bluuebunny/crossref_metadata_2025 huggingface dataset:
P4598Clinical implications and predictors of coronary perforations during chronic total occlusion percutaneous coronary interventions: insights from the multicenterLatin America CTO LATAM registry
Authors: Harada Ribeiro M , Belli K C , Piccaro P , Padilla L T , Silva A C B , Santiago R , De Paula J E T , Ribeiro E E , Franken M , Quadros A S , Campos C M
Published: October 2019

Background

Chronic total occlusions are still considered one of the most challenging procedures in the field of interventional cardiology and the most feared complication are the perforations. In past studies and series from Asia, Europe and United States the rate of perforations in percutaneous coronary interventions are described as 0.2% whereas this rate increases to 3% when recanalization of a chronic total occlusion is attempted.

Purpose

Our study sought to identify the frequency, predictors and clinical implications of coronary perforations in chronic total occlusion percutaneous interventions in a contemporary registry with data from Latin America.

Methods

We reported the data of a prospective multi center Latin American registry from January to December 2018 in 1066 patients who underwent chronic total occlusion percutaneous interventions in 30 centers in the following countries: Brazil, Argentina, Puerto Rico, Chile, Colombia, Ecuador and Mexico. Coronary perforation was defined as evidence of extravasation dye or blood from the coronary artery during or following the procedure. A stepwise logistic regression was performed to investigate the independent predictors of coronary perforations.

Results

The mean age was 64.2±10.7 years, 79.8% were male, 35.3% diabetics and 6.7% had heart failure. The most commonly involved CTO vessel was right coronary artery (41.4%), the mean J-CTO score was 2.0±1.3 and the mean CL score was 2.7±1.6. The overall procedural success rate was 81.9%. Coronary perforation occurred in 3.3% of cases: type 1 in 1.8%, Type 2 in 0.9% and Type 3 in 0.6%. In comparison with patients without coronary perforation was observed, those with such complication required more often blood transfusion (8.6% vs. 0.7%; p<0.001), experienced more cardiac tamponade (13.4% vs. 0.4%; p<0.001), but not all-cause in-hospital mortality (0 vs. 1.0%; p=1.0; respectively). At multivariate analysis, the independent predictor of coronary perforation was an activated clotting time (ACT) during PCI >470 seconds (OR 6.5; 95% CI 2.4 - 17.3; p<0.001), baseline heart failure (OR 4.2; 95% CI 1.2 - 14.6) and J-CTO score ≥2 (OR7.5; 95% CI 1.0–59.1).

Conclusions

Coronary perforation during percutaneous interventions in Latin America occurred in 3.3% of patients, being related with adverse events but not in-hospital all-cause mortality. Pharmacological management, high anatomical complexity and heart failure were identified as independent predictors of this still and so feared complication.

Acknowledgement/Funding

None
P4621Incidence, management, and in-hospital mortality of cardiogenic shock complicating ST-elevated myocardial infarction in China: insights from the China Acute Myocardial Infarction Registry
Authors: Ning Y , Chen G H , Yang J G , Yang Y J , Tian C Y , Wang Y , Xu H Y
Published: October 2019

Background and purpose

Limited data is available on the situation of cardiogenic shock (CS) complicating ST-elevated myocardial infarction (STEMI) in China. This study aims to disclose the incidence, management and in-hospital mortality (IHM) of patients with STEMI complicated by CS (STEMICS) in China and at different levels of hospitals.

Methods

We queried the 2013–2016 China Acute Myocardial Infarction (CAMI) registry databases to identify patients with STEMI and/or CS (developing before or during hospitalization). The overall and different hospital-level incidence of STEMICS and IHM were analyzed.

Results

Of 28230 STEMI patients, 2273 patients (8.05%) had CS. The incidence of STEMICS in provincial, prefectural and county-level hospitals were 5.23%, 8.46% and 13.76% (p<0.001), respectively. Primary PCI (PPCI) was performed on 675 patients (29.7%) with STEMICS. The proportion of STEMICS patients undertaking PPCI in provincial, prefectural and county-level hospitals were 46.53%, 31.48% and 8.00% (p<0.001). The overall IHM rate of patients with STEMICS was 49.8% with no difference among the different hospital levels. However, the IHM rate of prehospital STEMICS in county-level hospitals were significantly higher than that in prefectural and provincial hospitals (42.3% versus 33.3% and 28.3%, respectively; p<0.01), while that of in-hospital STEMICS were similar among the different hospital levels (66.5%, 66.9% and 62.2%; provincial, prefectural and county-level hospitals, respectively). After adjustment, the difference of IHM in prehospital STEMICS between county-level hospitals and the other two levels no longer existed. However, once PPCI was excluded from the multivariable adjustment model, the IHM of prehospital STEMICS remained higher in county-level hospitals.

Table 1. Differences in IHM of prehospital STEMICS between county-level hospitals and other two levels of hospitals before or after adjustment Provincial hospitals/ County-level hospitals Prefectural hospitals/ County-level hospitals Unadjusted OR (95% CI) 0.54 (0.36, 0.80); P=0.0019 0.68 (0.49, 0.94); P=0.0193 Adjusted OR* (95% CI) 0.63 (0.34, 1.17); P=0.1455 0.64 (0.38, 1.08); P=0.0962 Adjusted OR† (95% CI) 0.49 (0.27, 0.90); P=0.0214 0.54 (0.32, 0.91); P=0.0198 IHM: in-hospital mortality; OR: odd ratio; CI: confidence interval. *Adjusted for baseline characteristics, in-hospital medications and primary PCI; †adjusted for baseline characteristics and in-hospital medications.

Figure 1. Flowchart

Conclusion

The overall incidence and IHM rate of STEMICS in China are still high. Especially, higher IHM rate of prehospital STEMICS is observed in county-level hospitals, which may be attributed to the lower implementation rate of PPCI.

Acknowledgement/Funding

CAMS Innovation Fund for Medical Sciences (CIFMS) (2016-I2M-1-009)
P4639Plasma tissue factor coagulation activity in post-acute myocardial infarction patients
Authors: Lim X C , Yatim S M J M , Chong S Y , Wang X , Tan S H , Yang X , Chan S P , Richards A M , Charles C J , Chan M , Wang J W
Published: October 2019

Background

Coagulation is involved in fibroproliferative responses following acute myocardial infarction (AMI). Left ventricular (LV) remodeling following AMI is closely associated with progression to heart failure.

Purpose

We aimed to evaluate the association of plasma tissue factor (TF) coagulation activity with LV remodeling prior to heart failure in post-AMI patients.

Methods

This study was conducted in 228 subjects from the Post-AMI Left Ventricular Remodeling Biomarker Analysis (PAMILA) study and 57 healthy subjects. The post-AMI patients were divided into two age- and sex-matched groups: patients with adverse LV remodeling defined as an increase in LV end systolic volume by ≥15% over 6 months and patients with reverse LV remodeling defined as an decrease in LV end systolic volume by ≥15% over 6 months. TF coagulation activity was determined using human coagulation factor Xa generation based TF chromogenic activity assay and converted into concentrations of active TF (pM). Sodium-citrate anticoagulated plasma was collected at baseline (within 3 days after revascularization), 30 days and 6 months post-AMI. Results are presented as mean±S.E.M. One-way or two-way repeated measures ANOVA or a multiple multi-level longitudinal data analysis with structural equation model was used to assess differences in coagulation activity. P<0.05 was considered statistically significant.

Results

Plasma from healthy subjects and post-AMI patients at baseline had similar concentrations of active TF (TFa): 29.0±1.4 versus 29.1±0.7 pM. Patients treated with warfarin (15 out of 228 patients) showed lower plasma levels of TFa (mean difference −15.2 pM, [95% CI: −18.7, −11.7], p<0.001). Compared to baseline, plasma levels of TFa in the patients was significantly lower at 30 days post-AMI (mean difference −6.9 pM, [95% CI: −4.8, −8.9], p<0.001) and 6 months post-AMI (mean difference −2.8 pM, [95% CI: −0.8, −4.8], p=0.003). Intriguingly, plasma levels of TFa tended to recover from 30 days to 6 months post-AMI (mean difference 4.1 pM, [95% CI: 2.8, 5.4], p<0.001) toward the baseline level and the level in healthy subjects. Similar trends of temporal changes of plasma TFa levels were observed in patients with adverse LV remodeling and those with reverse LV remodeling although TFa levels were slightly higher in patients with reverse LV remodeling (F(2,448)=3.112, p=0.045 for interaction). After adjusting for age, gender, ethnicity, medications, lipid profile and risk factors, the temporal changes of plasma TFa levels in patients remain significant, however, the difference between patients with adverse versus reverse LV remodeling was not significant.

Conclusion

Plasma TF coagulation activity decreased post-AMI but did not differ in patients with adverse versus reverse LV remodeling.

Acknowledgement/Funding

National University Health System Singapore (NUHS O-CRG 2016 Oct-23) to JW Wang
P4649Whole exome sequencing and whole genome sequencing improves genetic diagnosis of fetals with heterotaxy syndrome revealed by prenatal ultrasound
Authors: Yi T , Sun H , Fu Y , Wang J , He Y
Published: October 2019

Background

Heterotaxy (Htx) syndrome is an congenital disorders resulting from incorrectly establishment of left-right patterning during embryogenesis. Over 96% of patients with Htx exhibit some form of congenital heart disease (CHD),and has relatively poor survival. Multiple lines of evidence support genetic contributions to the etiology of Htx. As a specific genetic etiology is currently identifiable in only a minority of patients, there remains enormous potential for novel gene and pathway discovery.

Purpose

The aim of this study was to investigate the diagnostic yield of whole-exome sequencing (WES) and whole-genome sequencing (WGS) in fetuses with the pathogenesis of Htx, to explore candidate genes for Htx and to expand the clinical phenotype of known genetic conditions.

Method

WES and WGS were performed on specimens from 46 fetuses diagnosed with Htx and their parents. The single-nucleotide variants (SNVs) and copy-number variants (CNVs) were filtered and annotated by standard analysis process. All reported variants were classified according to he American College of Medical Genetics and Genomics guidelines.

Results

In the 46 fetuses, the detection rates of pathogenic and likely pathogenic variations were21.7% (10/46) and 10.9% (5/46) respectively. Ten pathogenic variations were identified on genes of CCDC114, DNAH11, ARMC4, STRA6, PQBP1 (hemizygote), HYDIN, RAI1 (Alagille Syndrome), ZFMP2 and Del(22q11.2) Syndrome. Five likely pathogenic variation were on DNAAF1 (Holshner syndrome), NF1, NEXN, NOTCH3 and FOXC1. Of 30 fetuses with prenatally diagnosed right atrial isomerism (RAI), the main intracardiac anomalies were atrioventricular canal (AV canal), isomerism of right atrial appendages, pulmonary stenosis or atresia (PS & PA) and right aortic arch. In 16 fetuses diagnosed left atrial isomerism (LAI) the main intracardiac anomalies were isomerism of left atrial appendages, interrupted IVC and azygos vein continuation. Of the 10 positive cases, 8 fetus were diagnosed of RAI and 2 were diagnosed of LAI by prenatal ultrasonic examination or fetal autopsy. The detection rate was 8/30 (26.7%) for RAI and 2/16 (12.5%) for LAI.

Conclusion

This study outlines the way for a substantial improvement in the diagnostic yield of prenatal genetic disorders in Htx through WES and WGS. Our experience also expanded the knowledge of the clinical phenotype of known genetic conditions. Our results indicate that the proportion of SNV in Htx of prenatal cases was significantly higher than that in patients with other congenital heart abnormalities, and the recessive inheritance occurred in a higher proportion in Htx. Our results have important implications for clinical management and genetic counseling of Htx.

Acknowledgement/Funding

Ministry of Science and Technology of the People's Republic of China
P4650Sex differences in clinical presentation and in hospital outcomes among myocarditis and peri-myocarditis patients
Authors: Younis A , Matetzky S , Masalha E , Chernomordik F , Afel Y , Fardman A , Goitein G , Ben-Zekry S , Grupper A , Segev A , Beigel R
Published: October 2019

Background

Data are scarce regarding sex differences among patients with myocarditis and peri-myocarditis. Our aim was to define the sex differences in clinical characteristics as well as in-hospital outcomes in a cohort of consecutive patients hospitalized due to myocarditis and peri-myocarditis.

Methods and results

We analyzed data of 322 consecutive patients between January 2007 and October 2017 who were hospitalized with the diagnosis of myocarditis or peri-myocarditis at our medical center. Eighty-four percent of the patients were males. Both males as well as females had similar rates of chronic medical conditions. However, males were more likely to present with ST elevation (75% vs. 44%. P<0.001) as well as PR depression in ECG compared to women and have higher admission troponin levels (7.6±11 vs. 2.3±4, P<0.001). Women were older (45±17 vs. 36±14, P<0.001) and tended to present with a rather normal ECG. There were no differences in the incidence of in-hospital mortality or the need for escalation therapy between male and female patients. However, males were more likely to have ventricular arrhythmias (7% vs. 0%, P=0.05). no differences in long term mortality were observed among males and females.

Variable Male (N=272) Female (N=50) P-value Age 36±14 45±17 <0.001 Cardiology Department 243 (90%) 39 (78%) 0.03 Dyspnea 63 (23%) 22 (44%) 0.002 Pericardial chest pain 94 (35%) 20 (40%) 0.52 Admission SBP (mmhg) 122±16 116±16 0.02 Admission HR (b/min) 82±16 89±21 0.04 Normal ECG 37 (14%) 12 (24%) 0.06 ST elevation 204 (75%) 22 (44%) <0.001 LVEF <50% 215 (80%) 45 (90%) 0.08 LGE 176 (88%) 20 (69%) 0.009 Albumin 4±0.3 3.6±0.4 <0.001 Troponin admission 7.6±11 2.3±4 <0.001

Conclusions

Male patients, which constitute the majority of patients. Admitted with myocarditis are younger, with higher troponin levels at admission, are more likely to present with ST elevation, and have a higher rate of ventricular arrythmias when compared to women. However, there are no differences in early as well as long term mortality rates between men and women.
P4657Cardiac myxomas: are we dealing with distinct clinical entities?
Authors: Sa Mendes G , Abecasis J , Ferreira A , Ribeiras R , Reis C , Nolasco T , Gouveia R , Abecasis M , Mendes M , Ramos S , Neves J
Published: October 2019

Background

Cardiac myxomas are rare, despite being the most common primary cardiac tumours. A significant number of myxomas are discovered accidentally in asymptomatic patients (pts), as there is increased use of non-invasive cardiac imaging. Our aim was to describe the experience of a cardiac surgery centre managing cardiac myxomas during the last 28 years.

Methods

Single-center retrospective study of consecutive pts admitted with the diagnosis of a cardiac myxomas between 1990 and 2018. Registry data concerning clinical presentation, non-invasive imaging assessment and definitive histopathology were collected.

Results

From 154 pts with the diagnosis of cardiac tumours, we identified 106 (68.8%) myxomas (67% females; mean age at diagnosis 61,5±13,1 years). Myxoma diagnosis increased throughout the 3 decades (27 cases until 2000; 26 cases in the second decade; 52 cases from 2010 until present). 30% of the pts were asymptomatic at diagnosis. Obstructive symptoms (heart failure and syncope) and embolic events were the most common complaints among symptomatic pts. Transthoracic echocardiography firstly identified the tumours in 88% of the cases. Cardiac magnetic resonance and computed tomography were performed for further investigation in 7% of the cases. Presumptive pre-operative diagnosis was correct in 83.8% pts.

Surgical excision was successfully achieved in all cases. 89% of the tumours were located in the left atrium with inter-atrial septum implantation (13 in right chambers; 1 valvular tumour). There were 10 multifocal tumours.

At histopathology myxomas were grossly described as mucous jelly appearance (80%), solid (15%) and mixed type lesions (5%). Rare histologic findings were described in 30% of the cases (8 tumours with bone tissue; 1 with forming bone marrow; 4 with endocrine type glandular epithelium; 16 with lympho-plasmocytic infiltrates; 3 with high mitotic grade; 5 with concomitant thrombus).

For a median follow up of 86 [31–214] months there were 15 deaths (2 of them with tumour related deaths). There were 3 recurrences (2 with high mitotic grade histology), mostly occurring 3 years after the first intervention.

Conclusion

In this case series cardiac myxomas are the most common cardiac tumours, with a significant proportion of asymptomatic lesions. Clinical heterogeneity followed polymorphic histology, with recognized differences when compared to classical descriptions of this kind of tumour.
P4676Experience of three years of balloon pulmonary angioplasty in a single centre: safety and short term results
Authors: Gotti E , Palazzini M , Saia F , Dardi F , Rinaldi A , Zuffa E , Guarino D , De Lorenzis A , Pasca F , Rotunno M , Magnani I , Manes A , Marzocchi A , Galie' N
Published: October 2019

Background

Balloon pulmonary angioplasty (BPA) has recently been developed as an alternative and less-invasive treatment strategy for chronic thromboembolic pulmonary hypertension (CTEPH) but therapeutic efficacy and technical safety of the technique have to be established.

Purpose

To examine the effects of BPA on patients with inoperable disease or residual pulmonary hypertension (PH) after pulmonary endarterectomy (PEA).

Methods

From June 2015 to January 2019 we enrolled symptomatic (WHO-FC ≥II) inoperable CTEPH patients and patients with residual PH after PEA. At baseline and after 3 months after last BPA session all patients underwent clinical evaluation, six-minute walking distance (6MWD) and right heart catheterization. For comparisons Friedman test (with Bonferroni post-hoc pairwise analysis) was used.

Results

Forty-one patients [male 49%, median age 65 (52–75) years, 34 inoperable and 7 with residual PH after PEA] were treated for a total of 111 sessions (median number of sessions for each patient: 2); during each session we treated 2 (2.0–2.5) vessels. Results are shown in the Table. Forty patients were treated with medical therapy before BPA (16 with combination therapy). Four pulmonary artery dissection and 2 haemoptysis with clinical impairment were documented during the procedures; 27 patients had lung injury (radiographic opacity with/without hemoptysis and/or hypoxemia), none had renal dysfunction, 6 patients had access site complications. Five patients died during follow-up (none within 30 days from the procedure) because of sepsis (1), heart failure (1), cancer (1), arrhythmic storm (1) and sudden death in a patients with severe coronary atherosclerosis (1).

Table 1 Median (interquartile range) Baseline Baseline ÷ Pre-BPA Pre-BPA Pre-BPA ÷ Post-BPA Post-BPA Global (n=41) 8 (3–49) months (n=41) 10 (6–18) months (n=32) p-value WHO-FC III-IV (%) 88 N.S. 83 <0.05 42 <0.001 6MWD (m) 430 (346–560) N.S. 425 (357–500) <0.05 450 (375–605) <0.001 RAP (mmHg) 6 (5–8) N.S. 6 (5–8) N.S. 6 (4–8) 0.023 mPAP (mmHg) 46 (40–52) <0.05 43 (33–50) <0.05 36 (28–41) <0.001 CI (l/min/m2) 2.6 (2.2–3.0) N.S. 2.7 (2.2–3.0) <0.05 3.1 (2.6–3.5) 0.004 PVR (WU) 7.5 (5.6–11.5) <0.05 6.5 (4.7–10.3) <0.05 4.1 (3.3–5.9) <0.001 PA O2 Sat (%) 69 (63–71) N.S. 69 (63–72) N.S. 69 (63–73) 0.002 CI, Cardiac Index; mPAP, mean Pulmonary Arterial Pressure; PVR, Pulmonary Vascular Resistance; PA O2 Sat, Pulmonary Artery Oxygen Saturation; RAP, Right Atrial Pressure; 6MWD, 6 Minute Walking Distance; WHO-FC, World Health Organization Functional Class.

Conclusions

BPA is a safe and effective treatment able to improve symptoms and hemodynamic profile in inoperable CTEPH patients and in patients with residual PH after PEA.

Acknowledgement/Funding

None
P4678The hemodynamic improvement with balloon pulmonary angioplasty in chronic thromboembolic pulmonary hypertension depends on the lesion location
Authors: Nishihara T , Shimokawahara H , Matsubara H , Hayashi K , Tsuji M , Naito T , Shigetoshi M , Tabuchi I , Ogawa A , Munemasa M
Published: October 2019

Background

Pulmonary endarterectomy (PEA) is a treatment of choice for patients with chronic thromboembolic pulmonary hypertension (CTEPH). Patients with proximal pulmonary artery disease are considered to be good candidates for PEA because of their generally excellent outcomes. However, not all patients can be operated because of patients' advanced age, comorbidities and poor general condition. Balloon pulmonary angioplasty (BPA) has become an alternative treatment for CTEPH patients especially whose lesions locate in the distal site. The effectiveness of BPA in patients who have lesions in the proximal pulmonary arteries but cannot be a candidate for PEA remains unclear.

Purpose

The aim of this study was to investigate the outcome of BPA in CTEPH patients whose lesions appears operable but ineligible for PEA.

Methods

A total of 370 patients who underwent BPA in our institute from November 2004 to January 2018 were enrolled. All the patients were divided into operable group and inoperable group according to the difference of lesion location based on the findings of perfusion scintigraphy, computed tomography and pulmonary angiography. Hemodynamic effects of BPA in both groups were investigated. We also conducted survival analyses using the Kaplan-Meier method with the log-rank test.

Results

Among 370 patients, 90 patients deemed operable. The main reasons why not operated in the PEA operable group were patient's refusal (44%), advanced age (14%), and comorbidities (27%). There were no baseline characteristic differences between two groups except for the history of acute pulmonary embolism. Mean pulmonary artery pressure (mPAP) and pulmonary vascular resistance (PVR) equally improved after BPA in both groups (operable: 38.2±10.8 mmHg to 21.5±4.7mmHg, inoperable: 42.4±11.3 mmHg to 21.8±4.8 mmHg, p<0.001, operable: 8.0±4.2 wood unit to 3.5±1.5 wood unit, inoperable: 9.1±4.6 wood unit to 3.4±1.3 wood unit, p<0.001). Furthermore, five-year cumulative survival rates were not different between two groups (inoperable vs. operable: 93% vs. 88%, p=0.23, median follow-up period was 23.0 months (range: 5–136 months)). Meanwhile, the absolute change of mPAP and PVR in inoperable group were greater than those in operable group (inoperable: 20.7±11.2 mmHg, operable: 16.6±11.0 mmHg, p=0.010, inoperable: 5.6±4.4 wood unit, operable: 4.5±3.9 wood unit, p=0.015).

Conclusions

Although the outcome of BPA for CTEPH patients with operable lesions appears acceptable, absolute change in hemodynamics was lower than that of the patients with inoperable lesions. CTEPH with proximal lesions should be treated with PEA rather than BPA.
P4684Differential right ventricular adaptation patterns to chronic pressure overload
Authors: Garcia Lunar I , Pereda D , Ascaso M , Jorda P , Galan C , Solanes N , Santiago E , Sanchez J , Rigol M , Fuster V , Ibanez B , Garcia-Alvarez A
Published: October 2019

Background

Right ventricular (RV) dysfunction is the most important prognostic factor in chronic pulmonary hypertension (PH), but its underlying mechanisms are unknown. Clinical observation and prior experimental work suggest that RV pressure overload is not the only cause since the degree of RV adaptation varies with similar RV end-systolic pressures.

Purpose

Our aim was to characterize serial RV adaptation by cardiac magnetic resonance (CMR) in 3 different experimental large-animal models of increased afterload: a model of chronic postcapillary PH, a model of PH secondary to systemic-to-pulmonary shunt and a model of mechanical RV pressure overload (generated by pulmonary artery [PA] banding).

Methods

Four-week old piglets underwent pulmonary vein banding surgery to generate the chronic postcapillary PH model (n=20), aorto-pulmonary shunt (n=6), PA banding (n=7) or sham operation (n=7). They were followed up monthly with CMR and right heart catheterization (RHC). All procedures followed the “Principles of laboratory animal care”. Comparison of continuous variables among groups was performed with Mann-Whitney U test.

Results

Animals with either postcapillary PH or PH secondary to aorto-pulmonary shunt presented significant RV dilatation, hypertrophy and dysfunction that was maintained during follow-up (median RV end-systolic volume [RVESV]=32.6 ml/m2 for postcapillary PH and 32.6 ml/m2 for shunt vs. 16.1 ml/m2 in sham controls; median RV ejection fraction [RVEF]=61.5% for postcapillary PH and 60.5% for shunt vs. 69.6% in sham controls at the end of follow-up). Animals with PA banding also presented with significant RV dilatation and hypertrophy at the first month follow-up, but unlike all other groups, they developed reverse RV remodeling from the second month onwards and maintained normal RV volumes and RVEF values until the end of follow-up despite having severe RV hypertrophy (RV mass 22.6 g/m2 in PA banding vs. 16.1 g/m2 in controls at the 4th month follow-up; Figure).

CMR parameters (median values).

Conclusion

In PH there is a maladaptive RV hypertrophy that is not present in a model of progressive RV pressure overload without alterations of the pulmonary circulation. Increased RV pressure overload alone does not fully explain PH-associated RV dysfunction. Further research is needed to clarify the underlying mechanisms of adaptive and maladaptive hypertrophy in PH.

Acknowledgement/Funding

The CNIC is supported by the Ministerio de Ciencia, Innovaciόn y Universidades and the Pro CNIC Foundation, and is a Severo Ochoa Center of Excellence
P4686Multimodal assessment of right ventricular-arterial coupling allows better prognostication in pulmonary arterial hypertension patients
Authors: Kazimierczyk R , Malek L A , Szumowski P , Blaszczak P , Jurgilewicz D , Hladunski M , Sobkowicz B , Mysliwiec J , Grzywna R , Musial W J , Kaminski K A
Published: October 2019

Background

The concept of coupling mainly refers to the relationship between ventricular contractility and afterload. Together, strictly related parameters may provide a more accurate estimation of the RV performance status. Indexing RV function, assessed by CMR feature tracking analysis, with a pulmonary artery systolic pressure (PASP) obtained from right heart catheterization (RHC) allows estimation of ventricular-arterial coupling and could help in prognostic stratification of pulmonary arterial hypertension (PAH) patients.

Aim

To verify the prognostic value of multimodal approach to estimate RV ventricular-arterial coupling in PAH patients.

Methods

Twenty-six stable PAH patients (mean age 49.92±15.94 years) and twelve healthy subjects (control group, 44.75±13.51 years) were enrolled into the study. CMR feature tracking analysis of the RV was performed for generation of RV global longitudinal strain (RV GLS); RV ejection fraction was also obtained by CMR. Right heart catheterization was carried out only in the PAH group with a standard technique.RV- arterial coupling was evaluated by the ratio of RV GLS/PASP. Mean follow-up time of this study was 16.6±7.5 months and the clinical end-point (CEP) was defined as death or clinical deterioration.

Results

In study group, RV GLS significantly correlated with hemodynamic parameters from RHC – mean pulmonary artery pressure, mPAP (r=0.53, p=0.04) and pulmonary vascular resistance, PVR (r=0.57, p=0.002). Mean RV GLS/PASP ratio in PAH group was (−)0.24±0.15%/mmHg.

Patients who reached CEP (n=15) had a significantly higher RV GLS and RV GLS/PASP ratio (−13.3±7.9% vs −20.4±6.2%, p=0.01 and −0.15±0.09%/mmHg vs −0.36±0.19%/mmHg, p=0.005, respectively). However, ROC analysis revealed higher area under curve (AUC) of RV GLS/PASP in predicting CEP than of RV GLS alone (0.82 (95% CI 0.64–1) vs 0.77 (95% CI 0.58–0.96), p<0.0001). Interestingly, at univariate analysis only RV GLS/PASP (HR: 0.89; 95% CI: 0.79–1.08; p=0.03), together with mPAP were all significantly associated with CEP. Patients with RV GLS/PASP cut-off value (ROC analysis) higher than (−)0.29%/mmHg had worse prognosis, log-rank test, p=0.01 (Figure 1).

Figure 1

Conclusions

Combining CMR and hemodynamic measurements via catheterization offers the potential for more comprehensive assessment of pulmonary vascular load and right heart function, as required for evaluation of the hemodynamic state in patients with PAH.

Acknowledgement/Funding

This work was supported by National Center for Science in Poland [“Preludium” grant 2017/25/N/NZ5/02689 to R.K.]
P4709Subclavian CTO stenting using bilateral retrograde wrist approach
Authors: Petkoska D , Zafirovska Taleska B , Vasilev I , Antov S , Kedev S
Published: October 2019

Aims

To assess the procedural safety and results of subclavian artery stenting using bilateral retrograde radial (TRA) and/or ulnar approach (TUA).

Methods

We report 40 consecutive patients that underwent retrograde opening and stenting of the subclavian artery using wrist approach with contralateral control from the opposite TRA or TUA. Primary outcome was procedural success rate. Secondary outcomes were: presence of procedural complications, restenosis, MI, stroke or death and presence of any type of access site bleeding hemathoma. One year clinical follow up and duplex ultrasonography was done in all patients.

Results

The same technique was used in all patients: 6F guiding catheter Judkins right 4.0 was most frequently used (n=37) for coronary hydrophilic wire retrograde crossing of the occlusion and ballon predilatation. Exchange of wire was made with 0,035 guide wire. Balloon expandable stents were implanted solely through the short hydrophilic sheath, with contralateral contrast check. Contralateral injection strategy was used to confirm proper wire advancement within the lesion and optimal stent positioning. Most frequently used guide wire for CTO opening was CROSS IT 400. The average stent diameter was 7 mm (range 5.0–9.0 mm), and the average stent length was 29, 1 mm (range 15–80 mm).

38 procedures were successfully done using bilateral retrograde radial approach. Only two patients required transfer to transfemoral approach to open the subclavian chronic total occlusion. Minor access site bleeding complications were recorded in 4 patients. There were no other complications. Seven patients were discharged the same day, the others one day after admission. At follow up only one patient had symptomatic in stent restenosis and a balloon angioplasty was done inside the stent 3 years after the primary intervention, the patient was a smoker. One other patient had asymptomatic in stent restenosis documented 6 months after the intervention with duplex follow up.

Conclusions

Bilateral wrist access can be a successful and safe strategy in opening subclavian artery occlusions with a low rate of complications.
P4712Hyperbaric oxygen therapy enhanced circulating levels of endothelial progenitor cells and angiogenesis biomarkers, blood flow in ischemic area in patients with peripheral arterial occlusive disease
Authors: Li Y C , Lee F Y , Chua S , Yip H K
Published: October 2019

Background

Arterial atherosclerotic occlusive syndrome remains the leading cause of mortality and morbidity worldwide. Peripheral arterial occlusive disease (PAOD) is a manifestation of atherosclerosis in the lower extremities. In our previous preclinical study, hyperbaric oxygen (HBO) therapy improved ischemic PAOD mainly through an increase of vascular wall permeability and recruiting endothelial progenitor cells (EPCs) to enhance the angiogenesis and blood flow in the ischemic area.

Purpose

This study tested the hypothesis that hyperbaric oxygen (HBO) therapy enhanced the circulating levels of endothelial progenitor cells (EPCs), soluble angiogenesis factors and blood flow in ischemic area in patients with peripheral arterial occlusive disease (PAOD).

Methods

57 consecutive patients with PAOD undergoing the HBO therapy (3 atm for 2h/each time) were prospectively enrolled into the present study. The venous blood sampling was drawn for assessing the circulating levels of EPCs and soluble angiogenesis factors prior to and during five times of HBO therapy. Additionally, skin perfusion pressure (SPP), an indicator of blood flow at ischemic area, was measured by moorVMS-PRES.

Results

The results demonstrated that the circulating levels of EPCs (CD34+/CD133+/CD45dim, CD31+/CD133+/CD45dim, CD34+) and soluble angiogenesis factors (VEGF/SDF-1α/HGF/FGF) were significantly increased in post-HBO therapy than in pre-HBO therapy (all p<0.01). Additionally, Matrigel assay exhibited that the angiogenesis was significantly increased in post-HBO therapy than prior to the therapy (p<0.001). Furthermore, the SPP was significantly increased in ischemic area (i.e., plantar foot and mean SPP of the ischemic foot) in post-HBO therapy than in pre-HBO therapy (all p<0.01). Importantly, the HBO therapy did not show any complication and all the patients were uneventfully discharged without amputation.

Conclusions

HBO therapy augmented circulating levels of EPCs and angiogenesis factors as well as improved the blood flow in the ischemic area.

Acknowledgement/Funding

Kaohsiung Chang Gung Memorial Hospital, Taiwan Society of Stem Cell Research
P4720Mitraclip XTR device used for the treatment of functional tricuspid regurgitation provides significant reduction of annular size
Authors: Russo M , Zilbersac R , Werner P , Scherzer S , Taramasso M , Zuber M , Mascherbauer J , Andreas M
Published: October 2019

Background

Tricuspid valve regurgitation (TR) is a progressive disease strongly associated with increased cardiac and all-cause mortality. The transcatheter approach to this pathology has been recently described with promising results in the treatment of symptomatic patients despite optimal medical therapy. Development of annular dilation and leaflet tethering represent a continuous pattern in the pathophysiology of functional TR; for this reason, to reduce and stabilize the annulus is the goal of an efficacious therapy.

Purpose

In order to simplify leaflet grasping, the novel MitraClip XTRdevice has significantly longer clip arms compared to its predecessor. The increased grasping length could be able to apply a radial tension on the tricuspid annulus, reducing it in dimensions. Despite, the increased tension on the leaflets may theoretically impose a higher risk for leaflet tearing We analyzed our single-center experience in order to clarify the capability of the device in the feature of annular reshapement.

Methods

Five high-risk patients (4 females, 72 (quartiles 69–79) y.o., EuroSCORE II 10 (7.25–11.2)% affected by severe symptomatic functional TR were treated with MitraClip XTR implantation in tricuspid position. Right ventricular function was apparently preserved in all cases and the mean sPAP was 41 (quartiles 38–45) mmHg. Perioperative echo-results were collected prospectively and analyzed.

Results

Procedural success (defined as a reduction of more than 1 degree of TR) was achieved in 4 cases (80%). 3±1 devices were implanted per patient in the antero-septal commissure. The tricuspid annular diameter (measured in four chamber view) was reduced from 39 (quartiles 39–41) mm to 31 (quartiles 30–31) mm (p=0.043). Accordingly, the effective regurgitant orifice area (EROA) decreased from 110 (quartiles 70 to 160) mm2 to 45 (quartiles 9–55) mm2 (p=0.02) and the systolic VTI in the hepatic veins decreased by 42%. No significant increase of trans-valvular mean gradients was observed (2.5 (quartiles 2.25 to 2.75)) mmHg vs 3.75 (quartiles 3,75 to 4) mmHg; p=0.2) as well no cases of acute leaflet tearing.

Conclusion

The reduction in tricuspid annulus size with the novel XTRdevice represents an unexpected and interesting achievement of the procedure. A significant reduction of annular dimensions might provide a more durable reduction of functional TR. Long-term follow-up data will be required to clarify these initial results and as well as patient selection criteria.
P4727Comparing in-hospital outcomes of transcatheter mitral valve repair vs surgical mitral valve repair in patients with pulmonary hypertension
Authors: Ahmed A , Adegbala O , Akintoye E , Alhatemi G , Aldiwani H , Yassin A S , Khalid M , Mishra T , Ajam M , Abubakar H , Shokr M , Afonso L
Published: October 2019

Background

The comparative outcomes of transcatheter mitral valve repair with Mitraclip (TMVR) versus surgical mitral valve repair (SMVR) in pulmonary hypertension (PH) patients are underexplored.

Methods

The Nationwide Inpatient Sample (NIS) database was queried from 2009 to 2015 and those who underwent TMVR or SMVR with PH were identified. International Classification of Diseases (ICD) codes were used to identify the target population, primary and secondary outcomes. Propensity scores (PS) were calculated for each patient. A standardized morbidity ratio (SMR) weight was then calculated for each patient in both groups. Absolute standardized differences (ASD) were used to compare the baseline characteristics.

Results

We identified a total of 341 and 4,665 cases from NIS who underwent TMVR and SMVR, respectively, over the study period. The mean age of patients was 67 yrs. Patients who underwent TMVR were older (75 vs. 66, ASD =0.32). Women comprised 47.8% of TMVR admission while 42.16% of SMVR admissions were females. Patients who underwent TMVR had a significantly higher Elixhauser comorbidity score >4 (43.4% vs 34.2%, ASD =0.3). TMVR group had higher rates of previous myocardial infarctions (16.7% vs. 7.1%, ASD = 0.30), congestive heart failure (80% vs. 6.2%, ASD = 0.44), percutaneous intervention (PCI) (15.6% vs. 5.9%, ASD = 0.32), coronary artery bypass grafting (CABG) (22.8% vs. 2.7%, ASD = 0.63), cerebrovascular disease (13.5% vs. 5.5%, ASD = 0.27), chronic obstructive pulmonary disease (30.8% vs. 21.1%, ASD = 0.22)and chronic renal failure (43.1% vs. 18.9%, ASD = 0.54). Inpatient mortality was similar between the 2 groups (3.6% vs 6.2%, p=0.573). TMVR patients had less hemorrhage requiring transfusion (8.1% vs 21.1, p<0.001), acute kidney injury (22.2% vs 33.6%, p<0.001), pacemaker placement (1.20% vs 6.89%, p<0.001), cardiogenic shock (4.5% vs 11.5%, p=0.0012) and mechanical circulatory device need (3.9% vs 9.7%, p=0.003). The TMVR group had lower median hospital cost ($53,824 vs $68,311, p<0.001) and LOS (7.5 days vs 13.1 days, p<0.001).

Conclusions

While in-hospital mortality in PH patients after TMVR compared to SMVR, TMVR was associated with significantly lower periprocedural complications.
P4728Prognostic implications of the relationship between effective regurgitant orifice area and left ventricle end diastolic volume in patients with functional mitral regurgitation treated with MitraClip
Authors: Melillo E , Godino C , Ancona F , Sisinni A , Stella S , Capogrosso C , Camici P G , Denti P , Buzzatti N , Colombo A , Montorfano M , De Bonis M , Castiglioni A , Alfieri O , Agricola E
Published: October 2019

Background

The distinction between proportionate and disproportionate functional mitral regurgitation (FMR), based on the relationship between effective regurgitant orifice area (EROA) and left ventricle end diastolic volume (LVEDV), has recently been proposed as a possible new clinical and physiopathological concept to identify patients that could likely benefit from transcatheter mitral repair.

Purpose

The aim of our study was to explore the possible prognostic implications of the EROA/LVEDV ratio in patients with FMR treated with MitraClip.

Methods

Baseline EROA/LVEDV ratio was calculated in 72 patients with moderate-to-severe, symptomatic FMR treated with MitraClip. All patients underwent clinical, biochemichal and echocardiographic evaluation before MitraClip. EROA was calculated using PISA method. The primary outcome was a composite end-point of all-cause death or re-hospitalization for heart failure (HF).

Results

The median follow-up was 1 year. The primary outcome occurred in 25 patients (34.7%). The cut-off value of EROA/LVEDV ratio for primary outcome, identified by receiver operating characteristic curve, was 0.15 (p=0.007) with a sensitivity and specificity of 72 and 68%, respectively. Patients were divided in two groups according to the identified cut-off. Patients with higher ratio (Group I, n=35) presented a less dilated LV (LVEDVi: 113.2±33.4 mL vs 129.3±29.3 mL, p=0.033; LVESV: 140.7±49.0 mL vs 171.1±47.4 mL, p=0.010), a better LV systolic function (LVEF: 31.9±9.5% vs 27.8±5.8%, p=0.028) and a more severe MR (EROA: 44.5±12.9 mm2 vs 24.5±6.8 mm2, p<0.001; vena contracta: 7.4±1.5 mm vs 6.7±1.0 mm, p=0.045). Patients with lower ratio (Group II, n=37) showed a reduced prevalence of MV annular dilation (57.1% vs 91.7%, p=0.005) and a worse RV function (s'TDI: 9.2±2.2 cm/s vs 10.5±2.9 cm/s, p=0.039). At univariate analysis, EROA/LVEDV ratio >0.15 (HR = 2.467, 95% CI 1.017–5.982, p=0.046) and severe pulmonary hypertension (HR = 2.481, 95% CI 1.030–5.976, p=0.043) were associated with a worse clinical outcome. At multivariate Cox-regression analysis, both EROA/LVEDV ratio >0.15 and severe pulmonary hypertension were identified as independent predictors (HR 3.203, 95% CI 1–310–7.832, p=0.011; HR = 3.280, 95% CI 1.326–8.116, p=0.010, respectively).

Figure 1

Conclusion

Our data show that EROA/LVEDV ratio was an independent predictor of adverse clinical outcome in FMR patients treated with MitraClip. This preliminary experience shows that this index could help to identify subgroups of patients with potential different clinical benefits from MitraClip therapy. However, further and extended data are needed to provide more precise evidence.

Acknowledgement/Funding

None
P4732Sleep apnoea and cardiovascular events after coronary artery bypass grafting surgery
Authors: Koo C Y
Published: October 2019

Background/Introduction

Sleep apnoea (SA) is prevalent and independently associated with adverse cardiovascular events after percutaneous coronary intervention. Patients with complex and high-risk features are often referred for coronary artery bypass grafting surgery (CABG) and it remains unknown if SA is a risk marker.

Purpose

We evaluated the association between SA and major adverse cardiac and cerebrovascular events (MACCE) in patients undergoing non-urgent CABG.

Methods

This was a prospective cohort study conducted between November 2013 and December 2018. Patients from 3 public hospitals referred to a tertiary cardiac centre for non-urgent CABG were recruited for an overnight sleep study prior to CABG. The mean follow-up duration was 2.1 years.

Results

Among the 1007 patients who completed the study, SA (defined as apnoea-hypopnoea index ≥15 events per hour) was diagnosed in 513 patients (50.9%). Most of the patients underwent on-pump CABG (96.7%) and received a left internal mammary artery graft (95.2%). MACCE, a composite of cardiovascular mortality, non-fatal myocardial infarction, non-fatal stroke and unplanned revascularisation, occurred in 123 patients (12.2%). The crude incidence of MACCE was higher in the SA than the non-SA group (3-year estimate, 18.8% versus 11.7%; p=0.019). Likewise, the crude incidence of all-cause mortality (7.2% versus 4.3%; p=0.028), sudden cardiac death (3.9% versus 1.6%; p=0.028) and heart failure hospitalisations (10.9% versus 5.3%; p=0.001) was higher in the SA than the non-SA group. Multivariate Cox regression analysis demonstrated that SA was predictive of MACCE with an adjusted hazard ratio of 1.54 (95% confidence interval, 1.06–2.22; p=0.023), after adjusting for the effects of age, gender, body mass index, left ventricular ejection fraction, hypertension and chronic kidney disease.

Figure 1. KM curve for MACCE

Conclusion

Sleep apnoea is independently associated with increased MACCE in patients undergoing CABG. Further evaluation regarding the efficacy of treatment of sleep apnoea in patients undergoing CABG surgery is warranted.

Acknowledgement/Funding

Clinician Scientist Award from the National Medical Research Council of Singapore (NMRC/CSA-INV/002/2015)
P4744Patients with atrial fibrillation exhibit a systemic prothrombotic state attributable to impaired endogenous fibrinolysis
Authors: Gue Y X , Spinthakis N , Markides V , Wong T , Gorog D
Published: October 2019

Background

The association of atrial fibrillation (AF) with thromboembolic stroke due to stasis in the left atrium and left atrial appendage is well described. Whether AF is associated with a systemic prothrombotic state, detectable in peripheral blood, unclear. Previous studies have been inconsistent, with some very small previous studies (<30 patients each) variably indicating that patients with AF may have raised platelet reactivity and levels of antithrombin III, d-dimer, PAI-1 and t-PA-PAI complexes. These cumbersome laboratory tests of coagulation and fibrinolysis are not readily available in the clinical setting.

Purpose

It was our aim to compare, in peripheral venous blood, thrombotic and endogenous fibrinolytic profile of healthy volunteers and patients with newly diagnosed nonvalvular atrial fibrillation (NVAF), using a point-of-care technique.

Methods

In a prospective observational study, venous blood samples were taken from 98 healthy volunteers and 100 patients with newly diagnosed NVAF in the out-patient setting. Patients with newly diagnosed NVAF had venous blood tested before any treatment was initiated with aspirin or oral anticoagulation. Thrombotic status was assessed using the Global Thrombosis Test (GTT), a point-of-care test using native non-coagulated blood, assessed within 15 sec of blood withdrawal. The time to form an occlusive venous thrombus in native (non-citrated) blood, a measure of platelet reactivity (occlusion time, OT) and the time taken to spontaneous endogenous fibrinolysis to restore flow (lysis time, LT) were assessed.

Results

Basic blood tests (full blood count, renal and liver function, inflammatory markers) were normal in all subjects. The groups were matched for sex and race. Mean age of the healthy cohort was 34±8 years and patients 65±10 years.

Endogenous fibrinolysis was markedly impaired in patients with NVAF compared to healthy individuals as shown by markedly prolonged LT (median 2015s [interquartile range IQR 1555–2507] vs. 1124s [IQR 919–1554], p<0.ehz745.11201). There was no difference in platelet reactivity between patients and normal volunteers (369s [IQR 308–445]vs 368s [IQR 309–441], p=0.704). Sensitivity analysis was performed on a subgroup matched for age, sex and race. LT remained significantly longer in patients with NVAF compared to controls (1569s [IQR 1499–2244] vs. 1219s [IQR 943–1560], p=0.03), with no difference in platelet reactivity (p=NS).

Conclusion

In the largest study to date and using a clinically-friendly automated point-of-care technique, we show that patients with NVAF exhibit a systemic prothrombotic state, attributable to significantly impaired endogenous fibrinolysis compared with healthy volunteers. Further studies are needed to see if this could become a screening test for the prothrombotic state in patients with NVAF.

Acknowledgement/Funding

None