bluuebunny/crossref_metadata_2025_split huggingface dataset:
P1756The protein APRIL predicts adverse outcomes in DAPT patients better than NT-proBNP and troponin
Authors: Pemberton C J , Lee J A , Aldous S , Skelton L , Frampton C M , Than M , Troughton R W , Adamson P , Richards A M 
Published: October 2019

Abstract

Aim
Dual antiplatelet therapy (DAPT) is a mainstay of post-ACS treatment. However, prediction of adverse events in these patients needs improving. We show here that the TNFα-related protein APRIL (which is produced in platelets and atherosclerotic plaque) is a superior predictor of MACE and new MI in DAPT recipients post-ACS.

Methods
We prospectively recruited 518 patients presenting with the primary complaint of acute chest pain to our hospital ED. Patients were adjudicated to have ACS by 2 independent cardiologists in accordance with ESC guidelines with hsTnI as biomarker. Plasma EDTA samples taken at presentation and 2 hours after were interrogated for APRIL measurements using a two site ELISA. Clinical data/variables, standard biochemistry analytes, hsTnT and NT-proBNP were also measured. Statistical assessments were made using SPSS v23 (IBM). Data for all biomarkers were treated as continuous variables and are presented as median (interquartile range, (IQR)). Statistical assessment of the comparative diagnostic abilities of APRIL, hsTnT, NT-proBNP and hsTnI were assessed using receiver operator curve (ROC) area under the curve (AUC) analysis. The comparative power of each biomarker (log values) to predict new MACE, MI, bleeding and mortality in 1) the whole group and in 2) DAPT recipients alone, within 2 yrs of index presentation was undertaken using a logistic regression base model (95% CI) that included all clinical variables and hsTnI and hsTnT, with APRIL and NT-proBNP each included in additional multivariate analyses.

Results
Of the 518 recruited patients (median age 63 (IQR: 54–73, 35% female), 152 were adjudicated to have ACS (29%, 115 MI, 37 UAP). Presentation APRIL levels were higher in those with a cardiac versus non-cardiac cause for presentation (3.0, (2.0–4.7) vs. 2.4, (1.6–3.8) ng/mL, P=0.001) and positively correlated with hsTnT and NT-proBNP (all P<0.001), but it did not add to the hsTnI (ROC = 0.96) or hsTnT (ROC =0.92) assisted diagnosis of ACS. In all 518 patients, in the multivariate regression model, APRIL was a significant independent predictor of mortality (n=54, P=0.032), new MI (n=43, P=0.006), new ADHF (n=24, P=0.016) and MACE (n=71, P=0.005) that was additive to NT-proBNP and troponin. In DAPT recipients alone (n=156), APRIL was the only biomarker to independently predict new MI (n=27, 95% CI: 1.125–3.982, P=0.020) and MACE (n=37, 95% CI: 1.058–3.389, P=0.031). None of the markers, only age, predicted bleeding episodes.

Conclusion
APRIL is an platelet/plaque derived marker that provides independent risk assessment in ACS patients. In DAPT recipients, the ability of APRIL to predict new MI and MACE is superior to that of cardiac troponins and NT-proBNP and could be used to identify high risk individuals.

Acknowledgement/Funding
Health Research Council of New Zealand; Heart Foundation of New Zealand
P1765Hyperacute T-wave in the early diagnosis of acute myocardial infarction
Authors: Koechlin L , Strebel I , Boeddinghaus J , Nestelberger T , Wussler D , Walter J , Zimmermann T , Badertscher P , Wildi K , Puelacher C , Du Fay De Lavallaz J , Rubini Gimenez M , Reichlin T , Twerenbold R , Mueller C 
Published: October 2019

Abstract

Background
The clinical significance of prominent T-waves, also referred as hyperacute T-waves, in the early diagnosis of acute myocardial infarction (AMI) is unknown.

Purpose
To evaluate the clinical utility of hyperacute T-waves in the early diagnosis of AMI.

Methods
In a prospective diagnostic study enrolling patients presenting to the emergency department (ED) with symptoms suggestive of AMI, final diagnoses were adjudicated by two independent cardiologists based on clinical information including cardiac imaging. Electronic electrocardiogram data were available in 2946 consecutive patients. Patients with left ventricular hypertrophy, complete left bundle branch block or pacemaker were excluded from further analysis. In the remaining 2382 patients, the T-wave amplitude was automatically derived from the standard 10 seconds 12-lead ECG recorded at presentation to the ED using an established algorithm.

Results
Median (IQR) time from chest pain onset (CPO) to ED presentation was 5 (IQR [2.5, 12.2]) hours. A total of 219 patients (9%) presented to the ED within 1h or less from CPO. AMI was the final diagnosis in 18% (NSTEMI in 15%, STEMI in 3%) of patients. High T-wave amplitude in leads AVF, III and V1 were associated with AMI. Optimal cut-offs were derived to achieve a predefined positive predictive value (PPV) of at least 75%. These criteria were 473mV, 357mV and 483mV for AVF, III and V1, respectively. With these cut-offs 1.4%, 4.2% and 0.9% of all patients with AMI were detected and specificity was 99.9% (95% CI [99.7%, 100%]), 99.7% (95% CI [99.4%, 99.9%]) and 99.9% (95% CI [99.8%, 100%]). However, majority of the patients with AMI correctly identified by the hyperacute T-wave had also significant ST-element elevations (AVF: 5 out of 6; [83.3%]; III: 10 out of 18 [56%]; V1:1 out of 4; [25%]).

Conclusion
In patients presenting to the ED with symptoms suggestive of AMI, only leads AVF, III and V1 showed hyperacute T-waves with high PPV. However, incidence of this finding is very low. In addition, majority of the cases correctly identified by hyperacute T-waves also had concomitant ST-segment elevations. Therefore, hyperacute T-waves have only very limited utility in the early diagnosis of AMI in the ED.

Acknowledgement/Funding
Swiss National Science Foundation, the Swiss Heart Foundation, the KTI, the European Union,the Stiftung für kardiovaskuläre Forschung Basel
P1786Impact of surgery for mitral regurgitation at the time of aortic valve replacement
Authors: Kato N , Thaden J J , Miranda W R , Sarano M E , Greason K L , Pellikka P A 
Published: October 2019

Abstract

Background
Functional mitral regurgitation (MR) is expected to improve after aortic valve replacement (AVR) in patients with severe aortic stenosis (sAS) and MR. However, little is unknown about the impact of AVR on organic MR and whether concomitant mitral valve surgery (MVS) improves outcomes in patients with sAS and MR.

Purpose
We assessed the impact of AVR on MR severity according to MR mechanism. We also assessed the clinical outcomes in patients with sAS and MR that underwent AVR with vs without MVS.

Methods
We retrospectively investigated patients who received surgical AVR or transcatheter aortic valve implantation (TAVI) from 2008 to 2017. We identified patients with effective mitral regurgitant orifice area (ERO) ≥10 mm2 by the proximal isovelocity surface area method with transthoracic echocardiography. The change in MR after AVR was considered significant when there was at least one grade difference. We compared the all-cause mortality of patients with sAS and MR that underwent AVR with vs without MVS according to MR mechanism and patient age.

Results
We included 326 patients with sAS and MR (age 80 [Interquartile range 72–85] years, 53% male, 21% history of myocardial infarction). Organic and functional MR were present in 69% and 31%, respectively. Of these, 240 underwent AVR alone (AVR group) including TAVI in 112 while 86 underwent AVR and MVS (MVS group) including mitral valve replacement in 38 and mitral valve repair in 48. The median ERO at baseline was 17 (14–21) mm2 in AVR and 24 (19–33) mm2 in MVS (p<0.001). Improvement in MR was observed in 58% of AVR and 91% of MVS (p<0.001). In AVR group, organic MR improved as frequently as functional MR (58% vs. 59%, p=0.96). Predictors for improvement in organic MR were absence of atrial fibrillation and moderate or greater MR, and in functional MR, the only predictor was decrease in LV end-systolic diameter after AVR. During mean follow-up of 2.4±2.3 years, moderate or greater MR was observed in 23% of AVR and 7% of MVS (p=0.002). All-cause mortality was similar in AVR and MVS groups for organic and functional MR (hazard ratio for MVS group 0.68, 95% CI: 0.40–1.10, p=0.13 in organic MR and 0.62, 95% CI 0.29–1.22, p=0.68 in functional MR). All-cause mortality was lower in MVS group compared with AVR group in patients <80 years, and was similar in patients ≥80 years (Figure).

Conclusion
In patients with sAS and MR, MR improves after AVR, even in the majority of patients with organic MR. Compared with isolated AVR, concomitant MVS was associated with better prognosis in patients <80 years.
P1787Peripheral vascular access for transcatheter aortic valve implantation: transcarotid versus femoral access
Authors: Folliguet T A F 
Published: October 2019

Abstract

Objectives
The transcarotid (TC) approach for transcatheter aortic valve implantation (TC-TAVI) is potentially an optimal alternative to the gold standard, transfemoral approach. Unfortunately, few studies are reported regarding the safety and efficacy of TC-TAVI.

Methods
Using data from the national prospective French registry in France - the FRANCE TAVI registry – included a total of 12804 patients entered in the dataset between January 2013 and December 2015. Patients who underwent TF-TAVI or TC-TAVI were 11033 (10598 and 435 respectively) and represented our study cohort. The primary endpoints were perioperative all-cause mortality (either in-hospital mortality or 30-day mortality) and in-hospital complications (annulus rupture, aortic dissection, valve migration, cardiac tamponade, stroke, STEMI, permanent pacemaker implantation, pulmonary embolism, renal failure, renal dialysis). All-cause mortality at follow-up was a secondary endpoint of the study.

Results
Among 11033 patients included in the current study 10598 (96%) underwent a femoral TAVI, and 435 (4.1%) a TC-TAVI. Patients in the TC-TAVI access group presented with a higher risk profile (mean logistic EuroSCORE1 8.2 vs. 20.3, P<0.001), with a higher rate of peripheral vascular disease, known coronary artery disease, chronic pulmonary disease and renal failure, dialysis and urgent status of TAVI. Four hundred and nineteen patients (3.8%) died during in-hospital stay, with no differences between the two groups (p-value 0.73). TC-TAVI had higher postoperative incidence of stroke (4.4% vs 1.9%, chi-square p-value 0.001), ST elevated myocardial infarction (STEMI) (0.7% vs 0.2%, chi-square p-value 0.05), permanent pacemaker implantation (18.9% vs 15.2%, chi-square p-value 0.04), infections (6.7% vs 4.0%, chi-square p-value 0.01), bleeding (9.2% vs 4.7%, chi-square p-value <0.001), renal failure (5.1% vs 3.3%, chi-square p-value 0.06) and dialysis (5.1% vs 3.1%, chi-square p-value 0.03). Conversely, TF-TAVI was likely to have vascular complications (7.7% vs 3.2%, <0.001)
There was no difference in short or midterm mortality rates. The Kaplan-Meier estimates of survival at 1 and 2 years were respectively 85.8%±0.4%, and 75.8%±0.6%.

Conclusion
Compared to femoral peripheral TAVI, TC-TAVI is safe, and associated with similar outcome except for a higher postoperative incidence of stroke and a twice-lower rate of access site-related complications. It should be considered in case of non-femoral peripheral access as the second access choice, to increase the overall safety of TAVI procedures.
P1793Eight-year clinical outcome and valve durability after transcatheter aortic valve implantation
Authors: Lattuca B , Meilhac A , Robert C , Vandenbergh D , Manna F , Nagot N , Chettouh M , Akodad M , Gandet T , Macia J C , Delseny D , Schmutz L , Albat B , Cayla G , Leclercq F 
Published: October 2019

Abstract

Background
With the growing indications of transcatheter aortic valve implantation (TAVI) worldwide and among lower risk patients, valve durability has become a crucial issue.

Purpose
To assess mid and long-term evolution of different generations of percutaneous balloon-expandable prostheses, predictive factors of valve deterioration and its correlation with long-term mortality.

Methods
All consecutive patients undergoing TAVI for severe aortic stenosis with balloon-expandable prosthesis between 2009 and 2014 and with a minimum follow-up of one-year were included in this monocentric prospective study. All echocardiograms were reviewed by two independent experts. Clinical events were defined according to the Valve Academic Research Consortium criteria. Valve deterioration was defined according to the 2017 EAPCI-ESC-EACTS international consensus statement at the longest follow-up.

Results
A total of 160 patients were included with a median follow-up of 3.4 years [1.5–4.9] and a maximum of 8 years. Patients were mostly implanted with the first generation Sapien XT valve (n=138, 86.2%). Median age was 85 [79–86] years, with 42.5% of women and a median logistic Euro-SCORE of 14.2% [10.6–23.2]. Immediately after TAVI, mean aortic gradient decreased dramatically from 51±12mmHg to 9±2.6mmHg (p<0.0001) and remained overall stable with a mean gradient of 12±1mmHg at 8 years. Valve deterioration occurred in 5.6% (n=9) of patients, of which 3.7% (n=6) with severe deterioration. Moderate or severe peri-prosthetic aortic regurgitation was observed in 2.5% (n=4) of patients. The eight-year survival rate was 12.9%. During follow-up, hospitalization for acute heart failure was required for 23.7% (n=38) of patients, a myocardial infarction or a stroke occurred respectively among 1.9% (n=3) and 5% (n=8) of patients. After multivariate analysis, size or generation of valves were not independent predictive factors of valve deterioration.
Evolution of mean aortic gradient

Conclusions
After a maximal 8-year follow-up, valve deterioration after balloon-expandable TAVI is very low. In this high-risk population, TAVI seems to be a safe and durable alternative to surgery in severe aortic stenosis regardless of prosthesis generation.

Acknowledgement/Funding
Edwards Lifesciences
P1803Refining the 2015 European guidelines risk assessment tool for pulmonary arterial hypertension in adult congenital heart disease
Authors: Van Dissel A C , Van Dijk A P J , Duijnhouwer A L , Mulder B J M , Bouma B J 
Published: October 2019

Abstract

Background
Current European guidelines advocate a goal-oriented treatment approach in pulmonary arterial hypertension (PAH), based on a comprehensive risk assessment. However, this instrument has been based predominantly on patients with idiopathic PAH and its accuracy has not been well established for PAH associated with congenital heart disease (CHD)–a patient population known to be distinctly different for other PAH aetiologies.

Purpose
To investigate the discriminatory ability of the guidelines risk assessment tool and explore the benefit of including other cut-offs or variables in PAH-CHD.

Methods and results
Data from 112 PAH-CHD patients (age 42.1±16 years, 70% Eisenmenger, 38% Down syndrome) seen between 2004 and 2016 at two specialized adult PAH-CHD expert centres were prospectively collected. Patients were classified as “Low”, “Intermediate”, or “High” risk following the strategy proposed by Kylhammar (Eur Heart J, 2017) based on N-terminal pro-brain natriuretic peptide (NT-proBNP), 6-minute walk distance, functional class and imaging parameters and analysed by Kaplan-Meier method, truncated at 5 years. At baseline, 25% (28) of patients were classified as “Low risk”, 69% (77) as “Intermediate risk” and 6% (7) as “High risk”. Although survival was better (P=0.012) for patients with higher proportions of “Low risk” variables, this method did not discriminate well between the three risk groups (Figure 1A, P=0.371). One-year survival estimates corresponded moderately to those proposed by the guidelines, 96.4% in the “Low risk” (vs. >95%), 94.8% in the “Intermediate risk” (vs. 90–95%), and 85.7% in the “High risk” (vs. <90%) baseline cohorts, respectively. Analysis of different cut-off values for NT-proBNP (i.e., “Low”, “Intermediate”, “High” as <500, 500–1440 and >1400 ng/l, respectively) and use of tricuspid annular plane systolic excursion (TAPSE) measurements (“Low”, “Intermediate”, “High” as <1.6, 2.6–2.7 and >2.7 cm, respectively) as imaging parameter instead of right atrial area improved discrimination between the risk groups (Figure 1B). With these adjustments to the risk assessment tool, survival differed between all three risk groups (P<0.001).
Figure 1

Conclusion
Our preliminary findings suggest that an updated version of the European guidelines risk assessment tool–with different cut-off values for NT-proBNP and use of TAPSE–discriminates more accurately in the PAH-CHD population. Further analysis will be performed to estimate the prognostic benefit of reaching a “Low risk” profile, as this is the recommended treatment goal.
P1804Cancer in young patients with congenital heart disease: A registry-based, matched, prospective cohort study
Authors: Mandalenakis Z , Karazisi C K , Skoglund K S , Rosengren A R , Lappas G L , Eriksson P E , Dellborg M D 
Published: October 2019

Abstract

Background
Adult patients with congenital heart disease (CHD) have an increased incidence of cancer presumably due to repeated radiation exposure, genetic predisposition or a continued stress factor during heart interventions.

Purpose
We aimed to investigate the risk to be diagnosed with cancer from birth up to the age of 42 years in patients with CHD and compared to matched controls.

Methods
Using data from the Patient and Cause of Death Registers in Sweden, we identified successive cohorts of patients with CHD born 1970–79, 1980–89 and 1990–93. Each CHD patient was matched for birth year, sex and county with 10 controls without CHD from the general population with follow-up data and comorbidities collected from birth until 2011.

Results
We identified 21,982 patients with CHD and 219,816 matched controls of whom 428 (1.95%) and 2,072 (0.94%), respectively, were diagnosed with cancer over a mean follow-up of 26.2 and 27.5 years. The overall hazard ratio (HR) for cancer was 2.24 times (95% confidence interval [CI], 2.01–2.48) in children and young adults with CHD compared to controls; higher in men (HR 2.41 (95% CI, 2.08–2.79)) and among patients with isolated atrial or ventricular defects, as well as in the large group of miscellaneous anomalies. The cumulative incidence of cancer in patients with CHD increased by birth cohort with almost 2% among those born 1990–93 been diagnosed with cancer on reaching adulthood.

Conclusions
Young patients with CHD had more than 2 timmes increased risk to develop cancer compared to matched controls. At the age of 42, 1 out of 50 patients with CHD developed cancer and the risk was significantly higher in men with CHD. The patient groups with atrial and ventricular septal defects had a significantly increased risk of cancer and a systematic screening for cancer could be considered to this vulnerable group of patients.

Acknowledgement/Funding
By grants from the Swedish state under the agreement concerning research and education of doctors, the Swedish Research Council.
P1805Troponin-T, NT-proBNP and creatinine at presentation predict outcomes in patients with cardiac sarcoidosis
Authors: Kolluri N , Rosenbaum A , Schmidt T , Kapa S , Blauwet L 
Published: October 2019

Abstract

Background
Cardiac sarcoidosis (CS) is an infiltrative inflammatory condition defined by infiltration of noncaseating granulomas into the heart. Based on the location of sarcoid lesion involvement, patients can present with symptoms of congestive heart failure, arrhythmias, and even sudden cardiac death.

Purpose
Diagnosis of CS has been somewhat challenging, with the Heart Rhythm Society (HRS) and Japanese Ministry of Health and Welfare (JMHW) being the 2 widely accepted diagnostic guidelines. Endomyocardial biopsy is the gold standard to prove definite CS but has a low sensitivity. Imaging studies have been helpful as non-invasive methods to diagnose probable CS but these can be logistically difficult and expensive. Thus, investigating for laboratory biomarkers that can act as both diagnostic and prognostic can be crucial in how we diagnose and manage CS in the future.

Methods
Patients meeting HRS for CS were evaluated at a single institution (n=217). Biomarkers of interest included angiotensin-converting enzyme (ACE), erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), N-terminal pro B-type natriuretic peptide (NT-proBNP), troponin-T, 1,25 dihydroxyvitamin D (1,25-OHVit-D), and creatinine. Biomarkers were stratified by clinical variables of interest and their association with prognosis was examined. The primary endpoint was LVAD implantation, transplantation, or death.

Results
Mean values on presentation were: ACE 32.9±28, ESR 12±13, CRP 7.4±19, NT-proBNP 1630±2923, Troponin-T 0.03±0.1, 1,25-OHVit-D 55.5±20, and creatinine 1.12±0.3. None of the biomarkers differed by sex, definite or probable CS, or a history of immunosuppression. ACE levels were associated with the presence of cardiac fibrosis on cardiac MRI (mean difference 14.7, p=0.032). Troponin-T (p=0.006; HR 1.06 per 0.01 ng/mL), NT-proBNP (p=0.0003; HR 1.31 per 1,000 pg/mL), and creatinine (p=0.01; HR 4.02 per mg/dL) were each associated with the primary endpoint (52/217 patients).
Biomarkers associated with long term outcomes in patients with cardiac sarcoidosis Biomarker Hazard ratio P value Troponin-T 1.06 (1.02–1.11)* 0.006 NT-pro BNP 1.31 (1.15–1.48)** 0.0003 Creatinine 4.02 (1.41–9.94)*** 0.01 *Per 0.01 ng/mL change; 99th percentile upper reference limit <0.01 ng/mL; **per 1,000 pg/mL change; ***per 1 mg/dL change.

Conclusion
Troponin-T, NT-proBNP, and creatinine at presentation predict outcomes in patients with CS. Further investigation on the utility of biomarkers for assessment of disease activity and treatment response is warranted.