P1745Clinical characteristics and long-term outcome in patients with helicopter-transported acute coronary syndrome after primary percutaneous coronary intervention

Background

Reducing delay to percutaneous coronary intervention improves functional outcome and reduces long-term mortality. Transportation by helicopter is often quicker than ground transport and thus may improve overall prognosis through reduced ischemic injury and infarction size. Our hospital is located on the medically-depopulated peninsula surrounded by mountain. The journey from the southern tip of the peninsula to the critical care medical center of our hospital take 1.5 hour by a ground ambulance but only 15 minutes by helicopter.

We compared the clinical characteristics and long-term mortality between air and ground transport of ACS patients for primary PCI.

Methods

We conducted an observational cohort study evaluating 2324 patients (mean age 68.5±12.0, male 75.2%) with ACS underwent primary PCI between April 2004 and December 2017 at our hospital.

We divided into three groups according to transportation system type (air, ground, walk-in).

The primary outcome was defined as all-cause death during the long-term follow-up.

Results

Among the entire cohort, 577 patients (24.8%) were transported by air. 1326 (57.1%) patients by ambulance, 421 (18.1%) patients by walk. Baseline characteristics were comparable, but patients by air had a higher prevalence of ST-elevation myocardial infarction.

The rate of long-term mortality was comparable during the median follow up of 6 years (air, 21.1% vs. ground, 21.4% vs. walk-in, 21.1%, respectively, log-rank p=0.72). Multivariate Cox regression analysis showed no significant association between air transportation and long-term mortality (Adjusted HR [vs ground] 1.05, 95% CI 0.60–1.78, p=0.85 and [vs walk-in] 0.94, 95% CI 0.62–1.43, respectively, p=0.77).

Kaplan-Meier curve

Conclusions

The rate of long-term mortality in patients with ACS transported by air was comparable with those transported by ground.

P628Association of outpatient cardiac rehabilitation with mortality and morbidities in patients with acute myocardial infarction

Background/Introduction

Outpatient cardiac rehabilitation (CR) is commonly recommended for patients with acute myocardial infarction (AMI). However, the survival benefit has recently been contested, especially with no survival benefit having been found in non-Western countries.

Purpose

To investigate whether outpatient CR, under current real-world clinical practice, is associated with lower mortality and morbidity risks in patients with AMI.

Methods

The retrospective cohort study was conducted from January 2011 to June 2016 (final date of follow-up: July 31, 2016) with a nation-wide administrative database for acute-care hospitals in Japan. Data for 7,411 patients were analyzed, with 5,654 fulfilling the inclusion criteria of being admitted for AMI and receiving both percutaneous coronary intervention and inpatient CR between January 2011 and December 2014. We compared patients who participated in outpatient CR at least once within 180 days of discharge and who did not. To account for measured baseline imbalances between outpatient CR participants and non-participants, 1:1 propensity-score matching was performed. The primary outcome was a composite of all-cause death and recurrence of AMI after the landmark time-point of day 180 after discharge. Secondary outcomes included all-cause death, recurrence of AMI, and heart failure.

Results

Among 5,654 patients (mean [SD] age, 66.8 [12.4] years; 21.2% female; median follow-up period [IQR] 1.44 [0.87 to 2.27] years), 730 (12.9%) received outpatient CR. Of 1,458 propensity-score matched patients, outpatient CR participants did not show a significantly lower risk of the primary outcome than non-participants (1.38 vs. 2.12 per 100 patient-years; hazard ratio [HR], 0.71 [95% CI, 0.32 to 1.61]). Similarly, outpatient CR participation was not associated with lower risks of all-cause death (0.68 vs. 1.31 per 100 patient-years; HR, 0.83 [95% CI, 0.25 to 2.73]), recurrence of AMI (0.69 vs. 0.88 per 100 patient-years; HR, 0.56 [95% CI, 0.19 to 1.66]) or heart failure (2.01 vs. 2.06 per 100 patient-years; HR, 0.89 [95% CI, 0.47 to 1.72]), respectively.

Conclusion

Among patients with AMI who received percutaneous coronary intervention and inpatient CR, outpatient CR was not associated with lower risks of mortality and morbidities. The survival benefit of outpatient CR should be reaffirmed under current real-world clinical practice, especially in non-Western countries.

P4548Early drop in systolic blood pressure and worsening renal function in the elderly acute heart failure: how does heart rate interact?

Background

Renal dysfunction is a frequent finding in patients hospitalized for acute heart failure (AHF). Worsening renal function (WRF) during hospitalization was found to be related with a poor outcome independently of baseline renal function. Early drop in systolic blood pressure (SBP) has shown to predict WRF in AHF. However, there have been few studies that reported the impact of on-admission heart rate (HR) on the relationship between early SBP drop and WRF in the elderly AHF.

Purpose

We assessed the hypothesis that early SBP drop predict WRF in the elderly patients with AHF, and investigated that on-admission HR might have an interaction with that relationship.

Methods

SBP and HR were measured on admission and 6 times during 48 hours in the 245 elderly AHF inpatients (82.9±6.0 years old, male 49.4%). WRF was defined as a serum creatinine increase of ≥0.3 mg/dL by Day 5. Early drop in SBP was calculated as the difference between admission and the lowest value measured during the first 48 hour of hospitalization.

Results

Early SBP drop (51.3 vs 32.5mmHg, p<0.01) and on-admission HR (79.3 vs 89.6bpm, p<0.05) were significantly different between the group with WRF (n=36) and the group without WRF (n=209). In the multiple logistic regression analysis adjusted for the confounders including age, gender, hypertension, left ventricular ejection fraction, total cholesterol, BNP, baseline creatinine, beta-blockade use, intravenous loop diuretic, isosorbide dinitrate and carperitide use, early SBP drop (OR: 1.003, 95% CI: 1.003–1.03, p<0.04) and on-admission HR (OR: 0.98, 95% CI: 0.96–0.99, p<0.01) were significantly associated with WRF. The interaction term of early SBP drop by on-admission HR did not have a significant association with WRF (p=0.3).

Conclusions

In the elderly AHF patients, exaggerated early SBP drop and lower on-admission HR were shown as significant independent predictors of WRF. These two factors were additively associated with WRF. Too much reduction in SBP and that in HR might be harmful to renal circulation in AHF.

3332Exercise training ameliorates vasodilator capacity of coronary microvessels in patients with vasospastic angina - A new therapeutic approach for the coronary functional disorder

Background

We have recently demonstrated that coronary vasospasm could develop in both epicardial coronary arteries and intramuscular coronary microvessels in patients with vasospastic angina (VSA). However, it remains to be examined whether vasodilator capacity of coronary microvessels is impaired in VSA patients and if so, whether exercise training could ameliorate vasodilator capacity of coronary microvessels on the top of calcium channel blockers. The effectiveness of exercise training is established for organic coronary artery disease but remained to be examined for VSA.

Purpose

We thus examined whether vasodilator capacity of coronary microvessels is impaired in VSA patients without organic coronary stenosis using an adenosine-stress dynamic computed tomography perfusion (CTP) that can measure absolute value of myocardial blood flow (MBF). We also examined whether exercise training ameliorates not only vasodilator capacity of coronary microvessels but also exercise capacity and frequency of angina attack.

Methods

In the first protocol, we measured MBF using CTP in consecutive 32 VSA patients with acetylcholine-induced diffuse coronary spasm in the left anterior descending coronary arteries (LAD) and 12 non-VSA controls. In the second protocol, we conducted a randomized controlled trial (RCT; Exercise VSA trial, UMIN: ehz745.008423996), where 20 VSA patients were randomly assigned to either exercise group (Ex group: supervised exercise training session for 30-min using bicycle ergometer, once/week at the hospital and more than 3 times/week at home) or non-exercise group (Non-Ex group) (n=10 each) (Figure A). Before and 3 months after exercise training, we measured MBF with adenosine-stress dynamic CTP and peak VO2 by cardiopulmonary exercise tests, and also assessed angina attack with Seattle Angina Questionnaire (SAQ).

Results

In the first protocol, CTP showed that adenosine-stress MBF was significantly decreased in the VSA group compared with the non-VSA group (VSA, 137.2±6.6 vs. Non-VSA, 174.4±10.7 ml/100g/min, P<0.01) (Figure B), although patient characteristics were comparable between the 2 groups. In the second protocol, exercise training was performed safely in all patients, and RCT showed that MBF was significantly increased in the Ex group compared with the non-Ex group (Figures C, D), although patient characteristics were also comparable between the 2 groups. Furthermore, peak VO2 was significantly increased in the Ex group compared with the non-Ex group (Figure E), and frequency of angina was significantly decreased in the Ex group compared with the non-Ex group (Figure F). Finally, there was a significant positive correlation between the extents of the changes in peak VO2 and the SAQ score for angina frequency in the Ex group (P<0.01, R=0.67).

Figures

Conclusions

These results provide the first evidence that vasodilator capacity of coronary microvessels is impaired in VSA patients, which can be ameliorated by exercise training.

6066Equal significance of longitudinal and radial wall motion represents the normal right ventricular mechanical pattern: 3D echocardiographic study in 231 healthy volunteers

Three main mechanisms contribute to right ventricular (RV) pump function: (1) shortening of the longitudinal axis with traction of the tricuspid annulus towards the apex; (2) inward (radial) movement of the RV free wall, which is often referred as the “bellows effect”; and (3) bulging of the interventricular septum into the RV during the left ventricular contraction and stretching of the free wall over the septum (causing shortening in the anteroposterior direction). Despite the established clinical value of the functional changes among the aforementioned components, their relative importance remains to be quantified during physiological conditions.

Accordingly, the aim of our study was to evaluate the relative contribution of the different RV motion directions to global RV function on both global and segmental level in a large set of healthy individuals.

We have recruited 231 healthy volunteers (44% female, with a wide and balanced age range from 8 to 81 years) from two experienced centers performing transthoracic 3D echocardiography (3DE) on a routine basis. 3DE datasets focused on the RV were obtained using multi-beat acquisition. We determined RV volumes and subsequent ejection fraction (RVEF) by dedicated software. Using the ReVISION method, we have decomposed the motion of the RV to determine longitudinal (LEF), radial (REF) and anteroposterior ejection fraction (AEF). Their ratio to RVEF quantifies the relative contribution of the given component to global RV function. Moreover, regional subvolumes were also analyzed in a 15-segment model.

Mean value of RVEF was significantly higher in female subjects compared to male subjects (60±7 vs. 56±7%, p<0.001). The relative contributions of LEF and REF to RVEF were comparable, while the contribution of AEF was significantly lower (LEF/RVEF vs. REF/RVEF vs. AEF/RVEF: 0.48±0.08 vs. 0.49±0.07 vs. 0.39±0.11, p<0.001) in the pooled population as well as in the genders separately. In line with higher RVEF found in women, female gender was associated with a higher longitudinal and radial contribution compared to males, however, AEF was similar (women vs. men; LEF/RVEF: 0.49±0.08 vs. 0.47±0.07, p<0.05; REF/RVEF: 0.50±0.07 vs. 0.48±0.06, p<0.01; AEF/RVEF: 0.38±0.12 vs. 0.40±0.10, p=NS). Interestingly, AEF/RVEF showed a significant deterioration with age (r=−0.354, p<0.001), while age-dependency of the longitudinal and radial contributions were not observed concerning both genders. An age-related decrease could be demonstrated by the volume fractions of the 5 septal volumetric segments (r=−0.229, p<0.001).

Motion decomposition and the 15 segments

In physiological conditions, the relative importance of longitudinal and radial wall motions is similar in determining global RV function. Aging accompanied by a decrease in anteroposterior shortening, which may point to a deteriorating systolic LV-RV interaction. Our results may facilitate further research concerning the alterations of RV mechanical pattern in various disease states.

A novel method for transpulmonary pressure estimation using fluctuation of central venous pressure

The objective of the study is to develop a correction method for estimating the change in pleural pressure (ΔPpl) and plateau transpulmonary pressure (P_L) by using the change in central venous pressure (ΔCVP). Seven children (aged < 15 years) with acute respiratory failure (PaO₂/F_IO₂ < 300 mmHg), who were paralyzed and mechanically ventilated with a PEEP of < 10 cmH₂O and had central venous catheters and esophageal balloon catheters placed for clinical purposes, were enrolled prospectively. We compared change in esophageal pressure (ΔPes), ΔCVP, and ΔPpl calculated using a corrected ΔCVP (cΔCVP-derived ΔPpl). cΔCVP-derived ΔPpl was calculated as κ × ΔCVP, where κ was the ratio of the change in airway pressure (ΔPaw) to ΔCVP during the occlusion test. cΔCVP-derived ΔPpl correlated better than ΔCVP with ΔPes (R² = 0.48, p = 0.08 vs. R² = 0.14, p = 0.4) with lesser bias and precision in Bland-Altman analysis. The plateau P_L calculated using the cΔCVP-derived ΔPpl (17.6 ± 2.6 cmH₂O) correlated well with the ΔPes-derived plateau P_L (18.1 ± 2.3 cmH₂O) (R² = 0.90, p = 0.001). Our correction method can estimate ΔPpl and plateau P_L from ΔCVP with a reasonable accuracy in paralyzed and mechanically ventilated pediatric patients with respiratory failure.

Nuclear magnetic resonance on $LaFeAsO_{0.4}H_{0.6}$ at 3.7 GPa

A prototypical electron-doped iron-based superconductor $LaFeAsO_{1-x}H_x$ undergoes an antiferromagnetic (AF) phase for $x  \geq 0.49$. We performed NMR measurements on $LaFeAsO_{0.4}H_{0.6}$ at 3.7 GPa to investigate the magnetic properties in the vicinity of a pressure-induced QCP. The linewidth of $~^1H$-NMR spectra broadens at low temperatures below 30 K, suggesting that the ordered spin moments remain at 3.7 GPa. The coexistence of gapped and gapless spin excitations was confirmed in the ordered state from the relaxation time $T_1$ of $~^{75}As$. The pressure-induced QCP is estimated to be 4.1 GPa from the pressure dependence of the gapped excitation.   Edited by: A. Goñi, A. Cantarero, J. S. Reparaz

Post-Extubation Inhaled Nitric Oxide Therapy via High-Flow Nasal Cannula After Fontan Procedure

In 2014, our hospital introduced inhaled nitric oxide (iNO) therapy combined with high-flow nasal cannula (HFNC) oxygen therapy after extubation following the Fontan procedure in patients with unstable hemodynamics. We report the benefits of HFNC-iNO therapy in these patients. This was a single-center, retrospective review of 38 patients who underwent the Fontan procedure between January 2010 and June 2016, and required iNO therapy before extubation. The patients were divided into two groups: patients in Epoch 1 (n = 24) were treated between January 2010 and December 2013, receiving only iNO therapy; patients in Epoch 2 (n = 14) were treated between January 2014 and June 2016, receiving iNO therapy and additional HFNC-iNO therapy after extubation. There were no significant differences between Epoch 1 and 2 regarding preoperative cardiac function, age at surgery, body weight, initial diagnosis (hypoplastic left heart syndrome, 4 vs. 2; total anomalous pulmonary venous return, 5 vs. 4; heterotaxy, 7 vs. 8), intraoperative fluid balance, or central venous pressure upon admission to the intensive care unit. Epoch 2 had a significantly shorter duration of postoperative intubation [7.2 (3.7-49) vs. 3.5 (3.0-4.6) hours, p = 0.033], pleural drainage [23 (13-34) vs. 9.5 (8.3-18) days, p = 0.007], and postoperative hospitalization [36 (29-49) vs. 27 (22-36) days, p = 0.017]. Two patients in Epoch 1 (8.3%), but none in Epoch 2, required re-intubation. Our results suggest that HFNC-iNO therapy reduces the duration of postoperative intubation, pleural drainage, and hospitalization.

Outcomes of 'unrecognised situation awareness failures events' in intensive care unit transfer of children in a Japanese children's hospital

AIM

To demonstrate that unrecognised situation awareness failures events (UNSAFE) transfers are associated with poorer outcomes in the intensive care unit (ICU) at a Japanese children's hospital lacking a rapid response system.

METHODS

This retrospective cohort study was conducted between January 2013 and February 2016. UNSAFE transfers were defined as unplanned in-hospital ward-to-ICU transfers requiring tracheal intubation, vasoactive medications or ≥3 fluid boluses before arrival or in the first 60 min of ICU care. We compared ICU stay duration and mortality between UNSAFE and non-UNSAFE transfers.

RESULTS

There were 2126 admissions to the paediatric ICU during the study period, and 244 cases met the definition of an unscheduled in-hospital transfer (11.5%). Of these, the number of patients transferred following cardiopulmonary resuscitation, in the UNSAFE group and in the non-UNSAFE group were 9 (3.7%), 68 (28%) and 167 (68%), respectively. In the UNSAFE group, the number of patients who required tracheal intubation, initiation of vasoactive medications or ≥ 3 fluid boluses in the first 60 min of ICU care or before arrival in the ICU was 61 (90%), 38 (56%) and 9 (13%), respectively. ICU stay duration and mortality were significantly poorer in the UNSAFE group than in the non-UNSAFE group (9 vs. 4 days, P < 0.0001; 13 vs. 4.2%, odds ratio = 3.5, 95% confidence interval = 1.2-9.8, P = 0.020, respectively).

CONCLUSIONS

Patients who experienced UNSAFE transfers had longer ICU stays and higher mortality, and it may be used as a metric of evaluation of effects of rapid response system implementation.

195 Effect of feeding a licorice extract to Japanese Black cows on embryo production performance after superovulation treatment

The objective was to determine the effect of feeding a licorice extract that contains glycyrrhizic acid, which is known to have a liver function-enhancing effect, on embryo production performance after superovulation treatment in Japanese Black cows. Japanese Black breed cows (n=136) that had calved 1 to 4 times and had normal uteri as seen by ultrasonography after at least 40 days from the last calving were used as test animals. Animals in the treatment group (n=90) were continuously fed 20g head−1 d−1 of a licorice extract (Kanzou, Fabric Onishi Co. Ltd., Osaka, Japan), with at least 13% glycyrrhizic acid content) once a day, mixed with the formula feed, for 60 to 90 days starting from around the day of calving until ova/embryos were collected. The control group (n=46) received no Kanzou from the day of the last calving until ova/embryo collection. A total of 20 Armour units (AU) of FSH (Antorin R, Kyoritsu Seiyaku Corporation, Kanagawa, Japan) from porcine pituitary was given intramuscularly (IM) twice a day, morning and evening, for 3 consecutive days (decreasing dose schedule: 5 AU×2, 3 AU×2, and 2AU×2) as the superovulation treatment to the cows at 8 to 11 days post-oestrus in both groups. Prostaglandin F2α 25mg and 15mg (IM) were administered in the morning and evening, respectively, on the third day of FSH administration. Artificial insemination was done at 12 and 24h after the start of oestrus, and ova/embryos were collected using a uterine reflux method on Day 7 post-oestrus. The mean numbers of ova/embryos and transferable embryos collected and the mean embryo quality scores (according to the IETS guidelines) in the treatment and control groups were compared by t-test. A chi-squared test was used to compare the proportion of transferable embryos in the 2 groups. There was no significant difference in the mean number of ova/embryos retrieved between the treatment group (21.7±11.8) and the control group (15.8±11.3), although the former tended (P=0.07) to yield more ova/embryos. There was significant difference (P&lt;0.05) in the mean number of transferable embryos collected in the treatment group (13.1±8.3) than in the control group (8.1±5.3). The mean embryo quality score was significantly greater (P&lt;0.01) in the treatment group (1.6±0.4) than in the control group (2.2±0.6). The proportion of transferable embryos in the treatment group (60.3±26.4%) was also significantly higher (P&lt;0.05) than in the control group (51.2±26.0%). In conclusion, feeding a licorice extract to Japanese Black cows for 60 days or longer improves the quality of embryos obtained after superovulation treatment and leads to an increase in the mean number of transferable embryos per cow.

Predicting extubation readiness by monitoring the electrical activity of the diaphragm after prolonged mechanical ventilation: a pediatric case report

BACKGROUND

The intensity of the electrical activity of the diaphragm (Edi) correlates with inspiratory effort. The ratio of tidal volume to the Edi is known as neuroventilatory efficiency (NVE) and is used as an index for ventilation efficiency. Here, we present a case showing that Edi and NVE may be effective parameters to predict successful extubation.

CASE PRESENTATION

A 6-month-old female infant required prolonged mechanical ventilation after cardiac surgery. Fifty-two days after surgery, her trachea was extubated but required reintubation. Edi monitoring was initiated to assess diaphragm function. The Edi was > 70 mcV just after the reintubation, and her NVE was 1.0 mL/mcV, but gradually decreased. On day 59, her Edi values during the spontaneous breathing trials were 13 mcV with the improvement of NVE (2.5 mL/mcV) and her trachea was extubated without complications.

CONCLUSIONS

The Edi and NVE were valuable for deciding the extubation readiness in a long-term mechanically ventilated patient.