bluuebunny/crossref_metadata_2025 huggingface dataset:
P917Transcatheter treatment of severe tricuspid regurgitation: first experiences with the edge-to-edge technique using the MitraClip
Authors: Otto S , Velichkov M , Hamadanchi A , Baez L , Franz M , Schulze P C , Moebius-Winkler S
Published: October 2019

Background

Due to increased operative mortality in high-risk patients treated for severe tricuspid regurgitation (TR), there is a growing interest in interventional therapy in these patients that are otherwise solely treated with medication. The edge-to edge technique with implantation of one or more MitraClips is an therapeutic interventional option for these patients. So far, data for transcatheter TR treatment are sparse.

Purpose

The present cohort study investigates safety, feasibility and effectiveness of the edge-to-edge technique treating severe TR after starting a transcatheter TR treatment program at our institution in 2017.

Methods

A total of 17 high-risk patients (79.18±8.76 years, EUROScore II 9.31±8.23%, table) with symptomatic, severe TR were treated using the MitraClip system from 12/2017 until 12/2018. All patients received pre-interventional clinical, echocardiographic and invasive evaluation and were entered into a database. Safety and feasibility of the procedure, reduction of TR grade and clinical outcomes were collected and analyzed at the day of discharge and at 30-day follow-up.

Results

MitraClip device was successfully implanted in 16 of 17 patients (94.1%). In one patient grasping of the leaflets was impossible due to bad echo conditions by abdominal air. 76.5% of the patients had severe or massive and 23.5% had a torrential TR (figure). A total of 25 Clips were used (22 in anteroseptal, 3 in posteroseptal commissure). No intraprocedural deaths, emergency surgery or major vascular complications occurred. Postprocedural TR was significantly reduced (TR reduction ≥1 grade) from a mean TR grade of 3.8±0.8 at baseline to 1.74±0.59 postprocedural (p<0.001, table and figure). One patient had device detachment before discharge. There was one death due to progressive cardiogenic shock 4 days after the procedure. However, the procedure was planned as a last therapeutic option in this terminally ill patient. Echocardiography at discharge showed reduction of TR in 82,4% of patients (mean TR grade at discharge 2.21±0.66, p<0.001). At 30 day f/u symptoms were significantly improved from inital mean NYHA class of 3.06±0.56 to a mean NYHA class of 2.55±0.52 (p=0.002) and patients presented with reduced TR (mean TR grade at 30 day f/u 2.58±0.57, p<0.001).

Conclusion

Interventional treatment of severe TR in high-risk and mostly inoperable patients using the MitraClip technique is safe and effectivly reduces TR grade leading to clinical improvement. However, further investigations are needed to identify clear parameters highly predictive for a favorable acute and midterm procedural success. Also, more data and clinical trials are needed to determine the long-term course in these patients.
P918Tricuspid regurgitation in patients undergoing transcatheter aortic valve implantation
Authors: Shamekhi J , Stundl A , Al-Kassou B , Weber M , Sedaghat A , Grube E , Nickenig G , Werner N , Sinning J M
Published: October 2019

Background

Transcatheter aortic valve implantation (TAVI) has become the treatment of choice in elderly patients with severe aortic stenosis and increased surgical risk. A significant number of these elderly patients have concomitant tricuspid valve regurgitation. The impact on outcome, however, is still matter of debate.

Objectives

In this prospective observational study, we investigated the impact of concomitant tricuspid regurgitation (TR) on outcome in patients undergoing transcatheter aortic valve implantation.

Methods

Between February 2008 and May 2018, 1411 patients with severe symptomatic aortic stenosis and increased operative risk underwent TAVI at the Heart Center Bonn and participated in this study, after written informed consent was obtained.

Before TAVI procedure, all patients underwent a careful cardiac evaluation and interdisciplinary discussion within the local, institutional Heart Team.

The pre-interventional 3D echocardiography was used to determine the degree of tricuspid valve regurgitation. According to the severity of TR, patients were divided into two groups; patients with TR < II and patients with moderate to severe TR ≥ II andcompared regarding rates of mortality after 1 year of follow-up between the two groups.

Results

Out of 1411 TAVI patients, 802 (56.8%) had tricuspid regurgitation < II, 610 (43.2%) patients suffered from tricuspid regurgitation ≥ II.

The mean age of our study population was 81.1 (±6.5). The baseline characteristics did not differ significantly between the two groups, such as extracardiac arteriopathy (TR < II: 44% vs TR ≥ II: 41.6%; p=0.37), diabetes (TR < II: 27.5% vs TR ≥ II: 27.7%; p=0.92) or arterial hypertension (TR < II: 91% vs TR ≥ II: 93.2%; p=0.64). However, patients with concomitant TR ≥ II had significantly more often NYHA class IV (TR < II: 5.0% vs TR ≥ II: 15.4%; p<0.001) and a higher logistic EuroSCORE (TR < II: 12.9 (8.8/21.2) vs TR ≥ II: 20.6 (13.1/33.4); p<0.001). Additionally, patients with a TR ≥ II had significantly more often a concomitant mitral regurgitation ≥ II (TR < II: 43.3% vs TR ≥ II: 60.4%; p<0.001). Comparing rates of mortality, we found a significant association between the degree of tricuspid regurgitation and 1-year mortality in patients undergoing TAVI (TR < II: 85 (10.6%) vs. TR ≥ II: 136 (22.3%); p<0.001), as presented in Figure 1.

Figure 1

Conclusion

Moderate to severe tricuspid valve regurgitation is associated with higher rates of mortality in patients undergoing transcatheter aortic valve implantation. Our results are hypothesis-generating and it has to be elucidated whether the severity of TR is only a surrogate for more advanced stage of aortic stenosis or whether it is causative so that mortality could be reduced by its treatment.

Acknowledgement/Funding

None
P935Effect of hypertension and systolic blood pressure on cardiovascular and limb outcomes in patients with symptomatic peripheral artery disease: the EUCLID trial
Authors: Hiatt W , Hopley C W , Kavanagh S , Patel M R , Baumgartner I , Berger J S , Blomster J I , Fowkes F G R , Jones W S , Katona B G , Mahaffey K W , Norgren L
Published: October 2019

Background

Hypertension is a risk factor for major adverse cardiac events (MACE) in patients with symptomatic peripheral artery disease (PAD).

Purpose

The effects of a history of hypertension and baseline systolic blood pressure (SBP) on MACE and major adverse limb events (MALE), including acute limb ischemia and major amputation, were evaluated in the Examining Use of tiCagreLor In paD (EUCLID) trial.

Methods

EUCLID randomized 13,885 patients with PAD and found no benefit of ticagrelor compared with clopidogrel on risk of MACE or MALE. The median duration of follow up was approximately 30 months. This post hoc, subgroup analysis evaluated the effects of hypertension history at baseline on the hazard for MACE and MALE. An adjusted restricted cubic spline regression analysis evaluated the association of SBP with MACE and MALE.

Results

A clinical history of hypertension was present in 10,857 (78%) patients at baseline and these patients were more likely to be older, female, white or African American, and reside in North America compared with the 3026 without hypertension. Hypertension was associated with a higher prevalence of concomitant cardiovascular diseases, polyvascular disease, diabetes, and prior coronary interventions. MACE occurred at a rate of 4.63 events/100 pt-yrs in participants with hypertension and 3.64 events/100 pt-yrs in participants without hypertension, (adjusted hazard ratio [aHR] 0.94, 95% CI 0.82–1.08; p=0.38). MALE occurred at a rate of 1.11 events/100 pt-yrs in those with hypertension and 1.38 events/100 pt-yrs in those without hypertension (p=0.054) (aHR 0.93 (95% CI 0.73, 1.18) p=0.55. The adjusted spline model for MACE and SBP demonstrated a significantly non-linear relationship with a HR 1.08 (95% CI 1.01, 1.15), p=0.0275 for every 10-unit decrease <135 mmHg SBP and HR 1.11 (1.06, 1.16), p<0.0001 for every 10-unit increase >135 mmHg (figure). There was no association between baseline SBP and MALE events.

Conclusions

A history of hypertension was not associated with a higher adjusted hazard for MACE or MALE in participants with PAD. In contrast, SBP at baseline was associated with increased risk of MACE at values both above and below 135 mmHg.

Acknowledgement/Funding

EUCLID was sponsored by AstraZeneca
P939Cardiovascular outcomes in patients with Acute Coronary Syndrome and previous cardiovascular disease. An analysis from ACHILLES Registry
Authors: Esteve Pastor M A , Orenes-Pinero E , Ruiz-Nodar J M , Rivera-Caravaca J M , Quintana-Giner M , Veliz-Martinez A , Macias-Villanego M J , Pernias-Escrig V , Vicente-Ibarra N , Carrillo-Aleman L , Candela E , Sandin Rollan M , Lozano T , Tello-Montoliu A , Marin F
Published: October 2019

Background

Patients with acute coronary syndrome (ACS) and previous cardiovascular disease (CVD) [stroke, peripheral arterial disease (PAD) or coronary artery disease (CAD)] are at high risk of serious events and mortality. Current clinical guidelines recommend new antiplatelet drugs (NAD) for high cardiovascular risk patients with ACS; however, these drugs are underused in different scenarios.

Purpose

The aim of this study was to analyze the use of NAD and advese events in patients with ACS an previous CVD.

Methods

ACHILLES registry is and observational, multicenter and prospective registry of ACS patients. 1717 ACS patients were consecutively included in this study from 3 tertiary Hospitals. Of them, 641 (37.33%) suffered from previous CVD: 149 patients with stroke, 154 patients with PAD and 541 patients with CAD. Bleeding, mortality and major adverse cardiac events (MACE) at 1 year of follow-up after hospital discharge were analyzed.

Results

NADs administration during hospital stay and at discharge was less frequent in patients with previous CVDs. Cox analysis in this cohort of patients showed that clopidogrel prescription at discharge was independently associated with MACEs [HR: 1.59 (95% CI 1.03–2.45); p=0.036] and with death [HR: 1.99 (95% CI 1.00–3.98); p=0.049] in multivariate analysis. More specifically, when ticagrelor prescription at discharge was compared with clopidogrel prescription, a significant death reduction was found in both, the univariate and the multivariate Cox analysis [HR: 4.54 (95% CI 2.26–9.13); p<0.001 and HR: 2.61 (95% CI 1.16–5.90); p=0.021, respectively].

KM curves according NAD and CVD disease

Conclusion

New antiplatelet drugs, especially ticagrelor, showed lower rates of mortality in patients with CVD without differences for bleeding. Despite the recommendations of current clinical guidelines for high risk patients with ACS, the use of NADs is very low in “real-life” patients with previous CVD.
P943The impact of diabetes on patients with frail after endovascular treatments: from I-PAD registry
Authors: Nagae A , Nishikawa K , Fujimori K , Katoh T , Miura T , Miyashita Y , Kashiwagi D , Senda K , Sakai T , Saigusa T , Ebisawa S , Motoki H , Okada A , Kuwahara K
Published: October 2019

Background

Diabetes mellitus (DM) is known to be one of the risks of arteriosclerosis. However, it is still unknown whether DM is a risk factor also in secondary prevention of frail patients after endovascular treatments (EVT)

Purpose

To investigate impact of diabetes on patients with frail after EVT.

Methods

From July 2015 to July 2016, 371 consecutive PAD patients who performed EVT were enrolled in I-PAD registry. We could conduct follow up survey 361 patients (446 lesions) and divided into 2 groups; with diabetes (185 patients, 226 lesions) or without diabetes (176 patients, 220 lesions) and analyzed. And among them,we selected 96 patients with frail and divided into 2 groups; with diabetes (49 patients, 70 lesions) or without diabetes (46 patients, 58 lesions) and analyzed. We defined frail patients as the patients with Clinical Frailty Scale 5 (mild frail) or higher. The primary end point was all-cause-death and major adverse limb events (MALE: TLR, TVR, major amputations) at 1 year.

Result

At 1 years in the patients group with diabetes, overall survival and freedom from MALE were significantly lower (81.7% vs 95.8% P<0.0001; 80.0% vs 94.6%, P<0.0001) than the group without diabetes.Among the patients with frail, between the patients group with diabetes and the group without, there is no significant differences in overall survival and freedom from MALE (88.2% vs 88.9% P=0.83; 80.7% vs 84.1%, P=0.55) at 5 years.

Conclusion

The prognosis of patients with diabetes after EVT was worse than the patient without. On the other hand, the prognosis of frail patients with diabetes after EVT was no difference with the frail patient without diabetes in this study.
P968Comparison of re-proximal optimizing technique with kissing balloon technique in provisional stenting during primary percutaneous coronary intervention
Authors: Cetinkal G , Kilickesmez K , Balaban Kocas B , Keskin K , Yildiz S S , Kilci H , Sigirci S , Gurdal A , Er A , Dogan G M
Published: October 2019

Background

Re-proximal optimizing technique (rePOT) (POT, side branch inflation and final POT) is a new provisional coronary bifurcation stenting technique which has better results in bench tests in comparison with kissing balloon inflation (KBI) techique. A clinical study showed that rePOT had beneficial effects in terms of strut malapposition, side branch obstruction and stent geometry. But it has not been compared with KBI technique especially in patients with ST segment elevation myocardial infarction (STEMI) who underwent primary percutaneous coronary intervention (p-PCI).

Purpose

The aim of our study is to compare the new rePOT technique with a known and widely used provisional stenting technique in a real-world special patient population in terms of clinical and technical aspects

Methods

51 patients with STEMI who underwent p-PCI and needed provisional side branch stenting were enrolled in a tertiary center. Patients who needed “two stent strategy” at the beginning of procedure were deferred.

Results

Results were shown in Table 1. In-hospital death, contrast induced acute kidney injury, side branch dissection, need for side branch stenting and acute stent thrombosis were lower in rePOT group but there was no statistically significance.

Table 1 rePOT group (n=23) KBI group (n=28) p value Age 51.6±11.7 51.2±9.4 0.87 Male gender 18 (78.3%) 24 (85.7%) 0.16 Diabetes Mellitus 3 (13%) 6 (21.4%) 0.43 Hypertension 5 (21.7%) 5 (17.9%) 0.73 Ejection fraction 46.8±10.6 44.8±8.4 0.43 Killip class>2 1 (4.3%) 4 (14.3%) 0.47 Stent type (DES) 21 (91.3%) 23 (82.1%) 0.34 Side branch dissection 3 (13%) 8 (28.6) 0.18 Side branch stenting 3 (13%) 6 (21.4%) 0.43 In-hospital death 2 (8.7%) 3 (10.7%) 0.81 CI-AKI 3 (13%) 6 (21.4%) 0.43 Acute stent thrombosis 0 2 (7.1%) 0.19 DES: Drug eluting stent; CI-AKI: contrast induced acute kidney injury.

Conclusion

To the best of our knowledge this is the first study which compares the new rePOT technique with KBI in patients with STEMI who underwent p-PCI and needed provisional coronary bifurcation stenting. Although results are similiar in terms of clinical and technical aspects, rePOT may be a useful and user-friendly technique in such a complex and emergent procedure.

Acknowledgement/Funding

None
P980Post-procedural plasma brain natriuretic peptide level early after catheter ablation predicts the future clinical outcome in patients with persistent atrial fibrillation and reduced ejection fraction
Authors: Okada M , Tanaka K , Ninomiya Y , Hirao Y , Oka T , Tanaka N , Inoue H , Kitagaki R , Koyama Y , Okamura A , Iwakura K , Fujii K , Inoue K
Published: October 2019

Background

Successful restoration of sinus rhythm (SR) by catheter ablation (CA) for persistent atrial fibrillation (AF) improves cardiac function, resulting in decrease of plasma brain natriuretic peptide (BNP) level. The exact significance and prognostic implications of this change have yet to be determined.

Purpose

To examine the impact of pre- and post-procedural BNP level on the clinical outcome after CA in patients with persistent AF and reduced left ventricular ejection fraction (LVEF).

Methods

Out of 242 patients with LVEF <50% who underwent first-time CA for persistent AF between March 2012 and September 2018 at our institute, we enrolled 137 patients (61±10 years, 83% male) whose plasma BNP level was available both at baseline and early after CA (during 1–3 month). We evaluated the impact of the BNP levels on future AF recurrence 3 months after CA as the primary endpoint. Additional secondary endpoints included heart failure (HF) hospitalization and cardiovascular death.

Results

All patients successfully restored SR at the end of CA. Within 3 months of a blanking period (BP), improvement of LVEF (from 39±10% to 65±12%, p<0.001) and reduction of BNP levels (from 178 [107–332] pg/ml to 42.3 [21.1–78.6] pg/ml, p<0.001) were observed. During the median follow-up of 21 months after BP, the incidence of AF recurrence, HF hospitalization, and cardiovascular death was 37% (n=50), 3% (n=4), and 1% (n=1), respectively. Cox proportional hazard regression analysis after adjustment for age and gender revealed that post-procedural BNP level was a significant predictor of the AF recurrence (hazard ratio [HR] per 100-pg/ml increase, 1.13; 95% confidence interval [CI], 1.02–1.25; p=0.023), but pre-procedural BNP level was not (1.02; 0.95–1.09; p=0.56). Receiver operating curve analysis determined the post-procedural BNP level of 55.5 pg/ml as the best cut-off value for predicting the AF recurrence, with area under the curve of 0.620 (95% CI, 0.534–0.702; p=0.018). The incidence of AF recurrence was significantly higher in patients with post-procedural BNP level >55.5 pg/ml (n=50) than the others (50% vs. 29%; HR, 3.99; 95% CI, 2.07–7.68; p<0.001). No patients with post-procedural BNP level ≤55.5 pg/ml experienced HF hospitalization and cardiovascular death (8% vs. 0% and 2% vs. 0%, p=0.006 and p=0.17, respectively)

Conclusions

Not pre-procedural but post-procedural BNP level early after CA predicted the future clinical outcome in patients with persistent AF and reduced LVEF. Decreased but still elevated BNP level after restoration of SR would identify the residual risk for developing unfavorable outcome.
P983Long-standing persistent atrial fibrillation: what can we achieve with ablation?
Authors: Nunes Ferreira A , Cortez-Dias N , Silverio Antonio P , Lima Silva G , Goncalves I , Aguiar-Ricardo I , Rigueira J , R Agostinho J , Santos R , Rodrigues T , Cunha N , Barreiros C , Carpinteiro L , J Pinto F , De Sousa J
Published: October 2019

Introduction

Atrial fibrillation (AF) ablation presents suboptimal results in patients (pts) with persistent long-lasting forms (LSPAF, AF ≥12 months). Recently, the STAR AF-II trial has shown that in these pts complex additional strategies do not improve success compared to only performing pulmonary vein isolation (PVI).

Objectives

To evaluate the success of AF ablation, particularly in long-standing persistent AF

Methods

Single-center prospective study of pts with AF submitted to ablation. The strategy, regardless of the type of AF, was based on PVI, complemented by cavo-tricuspid isthmus line (CTI) in pts with history of flutter. Additional ablation strategies were selectively considered in pts with stable atypical flutter conversion, persistent triggers or no electrograms in the VPs. Pts were monitored with Holter/7-day event loop recorder (3, 6, 12 months and annually up to 5 years). Success was assessed from the 90th day after ablation, with the absence of recurrences of any sustained atrial arrhythmias (>30 sec). Cox regression and Kaplan-Meier survival were used to compare the success of ablation as a function of the clinical type of AF in our population and with pts included in STAR-II AF trial.

Results

620 patients were submitted to AF ablation, 67% male, 58±12 years, including 78 pts (13%) with LSPAF - pts with paroxysmal and persistent short duration AF represented 61% and 26% of the population. In LSPAF, VPI was performed with irrigated catheter (N=33), PVAC (N=44) or nMARQ (N=1), complemented by CTI ablation in 15, linear left atrial lesions in 3, ablation of areas of low voltage in 3 and elimination of fractionated electrograms in 1 patient.

With a median follow-up of 426 days (94–989), the 3-year success rate after a single procedure was 53% in LSPAF, lower than that observed in patients with paroxysmal AF (69%) or short-duration persistent AF (61%) - LogRank P=0.002. The risk of arrhythmias was double in LSPAF vs paroxysmal AF (HR: 2.0; P=0.001). However, after an average of 1.2 procedures/patient, the success rate in LSPAF was 80% at 3 years, comparable to that observed for other types of AF (Log Rank 2.5, p=0.29). Effectively, the long-term success rate of our LSPAF pts treated with PVI and very selective additional strategies was higher than that observed in the STAR-II AF pts treated with PVI and indiscriminate complex ablations (80% vs. 69%, t-test p<0.001, with similar mean follow-up).

Conclusions

AF ablation is more effective if it is performed earlier in the natural history of the disease. However, even in LSPAF, high success rates are achieved through PVI-based ablation strategies, although more procedures are required.
P995The extent of late gadolinium enhancement predicts defibrillator shocks in patients with non-ischaemic heart failure
Authors: Aimo A , Barison A , Mirizzi G , Castiglione V , Ripoli A , Panchetti L , Rossi A , Startari U , Emdin M , Aquaro G D , Piacenti M
Published: October 2019

Background

Implantable cardioverter defibrillator (ICD) is recommended for patients with non-ischaemic heart failure (HF) and left ventricular ejection fraction (LVEF) ≤35%, although most patients will not experience any appropriate ICD intervention. We assessed if cardiovascular magnetic resonance (CMR) findings may predict benefit from ICD implantation.

Methods and results

We retrieved the data of all patients (n=183) with non-ischaemic HF receiving an ICD for primary prevention at our Institution, and undergoing CMR within 1 month before implantation. 183 patients were evaluated (men 73%, median age 66 years, LVEF 24%, N-terminal fraction of pro-B-type natriuretic peptide 1217 ng/L, atrial fibrillation, flutter or atrial ectopic rhythm 21%). They received single-chamber (n=21, 12%), dual-chamber (n=34, 19%), or cardiac resynchronization therapy devices (n=127, 69%); 1 patient (1%) received a subcutaneous defibrillator. Twenty patients (11%) experienced a shock for ventricular tachycardia or fibrillation (VT/VF) over 2.5 years (0.8–5.4), and 13 (7%) had an inappropriate shock over 2.7 years (0.9–5.4). Late gadolinium enhancement (LGE) was present in 146 patients (80%), but on average accounted for limited percentage of LV mass (4% [2–11%]). LGE mass independently predicted shocks for VT/VF (HR 2.13, 95% CI 1.02–4.47; p=0.045). LGE mass ≥14% (the best cut-off at receiver operating characteristics analysis) independently predicted shocks for VT/VF (HR 3.82, 95% CI 1.51–9.68; p=0.005). LGE mass <4% was the only univariate predictor of inappropriate shocks (HR 4.82, 95% CI 1.07–21.76; p=0.041).

Conclusions

Patients with non-ischaemic HF and LGE mass ≥14% benefit most from ICD, while those with LGE mass <4% display mainly inappropriate shocks.
P1028Impact of atrial fibrillation ablation procedural volume on complication and recurrence rate across European centers. An ESC EORP registry: atrial fibrillation long-term
Authors: Pagourelias E , Vassilikos V , Blomstrom-Lundqvist C , Kautzner J , Maggioni A P , Pokushalov E , Tavazzi L , Dagres N , Brugada J , Arbelo E
Published: October 2019

Background

Catheter ablation has emerged as an effective therapy in patients with symptomatic and drug refractory atrial fibrillation (AF). Despite high success rates of the method, there is still heterogeneity of outcomes and complication rate across Europe. The impact of the annual procedural volume per center on success and complication rate of AF ablation, based on real-life data, has not been addressed till now.

Purpose

The aim of the study was to investigate if center AF ablation volume might be associated with one-year success or complication rate after the procedure.

Methods

Data for this analysis were extracted from the European AF Ablation Long-Term Study, a prospective registry designed to describe the clinical epidemiology of patients undergoing AF ablation. Based on 25th and 75th percentiles of AF ablation numbers performed, the participating centers were classified into high volume (HV) (≥250 procedures/year), medium volume (MV) (<250 and ≥58/year) and low volume (LV) (<58/year). One-year success was defined as patient survival free from any atrial arrhythmia, from the end of the 3-month blanking period to 12 months following the ablation procedure.

Results

A total of 91 centers in 26 European countries enrolled 3368 patients. There was a significantly higher reporting of cardiovascular complications in LV centers (5.2%), especially pericarditis (0.6%) and cardiac perforation (1.4%), while the HV and MV centers reported cardiovascular complications in 3.0 and 4.3% of cases, respectively (p=0.039). Additionally, stroke incidence after ablation was significantly higher in LV centers (0.5% of cases vs 0% in HV and MV centers, p=0.008). Kaplan-Meier survival analysis based on adjusted data of all complications demonstrated, however, that there was not a significant difference in complication rate according to volume's center (p=0.402, Figure A). One-year success after AF ablation ranged from 77.8% in HV vs 70.5% in LV vs 77.3% in MV centers (p<0.001). Nonetheless, adjusted recurrence rate was not significantly different among centers (p=0.363, Figure B), a result driven by differences both in ablation technical characteristics and risk/severity of cases ablated in different volume centers.

Conclusions

Despite the notion that “the higher, the better”, our results suggest that AF ablation is a safe procedure with high success rates in all European centers, independent of the AF ablation procedural volume. Differences in patients and procedural characteristics may justify the equality of complication and recurrence rate among centers, since expertise level counterbalances the risk of each case.
P1034Impact of ablation status on the efficacy and safety of dronedarone in patients with atrial fibrillation/flutter: a post-hoc analysis of the ATHENA trial
Authors: Vamos M , Calkins H , Kowey P R , Torp-Pederson C T , Corp Dit Genti V , Wieloch M , Koren A , Hohnloser S H
Published: October 2019

Background

Despite increasing use of ablation for atrial fibrillation/flutter (AF/AFL), few systematic data exist on the use of dronedarone and other antiarrhythmic drugs after ablation.

Purpose

To assess efficacy and safety of dronedarone after ablation in patients with paroxysmal/persistent AF/AFL randomized to dronedarone or placebo in the ATHENA trial (NCT00174785).

Methods

In ATHENA, 196 patients (dronedarone 90, placebo 106) had an ablation for AF/AFL prior to study entry. AF/AFL recurrence was evaluated in patients in sinus rhythm at baseline (dronedarone 63, placebo 65) by ECG during study visits or symptom recurrence.

Results

Ablated vs non-ablated patients were more likely to be male, have an implantable cardioverter defibrillator or pacemaker implanted, or be receiving an oral anticoagulant. Fewer ablated patients had an AF/AFL recurrence with dronedarone (36 [57%]) than with placebo (46 [71%]). Median time to first AF/AFL recurrence was significantly longer with dronedarone versus placebo (561 versus 180 days; hazard ratio 0.65 [95% CI 0.42–1.00], p<0.05; Fig 1). Time to first cardiovascular hospitalization or death was similar with dronedarone versus placebo (hazard ratio 0.98 [0.62–1.53]). On-treatment rates of treatment-emergent adverse events with dronedarone versus placebo were 83.1 versus 75.5%, serious treatment-emergent adverse events were 27.0 versus 18.9%, permanent drug discontinuations were 10.1 versus 15.1%, and deaths were 0 versus 1.9%.

Conclusions

Dronedarone delayed AF/AFL recurrence in patients with a prior AF/AFL ablation. Safety outcomes were consistent with the overall ATHENA trial. Adequately sized prospective studies are needed to confirm these observations. Given the sparsity of data for antiarrhythmic drugs after ablation, this retrospective analysis has merit and is useful for hypothesis generation.

Acknowledgement/Funding

Sanofi, New York, New York, Unites States of America
1109Enhancing transition from hospital to home for people with cardiovascular disease
Authors: Boyde M , Peters R , McGlynn E
Published: October 2019

Background

Health care services have a responsibility to ensure transition from hospital to home is seamless as this is a vulnerable time for patients. In 2013 the Cardiac Rehabilitation (CR) and Heart Failure (HF) Management Programs at a large tertiary referral hospital in our city, were re-configured to become one cardiac service. This model of care incorporated management of patients along the continuum of cardiac illness from initial diagnosis to end stage disease including end stage heart failure and intractable angina. This model included nurse-led in-patient consultations, post-discharge case management, CR and HF education and exercise programs, HF titration clinics, and home visits. Within health-care, organisational design can be considered a variable and evolving tool for improving the quality of patient care. The redesign of two clinical services provided an opportunity to improve health-care delivery for patients with cardiovascular disease.

Purpose

To evaluate a patient centred post-discharge model of care for patients admitted to hospital for an acute cardiovascular event.

Methods

A retrospective analysis of routinely collected data was undertaken using standard descriptive statistics to report the number of in-patient consultations, referrals generated, patients case-managed and all cause unplanned readmissions within 28 days of hospital discharge.

Results

Data was analysed from 1 January 2014 to 31 December 2018. Over the 5 years 11929 in-patients with cardiovascular disease received consultations from specialised nursing staff employed in the amalgamated cardiac service and 10598 (89%) patients were referred to appropriate post discharge CR and HF programs. From the in-patient consultations, 2254 (21%) patients who lived within our geographical area were case-managed by our specialist nursing staff. Post-discharge follow-up within 14 days was achieved for 1917 (85%) of these patients. Of the 2254 patients, 322 (14%) had an unplanned all cause readmission within 28 days of hospital discharge.

Conclusion

The evaluation data indicates that our model of integrated care provided effective post discharge management for patients with cardiac disease. Developing a model of care for these patients is challenging as they need to engage in self-care and adhere to a complex medication regime often with changing dosages. However effective case management post discharge including secondary prevention programs can decrease readmissions and improve outcomes for these patients.
1201Cardiac function, structure, and speckle-tracking echocardiography-derived parameters after distal and conventional renal denervation: a double-blind randomized study
Authors: Ripp T , Ryabova T , Pekarskiy S , Mordovin V , Buharova E , Anfinogenova Y A , Falkovskaya A , Lichikaky V , Sitkova E , Zubanova I , Popov S
Published: October 2019

Background/Introduction

Distal renal denervation (RD) of the segmental branches beyond the bifurcation of the main renal artery is considered more effective treatment than conventional RD of the trunk renal artery. Evidence accumulated over the last decade has shown that global longitudinal strain (GLS) from speckle-tracking analysis of 2-dimensional echocardiography may represent a sensitive parameter of the left ventricular (LV) dysfunction.

Purpose

We compared cardiac function, structure, and GLS parameters after distal and conventional RD in the double-blind randomized prospective study.

Methods

The study (NCT01499810) compromised 55 patients who met criteria for resistant hypertension and signed informed consent. Patients were randomized to either endovascular conventional RD of the main renal artery (group 1, n=27) or to distal treatment applied to the segmental branches after the bifurcation of the main renal artery (group 2, n=28). Parameters of GLS from speckle-tracking echocardiography, ejection fraction, thickness of the interventricular septum (IVS) and LV posterior wall (PW), as well as the parameters of the diastolic function of the heart were assessed at baseline and at 12-months follow-up. Reference echocardiographic values were adapted from the ASE/ESC guidelines. Baseline parameters of heart and drug intake did not significantly differ between patients at the time of randomization.

Results

Drug treatment consisted in combination therapy in the maximum tolerated doses. Patients used different types of drugs, but the number of drug classes did not significantly differ between groups (4.1 in group 1 vs. 4.2 in group 2). Reduction of systolic blood pressure was significantly greater after distal RD vs. conventional RD: −22.1 vs. −11.5 mm Hg, respectively (p<0.05). Decrease in the LV wall thickness was significantly greater after distal RD then after conventional RD, namely: changes in the IVS thickness were −0.21 (−0.39; 1.2) mm after distal RD vs. 1.21 (−0.44; −2.64) mm after conventional RD, p=0.023; changes in the PW thickness were −0.87 (−2.6; −0.62) mm after distal RD vs. 0.07 (−0.45; 1.25) mm after conventional RD, p=0.021. Normalization of diastolic function was found in 13% ((group 1) and 26% ((group 2) in patients with first and second degrees of LV diastolic dysfunction. Speckle-tracking parameters of the left ventricle and some parameters of the left atrium (reduced size by 18% vs 27% of patients) also improved after DRD.

Conclusion(s)

Compared to conventional RD, distal RD treatment applied to the segmental branches beyond the bifurcation of the main renal artery significantly greater attenuated the LV wall thickness and the number of patients with diastolic dysfunction. At 12-month follow up, the global longitudinal LV function also improved in distal RD patients.
1202The incidence, treatment and mortality of new-onset atrial fibrillation patients at the intensive care unit
Authors: Jacobs M , Loef B G , Reidinga A C , Postma M J , Van Hulst M , Tieleman R G
Published: October 2019

Background

Critically ill patients admitted to the intensive care unit (ICU) often develop atrial fibrillation (AF), with an incidence of around 5%. Stroke prevention in AF is well described in clinical guidelines. However, the extent to which stroke prevention is prescribed to ICU patients with AF is unknown.

Purpose

We aimed to determine the incidence of new-onset AF and describe the stroke prevention strategies that were initiated on the ICU of our teaching hospital. Also, we compared mortality in patients with new-onset AF to critically ill patients with previously diagnosed AF and patients without any AF.

Methods

This study was a retrospective cohort study including all admissions to the ICU of the our hospital in the period 2011–2016. Propensity score matching was used to compare the different patient groups. Survival analyses were performed using these real-world data.

Results

In total, 3334 patients were admitted to the ICU, of whom 213 patients (6.4%) developed new-onset AF. 583 patients (17.5%) had a previous diagnosis of AF, the other patients (76.1%) were in normal sinus rhythm. In-hospital mortality and one-year mortality after hospital discharge were significantly higher for new-onset AF patients compared to patients with no history of AF or previously diagnosed AF. At hospital discharge, only 50.4% of the new-onset AF-patients eligible for stroke prevention received an anticoagulant and anticoagulation was not dependent on CHA2DS2VASc score or other patient characteristics. An effect of anticoagulative status on mortality was not significant.

Conclusion

AF is associated with increased mortality in critically ill patients that were admitted to the ICU. More guidance is needed to optimize anticoagulant treatment in critically ill new-onset AF patients.

Acknowledgement/Funding

None
1204Pericardial fat volume outperforms classic risk markers in the prediction of relapse after pulmonary vein isolation
Authors: Nascimento Matos D J , Ferreira A M , Freitas P , Guerreiro S , Carmo J , Abecasis J , Costa F , Santos A C , Carmo P , Saraiva C , Cavaco D , Morgado F , Mendes M , Adragao P
Published: October 2019

Introduction

Pericardial adipose tissue has been implicated in the pathophysiology of atrial fibrillation (AF), but its relevance to clinical practice remains uncertain. The aim of this study was to assess the relative importance of pericardial fat as predictor of recurrence after pulmonary vein isolation (PVI).

Methods

We assessed 453 patients (278 men, age 61±13 years, 348 paroxysmal AF) with symptomatic AF undergoing cardiac CT prior to a PVI procedure. Pericardial fat was quantified on contrast-enhanced images using a new simplified semi-automated method. The study endpoint was symptomatic and/or documented AF recurrence.

Results

Over a median follow-up of 14 months (IQR 7–23), 170 patients (38%) relapsed. Survival analysis showed significant differences in AF-free survival across tertiles of pericardial fat (Figure). Pericardial fat volume was weakly correlated to body mass index [(BMI), Pearson's R=0.34]. After adjustment for BMI and other univariate predictors of relapse, three variables emerged independently associated with time to AF recurrence: non-paroxysmal AF (HR 2.08, 95% CI: 1.51–2.87, p<0.001), indexed left atrial (LA) volume (HR 1.02 per mL/m2, 95% CI: 1.01–1.02, p<0.001), and indexed pericardial fat volume (HR 1.50 per mL/m2, 95% CI: 1.37–1.64, p<0.001). Based on the Wald test, indexed pericardial fat volume was the strongest of these predictors of relapse (X2 values of 20, 13, and 77, respectively). The population attributable risk (PAF) was higher for pericardial fat (PAF=37% for 1st vs 4th quartile) vs LA volume (PAF=11% for 1st quartile vs 4th quartile) and non-paroxysmal AF (PAF=23%). Pericardial fat volume also showed greater discriminate power than indexed LA volume, with a C-statistic of 0.80 (95% CI 0.76–0.85) vs. 0.61 (95% CI 0.55–0.66), p for difference <0.001. The method for quantifying pericardial fat showed high inter-observer reproducibility (Pearson's R=0.90) and was quick to perform (38±3 seconds).

Conclusion

Pericardial fat volume is a strong independent predictor of AF relapse after PVI, outperforming classic risk markers such as LA volume and type of AF. The underlying mechanisms of this association deserve further study. Meanwhile, this simple parameter may help select patients who are more likely to derive sustained benefit from AF ablation.
1269Dual antiplatelet therapy to inhibit myocardial injury in patients with high-risk coronary artery plaque: a randomized controlled trial
Authors: Moss A , Dweck M R , Doris M K , Andrews J P M , Bing R , Raftis J , Williams M C , Van Beek E J R , Forsyth L , Lewis S C , Lee R , Newby D E , Adamson P D
Published: October 2019

Background

High-risk coronary atherosclerotic plaque is associated with higher plasma troponin concentrations suggesting ongoing myocardial injury that may be a target for dual antiplatelet therapy.

Purpose

To determine whether ticagrelor reduces high-sensitivity troponin I concentrations in patients with established coronary artery disease and high-risk coronary plaque with 18F-fluoride uptake.

Methods

In a randomized double-blind placebo-controlled trial, patients with multivessel coronary artery disease underwent coronary 18F-fluoride positron emission tomography-computed tomography and measurement of high-sensitivity cardiac troponin I and were randomized (1:1) to ticagrelor 90 mg twice daily or matched placebo. The primary endpoint was troponin I concentration at 30 days in patients with increased coronary 18F-fluoride uptake.

Results

In total, 202 patients were randomized and 191 met the pre-specified criteria for inclusion in the primary analysis. In patients with increased coronary 18F-fluoride uptake (n=120/191) there was no evidence that ticagrelor had an effect on plasma troponin concentrationsat 30 days (ratio of geometric means for ticagrelor versusplacebo, 1.11, [95% confidence interval 0.90 to 1.36], p=0.32) (Table 1). Over 1 year, ticagrelor had no effect on troponin concentrations in patients with increased coronary 18F-fluoride uptake (ratio of geometric means, 0.86, 95% confidence interval 0.63 to 1.17, p=0.33).

Table 1 Adjusted Geometric Mean (GSE) Ratio of Geometric Means p-value Ticagrelor Placebo (95% CI) Cardiac troponin I, ng/L (18F-fluoride activity) 3.8 (1.1) 3.4 (1.1) 1.11 (0.90 to 1.36) 0.32 Cardiac Troponin I, ng/L (No 18F-fluoride activity) 2.4 (1.1) 2.3 (1.1) 1.02 (0.80 to 1.31) 0.87 Plasma high-sensitivity cardiac troponin I concentration (ng/L) at 30 days for the per-protocol population.Estimates are back transformed estimates from analysis of log transformed values at 30 days adjusting for age, sex and log transformed baseline troponin. Ratio of geometric means is Ticagrelor divided by Placebo. GSE, geometric standard error.

Conclusions

Dual antiplatelet therapy with ticagrelor does not reduce plasma troponin concentrations in patients with coronary 18F-fluoride uptake. This suggests that subclinical plaque thrombosis does not contribute to ongoing myocardial injury in this setting.

Clinical Trials Study ID: NCT02110303Study ID: NCT02110303

Acknowledgement/Funding

Wellcome Trust Senior Investigator Award WT103782AIA
1272Physical activity and mortality with and without cardiovascular disease
Authors: Jeong S , Kang S H , Yoon C H , Youn T J , Chae I H , Kim S H
Published: October 2019

Background/Introduction

Physical activity has been shown to reduce mortality in a dose-response fashion. Current guidelines recommend 500 to 1,000 MET-min per week of regular physical activity. However, evidence is limited regarding the specific dose-response relationship in patients with cardiovascular disease.

Purpose

Our aim was to compare the impact of physical activity on mortality in primary versus secondary cardiovascular prevention.

Methods

We analyzed 441,798 individuals with complete information on physical activity levels between 2009 and 2015 were extracted from a population-based cohort (National Health Insurance Service-National Health Screening cohort). Physical activity measured by self-report questionnaires. A rating of 2.9, 4.0, and 7.0 METs were assigned for light-intensity, moderate-intensity, and vigorous-intensity activities, respectively. Physical activity-related energy expenditure (MET-min/week) was calculated by summing the product of frequency, intensity, and duration. The level of physical activity was classified into 0, 0 to 499, 500 to 999, 1,000 to 1,499, and ≥1,500 MET-min/week. Study participants were stratified by the presence of cardiovascular disease, defined as prior myocardial infarction, ischemic heart disease, prior stroke, and/or chronic heart failure. The main study outcome was all-cause mortality. The median follow-up duration was 5.9 years.

Results

Individuals with cardiovascular disease had lower physical activity levels and a higher risk of mortality than those without cardiovascular disease. There was an inverse relationship between the physical activity level and the mortality risk in both groups. The benefit in the secondary prevention group was shown to be greater than that in the primary prevention group: every 500 MET-min/week increase in physical activity resulted in a 14% and 7% risk reduction in mortality in the secondary and primary prevention groups, respectively (interaction P<0.001). In addition, while individuals without cardiovascular disease benefited the most between 0 and 500 MET-min/week of physical activity, the benefit in those with cardiovascular disease continued above 500 to 1,000 MET-min/week. The adjusted mortality risk of individuals with cardiovascular disease who performed a high level of physical activity (≥1,000 MET-min/week) was shown to be comparable to or lower than that of their counterparts without cardiovascular disease.

Adjusted risk of mortality

Conclusion

Individuals with cardiovascular disease may benefit from physical activity to a greater extent than do healthy subjects without cardiovascular disease. Clinicians should encourage patients with cardiovascular disease to maintain a physically active lifestyle as much as possible.
1444Metabolically healthy obesity (MHO) in the Malmo Diet Cancer Study - epidemiology and prospective risks
Authors: Korduner J , Bachus E , Jujic A , Magnusson M , Nilsson P M
Published: October 2019

Background/Aims

Metabolically healthy obesity (MHO) is a controversial topic, since the underlying mechanisms and contributing factors behind this phenotype remain unclear. Here we aimed to investigate the characteristics of MHO, as well as prospective mortality risk.

Method

A cross-sectional analysis was carried out in a subsample of 3,812 obese subjects (BMI ≥30 kg/m2) selected from the Malmo Diet Cancer Study (MDCS) cohort (n=28,403). Subjects with MHO (n=1182; mean age 58±7 years) were defined by having no records of hospitalization in the national Swedish Hospital Discharge Register prior to the baseline examination, other than hospitalization due to normal deliveries or external injuries. MHO subjects were further compared to subjects with metabolically unhealthy obesity, MUO (n=2,630; mean age 60±7 years), and all non-obese individuals (n=24,591; mean age 58±8 years) in the cohort study. Moreover, prospective risk analyses for incident morbidity and mortality were carried out by Cox regression.

Results

Compared to MOU individuals (one-way ANOVA), MHO individuals were younger (58±7 years vs. 60±7 years, p=0.001) and more likely to be male (41.2% vs 37.1%, p=0.016). MHO individuals reported a significantly lower proportion of sedentary life style than MUO (17.4% vs. 21.9%, p=0.009), and were more likely to hold a university degree (13.4% vs. 9.4%, p=0.003). Furthermore, MHO individuals had significantly lower HbA1c (p=0.012), fasting plasma glucose (p=0.001) and triglyceride levels (p=0.011) as compared to their MOU counterparts. Cox-regression analysis adjusted for age, sex, smoking and blood pressure (follow-up time 20±6 years) showed both a significantly lower all-cause mortality risk for MHO individuals as compared to MUO (HR 0.74, 95% CI: 0.66–0.82; p=0.001), as well as lower total incident cardiovascular (CV) morbidity risk (HR 0.69, 95% CI: 0.60–0.80; p=0.001). Interestingly, when comparing MHO individuals to all non-obese individuals in the MDCS, there were no significant differences in neither mortality risk (p=0.9), nor incident CV morbidity risk (p=0.7).

All-cause mortality risk

Conclusion

Compared to MUO individuals, MHO individuals presented with a higher level of education- and physical activity together with a more favorable lipid- and glucose profile. MHO individuals were at significantly lower prospective risk of total- and cardiovascular mortality during 20-years follow-up, as compared to MOU individuals. Notably, no significant differences could be seen in mortality and CV morbidity risks when comparing MHO subjects to all non-obese individuals in the total cohort.

Acknowledgement/Funding

The Research Council of Sweden and Skane University Hospital Funds and Foundations (Sweden)