bluuebunny/crossref_metadata_2025 huggingface dataset:
P5591Efficacy and safety of lower dose slow infusion of t-PA for intermediate-risk pulmonary embolism patients with risk for bleeding
Authors: Obradovic S , Dzudovic B , Sekulic I , Subotic B , Matijasevic J , Batranovic U , Salinger S , Nikolic M , Miloradovic V , Markovic-Nikolic N , Kos L J , Preradovic-Kovacevic T
Published: October 2019

Background

Current guidelines do not recommend thrombolytic therapy for the treatment of intermediate-risk pulmonary embolism (PE) because of the tight balance between the benefit and safety with classic protocols.

Aim

The aim of this study was to compare the new thrombolytic protocol with lower-dose slow-infusion (LDSI) of tissue plasminogen activator (tPA) to classic 2-hours tPA infusion protocol or no-reperfusion in patients with intermediate-high risk PE with higher bleeding risk regarding 30-day efficacy and safety.

Methods

Among 849 patients with PE from the Serbian multicenter registry, 469 patients who fulfilled criteria for intermediate-risk PE were involved in the study. After propensity score matching 425 patients [263 (61.9%), 99 (23.3%) and 63 (14.8%) were treated with no-reperfusion, classic tPA protocol (100 mg for 2 hours) and LDSI of tPA (2–5 mg/hour either vie local catheter or systemic venous infusion with dose range of 25–50 mg)]. The basic characteristics of patients were well balanced between groups except that patients treated with LDSI of tPA had significantly higher usage of drugs which can be associated to bleeding and more previous bleeding events. Thirty day all-cause and PE-caused mortality and 7-day major bleeding were the main efficacy and safety end-points, respectively.

Results

All-cause and PE-cause 30-day mortality were 8.7% vs 16.2% vs 1.6% (Log rank p=0.007) and 4.5% vs 11.0% vs 0.0% (Log rank p=0.008) in patients with no-reperfusion, classic tPA protocol and LDSI of tPA protocol, respectively. Major bleeding at 7 days were 2.7% vs 8.1% vs 14.3% (Log rank p=0.001) in patients with no-reperfusion, classic tPA protocol and LDSI of tPA protocol, respectively. There was one fatal intracranial bleeding during catheter infusion of tPA.

Conclusion

Lower-dose slow-infusion of tPA protocol decreased significantly all-cause and PE-cause mortality at 30-day at the cost of excess of non-fatal major bleeding at 7-day in patients with intermediate-risk PE and higher risk for bleeding.

Acknowledgement/Funding

None
P5600Surgical reconstruction of type A aortic dissection in octogenarians
Authors: Masuyama S , Inoue T , Ichihara T
Published: October 2019

Introduction

Because the population is aging, the indication for surgical reconstruction in older patients will increase. Japan is especially facing the most aging society worldwide. However, surgical reconstruction of type A aortic dissection (AADA) in patients who are octogenarians is not often performed because of the decision of the patient or surgeon. We examined the outcome of surgical reconstruction of AADA in octogenarians.

Method

Over 4 years, 132 cases of surgical reconstruction of AADA were analyzed. Twenty-five consecutive octogenarians with AADA were retrospectively reviewed. In our institution, we recommend an emergent operation to the patient or family in all generations unless they reject it for some reason.

Results

Operative factors in octogenarians with AADA were not significantly different compared with those in patients aged younger than 79 years (n=107) (operation: 238±11 vs. 246±5 min, p=0.54; cardiopulmonary bypass: 147±7.4 vs. 154±3.5 min, p=0.42; aortic-clamp: 114±6.0 vs. 120±2.8 min, p=0.36; hypothermic-arrest: 43±2.7 vs. 42±1.3 min, p=0.81). The overall mortality rate was 24.0% (n=6). The mortality rate was no difference between younger patients and octogenarians (OR: 2.7, 95% CI: 0.86–8.21, p=0.08). Furthermore, MACE (Major Adverse Cardiac Event) and the postoperative stroke rate were not significantly different between the two groups (OR: 1.5, 95% CI: 0.52–3.93, p=0.42; OR: 0.77, 95% CI: 0.16–2.59, p=0.69, respectively).

Conclusion

In AADA, the outcome of emergent surgical reconstruction in octogenarians is acceptable. Even with the risk of aging, surgeons should consider aggressive surgical reconstruction in octogenarians.
P5603Distal stent graft induced new entry: risk factors in acute and chronic type B aortic dissections
Authors: Lortz J , Leinburger F , Tsagakis K , Rammos C , Lind A , Schlosser T , Jakob H , Rassaf T , Janosi R A
Published: October 2019

Background

Distal stent graft induced new entry (dSINE) is a rare complication occurring in acute and chronic dissections after thoracic endovascular aortic repair (TEVAR) and is linked to a high reintervention rate. We analyzed potential predicting risk factors for dSINE and analyzed the long-term outcome in patients after reintervention.

Methods

In this single-center, retrospective study we evaluated patients after TEVAR and investigated possible predictors for dSINE development. Therefore, we used a multivariate analysis to test important interventional parameters such as distal oversizing (dOS), taper ratio (TR), angle between distal stent graft and aorta, acute dissection and stent graft length. Reinterventional characteristics were analyzed and further long-term follow-ups after reintervention evaluated.

Results

We analyzed 185 patients with acute (n=77) and chronic (n=108) dissections after TEVAR with a follow-up of 68.9±32.5 months. Within the follow-up period, 12 (6.5%) patients developed dSINE after a median time of 22.2±20.7 months. We identified acute dissection as a major predicting factor for dSINE development with a 15.8 times higher odds, followed by an increased dOS and TR. The reintervention rate was higher in the dSINE group (83% vs. 20%, p=0.001), but reinterventional results were mostly satisfying, including further freedom from reintervention and/or new endoleak development up to a mean follow-up of 60.7±54.8 months. No dSINE was seen in association to tapered stent grafts.

Conclusion

We found acute aortic dissection as a major predicting factor for dSINE development, followed by increased dOS and TR. The use of tapered stent grafts might be beneficial in cases with expected high dOS and TR. In rare cases with dSINE occurrence, reintervention is often required, but has a good prognosis even after years.
P5616Risk stratification of cardiovascular events among patients with functionally non-significant coronary stenosis
Authors: Jujo K , Shimazaki K , Furuki Y , Moriyama T , Shiozaki N , Iwanami Y , Arashi H , Hagiwara N , Saito K
Published: October 2019

Introduction

Deferral of percutaneous coronary intervention (PCI) of a functionally non-significant stenosis is associated with a favorable long-term clinical prognosis. However, to date, there has been limited evidence to stratify the risk for the development of cardiovascular (CV) adverse events in patients who were deferred of PCI due to a greater fractional flow reserve (FFR) than 0.80 at the target lesion.

Purpose

We aimed to stratify the risk of CV events in patients with functionally significant and non-significant coronary stenosis.

Methods

This observational study included 458 patients who were proven angiographically intermediate coronary stenoses and were measured FFR, of whom 298 deferred patients with FFR>0.80 and 160 intervened patients with FFR<0.80. The primary endpoint was the incidence of major adverse cardiac and cerebrovascular events (MACCE) including any death, non-fatal myocardial infarction, hospitalization due to heart failure, ischemic stroke and any unplanned revascularization. ROC curve for MACCE indicated the cut-off point of FFR as 0.85 and 0.76 in deferred patients and intervened patients, respectively.

Results

During the observation period, 27 MACCE (9.1%) in the Deferred group, and 33 MACCE (20.6%) in Intervened group were occurred. Kaplan-Meier curves showed a higher MACCE rate in the Intervened group than Deferred group (hazard ratio (HR): 2.19, 95% confidence interval (CI): 1.29–3.71, Figure A). However, even among patients in the Deferred group, the population with “intermediate” FFR (0.81–0.85) had a significantly higher MACCE rate than those with higher FFR (>0.85) (HR 2.55, 95% CI 1.14–5.69, Figure B). This rate was comparable to that of the Intervened group at the remote phase (at 4-year: 32.0% vs. 35.8%). Conversely, in the Intervened group, there was no statistically significant difference in MACCE rate between patients with higher FFR (0.76–0.80) and those with lower FFR (<0.76) (Log-rank: p=0.21, Figure C).

Conclusion

The population with relatively low FFR in patients who were deferred PCI by FFR>0.80 had comparable MACCE rate to patients with FFR<0.80. Close observation after the FFR evaluation should be considered in those population.
P5623Plaque characteristics, slow flow during percutaneous coronary intervention, and clinical outcomes of irregular protrusion by optical coherence tomography
Authors: Amano H , Noike R , Saito D , Yabe T , Watanabe I , Koizumi M , Okubo R , Toda M , Ikeda T
Published: October 2019

Introduction

In pathological studies, penetration of the lipid core into the stent strut is associated with neointimal growth and stent thrombosis. Irregular protrusion on optical coherence tomography (OCT) is associated with clinical events and target lesion revascularization. However, there are few reports about the relationship among irregular protrusion, plaque characteristics, and slow flow during percutaneous coronary intervention. We investigated clinical and procedure characteristics, plaque characteristics, slow flow after stent implantation, and clinical outcomes with irregular protrusion by using OCT.

Methods

Eighty-four lesions in 76 patients undergoing OCT before percutaneous coronary intervention were evaluated. Irregular protrusion was defined as protrusion of material with an irregular surface into the lumen between stent struts with a maximum height of ≥100 μm. Major adverse clinical outcomes were defined as death, acute myocardial infarction, acute coronary syndrome, or target lesion revascularization.

Results

Lesions with irregular protrusion were found in 56% (47/84). Compared with lesions without irregular protrusion, those with irregular protrusion had significantly higher low-density lipoprotein cholesterol (LDL-C) levels (108±31 mg/dL vs. 95±25 mg/dL, P=0.044); a tendency toward decreased use of statins (44% [19/43] vs. 67% [22/33], P=0.065); significantly larger reference vessel diameter (3.12±0.53 mm vs. 2.74±0.63 mm, P=0.004); significantly larger stent diameter (3.23±0.43 mm vs. 3.00±0.49 mm, P=0.025); a tendency toward longer total stent length (29.3±14.2 mm vs. 23.7±11.4 mm, P=0.056); significantly larger maximum balloon diameter (3.56±0.55 mm vs. 3.22±0.63 mm, P=0.010); significantly higher incidence of slow flow after stent implantation (38% [18/47] vs. 11% [4/37], P=0.006); significantly higher ΔTIMI flow from pre-stenting to post-stenting (0.4±0.6 vs. 0.1±0.3, P=0.009); significantly higher incidence of lipid-rich plaque (70% [33/47] vs. 35% [13/37], P=0.002); thin-cap fibroatheromas (TCFAs: 49% [23/47] vs. 5% [2/37], P<0.001); plaque rupture (40% [19/47] vs. 16% [6/37], P=0.018); macrophage accumulation (51% [24/47] vs. 24% [9/37], P=0.015); internal running vasa vasorum (51% [24/47] vs. 11% [4/37], P<0.001); thrombus (32% [15/47] vs. 3% [1/37], P<0.001); and a tendency higher incidence of one-year adverse clinical outcomes (12% [5/43] vs. 0% [0/33], P=0.075: log rank). The multivariable analysis showed that TCFA was an independent predictor of irregular protrusion (odds ratio 9.00, 95% CI 1.32–61.36, P=0.025).

Conclusions

Irregular protrusion on OCT was associated with high plaque vulnerability, higher LDL-C, less frequent use of statin, larger vessel diameter, longer total stent length, slow flow after stent implantation, and one-year adverse clinical outcomes.
P5643Simple 12-leads electrocardiography can predict cardiac death in patients with complete left bundle branch block
Authors: Shimizu M , Iiya M , Hara K , Ohmori M , Taomoto Y , Kaneda T , Yamakami Y , Shimada H , Manno T , Isshiki A , Kimura S , Fujii H , Suzuki M , Nishizaki M
Published: October 2019

Background

Patients with complete left bundle branch block (CLBBB) generally fall in two categories: CLBBB with good prognosis and poor prognosis. However, a simple electrocardiography (ECG) was considered impossible to predict the two categories.

Purpose

To elucidate the possibility of 12-leads ECG for predicting cardiac prognosis in patients with CLBBB

Methods

To estimate myocardial damage and left ventricular function, the ECG was performed with semiconductor SPECT simultaneously. Among consecutive 5864 patients who underwent ECG gated SPECT, finally 103 sinus-rhythm patients were enrolled. The observed period of them was median 632 days, and primary endpoint was set as cardiac death.

Results

Eight patients fell into cardiac death. Cox univariate analysis showed ventricular activation time (VAT: duration from onset of Q wave to peak of R wave) in V1 lead, T wave amplitude in aVR (aVR T-amp), and multiple fragmented QRS (At least 2 fQRS in LV anterior/inferior/lateral wall), and left ventricular ejection fraction, standard deviation of phase analysis (Phase SD), and summed rest score were significant predictors. After optimization of all significant continuous predictors by ROC curve analysis, all the significant predictors were analyzed by multivariate Cox analysis (stepwise regression). VAT in V1 (Hazard ratio: 4.594, P=0.034), aVR T-amp ≥-85microV (HR: 11.11, P=0.029), and Phase SD≥48.7 (HR6.047, P=0.035) were independent predictors. Kaplan-Meyer curve analysis demonstrated VAT V1≥70 and aVR T amp≥-85 showed the worst prognosis (P=0.008).

Cox Regression after Optimization by ROC Univariate Multivariate (Stepwise regression) HR 95% CI P HR 95% CI P VAT I ≥70 6.861 1.759–26.76 0.006 4.594 1.126–18.75 0.034 T amp in aVR ≥−85 27.34 3.458–216.2 0.002 11.11 1.274–96.85 0.029 Multiple fQRS 3.836 1.081–13.61 0.037 LVEF ≤37% 7.250 1.874–28.04 0.004 SD ≥48.7 17.30 3.671–81.57 <0.001 6.047 1.133–32.28 0.035 SRS≥17 4.178 1.206–14.48 0.024 SD: standard deviation of histogram by phase analysis of SPECT; SRS: summed rest score by myocardial perfusion analysis of SPECT.

Conclusion

Simple 12-leads ECG could predict the prognosis of patients with CLBBB.
P5648Efficiency and accuracy of arrhythmia detection using implantable cardiac monitor: A prospective multicenter randomized clinical trial comparing Reveal LINQ and Confirm Rx
Authors: Yokokawa M , Jaffe B , Ip R , Azad R , Castellani M , Ip J
Published: October 2019

Background

Implantable cardiac monitor (ICM) has been used to detect occult cardiac arrhythmias in a variety of clinical situations. The reliability and accuracy of diagnosing cardiac arrhythmia could impact patient care. However, it is not clear the efficiency and reliability of detecting cardiac arrhythmias between currently available two ICMs.

Purpose

To compare the efficiency and accuracy of diagnosing cardiac arrhythmias between Reveal LINQ™ and Confirm Rx™.

Methods

In the prospective multicenter randomized study, a total of 80 patients (age: 61±17 years, men: 41 [51%]) with cryptogenic stroke (n=52) or recurrent unexplained episodes of palpitations (n=3) or syncope (n=25) received an ICM for detection of arrhythmias. Patients were randomized one to one into receiving either Reveal LINQ™ or Confirm Rx™. Arrhythmic events are defined as pauses of ≥3.0 seconds, bradycardia with heart rate of ≤40 bpm, tachycardia with heart rate of ≥150 bpm, and atrial fibrillation (AF). The time of detected arrhythmic events and patient activated events to the time of data availability on respective website site for analysis were compared between the two ICM. All of the arrhythmia events were adjudicated by two cardiologists to assess the accuracy.

Results

A total of 680 arrhythmic events including 352 AFs, 109 bradycardias, 167 tachycardias and 52 pauses were transmitted over a mean follow-up of 4.2±2.5 months. The mean time to data transmission was significantly faster in Confirm Rx™ than in Reveal LINQ™ (24±103 vs 475±426 min, P<0.0001). One-hundred fifty-nine of 352 AF events (45%) and 237 of 328 non-AF events (72%) were accurately detected by ICMs (P<0.0001). Twenty-eight of 51 AF events (55%) were detected accurately by Reveal LINQ™ and 131 of 301 AF events (44%) were accurately detected by Confirm Rx™ (P=0.13). The reason for inaccurate AF detection was frequent ectopic beats (n=134), P-wave oversensing (n=15), T-wave oversensing (n=8), both P- and T-waves oversensing (n=18) and sinus tachycardia with R-wave undersensing (n=18).

Conclusions

Data transmission of arrhythmic events using Confirm Rx™ is significantly faster than Reveal LINQ™. The accuracy of AF detection with current algorithms in both ICM remains suboptimal. More patients and longer follow-up is required to confirm these findings.
P5661Validation of CHA2DS2-VA score (excluding female sex) in non-valvular atrial fibrillation patients: a nationwide population-based study
Authors: Choi S Y , Kim M H , Lee K M , Kim J K , Woo J Y , Cho Y R
Published: October 2019

Background

Sex category (Sc, ie, female sex) confers 1 point on CHA2DS2-VASc score. So, no woman with atrial fibrillation (AF) can have a CHA2DS2-VASc score of 0. This study aimed to compare CHA2DS2-VA (excluding female sex) and CHA2DS2-VASc score in Korean AF patients.

Methods

Using the Korean National Health Insurance Service database, we analyzed the risk of ischemic stroke in non-valvular AF patients between 2013 and 2017. The predictive value of the CHA2DS2-VA and CHA2DS2-VASc scores for ischemic stroke was evaluated by c-statistic difference and net reclassification improvement (NRI). The propensity score matching method was used to balance covariates across male and female AF patients.

Results

A total of 182,133 patients with AF (49.2% women) were included to this study. The adjusted incidence rate (IR) of ischemic stroke was not significantly different between males and females (0.89%/y and 0.90%/y, respectively, p=0.411) in low-risk patients without risk factor. Also, no sex difference was found in high-risk patients with above 2 risk factors for ischemic stroke (4.46%/y for male and 4.49%/y for male, p=0.498). In c-statistic analysis for ischemic stroke, there was no significant difference between the CHA2DS2-VA and CHA2DS2-VASc scores (AUC 0.662 vs. 0.664, z=1.572, p=0.116). When compared with CHA2DS2-VASc score, CHA2DS2-VA score was not significantly inferior in net reclassification improvement (NRI 0.031, 95% CI 0.002–0.037, p=0.118) for ischemic stroke.

C-statistics

Conclusions

In Korean AF patients, the CHA2DS2-VA score excluding female sex is a useful risk scoring system for ischemic stroke.
P5668A decision-support tool framework to predict adverse outcome in patients with atrial fibrillation: J-Rhythm registry substudy
Authors: Watanabe E , Yamashita T , Inoue H , Atarashi H , Okumura K , Kodani E , Origasa H , Kiyono K
Published: October 2019

Background

Atrial fibrillation (AF) is associated with increased mortality and morbidity. Modelling the risk of thrombosis, major bleeding and total mortality are often limited by the inadequate number of independent predictors.

Purpose

We compared the predictive accuracy of the decision-support tool framework and conventional risk score in AF patients.

Methods

We used data of AF patients enrolled into the nationwide AF registry. A random forest model was implemented to predict each outcome, and its predictive power was tested by a 5-fold cross-validation.

Results

We analyzed 7,937 patients with AF (age 70±10 years, female 31%). The type of AF was paroxysmal (37%), persistent (14%), and permanent (49%). The number of antithrombotic treatments were follows: warfarin only (n=5461), antiplatelet only (n=581), both warfarin and antiplatelet (n=1471) and no antithrombotic agents (424). The mean CHA2DS2-VASc score was 2.8±1.6 and HAS-BLED score was 2.7±1.2, respectively. We selected 20 from 50 clinical parameters and compared by the area-under-curve with the CHA2DS2-VASc score for thromboses and the HAS-BLED score for major bleeding. During the 2-year follow-up, 126 patients (1.6%) had thromboses, 140 (1.8%) had major bleeding, and 195 (2.5%) died. A random forest model had a higher value of the area-under-curve for predicting thromboses compared with the CHA2DS2-VASc (0.66 vs. 0.61, P<0.05), and had a significantly higher area-under-curve for major bleeding compared with the HAS-BLED (0.67 vs. 0.61, P<0.05). The area-under-curve for the all-cause mortality was 0.77.

Conclusions

A random forest model has a higher accuracy than conventional risk scheme in predicting thromboses and major bleeding, in addition to total mortality.
P5674Direct comparison of three high-sensitivity cardiac troponins in syncope
Authors: Du Fay De Lavallaz J , Badertscher P B , Zimmermann T Z , Walter J W , Strebel I S , Puelacher C P , Peacock F P , Boeddinghaus J B , Nestelberger T N , Geigy N G , Miro O M , Kuehne M K , Reichlin T R , Mueller C M
Published: October 2019

Background

It is unknown, whether high-sensitivity cardiac troponin I (hs-cTnI) or hs-cTnT provide higher accuracy for the diagnosis and risk-stratification of patients with syncope.

Methods

We directly compared the diagnostic and prognostic accuracy of hs-cTnI and hs-cTnT in a prospective international multicenter study enrolling patients older than 40 years presenting with syncope to the emergency department (ED). Hs-cTnI/T concentrations were measured in a blinded fashion using three assays. Cardiac syncope, as adjudicated by two independent physicians using all available clinical information including 1-year follow-up, was the diagnostic endpoint. Death and nonfatal major adverse cardiovascular events (MACE) at 5, 30 and 720 days were the prognostic endpoints.

Results

Among 1219 patients, cardiac syncope was the adjudicated final diagnosis in 204 (16.7%). All three hs-cTn showed higher concentrations in patients with cardiac syncope compared with other causes (all p<0.01, Figure 1) and remained independent predictors of cardiac syncope in multivariable models. While the diagnostic accuracy of the three assays for cardiac syncope was similar (area under the curve (AUC) of 0.76–0.77 (95% CI, 0.72–0.80, p>0.05 for all direct comparisons)), the percentage of patients above/below the assay-specific cut-off strongly varied (Figure 1). The prognostic accuracy of hs-cTnI/T was comparable among the assays and very high for imminent (within 5 days) death (AUC 0.93–0.94), and high for 30 and 720-day death (AUC 0.74–0.8), as well as MACE (AUC 0.74–0.78).

Figure 1

Conclusion

Hs-cTnI/T concentrations may have clinical utility in patients presenting with syncope as they provide diagnostic as well as prognostic information.

Acknowledgement/Funding

Swiss National Science Foundation, Swiss Heart Foundation, Cardiovascular Research Foundation, Basel (Switzerland), University Basel (Switzerland)
P5690Comparison of two methods to navigate the stereotactic body radiotherapy ablation for ventricular tachycardia, the invasive electrophysiological study and substrate identification
Authors: Neuwirth R , Cvek J , Jiravsky O , Knybel L , Chovancik J , Fiala M , Sknouril L
Published: October 2019

Purpose

To compare two methods used for identifying the arrhythmogenic substrate - invasive electrophysiological study versus PET-CT scar identification. The substrate is then targeted by stereotactic body radiotherapy (SBRT) in patients with previously unsuccessful radiofrequency catheter ablation.

Methodology

Patients with ischemic cardiomyopathy, LVEF less than 40% and unsuccessful conventional treatment resulting in recurring ventricular tachycardias, were divided into two groups with different methods of obtaining arrhythmogenic substrate. In the group A, invasive electrophysiological mapping was used, while in the group B, scar identification by PET-CT was done, enhanced with non-invasive body surface ecg mapping of all inducible ventricular tachycardias. This target obtained was then attacked with SBRT. We compared the size of the planned target volume (PVT), the SBRT duration, the calculated dose for the esophagus, stomach and lung and the incidence of acute complications.

Cohort description

Patients in group A were recruited from April 2014 to December 2018, patients in group B from June to December 2018. Group A (8 patients) – mean age 66, NYHA class 2.4, LVEF 29,4%. Group B (6 patients) – mean age 71, NYHA class 2.1, LVEF 25,2%. All patients were men.

Results

There was a statistically significant difference in PTV – Group A (mean 24.1ml, SD = 3,9), Group B (mean 76.0ml, SD 14.1), p<0,001 (two-sample t-test). There was no difference in the calculated secondary radiation doses acquired by surrounding organs. The most frequent adverse event was acute anorexia, occurring in 4 patients from Group A and in 2 patients from Group B. The anorexia subsided in one week time. One patient from Group B suffered from esophageal ulcer, which developed 6 months after the therapy.

Conclusion

Using invasive electrophysiology mapping to identify arrhythmogenic substrate for SBRT yields significantly smaller volume of targeted tissue. Despite this finding, we did not find any difference neither in radiation dose delivered to the surrounding organs, nor in the radiation duration.
P5695Catheter ablation of ventricular tachycardia in patients with acute vs. previous myocarditis
Authors: Peretto G , Sala S , Gigli L , Rizzo S , Palmisano A , Esposito A , Thiene G , Basso C , Della Bella P
Published: October 2019

Background

Ventricular tachycardias (VT) may occur late after myocarditis, as well as in the acute inflammatory phase of the disease. However, the role of catheter ablation (CA) in preventing VT recurrences in patients with acute (AM) vs. previous myocarditis (PM) has never been investigated so far.

Purpose

To evaluate the results of CA performed in patients presenting with VA and biopsy-proved myocarditis at different inflammatory stages.

Methods

We enrolled 46 consecutive patients (74% males, mean age 43±12y, mean LVEF 46±9%) with myocarditis and VT at index hospitalization. Based on endomyocardial biopsy and cardiac magnetic resonance (CMR) results, the patients were divided into AM and PM groups: in AM group, myocarditis was biopsy-proved, according to the ESC criteria; PM patients had a history of biopsy-proved myocarditis more than 12 months before, with no current signs of active inflammation (negative biopsy according to the ESC criteria; nonischaemic LGE at CMR with negative Lake-Louise criteria; absence of unexplained troponin abnormalities). ICD were implanted upon clinical indications. All of the patients underwent electroanatomical mapping (EAM) and VT CA. During 3 (2.5–3.5)y FU, VT recurrences were evaluated by 2/y Holter ECG and ICD interrogation.

Results

At baseline, 23 patients (50%) had AM, and 23 PM. Overall, 16 AM and 21 PM patients underwent ICD implant (p=n.s.). The clinical VT was monomorphic in 22 AM and 23 PM patients, respectively (p=n.s.) with a dominant right-bundle branch block with superior axis (RS) morphology in both groups (16 AM vs. 17 PM cases, p=n.s.). However, RS morphology was associated with left ventricular inferoposterior LGE at CMR in 9/16 AM vs. 17/17 PM patients (p=0.003). Similarly, inferoposterior localization of low-voltage areas at EAM was found in 11/16 AM vs. 17/17 PM patients (p=0.018). Furthermore, CMR showed a greater LGE transmural extension in AM patients (65±19%) as compared to PM ones (40±25%, p<0.001). Epicardial EAM and CA were performed in 14 AM vs. 15 PM patients, with endocardial-only approach adopted in the remaining cases (p=n.s.). VT CA was defined as successful (class A) in all of the subjets. However, during FU VT recurrences were documented in 7/23 AM vs. 0/23 PM patients (p=0.009). Four AM cases underwent redo CA late after myocarditis (1.5±0.3y after index hospitalization), with no further VT recurrences in FU.

Conclusion

In myocarditis patients presenting with VT, CA results are significantly better in PM cases as compared to AM ones. These findings are consistent with the different underlying substrate, and suggest the best role for ablation strategy after myocarditis healing.

Acknowledgement/Funding

None
P5702Non-invasive epicardial and endocardial mapping in patients with idiopathic right ventricular outflow tract premature ventricular contractions: new insights into arrhythmia substrate
Authors: Parreira A L , Carmo P , Adragao P , Pinho J , Jeronimo R , Cavaco D , Soares A , Budanova M , Zubarev S , Costa F , Carmo J , Marques H , Goncalves P
Published: October 2019

Background

It has been accepted for years that idiopathic premature ventricular contractions (PVCs) with origin in the right ventricular outflow tract (RVOT) are benign. They are thought to result from triggered activity and most studies do not describe abnormal findings during electroanatomical mapping

Dispersion of ventricular repolarization is associated with the susceptibility to ventricular arrhythmias and may indicate the presence of diseased myocardium. The activation recovery interval (ARI) has been used as a surrogate measure of ventricular action potential duration and refractory period.

Purpose

The aim of this study was to use the new non-invasive epicardial and endocardial mapping system (NEES) to study patients with RVOT PVCs in order to evaluate the ARI in the epicardium of RVOT during sinus rhythm (SR).

Methods

Non-invasive mapping was performed with the NEES, based on body surface electrocardiograms of a maximum of 224 electrodes and computed tomography imaging data. Unipolar electrograms were reconstructed on the epicardial and endocardial surfaces. Patients were excluded if they had structural heart disease, previous ablation or conduction abnormalities. ARI was defined as the interval between times of minimum derivative of the QRS and the maximum derivative of the T wave in the unipolar electrograms. We evaluated the ARI map in patients with RVOT PVCs and in a control group of patients without PVCs (Figure). We assessed the maximum value of ARI (Max ARI), the minimum value of ARI (Min ARI) and the difference between the Max ARI and the Min ARI (Diff ARI).

Results

We studied 8 patients with RVOT PVCs and 8 patients without PVCs.

The results are presented in the table.

Demographic and NEES data RVOT PVCs (n=8) Control (n=8) P value* Demographic data   Age in years, median (IQR) 53 (48–65) 59 (52–67) 0.536   Male gender, n (%) 4 (50) 6 (75) 0.608 NEES data   Max ARI in msec, median (IQR) 285 (236–331) 228 (197–298) 0.195   Min ARI in msec, median (IQR) 176 (138–192) 216 (185–255) 0.161   ARI diff in msec, median (IQR) 111 (83–147) 15 (4–34) <0.0001

NEES map

Conclusion

In this group of patients we found a significantly higher dispersion of the ARI measurements through the epicardium of the RVOT in patients with PVCs in comparison with patients without PVCs.
P5707An evaluation of the use of propensity scores in cardiovascular literature: a systematic review and recommendations
Authors: Samuel M , Batomen B , Rouette J , Kim J , Platt R W , Brophy J , Kaufman J S
Published: October 2019

Background

As randomized trials cannot always be conducted, propensity score (PS) methods are frequently used in cardiovascular observational studies. Previous evaluations found insufficient and inaccurate reporting of PS methods in the clinical literature, however; a comprehensive and current evaluation of their use and reporting is thus warranted.

Purpose

1) To conduct a systematic review of cardiovascular articles published in high-impact medical and cardiovascular journals to evaluate the use and reporting of PS methods, as well as interpretation of results. 2) To identify key reporting and analysis elements when using PS methods.

Methods

Cardiovascular articles using PS published between 2010 to 2017 in high-impact medical (5) and cardiovascular (3) journals were reviewed. Included studies used a PS-based method, and focused on cardiovascular diseases, outcomes, interventions, or techniques. Information was extracted on: (1) PS assumptions, (2) variable selection and assessment of model success, (3) specifics of each PS method, and (4) consistency of written interpretation with the causal effect estimated. Each article was evaluated by 2 reviewers. Recommendations for key elements to be included in publications were based on findings and PS methodological literature.

Results

Of the 296 included articles, most were published in Journal of the American College of Cardiology (83 articles; 28%), followed by Circulation (79 articles; 27%), European Heart Journal (46 articles; 14%), Journal of the American Medical Association (35 articles; 12%), British Medical Journal (30 articles; 10%), New England Journal of Medicine (10 articles; 3%), Annals of Internal Medicine (10 articles; 3%), and Lancet (3 articles; <1%). The most commonly used PS method was matching (53% of studies), followed by a combination of methods (19%), direct adjustment (13%), inverse probability weighting (IPW, 12%), and stratification (3%). Variables in the PS model were predefined in 77% of articles, selected with statistical testing in 17% of articles, or both in 5% of articles (no details for 1% of articles). Balance was not assessed in 16% of papers and 38% of articles that evaluated balance did not report standardized differences, the recommended measure to assess balance. For matching, most studies (85%) conducted a 1:1 match; however, 17% of studies had >50% of unmatched treated (or untreated) patients (based on targeted parameter). Overall, heterogeneity of effects was assessed in 89% of all articles. In 48% of the reviewed articles, however, interpretations of the effect estimates did not correspond to the PS method conducted or described.

Conclusions

Detailed reporting of PS methods is important to maintain transparency and reproducibility, evaluate the appropriateness of the method, and correctly interpret the results and the population to which they apply. This systematic review describes areas for improvement.
P5731Optimal blood pressure in diabetic hypertensive patients with overt proteinuria
Authors: Lee C J , Hwang J , Kang C Y , Kim H , Ha J , Chun K.-H , Oh J , Lee S.H.- , Kang S.-M , Park S , Yoo T.-H
Published: October 2019

Background

Evidence for the benefit of intensive blood pressure lowering in diabetic nephropathy is not clear at this time. The objective of this study was to demonstrate whether lower mean blood pressure (BP) in treated hypertensive patients with diabetic nephropathy is associated with better prognosis.

Methods

From the National Health Insurance Service (NHIS) Health Examination Database, diabetic hypertensive subjects with proteinuria between 2009 and 2010 were selected and followed-up until 2015 (N=8,663). Mean of the recorded systolic and diastolic BP during follow-up health examinations were stratified into five categories (SBP: <120, 120 to <130, 130 to <140, 140 to <150, and ≥150 mmHg; DBP: <70, 70 to <80, 80 to <90, 90 to <100, and ≥100 mmHg). All-cause death, myocardial infarction (MI), stroke, and renal outcome (progression to end stage renal disease or doubling of serum creatinine) were examined by Cox proportional hazard models with the propensity scores adjusted method.

Results

Compared to SBP of 130 to <140 mmHg, SBP of 120 to <130 mmHg was associated with lower risk of all-cause death (HR=0.78; 95% CI, 0.64–0.95), stroke (HR: 0.65; 95% CI, 0.45–0.94), and renal outcome (HR: 0.81; 95% CI, 0.68–0.97). SBP of <120 mmHg was associated with benefit for renal outcomes (HR: 0.69; 95% CI 0.55–0.88) but not with elevated risk of other outcomes. Compared to DBP of 80 to <90 mmHg, DBP of 70 to <80 mmHg were associated with lower risk of all-cause death (HR: 0.75; 95% CI, 0.64–0.88) but with higher risk of MI (HR: 1.52; 95% CI, 1.05–2.21). DBP of <70 mmHg was associated with reduced risk of all-cause death (HR: 0.79; 95% CI, 0.64–0.98).

Conclusion

In diabetic hypertensive subjects with overt proteinuria, deterioration of renal function decreased with decreasing SBP and the lowest risk of all-cause death and stroke were observed in SBP <130 mmHg. Low DBP was associated with low risk of all-cause death but there was a J curve phenomenon for MI in DBP of 70 to <80 mmHg.
P5738Multicenter analysis of left ventricular unloading on top of VA-ECMO for treatment of cardiogenic shock
Authors: Schrage B , Dabboura S , Bezerra H , Sinning J M , Thiele H , Pauschinger M , Frank D , Schulze P C , Pappalardo F , Morrow D , Li Y , Eitel I , Nordbeck P , Skurk C , Westermann D
Published: October 2019

Background

Veno-arterial extracorporeal membrane oxygenation therapy (VA-ECMO) is increasingly used for treatment of severe cardiogenic shock, although it causes an increase in left ventricular (LV) afterload and might therefore hamper myocardial recovery. Recently, the addition of catheter-based left ventricular assist device (cLVAD) on top of VA-ECMO has been used to unload the LV and to improve outcome measures. However, there is limited data on predictors of outcome in this high-risk population.

Aim

The aim of this study was to evaluate predictors of 30-day survival in a multicentre cohort of severe cardiogenic shock patients treated with cLVADon top of VA-ECMO.

Material and methods

We report on consecutive patients from six tertiary care centers being treated with cLVAD in addition to VA-ECMO for treatment of cardiogenic shock. The primary endpoint is 30-day all-cause mortality. To identify predictors of the primary endpoint, multivariate analysis using an “elastic net” variable selection algorithm was done after imputation of missing variables.

Results

A total of 220 patients treated with cLVAD on top of VA-ECMO were included in the analysis. Of these, 79.1% were male with a median age of 55.5 (25thpercentile 48.0, 75thpercentile 65.6) years. In 60.5% of the patients, acute myocardial infarction was the underlying cause of cardiogenic shock and in 44.6% VA-ECMO was used for refractory cardiac arrest (eCPR). In the multivariable analysis, the following baseline parameters were significantly associated with the primary endpoint: Age (odds ratio of 1.68 per standard deviation), duration of cardiopulmonary resuscitation (OR 2.08 per SD), lactate (OR 1.04 per SD) and time from onset of shock to VA-ECMO (OR 1.30 per SD).

Conclusion and outlook

In this large-scale multicentre analysis of severe cardiogenic shock patients treated with VA-ECMO plus additional cLVAD unloading, age, duration of cardiopulmonary resuscitation, lactate and time from onset of shock to VA-ECMO were significantly associated with 30-day all-cause mortality.

To further investigate this topic, we will evaluate predictors of outcome in distinct patient populations such as acute myocardial infarction vs. acute heart failure and patients without vs. patients with prior cardiopulmonary association.
P5975Diminished LV systolic velocity on tissue Doppler imaging is linked to an amplified risk of lethal arrhythmias independently of LV ejection fraction
Authors: Barakat M F , Sunderland N , Chehab O , Kaura A , Hayat S , Amin-Youssef G , Scott P , Okonko D O
Published: October 2019

Background

Life threatening arrhythmias (LTA) can trigger sudden cardiac death, or provoke implantable cardioverter defibrillator (ICD) discharges that escalate morbidity and mortality. Longitudinal myofibrils predominate in the subendocardium which is uniquely sensitive to arrhythmogenic triggers.

Objectives

To test the hypothesis that mitral annular systolic velocity (S'), a tissue Doppler index of LV long-axis systolic function, might predict lethal arrhythmias irrespective of LVEF.

Methods

We analysed data from diverse ICD and cardiac resynchronization therapy defibrillator (CRT-D) patients at 2 London centres. Channelopathies were excluded. S' was averaged from medial and lateral mitral annuli velocities. Primary outcome was time to sustained ventricular tachycardia (VT) or fibrillation (VF) needing device therapy.

Results

In 302 patients (mean age 68 years, LVEF 32%, 77% male, 52% ischemic, 35% primary prevention, and 53% CRT-D), median S' was 5.1 (IQR: 4.0–6.2) cm/s and lower in CRT-D than ICD subjects. After a median follow-up of 15 months, 56 (19%) subjects had LTA and those who did had a lower S' than those who did not (4.6±1.4 cm/s vs. 5.4±1.7 cm/s, P=0.003-Fig A). Each 1cm/s lower S' correlated to a 43% increased risk of LTA (HR: 0.70, 95% CI: 0.57–0.87, P=0.001) independently of age, gender, β-blocker use, centre, ICD use and LVEF. Adding S' to the baseline model improved net reclassification (P=0.02) implying incremental utility (Fig B). An S' ≤5.6cm/s was the best cut-off, conferring a 2.4-fold higher LTA risk than an S'>5.6 cm/s (95% CI: 1.17–4.37, P=0.02–Fig C).

Conclusion

A lower S' forecasts an enhanced probability of LTA in cardiac device recipients irrespective of LVEF, and could be used to titrate medical, device and ablative therapies to mitigate future arrhythmic risk.
P5978Mechanical dispersion is a predictor of 30-day permanent pacemaker implantation after transcatheter aortic valve replacement
Authors: Manshad A S , Hemu M , Ballout F A , Zimmerman A , Hein K Z , Kavinsky C J
Published: October 2019

Background

Transcatheter aortic valve replacement (TAVR) related conduction disturbance resulting in permanent pacemaker (PPM) implantation is a common complication. The mechanical effects of these conduction abnormalities can be measured as regional heterogeneity of contraction by myocardial strain imaging.

Objectives

The aim of this study was to investigate whether post-TAVR left ventricular mechanical dispersion (MD) can predict PPM implantation.

Methods

We retrospective analyzed 137 patients (48% men, 80±9 years) who underwent TAVR at our institution after excluding patients with pre-existing PPM. 2D speckle-tracking echocardiography was used to assess MD (SD of time from Q/R on the ECG to peak strain in 16 LV segments) immediately after TAVR (median, 1 day). Images were analyzed offline using a vendor-independent software (TomTec).

Results

At 30-days post-TAVR, 14 (10.2%) patients underwent PPM implantation. Patients requiring PPM had more pronounced MD (p=0.012), pre-existing RBBB (p=0.017), pre-existing LAHB (p<0.001), and peri-procedural AVB (p=0.005). Multivariate Cox regression analysis of important clinical covariates (model 1 = age, sex, RBBB, LAHB, AVB) showed significant predictive value for PPM implantation (chi-square 41.8, p<0.001). Addition of MD to the model resulted in a significant chi-square increase (from 41.8 to 47.3, p=0.01).

Conclusion

Left ventricular MD, measured immediately after TAVR, was associated with 30-day PPM and provided incremental predictive value to important clinical variables.
P5980Etiology of perioperative myocardial injuries after non-cardiac surgery and associated outcomes
Authors: Puelacher C , Gualandro D M , Lurati Buse G , Marbot S , Gueckel J , Hidvegi R , Wildi K , Espinola J , Kindler C , Lampart A , Bolliger D , Osswald S , Mueller C
Published: October 2019

Background

Perioperative myocardial injuries (PMI) are a common complication following non-cardiac surgery associated with significantly increased postoperative mortality. Due to its mostly asymptomatic presentation it is currently often missed in clinical routine. With the advent of routine screening PMI will be an increasingly recognised. Therefore, a more detailed understanding of the different etiologies causing PMI is needed to guide management.

Methods

We included consecutive high-risk patients (defined as known cardiovascular disease or aged ≥65 years) undergoing major non-cardiac surgery at two hospitals into this prospective multicenter observational study. All patients received a systematic screening using cardiac troponin (cTn) in clinical routine for detection of PMI, defined as an absolute cTn-rise from baseline values within 3 days of surgery. Patients were contacted to assess occurrence of major adverse events (MACE) including all-cause death at 30-days. First, we identified preoperative existing comorbidities as well as perioperative factors associated with PMI by multivariable regression analysis. Second, PMI were centrally adjudicated to identify predefined subtypes (“type I myocardial infarction (T1MI)”, “acute heart failure” (AHF), “tachyarrhythmia”, “extra-cardiac” triggers, “unknown”) by two independent reviewers using all clinical information available, and subtypes tested for association with 30-day (MACE).

Results

From 2014 to 2016 we enrolled 4250 patients undergoing 5375 surgeries. PMI occurred after 785 (14,5%) surgeries. Occurrence of PMI was more frequent with older age and cardiovascular comorbidities, especially insulin-dependent diabetes mellitus and chronic kidney disease. Perioperatively multiple known type II triggers (hypotension, bleeding, hypoxemia, tachycardia, length of surgery) were associated with PMI. Only 5,0% of PMI were adjudicated as “T1MI”, 4,3% as “AHF”, 4,3% as “tachyarrhythmia”, 12,0% “extra-cardiac” and the majority of 74,4% as “unknown”. The subtypes were associated increased MACE-rates (24% for T1MI, 40% for “AHF”, 22% for “tachyarrhythmia”, 24% for “extra-cardiac”, 7,1% for “unknown”) compared to non-PMI patients (1,8%, p<0,001 see Figure).

MACE within 30 days following surgery

Conclusion

PMI occurs more likely in patients with preoperative existing comorbidities, PMI are associated with type II triggers in the intra- as well as postoperative period. We identified subtypes allowing a risk-stratification to identify high-risk types and guide clinical management.

Acknowledgement/Funding

Swiss National Science Foundation, Swiss Heart Foundation, Cardiovascular Research Foundation Basel, Roche