bluuebunny/crossref_metadata_2025_split huggingface dataset:
P2725Transthyretin cardiac amyloidosis in heart failure with preserved ejection fraction: Imaging by Tc-99m bone scan
Authors: Fukuzawa S , Okino S , Ishiwaki H , Iwata Y , Uchiyama T , Kuroiwa N , Oka M , Furihata S , Shibayama N , Inagaki M 
Published: October 2019

Abstract

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

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

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

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

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

Abstract

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

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

Results
Between March 2012 and February 2019, 177 patients were included in our CA registry, however, TTE image quality was only sufficient for analysis in 143 patients. Of these, 83 patients (59.4%) were diagnosed with ATTR and 60 patients (42.0%) with AL. In total, 23 patients (16.1%) presented with isolated pericardial effusion and 36 (25.2%) with isolated pleural effusion. In 17 patients (11.9%) both pericardial and pleural effusion were found and in 66 patients (46.2%) no effusion was present at baseline. Overall, there was no significant difference in the type of effusion between patients with AL and ATTR. In general, pericardial effusions were small (median diameter 7.1 mm (IQR 5.2–9.7) and none were hemodynamically compromising. Interestingly, the presence of pleural effusion correlated well with poor RV function, measured by RV-FW strain (p=0.034). However, no such correlation could be found for pericardial effusion and RV-FW strain (p=0.319).
Kaplan Meier analysis showed that patients presenting with pleural effusion had a worse prognosis compared to patients with pericardial effusion alone or no effusion at baseline (p=0.001, Figure 1).
Figure 1

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

Abstract

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

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

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

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

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

Abstract

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

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

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

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

Abstract

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

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

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

Results
The 1227 patients were stratified to three groups, including aspirin alone (19.6%), warfarin alone (60.6%), and the combined use of aspirin and warfarin (19.9%) within 3 months after surgery. After adjusting propensity scores, the warfarin group (relative risk: 0.69, 95% CI: 0.54–0.88) and the combination group (relative risk: 0.57, 95% CI: 0.42–0.79) both had lower mortality rate compared to the aspirin alone group. Neither increasing major bleeding risk (adjusted relative risk: 0.62, 95% CI: 0.15–2.68) nor decreasing ischemic stroke risk (adjusted relative risk: 0.64, 95% CI: 0.36–1.14) was noticed in the combination group.
Incidence and risk of antithrombotics Crude Model 1 Model 2 Hazard Ratio (95% CI) p-value Hazard Ratio (95% CI) p-value Hazard Ratio (95% CI) p-value All cause mortality   Antiplatelet user Reference Reference Reference   Warfarin user 0.65 (0.52–0.81) <0.001 0.71 (0.56–0.91) 0.006 0.69 (0.54–0.88) 0.002   Antiplatelet + warfarin user 0.59 (0.44–0.81) 0.001 0.63 (0.46–0.85) 0.003 0.57 (0.42–0.79) 0.001   Ischemic stroke antiplatelet user as reference   Warfarin user 0.77 (0.51–1.17) 0.224 0.85 (0.55–1.33) 0.485 0.82 (0.52–1.27) 0.369   Antiplatelet + warfarin user 0.63 (0.36–1.10) 0.102 0.67 (0.38–1.21) 0.185 0.64 (0.36–1.14) 0.130   Major bleeding antiplatelet user as reference   Warfarin user 0.32 (0.10–1.05) 0.061 0.71 (0.14–3.60) 0.674 0.40 (0.11–1.40) 0.150   Antiplatelet + warfarin user 0.57 (0.14–2.39) 0.444 1.56 (0.26–9.46) 0.627 0.62 (0.15–2.68) 0.526 Model 1: Adjusted for all covariates; Model 2: Adjusted for propensity score of using warfarin.

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

Abstract

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

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

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

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

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

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

Abstract

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

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

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

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

Abstract

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

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

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

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

Conclusion
Results point that large vegetations, but also perivalvular abscesses are coupled with higher rate of embolic complications in patients with IE. Staphylococcus aureus, HACEK group and non-HACEK bacteria are, more than other causative IE microorganisms, associated with embolism. These results might be clinically important for treatment chose and prognosis of the patients with IE.