Prospective international validation of the predisposition, infection, response and organ dysfunction (PIRO) clinical staging system among intensive care and general ward patients

Background

Stratifying patients with sepsis was the basis of the predisposition, infection, response and organ dysfunction (PIRO) concept, an attempt to resolve the heterogeneity in treatment response. The purpose of this study is to perform an independent validation of the PIRO staging system in an international cohort and explore its utility in the identification of patients in whom time to antibiotic treatment is particularly important.

Methods

Prospective international cohort study, conducted over a 6-month period in five Portuguese hospitals and one Australian institution. All consecutive adult patients admitted to selected wards or the intensive care, with infections that met the CDC criteria for lower respiratory tract, urinary, intra-abdominal and bloodstream infections were included.

Results

There were 1638 patients included in the study. Patients who died in hospital presented with a higher PIRO score (10 ± 3 vs 8 ± 4, p < 0.001). The observed mortality was 3%, 15%, 24% and 34% in stage I, II, III and IV, respectively, which was within the predicted intervals of the original model, except for stage IV patients that presented a lower mortality. The hospital survival rate was 84%. The application of the PIRO staging system to the validation cohort resulted in a positive predictive value of 97% for stage I, 91% for stage II, 85% for stage III and 66% for stage IV. The area under the receiver operating characteristics curve (AUROC) was 0.75 for the all cohort and 0.70 if only patients with bacteremia were considered. Patients in stage III and IV who did not have antibiotic therapy administered within the desired time frame had higher mortality rate than those who have timely administration of antibiotic.

Conclusions

To our knowledge, this is the first external validation of this PIRO staging system and it performed well on different patient wards within the hospital and in different types of hospitals. Future studies could apply the PIRO system to decision-making about specific therapeutic interventions and enrollment in clinical trials based on disease stage.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13613-021-00966-7.

Impact of missing outcome data in meta-analyses of lifestyle interventions during pregnancy to reduce postpartum weight retention: An overview of systematic reviews with meta-analyses and additional sensitivity analyses

High risk of bias associated with missing outcome data (MOD) in meta-analyses (MAs) of the effects of lifestyle interventions during pregnancy on postpartum weight retention (PPWR) casts doubt on whether such interventions can be relied upon as truly effective. This systematic overview of three MAs (19 RCTs), each with high MOD rates in the subset of RCTs included, examined how MOD were addressed in the estimation of summary intervention effects. All MAs reported beneficial and statistically significant intervention effects estimated based on complete case analyses, deemed valid if MOD was missing at random (MAR). Therefore, we conducted sensitivity analyses using pattern mixture models and informative missingness parameters (describing how the outcome in the missing participants may be related to the outcome in the completers), to ascertain the robustness of the estimates to reasonable deviations from the MAR assumption. In plausible scenarios where the response in intervention group participants with versus without MOD was worse (by just 0.5 kg), effect estimates were attenuated in all MAs and no longer statistically significant in two MAs. Statistical significance was retained when all 19 RCTs identified across MAs were examined together in a broader meta-analysis: -0.63 kg (95%CI -0.17, -0.08), but the clinical relevancy of effects of this magnitude remains unclear.

Clinical impact on treatment and prognosis of advanced cardiac imaging with echocardiography in the acute setting of a COVID-19 infection

Background and objectives

Despite myocardial injury being related to excess mortality in acute COVID-19 infection, its impact on imaging findings remains unclear. This study aimed to characterize transthoracic echocardiographic (TTE) findings in patients admitted with COVID-19 infections and its impact on management and prognosis.

Methods

A prospective observational cohort study was performed among 66 COVID-19 patients who were admitted to a tertiary center between March 1 and May 25, 2020 and underwent TTE. High-sensitivity troponin I (hs-cTnI) data, echocardiographic assessment of right and left ventricular (LV) functional parameters, strain, and myocardial work analysis were obtained.

Results

2025 patients were admitted with COVID-19 and in 200 a complete TTE study was performed. Due to poor image quality, only 66 studies were included in the final analysis. The median age was 62 years (IQR, 55–70) and 59.1% of patients were males. The most common comorbidity was hypertension (47%), followed by smoking history (30.3%), atrial fibrillation (9.1%), and chronic obstructive pulmonary disease (7.9%). More than half of the patients (39, 59%) were admitted to the ICU, and half of them (33, 50%) required invasive mechanical ventilation. TTE was mainly indicated because of concerns for systemic conditions (50%) and evaluation of hemodynamic assessment (30%). Thirty-six patients (54.5%) had an abnormal TTE result and 57% had elevated hs-cTnI levels. The most common cardiac abnormality was LV diastolic dysfunction in 33% of the patients, followed by right ventricular dysfunction (12%) and LV dysfunction (6%) (Figure 1). LV GLS was reduced in 48.5% of the cases. Myocardial work performance indices were all reduced in patients with an abnormal TTE (GWI 30%, GCW 30%, GWW 40%, and GWE 40%), although differences were not significant (P&gt;0.2 for all parameters). Patients with an abnormal TTE were older and presented a higher cardiovascular risk profile. There were no significant differences in the levels of D-dimer, NTproBNP, and hs-cTnI between patients with and without diastolic dysfunction, RV, or LV dysfunction (P&gt;0.3 for all parameters). Using Spearman rank correlation, there was an inverse relationship between hs-cTnI and LV strain and myocardial work analysis. TTE results impacted clinical management in 60 patients, mainly de-escalation of medical treatment (Figure 2). Abnormal TTE results did not impact in-hospital outcomes.

Conclusions

Severe echocardiographic abnormalities are uncommon in hospitalized patients with COVID-19 infections, presenting mostly with subclinical myocardial changes, such as diastolic dysfunction, reduced LV GLS, and myocardial work indices, both associated with high-sensitivity troponin I elevation. An echocardiographic study should be limited to rule out long-term ICU complications or to evaluate hemodynamic instability. Although TTE was a valuable tool for guiding management, it had no significant impact on prognosis.

Funding Acknowledgement

Type of funding sources: None. Figure 1. Findings on TTE studies.Figure 2. Changes in management.

Prognostic value of baseline versus 6-month follow infarct size in patients with reperfused STEMI

Background

Acute infarct size is a predictor of clinical outcomes in acute ST segment elevation myocardial infarction (STEMI) patients, although its prognostic value has differed between studies. In acute STEMI, infarct size is often overestimated due to the presence of extensive myocardial oedema, a confounder that is no longer present at a 6-month follow-up study. It was our purpose to assess whether infarct size in the acute phase or at 6-months follow-up provided superior prognostic information in STEMI patients.

Methods

STEMI patients who underwent successful primary percutaneous revascularization were included and a cardiac magnetic resonance (CMR) was performed between 5–7 days after STEMI and at 6 months to study infarct size (as a % of myocardial mass). The primary endpoint was a composite of cardiovascular mortality, hospitalization for heart failure and ventricular arrhythmia.

Results

A total of 796 patients were included (mean age 58.3±11.5 years, 82.4% male, 52.3% anterior infarction). During a mean follow-up of 59 months, 59 patients (7.4%) presented with the primary end-point (cardiovascular death n=7, hospitalization for heart failure n=52, ventricular arrhythmia n=1). ROC curve analysis (figure 1) showed a non-significant difference between baseline and 6-month infarct size for the prediction of the primary endpoint (baseline AUC 0.685 95% CI 0.610–0.760, 6-month AUC 0.713 95% CI 0.643–0.782, p=0.60). Optimal cut-off values for baseline and 6-months follow-up infarct size for prediction of outcomes, respectively 22% and 17.5%, were used for Kaplan-Meier curve analysis (figure 2).

Conclusion

Infarct size estimated during the first week after STEMI and at 6-months follow-up showed similar predictive value and with similar cut-off values. Therefore, the prognostic information provided by infarct size can be obtained during initial STEMI admission and does not require a waiting period for infarct size stabilization.

Funding Acknowledgement

Type of funding sources: None. ROC curve analysisKaplan-Meier analysis

1463Impact of missing outcome data in meta-analyses of lifestyle interventions during pregnancy to reduce postpartum-weight-retention

Background

High risk of bias associated with missing outcome data (MOD) in meta-analyses (MAs) of the effects of lifestyle interventions during pregnancy on postpartum weight retention (PPWR), casts doubt on whether such interventions can be relied upon as truly effective, since estimates are deemed valid only if MOD was missing at random (MAR).

Methods

We conducted a systematic overview of MAs to examine the impact of MOD on the estimation of meta-analytic summary intervention effects and conducted sensitivity analyses using pattern mixture models and informative missingness parameters (describing how the outcome in the missing participants may be related to the outcome in the completers), to ascertain the robustness of the estimates to reasonable deviations from the MAR assumption.

Results

Three relevant MAs were identified, all with high MOD rates in the RCTs included (median&gt;30%), and all reporting beneficial intervention effects on PPWR (in kg) estimated based on complete case analyses: [-0.78 (95%CI: -1.39,-0.16), -0.81 (-1.57,-0.06), and -0.94 (-1.52,-0.37)] in MAs of any lifestyle, exercise, or diet + exercise interventions, respectively. In plausible scenarios where the outcome for the intervention group in participants with vs without MOD was worse (by 0.5kg), effect estimates were attenuated in all and no longer significant in 2 of the MAs [-0.58 (-1.29,0.13), -0.70 (-1.50,0.10) and -0.88 (-1.73,-0.02)].

Conclusions

Statistical significance was retained when all 19 RCTs identified across MAs were meta-analysed: -0.63 (-0.17,-0.08).

Key messages

The clinical relevancy of effects of this magnitude remains unclear.

Influence of operator experience on the technical and clinical results of Woven EndoBridge endovascular treatment for intracranial aneurysms

BACKGROUND & PURPOSE

The safety and efficacy of the Woven EndoBridge (WEB) device has been proven in recent multicenter trials. This study investigated whether operator experience influences WEB treatment-related outcomes.

MATERIAL AND METHODS

This was a retrospective analysis of a prospectively collected multicenter database. The data of all patients who underwent WEB treatment for an intracranial aneurysm from March 2014 to June 2020 in two high-volume centers were pooled. Operator experience was indexed by the number of WEB treatments performed previously. The primary endpoint was the overall complication rate. Secondary endpoints were long-term adequate (Raymond-Roy classification of 1-2.) angiographic occlusion, WEB-related complications, number of WEB not deployed, procedure duration, and radiation exposure (air kerma).

RESULTS

Among 237 patients (mean age 59.4 +/- 11.5 years) treated with WEB (median aneurysm diameter, 5.8 mm; interquartile range 4.5-7 mm), WEB-related complications occurred in 28 patients (11.8%) and adequate long-term occlusion was achieved for 154 aneurysms (86%). The median number of WEB treatment performed previously per operator was 20 (IQR, 9-41). The overall complication rate, WEB-related complication rate and aneurysm occlusion rate were not significantly correlated with WEB operator experience. There were also no significant correlations between the WEB operator experience and the number of WEB not deployed, procedure duration or radiation exposure.

CONCLUSION

There was no significant association between the number of WEB treatments previously performed per operator and any technical or clinical results after intracranial aneurysm treatment with WEB. These results imply a relatively short learning curve for this device in high-volume neurovascular centers.

Electronic control of drug release from gauze or cellulose acetate fibres for dermal applications

Electronic controlled drug release from fibres was studied using ibuprofen as a model drug, one of the most popular analgesics, to impregnate gauze and cellulose acetate (CA) membranes. Conductivity in the range of 1-10 mS cm-1 was obtained in polypyrrole (Ppy) functionalised gauze and CA fibres, providing voltage-controlled drug release in a system consisting of Ppy/Ibuprofen/Ppy membranes and an Ag electrode. SEM images evidenced the Ppy adhesion to fibres and Micro Raman spectra proved drug incorporation and release. A small wound adhesive built with these membranes retains ibuprofen at 1.5 V and quickly releases it when -0.5 V is applied.

Aortic rotational flow patterns and stiffness by 4D flow CMR in patients with Loeys-Dietz syndrome compared to healthy volunteers and patients with Marfan syndrome

Funding Acknowledgements

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): La Marató de TV3, Instituto de Salud Carlos III through the project and Spanish Ministry of Science, Innovation and Universities.

BACKGROUND

Loeys-Dietz (LDS) and Marfan (MFS) syndromes are rare genetic connective tissue disorders associated with progressive aortic dilation, however, aortic dissections have been observed at lower aortic root diameters in LDS than in MFS. Recent CMR studies in MFS patients reported increased aortic stiffness (1–3) and altered rotational flow (4), but research on aortic flow dynamics and biomechanics in LDS is lacking.

PURPOSE

The aim of this study was to assess rotational aortic flow and aortic stiffness in LDS compared to healthy volunteers (HV) and MFS patients, using 4Dflow CMR.

METHODS

Twenty-one LDS and 44 MFS patients, without previous aortic dissection or surgery, and 43 HV underwent a non-contrast-enhanced 4D flow CMR. Aortic stiffness was quantified at the AAo and DAo using pulse wave velocity (PWV). In-plane rotational flow (IRF), systolic flow reversal ratio (SFRR) (5) and local aortic diameters were obtained at 20 equidistant planes from the ascending (AAo) to the proximal descending aorta (DAo).

RESULTS

LDS patients had lower IRF at the distal AAo and proximal DAo compared to HV (p = 0.053 and 0.004, respectively), once adjusted for age, stroke volume and local aortic diameter; but no differences were found with respect to MFS (Figure). Although SFRR at the proximal DAo was increased in LDS patients compared to both HV (p = 0.037) and MFS populations (p = 0.015), once adjusted for age and aortic diameter, the difference in magnitude was small (Figure). On the other hand, AAo and DAo PWV revealed stiffer aortas in LDS patients compared to HV but no differences versus MFS patients (Table).

CONCLUSIONS

Patients with Loeys-Dietz syndrome showed decreased in-plane rotational flow and abnormally-high regional aortic stiffness compared to healthy controls, and similar hemodynamics and aortic stiffness with respect to patients with Marfan syndrome.

Probiotic properties of yeasts isolated from Brazilian fermented table olives

AIMS

To investigate the probiotic potential of yeasts isolated from naturally fermented Brazilian table olives.

METHODS AND RESULTS

Eighteen yeast strains were tested in terms of: safety; survival of gastrointestinal and digestion conditions; antimicrobial activity; cellular hydrophobicity; autoaggregation ability and adhesion to epithelial cells; coaggregation and inhibition of pathogenic bacteria adhesion. Six yeasts showed favourable results for all probiotic attributes: Saccharomyces cerevisiae CCMA 1746, Pichia guilliermondii CCMA 1753, Candida orthopsilosis CCMA 1748, Candida tropicalis CCMA 1751, Meyerozyma caribbica CCMA 1758 and Debaryomyces hansenii CCMA 1761. These yeasts demonstrated resistance to 37°C, pH 2·0 and bile salts, and survived in vitro digestion (≥10⁶  CFU per ml). Furthermore, the yeasts exhibited a hydrophobic cell surface (42·5-92·2%), autoaggregation capacity (41·0-91·0%) and adhesion to Caco-2 (62·0-82·8%) and HT-29 (57·6-87·3%) epithelial cell lines. Also, the strains showed antimicrobial activity against Salmonella Enteritidis as well as the ability to coaggregate and reduce the adhesion of this pathogen to intestinal cells.

CONCLUSIONS

Autochthonous yeasts from naturally fermented Brazilian table olives have probiotic properties, with potential for development of new probiotic food products.

SIGNIFICANCE AND IMPACT OF STUDY

These data are important and contribute to the knowledge of new potential probiotic yeasts capable of surviving gastrointestinal tract conditions and inhibiting pathogenic bacteria.

Long term outcomes in left ventricular noncompaction

Funding Acknowledgements

Type of funding sources: None.

Background

Left ventricular noncompaction (LVNC) is a heterogeneous entity with a wide phenotypic expression. Risk factors have not been well established and prognostic stratification remains challenging.

Objectives

Describe long term outcomes of LVNC patients and determine predictors of cardiovascular events. 

Methods

 

Prospective multicentric study of consecutive patients fulfilling imaging diangostic criteria for LVNC (Jenni echo criteria and Petersen CMR criteria). Demographic, ECG, imaging and genetic variables were collected. End points were heart failure (HF), ventricular arrhythmias (VA), systemic embolisms (SE) and all-cause death. Major adverse cardiovascular events (MACE) was the combination of the four previous end points.

Results

585 patients from 12 referral centres were included from 2000 to 2018. Age at diagnosis was 45 ± 20 years, 334 (57%) were male, baseline LVEF was 48 ± 17% and 18% presented late gadolinium enhancement (LGE). During a median follow-up of 5.1 years (IQR 2.3-8.1), 110 (19%) patients presented HF, 87 (15%) VA, 18 (3%) SE and 34 (6%) died. MACE occurred in 223 (38%) patients.

LVEF was independently associated with HF, VA, SE and MACE: HR were 1.08, 1.02, 1.04 and 1.02 respectively (all p &lt; 0.05). LGE was more frequent in patients with reduced LVEF (39 Vs 53%, p &lt; 0.001) and was associated with higher HF and VA risk in patients with LVEF &gt; 35% (HR 2.69 and 2.48 respectively, p &lt; 0.05) (Figure 1). Patients with a normal ECG, LVEF≥50%, no LGE and no family aggregation presented no MACE (0%) at long term follow-up.

Among patients who underwent genetic testing (354, 61%), TTN variants and complex genotype (more than one variant) presented lower LVEF and higher HF risk. ACTC1 variants were associated with VA.

Conclusions

LVNC carries a high long term risk of heart faliure and ventricular arrhythmias. LVEF is the most important predictor and myocardial fibrosis is associated with increased risk in patients without severe systolic dysfunction. Genotype is a modifier of outcomes. These factors might be used to risk stratify LVNC patients.

Abstract Figure. Kaplan Meier survival curves

Aortic root longitudinal strain by speckle-tracking echocardiography predicts progressive aortic root dilation in Marfan syndrome patients

Funding Acknowledgements

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Spanish Ministry of Science, Innovation and Universities; Instituto de Salud Carlos III

Introduction

In Marfan syndrome (MFS) patients reduced longitudinal strain of the ascending aorta (AAo) as measured by applying feature-tracking on cine cardiac magnetic resonance (CMR) images predicts aortic root dilation and aortic events during the follow-up. Speckle-tracking is well established for cardiac deformation assessment but proximal aorta applications are challenging due to limited wall thickness and substantial cardiac motion. Moreover, echocardiography is widely used in the clinical assessment aortic diseases.

Purpose

We aimed to test a speckle-tracking tool for root longitudinal strain analysis in terms of comparison with CMR-derived AAo longitudinal strain and reproducibility and as predictor of dilation in MFS patients.

Methods

Thirty-five MFS patients diagnosed by original GHENT criteria, with maximum aortic root diameter of 45 mm and free from previous aortic dissection or cardiac/aortic surgery and non-severe aortic regurgitation were consecutive enrolled and followed-up. CMR and echocardiography were performed less than 2 months apart. Baseline and final aortic root diameter were measured on CMR images. To quantify aortic root cyclic elongation by echocardiography, two regions of interests were manually created covering both walls in a parasternal long-axis view and tracked along the cardiac cycle (Figure 1). Longitudinal strain was computed as the average of maximum increase in relative distance of several sub-regions covering both walls. CMR-derived AAo longitudinal strain was available in 29 patients. Intra-observer reproducibility was tested in 15 patients via intraclass correlation coefficient (ICC) for single-rater absolute agreement.

Results

Aortic root longitudinal strain by echocardiography was mildly related to CMR-derived AAo longitudinal strain (R = 0.27) and was larger compared to CMR-derived values (16.2 ± 6.0 vs 11.3 ± 4.3). Reproducibility was high, with ICC of 0.811, R = 0.802, p &lt; 0.001. After a mean follow up of 76 ± 13 months, aortic root diameter grew in 20 patients with a rate of 0.29± 0.24 mm/year. Overall mean growth-rate was 0.87 ± 0.33 mm/year. In multivariable analysis corrected for age and baseline aortic root diameter, baseline longitudinal strain by echocardiography was independently and inversely related to progressive dilation (p = 0.033).

Conclusions

The measurement of aortic root longitudinal strain by speckle-tracking echocardiography is feasible. Aortic root longitudinal strain is an independent predictor of progressive dilation in MFS patients. This may permit the improvement of risk-stratification in aortic diseases in large scale studies.

Abstract Figure 1

Leaflets fusion length in bicuspid aortic valve is related to ascending and aortic root dilation and ascending aorta wall shear stress

Funding Acknowledgements

Type of funding sources: Public Institution(s). Main funding source(s): Spanish Ministry of Science, Innovation and Universities, Instituto de Salud Carlos III

Background

Bicuspid aortic valve (BAV) is the most common congenital heart defect, consisting in the fusion of two aortic valve leaflets. Altered flow patterns have been related to aortic wall degeneration in BAV patients and may be responsible for the high prevalence of aortic disease in these patients. A number of studies on excised BAV or using advanced imaging modalities reported a wide variability of fusion extent between leaflet, but no previous study assessed whether leaflet fusion length may be used to stratify BAV patients.

Purpose

We aimed to test whether leaflet fusion extent can be quantified by cardiac magnetic resonance imaging (CMR) and whether it is related to aortic dilation and flow abnormalities in non-dysfunctional BAV.

Methods

One hundred and twenty BAV adults with no previous aortic or aortic valve surgery or significant valvular disease were consecutively enrolled. Patients with two sinuses of Valsalva (true BAV) or fusion of the left and non-coronary cusps, both being rare forms of BAV, were excluded. Twenty-eight healthy volunteers were also included for comparison. A 4D flow CMR sequence was acquired and circumferential wall shear stress and pulse wave velocity were assessed in the ascending aorta. A stack of double-oblique cine images of the aortic valve were used to quantify the length of the fusion between leaflets.

Results

The length of the fusion between leaflets was effectively measured in 112/120 patients (93%). Reproducibility was good (ICC = 0.826). Fusion length varied greatly (range 2.3 – 15.4 mm, 7.8 ± 3.2 mm, tertiles cut-off points were 6 and 9.3 mm). After correction for age, BSA, stroke volume and BAV fusion morphotype, fusion length was independently associated with diameter at the sinus of Valsalva (p = 0.002). Moreover, once corrected for age, stroke volume and ascending aorta pulse wave velocity, fusion length was positively related to ascending aorta diameter (p = 0.028). The comparison of maps of circumferential peak-systolic WSS in healthy volunteers (left) and BAV patients pertaining to the three leaflet fusion length tertiles is shown in Figure 1. Circumferential WSS progressively increase with larger fusion length. This trend was statistically significant (p &lt; 0.05) in the right and outer regions of the proximal and mid ascending aorta.

Conclusions

Bicuspid aortic leaflet fusion length varies considerably and it is independently associated with ascending aorta and aortic root dilation, possibly through flow alterations.

Abstract Figure 1

Regional curvature in thoracic aortic aneurysms of different aetiologies and its relationship with established risk factors

Funding Acknowledgements

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Spanish Ministry of Science, Innovation and Universities ; Instituto de Salud Carlos III

Introduction

The aorta is a 3D hollow, curvilinear elastic structure whose diseases have life-threatening consequences. Despite much effort has been paid to study aortic diameter, diameter is a poor predictor of events. Conversely, much less is known about aortic curvature, its distribution in the thoracic aorta and the potential impact of risk factors in aneurysms associated with different conditions. Currently, 4D flow magnetic resonance imaging (4D flow CMR) allows to obtain 3D geometry, 4D flow data and regional aortic stiffness.

Purpose

We aim to study regional aortic curvature in thoracic aorta aneurysms of different aetiologies and define its relationship with established risk factors.

Methods

One-hundred twenty patients (40 for each group, selected out of prospective cohorts of 156 bicuspid aortic valve – BAV-, 77 Marfan –MFS- and 67 patients with a degenerative aneurysm – TAVdeg-) were matched for age, sex and BSA via propensity score with 40 healthy volunteers (HV). The thoracic aorta was semi-automatically segmented from angiograms and the centreline was computed. Local curvature was assessed at 20 planes covering the thoracic aorta from the sinotubular junction to the proximal descending aorta (DAo) at the level of the pulmonary artery bifurcation. Local curvature was normalized by subject mean thoracic aorta curvature. Length was measured as centreline length. Aortic stiffness was measured in the DAo by pulse wave velocity (PWV). Aneurysm was defined by z-score ≥ 2 using diameters measured by double-oblique cine CMR.

Results

Matching was successful in all groups with the exception of a residual age difference between HV and TAVdeg. Curvature in HV showed a fairly smooth transition between the straighter ascending aorta (AAo) and DAo to a more curved aortic arch, with a peak in the mid aortic arch (Figure 1A).  Conversely, all patients’ groups presented a peak in curvature in the proximal DAo and a decreased local curvature in the aortic arch and mid DAo close to the level of the pulmonary artery. BAV and TAVdeg patients showed also increased curvature in the mid AAo, were dilation is prevalent. Conversely, in the same area MFS showed a reduced curvature and limited prevalence of aneurysm. In the overall population, age, AAo and root diameters, mean blood pressure, DAo PWV and aortic length, all established risk factors for aortic events, were inversely related to curvature in the distal AAo and aortic arch (Figure 1B).

Conclusions

Aneurysms related to different aetiologies show similar abnormalities in aortic curvature, with limited curvature in the aortic arch and a peak soon after the third supra-aortic vessel. Age, aortic diameter, length, stiffness and blood pressure, all known risk factors, are all related to reduced curvature in the distal ascending aorta and aortic arch.

Abstract Figure.

Reinforcement machine learning-based aortic anatomical landmarks detection from phase-contrast enhanced magnetic resonance angiography

Funding Acknowledgements

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Spanish Ministry of Science, Innovation and Universities; La Marató de TV3

Introduction

Automatic analysis of medical imaging data may improve their clinical impact by reducing analysis time and improving reproducibility. Many medical imaging data, like 4D-flow magnetic resonance imaging (MRI), are often quantified regionally, implying the need for anatomical landmark identification to locate correspondences in the extracted data and compare among patients. Machine learning (ML) techniques hold potential for automatic analysis of medical imaging. Phase-contrast enhanced magnetic resonance angiography (PC-MRA) is a class of angiograms not requiring the administration of contrast agents.

Purpose

We aimed to test whether a machine learning algorithm can be trained to identify key anatomical cardiovascular landmarks on PC-MRA images and compare its performance with humans.

Methods

Three-hundred twenty-three aortic PC-MRA were manually annotated with the location of 4 landmarks: sinotubular junction, pulmonary artery bifurcation and first and third supra-aortic vessels (Figure 1), often used to separate the aorta in sub-regions. Patients included in the training dataset comprised healthy volunteers (40), bicuspid aortic valve patients (141), patients with degenerative aortic disease (60) and patients with genetically-triggered aortic disease (82), all without previous aortic surgery and with native aortic valve. PC-MRA images and manual annotations were used to train a DQN, a reinforcement learning algorithm that combines Q-learning with deep neural networks. The agents can navigate the images and optimally find the landmarks by following the policies learned during training. Data from thirty patients, distributed in terms of aortic condition as the training set, unseen by the algorithm in the training phase, were used to quantify intra-observer reproducibility and to assess ML algorithm performance. Distance between points was used as metric for comparisons, original human annotation was used as ground-truth and repeated-measures ANOVA was used for statistical testing.

Results

Human and machine learning performed similarly in the identification of the sinotubular junction (distance between points of 11.0 ± 8.1 vs. 11.1 ± 8.6 mm, respectively, p = 0.949) and first (6.6 ± 3.9 vs. 6.8 ± 5.6 mm, p = 0.886) and third (6.8 ± 4.0 vs. 8.4 ± 7.4 mm, p = 0.161) supra-aortic vessels branches but human annotation outperformed ML landmark detection in the identification of the pulmonary artery bifurcation (10.2 ± 7.0 vs. 15.2 ± 13.1 mm, p = 0.008). Computation time for landmark detection by ML was between 0.8 and 1.6 seconds on a standard computer while human annotation took approximatively two minutes.

Conclusions

ML-based aortic landmarks detection from phase-contrast enhanced magnetic resonance angiography is feasible and fast and performs similarly to human. Reinforced learning anatomical landmark identification unlock automatic extraction of a variety of regional aortic data, including complex 4D flow parameters.

Abstract Figure

Investigation of boron carbide and iridium thin films, an enabling technology for future x-ray telescopes

We present an experimental examination of iridium and boron carbide thin-film coatings for the purpose of fabricating x-ray optics. We use a combination of x-ray reflectometry and x-ray photoelectron spectroscopy to model the structure, composition, density, thickness, and micro-roughness of the thin films. We demonstrate in our analyses how the two characterization techniques are complementary, and from this we derive that an overlayer originating from atmospheric contamination with a thickness between 1.0-1.6 nm is present on the surface. The magnetron sputtered iridium films are measured to have a density of 22.4g/cm³. The boron carbide film exhibits a change in chemical composition in the top ∼2nm of the film surface when exposed to the ambient atmosphere. The chemical reaction occurring on the surface is due to an incorporation of oxygen and hydrogen present in the ambient atmosphere. Lastly, we present a correlation between the absorption edges and the emission lines exhibited by the thin films in an energy range from 50-800 eV and the impact on the reflectivity performance due to contamination in thin films.

Allergic contact dermatitis: From pathophysiology to development of new preventive strategies

As the body's first line of defense, the skin is the organ most frequently exposed to chemicals present in personal hygiene products, household products, or materials used in the work environment. In this context, skin disorders account for more than 40 % of all occupational and work-related diseases, constituting a significant public health burden. Among skin disorders, allergic contact dermatitis (ACD) is the most prevalent occupational disease and the most common form of immunotoxicity in humans. ACD is a T-cell-mediated skin inflammation resulting from the priming and expansion of allergen-specific CD4⁺ and CD8⁺ T cells. The clinical condition is characterized by local skin rash, itchiness, redness, swelling, and lesions, being mainly diagnosed by the patch test. Upon ACD diagnosis, avoiding the exposure to the triggering allergen is the mainstay of treatment to prevent future flares. In cases where avoidance is not possible, the use of a standard of care interim treatments such as steroid creams or ointments, barrier creams, and moisturizers are strongly recommended to alleviate symptoms. In this review, we sought to provide the reader with an overview of the pathophysiology of ACD as well as the currently available pharmacological treatment options. Furthermore, a comprehensive outline of several preventive strategies is also provided.

Long term outcomes in left ventricular non-compaction

Background

Left ventricular non-compaction (LVNC) is a highly heterogeneous entity with a wide phenotypic expression. Risk factors have not been well established and prognostic stratification remains challenging.

Objectives

Describe long term outcomes of LVNC patients and determine predictors of cardiovascular events.

Methods

Prospective multicentric study of consecutive patients fulfilling imaging criteria for LVNC. Demographic, ECG, imaging and genetic variables were collected. End points were heart failure (HF), ventricular arrhythmias (VA), systemic embolisms (SE) and all-cause death. Major adverse cardiovascular event (MACE) was described as the combination of the four previous end points.

Results

592 patients from 13 referral centres were included from 2000 to 2018. Mean age at diagnosis was 45 years, 252 (43%) were female and mean LVEF was 48% (Table 1). During a median follow-up of 55 months (IQR 24–90), 144 (25%) patients presented HF, 101 (18%) VA, 27 (5%) SE and 33 (6%) died. MACE occurred in 223 (39%) patients.

In multivariate analysis, independent predictors of HF were LVEF (OR 0.9), PSAP (OR 1.17) and late gadolinium enhancement (LGE) (OR 1.3). VA were independently associated with LVEF (OR 0.97) and LGE (OR 2.51). Independent predictors of SE were LVEF (OR 0.96) and LA diameter (OR 1.07). No independent predictors of all-cause death could be described. MACE were independently associated with LVEF (OR 1.04) and PSAP (OR 1.08) (Table 1).

Among patients who underwent genetic testing (340, 57%), genotype was associated with outcomes: MYH7 and ACTC1 variants were protective while multiple mutations, TTN and MYBPC3 variants exhibited worse prognosis.

Conclusions

In a large prospective multicentric cohort of LVNC patients, there was a moderate long term incidence of cardiovascular events. LVEF and fibrosis were the main predictors and genotype was a modifier of outcomes. These factors might be used to risk stratify LVNC patients.

Funding Acknowledgement

Type of funding source: None

Relationship between aortic distensibility and aortic regurgitation depending on aortic valve anatomy. A CMR study

Background

Aortic regurgitation (AR) can be evaluated by cardiac magnetic resonance (CMR).The most commonly used method to quantify AR is direct measurement using phase contrast (PC) imaging, at the aortic root (as close as possible to the aortic valve), for the calculation of regurgitant fraction (RF). Aortic distensibility (AD) may affect aortic valve dynamics and, as a result, aortic regurgitation grade. However, the impact of aortic distensibility in this evaluation remains unknown.

Purpose

The aim of the study was to evaluate the relationship between AD and AR in patients with different aortic valve anatomy.

Methods

213 patients with different AR severity grades and aortic valve anatomy (tricuspid (TAV) and bicuspid valve (BAV) patients) were enrolled (32.2% female, 74% BAV, 55.5±15.4 years), excluding connective tissue disease. All patients underwent a CMR study with PC sequences for the evaluation of regurgitant fraction at the aortic valve level. AR was considered as mild (&lt;15%), moderate (15–30%) or severe (&gt;30%) depending on RF value. Furthermore we used cine-sequences to estimate aortic diameters and distensibilities, using Art Fun software. Distensibility was calculated as (change in aortic area between systole and diastole/diastolic area)/brachial pulse pressure.

Results

159 (73.7%) AR were mild, 30 (14.1%) moderate and 24 (11.3%) severe. RF significantly correlated with aortic root diameter (r=0.337, p&lt;0.001) and did not correlate with AD at the level of proximal descending aorta (r=0.121 and p=0.107). Furthermore descendig aorta distensibility correlated with age (r=−0.631, p&lt;0.001) and aortic root diameter (r=−0.224, p=0.002). Dividing population in two different groups, depending on aortic valve anatomy, in TAV patients RF continued to not correlate with AD (r=0.159, p=0.369). In contrast, RF in BAV patients was positively correlated with AD (r=0.223, p=0.007) even after adjustment for aortic diameter and age in a multiple regression model (p&lt;0.001, R2=0.478).

Conclusions

In our study, aortic regurgitation is positively related to descending aorta distensibility in BAV patients, regardless of age and aortic root diameter. Thus, AD may play a role in the evaluation of AR in case of bicuspid valves. In contrast, in TAV patients, distensibility does not seem to influence the assessment of AR severity.

Descending aorta distensibility

Funding Acknowledgement

Type of funding source: Other. Main funding source(s): Research grant provided by the Cardiopath PhD program

Aortic stiffness and hemodynamics in Loeys-Dietz syndrome by 4Dflow CMR: a comparison with healthy volunteers and patients with Marfan syndrome

Background

Connective tissue disorders, such as Loeys-Dietz (LDS) and Marfan (MFS) syndromes, are rare genetic diseases associated with progressive aortic dilation. Aortic dissections have been observed at lower aortic root diameters in LDS than in MFS, and research on aortic flow dynamics and biomechanics in LDS is lacking.

Purpose

To evaluate rotational aortic flow and aortic stiffness in LDS compared to healthy volunteers (HV) and MFS patients, using 4Dflow CMR.

Methods

Twenty-one LDS and 44 MFS patients, without previous aortic dissection or surgery, and 44 HV underwent a non-contrast-enhanced 4D flow CMR. In-plane rotational flow (IRF), systolic flow reversal ratio (SFRR) and local aortic diameters were obtained at 20 equidistant planes from the ascending (AAo) to the proximal descending aorta (DAo). Aortic stiffness was quantified at the AAo and DAo using pulse wave velocity (PWV).

Results

LDS patients had lower IRF at the distal AAo and proximal DAo compared to HV (p=0.053 and 0.004, respectively), once adjusted for age, stroke volume and local aortic diameter; but no differences were found with respect to MFS (Figure). Although SFRR at the proximal DAo was increased in LDS patients compared to both HV (p=0.037) and MFS populations (p=0.015), once adjusted for age and aortic diameter, the difference in magnitude was small (Figure). On the other hand, AAo and DAo PWV revealed stiffer aortas in LDS patients compared to HV but no differences versus MFS patients (Table).

Conclusions

LDS patients showed decreased in-plane rotational flow and abnormally-high regional aortic stiffness compared to healthy controls, and similar hemodynamics and aortic stiffness with respect to MFS patients

Funding Acknowledgement

Type of funding source: Public Institution(s). Main funding source(s): Instituto de Salud Carlos III, La Maratό TV3

Patients with blunt traumatic thoracic aortic injury treated with TEVAR present increased flow dynamics alterations and pulse wave velocity: a 4D flow CMR study

Background

Thoracic endovascular aortic repair (TEVAR) is widely used for the treatment of blunt traumatic thoracic aortic injuries. Aortic flow dynamics and mechanical implications of this intervention are poorly investigated and may be of particular interest in the long-term follow-up of these mostly young patients.

Purpose

To assess whether the presence of TEVAR in a cohort of otherwise healthy subjects was related to dilation of the proximal aorta or increase in aortic stiffness and flow alterations.

Methods

Nineteen patients who underwent TEVAR implantation after a traumatic injury of the thoracic descending aorta (DAo) (10.0±6.1 years from intervention) and 44 healthy volunteers (HV) underwent 4D flow CMR to compute ascending aorta (AAo) pulse wave velocity (PWV), a marker of aortic stiffness, systolic flow reversal ratio (SFRR), quantifying backward flow during systole and in-plane rotational flow (IRF), measuring in-plane strength of helical flow. IRF and SFRR were assessed at 20 planes between the sinotubular junction and the mid thoracic DAo. Aortic diameters were measured using double-oblique cine CMR.

Results

Patients with TEVAR and HV did not differ in age, sex, body surface area, blood pressure and DAo diameter distal to TEVAR (Table). However, TEVAR patients presented larger diameters at the sinus of Valsalva and AAo, increased AAo PWV and strong flow alterations: IRF was reduced from the distal AAo to the proximal DAo, while SFRR was increased in the whole thoracic aorta (Figure).

Conclusions

In patients with blunt traumatic thoracic aortic injury treated with TEVAR the aorta proximal to TEVAR is dilated, stiffer and present potentially pathogenic flow conditions. Longitudinal studies are needed to assess whether these alterations have prognostic value and may improve clinical prevention and management of these patients.

Figure 1. IRF and SFRR in healthy vs TEVAR

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): This study has been funded by Instituto de Salud Carlos III, Spanish Ministry of Science and Innovation (PI19/01480). Guala A. received funding from the Spanish Ministry of Science, Innovation and Universities (IJC2018-037349-I).

The length of the fusion between leaflets in bicuspid aortic valve is independently related to ascending aorta dilation and flow dynamics alterations assessed by 4D-flow CMR

Background

Aortic dilation in bicuspid aortic valve (BAV) patients has been related to altered flow patterns, which contribute to aortic wall degeneration. However, preventive aortic replacement is currently based on a diameter threshold. Several studies on excised BAV reported wide variability of fusion extent.

Purpose

To unveil whether leaflet fusion extent can be quantified by CMR and is related to aortic dilation and flow abnormalities in non-dysfunctional BAV.

Methods

One hundred and twenty adults with non-dysfunctional BAV and no previous aortic or aortic valve surgery and 28 healthy volunteers underwent double-oblique cine and 4D flow CMR. BAV patients with two sinuses of Valsalva or left and non-coronary cusps fusion were excluded. Peak systolic circumferential wall shear stress (WSSc) and pulse wave velocity (PWV) in the ascending aorta (AAo) were assessed by 4D flow CMR. Fusion length between leaflets was measured using a stack of double-oblique cine CMR images of the aortic valve.

Results

The length of the fusion was effectively measured in 112/120 (93%) patients with good reproducibility (ICC = 0.826) and showed great variability (range 2.3–15.4 mm, 7.8±3.2 mm and tertiles cut-off points 6 and 9.3 mm). In multivariate analysis adjusted for clinical and demographic characteristics and PWV, fusion length was independently associated with the diameter at the sinus of Valsalva (p=0.002) and the AAo (p=0.02) (Table). WSSc progressively increased with larger fusion length (Figure), with statistical significance (p&lt;0.05) in the right and outer regions of the proximal and mid AAo.

Conclusions

Bicuspid aortic leaflet fusion length varies considerably, and it is independently associated with AAo and aortic root dilation, possibly through flow alterations.

Figure 1. Maps of circumferential WSS

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): This study has been partially funded by Instituto Carlos III, Spanish Ministry of Science and Innovation (PI17/00381). Guala A. has received funding from the Spanish Ministry of Science, Innovation and Universities (IJC2018-037349-I).

The role of descending aorta diastolic reverse flow in the quantification of aortic regurgitation by CMR

Background

EACVI recommends the use of an “integrative approach”, using several parameters, in aortic regurgitation (AR) quantification. This approach is easily achieved by echocardiography although cardiovascular magnetic resonance (CMR) remains the gold standard for the quantification of regurgitant fraction (RF).

Purpose

The aim of the study was to analyze the accuracy of descending aorta (DA) diastolic reverse flow in the assessment of chronic AR severity by CMR to identify an additional parameter.

Methods

188 patients (34% female, 54.6±15.6 years) with different severity grades of chronic AR were enrolled. All patients underwent a CMR study. Aortic regurgitation was considered as absent (≤1%), mild (≤15%), moderate (≤15%) or severe (≥30%) depending on RF value at valve level. Furthermore, cine-sequences were used to estimate aortic diameters and distensibilities using Art Fun software. Velocity-time integral (VTI) of reverse flow in DA was calculated from maximum velocity curves by an in-house MatLab code.

Results

AR was absent in 21 (12%) patients, mild in 114 (62.9%), moderate in 23 (12.7%) and severe in 21 (11.6%).DA VTI reverse flow was significantly higher as was the RF at valve level (r=0.805, p&lt;0.001) (IMG, Table). It also positively correlated withaortic root diameter (r=0.347, p&lt;0.001) and DA distensibility (r=0.279, p&lt;0.001). It did not correlate with age (r=−0.91, p=0.22). In a statistically significant multiple regression model (p&lt;0.001, R2 = 0.697), although VTI reverse flow in DA correlated strongly with RF at valve level (p&lt;0.001; beta = 0.733), it was also influenced by DA distensibility (p&lt;0.001; beta = 0.197) and aortic root diameter (p&lt;0.001; beta= 0.140).

Conclusions

VTI reverse flow in DA correlates strongly with the degree of AR and may be useful in the assessment of its severity. Neverthless, owing to the influence of other factors (aortic distensibility and aortic root diameter), it cannot be used as a single parameter in the quantification of AR severity by CMR.

Scatter Plot graphs

Funding Acknowledgement

Type of funding source: Other. Main funding source(s): research grant provided by the Cardiopath PhD program

Prognostic value of odor identification impairment in multiple sclerosis: 10-Years follow-up

BACKGROUND

Olfactory dysfunction has been linked to clinical severity variables in multiple MS populations. Though, its prognostic value is still unknown.

OBJECTIVE

The aim of this study was to explore the long-term outcome associated with Brief-Smell Identification Test (B-SIT) performance in a cohort of MS patients.

METHODS

A retrospective review of the clinical records was conducted in 149 patients who participated in a previous study, with a median follow-up of 121 months. Demographic and clinical data regarding the last clinical appointment with EDSS measurement were collected. Multiple Sclerosis Severity Scale (MSSS) and Age-Related Multiple Sclerosis Severity (ARMSS) scores were calculated. Date of the last clinical contact or death was recorded.

RESULTS

Among MS patients with progressive clinical course (n = 33), those with impaired B-SIT at baseline had greater change per month during follow-up (as measured by increases in MSSS and ARMSS scores) and a higher hazard of death. No significant associations were found among patients with relapsing and remitting MS (n = 116).

CONCLUSIONS

The study results demonstrate that odor identification impairment has prognostic value in progressive MS, suggesting that a brief odor identification measure can be a marker of neurodegeneration in progressive MS.