bluuebunny/crossref_metadata_2025 huggingface dataset:
P811Functional assessment of microcirculation in Takotsubo cardiomyopathy - a pilot study
Authors: Brazdil V , Hudec M , Stipal R , Bocek O , Jerabek P , Poloczek M , Kanovsky J , Kala P
Published: October 2019

Background

Takotsubo cardiomyopathy (TTC) is a severe cardiologic disorder with an increasing incidence that often mimics acute coronary syndrome. Both of the entities are characterized by systolic dysfunction of the left ventricle myocardium. However, this dysfunction is reversible in most cases of TTC. Takotsubo syndrome affects predominantly postmenopausal females, typically with a direct link to emotional or physical stress factors. The pathophysiology of TTC remains unclear. In this study, we aimed to assess the pathophysiology of TTC using the invasive functional testing of coronary microcirculation.

Methods

Ten female patients diagnosed with TTC in line with interTAK Diagnostic Criteria were included in this pilot study. In all subjects we measured fractional and coronary flow reserve in the left anterior descending and left circumflex coronary arteries (FFR LAD, FFR LCx, CFR LAD, CFR LCx), and the index of microcirculatory resistance in the same arteries (iMR LAD, iMR LCx) in addition to acute and late (after 12 weeks) transthoracic echocardiography (TTE) and acute cardiac biomarkers (troponin and NT-proBNP). The results of the microcirculatory assessment were statistically compared with normal population values.

Results

In all subjects, the troponin level was elevated in the acute phase and repeated TTE revealed transient dysfunction of the left myocardial ventricle. Whilst fractional flow reserve was normal in both assessed epicardial artery territories for all patients (mean FFR LAD: 0.92±0.04; mean FFR LCx: 0.98±0.046), both mean values of coronary flow reserve disclosed pathological microcirculatory findings (CFR LAD: 1.9±1.197; CFR LCx: 1.75±0.742) and were pathological in nine out of ten subjects. Index of microcirculatory resistance revealed abnormal values in five out of ten patients for LAD (31.03±18.515) and three out of ten for LCx (23.8±17.86).

Conclusions

Our pilot study confirmed non-obstructive findings in the epicardial coronary arteries assessed by FFR. On the other hand, the investigation of both CFR and iMR, microcirculatory functional testing, revealed pathological findings in a significant number of evaluated subjects. From this aspect, our study validates further research in the field of microcirculatory functions as a possible mechanism in the origin of TTS.

Acknowledgement/Funding

Supported by MH CZ - DRO (FNBr, 65269705)
P816Mortality during weekend admission for takotsubo syndrome: a national cross sectional large scale study
Authors: Malanchini G , Lombardi F
Published: October 2019

Background

Higher mortality rates in patients admitted for an acute myocardial infarction during weekends has been recently confirmed. Differences in staffing and in lower rates of early reperfusion therapy are thought to affect outcomes of these patients particularly of those presenting with ST segment elevation. Patients affected by Takotsubo cardiomyopathy may present themselves mimicking those affected by heart attack and are frequently admitted with supposed diagnosis of acute coronary syndrome. No data is available about influence on mortality in relation to the time of admission among patients with Takotsubo cardiomyopathy.

Rationale

The aim of this study is to assess the effect on mortality due to admission during weekend among patients discharged with diagnosis of Takotsubo cardiomyopathy.

Methods

We retrieved administrative data about every admission to National Healthcare System hospitals in Italy between 2009 and 2017 with final diagnosis of Takotsubo cardiomyopathy according to ICD9-CM classification of diseases (code 429.83). Date of admission was used to determine the weekend (Saturday and Sunday) or weekdays exposure (Monday to Friday). The primary outcome was in-hospital mortality. Demographical characteristics of patients (age and sex) were included in a multivariate logistic regression analysis. We also analyzed the impact of weekend admission on time to coronary angiography and on length of hospital staying. Analyses were performed using Stata 13.0.

Results

A total of 10,861 Takotsubo admissions were identified. Mean age was 70.7 years and 91.7% were women. The in-hospital mortality was 2.21%. We found that there was no significant increase in the risk of death among patients admitted during weekends (OR 1.07; 95% CI 0.77–1.44). The variability explained by the model was of 4.2% (pseudo R-squared 0.042). Men have a higher risk of mortality as compared to women (OR 2.37, 95% C.I 1.69–3.33). Patients admitted during weekend tends to stay in hospital longer, but they do not seem to wait more days to get a coronary angiography.

Conclusions

At variance with patients with ST elevated acute myocardial infarction, subjects admitted during weekends for Takotsubo cardiomyopathy did not show an excess of in-hospital mortality in comparison to those admitted during week days.
P860Adding clinical risk scores to troponin-based rule-out algorithms improves identification of patients at high risk for coronary revascularization within 6 weeks: the WESTCOR study
Authors: Steiro O , Tjora H , Langorgen J , Omland T , Bjorneklett R , Nygard O , Renstrom R , Skadberg O , Bonarjee V , Lindahl B , Vikenes K , Aakre K
Published: October 2019

Background

The ESC 0/3-h and High-STEACS study algorithms using high-sensitive troponin assays have proven effective in ruling out NSTEMI, but the safety of out-of-hospital follow-up of ruled out patients is disputable. Clinical risk scores may help to identify patients who develop major adverse cardiac events (MACE) defined as NSTEMI, death or coronary lesions in need of acute or elective revascularization within six weeks after admittance.

Purpose

Assess the ability of the ESC and High-STEACS study algorithms alone and in combination with clinical risk scores to identify MACE in unselected patients presenting with chest pain.

Methods

985 patients (mean 63 years, 61% male) with suspected NSTE-ACS were consecutively included from Sept. 2015 to Feb. 2017. Serum samples were collected at 0, 3 and 8–12 hours and hs-cTnT and hs-cTnI were measured. The final diagnosis was adjudicated by two independent cardiologists. The troponin-based algorithms where compared to nine clinical risk scores, HEART, CARE, GRACE, T-MACS, TIMI, EDACS, sEDACS, Goldman and Geleijnse.

Results

The prevalence of NSTEMI during index hospitalization was 13%. The ESC 0/3-h and High-STEACS algorithms missed 3 events of NSTEMI with excellent NPV of 99.5 and 99.6. Rule-out patients with normal ECGs, GRACE score <140 and no residual pain had a prevalence of MACE within 6 weeks of 9% using both algorithms. The most frequent event was non-acute revascularization due to unstable angina pectoris. Three of ten clinical risk scores had higher accuracy than the ESC 0/3-h algorithm for identification of MACE: HEART (AUC 0.84), CARE (AUC 0.79) and T-MACS (AUC 0.76). Combining the ESC 0/3-h rule-out algorithm and HEART≤3 had the best AUC of 0.85, missing only 12 (3%) MACE.

Troponin-based algorithms and HEART True pos. True neg. False pos. False neg. NPV PPV Sens. Spes. Prop. low-risk AUC Troponin-based algorithms, endpoint NSTEMI ESC 0/3h TnT 118 628 196 3 99.5 37.6 97.5 76.2 66.8 0.87 High-STEACS TnI 118 715 109 3 99.6 52.0 97.5 86.8 76.0 0.92 Troponin-based algorithms, endpoint MACE ESC 0/3h TnT 143 577 171 54 91.4 45.5 72.6 77.1 66.8 0.75 High-STEACS TnI 130 651 97 67 90.7 57.3 66.0 87.0 76.0 0.77 Troponin-based algorithms combined with HEART score, endpoint MACE ESC 0/3h HEART 3 185 414 334 12 97.2 35.7 94.1 55.4 44.6 0.85 High-STEACS HEART 3 186 411 337 11 97.4 35.6 94.7 55.0 44.7 0.85

Causes of MACE

Conclusion

The ESC 0/3-h and High-STEACS algorithms identify almost all patients with low risk of NSTEMI, who are candidates for none or out-of-hospital follow-up. However, 9% of ruled out patients have MACE within 6 weeks. The combination of ESC algorithm and clinical risk scores markedly reduce the number of ruled out patients with MACE.
P898Association of acroparesthesias and angiokeratomas with the alpha-galactosidase A gene polymorphisms in females with hypertrophic cardiomyopathy
Authors: Poliakova A A , Gudkova A Y A
Published: October 2019

Introduction

Clinical implications of different single nucleotide polymorphisms (SNPs) in the alpha-galactosidase A gene (α-GLA) as potential cause of symptoms and organ manifestations similarly to those seen in Fabry disease (FD) remain unclear.

Purpose

To study the prevalence of FD among patients with hypertrophic cardiomyopathy (HCM), as well as to evaluate the impact of polymorphic variants of the α-GLA gene on extracardiac manifestations in females with HCM.

Methods

The study included 321 patients with left ventricular hypertrophy ≥15 mm. 24 of the 321 patients (males (n=15) and females (n=9)) presented with HCM phenotype and extracardiac features suggestive of FD: acroparesthesias and pain in hands and feet, stroke at a young age, angiokeratomas, kidney damage (microalbuminuria, proteinuria, decreased glomerular filtration rate), suspicion for X-linked inheritance. This patients carried out screening for FD. A combined enzymatic and genetic strategy was used, measuring the activity of α-D-galactosidase A by tandem mass spectrometry (ESI-MS/MS) and genotyping the α-GLA (in females) in dried filter-paper blood spot samples.

Results

We haven't identified any pathogenic genetic variants in the α-GLA gene. However, in three patients with HCM, the two intronic SNPs within the α-GAL gene (c.640–16A>G [rs2071397] and c.1000–22C>T [rs2071228]) were identified.

Patient no. 1, a 64-year-old female, was admitted to our clinic for the diagnosis of obstructive HCM. She also had a transient 2:1 second degree atrioventricular block, an Adams-Stokes attack, angiokeratomas and left median cerebral artery lacunar stroke in middle age. In case no. 2, a 75-year-old female, were verified obstructive HCM, a 1st degree atrioventricular block, paroxysms of nonsustained ventricular tachycardia, acroparesthesia, pain in hands and angiokeratomas. In patient no. 3, a 41-year-old female, were established combined phenotypes (nonobstructive hypertrophic + restrictive), acroparesthesia, pain in hands and angiokeratomas.

Conclusions

In females with HCM, the intronic SNPs (rs2071397 and rs2071228) in the α-GLA gene can be associated with angiokeratomas and acroparesthesias.
P905Association of ionized serum magnesium with progression of aortic valve calcification
Authors: Mary A , Issa H , Boullier A , Henaut L , Avondo C , Brazier M , Mentaverri R , Tribouilloy C , Messika-Zeitoun D , Kamel S
Published: October 2019

Background

Calcific aortic valve disease (CAVD) is the most common heart valve disease among adults. It is a progressive disease whose final step leads to severe aortic stenosis (AS). Pharmacotherapeutic strategies aimed to limit the progression of valve leaflet calcification could be beneficial to slow-down the CAVD progression and to preserve left ventricular function. Several recent clinical studies demonstrated that lower serum magnesium (Mg) level is associated with vascular calcification. Whether serum magnesium is a determinant of aortic calcific stenosis progression remains unkwown.

Methods

In an ongoing prospective cohort of AS patients (COFRASA/GENERAC) we studied the association between serum Mg with the aortic valve calcification prevalence and progression. Serum Mg was measured at baseline in both its ionized (iMg) and total (tMg) forms. AS stenosis severity was evaluated at baseline and yearly thereafter using mean pressure gradient (MPG), the aortic valve area indexed to body surface (AVAi) assessed by echocardiography and the degree of aortic valve calcification (AVC) assessed by computed tomography. Annual progression was calculated as: (final measurement − baseline measurement)/follow-up duration.

Results

We enrolled 356 patients (73.1±10 years, 73% men), the mean follow-up duration was 2.5±2 years. There was a highly significant correlation between iMg and t Mg concentrations values (r=0.85, p<0.0001). Approximately 37% and 25% of patients have respectively iMg values ≤0.45 mmol/L (normal range 0.45–0.60 mmol/L) and t Mg ≤0.80 mmol/L (normal range 0.80–0.95 mmol/L). At baseline, lower i Mg and t Mg were significantly associated with sex, diabètes, lower heamoglobin and hypertension but not with AVC neither with MPG or AVAi. After mean follow-up of 2.5±2 years, the annual mean Log AVC progression was significantly greater (p=0.01) in patients with values of iMg ≤0.45 mmol/L (2,04±0.73) as compared to patients with iMg >0,45 mmol/L (1.78±0.94). Annual Mean MGP and AVAi also progressed greater in patients with low iMg but without reaching a significant level. Similar association was not found with tMg. In multivariate analysis, iMg remained significantly associated with the progression of AVC (odds ratio per 0.1 mmol/L increment [95% confidence interval] = 0.36 [0.15–0.83]; p=0.015) independently of age, tMg, glucose, type 2 diabetes, Tobacco use, baseline AVC, MPG and AVAi.

Conclusion

In a prospective cohort of asymptomatic patients with a wide range of AS severity, low serum ionized Mg but not low total Mg was independently associated with AVC progression.

Acknowledgement/Funding

ANR -RHU-STOPAS
P908Prognostic value of energy loss index in patients with low gradient severe aortic stenosis and preserved ejection fraction
Authors: Altes A , Ringle Griguer A , Bohbot Y , Bouchot O , Delelis F , Castel A L , Guerbaai R A , Ennezat P V , Graux P , Tribouilloy C , Marechaux S
Published: October 2019

Background

Assessment of pressure recovery adjusted indexed aortic valve area (AVAi) – energy loss index (ELI) – has been shown of prognostic interest for patients with asymptomatic and/or mild aortic stenosis (AS), but limited data are available in the setting of low gradient aortic stenosis (LG-AS).

Purpose

We hypothesized that among these patients with LG-AS, reclassification of AS severity as moderate by ELI may help to identify a subgroup of patients with moderate AS.

Methods

379 patients with low gradient severe AS (defined by AVAi ≤0.6 cm2/m2 and mean aortic pressure gradient (MPG) <40 mmHg) and preserved left ventricular ejection fraction (LVEF ≥50%) were prospectively included. Reclassification as moderate AS by ELI was defined as AVAi ≤0.6 cm2 /m2 but an ELI >0.6 cm2/m2. Clinical and echocardiographic features of patients reclassified by ELI were studied. Clinical outcomes were all-cause and cardiac mortality.

Results

148 patients (39%) were reclassified as moderate AS by ELI. By multivariable logistic regression analysis, patients being reclassified as moderate AS by ELI were associated with increased stroke volume index (SVi), absence of documented coronary artery disease and decreased body surface area, left indexed ventricular mass (all p<0.05). During a median follow-up of 34 months (30–38 months), 119 patients died, 52 of them from cardiac causes. Three-year survival free from all-cause or cardiac death were 76±4%, 96±2% for patients with moderate AS by ELI and 71±3%, 84±3% for patients with severe AS by ELI (p=0.178 and p=0.013, respectively). After adjustment for variables of prognostic interest including aortic valve replacement as a time-dependent covariable, there was a significant reduction of risk of cardiac mortality in patients with moderate AS by ELI (adjusted HR 0.44 [95% CI, 0.23–0.85]; p=0.014) but not for all-cause mortality (adjusted HR 0.85 [95% CI, 0.58–1.25]; p=0.403)

Conclusion

In patients with low gradient “severe” AS and preserved ejection fraction, calculation of ELI permits to reclassify almost 40% of patients as having moderate AS. Patients reclassified as moderate AS by ELI had a reduction of risk of cardiac mortality during follow-up but not for all-cause mortality. Calculation of ELI may be useful for decision making in AS patients with discordant grading and preserved ejection fraction.

Acknowledgement/Funding

Local funding
P913What can we expect after valve-in-valve procedures in failed transcatheter aortic valves?
Authors: Goppel G , Ruge H , Erlebach M , Deutsch O , Ziegelmueller J , Krane M , Lange R
Published: October 2019

Background/Purpose

With the growing use of transcatheter aortic valve replacement (TAVR), we need to determine if repeat TAVR (TAV-in-TAV) is comparable or even superior to surgical aortic valve replacement followed by TAVR (TAV-in-SAV). Although TAV-in-SAV procedures were shown to provide an almost complete sealing of paravalvular leakage at the expense of elevated gradients, data for TAV-in-TAV are lacking. Hence, we compared echocardiographic and clinical outcome in all TAV-in-TAV and TAV-in-SAV procedures in our institution between Oct. 2007 and July 2017.

Methods

130 consecutive valve-in-valve patients out of 2351 TAVR-patients were identified. 24 patients were excluded. Patient data were analysed from our prospectively collected, institutional database. 93% underwent routine out-patient follow-up at 12 months.

Results

75 TAV-in-SAV (75±8 years, male 60%; STS score 5.2±4.0%) and 31 TAV-in-TAV patients (78±8 years, male 65%; STS score 4.6±2.8%) formed the final study population. The type of TAV was similarly distributed in both groups (self-/balloon-expandable valves [%] 57/43 vs. 61/39) with transfemoral being the most frequent access site (68% vs. 87%). The mode of prosthesis failure was mainly stenosis in the TAV-in-SAV group (77%), whereas it was mainly intraoperative paravalvular regurgitation (90%) in the TAV-in-TAV group. 10% TAV-in-TAV patients (78±10 years, 33% male, STS score 5.1±1.5%) underwent redo-TAVR for prosthesis-degeneration after a mean time of 2614±862 days. The TAV-in-TAV group (90% single session vs. 10% staged: mean gradient 10±4 mmHg vs. 15±3 mmHg, p=0.096; aortic valve area 1.62±0.36 cm2 vs. 1.45±0.18 cm2, p=0.240) showed lower gradients and larger aortic valve areas (Table 1). No major intraprocedural complications occurred in either group. 30-day mortality was 0%.

Table 1 75 TAV-in-SAV discharge 31 TAV-in-TAV discharge p-value 69 TAV-in-SAV 12mFU 30 TAV-in-TAV 12mFU p-value AVA (cm2) * 1.18±0.32 1.61±0.35 <0.001† 1.21±0.36 1.63±0.43 <0.001† Peak Gradient (mmHg) 33±14 23±8 <0.001† 31±14 21±8 <0.001† Mean Gradient (mmHg) 19±8 12±5 <0.001† 18±9 11±4 <0.001† AR (0–3)** 0.4±0.5 0.8±0.7 0.003† 0.4±0.5 0.8±0.6 0.001† LV ejection fraction (%) 49±12 49±16 0.970 54±12 50±10 0.081 *AVA = Aortic valve area; **AR = Aortic regurgitation. 0 = none, 1 = mild, 2 = moderate, 3 = severe. †p<0,05 significant.

Conclusion

Indications for TAV-in-TAV differ from those for TAV-in-SAV. TAV-in-TAV results in significantly lower gradients and larger aortic valve areas with no relevant aortic regurgitation. Accordingly, failed TAV valves may be treated with TAV-in-TAV in the future.
P926Comparative safety and effectiveness of vitamin K antagonist and direct oral anticoagulants in patients with atrial fibrillation undergoing transcatheter aortic valve implantation
Authors: Butt J H , De Backer O , Olesen J B , Havers-Borgersen E , Gislason G H , Torp-Pedersen C , Sondergaard L , Kober L , Fosbol E L
Published: October 2019

Background

Data on the comparative safety and effectiveness of direct oral anticoagulants (DOACs) and vitamin K antagonists (VKAs) in patients with atrial fibrillation (AF) undergoing transcatheter aortic valve implantation (TAVI) are sparse.

Purpose

To examine the risk of thromboembolism, bleeding, and all-cause mortality in patients treated with DOACs versus VKAs.

Methods

Danish nationwide registries were used to identify all patients undergoing TAVI (2011–2016) with a history of AF and who were treated with oral anticoagulants. The risk of outcomes in patients treated with DOACs versus VKAs were examined by the Aalen-Johansen estimator and cause-specific Cox regression models.

Results

The study population comprised 762 patients (median age 82 [interquartile range 77–85], 52.9% men), of whom 216 (28.3%) and 546 (71.7%) patients were treated with DOACs and VKAs, respectively. The DOAC group was characterized by a higher prevalence of previous thromboembolism and a lower prevalence of chronic kidney disease compared with the VKA group. The distribution of age, sex, CHA2DS2-VASc and HAS-BLED score, and concomitant antiplatelet therapy was similar between groups. Compared with VKA, treatment with DOACs was not associated with a significantly different 3-year absolute risk of thromboembolism (9.5% [95% confidence interval [CI], 4.7%-16.2%] versus 7.7% [95% CI, 5.3%-10.8%] in the DOAC and VKA group, respectively), bleeding (5.3% [95% CI, 2.4%-10.0%] versus 6.3% [95% CI, 4.1%-9.0%]), and all-cause mortality (32.6% [95% CI, 21.9%-43.7%] versus 33.3% [95% CI, 28.3%-38.5%]). In adjusted analyses, treatment with DOACs, as compared with VKA treatment, was not associated with a significantly different risk of thromboembolism (hazard ratio [HR], 1.25 [95% CI, 0.61–2.57]), bleeding (HR, 1.22 [95% CI, 0.54–2.75]), and all-cause mortality (HR, 0.90 [95% CI, 0.60–1.35]).

Conclusions

In patients with atrial fibrillation undergoing TAVI, treatment with DOACs was not associated with a significantly different risk of thromboembolism, bleeding, and all-cause mortality compared with treatment with VKA.

Acknowledgement/Funding

None
P936Impact of left ventricular ejection fraction in patients with peripheral artery disease: from I-PAD registry
Authors: Fujimori K , Nagae A , Miura T , Katoh T , Hirabayashi M , Kashiwagi D , Yokota D , Yanagisawa T , Sakai T , Senda K , Saigusa T , Ebisawa S , Okada A , Motoki H , Kuwahara K
Published: October 2019

Introduction

In patients with peripheral artery disease (PAD) it is known that CVD is one of prognostic factors. But, it is unclear whether left ventricular ejection fraction (LVEF) affects prognosis of PAD patients. So we investigated that LVEF affects prognosis of PAD patients.

Methods

From July 2015 to July 2016, 371 consecutive PAD patients who performed endovascular treatment (EVT) were enrolled in I-PAD registry. We could conduct follow up survey about 337 (age 73.8±9.6, men 72.4%) patients and divided two groups according to their LVEF (group with LVEF≤40%, n=18, group without LVEF≤40%, n=319). The primary end point was major adverse limb events (MALE: TLR, TVR, major amputations) and secondary end point was all-cause death.

Results

The median follow-up period was 13.6±5.7 months. The 18 months MALE and all-cause death rate were significantly higher in the group with low LVEF than group without low LVEF (61.1% vs 21.6% p<0.001, 44.4% vs 11.6% p<0.001).

Conclusion

LVEF was significantly associated with MALE and all-cause death in patients with PAD.
P950Synergistic impact of renal failure and left ventricular dysfunction on short- and long-term mortality in patients with STEMI undergoing primary PCI
Authors: Pavlovic A S , Milasinovic D , Mehmedbegovic Z , Dedovic V , Jelic D , Zaharijev S , Zobenica V , Zivkovic I , Dudic J , Vukcevic V , Asanin M , Stankovic G
Published: October 2019

Background

Impaired left ventricular function (LV) and renal failure (RF) have both been separately associated with increased risk of mortality in ST-elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PCI).

Purpose

Our aim was to comparatively evaluate the relative impact of LV dysfunction and renal failure (RF) on the risk of mortality in primary PCI-treated STEMI patients.

Methods

5878 patients admitted for primary PCI during 2009–2015, from a prospectively kept, electronic registry of a high-volume catheterization laboratory, were included in the analysis. LV dysfunction was defined as EF<40%, and RF as estimated glomerular filtration rate (eGFR) <60 ml/min/1.73 m2 according to Cockcroft-Gault formula. Adjusted Cox regression models were used to assess 30-day and 3-year mortality hazard, with patients with EF≥40% and normal renal function serving as the reference group.

Results

RF was documented in 17.1% (n=1006), whereas 36.5% had LV dysfunction (n=2141). LV dysfunction and RF were separately associated with increased crude mortality rates, whereas the concurrence of both resulted in the highest mortality rate at 30 days (0.7% if no RF and normal EF vs. 5.4% if RF alone vs. 3.9% if EF<40% alone vs. 12.6% if both RF and EF<40%; p<0.001), and at 3 years (5.7% if no RF and normal EF vs. 29.0% if RF alone vs. 19.0% if EF<40% alone vs. 47.4% if both RF and EF<40%; p<0.001). After multivariable adjustment for other significant mortality predictors, such as age, previous stroke, diabetes, hyperlipidemia, anemia and Killip≥2, RF and LV dysfunction were associated with a comparable increase in mortality risk at 30 days (HR=4.1 and HR=3.7, respectively, p<0.001 for both) and at 3 years (HR=2.8 and HR=2.7, respectively, p<0.001 for both). Importantly, the combined presence of RF and low EF was independently associated with a marked increase in both 30- day (HR=6.5, 95% CI 3.7–11.4, p<0.001), and 3-year mortality (HR=4.3, 95% CI 3.3–5.6, p<0.001).

Kaplan Meier cumulative mortality curves

Conclusion

Apart from each being independently associated with an increased risk of mortality, the concurrence of renal failure and LV dysfunction had a synergistic negative impact on the prognosis of primary PCI-treated STEMI patients
P958Outcomes in nonagenarians with myocardial infarction who activate the primary PCI pathway
Authors: Meah M N U M , Joseph T J , Ding W Y D , Shaw M S , Hasleton J H , Palmer N D P , Velavan P V , Aggarwal S K A
Published: October 2019

Introduction

Current guidelines recommend immediate revascularisation in patients with ST elevation myocardial infarction (STEMI). However it remains unclear whether PPCI reduces mortality in nonagenarians. We aimed to compare mortality in nonagenarians, presenting via the PPCI pathway, who were managed medically (MM) versus those who underwent PCI.

Methods

Electronic records of every nonagenarian who presented as a PPCI activation between 2013–2018 were reviewed. Patients were divided into those who had PCI and those MM. Standard univariate and Kaplan Meier survival analyses were performed. We compared outcomes to an age and sex matched cohort using life tables from the Office for National Statistics (ONS).

Results

There were 157 nonagenarians presenting via the PPCI pathway, of which 111 were “true” myocardial infarction. Table 1 summarises baseline variables and comorbidities. The cohorts were generally well matched. Both groups had similar BCIS PCI 30-day mortality risk scores. The commonest reason to treat medically was presentation 12 hours after symptom onset. There was a trend towards increased 30-day mortality in the MM group. Kaplan Meier analysis (Figure 1) show the survival curves diverge immediately and reach statistical significance at 3 years. Compared to a matched population from ONS life tables, outcomes are worse in MM.

Table 1.S Admission variables & results PCI Group (n=42) Medically Managed Group (n=69) P-value Age 92 (91, 94) 93 (91, 95) 0.22 Female 21 (50.0%) 45 (65.2%) 0.11 Left ventricular failure (EF <45%) 27 (64.3%) 46 (66.6%) >0.99 Cardiogenic shock (Systolic BP <90mmHg) 4 (9.5%) 6 (8.7%) >0.99 Hx of hypertension 24 (57.1%) 45 (65.2%) 0.39 Hx of diabetes 5 (11.9%) 18 (26.1%) 0.07 Hx of chronic kidney disease 12 (28.6%) 25 (36.2%) 0.41 Hx of previous stroke 8 (19.1%) 15 (21.7%) 0.73 Hx of atrial fibrillation 1 (2.4%) 16 (23.2%) 0.003 Presented as non-STEMI 1 (2.4%) 12 (17.4%) 0.017 Presented as completed STEMI 2 (4.8%) 30 (43.5%) <0.001 BCIS PCI 30-day mortality risk 15.7 (14.3, 23.6) 17.5 (15.3, 22.3) 0.17 30-day mortality 10 (23.8%) 28 (40.6%) 0.07

Figure 1. Kaplan Meier Chart

Conclusions

Long term survival even in nonagenarians is significantly improved by timely PPCI when compared with medical management.
P969Predictors of survival after bifurcation stenting (practical insights from COSIBRIA registry)
Authors: Vassilev D , Nikolov P , Mileva N , Zlatancheva G , Dimitrov G , Ivanov V , Karamfiloff K , Panayotov P , Collet C , Gil R
Published: October 2019

Background

There is no much information about survival after coronary bifurcation stenting. We explored specifically predictors of death in all-comers registry database.

Methods

The COSIBRIA registry (COronary SIde Branch Residual IschemiA and COllateralization Assessment Study, Identifier: NCT01268228) collected all coronary bifurcation patients treated with intracoronary ECG (icECG) guidance or angiographically guided PCI. It was designed to explore relation between periprocedural ischemia assessed by means of icECG and post-procedural myonecrosis (troponin rise). Patients with STEMI, distal left main, cardiogenic shock or hemodynamic instability or BVS implantations were excluded. Unipolar icECGs were recorded before, during and after stent placement and at the end of procedure in side branch (SB) and main branch (MB). The coronary wire was placed in all distal vessels with diameter >1.5mm, to “map” the distal zones of ischemia. Provisional T-stenting, with proximal balloon optimization (POT) after stent implantation was default strategy. SB was stented in case of non-normalization of icECG ST-segment elevation after kissing-balloon dilatation or flow compromise and severe dissection (>type C) associated with symptoms. All patients were treated with 3rd and higher generation drug-eluting stents.

Results

731 patients were included in the analysis recruited from 01.08.2014 to 31.12.208 – 321 (44%) icECG guided. The mean age of patients was 67±10 years, 68% males, 38% smokers, 94% dyslipidemic, 41% diabetics, 26% had previous MI, 47% previous PCI, previous CABG 3%, renal failure 32%, cerebrovascular and peripheral artery disease – 15% and 10%. At median follow-up of 28 months (IQR 18–45 months), 110 patients died (15%): icECG-guided vs. angio guided (18.1% (58/321) vs. 12.7% (52/410), p=0.043, log-rank p=0.045). Side branches were stented in 27%. On univariate analysis significantly associated with mortality were: age, sex, COPD, renal failure, total cholesterol, atrial fibrillation, cerebrovascular disease, ejection fraction (EF), mitral regurgitation >1st degree, SB stenting, kissing balloon inflation, stent length, lesion location (LAD), SYNTAX score. On Cox-regression analysis an independent predictors of survival were: age (HR=1.033, CI: 1.011–1.055, p<0.001), male sex (HR=1.733, CI: 1.056–2.845, p=0.030), COPD (HR=0.586, CI: 0.349–0.985, p=0.044), EF (HR=0.972, CI: 0.953–0.992, p=0.006), MR>1 (HR=1.617, CI: 1.224–2.136, p=0.001), SB stenting (for non-stent implantation HR=0.497, CI: 0.300–0.824, p=0.007).

Conclusions

Even with modern treatment of coronary bifurcations the demographic factors and parameters of left ventricular function governs the patient survival. The only technical factor associated with survival was implantation of stent in SB, associated with worse survival. Intracoronary ECG guided PCI was not independently associated with survival.
P971Impact of treatment strategy on 1-year outcome for Left Main trifurcation lesions
Authors: Tani K , Mitomo S , Tanaka K , Tahara S , Nakamura S
Published: October 2019

Background/Introduction

Limited data exist regarding procedural strategy and clinical outcomes after percutaneous coronary intervention (PCI) for unprotected left main (LM) trifurcation lesion.

Purpose

The aim of this study is to evaluate 1-year clinical outcomes after LM trifurcation PCI comparing different strategies in kissing balloon inflation (KBI).

Methods

From 1, January, 2011 to 31, March, 2017, patients who underwent LM trifurcation PCI with second generation drug-eluting stent in our center were retrospectively analyzed. They were categorized into single-stent KBT group (KBT in left anterior descending artery [LAD] and left circumflex artery [LCX], or LAD and high lateral branch [HL]) and no-KBT group. Primary endpoint is restenosis in the lesions.

Results

Among 1301 patients who underwent LM PCI during the study period, 163 patients (12.5%) had a trifurcation lesion. Regarding the number of stents used for the lesions, 1, 2 and 3 stents were used in 75.4%, 22.0% and 2.5%, respectively. Median follow-up period of LM trifurcation patients was 265 days (interquartile range: 81–564). In the no-KBT group (64 patients), 19 patients experienced restenosis of HL and LCX (HL: 8 patients, LCX: 0 patient, and both: 11 patients). In the KBT-group, KBT for LAD and LCX was performed in 47 patients, and of them, 19 patients experienced restenosis of LM-LAD, HL and LCX (HL: 12 patients, LCX: 6 patients and all: 1 patient). On the other hand, in 9 patients with KBT for LAD and HL, there were no restenosis cases at 1-year follow-up. There was no statistically significant difference in restenosis rate between the no-KBI and KBT group (29.6% vs. 40.4%, p=0.69).

Restenosis rates in each segments

Conclusion

After LM trifurcation PCI, restenosis rate at 1-year follow-up was high, and no difference between no-KBT and KBT group overall. However, there was no restenosis case in patients with KBT for LAD and HL.
P978Core to block: a new ablation strategy for treating persistent atrial fibrillation
Authors: Shi R , Pope M T B , Boyalla V , Jones D G , Haldar S , Hussain W , Markides V , Betts T R , Wong T
Published: October 2019

Background

Ablation strategy targeting the core of atrial fibrillation (AF) rotors alone can lead to both stabilisation and destabilisation of rotational activity. Non-contact dipole density mapping system is designed to rapidly identify dynamic regional atrial activation patterns of interest (API) during AF.

Purpose

To assess the feasibility of an ablation strategy consisted of pulmonary vein isolation + targeting the core of APIs followed by linear ablation to the nearest non-conducting boundary to treat persistent AF.

Methods

The ablation strategy includes: 1. Antral pulmonary vein electrical isolation (APVI); 2. APIs (focal, localised rotational and localised irregular activation; Figure1) detection by dipole density mapping; 3. API core ablation followed by linear ablation to the nearest non-conduction barrier (APVI/mitral valve); 4. repeat step 2 and 3 in LA (RA, if necessary) until sinus rhythm is achieved.

Results

Consecutive 40 persistent AF patients (mean 62±12 years, 29 males, AF duration 10±4 months, LA diameter 42±9 mm) were included from 2 centres. An average of 2.0±0.7 APIs per patient were targeted post-APVI. Acute AF termination by ablation was achieved in 27/40 (68%) patients. The mean ablation time of APVI and “Core to block” was 33±12 mins and 31±22 mins, respectively. No major complication occurred. During a mean follow-up of 12±5 months, 32/40 patients (80%) maintained sinus rhythm.

Conclusion

APVI + “Core to block” guided by the dipole density mapping is feasible for treating persistent AF. A larger randomised study is needed to test the effectiveness of this ablation strategy.

Acknowledgement/Funding

None
P991Predicting arrhythmic risk in dilated cardiomyopathy: a systematic review & meta-analysis of clinical parameters
Authors: Sammani A , Kayvanpour E , Bosman L P , Sedaghat-Hamedani F , Proctor T , Jensen K , Katus H A , Te Riele A S J M , Meder B , Asselbergs F W
Published: October 2019

Background

Patients with non-ischemic dilated cardiomyopathy (NIDCM) are at increased risk of ventricular arrhythmias and sudden cardiac death (SCD). However, identifying patients at high risk for life-threatening ventricular arrhythmia (LTVA) who may benefit from an implantable cardioverter defibrillator (ICD) remains challenging.

Methods

We searched MEDLINE and EMBASE for prognostic studies describing predictors of LTVA (defined as sustained ventricular tachycardia (VT), haemodynamically unstable VT, ventricular fibrillation, (aborted) SCD or appropriate ICD intervention) in patients with NIDCM. We excluded articles with composite heart failure and arrhythmic endpoints but lacking (subgroup) analysis for LTVA. Study quality and risk of bias was assessed using the QUIPS-tool, and articles with high risk of bias in ≥2 areas were excluded from analysis. Univariable hazard ratios of reported predictors were pooled from the remaining studies in a meta-analysis using a random-effects model and presented with 95% confidence interval (CI).

Results

Out of 1996 unique citations, 51 studies were included comprising 9798 patients with 1493 arrhythmic events. 28 studies were pooled for meta-analysis (mean age 55±4.1 years, 72% male) with a mean follow-up of 3.7±1.9 years. Crude event rate was 4.3% (95% CI 4.02–4.57) per year. From our meta-analysis, hypertension (HR 1.95; CI [1.26–3.00]), history of out of hospital cardiac arrest or sustained VT (HR 4.15; CI [1.32–13.02]), T-wave alternans (HR 6.50; CI [2.46–17.14]), LVEDV per 10ml/m2 increase (HR 1.10; CI [1.10–1.10]), LVESV per 10ml/m2 increase (HR 1.10; CI [1.00–1.22]) and delayed gadolinium enhancement (HR 5.55; CI [4.02–7.67]) were significantly associated with LTVA (figure). The quality of evidence was moderate and there was significant heterogeneity (median i2 57%; IQR 76%) among studies. Additionally from data that could not be pooled, decreased LVEF, history of nsVT and decreased heart rate variability were significantly associated with LTVA.

Summary of meta-analysis results

Conclusion

The risk of LTVA in NIDCM is 4.3% per year and is considerably higher in patients with hypertension, history of LTVA, decreased LVEF, high LVEDV, high LVESV, T-wave alternans, history of nsVT, decreased heart rate variability and delayed gadolinium enhancement. These results may help determine appropriate candidates for ICD implantation. The high heterogeneity in reported results indicate the need for future multicentre studies to further improve risk stratification in NIDCM.

Acknowledgement/Funding

ERA-CVD JTC2016: DETECTIN-HF, 680969 & Dutch Heart Foundation (2016T096)
P992Incidence, predictors, and success of ventricular tachycardia catheter ablation in arrhythmogenic right ventricular cardiomyopathy (ARVC): A long-term cohort study from the Nordic ARVC registry
Authors: Christiansen M K , Haugaa K , Svensson A , Gilljam T , Madsen T , Hansen J , Holst A , Bundgaard H , Edvardsen T , Svendsen J H , Platonov P , Jensen H K
Published: October 2019

Background

Catheter ablation may reduce ventricular tachycardia (VT) burden in arrhythmogenic right ventricular cardiomyopathy (ARVC) patients. However, little is known about factors predicting need for ablation and various outcomes have been reported.

Purpose

We sought to investigate predictors and use of VT ablation and to evaluate the post-procedural outcome in ARVC patients.

Methods

We studied 435 patients from the Nordic ARVC registry including 220 probands with definite ARVC according to the 2010 task force criteria and 215 mutation-carrying relatives identified through cascade screening. Patients were followed until first-time VT ablation, death, heart transplantation, or January 1st 2018. Additionally, patients undergoing VT ablation were further followed from the time of ablation for recurrent ventricular arrhythmias.

Results

Cumulative use of VT ablation was 4% (95% CI 3%-6%) and 11% (95% CI 8%-15%) after 1 and 10 years. All procedures were performed in probands in whom the cumulative use was 8% (95% CI 5%-12%) and 20% (95% CI 15%-26%). In adjusted analyses restricted to probands, only young age predicted need for ablation. In patients undergoing ablation, risk of recurrent arrhythmias was 59% (95% CI 44%-71%) and 74% (95% CI 59%-84%) 1 and 5 years after the procedure. Despite high recurrence rates, the burden of ventricular arrhythmias was reduced after ablation (p=0.0042). Young age, use of several antiarrhythmic drugs and inducibility to VT immediately after ablation were associated with an unfavorable outcome.

Conclusions

Twenty percent of ARVC probands developed a clinical indication for VT ablation within 10 years after diagnosis whereas mutation-carrying relatives were without such need. Although the burden of ventricular arrhythmias decreased after ablation, risk of recurrence was substantial.
P996Early experience of transnasal micro-transesophageal echocardiography to guide left atrium appendage closure under conscious sedation
Authors: Couture E , Darmon A , Stein G , Platonov I , Brennt V , Horvilleur J , Chevalier B , Garot P
Published: October 2019

Introduction

Percutaneous left atrial appendage closure (LAAC) is typically performed utilizing transesophageal echocardiography (TEE) and fluoroscopy under general anesthesia (GA) or intracardiac echocardiography (ICE) under conscious sedation. Transnasal microtransesophageal echocardiography (micro-TEE) is a recently described technique to guide structural heart interventions eliminating the need for GA, which is beneficial for all, especially older patients. In this series, we report our initial experience with this novel technique to guide LAAC.

Methods and results

Between June 2018 and January 2019, we performed 30 consecutives LAAC (mean age 80,2 years old) with the Amplatzer AMULET in whom we considered using transnasal micro-TEE under conscious sedation instead of TEE under GA. All patients had a CT prior to the procedure to assess anatomy suitability and to rule out thrombus as well as a follow-up CT performed at 3 months post-LAAC to confirm complete sealing. Three patients had TEE instead of micro-TEE for various reasons (patient preference, cognitive impairment, INR >2). We observed one cross-over to TEE+GA because of a failed esophageal intubation under conscious sedation. Device implantation success rate was 100%. Imaging quality was quoted either good or excellent in 25 of the 26 patients with the remaining being quoted as suboptimal. Patient tolerance was either good or excellent in 24 of the 26 cases. There were five epistaxis noticed, one requiring nasal packing. No device embolization, no significant peri-device leak, no tamponade occurred in any patient during this period. At 3 months, there was no prosthesis thrombosis observed and 23% (6/26) had partial opacification of the LAA behind the prosthesis.

Conclusion

In this series, transnasal micro-TEE was feasible, safe, well tolerated and provided sufficient imaging quality to guide LAAC with the Amplatzer AMULET under conscious sedation. The cheaper cost and the wider field of view of micro-TEE over ICE are potential advantages that could impact the organization of LAAC programs especially when these interventions are planned in the elderly in whom GA carries a significant risk.
P998Left atrial appendage closure device thrombosis is associated with systemic embolization
Authors: Hala P , Lekesova V , Mraz T , Prokopova M , Petru J , Sediva L , Janotka M , Chovanec M , Molnarova K , Neuzil P
Published: October 2019

Introduction

Atrial fibrillation, in one of its forms, is the most frequent sustained tachyarrhythmia and increases the risk of stroke more than 5 times. Cardioembolic stroke and systemic embolism (CS/SE) represents the most severe complication of this arrhythmia. Approximately 92% of intracardiac thrombosis originates from the left atrial appendage (LAA) and, although its mechanical occlusion is proved method to prevent cardioembolism, thrombosis of all types of LAA occlusion devices and their associations with CS/SE were observed.

The purpose of this study is to evaluate the rate of LAA occlusion device thrombosis, its predictors and the risk for cardioembolism.

Methods

We analyzed a group of 359 patients (65% male, mean age 72 years) with high risk for thromboembolism (mean CHADSVASc = 4.0) after LAA catheter occlusion using any of 9 different occluder types since 2005. During clinical follow-up 819 patientyears were collected and an intracardiac thrombus was found on 22 devices. Total of 17 patients suffered CS/SE.

Results

Thrombosis was found in 11 men and 11 women, mean age 76 years, average CHADSVASc = 4.5 and HASBLED = 2.0. The thrombus was discovered on average 4.0 months after the LAA occlusion. In that time patients were receiving dual antiplatelet therapy (11x), acetysalicic acid (4x), or interrupted anticoagulation (6x). In 3 cases the thrombosis was associated with CS/SE which represented risk of 6.6% per year. In patients with no thrombosis annual risk of CS/SE was only 1.7% (P<0.001).

Figure 1

Conclusion

In our single center register thrombosis was found in total of 6.3% patients after LAA device implantation. In these patients, risk of CS/SE is 3.9-fold higher compared to patients without thrombus formation. Elderly patients and patients with more risk factors in general were affected more frequently.
P1026Risk factors for the occurrence of stroke after atrial fibrillation ablation
Authors: Lim H E , Ahn J , Han S J , Shim J , Kim Y H , Choi E K , Oh S , Shin S Y , Lip G Y H
Published: October 2019

Background

Risk factors for the occurrence of embolic stroke (ES) after atrial fibrillation (AF) ablation have not been fully elucidated. Our aim was to assess incidence of ES during long-term follow-up following AF ablation and to identify predicting factors associated with post-ablation ES.

Methods

We enrolled patients who experienced ES after AF ablation and body mass index-matched controls from AF ablation registries. Epicardial adipose tissue (EAT) was assessed using multislice computed tomography prior to ablation.

Results

A total of 3,464 patients who underwent AF ablation were recruited. During a mean follow-up of 47.2 months, ES occurred in 47 patients (1.36%) with a mean CHA2DS2-VAS score of 2.15 and overall incidence of ES was 0.34 per 100 patients/year. Compared with control group (n=190), ES group had more higher prior thromboembolic event and AF recurrence rates, larger LA size, lower creatinine clearance rate (CCr), and greater total and periatrial EAT volumes although no differences in AF type, CHA2DS2-VASc score, ablation extent, and anti-thrombotics use were found. On multivariate regression analysis, a prior history of thromboembolism, CCr, and periatrial EAT volume were independently associated with ES occurrence after AF ablation.

Cox regression analysis Risk factor Univariate Multivariate HR (95% CI) p value HR (95% CI) p value Age 1.017 (0.984–1.051) 0.31 Prior thromboembolism 2.488 (1.134–5.460) 0.023 2.916 (1.178–7.219) 0.021 CHA2DS2-VASc score 1.139 (0.899–1.445) 0.282 CCr 0.984 (0.970–0.999) 0.038 0.982 (0.996–0.998) 0.029 LA diameter (mm) 1.070 (1.012–1.130) 0.017 1.072 (0.999–1.150) 0.054 EAT_total (ml) 1.020 (1.010–1.029) <0.001 1.008 (0.993–1.023) 0.297 EAT_periatrial (ml) 1.085 (1.045–1.126) <0.001 1.065 (1.005–1.128) 0.032 PVI + additional ablation 0.846 (0.460–1.557) 0.592 No anticoagulant use 0.651 (0.346–1.226) 0.184 Recurrence 2.011 (1.007–4.013) 0.048 1.240 (0.551–2.793) 0.603 CCr, creatinine clearance rate; EAT, epicardial adipose tissue; LA, left atrium; PVI, pulmonary vein isolation.

K-M curve for stroke-free survival

Conclusions

Incidence of ES after AF ablation was lower than expected rate based on CHA2DS2-VASc score even though anticoagulants use was limited. Periatrial EAT volume, a prior thromboembolism event, and CCr were independent factors in predicting ES irrespective of AF recurrence and CHA2DS2-VASc score in patients who underwent AF ablation.