bluuebunny/crossref_metadata_2025_split huggingface dataset:
2387Recurrent cardiovascular events and mortality in relation to antiplatelet therapy in patients with myocardial infarction without obstructive coronary artery disease (MINOCA)
Authors: Bossard M , Yusuf S , Tanguay J F , Faxon D P , Boden W E , Steg P G , Granger C , Kastrati A , Budaj A , Di Pasquale G , Valentin V , Diaz R , Joyner C , Gao P , Mehta S 
Published: October 2019

Abstract

Background
Approximately 10% of patients presenting with myocardial infarction (MI) do not have obstructive coronary artery disease (MINOCA). The role of antiplatelet therapy and outcomes in this group remain unclear. We assessed prognosis and the effect of an intensified clopidogrel regimen in MINOCA patients.

Methods
We analyzed data from the CURRENT-OASIS 7 trial, which randomized 25,086 patients with acute coronary syndromes (ACS) referred for early intervention to receive either double-dose (600mg day 1; 150mg days 2–7; then 75mg daily) or standard-dose (300mg day 1; then 75mg daily) clopidogrel. We evaluated clinical outcomes at 30-days in patients with versus without obstructive CAD and in relation to standard versus double-dose clopidogrel.

Results
Overall, 23,783 MI patients were included, of which 1,599 (6.7%) had MINOCA. MINOCA patients were younger, more frequently presented with non-ST-segment elevation MI and had fewer comorbidities. Rates of all-cause mortality (0.7% versus 2.4%, p=0.0046), cardiovascular mortality (0.6 versus 2.2%, p=0.0056), repeat MI (0.5% versus 2.3%, p=0.0009) and major bleedings (0.7% versus 2.5%, p=0.0001) were significantly lower among patients with MINOCA versus those with obstructive CAD. Compared with the standard-dose clopidogrel regimen, the double-dose regimen appeared to increase the risk of cardiovascular death, MI or stroke in MINOCA patients (0.8% versus 2.1%, hazard ratio (HR) 2.74, P=0.033). There was no difference in those with obstructive CAD (4.7% versus 4.4%, HR 0.93, P=0.226; P-for-interaction=0.023) (see Figure 1A). Major bleeding did not occur more frequently in MINOCA patients with double- versus standard-dose clopidogrel regimen (0.7% versus 0.6%, (HR 1.16 (95% CI 0.35–3.80), p=0.805), but their rate was higher In MI patients with obstructive CAD (2.7% versus 2.2% (HR 1.26 (95% CI 1.06–1.49), p=0.008) (Figure 1B).
Figure 1A & B

Conclusions
Compared to MI patients with obstructive CAD, patients presenting with MINOCA represent a distinct cohort, which is generally younger, has a higher NSTEMI prevalence and fewer comorbidities. Their risk for adverse events, especially repeat MI, stroke, death, and bleeding, is low (<1%) at 30 days. Applying an intensified clopidogrel regimen in MINOCA patients appears to be related to a higher risk for CV death, MI and stroke. Accordingly, more potent antiplatelet regimens might be harmful among MINOCA patients and should not be administered routinely. Nevertheless, there is a need for more prospective studies evaluating the role of dual antiplatelet therapies in MINOCA patients.

Acknowledgement/Funding
The CURRENT-OASIS 7 trial was sponsored by Sanofi-Aventis and Bristol-Myers Squibb.
2398Efficacy of remote controlled catheter ablation for atrial arrhythmias in patients with atrial switch
Authors: Guarguagli S , Cazzoli I , Dimopoulos K , Kempny A , Ernst S 
Published: October 2019

Abstract

Introduction
Since arterial switch procedure replaced the Mustard and Senning (M/S) operations for D-transposition of great arteries (TGA) in 1980s, there are many M/S survivors who are now over 30 yrs old. Atrial arrhythmias are common in these patients and catheter ablation is a valid alternative to medical treatment.

Purpose
Assess the efficacy of atrial arrhythmia ablation using remote magnetic navigation (RMN) in M/S patients.

Methods
All ablations performed on patients with M/S by a single operator in a tertiary center over a 10 year period (2008–2019) were reviewed and analyzed. All documented sustained recurrences were recorded.

Results
Twenty-eight patients (57% M, age 41 [33–44] yrs, 2 Senning), underwent 41 procedures, 40 of which consisted of ablation for atrial tachycardia (AT, 36, 91%: 81% in PVA, 8% SVA, 11% in PVA+SVA), atrio-ventricular nodal re-entry tachycardia (1, 1%) or atrial fibrillation (AF 3, 8%). All procedures were carried out using remote navigation, electroanatomical mapping and 3D image integration. Pre-procedure echo showed at least moderately impaired systemic ventricle in 68% and moderate or severe tricuspid regurgitation in 58% of patients. Access to pulmonary venous atrium (PVA) was gained retrogradely in all cases while to access systemic venous atrium (SVA) either via femoral, subclavian or jugular veins.
All except one procedure (98%) were acutely successful. At 1 and 3 years, 82% and 74% of patients were free from recurrent arrhythmia. Multiple procedures were required to control arrhythmias in 10 (36%) patients ablated for AT (60% in PVA, 30% in PVA+SVA). After the 2nd ablation 60% of these patients were in sinus rhythm at 3 years. On multivariate Cox analysis, Senning repair was associated with a higher recurrence risk after ablation compared to patients undergone a Mustard procedure (HR 1.47, p=0.01). Overall median procedural duration was 210 [155–265] min with a median fluoroscopy time of 0.9 [0.4–1.5] min and fluoroscopy exposure of 60 [43–120] μGy·m2.

Conclusions
Remote magnetic navigation represents a valid treatment for atrial arrhythmias in patients post M/S operation, with good short and longer-term results. Moreover, it allows the retrograde approach sparing the transbaffle puncture and enables a low fluoroscopy exposure.
2399Contemporary outcomes of catheter ablation for adult Fontan patients using advanced technologies
Authors: Cazzoli I , Larsen S H , Guarguagli S , Dimopoulos K , Kempny A , Kongstad O , Gatzoulis M A , Ernst S 
Published: October 2019

Abstract

Background
The Fontan operation, followed by the total cavo-pulmonary connection (TCPC), has been the primary technique for surgical treatment of patients with functionally univentricular heart. Post-surgical arrhythmias contribute considerably to the morbidity and mortality within this cohort

Purpose
To demonstrate feasibility and outcome of catheter ablation procedures aided by three-dimensional (3D) image integration combined with advanced technologies in adult Fontan patients, as well as correlation of arrhythmia type.

Methods
We included adult pts who underwent catheter ablation between 2008 and 2018. Procedures were carried out with electro-anatomical mapping and 3D image integration. Mapping and ablation were performed manually or with remote magnetic navigation (RMN). A retrograde access via the aortic valve was used to reach the atria in TCPC pts.

Results
A total of 63 pts were reviewed with either TCPC or Fontan operation (see figure). A total of 215 arrhythmias were inducible (117 in Fontan, 2/procedure, range 1–5; 98 in TCPC, 1/procedure, range 1–5), in 2 pts (3%) no ablation was performed, whereas 8 (3.7%) arrhythmias were not sustained. In TCPC pts 36 (36.7%) were macro-reentrant atrial tachycardia (MRAT) mostly from the right atrium (RA), 31 focal AT (FAT, 31.6%) almost equally from either the RA or the TCPC; 10 (10.2%) were atrio-ventricular nodal re-entrant tachycardia (AVNRT), 7 from twin AV node, and 3 concealed accessory pathways (AP) with AVRT (3%). Nine AT originated from several sites within the left atrium (9.1%). For the MRAT, most of the ablation lines were performed between the TCPC and the tricuspid annulus. In Fontans, all ATs originated from the RA, either MRAT (54, 46.1%) mostly around surgical scars, or FAT (58, 49.6%). Three pts (2.5%) presented in AF, while 1 (0.8%) had a left AP. Irrigated tip ablation resulted in acute success of 78.3% in the TCPC cohort and 76.7% in the Fontan cohort. The mean procedure time was 254±99 min and 255±106 min with a mean fluoroscopy time 2.3±1.9 min and 5.5±4.8 min for each TCPC and Fontan, respectively. During a mean follow-up of 4.2±3.0 years (maximum of 10.8 years), 58% (41–72) of TCPC pts and 22% (10–38) of Fontan pts remained free of symptoms/significant arrhythmia [at 2 years: 69% (55–79) and 31% (18–46), respectively]. Eleven TCPC (26%, 4 new arrhythmias) and 14 Fontan patients (70%, 3 new arrhythmias) needed repeat procedures. In multivariate Cox regression analysis, Fontan operation and female gender were associated with worse outcome, independently of the type of arrhythmia.

Conclusions
Advances in 3D mapping, image integration and the introduction of RMN has facilitated a dramatic improvement of ablation outcomes for adult patients after single ventricle repair. Patients with TCPC have fewer arrhythmias than Fontans and are more likely to benefit longterm, whilst transbaffle puncture can be avoided using RMN.
2400Early and late effects of cardiac resynchronization therapy in adult congenital heart disease
Authors: Yin Y , Dimopoulos K , Shimada E , Lascelles K , Griffiths S , Wong T , Gatzoulis M A , Babu-Narayan S V , Li W 
Published: October 2019

Abstract

Background
There are limited data regarding cardiac resynchronization therapy (CRT) in adult congenital heart disease (ACHD).

Purpose
We aimed to assess early and late outcomes of CRT amongst patients with ACHD.

Methods
We retrospectively studied ACHD patients receiving CRT (2004–2017). Clinical and echocardiographic data were analyzed at baseline, early (1.8±0.8 years) and late (4.7±0.8 years) follow-up after CRT.

Results
Fifty-four ACHD patients (median age 46 years, range 18–73 years, 74% male) had CRT (biventricular paced >90%) and were followed for 5.7±3.0 years. Thirty-nine (72%) patients had a systemic left ventricle (LV). Underlying cardiac anatomy included left ventricular outflow tract lesions (n=17; 32%), tetralogy of Fallot (n=11; 20%), right ventricular outflow tract lesions (n=5; 9%), atrioventricular septal defects (n=5; 9%) and atrial septal defect with right aortic arch (n=1; 2%). Fifteen (28%) patients had a systemic right ventricle (RV): 13 (24%) with congenitally corrected transposition of great arteries, and 2 (4%) with transposition of the great arteries after Mustard repair.
Compared to baseline, CRT was associated with significant improvement at early follow-up in NYHA functional class, QRS duration, cardiothoracic ratio, left and right atrial volume index (P<0.05 for all) in the overall population; improvement in NYHA class was sustained at late follow-up. Amongst patients with a systemic LV, there was significant increase in LV ejection fraction and reduction in LV end-systolic volume at early and late follow up (P<0.05 for both). There is trend in improvement of RV fractional area change in the patients with a systemic RV but not met statistical significance (P=0.070). Findings were summarized in Figure 1.
Eleven patients died and 2 had heart transplantation unrelated to systemic ventricular morphology. Thirty-five (65%) patients responded positively to CRT but only baseline QRS duration was a predictor of the positive response.

Conclusion
CRT results in sustained improvement in functional class, systemic LV size and function. QRS duration but not QRS morphology was a predictor of the positive response seen at early follow-up in 2/3 of ACHD patients.
2406Role of implantation access on complication rates in pacemaker implantation
Authors: Droth K , El-Armouche A , Andresen D , Bestehorn K P 
Published: October 2019

Abstract

Introduction
The implantation access (IA) either via vena cephalica (VC) or vena subclavia (VS) is the usual procedure in pacemaker implantation (PI). Valid data on head-to head comparisons between access via CV and VS regarding serious complications are missing.

Purpose
We analyzed potential associations between the type of implantation access and complication rates in a real world data set with 69.957 cases.

Methods
The 2013 dataset of the German Federal Council, containing information about all 1st pacemaker implantations for Germanywas analyzed. First two cohorts of patients treated via CV or CS access were compared for all relevant variables through descriptive statistics. Secondly all patient-clusters with exactly the same risk-/condition-vector were identified based on the following variables: age, sex, ASA classification (ASA 1–ASA 5), leading symptom, indication for implantation, etiology, ejection fraction (EF), estimated need of stimulation, and all possible 1:1 exact matchings were compared.

Results
Out of the total cohort of 69,957 patients (mean age 76.2 years, 43.3% females, VC access 36%, VS access 64%) 19,643 pairs with identical profile of all factors contained in the database could be identified. These pairs of all 1:1 matchings had following profile: age 77.07 years, ASA 1 to 4 6.3%, 2 45.0%, 46.9%, 4 1.7%, leading symptoms (dizziness 51.9%, singular cardiac syncope 10.3%, recurring syncope 28,7%), pacemaker indication (AV-Block II/III 11.6%/26.3%, sick sinus syndrome 39,8%, bradycardia in atrial fibrillation 20.0%), unknown etiology 90.3%, estimated need of stimulation (permanent (>90%) 20.9%, frequent (5–90%) 70.2%, rare (<5%) 8.9%), EF (≤35%: 0.4%: 35, 50%: 9.1%, >50%: 79.9%, unknown: 10.5%).
Intra- and post-procedural complication [C] rates different between VC and VS are: at least one C: 2.6% (VC), 3.0% (VS) p=0.018; surgical C with need for intervention (haematothorax, pericardial effusion, pouch hematoma): 0.5% (VC), 1.0% (VS) p=0.005; asystole: 0.1% (VC), 0.2% (VS) p=0.047; pneumothorax: 0.1% (VC), 0.7% (VC) p<0.001; dislocated atrial lead: 0.8% (VC), 0.6% (VS) p=0.027. Intra-hospital mortality was 1.0% (VC), 1.1% (VS) p=0.521.

Conclusion
Our analysis of a large-scale database shows that in patients with first pacemaker implantation the overall rate of complications is relatively low. But even after adjustment for available risk factors there are differences between the access routes: whereas VS access route is associated with statistically significant higher risk of overall complications, i.e. surgical complications, asystole, pneumothorax the VC access has a greater risk of dislocated atrial lead. In view of the two times higher rate of implantations via VS (64 vs. 36%) the clinical implications should be considered when choosing the access route and the VC access should be preferred.

Acknowledgement/Funding
None
2421Immunosuppressive therapy and prognosis in biopsy-proven fulminant lymphocytic myocarditis requiring veno-arterial extracorporeal membranous oxygenation support
Authors: Okumura T , Sawamura A , Kondo T , Ito M , Ozaki Y , Ohte N , Amano T , Murohara T 
Published: October 2019

Abstract

Background
Fulminant myocarditis is one of the fatal diseases for which effective management has not yet been established. Immunosuppressive therapy (IST) using corticosteroid has been actively applied to giant cell or eosinophilic myocarditis, there is no consensus on the efficacy of lymphocytic myocarditis, which is suspected of involving viral infection. Actually, IST for lymphocytic myocarditis is not recommended in the European Society of Cardiology guidelines, but in the Japanese Circulation Society guidelines, it is approved for use in refractory cases in the absence of curative therapy for myocarditis established.

Purpose
The purpose of this study was to explore the potential efficacy of immunosuppressive therapy on acute phase in fulminant lymphocytic myocarditis (FLM) requiring veno-arterial extracorporeal membranous oxygenation (VA-ECMO) support.

Method
We conducted CHANGE-PUMP study that was retrospectively enrolled 99 patients with fulminant myocarditis required VA-ECMO support in the Tokai area (central part of Japan) for the past 20 years. Lymphocytic myocarditis was defined by pathological category. Patients were divided into two groups depending on whether IST using corticosteroid was performed in the clinical course. Results: Sixty-six patients were pathologically diagnosed as fulminant myocarditis by endomyocardial biopsy, of which only 49 patients were FLM. IST were indicated in 8 (16%) out of 49 patients of FLM (IST group; n=8, non-IST group; n=41). Kaplan-Meier survival analysis showed a lower survival rate in the IST group than in the non-IST group (p=0.073). However, in all cases, based on our guidelines, IST was initiated after becoming refractory to MCS treatment.
Immunosupressive therapy and prognosis

Conclusion
In the retrospective analysis, biopsy-proven FLM patients with IST required VA-ECMO support had low survival rates. However, the timing of IST introduction was late and concerned. In the present era when advanced mechanical support appears and the survival rate of fulminant myocarditis is expected to improve, a multicenter prospective study is needed to establish an indication of IST in the acute phase of fulminant myocarditis.
2423Familial cardiomyopathy in patients affected by acute myocarditis is strongly associated to DSP gene mutations
Authors: Marteau L , Kyndt F , Toquet C , Serfaty J M , Guijarro D , Le Gloan L , Lande G , Gourraud J B , Warin Fresse K , Conan E , Thollet A , Le Tourneau T , Trochu J N , Probst V , Piriou N 
Published: October 2019

Abstract

Background
The link between acute myocarditis (AM) and familial cardiomyopathy remains unclear.

Purpose
To assess the clinical significance of AM in families with cardiomyopathy.

Methods and results
We describe the pedigree of 6 families with at least one familial case of AM and a familial history of cardiomyopathy or sudden death (SD). AM was defined as an infarct-like clinical presentation with normal coronary arteries and myocardial inflammation (MI) documented by cardiac magnetic resonance (CMR), or as an autopsy proven AM. Detailed familial pedigrees are shown in the picture. In family 1 to 5, genetic testing was triggered by the association of a documented case of AM with an index case of cardiomyopathy or early SD. In this setting, all genetic testing revealed a mutation in the desmoplakin (DSP) gene. In family 1, patient II.1 (15 y.o) was diagnosed with AM, 6 months after his sister died suddenly at the age of 12. In family 2, patient II.4 (17 y.o) was diagnosed with AM. His mother had a DCM, with a CMR revealing the presence of MI. In family 3, patient IV.3 (22 y.o) died suddenly from an AM, attested by post-mortem autopsy. Her aunt had a DCM. In family 4, patient II.4 (41 y.o) had an AM, progressing toward a DCM. Her mother had died suddenly at the age of 39, and her niece had a DCM. In family 5, patient V.16 (9 y.o) presented 4 recurrent episodes of AM. Her cousin's mother had a DCM. In family 6, patient IV.3 had 3 episodes of AM, his father had previously been diagnosed with an arrythmogenic right ventricular cardiomyopathy (ARVC) with a desmoglein 2 (DSG2) mutation. Table shows detailed genotype-phenotype relationship in all mutation carriers screened in the 6 families.
Phenotypes observed in mutation carriers Mutation DCM ARVC AM Isolated LGE (no cardiomyopathy, no AM) Family 1 (n=3) DSP 0 0 1 1 Family 2 (n=3) DSP 1 0 1 0 Family 3 (n=11) DSP 5 0 1 0 Family 4 (n=3) DSP 2 0 1 0 Family 5 (n=7) DSP 2 0 1 3 Family 6 (n=5) DSG2 0 1 1 1
Family Pedigrees

Conclusion
AM is strongly associated to desmosomal mutations when a familial history of cardiomyopathy is present, particularly in DSP gene. In these families, DCM phenotype and SD are frequent, and a notable proportion of isolated LGE suggestive of myocardial fibrosis is present in asymptomatic relatives. These results highlight the need for a comprehensive familial screening in case of AM.
P1223Attributable risk proportion of uncontrolled low-density lipoprotein cholesterol in recurrent acute coronary syndromes
Authors: Cordero A , Rodriguez Manero M , Bertomeu Gonzalez V , Agra Bermejo R , Garcia Acuna J M , Moreno Arribas J , Moreno M J , Alvarez B , Martinez Rey-Ranal E , Bertomeu Martinez V , Gonzalez-Juanatey J R 
Published: October 2019

Abstract

Background
Coronary heart disease is chronic condition that usually has recurrent events. Risk factors for incident coronary heart disease are well known conditions related to recurrences have not been clearly outlined. Attributable risk proportion (ARP) refers to the proportion of incident cases in subjects exposed to risk factors that are attributable to that risk factor so we analysed ARP in wide cohort of patients admitted for an acute coronary syndrome (ACS).

Methods
Cross-sectional analysis of all patients admitted in two hospitals between January 2006 and December 2016. ARP was calculated by the equation: prevalence in exposed – (prevalence in exposed/odds ratio). LDL uncontrolled was codified as >70 mg/dl in patients with previous cardiovascular disease; >100 mg/dl in patients with diabetes without previous cardiovascular disease or; >155 mg/dl in patients without cardiovascular disease.

Results
We included 7,518 patients, mean age 66.9 (12.9) years, 72.5% males, median GRACE score 143.2 (40.3) and 35.3% STEMI. Previous coronary heart disease total was present in 2,032 (23.2%) patients and they had statistically higher mean age (70.6±11.11 vs. 65.8±13.3), prevalence of diabetes (37.9% vs. 25.3%) and hypertension (72.9% vs. 53.3%) and lower smoking habit (15.5% vs. 30.9%). LDLc was lower in patients with previous coronary heart disease (90.3±33.8 vs. 111.7±38.1; p<0.01), as well as HDLc (33.5±14.29 vs. 35.9±35.5; p<0.01) and haemoglobin (13.5±3.7 vs. 14.0±2.4; p<0.01). Uncontrolled LDLc was present in 83.4% of the patients with previous coronary heart disease, in contrast to the 28.7% of patients without previous coronary heart disease; this resulted in an ARP of 13.8%. The ARP for diabetes and hypertension were 1.6% and 1.4%, respectively.

Conclusions
The proportion of attributable risk of uncontrolled LDL on recurrent ACS is 13.8% and, therefore, 1 out of every 7 recurrent ACS could be prevented by an accurate LDLc control.