bluuebunny/crossref_metadata_2025 huggingface dataset:
White Slave Fiction, So-Called
Authors: Fisher Laura R
Published: November 2020

In the early twentieth century, the widespread belief that young white women were at risk of being captured and forced into sex work led to significant legislative victories, and this crisis also shaped US literature in surprising ways. When writing about so-called white slavery crossed over from the spheres of journalism, social reform, and the law into fiction, authors devised a suite of quasi-empirical literary techniques that turned the dubious facts of white slavery into the stuff of popular art. Novelists drew heavily on juridical and social scientific evidence to lend authority and specificity to stories that they insisted (counterfactually) were gravely true. White slavery fiction marries empiricism with sensationalism, data with melodrama, cold statistics with exaggeration and falsehood. This essay examines the literary empiricism of Reginald Wright Kauffman’s 1910 novel The House of Bondage and the amateur literary criticism of progressive anti-vice reformers to examine a tradition of mutual borrowing between nonfictional genres such as the report, tract, and newsletter and modern US fiction. An analogy between slavery and forced sex work was pivotal to the social critique that white slavery novels existed to forward. Yet the genre’s catalyzing metaphor circulated a radically dehistoricized, racist conception of enslavement for a twentieth-century white readership, drawing its figurative vocabulary and sense of political urgency from chattel slavery while eliminating any concern with Black men, women, or children.
Of principle, practicality, and precedents: the presumption of the arbitration agreement’s governing law
Authors: Yoong Aaron
Published: November 2020

The issue of determining the appropriate law governing an arbitration agreement is one that has long vexed the courts in many jurisdictions. Most recently, both the English and Singapore Court of Appeals have waded into the fray, contributing contrary opinions in their respective decisions of Enka Insaat Ve Sanayi AS v OOO “Insurance Company Chubb” and BNA v BNB. This article examines these decisions and argues that there should be a presumption that the governing law of the arbitration agreement follows the matrix contract within which it is situated.
The agreement terminating intra-EU BITs: are its provisions on ‘New’ and ‘Pending’ Arbitration Proceedings compatible with investors’ fundamental rights?
Authors: Nardell QC Gordon , Rees-Evans Laura
Published: November 2020

On 5 May 2020, 23 Member States of the EU signed a plurilateral treaty with the purpose of terminating the nearly 130 Bilateral Investment Treaties (BITs) between them (the so-called ‘intra-EU BITs’) and the 11 sunset clauses that continue in effect in intra-EU BITs that have already been terminated. The treaty, entitled the ‘Agreement for the Termination of Bilateral Investment Treaties Between the Member States of the European Union’, marks the beginning of the next—but by no means the final—chapter in the controversy over the status of intra-EU BITs. In this article, we examine one of the many important legal questions raised by the Agreement; namely, whether its attempt to undercut arbitrations commenced well before the Agreement came into force, including those resulting in awards rendered before the Achmea judgment, is compatible with investors’ rights under the European Convention on Human Rights and the Charter of Fundamental Rights of the European Union. We argue that by purporting to deprive investors of the fruits of valid claims in this way, the Agreement infringes Article 1 of the First Protocol to the ECHR (‘A1P1’) and may also breach the rights of access to justice and a fair hearing under Article 6(1) (and their equivalents in the Charter).
Selective disappearance does not underlie age-related changes in trait repeatability in red squirrels
Authors: Martinig April Robin , Mathot Kimberley J , Lane Jeffrey E , Dantzer Ben , Boutin Stan
Published: November 2020

Understanding the causes and consequences of repeatable among-individual differences in behavior (i.e., animal personality) is a major area of research in behavioral and evolutionary ecology. Recently, attention has turned to understanding the processes behind changes in repeatability through ontogeny because of their implications for populations. We evaluated the relative importance of selective disappearance (i.e., differential mortality), an among-individual mechanism, in generating age-related changes in the repeatability of aggression and activity in juvenile North American red squirrels (Tamiasciurus hudsonicus). We observed age-related decreases in the repeatability of aggression across ages, arising from lower among-individual variance. Although we found evidence for directional selection on aggressiveness, it was insufficient to erode among-individual variance. Thus, ontogenetic decreases in the repeatability of aggression do not appear to be due to selective disappearance. In contrast, the repeatability of activity was higher across ages due to higher among-individual variance in activity, but there was no support for selective disappearance based on activity. Taken together, our results suggest that age-related changes in trait repeatability in red squirrels are not the result of selective disappearance and instead may be the result of within-individual developmental processes, such as individual differences in developmental trajectories.
Heterogeneous graph inference with matrix completion for computational drug repositioning
Authors: Yang Mengyun , Huang Lan , Xu Yunpei , Lu Chengqian , Wang Jianxin
Published: November 2020

Motivation

Emerging evidence presents that traditional drug discovery experiment is time-consuming and high costs. Computational drug repositioning plays a critical role in saving time and resources for drug research and discovery. Therefore, developing more accurate and efficient approaches is imperative. Heterogeneous graph inference is a classical method in computational drug repositioning, which not only has high convergence precision, but also has fast convergence speed. However, the method has not fully considered the sparsity of heterogeneous association network. In addition, rough similarity measure can reduce the performance in identifying drug-associated indications.

Results

In this article, we propose a heterogeneous graph inference with matrix completion (HGIMC) method to predict potential indications for approved and novel drugs. First, we use a bounded matrix completion (BMC) model to prefill a part of the missing entries in original drug–disease association matrix. This step can add more positive and formative drug–disease edges between drug network and disease network. Second, Gaussian radial basis function (GRB) is employed to improve the drug and disease similarities since the performance of heterogeneous graph inference more relies on similarity measures. Next, based on the updated drug–disease associations and new similarity measures of drug and disease, we construct a novel heterogeneous drug–disease network. Finally, HGIMC utilizes the heterogeneous network to infer the scores of unknown association pairs, and then recommend the promising indications for drugs. To evaluate the performance of our method, HGIMC is compared with five state-of-the-art approaches of drug repositioning in the 10-fold cross-validation and de novo tests. As the numerical results shown, HGIMC not only achieves a better prediction performance but also has an excellent computation efficiency. In addition, cases studies also confirm the effectiveness of our method in practical application.

Availabilityand implementation

The HGIMC software and data are freely available at https://github.com/BioinformaticsCSU/HGIMC, https://hub.docker.com/repository/docker/yangmy84/hgimc and http://doi.org/10.5281/zenodo.4285640.

Supplementary information

Supplementary data are available at Bioinformatics online.
Cognitive decline in Parkinson’s disease is associated with reduced complexity of EEG at baseline
Authors: Keller Sebastian M , Gschwandtner Ute , Meyer Antonia , Chaturvedi Menorca , Roth Volker , Fuhr Peter
Published: November 2020

Parkinson’s disease is a neurodegenerative disorder requiring motor signs for diagnosis, but showing more widespread pathological alterations from its beginning. Compared to age-matched healthy individuals, patients with Parkinson’s disease bear a 6-fold lifetime risk of dementia. For individualized counselling and treatment, prognostic biomarkers for assessing future cognitive deterioration in early stages of Parkinson’s disease are needed. In a case–control study, 42 cognitively normal patients with Parkinson’s disease were compared with 24 healthy control participants matched for age, sex and education. Tsallis entropy and band power of the δ, θ, α, β and γ-band were evaluated in baseline EEG at eyes-open and eyes-closed condition. As the θ-band showed the most pronounced differences between Parkinson’s disease and healthy control groups, further analysis focussed on this band. Tsallis entropy was then compared across groups with 16 psychological test scores at baseline and follow-ups at 6 months and 3 years. In group comparison, patients with Parkinson’s disease showed lower Tsallis entropy than healthy control participants. Cognitive deterioration at 3 years was correlated with Tsallis entropy in the eyes-open condition (P < 0.00079), whereas correlation at 6 months was not yet significant. Tsallis entropy measured in the eyes-closed condition did not correlate with cognitive outcome. In conclusion, the lower the EEG entropy levels at baseline in the eyes-open condition, the higher the probability of cognitive decline over 3 years. This makes Tsallis entropy a candidate prognostic biomarker for dementia in Parkinson’s disease. The ability of the cortex to execute complex functions underlies cognitive health, whereas cognitive decline might clinically appear when compensatory capacity is exhausted.
A structured training pathway to implement robot-assisted minimally invasive esophagectomy: the learning curve results from a high-volume center
Authors: Kingma B Feike , Hadzijusufovic Edin , Van der Sluis Pieter C , Bano Erida , Lang Hauke , Ruurda Jelle P , van Hillegersberg Richard , Grimminger Peter P
Published: November 2020

To ensure safe implementation of robot-assisted minimally invasive esophagectomy (RAMIE), the learning process should be optimized. This study aimed to report the results of a surgeon who implemented RAMIE in a German high-volume center by following a tailored and structured training pathway that involved proctoring. Consecutive patients who underwent RAMIE during the course of the program were included from a prospective database. A single surgeon, who had prior experience in conventional MIE, performed all RAMIE procedures. Cumulative sum (CUSUM) learning curves were plotted for the thoracic operating time and intraoperative blood loss. Perioperative outcomes were compared between patients who underwent surgery before and after a learning curve plateau occurred. Between 2017 and 2018, the adopting center adhered to the structured training pathway, and a total of 70 patients were included in the analysis. The CUSUM learning curves showed plateaus after 22 cases. In consecutive cases 23 to 70, the operating time was shorter for both the thoracic phase (median 215 vs. 249 minutes, P = 0.001) and overall procedure (median 394 vs. 440 minutes, P = 0.005), intraoperative blood loss was less (median 210 vs. 400 milliliters, P = 0.029), and lymph node yield was higher (median 32 vs. 23 nodes, P = 0.001) when compared to cases 1 to 22. No significant differences were found in terms of conversion rates, postoperative complications, length of stay, completeness of resection, or mortality. In conclusion, the structured training pathway resulted in a short and safe learning curve for RAMIE in this single center’s experience. As the pathway seems effective in implementing RAMIE without compromising the early oncological outcomes and complication rates, it is advised for surgeons who are wanting to adopt this technique.
Non-invasive myocardial workiIndices derived from left ventricular pressure-strain loops in predicting the response to cardiac resynchronization therapy
Authors: Zhu M.R , Shu X , Chen H.Y , Wang Y.N , Cheng Y.F , Su Y.G , Ge J.B
Published: November 2020

Background

Non-invasive left ventricular (LV) pressure-strain loops (PSLs) which generated by combining LV longitudinal strain with brachial artery blood pressure, provide a novel method of quantifying global and segmental myocardial work (MW) indices with potential advantages over conventional echocardiographic strain which is load-dependent. The method has been introduced in echocardiographic software recently, making MW calculations more effectively and rapidly. The aim was to evaluate the role of non-invasive MW indices derived from LV PSLs in the prediction of cardiac resynchronization therapy (CRT) response.

Methods

106 heart failure (HF) patients scheduled for CRT were included for MW analysis. Global and segmental (septal and lateral at the mid-ventricular level) MW indices were accessed before CRT. Response to CRT was defined as ≥15% reduction in LV end-systolic volume at 6-month follow-up in comparison with baseline value.

Results

CRT response was observed in 78 (74%) patients. At baseline, global work index (GWI) and global constructive work (GCW) were significant higher in CRT responders than in non-responders (both P<0.05). Besides, responders exhibited a significantly higher Mid Lateral MW and Mid Lateral constructive work (CW) (both P<0.001) but a significantly lower Mid Septal MW and Mid Septal myocardial work efficiency (MWE), as well as a significantly higher Mid Septal wasted work (WW) than non-responders (all P<0.01). Baseline Mid Septal MWE (OR 0.975, 95% CI 0.959–0.990, P=0.002) and Mid Lateral MW (OR 1.003, 95% CI 1.002–1.004, P<0.001) were identified as independent predictors of CRT response in multivariate regression analysis. Mid Septal MWE ≤42% combined with Mid Lateral MW ≥740 mm Hg% predicted CRT response with the optimal sensitivity of 79% and specificity of 82% (AUC = 0.830, P<0.001).

Conclusion

Mid Septal MWE and Mid Lateral MW can successfully predict response to CRT, and their combination can further improve the prediction accuracy. Assessment of MW indices before CRT could identify the marked misbalance in LV myocardial work distribution and has the potential to be widely used as a reliable complementary tool for guiding patient selection in clinical practice.

Funding Acknowledgement

Type of funding source: None
Decreased right ventricular strain before LVAD implantation is associated with adverse early outcome
Authors: Tan T.S , Lin G , Pislaru S.V , Luis S.A , Frantz R.P , Clavell A.L , Stulak J.M , Pislaru C , Brady P , Liu M , Ye Z
Published: November 2020

Objectives

Right ventricular (RV) failure occurring after left ventricular assist device (LVAD) implantation is associated with increased mortality.

Purpose

We sought to determine whether RV strain by echocardiography predicts outcomes following LVAD.

Methods

Consecutive patients who underwent continuous flow LVAD placement at our clinic between February 2007 and October 2018 were included. Patients with complex congenital heart disease and arrhythmogenic right ventricular cardiomyopathy were excluded. Baseline characteristics, pre-operative hemodynamic catheterization (1 week) transthoracic echocardiography (1 month) measurements were obtained from the medical record. Speckle tracking RV free wall longitudinal 2D strain was measured using TomTec Imaging System. Univariate and multivariable analysis performed to identify predictors of mortality following LVAD.

Results

The study group was comprised of 323 patients (mean age 60.8±11.5, 79.9% male) of which 256 had adequate image quality for RV strain. RV strain was impaired in most patients (mean −11.7±3.47). RV strain of −8.1% was identified as predictive of poor outcomes. RV strain did not correlate with other measures of RV dysfunction including pulmonary artery pulsatility index (PAPi) and RVFAC. After adjusting for PAPi, RA pressure, and clinical cumulative risk scores (Matthews, Kormos and Lietz-Miller) impaired RV free wall longitudinal strain (OR: 1.14; 95% CI: 1.01–1.29, p=0.025), tricuspid regurgitation (by vena contracta width (TRvc) (OR: 1.19; 95% CI: 1.05–1.36, p=:0.0021) and smaller LVEDD (OR: 0.95; 95% CI: 0.92–0.99, p:0.023) predicted 30-day all-cause mortality and RV failure. Decreased RV free wall strain also predicted peri-operative mortality (22.58% vs. 4.89%, p=0.0003) and prolonged inotropic support (247.0.±277.4 vs. 122.8±139.3, p=0.024).

Conclusions

RV free wall strain is a non-invasive independent predictor of 30-day adverse outcomes (RV failure or all-cause mortality) Routine measurement of RV free strain may identify those patients at highest risk for early and long term mortality following LVAD.

Funding Acknowledgement

Type of funding source: None
Impact of coronary plaque characteristics on periprocedural myocardial injury after elective percutaneous coronary intervention -MDCT and CMR analysis-
Authors: Usami K , Watabe H , Otani M , Maruta S , Hiraya D , Hoshi T , Sato A , Ieda M
Published: November 2020

Background

Percutaneous coronary intervention (PCI) is often complicated by periprocedural myocardial injury (PMI) manifested by elevated cardiac biomarkers. The occurrence of PMI has been shown to be associated with worse clinical outcome over short- and long-term.

Purpose

We performed multidetector computed tomography (MDCT) and cardiac magnetic resonance imaging (CMR) to evaluate the relationship between culprit plaque characteristics and PMI.

Methods

A total of 90 patients who underwent elective PCI were underwent CMR and multidetector coronary tomography before PCI. The high intensity plaque (HIP) on CMR was defined as a coronary plaque to myocardium signal intensity ratio (PMR) of >1.4. The plaque characteristics and the presence of napkin-ring sign (NRS) were analyzed on MDCT. PMI was defined as an increase in cardiac Troponin T levels to more than 5 times the upper limit of normal at 24 h after PCI. Patients were divided into 2 groups according to the presence (Group I, n=26) or absence (Group II, n=64) of PMI.

Results

Spotty calcification, positive remodeling, low attenuation plaque and NRS on MDCT were significantly more observed in Group I than in Group II. HIP on CMR was significantly more observed in Group I than in Group II. In the multivariable logistic regression analysis, the presence of NRS and HIP were significantly independent predictors of PMI (odds ratio (OR) 4.82, 95% confidence interval 1.13–20.60, P=0.034 and OR 3.66, 95% CI 1.09–12.30, P=0.036, respectively). Moreover, for prediction of PMI, NRS and HIP showed a high positive predictive value of 81%, and their absence showed a high negative predictive value of 91%.

Conclusions

MDCT and CMR may play an important role in detecting which lesions are high risks for myocardial necrosis after PCI in elective coronary stenting.

Funding Acknowledgement

Type of funding source: None
GENECHOC study: genetic markers of arrhythmic risk in heart failure
Authors: Anys S , Rigade S , Rigade S , Baron E , Baron E , Lecointe S , Lecointe S , Guyomarch B , Guyomarch B , Klug D , Klug D , Babuty D , Babuty D , Mansourati J , Mansourati J , Bordachar P , Bordachar P , Mabo P , Mabo P , Thollet A , Thollet A , Dina C , Dina C , Schott J.J , Schott J.J , Barc J , Barc J , Probst V , Probst V
Published: November 2020

Background

Ventricular arrhythmic events are responsible for 50% of death in heart failure but no reliable predictive marker is known to discriminate patients at risk of fatal arrhythmia. Interestingly, familial predisposition has been reported suggesting a role of genetic factors.

Purpose

Identify genetic markers increasing the arrhythmic risk in heart failure population.

Method

We prospectively included heart failure patients with left ventricular ejection fraction (LVEF) under 35% and a cardioverter defibrillator in primary prevention in 22 French centres between 2009 and 2017. Patients were followed for 72 months and divided into two groups: cases with an arrhythmic event during follow-up and controls. A Genome Wide Association Study (GWAS) was done. Single Nucleotide Polymorphisms (SNPs) genotyping was performed on Affymetrix Axiom Precision Medicine Research Array plates. To complement the directly genotyped SNPs we performed large-scale imputation based on the Haplotype Reference Consortium European ancestry panel leading to a dataset of 7,5 million of SNPs.

Results

332 cases and 567 controls were included (86% men, mean age at implantation 52±11 years). 78% of patients had ischaemic cardiopathy, 20% had dilated cardiomyopathy. Mean LVEF was 27±5%. No statistical difference was found between cases and controls on clinical parameters, biological results, electrocardiographic measures. No locus shows genome-wide significant association (p<5.10–8) on the GWAS analysis. However, 16 signals with a p-value between 5.10–8 and 5.10–5 were investigated. eQTL and chromatin conformation point to 35 genes with cardiac expression previously associated with heart failure, cardiomyopathies, cardiogenesis, arrhythmias and inflammation. Variants identified point to regulatory regions of the genome and may then propose a molecular mechanism predisposing patients to arrhythmias.

Conclusion

No locus raises genome-wide significance, but several signals with a nominal p-value point to relevant genes and pathways. Replication of the GWAS is ongoing on a cohort of 156 new patients with a less severe cardiopathy implanted with a cardioverter defibrillator in secondary prevention.

Funding Acknowledgement

Type of funding source: Public hospital(s). Main funding source(s): Nantes University Hospital
Characteristics and outcomes of pace mapping for ablation of premature ventricular complexes
Authors: Kemme M.J.B , Ozer R , Mulder M.J , Hauer H.A , Tahapary G.J.M , Van Zutphen E.M , Allaart C.P
Published: November 2020

Background/Introduction

Activation mapping is the “gold standard” for localisation of the site of origin during mapping and ablation of symptomatic premature ventricular complexes (PVC). In case of suppression of PVCs during the procedure, the origin of the PVC can be located using a pace mapping technique. The PASO module is an addition in the CARTO3 mapping system that calculates the correlation between the induced and observed 12-lead ECG PVC morphology, and visualises this correlation on an isochronal 3D colour map.

Purpose

The aim of this study was to compare the follow-up success rate of pace mapping using the PASO module and activation mapping and to determine cut-off values for clinical success.

Methods

Seventy-six consecutive ablation procedures of symptomatic PVCs were included in this single-center retrospective study. Mapping and ablation parameters were derived from the CARTO3 mapping system. Ablation success was defined as a ≥95% reduction in PVC burden on 24-hour Holter recordings or absence of the clinical PVC on multiple ECGs in case of multiple PVC morphologies. Logistic regression analysis was performed to evaluate the relationship between applied mapping methods and ablation parameters. Optimal cut-off values of ablation characteristics for successful ablation were determined using ROC curves.

Results

Thirty-five (46%) patients were male and 39 (51%) patients had a reduced left ventricular ejection fraction. Pace mapping was used in 36 (47%) patients. Baseline PVC burden was lower in patients when pace mapping was applied (18% vs. 28%, p<0.001). The use of either mapping technique was influenced by PVC localisation (p=0.004). Pace mapping was used predominantly in the right ventricular outflow tract (n=21/31) whereas activation mapping was used predominantly in the left ventricle (n=14/22) and left ventricular outflow tract (n=7/7). Ablation success did not differ between activation mapping (77.5%) and pace mapping (77.8%). Median [IQR] maximum PASO correlation was 98.2% [97.1–98.6] for successful ablations and 96.5% [92.9–97.5] for unsuccessful ablations (p=0.030). The optimal cut-off value for successful ablation of the PASO correlation was 97.6% (AUC 0.754, sensitivity 68%, specificity 88%). There were no significant differences in other ablation parameters between both groups.

Conclusion

This study indicates that pace mapping using PASO is a good alternative for activation mapping for localisation of the PVC. A minimum PASO correlation coefficient of 97.6% is the optimal cut-off value for successful PVC ablation.

ROC of maximum PASO coefficient

Funding Acknowledgement

Type of funding source: None
Durable pulmonary vein (PV) isolation at repeat atrial fibrillation (AF) ablation procedure: a comparison between 4 ablation technologies
Authors: Morales G , Boghossian E , Rajendra A , Osorio J
Published: November 2020

Background

Durable PV isolation is the sought-after endpoint to obtain long term success after AF catheter ablation. Evolution in technology improves efficiency, safety and effectiveness in AF catheter ablation.

Purpose

To investigate the effectiveness of different catheter technologies in obtaining durable PV isolation in a real-world practice.

Methods

Retrospective analysis of prospectively collected data of patients undergoing repeat procedures for recurrence of AF or atrial flutter at our institution was performed. Incidence of all PVs being isolated at repeat procedure was recorded and patients 4 groups created based on catheter technology used during index AF ablation procedure (SF: multipored, irrigated catheter; ST: contact force sensor catheter; Cryo: 2nd generation cryobaloon; and STSF: multipored, irrigated, contact force sensing catheter).

Results

We identified 269 subjects undergoing repeat ablation from May 2014 to September 2019. Mean age was 67±9.7 years, 54.6% were males, 74.4% non-paroxysmal AF at the index procedure. The mean CHA2DS2Vasc score was 2.5±0.26, LA size 4.2±0.6 cm, EF 55.3±10%. The mean time from index to redo procedure was 374±331 days. At repeat procedure all veins were isolated in 24% (6/25) who were initially ablated using SF; 36% (8/22) with Cryo; 44% (47/108) with ST; and 74% (84/114) with STSF catheter. (Figure)

Conclusion

Patients undergoing index ablation with STSF catheter technology were significantly more likely to have all 4 PVs isolated at repeat procedure compared to previous generation technology.

Funding Acknowledgement

Type of funding source: Private grant(s) and/or Sponsorship. Main funding source(s): Biosense Webster
Comparison between non-vitamin K antagonist oral anticoagulants versus warfarin for the risk of dementia in Asian patients with non-valvular atrial fibrillation
Authors: Lee S.R , Choi E.K , Park S.H , Han K.D , Oh S , Lip G
Published: November 2020

Background

Atrial fibrillation (AF) is a risk factor for dementia and oral anticoagulant (OAC) use is associated with a decreased risk of dementia in patients with AF.

Objective

We sought to find whether the risk of dementia would be different between patients treated with non-vitamin K antagonist oral anticoagulants (NOACs) and those treated with warfarin.

Methods

Using the Korean National Health Insurance database from January 2014 to December 2017, we identified OAC naïve non-valvular AF patients aged 40 years or older. For the comparison, warfarin and NOAC groups were balanced using the inverse probability of treatment weighting method (IPTW). The primary outcome was incident dementia. Patients were censored at the occurrence of dementia, discontinuation of index treatment, or the end of the study period (December 31, 2018).

Results

Among 72,846 of total study patients, 25,948 were treated with warfarin and 46,898 were treated with NOAC (17,193 with rivaroxaban, 9,882 with dabigatran, 11,992 with apixaban, and 7,831 with edoxaban). Crude incidence of dementia was 4.65 per 100 person-years in warfarin group and 4.98 per 100 person years in NOAC group. Baseline characteristics were well-balanced after IPTW (mean age 72 years, 93% CHA2DS2-VASc ≥2, 58% men). Compared to warfarin, NOAC showed a comparable risk of dementia (hazard ratio [HR] 0.944, 95% confidence interval [CI] 0.934–1.059), vascular dementia (HR 0.921, 95% CI 0.814–1.043) and Alzheimer dementia (HR 1.101, 95% CI 1.019–1.191). When comparing individual NOACs with warfarin, edoxaban was associated with a lower risk of dementia (HR 0.830, 95% CI 0.740–0.931). Rivaroxaban (HR 0.767, 95% CI 0.648–0.907) and edoxaban (HR 0.786, 95% CI 0.620–0.996) were associated with a lower risk of vascular dementia than warfarin. In subgroup analyses, NOAC was associated with a lower incidence of dementia than warfarin particularly in patients with prior stroke (HR 0.891, 95% CI 0.820–0.968) and in patients aged 65–74 years (HR 0.815, 95% CI 0.709–0.936).

Conclusion

In this large Asian population with AF, NOAC showed a comparable result with warfarin on the risk of dementia. Edoxaban was associated with a lower risk of dementia. NOAC appeared more beneficial especially in those with AF who had a history of prior stroke and aged 65–74 years.

Funding Acknowledgement

Type of funding source: None
Extensible artificial intelligence model predicts post-ablation AF recurrence using coronary sinus electrogram
Authors: Huang D , Zhang Z , Lin K , Zuo Z , Chen Q , Qian D , Zhu W , Li J
Published: November 2020

Background

Atrial fibrillation (AF) is a major public health problem with significant adverse outcomes and catheter ablation is a widely adopted treatment. The CABANA trial showed that catheter ablation reduced AF recurrence to a greater extent than medications. However, some of patients who underwent this procedure still experience relapse. Here, we present an innovative way to identify this subgroup using an artificial intelligence (AI) -assisted coronary sinus electrogram.

Hypothesis

Our hypothesis is that credible features in the electrogram can be extracted by AI for prediction, therefore rigorous drug administration, close follow-up or potential second procedure can be applied to these patients.

Methods

67 patients from two independent hospitals (SPH & ZSH) with non-valvular persistent AF undergoing circumferential pulmonary vein isolation were enrolled in this study, 23 of which experienced recurrence 6 months after the procedure. We collected standard 2.5-second fragments of coronary sinus electrogram from ENSITE NAVX (SPH) and Carto (ZSH)system before the ablation started. A total of 1429 fragments were obtained and a transfer learning-based ResNet model was employed in our study. Fragments from ZSH were used for training and SPH for validation of deep convolutional neural networks (DCNN). The AI model performance was evaluated by accuracy, recall, precision, F-Measure and AUC.

Results

The prediction accuracy of the DCNN in single center reached 96%, while that in different ablation systems reached 74.3%. Also, the algorithm yielded values for the AUC, recall, precision and F-Measure of 0.76, 86.1%, 95.9% and 0.78, respectively, which shows satisfactory classification results and extensibility in different cardiology centers and brands of electroanatomic mapping instruments.

Conclusions

Our work has revealed the potential intrinsic correlation between coronary sinus electrical activity and AF recurrence using DCNN-based model. Moreover, the DCNN model we developed shows great prospects in the relapse prediction for personalized post-procedural management.

Funding Acknowledgement

Type of funding source: Foundation. Main funding source(s): The National Natural Science Foundation of China
Sex differences in the predictors of recurrent atrial fibrillation after catheter ablation: insights from the Kansai Plus Atrial Fibrillation (KPAF) registry
Authors: Tanaka N , Inoue K , Kobori A , Kazutai K , Morimoto T , Kurotobi T , Morishima I , Kusano K , Yamaji H , Nakazawa Y , Tanaka K , Iwakura K , Fujii K , Kimura T , Shizuta S
Published: November 2020

Background

The impact of sex differences on the clinical outcomes of radiofrequency catheter ablation (RFCA) of atrial fibrillation (AF) is controversial. We previously reported that females experienced more frequent AF recurrences than males after the index and last RFCA procedures.

Purpose

To identify the risk factors associated with recurrent AF in females and males after RFCA of AF.

Methods

We conducted a large-scale, prospective, multicenter, observational study (Kansai Plus Atrial Fibrillation Registry). We enrolled 5010 consecutive patients who underwent an initial RFCA of AF at 26 centers (64±10 years; 1369 [27.3%] females; non-paroxysmal AF, 35.7%). The median follow-up duration was 2.9 years.

Results

The incidence of AF recurrences after a single procedure was 43.3% in females and 39.0% in males. After a multivariate adjustment at baseline, the significant predictors of AF recurrence in females after the index RFCA were non-paroxysmal AF (hazard ration [HR],1.59; 95% confidence interval [CI],1.31–1.93, p<0.0001), a history of AF ≥2 years (HR,1.47; 95% CI,1.24–1.74, p<0.0001), coronary artery disease (HR,1.43; 95% CI,1.03–1.98, p=0.0035), and an estimated glomerular filtration rate (eGFR)<60 mL/min/1.73m2 (HR,1.46; 95% CI,1.10–1.95, p=0.0086). On the other hand, significant predictors of AF recurrence in males after the index RFCA were non-paroxysmal AF (HR,1.54; 95% CI,1.37–1.73, p<0.0001), a history of AF ≥2 years (HR,1.40; 95% CI,1.26–1.56, p<0.0001), the number of antiarrhythmic drugs (HR,1.06; 95% CI,1.003–1.13, p=0.040), a left atrial diameter≥40mm (HR,1.13; 95% CI,1.007–1.27, p=0.038), and dilated cardiomyopathy (HR,1.55; 95% CI,1.07–2.26, p=0.021), however, an eGFR<60 mL/min/1.73m2 was not associated with AF recurrence in males (HR, 1.00; 95% CI, 0.88–1.13, p=0.97).

Conclusion

The Kansai Plus Atrial Fibrillation Registry revealed a distinct sex difference in terms of the predictors of recurrent AF after RFCA. Non-Paroxysmal AF and a long history of AF were common risk factors both in females and males. However, renal dysfunction was a significant predictor of AF recurrence in females, while it was not a risk of recurrence in males.

Funding Acknowledgement

Type of funding source: Foundation. Main funding source(s): Research Institute for Production Development in Kyoto, Japan.
D-dimer for the prediction of left atrial appendage thrombosis: daydream or reality? A meta-analysis
Authors: Casula M , Fortuni F , Frassica R , Coccia M.G , Magrini G , Fabris F , Gnecchi M , Leonardi S , Savastano S , Rordorf R
Published: November 2020

Introduction

Left atrial appendage thrombosis (LAAT) is a dangerous condition that mainly affects patients with atrial fibrillation (AF) or those with mitral stenosis (MS), increasing their risk of stroke. Transesophageal echocardiography (TEE) is the gold standard for the diagnosis of LAAT but some technical issues and the suboptimal sensitivity in identifying small thrombi, especially within a side lobe, can limit its clinical usefulness. Reliable non-invasive diagnostic methods could be useful in clinical practice. D-dimer, a fibrin degradation product already commonly used in the diagnostic work-up of conditions such as venous thromboembolism, may have a role as a non-invasive marker of LAAT.

Purpose

To evaluate the diagnostic performance of D-dimer for the detection of LAAT in patients with AF and/or MS, using TEE as the reference standard.

Methods

We searched the literature for studies that evaluated the ability of D-dimer to predict LAAT. For each study a 2x2 table of D-dimer positivity and LAAT presence was constructed. Sensitivity, specificity, positive predictive value and negative predictive value were calculated. Considering the different diagnostic thresholds used in the included studies, the overall sensitivity and specificity were calculated using a hierarchal summary receiver operating characteristic (HSROC) model and a SROC curve was generated.

Results

6 studies, evaluating 1380 patients of whom 154 had LAAT, were included in the analysis. The prevalence of LAAT in the studies ranged from 9% to 26%, with a median of 12%. The mean age was 60±13 years, 63% were male. The mean left atrial diameter was 43±3 mm. The D-dimer diagnostic threshold ranged from 200 mcg/l to 1150 mcg/l. The overall sensitivity calculated with the HSROC model was 85%±28% and the overall specificity was 82%±29%. The negative predictive value was 98%. Figure 1 shows the summary ROC curve: individual studies are depicted by a clear circle; the red circle marks the pooled sensitivity and specificity across the 6 studies. The red dot-dashed-curve marks the boundary of the 95% credible region for the pooled estimates of sensitivity and specificity.

Conclusions

Our analysis shows that D-dimer has a good diagnostic performance with a very high negative predictive value for LAAT and therefore it might be of clinical aid for ruling out the presence of LAAT in patients with AF and/or MS. Further studies are needed to determine the best diagnostic threshold.

Figure 1

Funding Acknowledgement

Type of funding source: None
Continuation or discontinuation of oral anticoagulants after an increase in HAS-BLED scores and the risks of clinical outcomes in patients with atrial fibrillation. a nationwide cohort study
Authors: Chao T.F , Liao J.N , Lip G.Y.H , Chen S.A
Published: November 2020

Background

The bleeding risk profile of patients with atrial fibrillation (AF) may change over time and the increment of HAS-BLED score (a validated bleeding risk score) is perceived to result in discontinuations of oral anticoagulants (OACs). The goal of the present study was to investigate the changes of HAS-BLED scores of AF patients initially with a low bleeding risk (HAS-BLED 0–2). Second, the impact of continuation or discontinuation of OACs on clinical outcomes after patients' bleeding risk profile worsened (ie HAS-BLED increased) were also studied.

Methods

The present study used the Taiwan nationwide health insurance research (NHIRD) database. From year 2000 to 2015, a total of 24,990 AF patients aged >20 years with a CHA2DS2-VASc score >1 (males) or >2 (females) having a HAS-BLED score of 0–2 who were treated with OACs (warfarin or NOACs) were identified and followed up for changes of the HAS-BLED scores. The risks of clinical outcomes were compared between patients who continued or stopped OAC's once their HAS-BLED score increased to ≥3.

Results

Mean HAS-BLED score of study population continuously increased from 1.54 (SD 1.63) at baseline, to 3.33 (SD 1.36) at the end of follow up with increasing age and incident comorbidities (Figure A). At end of 1 year, 5,229 (20.9%) patients had an increment of their HAS-BLED score to ≥3, mainly due to newly diagnosed impaired renal function, occurrences of bleeding events and concurrent use of antiplatelet agents or NSAIDs. Among 4,777 patients who consistently had a HAS-BLED score > =3, 1,062 (22.2%) stopped their use of OACs. Patients who kept on OACs (n=3,715; 77.8%) even after their HAS-BLED score increased to ≥3 were associated with a lower risk of ischemic stroke (aHR 0.601), major bleeding (aHR 0.780), all-cause mortality (aHR 0.876) and any adverse events (aHR 0.748) (Figure B).

Conclusions

For patients whose HAS-BLED scores increased to ≥3, the continuation of OACs (which occurred in the majority of patients) was associated with better clinical outcomes. An increased HAS-BLED score in AF patients is not a reason to withhold OACs, but reminds physicians to correct modifiable bleeding risk factors and follow up patients more closely. The low risk of bleeding despite continuing OAC in high HAS-BLED score patients may reflect the early reviews and careful follow-up of these “high risk” patients (as recommended in guidelines).

Funding Acknowledgement

Type of funding source: None
QRS voltage in precordial leads in patients with neurally mediated syncope
Authors: Blendea D , Cimpeanu M , Jelnean M , Chiorescu R , Crisan S , Pop S
Published: November 2020

Background

We have previously demonstrated that patients with neurally mediated syncope (NMS) who have an isolated QRS complex, of very low voltage (≤0.3mV cutoff), in one of the frontal leads on the 12-lead electrocardiogram have a threefold increase in the risk of syncope recurrence. The potential relationship between isolated low voltage (ILV) in precordial leads (Figure A) and recurrent NMS has not been yet explored.

Purpose

To prospectively evaluate whether the presence of ILV in the precordial leads predicts recurrence of NMS.

Methods

We included 135 patients with NMS (age 49±20) years, with a median of 4 syncopal episodes. During a median period of 15 months, 43 patients (32%) experienced recurrent syncope. The lowest QRS voltage (QRSmin) was determined separately for the frontal and precordial leads. The cutoff for precordial QRSmin that best discriminated between patients with recurrent and no recurrent syncope was ≤0.7mV (ROC curve AUC=0.65).

Results

Isolated low voltage in precordial leads was present in 49 (36%) of patients. The lead which displayed QRSmin in the precordial leads was V1 in 35 (71%) patients. The actuarial total syncope recurrence rate at 1 year was 26% (95% CI 16–42%) in patients with ILV in precordial leads, and 21% (95% CI 6–39%) in patients without ILV (log rank test P=0.043; Figure B). The significant relationship between the presence of ILV in precordial leads and syncope recurrence was retained in Cox multivariate analysis that included isolated very low voltage in frontal leads (≤0.3mV cutoff), as well as the number of syncopal episodes.

Conclusions

Isolated low QRS voltage in the precordial leads predicts recurrence of NMS independent of isolated low QRS voltage in the frontal leads.

Figure 1

Funding Acknowledgement

Type of funding source: None
Silent myocardial infarction among young sudden cardiac death victims
Authors: Vahatalo J.H , Pakanen L , Huikuri H.V , Perkiomaki J.S , Kaikkonen K.S , Junttila M.J
Published: November 2020

Background

Silent myocardial infarctions (SMIs) occur with atypical or no symptoms at all. The burden of SMIs among sudden cardiac death victims have recently been acknowledged. However, the prevalence of previously undetected SMI in young victims remains unclear.

Purpose

The aim of the present study was to determine the prevalence of autopsy verified SMI in SCD victims under 50 years old without a prior diagnosis of coronary artery disease (CAD).

Methods

Fingesture study consists of systematically collected consecutive victims of SCD in Northern Finland between years 1998–2017 (n=5,869). According to Finnish law, all unexpected deaths undergo medico-legal autopsy. The autopsies routinely included histological examinations, and a toxicology investigation was carried out if needed. The SMI was defined as focal scar detected by macroscopic evaluation of the dissected ventricles and histologic analysis of the myocardial samples with an absence of a history of previously diagnosed CAD. Pre-mortem clinical history was obtained from medical records, standardized questionnaire to the closest family members of the victims and police reports about the conditions of the death.

Results

Overall, 10.4% off all SCDs occurred among victims under the age of 50 years (610 victims). Most common underlying cause of SCD among young was CAD (44%). About 90% of the victims had no clinical diagnosis of CAD, however, 34% (78 victims) had previously undetected myocardial scar at autopsy indicating a previous SMI. The mean age of the young SMI victims was 44±4 and they were mostly men (87%). 24% of SCDs occurred during physical activity and 21% had SCD outdoors. The mean heart weight was 466±110 g and 67% had hypertrophied hearts. Three vessel disease was detected in 69% of the victims. Alcohol was detected in 17% of victims in toxicology investigations.

Conclusions

Previously undetected myocardial infarction is also common among young victims who experienced CAD associated SCD. Three vessel disease and cardiac hypertrophy were common autopsy findings among young SMI victims and about a fourth had SCD during physical activity.

Funding Acknowledgement

Type of funding source: Foundation. Main funding source(s): Sigrid Juselius Foundation, Finnish Foundation for Cardiovascular Research
Fragmented QRS, a predictor of clinical events in patients on cardiac resynchronization therapy
Authors: Martinez Milla J , Garcia-Talavera C , Arroyo B , Camblor A , Garcia-Ropero A , Miracle A , Benezet-Mazuecos J , Rubio-Campal J.M , Romero-Daza A
Published: November 2020

Introduction

Cardiac resynchronization therapy with defrilator (CRT-D) has been shown to reduce mortality in HFrEF. The width and morphology of the QRS are essential when deciding on the implantation of these devices. QRS fragmentation (fQRS) has been shown to be a good predictor of cardiovascular events in certain patients, but its role in patients with CRT-D has not been studied. The aim of this study is to determine whether the presence of a fQRS at the time of CRT-D implantation can predict clinical events.

Methods

All patients who underwent CRT-D implantation from 2010 to 2017 were included. Patients' ECG were evaluated at the time of implantation, and the incidence of clinical events during follow-up was also assessed. fQRS was defined as the presence of an RSR' pattern with a notch in the R wave or in the ascending or descending branch of the S wave in two continuous leads on the ECG.

Results

We studied 131 patients (mean age 73 years, 76.5% male). The mean follow-up period was 37±26 months. No difference in baseline characteristics was found (Table 1); the proportion of fQRS was 48.9%. 25 patients (19.1%) had hospital admissions secondary to cardiovascular causes (heart failure, arrhythmic events, acute coronary syndrome, and death from other causes). We performed a multivariate logistic regression analysis aiming at an association between the presence of fQRS and the increased risk of hospital admissions due to cardiovascular causes OR 2.92 (95% CI: 1.04–8.21, P=0.04).

Conclusion

The presence of a fQRS at the time of implantation of a CRT-D is an independent predictor of hospital admissions due to cardiovascular causes. Therefore this could be a useful marker to identify the population at high risk of cardiovascular events, for this we consider necessary to conduct future studies and thus assess the value of the fQRS for the selection of patients requiring closer monitoring thus avoiding further hospital admissions.

Funding Acknowledgement

Type of funding source: None