dogs. All diets were well accepted by the dogs, resulting in similar (P > 0.05) daily food intakes among treatments. Likewise, fecal output and scores did not differ (P > 0.05) among dietary treatments, with the latter being within the ideal range (2.5–2.9) in a 5-point scale. All diets were highly digestible and had similar (P > 0.05) ATTD of dry matter (81.6%–84.4%), organic matter (86.4%–87.3%), and crude protein (86.6%–87.3%). However, total dietary fiber (TDF) digestibility was greater for dogs fed the FSE diet (P < 0.05) in contrast with dogs fed the CT and SE diets, whereas dogs fed FP diets had intermediate TDF digestibility, but not different from all other treatments. Fecal acetate and propionate concentrations were greater (P < 0.05) for dogs fed FP and FSE diets. Fecal concentrations of isobutyrate and isovalerate were greater for dogs fed CT (P < 0.05) compared with dogs fed the other three treatments. No shifts in fecal microbial richness and diversity were observed among dietary treatments. Overall, the data suggest that dietary supplementation of fiber and prebiotic blend was well tolerated by dogs, did not cause detrimental effects on fecal quality or nutrient digestibility, and resulted in beneficial shifts in fecal metabolites that may support gut health.
A comparative assessment of salt marsh crabs (Decapoda: Brachyura) across the National Estuarine Research Reserves in New England, USA
Authors: Raposa Kenneth B , Goldstein Jason S , Grimes Kristin Wilson , Mora Jordan , Stacey Paul E , Mckinney Richard A
Published: October 2019

Salt marsh degradation and loss is accelerating in many regions of the United States as well as worldwide. Multiple stressors are often responsible, sometimes including crab burrowing and herbivory. A recent national assessment identified stark differences in crab indicators between northern and southern New England, with the latter exhibiting intense signs of impacts by crabs, but more details on crab patterns across the entire region are needed beyond this “broad-brush” assessment. Our study used green crab (Carcinus maenas (Linnaeus, 1758)) traps, intensive marsh platform burrow counts, and a new multi-metric index of relative crab abundance to examine patterns in marsh crabs across four National Estuarine Research Reserves in New England. Crab indicators from the multi-metric index and burrow counts were higher in southern New England marshes; patterns from trapping of green crabs were less clear. At the marshes examined, green crabs were very abundant in Maine, lower in New Hampshire, and intermediate in southern New England. Our study confirms that abundance and impacts by crabs vary dramatically between sites in northern and southern New England, and provides improved context for managers and researchers when considering impacts to marshes from multiple crab species across New England and elsewhere.