Influence of land use and host species on parasite richness, prevalence and co-infection patterns

Tropical forests are experiencing increasing impacts from a multitude of anthropogenic activities such as logging and conversion to agricultural use. These perturbations are expected to have strong impacts on ecological interactions and on the transmission dynamics of infectious diseases. To date, no clear picture of the effects of deforestation on vector-borne disease transmission has emerged. This is associated with the challenge of studying complex systems where many vertebrate hosts and vectors co-exist. To overcome this problem, we focused on an innately simplified system - a small oceanic island (São Tomé, Gulf of Guinea). We analyzed the impacts of human land-use on host-parasite interactions by sampling the bird community (1735 samples from 30 species) in natural and anthropogenic land use at different elevations, and screened individuals for haemosporidian parasites from three genera (Plasmodium, Haemoproteus, Leucocytozoon). Overall, Plasmodium had the highest richness but the lowest prevalence, while Leucocytozoon diversity was the lowest despite having the highest prevalence. Interestingly, co-infections (i.e. intra-host diversity) involved primarily Leucocytozoon lineages (95%). We also found marked differences between bird species and habitats. Some bird species showed low prevalence but harbored high diversity of parasites, while others showed high prevalence but were infected with fewer lineages. These infection dynamics are most likely driven by host specificity of parasites and intrinsic characteristics of hosts. In addition, Plasmodium was more abundant in disturbed habitats and at lower elevations, while Leucocytozoon was more prevalent in forest areas and at higher elevations. These results likely reflect the ecological requirements of their vectors: mosquitoes and black flies, respectively.

Erratum: Evolution of π^{0} Suppression in Au+Au Collisions from sqrt[s_{NN}]=39 to 200 GeV [Phys. Rev. Lett. 109, 152301 (2012)]

This corrects the article DOI: 10.1103/PhysRevLett.109.152301.

A nonsense variant in the KRT14 gene in a domestic shorthair cat with epidermolysis bullosa simplex

Epidermolysis bullosa simplex (EBS) is a hereditary blistering disease affecting the skin and mucous membranes. It has been reported in humans, cattle, buffaloes and dogs, but so far not in cats. In humans, EBS is most frequently caused by variants in the KRT5 or KRT14 genes. Here, we report a case of feline epidermolysis bullosa simplex and describe the causative genetic variant. An 11-month-old male domestic shorthair cat presented with a history of sloughed paw pads and ulcerations in the oral cavity and inner aspect of the pinnae, starting a few weeks after birth. Clinical and histopathological findings suggested a congenital blistering disease with a split formation within the basal cell layer of the epidermis and oral mucous epithelium. The genetic investigation revealed a homozygous nonsense variant in the KRT14 gene (c.979C>T, p.Gln327*). Immunohistochemistry showed a complete absence of keratin 14 staining in all epithelia present in the biopsy. To the best of our knowledge, this is the first report of feline EBS, and the first report of a spontaneous pathogenic KRT14 variant in a non-human species. The homozygous genotype in the affected cat suggests an autosomal recessive mode of inheritance.

P694 Late shunt closure: is it the only cause of pulmonary hypertension after surgical repair?

Introduction

Atrial septal defects (ASD) may be a cause of pulmonary hypertension (PH) specially when they are only detected in adulthood. Sinus venosus type ASD are rare, with an estimated prevalence of 4-11%, and frequently they are associated with anomalous venous return of the right superior pulmonary vein (RSPV). Surgical closure is safe and effective, and it is associated with normal life expectancy when performed before age 25; the risk of PH is higher in untreated defects or late closure.

Clinical case

The authors present the case of a 74-years old female patient with previous diagnosis of a sinus venosus type ASD. Closure of the shunt and correction of venous return was performed when the patient was 36. Follow up in the following years was normal, and the patient was discharged from the congenital surgical center. The patient was referred to our PH unit due to symptomatic PH for etiological investigation (PSAP of 70 mmHg in transthoracic echocardiogram). After excluding PH related to left heart disease and lung disease, the most likely cause was pulmonary arterial hypertension due to late closure of left to right shunt, but complete investigation was performed. A transesophageal echocardiogram showed dilatation of right heart chambers and a communication of 36 mm at the high atrial septum between the RSPV and superior vena cava entrance with spontaneous left to right shunt. A severe dilation of coronary sinus (maximal dimension 33.4mm) suggestive of persistent left superior vena cava (PLSVC) was also found. A cardiac magnetic resonance was performed showing dilated right chambers, abnormal drainage of right superior pulmonary vein to right atrium, a dilated coronary sinus with a PLSVC and Qp/Qs 1.7. Right heart catheterization showed a mean pulmonary artery pressure of 25 mmHg with normal pulmonary vascular resistance (2.4 UWood) suggesting that the intracardiac shunt is the responsible for the PH with reversible pulmonary vascular disease. The patient was proposed to surgical repair.

Conclusion

The authors present a rare clinical case of an undiagnosed persisting sinus venous ASD after surgical repair. Failure of shunt closure led to the development of PH, emphasizing the need to maintain lifelong follow up of these patients in specialized centers.

Abstract P694 Figure.

475 A rare cause of right ventricular mass

Introduction

Intracardiac masses are always a challenging diagnosis, especially when it involves the right side of the heart. There are multiples etiologies that can be responsible for these masses, namely thrombosis, neoplasm or vegetations. Occasionally, these may be related to an autoimmune process not yet discovered.

Case Report

17-year-old male, with a previous history of genital ulcers, medicated with penicillin with complete resolution of symptoms.

In January 2019, he started an history of recurrent fever, associated with right anterior thoracalgia, weight loss and oral afthosis. He went to the emergency department several times, where he was medicated with antibiotic, with partial symptom relief.

Three months later, he returned to medical attention due to an episode of abundant hemoptysis, followed by hematemesis and cough. At hospital admission, he was hemodynamically stable, tachycardic (100/min) and with occasional episodes of cough. Cardiac and pulmonary auscultation were unremarkable. Thoracic CT revealed the presence of pulmonary thromboembolism (PTE) and a large mass in the right ventricle (RV). It was performed an echocardiogram (echo) that confirmed the presence of a large mass in the RV (50x53mm) from which a projecting hypermobile mass appeared to prolapse into the right atrium.

Taking into account the diagnosis of PTE and the presence of a right ventricular mass, the patient was hospitalized and started anticoagulation. The case was immediately discussed with cardiac surgery, that confirmed that there was no surgical indication. During hospitalization, there were no more episodes of hemoptysis or hematemesis.Consecutive echos were performed, that did not reveal a significant decrease in mass dimensions despite anticoagulation. Viral serologies and autoimmunity panel were all negative. Cardiac RMI was performed raising the suspicion of a possible mass covered with thrombus.

After discussion with rheumatology, and according to clinical signs, the hypothesis of vasculitis was placed, and the patient started treatment with steroids. This treatment had to be suspended after a few days due to an infectious intercurrence. After a course of antibiotic therapy, the patient started therapy with cyclophosphamide with good clinical and echocardiographic response (reduced mass dimensions).

It was admitted Behçet’s disease with cardiac complications, and the patient was referred to the rheumatology consultation.

Conclusion

Behçet’s disease is a multi-system, chronic disorder that behaves like vasculitis.There are some typical clinical manifestations associated with this disease, such as oral and genital afthosis, uveitis, arthritis, skin lesions and nervous system involvement.Presentations with cardiac symptoms are one of the extremely rare manifestations of this disease, posing a challenge for the treating physician.

Abstract 475 Figure. Right ventricular mass

P1461 Concomitant potential cardioembolic sources in a patient with an acute ischemia of the limb

Introduction

Transesophageal echocardiography (TEE) is the gold standard exam to look for a cardioembolic source in a patient with an otherwise unexplained suspected systemic ischemic event. Purpose: This clinical case aims to illustrate the importance of a thorough TEE evaluation in the presence of a suspected systemic emboli, and to not neglect thoracic aorta evaluation when a potential intracardiac cause has been detected. Case presentation: We present the case of a 55-year-old man, obese (BMI 30kg/m2), active smoker, with no past medical history or medication, and whose father died from an unspecified cardiovascular cause at 45 years-old. He was admitted to the hospital because of an acute ischemia of the right lower limb, for which he underwent urgent percutaneous femoral embolectomy of the limb, with success. During hospitalization, he was referred for a TEE, which showed valves and cavities with no evidence of potential embolic sources. However, he had a thin and hypermobile atrial septum, with no obvious defect after color flow mapping, but with a patent foramen oval (PFO) that was detected after agitated saline injection associated with a Valsalva maneuver, with the passage of 5-25 microbubbles (grade 2/4 shunt) and an atrial septum aneurysm (ASA), with an excursion of the fossa ovalis towards the left atrium of 10.1mm (Figure 1). The ascending aorta was normal, but the descending aorta depicted 2 hypermobile masses, 1 starting at 35cm from the dental arch (transversal area: 0,52cm2), the longest (7cm) starting at 32cm and ending at the aortic arch (transversal area: 1,76cm2). An angio-CT was immediately performed, which depicted an atheromatous calcified plaque in the terminal portion of the aortic arch, giving rise to the image suggestive of thrombus, and extending for about 6cm to the medium third of the descending thoracic aorta. The remaining portions of the aorta and iliac arteries depicted diffuse atheromatous and partially calcified plaques (Figure 2). The patient was submitted to an urgent thoracic endovascular aortic repair with a 26x10cm prosthesis implantation with occlusion of the left subclavian artery and an adequate final clinical result. Syphilis and auto-immune disease were excluded and a diffuse atheromatous disease of the aorta was assumed as the cause of the thrombus and the embolic event. After 16 days, he was discharged asymptomatic and with no signs of chronic ischemia, treated with oral anticoagulation with rivaroxabano, high-dose statin and strict smoking cessation. Conclusion: Cardioembolic source is a heterogeneous entity. In this patient, 2 potential cardioembolic sources were detected: while the PFO and ASA are minor or unclear risk sources of emboli, TEE also allowed for the detection of a large thrombus arising from an atherosclerotic calcified plaque in the thoracic aorta, which was considered a major risk source, thus implying urgent surgery to obviate the risk of further embolic events.

Abstract P1461 Figure. Fig.1.POF and ASA;Fig.2.Aortic Thrombus

107 Low-flow low-gradient aortic stenosis: aortic valve area estimated by continuity equation versus simplified method of projected aortic valve area

Introduction

The evaluation of real severity of "low-flow low-gradient" aortic stenosis (LFLG AS) is particularly challenging. TOPAS study demonstrated that projected aortic valve area at a normal transvalvular flow rate (AVAproj) derived from dobutamine stress echocardiography (DSE) is superior to the traditional Doppler indices to discriminate true severe-AS and pseudosevere-AS.

Purpose

To compare two echocardiographic methods to estimate severity of LFLG AS with DSE (aortic valve area (AVA) estimated by continuity equation (AVA-CE) and simplified method of AVAproj) in patients (pts) with low transvalvular flow rate (<250mL/seg).

Methods

Unicentric, retrospective study, that included pts with LFLG AS undergoing DSE with low dose dobutamine protocol, during Nov 2013-Dec 2018 period. Evaluation at rest and peak DSE of vital signs, mean transaortic gradient, aortic VTI, LVOT VTI and VTI ratio, valvulo-arterial impedance (ZVA), AVA-CE, simplified method of AVAproj and global longitudinal strain (GLS).

Results

A total of 27 DSE were performed in 23 different pts, mean age of 76 ± 8 years, 82% male. At rest 55% in sinus rhythm, mean heart rate (HR) was 76 ± 12 bpm, mean systolic arterial pressure (SAP) was 122 ± 22 mmHg, mean ZVA 4.3 ± 2 mmHg/ml/m2; mean diameter of LVOT was 21,7 ± 2,6cm, mean of mean aortic gradients 21 ± 7 mmHg, 67% of pts had a VTI ratio at rest compatible with severe AS and remaining compatible with moderate AS. Estimated mean AVA-CE was 0.86 ± 0.29 cm2 with 67% of pts classified as severe AS. Mean left ventricular ejection fraction at rest was 31 ± 9%, systolic volume index 28,7 ± 8 mL/m2 and GLS -5,9%.

During low dose perfusion protocol of dobutamine

100% patients remained asymptomatic, mean HR was 110 ± 25 bpm, mean SAP was 123 ± 26 mmHg, mean ZVA 3.6 ± 1.7 mmHg/mL/m2, mean of mean aortic gradients 28 ± 9mmHg, 37% of pts presented VTI ratio compatible with severe AS and remaining compatible with moderate AS. Mean flow reserve was 16 ± 16% and mean GLS-7.2%. AVA-CE was 1,06 ± 0,35 cm2 with 56% of pts classified as severe AS and mean projected AVA was 1.01 ± 0.22cm2, without significant difference in AVA estimated by the two methods (p = 0.344). Projected AVA allowed re-classification of AS in 22% of pts (5 patients), with 31% of severe AS reclassified as moderate AS while AVA-CE allowed re-classification in 13% (3 patients), with 19% of severe AS reclassified as moderate AS.

Considering medium follow up of 24 months, 6 patients were submitted aortic valve replacement surgery and another 6 patients to transcatheter aortic valve replacement. The simplified projected valve area calculation show no significant therapeutic impact in the selection of this patients.

Conclusion

The simplified projected valve area calculation is technically feasible and accessible. This study shows a good correlation in pts with low cardiac flow. If AVAproj method had been used 2 extra patients would have been reclassified during DSE.

P1808 The impact of valve type in morbimortality of patients with infectious endocarditis

Introduction

Infectious endocarditis (IE) represents one of the main causes of morbimortality in patients (pts) with valvular heart disease. Prosthetic valves infection is usually associated with worse outcomes.

Aim

To compare the clinical features and adverse outcomes of patients with native vs prosthetic valve IE.

Methods

We analysed a population with suspected/confirmed IE, according to Duke criteria, in the last 12 years (2006-2017). The clinical and imaging data were collected as well as complication rates and mortality data.

Results

174 pts, 75% males with mean age of 61 ± 16 years. Native valve EI occurred in 74,1%. of pts. 25,3% had heart failure (HF), 16,1% chronic kidney disease(7,1% on haemodialysis), 12,8% HIV infection, 9,3% active neoplasm and 7,1% were on immunosuppression. 16 pts with native valve disease had previous valvular disease: 1 congenital valve disease, 2 with rheumatic heart disease, 3 with previous IE and 10 with degenerative disease. At admission: 73,1% had fever, 53,2% murmur and 47,9% anemia. The majority (78,4%) had single valve IE and 15,8% had double valve involvement. Aortic valve (AoV) was affected in 54% of the cases and mitral valve involvement was seen in 43,7%. 13,3% had right valve disease. S. Aureus was the most frequent microrganism. Echocardiographic findings: 87,7% had vegetation, 21,2% valve destruction , 5,6% valve obstruction, 14,3% abscess, 3,7% valve aneurysm, 5,6% pseudoaneurysm and 5,6% fistula. Regurgitation was observed in 62,1%. The intrahospitalar mortality was 29,9%.

Comparing both groups, pts with prosthetic IE had more previous history of HF (40,5% vs 20,5% p = 0,009) and diabetes (31,7% vs 15,3% p = 0,020). No differences were found in what concerns microrganisms involved.

Echocardiographically, pts with prosthetic valve had predominantly AoV involvement (81,1% vs 45,5% p < 0,001), less vegetation (75% vs 91,8% p = 0,01) and less regurgitation (45% vs 67,8% p = 0,01). They had more local complications (61% vs 27,7% p> 0,001) like valve obstruction (12,5% vs 3,3% p = 0,043), abscess (32,5% vs 8,3% p> 0,001) or pseudoaneurysm (17,5% vs 1,7% p= 0,001).

In what concerns morbidity burden, developed more HF during hospitalization (56,1% vs 37,7% p= 0,037) as well as more isquemic and haemorragic stroke(85,7% vs 42,3%. P = 0,004 and 28,6% vs 2,4% p = 0,012, respectively). However there were no differences regarding the development of septic shock (p = 0,542) or overall embolization (p = 0,732). At last, no differences were found in intrahospitalar(IH) mortality (p = 0,085), relapse (p = 0,573) or overall survival between both groups (log rank: 1,5, p = 0,217).

Conclusion

Pts with prosthetic valve IE usually have worse outcomes. However,for this population,we conclude that besides having more HF and stroke, there were no differences in what concerns septic shock or overall embolization, as well as IH mortality and survival between both groups.

P829 Cardiac uptake level in 99mTc-DPD scintigraphy in ATTR amyloidosis: is there any association with the prognosis?

Introduction

The uptake of bone-seeking radiotracers in 99mTc-DPD scintigraphy has been shown to be highly sensitive for cardiac transthyretin (ATTR) amyloid. Progressive levels of cardiac involvement are associated with poor prognosis.

Purpose

Evaluation of the prognostic impact of the tracer uptake level in the heart through 99mTc-DPD scintigraphy.

Methods

Single center retrospective analysis of patients’ data referred to perform a 99mTc-DPD between September 2014- July 2018 due to an abnormal echocardiogram or family history of ATTR. Data was collected regarding clinical, echocardiographic and 99mTc-DPD parameters to evaluate prognostic impact of the uptake level on cardiovascular events, namely hospitalizations due to acute heart failure, myocardial infarction or stroke, and all-cause mortality.

Results

35 patients were reviewed of whom 12 (34.3%) had a positive 99mTc-DPD, performing the diagnosis of an ATTR amyloidosis: mean age 78.4 ± 7.3 years, 100% male. 33.3% had a cardiac uptake level 2 (group 1) and 66.6% level 3 (group 2). Group 1 patients were younger (mean age 72.3 ± 4.6 versus 81.5 ± 6.5 years, p 0.03). At the time of diagnosis, most patients in both groups were in NYHA class II. Mean value of NTproBNP in group 1 patients was 4322.4 ± 35.0 versus 6387.7 ± 60.0 pg/ml (p 0.03); troponin level was not statistically different between groups (88.3 ± 63.1 versus 54.5 ± 16.1 pg/ml, p 0.228). On transthoracic echocardiogram evaluation, there were no significant differences between groups regarding cardiac function: mean ejection fraction 48.8 ± 6.3 versus 43.9 ± 11.5% (p 0.453) and mean global longitudinal strain -10.4 ± 2.8 versus -9.0 ± 2.9% (p 0.531). Although almost patients presented a nearly normal ejection fraction, almost have diastolic dysfunction (75 versus 100%, p 0.140) and pericardial effusion (100% in both groups). Hypertrophy level was similar between groups: septum thickness was 19.5 ± 0.7 in group 1 and 19 ± 1.4mm in group 2 (p 0.386). During follow-up, 25% of group 1 patients were hospitalized due to acute heart failure and 25% died. In group 2 patients, there were 25% of hospitalizations due to heart failure and all-cause mortality rate of 50%.

Conclusions

In our population, there was no significant association between the cardiac uptake level in 99mTc-DPD scintigraphy and cardiac symptoms or cardiac function evaluated through transthoracic echocardiogram at the time of diagnosis. However, higher levels of cardiac uptake were associated with higher mortality in the follow-up period. This data suggests that 99mTc-DPD scintigraphy should be performed not only for diagnosis but also for prognosis assessment in these patients.

P1788 Prognostic value of stress echocardiography in preoperative risk stratification and management

Introduction

The prognostic value of pharmacologic stress echocardiography has been extensively demonstrated in patients undergoing noncardiac surgery since 42% of the perioperative complications are cardiac. Coronary artery stenoses can became flow-limiting due to hemodynamic fluctuations in this period leading to myocardial ischemia.

Purpose

Evaluation of prognostic value of pharmacologic stress echocardiography in preoperative risk stratification.

Methods

Single center retrospective analysis of patients’ data referred to perform a preoperative risk stratification through pharmacological stress echocardiography between January 2014- December 2018. Data was collected regarding clinical and echocardiographic parameters to predict perioperative cardiac complications (myocardial infarction and development of arrythmias) and evaluate the impact of the result of DSE in patients´ clinical management.

Results

Of 910 pharmacological stress echocardiograms, 106 were performed to evaluate preoperative risk. Patients´ mean age was 66 ± 11 years, 85% males. 64% had hypertension, 45% dyslipidaemia, 38% current smokers and 18% diabetes. 189% had previously myocardial infarction and 9% stroke. All patients were proposed to intermediate-high risk surgeries: 73% to vascular surgery, 14% to kidney transplant and 13% to other type of surgery (especially abdominal surgery). Most of the stress tests (64%) were performed with dobutamine and the others 34% with dipyridamole. 91% of stress echocardiography were negative, 6% positive and 4% inconclusive. The patients with a positive stress test was submitted to coronary angiography to treat relevant lesions and cardiovascular risk factors were optimized. 72% of the patients has already been submitted to the proposed surgery; in this population, there was a 5% rate of cardiac complications following the surgery, all in patients with previous negative stress echocardiography. Complications were non-ST elevation myocardial infarction in 1% and de novo atrial fibrillation in 4%. Half of the patients with a positive stress echocardiography were operated with no cardiac perioperative complications, possibly related to patient´s optimization before the surgery; in the other half it was decided not to perform the surgery due to the potential cardiac risk. Predictor factors for perioperative cardiac complications, evaluated through univariate and multivariate analysis, were age (odds ratios (OR) 1.232, confidence interval (CI) 1.043-1.456, p 0.007) and stroke (OR 0.057, CI 0.947-44.592, p 0.033).

Conclusion

In our study, patients with a positive stress echocardiography were optimized before the surgery leading to none cardiac perioperative complications, emphasizing the importance of this test in preoperative patients´ management.

P1551 Exercise echocardiographic determinants of exercise tolerance in aortic stenosis

Introduction

A variation of 20 mmHg in the mean aortic gradient in asymptomatic aortic stenosis (AS) was proposed as an indicator of severity during exercise echocardiography.

Objective

to identify echocardiographic predictors of exercise tolerance in AS and analyze the association of the variation in mean aortic gradient (MAG) with exercise tolerance.

Methods

prospective study of patients (pts) referred for testing with asymptomatic AS. We performed exercise echocardiography using the modified Bruce Protocol. Baseline, peak and recovery imaging was performed. Exercise tolerance was expressed as METS and % of predicted METS for age and sex.

Population

24 pts, 14 males, age 72+-9 years, body mass index (BMI): 28+-4 Kg/m2, etiology: bicuspid 6 pts, degenerative tricuspid 18 pts, 4 pts were in sinus rhythm, the remaining were in atrial fibrillation.

Results

baseline parameters: indexed aortic valve area (AVAi): 0,51+-0,13 cm2/m2, MAG 37+-12 mmHg, left ventricle: ejection fraction (LVEF): 63+-9%, cardiac index L/min/m2(CI) 3,2+-0,6, global longitudinal strain (LVGLS) -16+-3%, VTI ratio: 0,26+-0,05, valvulo-arterial impedance mmHg.ml-1.m2(Zva): 3,9+-0,9 . Peak parameters: AVAi: 0,54+-0,14 cm2/m2, MAG 53+-17 mmHg, LVEF: 69 (IQR 10)%, CI 3,2+-0,6, LVGLS -19+-5% , VTI ratio: 0,28+-0,06, Zva: 4,3+-1,4. Exercise tolerance: METS 6+-2, representing 86+-26% of the predicted exercise tolerance for age and sex.

Statistics

we performed an univariate analysis to identify the echocardiographic parameters associated with exercise tolerance, which were then used in a multiple regression analysis. A higher peak CI correlated with a higher exercise capacity (r = 0,5, p 0,01) and higher mean aortic gradient variation (r = 0,6 p < 0,01). The strongest predictor was the peak CI (B coefficient 0,5, R = 0,75, R² 0,57): when corrected for age, sex and BMI, for each increase of 0,5 mL/min/m2 in the peak CI we would expect an increase of 1 MET. This model explains 57 % of the variation in exercise capacity in these patients.

Conclusions

higher mean aortic gradient variation is associated with higher exercise tolerance and the strongest determinant of exercise tolerance in AS is the peak CI.

P1728 Pulmonary hypertension in a pregnant Women - a rare anatomical aetiology

A 32 year old female patient, with a medical history of an ill-characterized Pulmonary Arterial Hypertension associated with congenital heart disease, lost in the follow up with no medical therapy, attended an emergency department for a gynecological hemorrhage at 16 weeks of pregnancy. Due to high maternity mortality risk, informed consent was obtained, and termination of pregnancy was performed. She was then referred to our pulmonary hypertension center.

At our center she had complains of fatigue with moderate intensity exertion, classified in a class II of the World Health Organization (WHO) classification, but was otherwise asymptomatic, with no history of dyspnea, angina or syncope. There was allusion to a self-limited episode of hemoptysis in the past. On physical examination she had an increased pulmonary component of the second heart sound, continuous heart murmur in left sternal border and no cyanosis (O2 peripheral saturation in the upper and lower limbs of 99% at room air).

The performed echocardiograms (both transthoracic and transesophageal) showed an estimated systolic pulmonary artery pressure of 120 mmHg with severe right ventricular hypertrophy and systolic dysfunction. There was dilatation of the trunk and right pulmonary artery. The left pulmonary artery was not seen.

Biochemical evaluation and viral serologies were unremarkable. The pulmonary function tests and the arterial blood gases were normal.

Cardiac MRI demonstrated the presence of a right aortic arch and a right patent arterial duct. An anomalous origin of the left pulmonary artery from the ascending thoracic aorta could be noted. Associated congenital cardiac defects were excluded.

A right heart catheterization confirmed the presence of severe pulmonary hypertension with mean pulmonary artery pressure of 86 mmHg and Pulmonary vascular resistance of 11 Wood Units. A large persistent arterial duct to the right pulmonary artery was confirmed with persistent left to right shunt. The left pulmonary artery was visualized when injection was performed in the aortic root. Coronary arteries were normally implanted.

The patient was started on Sildenafil and Bosentan (later replaced by Macitentan due to hepatic toxicity). After 3 years of follow up, there was an improvement in symptoms and in the 6 minutes walking test, remaining in a low risk category and on a WHO class I.

This case reports a very rare congenital abnormality identified in an adult patient. Despite the complex anatomy and severe pulmonary hypertension, the patient is reasonably well under medical therapy and close follow up.

Abstract P1728 Figure. Cardiac MRI Cine Sequences

P983 ATTR cardiac amyloidosis and aortic stenosis: the same physiopathology, different prognosis?

Introduction

Degenerative aortic stenosis and age-related amyloidosis share common demographic and clinical characteristics. Both surgical and transcatheter aortic valve replacement provide excellent outcomes in elderly patients with isolated aortic stenosis, however previous reports have suggested the potential negative impact of concomitant transthyretin amyloidosis.

Purpose

Evaluation of the association of ATTR amyloidosis and degenerative aortic stenosis.

Methods

Single center retrospective analysis of patients’ data referred to perform a 99mTc-DPD between September 2014- July 2018 due to an abnormal echocardiogram or family history of ATTR. Data was collected regarding clinical, echocardiographic and 99mTc-DPD parameters to evaluate prognostic impact of concomitant cardiac ATTR amyloidosis and aortic stenosis.

Results

35 patients were reviewed. 12 (34.3%) had a positive 99mTc-DPD, performing the diagnosis of an ATTR amyloidosis. 33.3% had a cardiac uptake level 2 and 66.6% level 3. 16.7% of patients with ATTR amyloidosis had at the same time of amyloidosis diagnosis, a diagnosis of at least moderate degenerative aortic stenosis (mean maximal velocity 3.73 m/sec and mean gradient 22mmHg). These patients were older (mean age 80.5 ± 14.1 versus 77.9 ± 6.4 years, p 0.527) and all male gender in both groups. There was no evidence of higher level of cardiac uptake in patients with aortic stenosis. Cardiac function was not significantly different between groups: mean ejection fraction 45.5 ± 13.4% in patients with concomitant aortic stenosis versus 45.5 ±10.1% in patients without (p 0.672); mean global longitudinal strain -8.7 ± 2.4% versus -7.3 ± 3.0% (p 0.402). Most patients in both groups were at NYHA class II at the diagnosis. There was no difference regarding mean value of NTproBNP (7381.5 ± 32.6 versus 43332.1 ± 23.7 pg/ml, p 0.267). During follow up, 30% of patients without aortic stenosis was hospitalized due to acute heart failure and 50% died. In the group of aortic stenosis, the hospitalization and all-cause mortality rate was 100%.

Conclusions

In this study, although there were no differences regarding demographic neither clinical parameters between groups, patients with aortic stenosis presented more cardiac events and higher mortality, dying yet before the aortic stenosis became symptomatic. More studies are needed to evaluate the prognosis of cardiac amyloidosis on the postoperative.

Bridging the Atlantic Projects: nursing students learning to work globally with vulnerable groups

Background

Providing care for vulnerable groups requires the development of competencies such as openness to diversity, cultural sensitivity and equity. Health education institutions face the challenge of preparing students in developing these competencies in a global world. The Bridging the Atlantic program, a partnership between the University of the Azores (Portugal) and the University of Dartmouth (MA, US) in the field of Community Nursing, was created to respond to this need. Students from both universities work collaboratively to develop competencies in providing health care to vulnerable groups based on the IN-STEP (International Student Exchange Partnership) Framework.

Objectives

(i) to contribute to the improvement of the health status of vulnerable groups; (ii) to develop clinical competencies addressing vulnerable groups among nursing students.

Results

Between 2015 and 2019, 110 students were involved in health promotion projects carried out with aggregates of elderly immigrants, deportees, fishermen, children from low income schools. The benefits for the vulnerable groups were mainly related to raise awareness in the communities concerning the problems these groups face. Regarding the impact of the program on training, students reported they developed competencies on: (i) understanding cultural differences; (ii) recognizing different health care systems; (iii) reconsidering the role of the nurse; (iv) building teamwork; (v) integrating theory into practice; and, (vi) peer mutual learning.

Conclusions

Engaging in health promotion projects globally through collaborative efforts seemed to be effective for the improvement of health of vulnerable groups and student development.

Key messages

Universities need to deepen the development of competencies in students to intervene with vulnerable groups in a global world. Although designed for nursing students in a community context, this model can be used in similar ways by other fields of health or social intervention.

2210Symptomatic severe aortic stenosis: predictor factors and outcomes

Introduction

The natural history in aortic stenosis (AS) is a slowly progressive process which begins as aortic sclerosis and subsequently progresses to severe opening restriction, conditioning symptoms development. At this time, surgical aortic valve replacement is strongly recommended due to its poor prognosis.

Purpose

Evaluation of predictor factors of symptomatic severe AS and its prognostic impact.

Methods

Single center retrospective analysis of patients' data accompanied in cardiology consultation due to severe AS diagnosed between 2015–2016. Data was collected regarding clinical and echocardiographic parameters to determine predictor factors of stablished endpoints.

Results

150 patients were reviewed, mean age 76.6±9.0 years, 72% males. 68.7% had hypertension, 42% dyslipidaemia and 32.7% diabetes. 64.7% of the patients had symptoms attributable to severe AS: 48% dyspnoea, 12% angina and 4.7% syncope. 7.3% of the patients were hospitalized due to acute heart failure in this context. Comparing echocardiographic parameters between symptomatic versus non-symptomatic patients with severe AS, symptomatic patients had higher values of aortic maximum velocity (4.5±0.5 vs 4.3±0.4 m/sec, p<0.001) and mean gradient (50.1±12.7 vs 43.2±7.7 mmHg, p<0.001). There were no significant differences regarding mean aortic valvular area neither left ventricle ejection fraction. At univariate analysis, predictor factors of symptoms attributable to severe AS development were: hypertension (odds ratio (OR) 2.044, confidence interval (CI) 1.004–4.161, p 0.049), anaemia (OR 0.420, CI 0.207–0.851, p 0.016), aortic maximum velocity (OR 5.497, CI 2.014–15.000, p 0.001) and mean gradient (OR 1.073, CI 1.029–1.118, p 0.001). At multivariate analysis, only aortic maximum velocity showed to be independent predictor factor of symptomatic severe AS (p 0.012). Hospitalization and all-cause mortality rates (respectively: 9.3 vs 9.4%, p 0.975; and 25.8 vs 34%, p 0.305) did not differ between groups.

Conclusion

In patients with severe AS, aortic maximum velocity showed to be the only independent predictor factor of symptoms development, however it was not associated with an increased hospitalization or mortality rates.

P975Safety and clinical outcomes of rotational atherectomy: an eleven-year centre experience

Introduction

Rotational atherectomy (RA) is an adjunctive tool for the management of heavily calcified coronary lesions during percutaneous coronary intervention (PCI), but the clinical outcomes remain unclear. Access site choice is also poorly defined and there is growing evidence that transradial approach (TRA) is associated with lower complications and lower mortality.

Objectives

To assess the safety and long-term outcomes of RA for calcified coronary lesions and to investigate the influence of vascular access site in the efficacy and safety of the procedure.

Methods

Retrospective single-centre study that included consecutive PCI with RA performed from January 2006 to December 2017. Endpoint was a composite of major adverse cardiac events (MACE), defined as cardiovascular death, nonfatal myocardial infarction, nonfatal stroke and target vessel revascularization, at 1- and 5-year.

Results

246 procedures were included in a total of 236 patients (pts): mean age 70.1±9.7 years, 73.6% male; 36.2% had previous PCI, 12.2% vascular peripheral disease (VPD), 24% reduced left ventricle ejection fraction (LVEF) and 6.9% were under hemodialysis. PCI with RA was mostly performed due to stable angina (48.9%) and via TRA (55.3%), with a total of 371 treated segments and a median number of 1 vessel treated per intervention. The left anterior descending artery was the most frequently treated artery (67.5%). Single burr was used in 76% of cases (mean number of burrs 1.23; mean burr size 1.5 mm). Procedural success rate was 94.7%. Complications were recorded in 9.3%, with no procedure related death. Clinical follow-up was complete in 98.8% of pts at 1-year and 81.3% at 5-year (mean time 62.3±41.8 months). Survival free of MACE at 1- and 5-year were 83.7% and 73.2%, respectively. Multivariate Cox regression identified 6 independent predictors (only 1 protector) for 1-year MACE (Fig. A) and 6 independent predictors (all of increased risk) for 5-year MACE (Fig. B). TRA was protector of 1-year MACE and Kaplan-Meier curves showed benefit for both 1- and 5-year MACE occurrence (Fig. C and D), without significant difference in procedural success (p=0.92) and complications (p=0.45) rate comparing to transfemoral approach.

Conclusions

RA followed by stenting was a safe procedure with a high immediate success rate but an increased number of long-term cardiovascular events. Some clinical conditions, such as previous PCI, VPD and reduced LVEF, seems to adversely influence the long-term outcome while TRA appears to be protective.

P846Discriminatory power of the grace score in non-ST segment elevation myocardial infarction in the real world: results from the portuguese registry on acute coronary syndromes

Introduction

Current clinical practice guidelines recommend risk stratification in patients with acute coronary syndrome (ACS) upon admission to the hospital. The Global Registry of Acute Coronary Events (GRACE) risk score was developed in a large multinational registry to predict both mortality and the combined events of death or reinfarction during the hospital stay and 6 months after discharge. Given the substantial regional variation and temporal changes in patient characteristics and management patterns, specially in non-ST segment elevation myocardial infarction (NSTEMI) patients, we sought to validate this risk score in a contemporary Portuguese population.

Purpose

To assess the discriminatory power of the GRACE risk score in a Portuguese contemporary cohort of patients with NSTEMI submitted to invasive strategy, regarding in-hospital mortality and the combined end-point of reinfarction and/or in-hospital mortality.

Methods

We included patients with NSTEMI submitted to coronary angiogram from the Portuguese Registry on Acute Coronary Syndrome (ProACS). For each patient, we calculated the GRACE risk score and classified them in low, intermediate or high risk, according to the cut-offs recommended in the guidelines. The discriminatory capacity of the GRACE risk score was evaluated by the area under the receiver operating characteristic [ROC] curve. The primary endpoint was defined as the occurrence of reinfarction and in-hospital mortality, and the secondary endpoint was in-hospital mortality.

A model with an AUC-ROC between 0.8 and 0.9 was considered to have a good capacity for discrimination.

Results

Among the 19.430 patients included in the ProACS between October 2010 and January 2019, we identified 7304 patients with NSTEMI that performed coronary angiogram and had the GRACE score calculated (37.6%). Patients were divided in three groups according to the GRACE score (group 1: 1–108; group 2: 109–140; group 3: 141–372), with 24.9% included in group 1, 33.0% in group 2, and 42.1% in group 3. Most patients were male (73.4%), with a mean age of 66±12 years, and 48.0% were admitted to non-percutaneous coronary intervention centers. In-hospital mortality was 1.0% and the primary endpoint occurred in 2.2% of the patients. The discriminatory capacity of the GRACE score in our population was good regarding in-hospital mortality: the area under the ROC curve was 0.83 (95% confidence interval [CI], 0.783–0.878), with the best cut-off of 148. The discriminatory capacity for the primary end-point was reasonable; the area under the ROC curve was 0.700 (95% CI 0.654–0.745), and the best cut-off was 164.

Conclusions

In our population of patients with NSTEMI submitted to an invasive strategy, the GRACE risk score presented a moderate discriminatory capacity for the occurrence of reinfarction and in-hospital, and a a good discriminatory power for in-hospital mortality.

P4674Implementation of the new chronic thromboembolic pulmonary hypertension treatment algorithm: an ongoing effort from a portuguese referral centre

Background

To date, the first-line treatment for chronic thromboembolic pulmonary hypertension (CTEPH) is pulmonary endarterectomy (PEA), although a significant number of patients will have inoperable disease or residual pulmonary hypertension (PH). Balloon pulmonary angioplasty (BPA) has provided a new therapeutic option for these patients. In addition, medical therapy (MT) also plays an important role.

Purpose

Characterization of a population of patients with CTEPH or chronic thromboembolic disease (CTED) and comparison of the different treatment strategies according to the updated treatment algorithm.

Methods

Retrospective analysis of patients with CTEPH/CTED followed in a referral centre for the treatment of PH submitted to different treatment strategies: PEA plus MT and BPA in patients with residual PH (group 1), MT plus BPA (group 2), and MT only (group 3). Cox regression was used to identify predictors of all-cause mortality.

Results

58 patients were included (median age 63.5 years, 74% female); 17% had CTED, and the remaining had CTEPH 50% (n=29) were submitted to PEA (group 1), of which 58% had residual PH (21% underwent BPA, n=3). Among the remaining patients, 31% (n=9) underwent MT plus BPA (group 2), and 69% (n=20) were treated with MT only (group 3). Overall, 55% were under pulmonary vasodilator therapy, including 38% with riociguat. Most of the patients (67%) were in functional class III or IV, the distance in the 6MWT was 328±147 meters, the median NT-proBNP was 538pg/ml, 40% had RV systolic dysfunction, the mean mPAP was 42±13 mmHg, and the mean PVR was 11±6 WU. Comparing the different treatment strategies, during follow-up (median 945 days) the following differences were found (comparison between group 1 vs group 2 vs group 3): improvement in functional class (class III-IV: 0% vs 0% vs 58%); distance in 6MWT (438±83 vs 390±79 vs 281±105 meters); evolution of NT-proBNP (−984±1736 vs −198±205 vs +1177±2342); normalization of RV dimensions (89% vs 50% vs 20%); resolution of pericardial effusion (100% vs 100% vs 0%); normalization of mPAP (73% vs 71% vs 0%); PVR (median 3.4 vs 2.7 vs 10.6 WU); all-cause mortality (7% vs 0% vs 35%) (p<0.02 in all).

In the overall population, the most relevant predictors of all-cause mortality were the absence of functional class improvement, baseline and follow-up NT-proBNP, baseline and follow-up SPAP by echocardiogram, and maintenance of treatment with prostanoids (p<0.05 in all).

Conclusion

Our results confirm that, in patients with CTEPH/CTED, PEA is associated with functional, and hemodynamic improvement and increased survival, although BPA is an alternative in patients with inoperable disease or residual PH, with similar results on short-term follow-up. Patients who are not submitted to surgical or percutaneous intervention have a poor prognosis, both in terms of morbidity and mortality.

P5553Right ventricular involvement in hypertrophic cardiomyopathy: insights from a tertiary centre

Introduction

Hypertrophic cardiomyopathy (HCM) is the main cause of sudden cardiac death in the young and a cause of heart failure (HF) and death at any age. Nevertheless, adverse long-term outcomes are not easy to predict.

Objectives

To assess the prevalence and prognostic value of right ventricular (RV) involvement in patients (pts) with HCM.

Methods

Retrospective single-centre study of consecutive pts with HCM evaluated in a specialized consultation. Selected those submitted to cardiac magnetic resonance imaging (CMR) as the gold-standard for RV assessment. The primary endpoint (PE) was a composite of cardiovascular death, nonfatal myocardial infarction, nonfatal stroke, ventricular arrhythmias with hemodynamic instability and unplanned HF admission.

Results

Of a total of 181 pts, 104 fulfilled the inclusion criteria (mean age at first consultation 62.1±9.7 years, 63.5% male). Septal asymmetric phenotype was the most frequent (73.1%) and 24 pts (23.1%) had rest LV outflow tract obstruction. Mean value of maximum wall thickness was 18.8±4.6 mm. Regarding CMR parameters (Fig A), 5.8% had RV dysfunction and 2.9% RV free wall hypertrophy; no patient presented RV dilation. Late gadolinium enhancement (LGE) of joint points was observed in 47.1%. During follow-up (FU, mean 56.6±29.5 months), survival free of RV dysfunction was 94.3%. Only 5 pts developed RV compromise assessed by echocardiographic parameters: TAPSE 12.0±3.4 mm and pulsed tissue Doppler systolic annular velocity (tricuspid S') wave 7.3±0.9 cm/s. These pts were significantly older (p<0.01) and had higher values of average tissue doppler E/E' ratio at diagnosis (p<0.01). Global RV involvement (at diagnosis or during FU) were associated with increased values of indexed left atrial area (p<0.01), LV dysfunction (p=0.01), LGE of joint points (p=0.01) and higher values of NT-proBNP (p=0.01). In multivariate logistic regression, left atrial enlargement was the only independent predictor of global RV dysfunction (OR 1.9, 95% CI 1.1–3.2, p=0.01) and average E/E' ratio an independent predictor of RV dysfunction during FU (OR 1.3, 95% CI 1.1–1.5, p<0.01). PE rate was 10.6%. It was significantly higher in pts with global RV involvement and there was a significant difference in survival analysis (Fig B). Average E/E' ratio (OR 1.5, 95% CI 1.1–1.9, p=0.01) and RV ejection fraction (OR 0.8, 95% CI 0.7–0.9, p=0.01) were independent predictors of the outcome.

Conclusions

Although not common, RV dysfunction was associated with a higher rate of cardiovascular events. Average E/E' ratio, as a measure of left ventricular filling pressure, was a risk factor for both RV dysfunction and PE. Higher values of RV ejection fraction were protective of adverse events occurrence. Together, these results support a potential role of RV function in the risk stratification of HCM pts.

P3128Unprotected left main revascularization in patients with acute myocardial infarction: insights of a multicenter national registry

Introduction

Unlike stable coronary disease, there is no consensus about the best revascularization strategy for unprotected left main coronary artery (ULMCA) disease associated with acute myocardial infarction (MI). Recent studies have shown that percutaneous coronary intervention (PCI) is technically feasible with acceptable outcomes, making it a reasonable alternative to surgical revascularization (CABG).

Aims

To describe the practice of ULMCA revascularization in MI patients (pts) and its evolution over an 9-year period. To analyze the prognosis of this population and determine the effect of revascularization on outcome.

Methods

Retrospective, multicenter national observational study that included 19 430 MI pts from October 2010 to December 2018. Pts who presented ULMCA as culprit lesion were selected and then compared the subgroup that underwent revascularization by PCI alone versus (vs.) CABG alone. Primary endpoint (PE) was a composite of all-cause death, nonfatal re-MI and nonfatal stroke during hospital stay. Secondary endpoint (SE) was all-cause death rate at 1-year after hospital discharge.

Results

204 pts with ULMCA as culprit lesion were selected (1.1% of all pts): 77.9% male, mean age 69±12 years, 97 (47.5%) underwent CABG alone, 92 (45.1%) PCI alone, 10 (4.9%) no revascularization and 5 (2.5%) both strategies. At admission, pts undergoing PCI alone presented more frequently with ST-segment elevation, persistent chest pain, cardiogenic shock and higher values of GRACE risk score. During hospital stay, severe left ventricular (LV) systolic dysfunction (<30%), need for mechanical ventilation, sustained ventricular tachycardia and aborted cardiac sudden death were also more common in these pts. Concerning PE, global rate was 18.5% (27 deaths, 6 nonfatal re-MI and 2 nonfatal stroke). It was significantly higher in pts undergoing PCI alone (32.6% vs. 3.1%, p<0.01). After adjustment, surgical revascularization had 98% lower odds of PE occurrence compared to PCI (OR 0.02, 95% CI 0.002–0.22, p<0.01). Cardiogenic shock at admission (OR 5.06, 95% CI 1.21–21.11, p=0.03) and severe LV systolic dysfunction (OR 7.77, 95% CI 1.49–40.56, p=0.02) were also independent predictors of adverse outcome. One-year all-cause death rate was 4.9%, with no significant difference at survival curves between PCI vs. CABG (Log-Rank p=0.96).Over the 9-year, there was not a significant change in the use of one revascularization technique over the other.

Conclusions

MI with ULMCA as culprit lesion is infrequent and associated with a high rate of adverse events during hospital stay. PCI was preferred in higher risk pts but, even after adjustment, it was associated with a less favorable short-term outcome compared to surgical strategy. Nevertheless, long-term prognosis was excellent in hospital survivors with no difference between both techniques. Randomized trials are needed to determine the ideal revascularization strategy for these pts.