bluuebunny/crossref_metadata_2025 huggingface dataset:
P2704The association between global coronary flow reserve and coronary inflammation assessed by attenuation index on computed tomography in patients with stable angina pectoris
Authors: Hirano H , Kanaji Y , Horie T , Yuki H , Kanno Y , Ohya H , Hada M , Sumino Y , Yamaguchi M , Hoshino M , Sugiyama T , Yonetsu T , Kakuta T
Published: October 2019

Background

Impaired global coronary flow reserve (G-CFR) is known to predict worse outcomes in patients with coronary artery disease. Phase contrast cine-magnetic resonance imaging (PC-CMR) of the coronary sinus (CS) is a promising approach for quantifying coronary sinus flow (CSF) and G-CFR without the need for ionizing radiation, radioactive tracers, or intravascular catheterization. Although G-CFR impairment is previously reported to be linked with endothelium dysfunction and progression of atherosclerosis, the association of perivascular adipose tissue inflammation with myocardial coronary flow remains to be determined.

Purpose

We evaluated the association between G-CFR by quantifying CSF using PC-CMR and the extent of coronary inflammation evaluated by perivascular adipose tissue inflammatory status using CT to assess if coronary inflammation is linked with G-CFR in patients with stable angina pectoris (SAP) treated with elective percutaneous coronary intervention (PCI).

Methods

The study enrolled 74 SAP patients with single denovo lesion who underwent coronary CT angiography and PC-CMR within 90 days before coronary intervention. Proximal 40-mm segments of all three major epicardial coronary vessels were traced and examined. Coronary inflammation was assessed by the CT fat attenuation index of perivascular adipose tissue (FAI-PVAT) defined as the mean attenuation of the perivascular adipose tissue (−190 to −30 Hounsfield units (HU)) in a layer of tissue within a radial distance from the outer coronary artery wall equal to the diameter of the vessel. CMR images were also acquired to assess absolute CSF at rest and during maximum hyperemia before elective PCI. The patients were divided into 4 groups according to the number of inflamed vessels as defined by showing FAI ≥−70.1 HU.

Results

In the final analysis of 69 patients (mean age 67, Male 45 (65.2%)), 18, 19, 20, 12 patients exhibited none, 1, 2, 3 inflamed vessels with FAI ≥−70.1 HU, respectively. Rest and maximal hyperemic CSF and corrected G-CFR were 1.28 [0.76,1.55] vs 1.47 [1.11, 1.81] vs 1.30 [0.94, 1.64] vs 1.27 [1.11, 2.00] ml/min/g; P=0.49, 3.50 [2.84, 5.25] vs 3.28 [2.62, 4.31] vs 3.11 [2.16, 3.63] vs 2.37 [1.40, 2.98] ml/min/g; P=0.049, 3.57 [2.17, 4.54] vs 2.25 [1.73, 3.49] vs 2.26 [1.64, 3.38] vs 1.89 [0.89, 2.32]; P=0.023, respectively. G-CFR and hyperemic CSF were both significantly lower in the group with larger number of inflamed vessels.

Conclusions

In SAP patients with significant coronary artery stenosis, G-CFR obtained by PC-CMR significantly associated with the prevalence of inflamed vessels detected by coronary CT. The extent of coronary inflammation may influence global coronary endothelium dysfunction, resulting in decreased G-CFR.
P2710Anti-ischemic effect of 2-week cycle of heparin plus exercise-to-ischemia twice daily in patients with “no-option” angina: the CARHEXA trial
Authors: Petrovic M T , Djordjevic-Dikic A , Stepanovic J , Giga V , Boskovic N , Vukcevic V , Cvetic V , Mladenovic A , Radmili O , Markovic Z , Kalimanovska-Ostric D , Stankovic S , Ostojic M C , Beleslin B , Picano E
Published: October 2019

Background

Coronary collateral circulation (CCC) exerts protective effects on myocardial ischemia due to coronary artery disease (CAD), but the anti-ischemic, pro-CCC effects of exercise (E) with or without heparin (H) co-administration remain unclear.

Purpose

To establish the anti-ischemic functional efficacy of 2-week cycle of E-to-ischemia twice daily, with or without unfractionated i.v. H immediately before E, in patients with “no-option” CAD

Methods

In a prospective, single-center, parallel group study design we recruited 32 “no-option” patients (27 males; mean age of 61±8 years) with at least one chronically occluded coronary artery and stable angina, refractory to optimal medical management, not suitable for revascularization therapy and with E-induced ischemia. All underwent a 2-week cycle of E (2 E test per day, 5 days a week, for 2 weeks) and were randomized, with a double-blind design, to i.v. placebo (0.9% saline) versus unfractionated H (100 IU/kg up to a maximum of 5.000 IU iv, 10 min prior to E). Seattle stable angina questionnaire (SAQ), 12-lead E-ECG for time-to-ischemia (treadmill exercise testing), and MDCT angiography for CCC imaging (Rentrop score, from 0= absent to 3= full opacification of occluded vessel) were assessed at entry and re-assessed after treatment for symptomatic, ECG, and anatomic end-points respectively.

Results

In H+E group (n=16), time to 1 mm ST segment depression (ST-D) increased, and CCC improved, p<0.05. On the contrary, no difference was observed in E group (n=16) in the pre-specified end-points (p>0.05) (see table). Clinically important change of more 10 points in SAQ was observed regarding physical limitation, angina stability and disease perception in H+E patients, and in only angina frequency in E group.

The ECG and angiographic results Heparin + Exercise Placebo + Exercise Rentrop baseline 0.73±0.88 1.06±1.06 Rentrop 2-week 1.6±0.99* 1.19±1.05 Time to ST-D base (s) 269±64 273±176 Time to ST-D 2-week (s) 328±65* 306±151 *p<0.05.

Conclusion

A 2-week, 10 E test cycles are well tolerated and effective particularly with H in ameliorating symptoms, E-induced ischemia and CCC in “no-option” CAD patients with refractory angina.
P2711Prevalence of collateral circulation and its importance on the development of reperfusion injury in patients with acute myocardial infarction with ST-segment elevation
Authors: Quispe-Villca Y A , Martinez-Sanchez C , Arias-Mendonza A , Azar-Manzur F , Mendoza-Garcia S , Altamirano-Castillo A , Alvarez-Sangabriel A , Briseno-Cruz J L , Gonzalez-Pacheco H
Published: October 2019

Prevalence of collateral circulation and its importance on the development of reperfusion injury in patients with acute myocardial infarction with st segment elevation treated with primary percutaneous coronary angioplasty

Introduction

In myocardial infarction with ST-segment elevation, early restoration of flow is the most important objective, but there is a possibility that reperfusion may induce ischemia-reperfusion injury. There is little information about the relationship of collateral circulation and reperfusion damage in patients with infarction, which is the reason for our study. Objective: To determine the prevalence of collateral circulation and its importance in the development of microvascular occlusion and intramyocardial hemorrhage evaluated by magnetic resonance imaging in patients with acute myocardial infarction with ST-segment elevation.

Methods

Observational, analytical study, retrospective cohort.

Methods

From March 2008 to April 2017, 359 patients were included and they were over 18 years of age with acute myocardial infarction with ST-segment elevation undergoing primary angioplasty who had magnetic resonance imaging. It was classified into 2 groups of patients: Group 1 (309 patients, without collateral circulation) and group 2 (50 patients, with collateral circulation). The presence or absence of collateral circulation was determined by coronary angiography and reperfusion injury (microvascular obstruction and intramyocardial hemorrhage) was evaluated by magnetic resonance. The x2 test was used to compare the categorical variables and the Mann-Whitney U test for continuous numerical variables.

Results

Of 359 patients, 50 (13.9%) patients had collateral circulation. The presence of reperfusion damage by magnetic resonance was compared. Patients in group 1 had reperfusion injury in 73.8% and group 2, 70.0% (p: 0.57).

Presence or absence of reperfusion injury in patients with and without collateral circulation No Collateral circulation Collateral circulation “p” value n=309 (%) n=50 (%) Reperfusion inury 0.57   No 81 (26.2%) 15 (30.0%)   Yes 228 (73.8%) 35 (70.0%) Microvascular Obstruction 0.59   No 81 (26.4%) 15 (30.0%)   Yes 226 (73.6%) 35 (70.0%) Myocardial Hemorrhage 0.24   No 189 (61.4%) 35 (70.0%)   Yes 119 (38.6%) 15 (30.0%)

Conclusions

In the present study it is demonstrated that the presence of collateral circulation did not influence the reperfusion damage, so the collateral circulation does not protect the myocardium from reperfusion injury. Prospective studies were needed to confirm this results.

Acknowledgement/Funding

Carlos Slim Fundation
P2712Integration of new CENTAUR high-sensitivity Troponin I assay with HEART score chest pain pathway to maximise early discharge from emergency department
Authors: Thet E M , Murphy J J , Crilley J G
Published: October 2019

Introduction

Chest pain is a common presentation to the emergency department (ED). Differentiating those with an Acute Coronary Syndrome from the majority without, within 4 hours, is a priority. Introduction of high-sensitivity TnI assays has the potential to allow early discharge from ED but at the expense of lower specificity. Given the pressure in ED to identify patients who can safely be discharged we developed an algorithm based on the HEART score. This combines the history, ECG, age, risk factors and hsTnI level and outperforms TIMI and GRACE scores in identifying low-risk patients. Patients with a score of ≥4 have an increased major adverse cardiac event (MACE) rate at 30 days; those with a score of <4 are suitable for early discharge. There are no studies utilising the CENTAUR assay combined with a clinical risk score.

Methods

An initial algorithm based on the HEART score tool was developed incorporating estimated hsTnI boundaries for the CENTAUR assay to inform the “T” component of the tool. This was tested on a 2 month sample of patients presenting with chest pain to the ED. Following review a revised pathway was developed. Patient outcome was recorded with both pathways including subsequent investigations and MACE at 30 days and compared with historical discharge rates for chest pain from the same ED. Sensitivity, specificity and NPV were calculated.

Results

There were 478 presentations with chest pain and at least one hsTnI level. Age ranged from 13 to 98 years (median 56); 50% were male. There were 21 (4%) MACE within 30 days of the initial presentation (NSTEMI: 18, STEMI: 1, unstable angina requiring CABG: 1, acute pulmonary oedema: 1). A 2 hour hsTnI ≤8 identified a low-risk group with no MACE <30 days. 30% of patients using the initial pathway had a HEART score of ≥4 (100% sens, 73% spec). 70% were suitable for ED discharge; there were no MACE in this group (100% NPV). A revised pathway was derived incorporating previous cardiac history and modified hsTnI boundaries. Applying this to the original cohort would have increased the proportion suitable for ED discharge to 82%. Both pathways improved the proportion of patients who could be discharged directly from ED from a historical 64%. The revised pathway demonstrated improved specificity for the identification of MACE with no loss of sensitivity and excellent negative predictive value. (100% sens, 86% spec, 100% NPV).

Conclusions

The CENTAUR hs-TnI assay and HEART score with modifications would facilitate the early discharge of patients with chest pain from ED within 4 hours without missing any MACE at 30 days. This conclusion should be validated in a prospective cohort.
P2713A genetic risk score improves discrimination of hemodynamically obstructive coronary artery disease (CAD) beyond the CAD Consortium scores in patients at low-to-intermediate risk of CAD
Authors: Christiansen M K , Winther S , Nissen L , Johansen J K , Westra J S , Holm N R , Frost L , Botker H E , Christiansen E H , Bottcher M , Nyegaard M
Published: October 2019

Background

Genetic risk scores (GRSs), based on variants identified in genome-wide association studies (GWAS), have been shown to predict risk of coronary artery disease (CAD). However, the clinical potential remains unknown.

Purpose

To investigate whether a GRS improves discrimination of hemodynamically obstructive CAD beyond the CAD Consortium scores and coronary artery calcium score (CACS) in patients referred for coronary computed tomography angiography (CTA).

Methods

We consecutively included and genotyped 1645 patients undergoing CACS scoring and coronary CTA on a suspicion of CAD. Using LDPred, a recently validated GRS was calculated as the weighted sum of the number of CAD risk variants identified from the CARDIoGRAMplusC4D GWAS meta-analysis. Patients with a ≥50% stenosis on CTA further underwent invasive coronary angiography (ICA) with fractional flow reserve (FFR). Hemodynamically obstructive CAD was defined as a visual ICA stenosis >90%, FFR <0.80, or a quantitative coronary analysis stenosis >50% if FFR was not feasible. Discrimination was evaluated by receiver-operating characteristics.

Results

Median age was 57 (interquartile range 50–64) years and 799 (49%) were males. Hemodynamically obstructive CAD was present in 14 (4%) with a low GRS (<20th percentile), 91 (9%) with an intermediate GRS (20th–80th percentile) and 53 (16%) with a high GRS (>80th percentile) (p<0.0001). Adding the GRS improved the area under the receiver-operating curve (AUC) on top of the CAD Consortium basic score (from 0.67 to 0.72, p=0.0052), and the CAD Consortium clinical score (0.70 to 0.74, p=0.0084), but not on top of the CAD Consortium clinical score + CACS (0.85 to 0.86, p=0.30). Improvement in discrimination on top of the CAD Consortium scores was predominantly driven by females ≤57 years (CAD Consortium basic score ± GRS: 0.60 to 0.78, p=0.0004; CAD Consortium clinical score ± GRS: 0.63 to 0.78, p=0.0007). The GRS did not improve discrimination in any subgroups including CACS (CAD Consortium clinical score + CACS ± GRS: all p-values >0.05).

Conclusion

A GRS improves discrimination of hemodynamically obstructive CAD beyond CAD consortium scores, particularly in young women. However, the additive discriminative value is attenuated in models including CACS.
P2716Correlation between computed tomography derived ischemia index and conventional fractional flow reserve
Authors: Yamaji K , Katsuki A , Haque H , Uetake N , Miyazaki A , Ichinose R , Ando K
Published: October 2019

Background

Computed tomography (CT) derived ischemia index is a novel tool to determine the significance of coronary artery disease, however, its ability to identify myocardial ischemia has not been examined.

Methods

From Jan. 2013 to Dec. 2015, 14,000 patients underwent ECG-gated CT coronary angiography for suspected coronary artery disease. From Jan. 2013 to Jan. 2016, 483 patients (589 vessels) underwent conventional FFR to assess myocardial ischemia. Among those, FFR was assessed in 148 patients (167 vessels) within 30 days after CT coronary angiography. We further excluded 24 patients with prior stenting or bypass grafting, 3 patients with multiple MDCT or FFR, and 6 patients with insufficient datasets. Finally, we included 117 patients (127 vessels) to assess the correlation between CT derived ischemia index and conventional FFR.

CT derived ischemia index was calculated as follows: left ventricular volume distally to the coronary artery lumen (cm3)/coronary artery lumen area (mm2). Left ventricular volume was automatically determined using Advantage Workstation and divided according to the nearest coronary artery tree. Center of coronary arteries were manually traced and contours of coronary artery lumen were automatically depicted. CT derived ischemia index was calculated at approximately every 0.625mm point of coronary artery. Moving median of consecutive 5 points (approximately 3.125mm) were used to remove outliers. Maximum value of CT derived ischemia index per coronary artery segment was calculated to determine the significance of coronary artery disease.

Results

Mean age was 71.3±10.5 years and 63.8% of patients were male. Coronary angiography was performed to assess conventional FFR at the median of 13 days (IQR 7 to 18 days) after CT. Majority of the target vessel was left anterior descending artery (71.7%), followed by right coronary artery (14.2%), left circumflex artery (13.4%) and left main coronary artery (0.8%). According to the quantitative coronary angiography, minimum lumen diameter was 1.47±0.32mm with percent diameter stenosis of 48.3±10.4%. Median FFR value was 0.83 (IQR 0.76 to 0.88) and positive test for myocardial ischemia (FFR <0.80) was observed in 42 vessels (33.1%). Maximum CT derived ischemia index per segment ranged from 1.825 to 57.296 (median 8.333, IQR 4.911 to 14.484). There was a negative correlation between CT derived ischemia index and FFR (r=−0.319, 95% confidence interval −0.467 to −0.153, P<0.001). Receiver operating characteristic analysis indicated CT derived ischemia index of 9.962 has 76.2% sensitivity and 70.6% specificity for the presence of FFR<0.80 (AUC 0.73, 95% CI 0.64 to 0.82).

Conclusions

A novel tool of CT derived ischemia index has a significant negative correlation with conventional FFR in lesions with mild to moderate stenosis. Larger multicenter prospective studies are needed to fully determine the impact of CT derived ischemia index.
P2718Interim study: analysis of myocardial deformation using fSENC-CMR on patients with chest pain
Authors: Siry D , Salatzki J , Andre F , Hirschberg K , Friedrich M , Giannitsis E , Katus H A
Published: October 2019

Background

In acute situations such as non-ST-elevation infarction (NSTEMI) or relevant coronary artery disease (CAD) CMR does not yet play a key role due to its lengthy protocols. fSENC is a new CMR technique which may detect subclinical signs of myocardial damage by measuring myocardial strain (change in length/ unit length). A whole-heart coverage is generated in 6 heart-beats and the information obtained is converted into a colour-coded map. fSENC does not require major post-processing, long breath-holds and the administration of contrast agents/medication.

Purpose

In this observational study fSENC is assessed in patients with chest pain and its capability to differentiate between an ischemic cause (NSTEMI, significant CAD), an underlying non-ischemic cardiac disease and non-cardiac chest pain. Additionally, we aim to identify the affected coronary arteries in the ischemic cohort. With fSENC it could be possible to successfully diagnose patients with suspected AMI in <1h after admission and also gain diagnostic information regarding the underlying pathology.

Methods

Patients with chest pain and an initial hscTnT level between 5pg/ml and 52 pg/ml are recruited. These patients then undergo an fSENC-CMR before 2nd hscTnT measurement. Additionally, a stress-induced fSENC-image is acquired (1-minute hyperventilation, followed by a single breath-hold). This breathing manoeuvre leads to an increase in oxygenation through vasodilation, therefore identifying ischemic areas. The fSENC analysis is later compared to the patient's final diagnosis and therapy.

Results

So far 50 patients have been analysed by fSENC in this observational study (26 female, aged 57±18). fSENC correctly identified 7 patients suffering from NSTEMI or significant CAD and their affected coronary arteries. 42 other patients were safely ruled-out by fSENC which was consistent with the serial hscTnT results. In 11 patients fSENC was able to detect generalized impaired myocardial deformation, implying an underlying cardiac disease (hypertrophic cardiomyopathy, myocarditis). fSENC currently exhibits a sensitivity of 100% and specificity of 97,7% for correct rule-in/-out of an ischemic cause.

Conclusions

At this stage fSENC allows correct identification of patients suffering from myocardial infarction and their affected coronary arteries. Additionally, fSENC can safely rule-out patients with chest pain but no underlying ischemic cause. This novel technique is a rapid additional diagnostic tool which assesses myocardial function non-invasively without radiation exposure.
P2719The impact of “diseased only coronary artery” invasive diagnostics strategy on contrast and radiation dose in patients with coronary artery disease following coronary computed tomography angiography
Authors: Debski M A , Kruk M , Bujak S , Dzielinska Z , Demkow M , Kepka C
Published: October 2019

Background

Coronary computed tomography angiography (CTA) has high diagnostic accuracy in ruling out significant stenosis of coronary arteries in patients with intermediate probability of coronary artery disease. Based on CTA result, some patients are scheduled for invasive coronary angiography (ICA). As no specyfic guidelines exist for such situations, during ICA contrast media is routinely injected into both coronary arteries, irrespectively of CTA result. Conceivably, patients scheduled for ICA with one vessel disease may benefit from invasive interrogation limited to the diseased vessel only, presumably resulting in less contrast, lower radiation dose and less complications related to catheterization.

Purpose

The aim of this study was to analyse the potential trade-off between the benefits and costs of a “diseased-vessel-only” (>50% DS in CTA) invasive diagnostic approach in patients undergoing ICA following coronary CTA, as compared to the traditional “total ICA” (including both arteries regardless of CTA result) approach. The potential benefits were defined as contrast and radiation doses reduction during ICA and the costs were defined as missing significant coronary stenosis.

Methods

In 85 patients who underwent CTA and subsequently ICA we precisely measured contrast volume and radiation dose used to visualise each vessel during ICA. Then we proposed excluding a vessel (either left or right coronary artery) without >50% diameter stenosis in CTA from ICA, and studied how it would affect ICA contrast and radiation values. DS in CTA and ICA were assessed quantitatively.

Results

CTA sensitivity, specificity, positive predictive value and negative predictive value in diagnosing >50%DS as assessed by ICA were 95.2%, 96.2%, 91.6% and 97.9%, respectively. Applying <50% DS in CTA as a threshold not to visualise the artery during ICA would reduce contrast volume by 47% (27ml, Fig. 1) and radiation dose by 51% (3.14mSv, Fig.2, both p<0.0001). No significant (>50%DS in ICA) stenosis would be missed by CTA.

Figures 1 and 2

Conclusion

These real-world data support the concept that vessels with <50%DS in CTA do not need to be visualised during ICA. Such approach would result in significant reduction in contrast media volume and patient's exposure to radiation during ICA, without underdiagnosing any of the patients.
P2725Transthyretin cardiac amyloidosis in heart failure with preserved ejection fraction: Imaging by Tc-99m bone scan
Authors: Fukuzawa S , Okino S , Ishiwaki H , Iwata Y , Uchiyama T , Kuroiwa N , Oka M , Furihata S , Shibayama N , Inagaki M
Published: October 2019

Background

Heart failure with preserved ejection fraction (HFpEF) is a heterogeneous clinical syndrome with multiple underlying causes. Transthyretin amyloidosis (ATTR) is an underdiagnosed cause of HFpEF. Extraosseous uptake, in particular, myocardial uptake, was observed in a number of ATTR patients examined with the bone scan tracers.

Objectives

We sought to determine the prevalence of ATTR as detected by the bone scan among the patients admitted due to HFpEF.

Methods

We screened all consecutive patients ≥60 years old admitted due to HFpEF (left ventricular ejection fraction ≥50%). All eligible patients were offered an echocardiogram and a bone scan (a 99mTc-DPD/MDP/HMDP scintigraphy). Echocardiographic and clinical variables were gathered in all the subjects. The intensity of the myocardial uptake was graded according to a visual scale ranging from 0 to 3 points, in which the absence of uptake was assigned a score of 0 points; uptake less than that of bone (referred to as the adjacent rib), 1 point; uptake similar to that of bone, 2 points; and uptake greater than that of bone, 3 points. The distribution of the uptake in myocardium was defined as focal uptake, diffuse uptake, uptake in a ventricular wall segment, diffuse ventricular uptake, or diffuse biventricular uptake.

Results

The study included 62 HFpEF patients (52% women, 73±9 years). The bone scintigraphic analysis revealed relatively intense myocardial uptake in 7 of 62 patients (11.2%). 7 patients had intense Tc-99m uptake (score of 2–3) in the cardiac region, showing deposition in both right and left ventricles in every case. Patients with amyloid deposition were older (78±6 vs. 70±12 years, p<0.05), had a lower systolic blood pressure (118±23 vs. 148±28 mmHg, p<0.05), and left ventricular ejection fraction (52±11 vs. 58±6%, p<0.05). Both groups had at least moderate left ventricular hypertrophy and abnormal global longitudinal strain with no significant difference between groups. In 6 all the cases, the final diagnosis of amyloidosis was based on the results of abdominal fat aspiration biopsy.

Conclusion

ATTR is an underdiagnosed disease that accounts for a significant number (11.2%) of HFpEF cases. These findings create an opportunity for further investigation in the targeted therapy of patients with HFpEF.
P2730Pericardial and pleural effusion in patients with cardiac amyloidosis
Authors: Binder C B , Duca F D , Aschauer S A , Rettl R R , Camuz Ligios L C , Dusik F D , Capelle C C , Agis H A , Hengstenberg C H , Bonderman D B
Published: October 2019

Background

Pericardial and pleural effusion are common findings in patients with cardiac amyloidosis (CA). While this might be suggestive of a sign of right heart failure, it is not known, whether effusions correlate with right ventricular (RV) function in patients with CA. Furthermore, data on the prognostic significance of pleural and pericardial effusion in CA is scarce.

Methods

Patients with cardiac transthyretin (ATTR) and light chain (AL) amyloidosis were included in a clinical registry at our dedicated CA outpatient clinic. CA was diagnosed according to current guidelines. All patients underwent a comprehensive transthoracic echocardiography (TTE) exam at the time of study inclusion. The TTE protocol included standard and advanced parameters describing left ventricular and RV function, including speckle-tracking imaging to assess global longitudinal left ventricular and RV free wall (RV-FW) strain. The presence of pericardial and pleural effusion was determined in every patient and was verified by cardiac magnetic resonance imaging when present. The size of pericardial effusion was measured at the point of its maximum extension. The clinical endpoint was defined as all-cause death.

Results

Between March 2012 and February 2019, 177 patients were included in our CA registry, however, TTE image quality was only sufficient for analysis in 143 patients. Of these, 83 patients (59.4%) were diagnosed with ATTR and 60 patients (42.0%) with AL. In total, 23 patients (16.1%) presented with isolated pericardial effusion and 36 (25.2%) with isolated pleural effusion. In 17 patients (11.9%) both pericardial and pleural effusion were found and in 66 patients (46.2%) no effusion was present at baseline. Overall, there was no significant difference in the type of effusion between patients with AL and ATTR. In general, pericardial effusions were small (median diameter 7.1 mm (IQR 5.2–9.7) and none were hemodynamically compromising. Interestingly, the presence of pleural effusion correlated well with poor RV function, measured by RV-FW strain (p=0.034). However, no such correlation could be found for pericardial effusion and RV-FW strain (p=0.319).

Kaplan Meier analysis showed that patients presenting with pleural effusion had a worse prognosis compared to patients with pericardial effusion alone or no effusion at baseline (p=0.001, Figure 1).

Figure 1

Conclusion

More than 50% of patients with CA presented with pleural and/or pericardial effusions. While pleural effusion was clearly associated with poor RV function, we were not able to detect this association with pericardial effusion. In addition, patients with pleural effusions had an exceptionally poor prognosis compared to patients with pericardial effusions or no effusion at baseline.
P2743Right ventricular size in repaired tetralogy of Fallot: correlations between transthoracic echocardiography and cardiovascular magnetic resonance
Authors: Bredy C , Simard F , Marcotte F , Dore A , Mondesert B , Ibrahim R , Asgar A , Chaix M A , Khairy P , Mongeon F P
Published: October 2019

Introduction

Right ventricular (RV) size informs about prognosis and need for pulmonary valve replacement in patients with repaired tetralogy of Fallot (rTOF). Cardiac magnetic resonance (CMR) is considered the reference standard for measurement of RV volumes. Despite known limitations for RV evaluation, 2D transthoracic echocardiography (TTE) remains the primary and most available imaging modality in the rTOF population.

Purpose

To determine which TTE RV size parameters best correlate with CMR-derived indexed RV end-diastolic (RVEDVi) and end-systolic (RVESVi) volumes in the rTOF population. We sought to determine the best TTE measurement thresholds to predict normal RV volume (RVEDVi ≤110 mL/m2) and significant RV dilatation by CMR (RVEDVi ≥150ml/m2).

Method

We retrospectively enrolled all rTOF patients followed at a single-center between 2010 and 2018 who had both TTE and CMR exams performed within a 12-month interval. All TTE exams were reviewed by an observer measuring RV areas, RV inlet and RV outlet at end-diastole and end-systole. Analyses of CMR studies were performed by 3 observers who measured RV area, RV inlet, RV outlet and RV volumes at end-diastole and end-systole. Correlations between TTE and CMR parameters were performed using Pearson correlation coefficients. Using the TTE RV parameters with the strongest correlation with CMR, we subsequently determined thresholds to predict a CMR RVEDVi ≤110ml/m2 and ≥150ml/m2 using ROC analysis.

Results

We enrolled 130 patients (59 women [45%], mean age 43±12.8 years). Median age at TOF repair was 4 [3–6] years; 18 patients (14%) had subsequent pulmonary valve replacement. Median interval between TTE and CMR exams was 114 [59–239] days. There were significant correlations between all TTE parameters and CMR RVEDVi. TTE indexed RV end-diastolic area (RVEDAi) most strongly correlated with CMR RVEDVi (r=0.73, p<0.0001). All TTE RV parameters significantly correlated with CMR RVESVi but indexed RV end-systolic area had the strongest correlation (r=0.77, p<0.0001). ROC analysis performed to predict RVEDVi of ≤110ml/m2 and ≥150ml/m2 using TTE RVEDAi revealed areas under the curve of 0.86±0.04 and 0.90±0.03, respectively. A TTE RVEDAi ≤17cm2/m2 predicted a normal CMR RV volume (≤110ml/m2) with a sensitivity of 90% and a specificity of 74%. A TTE RVEDAi ≥19cm2/m2 predicted a CMR RVEDVi ≥150 mL/m2 with a sensitivity of 93% and a specificity of 76%.

Conclusion

In rTOF patients, both diastolic and systolic TTE RV area best correlate with CMR-derived RV end-diastolic and end-systolic volumes. A cut-off value of TTE RVEDAi of 19cm2/m2 is 93% sensitive and 76% specific to predict a CMR RVEDVi ≥150ml/m2. Simple RV size measurement using TTE may help inform the need and frequency of CMR evaluations in rTOF patients.
P2751Case-controlled study of predictors of waitlist, operative and late mortality for patients undergoing aortic stenosis interventions
Authors: Wang T K M , Dimalapang E , Stewart R
Published: October 2019

Background

Surgical or transcatheter aortic valve interventions are both effective treatments for severe aortic stenosis. Although risk factors of procedural-related mortality are well established, there is paucity of literature for predictors of death whilst awaiting these procedures. We assessed the predictors of waitlist, operative and long term mortality for aortic stenosis interventions at our centre.

Methods

2966 patients were referred for aortic stenosis interventions during 2005- 2018, and excluding 412 who didn't have a procedure and was off the waitlist for another reason, 26 patients (1%) died whilst still on the waitlist. Controls (n=267) were randomly selected. Clinical characteristics and outcomes were obtained for comparative and multivariable analysis.

Results

The mean time of referral for intervention to death on waitlist and intervention were 69 and 104 days respectively (P=0.14). Independent predictors of death on waitlist include outpatient surgery, peripheral vascular disease, lower haemoglobin and impaired right ventricular function. Operative and late mortality occurred in 15 (5.6%) and 72 (29%), with 1, 5 and 10 year survival of 93%, 82% and 63%. Poor mobility independently predicted operative mortality, while inpatient surgery and poor mobility predicted late mortality. EuroSCORE II discriminated waitlist, operative and late mortality with c-statistics 0.70, 0.64 and 0.67 respectively (P<0.05 for both).

Conclusions

Key and differing predictors of mortality were identified before and after aortic stenosis procedures. Earlier surgery should be considered for those with predictors of death on waitlist, and cautious approach mandated for selecting aortic valve surgery in frail patients with poor mobility.
P2752Impact of different antithrombotic regimens on the outcomes of bioprosthetic valve replacement in elderly asian population
Authors: Lu Y , Chou R , Tsai Y , Huang P
Published: October 2019

Background

Lifelong antithrombotic therapy is necessary for patients undergoing mechanical valve replacement. However, the optimal regimen and duration of antithrombotic agents are still controversial for patients underwent bioprosthetic valve replacement.

Purpose

We investigated the effect of different antithrombotic strategies on the prognosis of patients underwent bioprosthetic valve replacement in the elder Asian population.

Methods

Based on the National Health Insurance Database in Taiwan, 1227 patients elderly than 50 years-old and underwent bioprosthetic valve replacement between 2003 to 2010 were enrolled for analysis. Patients were classified according to their antithrombotic therapies within 3 months after bioprosthetic valve replacements.

Results

The 1227 patients were stratified to three groups, including aspirin alone (19.6%), warfarin alone (60.6%), and the combined use of aspirin and warfarin (19.9%) within 3 months after surgery. After adjusting propensity scores, the warfarin group (relative risk: 0.69, 95% CI: 0.54–0.88) and the combination group (relative risk: 0.57, 95% CI: 0.42–0.79) both had lower mortality rate compared to the aspirin alone group. Neither increasing major bleeding risk (adjusted relative risk: 0.62, 95% CI: 0.15–2.68) nor decreasing ischemic stroke risk (adjusted relative risk: 0.64, 95% CI: 0.36–1.14) was noticed in the combination group.

Incidence and risk of antithrombotics Crude Model 1 Model 2 Hazard Ratio (95% CI) p-value Hazard Ratio (95% CI) p-value Hazard Ratio (95% CI) p-value All cause mortality   Antiplatelet user Reference Reference Reference   Warfarin user 0.65 (0.52–0.81) <0.001 0.71 (0.56–0.91) 0.006 0.69 (0.54–0.88) 0.002   Antiplatelet + warfarin user 0.59 (0.44–0.81) 0.001 0.63 (0.46–0.85) 0.003 0.57 (0.42–0.79) 0.001   Ischemic stroke antiplatelet user as reference   Warfarin user 0.77 (0.51–1.17) 0.224 0.85 (0.55–1.33) 0.485 0.82 (0.52–1.27) 0.369   Antiplatelet + warfarin user 0.63 (0.36–1.10) 0.102 0.67 (0.38–1.21) 0.185 0.64 (0.36–1.14) 0.130   Major bleeding antiplatelet user as reference   Warfarin user 0.32 (0.10–1.05) 0.061 0.71 (0.14–3.60) 0.674 0.40 (0.11–1.40) 0.150   Antiplatelet + warfarin user 0.57 (0.14–2.39) 0.444 1.56 (0.26–9.46) 0.627 0.62 (0.15–2.68) 0.526 Model 1: Adjusted for all covariates; Model 2: Adjusted for propensity score of using warfarin.

Conclusion

Comparing with aspirin alone, warfarin only or combined warfarin with aspirin therapy have a lowering one-year all-cause mortality rate without increasing the occurrence of bleeding events.
P2754Streptococcal infective endocarditis: distribution of species and their prognosis
Authors: Chamat S , Dahl A , Hassager C , Arpi M , Oestergaard L , Bundgaard H , Lauridsen T K , Oestergaard L B , Gislason G H , Fosboel E L , Voldstedlund M , Bruun N E
Published: October 2019

Background

Infective endocarditis (IE) is frequently caused by streptococcal species. However, there is limited knowledge about the relationship between different streptococcal species and IE, and their associated outcomes.

Purpose

To examine the prevalence of streptococci at species level in IE, and to relate these different species to outcomes.

Methods

From 2002–2012 we prospectively collected consecutive patients with IE admitted to two tertiary heart centres covering a catchment area of 2.4 million people. The registry comprises 915 IE patients, 366 (40%) with streptococcal IE. Based on phylogenetic relationship, streptococcal species were classified into seven main groups: Mitis, Bovis, Mutans, Anginosus, Salivarius, Pyogenic and Nutritionally Variant Streptococcus (NVS). Classification at species level was not possible in 51 patients, who were excluded. Complications and prognosis of streptococcal IE were compared between the subgroups, and at species level.

Results

We included 315 patients with streptococcal IE. Mean age was 63 (IQR 52–76) years, and most were men (67%). A total of 115 patients (37%) had a previous heart valve disease, 58 (18%) had a prosthetic valve, 22 (7%) had previously had IE and 29 (9%) had a cardiac electronic device. With 148 episodes (47%) the Mitis group was the most common cause of IE. Other frequent groups were the Pyogenic group and the Bovis group, accounting for 66 (21%) and 51 (16%) of the cases, respectively. Surgery was carried out in 55% (n=173) of all cases. Patients infected with S. pneumoniae or S. agalactiae had a significantly higher rate of surgery, 72.2% (n=13) and 71.9% (n=23) respectively, whereas the Bovis group had a significantly lower rate, 35.5% (n=18) (p=0.048). The aortic valve was infected in 137 patients (43.5%), mitral valve in 105 patients (33.3%) and both valves were infected in 53 patients (16.8%). Twenty patients (6.3%) had right-sided IE, including pacemaker lead IE. There was no significant difference between the species subgroups regarding type of infected valve. Embolization and osteitis were observed in 76 (24.1%) and 30 (9.5%) patients, respectively. There was no significant difference between the species groups, as was the case with mortality: 23 patients (7.3%) died in-hospital and the one-year mortality was 16% (n=50).

Distribution of streptococcal IE

Conclusion

Species of the Mitis group were the most frequent Streptococci causing IE. Patients infected with S. pneumonia or S. agalactiae had significantly higher rate of surgery, and patients infected with S. bovis group had lower rate of surgery. There was no significant difference in rate of complications such as abscesses, embolization, osteitis or mortality between the streptococcal species.

Acknowledgement/Funding

Supported by grants from Herlev-Gentofte University Hospital Research Foundation
P2757Embolic risk stratification and prognostic impact of early surgery in left-sided infective endocarditis
Authors: Scheggi V , Ceschia N , Andrei V , Stefano P L
Published: October 2019

Background

Surgery is performed in 50% to 60% of infective endocarditis. In patients with definite surgical indication for hearth failure and with large vegetation, early surgery prevents embolic events. The optimal timing of surgery for other indications is still debated. Moreover, patients with large vegetation as unique indication to surgery, have a weak class of recommendation to it. Accurate risk stratification for embolic events is desirable to optimize selection of surgical candidates.

Materials and methods

We retrospectively analyzed 195 consecutive patients (72 women and 123 men) admitted to our department between 2013 and 2017 with definite IE according to modified Duke University criteria. Transesophageal echocardiography and blood cultures were performed in all patients for confirmation of diagnosis. Systemic embolism was soughton admission clinically and with imaging techniques (Brain and chest CT plus abdominal CT or US scan). Seventy-seven percent of patients underwent surgery (valve repair or replacement). Outcome following discharge was systematically assessed by structured telephone interviews.

Results

Of the 195 patients with left sided IE, 151 underwent surgery, 29 were low risk and treated medically, 5 refused surgery and 10 were not operated due to high surgical risk. Overall survival was 78% at 4 years. Patients excluded from surgery had the worst prognosis, while operated patients with high-risk IE showed comparable survival to non-complicated infections treated medically. Early surgery (<2 weeks from diagnosis) was associated with similar survival compared to later intervention. Euroscore II was the main predictor of mortality when above a threshold of 7 before 2015 and 16 after 2015, reflecting surgical management of higher risk patients over time.In left sided IE, mean vegetation length was 11.1 mm; embolic events before diagnosis occurred in 35% of cases and Staphylococcus aureus etiologywas the main risk factor associated with embolism (OR 4, p<0.05). Vegetation size >10 mm was also independently associated with embolic risk (p=0.033) whereas renal failure, age, sex, endocarditis location (mitral or aortic), type of valve (native or prosthetic), perivalvular extension and degree of valveregurgitation were not.

Conclusions

Compared to low-risk IE patients treated medically, those at high-risk showed comparable survival when managed surgically, whereas a conservative approach was associated with adverse prognosis. In patients with left sided IE and intermediate vegetation length, S. aureus infection was the best independent predictor of systemic embolic events. Our data support extensive surgical referral in high risk IE and suggest that its etiology represents an important factor in decision-making.
P2758Role of echocardiographic findings and blood culture in embolic complications in patients with infective endocarditis
Authors: Gavrilovic N , Petrovic O , Boricic-Kostic M , Tomic-Dragovic M , Jovanovic I , Draganic G , Matic S , Petrovic J , Paunovic I , Tutus V , Putnik S , Obrenovic-Kircanski B , Ivanovic B , Trifunovic D
Published: October 2019

Echocardiography is essential for the diagnosis of infective endocarditis (IE), treatment choice and follow-up. Prognosis in IE is multifactorial and includes both structural changes of the heart induced by IE and extra-cardiac IE complications.

Aims

Aims of the study were to analyse: 1) relation between embolic complications of IE and structural changes of the heart detected by echocardiography in IE patients; 2) association between embolic complications of IE and IE causative microorganism.

Methods

335 patients with definitive IE from the single tertiary center were enrolled in the study between 2009–2018. Echocardiographic changes are defined in accordance with 2015 ESC guideline. Associations between embolic complication and structural heart changes, as well as between

IE causative microorganism and embolic complications were tested by Chi square test.

Results

Observed embolic complication were: ischemic stroke (in 12.5% of patients), haemorrhagic stroke (2.1%), neuroinfection (9.6%), brain abscess (1.8%), discitis (3%), pulmonary embolism (1.5%), spleen abscess (7.8%) and peripheral arterial embolization (1.5%). There were several significance associations: vegetations larger than 15 mm were associated with ischemic stroke (p=0.041) and peripheral arterial embolization (p=0.05); perivalvular abscess was associated with brain abscess (p=0.037) and peripheral arterial embolization (p=0.019). Staphylococcus aureus isolated from blood cultures was associated with discitis (p<0.001), brain abscess (p<0.001) and neuroinfection (p<0.001). Bacterias from HACEK group were associated with peripheral arterial embolisation (p<0.001) and non-HACEK bacterias were associated with ichemic stroke (p=0.016). Patients with more than one isolated bacteria from blood culture had more often spleen abscess (p=0.003) and ichemic stroke (p=0.049).

Conclusion

Results point that large vegetations, but also perivalvular abscesses are coupled with higher rate of embolic complications in patients with IE. Staphylococcus aureus, HACEK group and non-HACEK bacteria are, more than other causative IE microorganisms, associated with embolism. These results might be clinically important for treatment chose and prognosis of the patients with IE.
P2767Outcomes and incremental prognostic value of renal function impairment after acute pulmonary embolism
Authors: Chopard R , Serzian G , Humbert S , Falvo N , Morel-Aleton M , Bonnet B , Kalbacher E , Obert L , Capellier G , Cottin Y , Schiele F , Meneveau N
Published: October 2019

Background

We explored the relation between adverse outcomes after acute pulmonary embolism (PE)and renal dysfunction classified by estimated glomerular filtration rate (eGFR) using the CKD-EPI equation. We assessed the incremental value of adding eGFR CKD-EPI to the ESC score for predicting 30d mortality.

Methods

Prospective, multicenter study of 1664 acute PE admitted from 01/2011 to 12/2017. Pts were categorized in 4 eGFR groups: Group 1 (eGFR ≥60 ml/min/1.73m2, n=1178), group 2 (45–59; n=257); group 3 (30–44; n=150), group 4 (≤29; n=79).

Results

All-cause and CV death at 30 days and 6 months were higher in group 3 (p=0.005 and p=0.03) and group 4 (p<0.001 and p<0.001 respectively) vs group 1. Major bleeding at 30d and 6m was higher in group 2 vs group 1 (p=0.003 for both). Renal dysfunction combined with the ESC prognostic algorithm for prediction of 30d death improved discriminatory capacity of the model and enabled reclassification in different risk categories in 27% of pts (Table).

Without eGFR CKD-EPI OR (95% CI) With eGFR CKD-EPI OR (95% CI) ESC algorithm 2.59 (1.95–3.43) 2.30 (1.72–3.07) eGFR CKD-EPI – 2.60 (1.62–4.7) Measures of fit   Bayes information criterion 607.30 599.32   Akaike information criterion 596.47 583.06   C-statistic 0.71* 0.77*   P (Hosmer-Lemeshow) 0.057 0.43   Integrated discrimination improvement – 0.054 (0.052–0.056)   Net reclassification improvement – 0.93 (0.90–0.95) Prognostic performance   Sensitivity 62.5 (51.2–72.3) 76.2 (61.5–90.2)   Specificity 64.2 (49.1–74.4) 69.9 (47.6–83.5)   Positive predictive value 10.1 (8.2–11.3) 16.2 (14.2–18.2)   Negative predictive value 0.97 (0.96–0.98) 98.1 (97.2–99.2)   Positive likelihood ratio 1.96 (1.12–3.41) 2.12 (1.54–3.12)   Negative likelihood ratio 0.50 (0.25–1.81) 0.54 (0.20–1.56)   Youden index 0.31 (0.28–0.34) 0.39 (0.36–0.41) Difference in C-statistic: *p=0.04.

Conclusion

Renal function impairment increases the rate of adverse events after acute PE. Combined with the ESC early mortality risk score, eGFR improves risk classification.