Biomarkers of left atrial overload in obese and nonobese patients with atrial fibrillation qualified for electrical cardioversion

BACKGROUND

Biomarkers of left atrial (LA) overload are considered factors affecting the efficacy of atrial fibrillation (AF) treatment. Increasing obesity rates contribute to a growing number of obese patients qualified for electrical cardioversion (CVE).Biomarkers of left atrial (LA) overload are considered as factors influencing efficacy of atrial fibrillation (AF) treatment. The increasing rate of obesity contributes to obese patients constituting a significant group of subjects qualified to electrical cardioversion (CVE).

AIMS

The aim of the study was to evaluate serum concentrations of biomarkers of LA overload and their impact on the efficacy of CVE.

METHODS

A total of 82 patients with persistent AF who underwent successful CVE were prospectively enrolled in the study. The study population was divided into the obese group (OG) and the nonobese group (NOG). The serum levels of the following biomarkers were measured on the day of admission and at follow‑up: high‑sensitivity C‑reactive protein (hs‑CRP), N‑terminal pro‑B‑type natriuretic peptide, copeptin, galectin 3, growth differentiation factor 15 (GDF‑15), and renalase.

RESULTS

Baseline and follow‑up hs‑CRP levels were increased in the OG compared with the NOG. Four‑week CVE efficacy was 38.8% in the OG and 60.6% in the NOG. Time of the observation, allocation to the groups, and CVE outcomes showed no associations with most LA biomarkers during follow‑up. Baseline concentrations of 2 biomarkers of LA overload were associated with clinical characteristics of the study group, that is, log10 serum GDF‑15 and log10 serum renalase levels correlated positively with the CHA2DS2‑VASc score.

CONCLUSIONS

Although obesity modifies the long‑term efficacy of CVE, the OG and NOG did not differ significantly in most biomarkers of LA overload, except hs‑CRP. The efficacy of CVE seems to be independent of the levels of biomarkers. A favorable procedure outcome did not affect their blood concentrations.

Exhaled air analysis for pulmonary arterial hypertension fingerprints identification

Background

Pulmonary arterial hypertension (PAH) is a rare disease which is often diagnosed in the late phase as its symptoms are non-specific and there is a lack of screening tests. Therefore, there is a strong need for identifying of its biomarkers.

Aim

To identify the biomarkers for PAH in the exhaled breath and in the serum.

Methods

The breath phase of all the patients was collected on the highly porous aseptic material by the use of special patented holder PL 232911. The collected air was then examined with gas chromatography mass spectrometry (GC/MS). For the control of the obtained results plasma of all the patients was examined by the use of Ultra High Performance Liquid Chromatography (UHPLC). A group of 10 patients (2 men, 8 women, mean age 60.4±10.9 years, BMI 27.6±6.0 kg/m2) with diagnosed PAH as well as the group of 10 healthy persons (6 men, 4 women, mean age 35±11 years, BMI 25.6±6.0 kg/m2) were enrolled into the study.

Results

The obtained spectral and chromatographic results clearly presents the qualitative and quantitative QA/QC sensitivity to the metabolites changes in the patient's breath. The identification of changes in ratio of the whole spectra of biomarkers can allow to obtain a multi-dimensional pathways for PAH diagnostics fig. 1. The chromatography data from patients suffering from PAH have been processed by the aid of signal processing toolbox in MATLAB. Only the peaks of the prominence of at least 10000 (experimentally established) have been taken under consideration. The prominence of a peak measures how much the peak stands out due to its intrinsic height and its location relative to other peaks. Next, for the each found peak the arguments of the two neighboring local minima, have been determined and the integration range for calculating the area under the each peak have been established. The ratio of the area under the significant peak to its prominence have been applied for further analysis.

Conclusions

Based on our preliminary results it seems that our method is specific and sensitive in the range of selected bio-fingerprints in patients with PAH. If confirmed on larger population the molecular level breath analysis can be used as a screening test as well as complementary diagnostic method in PAH to the standard clinical practice.

Figure 1. The chromatograms of representative spectra for patients suffering from PAH (red), control (blue) with distinguished significant peaks (presented in the magnification according to their prominence). On the right side, there are the graphical presentation (area/prominence for peaks) of arbitrary chosen patient, but with reference to the original data and for two data approximations obtained by the DWT, which are important in the case of weak separated peaks.

Funding Acknowledgement

Type of funding source: Public Institution(s). Main funding source(s): University of Silesia in Katowice

Pulmonary vein isolation procedure may be associated with intracranial artery microembolism and increased risk of acute neurological incidents

Background

Atrial fibrillation ablation can be associated with the microembolism detected in intracranial arteries and risk of acute neurological incidents.

Purpose

The aims of this study were a quantitative and a qualitative evaluation of microembolic signals (MES) during pulmonary vein isolation (PVI) and establishing the potential significance of MES for damage of brain assessed in radiological investigation and neurological state of patients.

Methods

To the prospective project we qualified patients with atrial fibrillation undergoing percutaneous pulmonary vein isolation (radiofrequency ablation / balloon cryoablation) with ultrasound monitoring of microembolisms in right middle cerebral artery. Baseline and up to 12 months post pulmonary vein isolation the neurological examination and brain MRI were performed in all participants.

Results

The study enrolled 80 patients at a mean age of 58 years. Microembolisms during the monitoring of the flow in the right middle cerebral artery were recorded in 61 (76.3%) patients in the amount of 51–489 (mean 239). Most often the microembolic signals were registered during the trans-septal puncture and the stage of ablation. In 89%, microembolisms were gaseous. Mean score on Fazekas scale for the whole group before ablation: 0.87±0.7 (0–3, med. 1); after: 0.93±0.71. In 3 (4.3%) patients the lesions worsened during the follow-up period. None of the patients revealed a cardiovascular event during the follow-up period and no changes were observed in the neurological status.

Conclusions

The majority of cerebral microembolism generated during PVI are gaseous in nature. The cerebral microembolism associated with PVI probably result from the technical aspects of the procedure and do not cause neither the permanent brain damage in the radiological investigation nor neurological deficit.

Funding Acknowledgement

Type of funding source: Public Institution(s). Main funding source(s): Medical University of Silesia, Katowice, Poland - statutory work

Availability and applicability of cardiac magnetic resonance imaging in diagnosis in cardiomyopathies: the Cardiomyopathy/Myocarditis registry of the EURObservational Research Programme of the ESC

Background

Cardiac magnetic resonance (CMR) constitutes a gold standard in the diagnosis of cardiomyopathies. Regardless of CMR advantages, the method is time-consuming, high-cost, with limited availability in some European regions.

Purpose

To assess the availability and applicability of CMR for establishing the diagnosis in different populations of patients with cardiomyopathies.

Methods

Overall, 3208 adult patients with cardiomyopathy (1119 / 34.9% females; median age at diagnosis: 49.0 years): 1260 with dilated (DCM), 1739 with hypertrophic (HCM), 66 with restrictive (RCM) and 143 with arrhythmogenic right ventricular cardiomyopathy (ARVC) enrolled in EURObservational Research Programme (EORP) – Cardiomyopathy/Myocarditis Long-Term Registry were analysed.

Results

CMR scan was performed as a baseline diagnostic method in 29.4% of patients; CMR was a single diagnostic method in 0.9% of patients and in 28.6% of patients CMR was used along with transthoracic echocardiography (TTE). In 67.6% of patients TTE was at the baseline the single diagnostic imaging method. Prevalence of CMR use in different cardiomyopathies was as follows: 20.6% in DCM, 33.8% in HCM, 36.4% in RCM and 51.1% in ARVC (p<0.001). Range of CMR applicability in different European regions was diverse from 0% up to 63.2%.

The population with CMR use was younger, less symptomatic, with decreased prevalence of other cardiovascular risk factors and of associated cardiovascular diseases as compared to the population diagnosed without CMR scanning (p<0.001).

Abnormal CMR results were present in 93.4% of patients with the highest percentage in RCM (95.8%) and HCM (94.9%) followed by DCM (91.5%) and the lowest abnormal CMR scan ratio in ARVC (87.7%) (p=0.030). The majority of CMR examinations comprised the assessment of late gadolinium enhancement (LGE, 93.3% at baseline). Presence of CMR LGE was observed in 69.3% of all patients: 59.1% in DCM, 73.8% in HCM, in 63.9% in ARVC and with the highest prevalence in RCM (83.3%) (p<0.001).

Conclusion

The study reveals real-life data on the low availability and applicability of CMR in adult patients with cardiomyopathies. The analysis shows the advantages of CMR imaging but also identifies the gaps between recommendations and clinical practice. Improvement regarding access, training and reimbursement is necessary to offer CMR to cardiomyopathy patients in accordance with the ESC guidelines.

Funding Acknowledgement

Type of funding source: None

Small vessel coronary artery disease: How small can we go with myocardial revascularization?

The issue of small coronary artery atherosclerosis represents an intriguing aspect of coronary artery disease, which is related with higher rates of peri- and post-procedural complications and impaired long-term outcome. This problem is further complicated by the unclear definition of small coronary vessel. Recent randomized controlled trials have provided new data on possible novel interventional treatment of small coronary vessels with drug-coated balloons instead of traditional new-generation drug-eluting stent implantation. Also, the conservative management represents a therapeutic option in light of the results of the recent ISCHEMIA trial. The current article provides an overview of the most appropriate definition, interventional management, and prognosis of small coronary artery atherosclerosis.

On the search for the right definition of heart failure with preserved ejection fraction

The definition of heart failure with preserved ejection fraction (HFpEF) has evolved from a clinically based "diagnosis of exclusion" to definitions focused on objective evidence of diastolic dysfunction and/or elevated left ventricular filling pressures. Despite advances in our understanding of HFpEF pathophysiology and the development of more sophisticated imaging modalities, the diagnosis of HFpEF remains challenging, especially in the chronic setting, given that symptoms are provoked by exertion and diagnostic evaluation is largely conducted at rest. Invasive hemodynamic study, and in particular - invasive exercise testing, is considered the reference method for HFpEF diagnosis. However, its use is limited as opposed to the high number of patients with suspected HFpEF. Thus, diagnostic criteria for HFpEF should be principally based on non-invasive measurements. As no single non-invasive variable can adequately corroborate or refute the diagnosis, different combinations of clinical, echocardiographic, and/or biochemical parameters have been introduced. Recent years have brought an abundance of HFpEF definitions. Here, we present and compare four of them: 1) the 2016 European Society of Cardiology criteria for HFpEF; 2) the 2016 echocardiographic algorithm for diagnosing diastolic dysfunction; 3) the 2018 evidence-based H2FPEF score; and 4) the most recent, 2019 Heart Failure Association HFA-PEFF algorithm. These definitions vary in their approach to diagnosis, as well as sensitivity and specificity. Further studies to validate and compare the diagnostic accuracy of HFpEF definitions are warranted. Nevertheless, it seems that the best HFpEF definition would originate from a randomized clinical trial showing a favorable effect of an intervention on prognosis in HFpEF.

Atrial fibrillation, anticoagulation management and risk of stroke in the Cardiomyopathy/Myocarditis registry of the EURObservational Research Programme of the European Society of Cardiology

Aims

Cardiomyopathies are a heterogeneous group of disorders that increase the risk for atrial fibrillation (AF). The aim of the study is to assess the prevalence of AF, anticoagulation management, and risk of stroke/transient ischaemic attack (TIA) in patients with cardiomyopathy.

Methods and results

Three thousand two hundred eight consecutive adult patients with cardiomyopathy (34.9% female; median age: 55.0 years) were prospectively enrolled as part of the EURObservational Research Programme Cardiomyopathy/Myocarditis Registry. At baseline, 903 (28.2%) patients had AF (29.4% dilated, 27.5% hypertrophic, 51.5% restrictive, and 14.7% arrhythmogenic right ventricular cardiomyopathy, P < 0.001). AF was associated with more advanced New York Heart Association class (P < 0.001), increased prevalence of cardiovascular risk factors and co‐morbidities, and a history of stroke/TIA (P < 0.001). Oral anticoagulation was administered in 71.7% of patients with AF (vitamin K antagonist: 51.6%; direct oral anticoagulant: 20.1%). At 1 year follow‐up, the incidence of cardiovascular endpoints was as follows: stroke/TIA 1.85% (AF vs. non‐AF: 3.17% vs. 1.19%, P < 0.001), death from any cause 3.43% (AF vs. non‐AF: 5.39% vs. 2.50%, P < 0.001), and death from heart failure 1.67% (AF vs. non‐AF: 2.44% vs. 1.31%, P = 0.033). The independent predictors for stroke/TIA were as follows: AF [odds ratio (OR) 2.812, P = 0.005], history of stroke (OR 7.311, P = 0.010), and anaemia (OR 3.119, P = 0.006).

Conclusions

The study reveals a high prevalence and diverse distribution of AF in patients with cardiomyopathies, inadequate anticoagulation regimen, and high risk of stroke/TIA in this population.

Renal resistive index and long-term outcome in patients with coronary artery disease

Background

The study aimed to evaluate the application of intra-renal Doppler flow indices for the prediction of major adverse cardiac and cerebrovascular events (MACCE) during 24-month follow-up in patients with coronary artery disease (CAD) subject to coronary angiography (CA).

Methods

This prospective study comprised 111 consecutive patients with stable and unstable CAD (68.5% men; median age 65 years), referred for CA. Ultrasonographic parameters of intra-renal blood flow in arcuate/interlobular arteries, including renal resistive index (RRI) and pulsatility index (RPI), were acquired directly before and 1 h after the procedure. Endpoint of MACCE (cardiovascular death, myocardial infarction, myocardial revascularization or stroke) were recorded during 24-month follow-up.

Results

MACCE occurred in 14 patients (12.6%). Patients with MACCE had more diffuse CAD reflected by Syntax score (23.6 vs.14.4 pts., p = 0.02), higher platelet level (242.4 vs. 207.2 × 1000/μl, p = 0.01), higher rate of left main CAD (42.9% vs.5.2%, p < 0.001) and left ventricular ejection fraction < 50% (50% vs.23.7%,p = 0.045). Patients with MACCE had higher pre-procedural (0.68 ± 0.06 vs. 0.62 ± 0.06, p < 0.001) and post-procedural RRI (0.72 ± 0.06 vs.0.66 ± 0.06, p = 0.01), but comparable RPI (p = 0.63 and p = 0.36, respectively). Cox proportional hazards model revealed that pre-procedural RRI (OR = 1.11 per 0.01; p = 0.02) and left main CAD (OR = 5.75, p = 0.002) were the only independent predictors of MACCE occurrence. Receiver operator characteristic curve analysis revealed that preprocedural RRI > 0.645 accurately predicted the composite endpoint (AUC = 0.78, p = 0.001) and identified patients with impaired 24-month prognosis according to Kaplan-Meier curve (log-rank p < 0.001).

Conclusions

Increased pre-procedural RRI, together with left main CAD, are associated with worse 24-month prognosis in patients with CAD referred for CA.

Treatment of chronic thromboembolic pulmonary hypertension in a multidisciplinary team

Background:

Chronic thromboembolic pulmonary hypertension (CTEPH) may be treated with pulmonary endarterectomy (PEA), balloon pulmonary angioplasty (BPA) and medical therapy (MT). Assessment in a multidisciplinary team of experts (CTEPH team) is currently recommended for treatment decision making. The aim of the present study was to report the effects of such an interdisciplinary concept.

Methods and results:

A total of 160 patients were consulted by the CTEPH team between December 2015 and September 2018. Patient baseline characteristics, CTEPH team decisions and implementation rates of diagnostic and therapeutic procedures were analysed. Change in World Health Organization (WHO) functional class and survival rates were evaluated by treatment strategy. A total of 51 (32%) patients were assessed as operable and 109 (68%) were deemed inoperable. Thirty-one (61% of operable patients) underwent PEA. Patients treated with PEA, BPA(+MT) and MT alone were 50.9 ± 14.7, 62.9 ± 15.1 and 68.9 ± 12.7 years old, respectively. At the follow-up, PEA patients had the highest WHO functional class improvement. Patients treated with BPA(+MT) had significantly better survival than PEA (p = 0.04) and MT patients (p = 0.04; 2-year survival of 92%, 79% and 79%, respectively).

Conclusions:

The CTEPH team ensures that necessary diagnostic procedures are performed. A relatively low proportion of patients was assessed by the CTEPH team as operable and underwent surgery, which in survivors resulted in the best functional improvement. Although patients undergoing BPA(+MT) were older than patients treated with PEA, their survival was better than patients subjected to PEA or MT alone.

The reviews of this paper are available via the supplemental material section.

Temporal trends in the availability and efficacy of catheter ablation for atrial fibrillation and atrial flutter in a highly populated urban area

BACKGROUND

Pulmonary vein isolation has become one of the core modalities of the rhythm control strategy in patients with atrial fibrillation (AF).

AIMS

The aim of the study was to analyze temporal trends in the availability and efficacy of AF and atrial flutter (AFL) catheter ablation in an urban area of Upper Silesia in Poland.

METHODS

The source data were obtained from the SILCARD (Silesian Cardiovascular Database) covering an adult population of 3.8 million. The final study population included patients with diagnosis code I48 referred for catheter ablation between 2006 and 2017. The data included total number of procedures, patient sex, age, comorbidities, number of hospital admissions, and mortality rate.

RESULTS

A total of 2745 patients were enrolled. The number of ablated patients increased more than 10‑fold (43 in 2006 vs 507 in 2017; P = 0.008) in the follow‑up period. The analysis showed an upward trend in the proportion of women (P = 0.02), hypertension prevalence (P = 0.004), and percentage of patients implanted (P = 0.02). A decrease was observed in the percentage of patients with stable angina (P <0.005) and hospitalization length (P <0.005). The all‑cause hospital readmissions rate decreased from 55.8% to 25.4% (P <0.005). There were significant reductions in the 12‑month all‑cause mortality (2.3% in 2006 vs 0.2% in 2017; P <0.005), stroke (2.3% in 2006 vs 0.2% in 2017; P = 0.047), and myocardial infarction rates (2.3% in 2006 vs 0.4% in 2017; P = 0.03).

CONCLUSIONS

A considerable increase in the availability and efficacy of AF / AFL ablations was documented over the 12‑year follow‑up period.

Anterior wall myocardial infarction in a young man caused by spontaneous dissection and hematoma of coronary artery

A 55-year-old man without any cardiac history has been admitted to Ist Department of Cardiology due to anterior wall infarction. In echocardiography (ECG), local anterior wall dysfunction has been observed, with good left ventricle ejection fraction. In angiography performed immediately after transfer to hospital, long lesion in left anterior descending coronary artery has been visualized with high angiographic suspicion of dissection and intramural coronary hematoma. Intravascular ultrasound (IVUS) has been performed and further confirmed the diagnosis of hematoma - LAD was stented using three coronary stents. IVUS has confirmed good position of stents. Integrillin has been used. Periprocedural time was uncomplicated. ECG showed resolution of myocardial infarction pattern and evolution of infarction has been observed. The patient was discharged home in good clinical condition. Coronary dissection and coronary hematoma are the potential cause of infarction and IVUS, despite optical coherence tomography being reference nowadays, is still a very valuable tool in diagnosis and treatment guiding in such cases.

P1323 From a suspicion of pulmonary arterial hypertension to a rare form of Takayasu disease

A 27-year-old female with a history of glomerulonephritis,with diagnosed systemic lupus

and retroperitoneal fibrosis was admitted due to fast worsening dyspnoea(NYHA class IV)

over the prior four weeks with suspicion for PA hypertension. In 2015, retroperitoneal fibrosis was diagnosed based on MR examination. With the methylprednisolone treatment a regression of changes was obtained. The patient was chronically treated with prednisone 7.5mg/day and mycophenolate

mofetil 2g/d.

When admitted to the ward, the patient was in a severe condition, with

symptoms of resting dyspnea and blood oxygen saturation up to 80%. A loud systolic

murmur was audible over the entire chest. In laboratory tests, the NT-proBNP values

(11,000 pg/ml) were significantly elevated, arterial blood gases showed tendency to alkalosis, hypoxemia (PO2 45mmHg)with hypocapnia. Parameters of inflammation were moderately elevated

(CRP 25mg/l, WBC 12,000/ul), with normal serum IgG4 concentrations. In TTE, significant dilatation of the right ventricle with left chamber compression were observed. Tricuspid ring dilation with no leaflets coaptation and a severe tricuspid regurgitation

(Vmax 5m/s, RVSP 100mmHg) were found. In addition, the critical proximal pulmonary artery

(PA) stenosis was revealed (left PA Vmax 3.3m/s, Pmax 42mmHg, right PA Vmax 5.2 m/s,

Pmax 110mmHg). Angio-CT confirmed critical proximal constriction of both PAs with a flow

channelup to 4 mm. Based on angio-CT and cardiac MR study the inflammatory

etiology of stenoses was suspected and an empiric diagnosis of the Takayahu disease of

pulmonary arteries was made. The patient was qualified for conservative treatment using prednisone and cyclophosphamide.

Over the course of two months,2.8 g of cyclophosphamide were administered intravenously in

three cycles with good response to the treatment. It resulted in regression of dyspnea and a

improvement in exercise tolerance - to the NYHA class II, normalization of

saturation. Laboratory tests showed reduction of NT-proBNP (1300 pg/ml). Control

TTE revealed reduction in the size of the right ventricle and regression of PAs stenoses

(left PA 11mm, right PA 7mm), also reduction of systolic flow gradients

(left PA Vmax 3.1 m / s, Pmax 39 mmHg, right PA 4.1 m/s, Pmax 68 mmHg).

Because of the significant improvement in patient’s condition,it was decided to continue the treatment.

Legend for the Fig.1 A angio-CT, critical proximal constriction of both PA B TTE, parasternal short axis view, imflammatory infiltration C TTE, continuous wave doppler, flow velocity pattern in the PA stenosis D TTE PLAX, dilatation of the right ventricle with left chamber compression fig. 1

Abstract P1323 Figure. Fig.1 artety pulmonary stenosis

Cerebral microembolism during atrial fibrillation ablation can result from the technical aspects and mostly does not cause permanent neurological deficit

INTRODUCTION

Atrial fibrillation ablation can be associated with microembolism detected in the intracranial arteries and risk of neurological incidents. The aims of this study were to evaluate microembolic signals (MES) during pulmonary vein isolation (PVI) and establish the potential significance of MES for damage of the brain in radiological investigation and neurological state.

MATERIAL AND METHODS

In the prospective study we included patients with atrial fibrillation undergoing percutaneous pulmonary vein isolation (radiofrequency ablation/balloon cryoablation) with ultrasound monitoring of microembolisms in the middle cerebral artery. Neurological examination and MRI of the head were performed in all participants.

RESULTS

The study enrolled 80 patients at a mean age of 58 years. Microembolisms during the monitoring of the flow in the right middle cerebral artery were recorded in 61 (76.3%) patients in the amount of 51-489 (mean: 239). Most often the microembolic signals were registered during the trans-septal puncture and the stage of ablation. In 89%, microembolisms were gaseous. Mean score on the Fazekas scale for the whole group before ablation: 0.87 ±0.7 (0-3, med. 1); after: 0.93 ±0.71. In 3 (4.3%) patients the lesions worsened during the follow-up period. None of the patients revealed a cardiovascular event during the follow-up period and no changes were observed in the neurological status.

CONCLUSIONS

The majority of cerebral microembolisms generated during PVI are gaseous in nature. The cerebral microembolisms associated with PVI probably result from the technical aspects of the procedure and do not cause either permanent brain damage in the radiological investigation or neurological deficit.

P1723 Spectacular left ventricle post infarction aneurysm

Sixty six-y.o. woman 2 months after anterior wall ST-segment elevation myocardial infraction and PCI LAD + 3DES (TIMI 1) was re-admitted to the clinic because of progressive severe heart failure (NYHA III/IV). In admission NT-proBNP level was 14 000 pg/ml, INR 1,7, bilirubin 4,5mg/dl. The electrocardiogram showed persistent ST elevation on anterior leads. Transthoracic echocardiography (TTE) revealed spectacular finding: aneurysm of left ventricle (LV) involving ½ distal part of interventricular septum, apex, inferior, anterior and lateral wall with LVEF 24%, LVEDV 272ml. Thickness of intraventricular septum (IVS) on aneurysm level was only 2,5-3,5mm. In the middle part of IVS a minimal ventricular septal defect (VSD) was showed. Cardiac magnetic resonance examination confirmed TTE findings. The course of the disease was dynamic. The diameter of VSD was increased during consecutive days of hospitalization with maximum width 6,5mm. The patient was hemodynamical unstable, she needed pressure amines, diuretics and intra-aortic balloon pumping. The patient underwent several Heart Team consultations. She was disqualified from percutaneous VSD closing because of thickness of IVS and spiral shape of VSD. Due to potentially too small LV volume after LV plastic surgery the patient was also disqualified from that procedure. We reported the patient to heart transplantation (HTX). There was no transplant donor. In next days we observed progressive signs of a cardiogenic shock with right ventricle decompensation secondary to widening of VSD. Because of unstable stage and growing decompensation, no possibility of HTX patient had life—saving cardiac surgery of LV with mitral valve and tricuspid valve anuloplasthies. The patient survived operation.

Abstract P1723 Figure.

P1816 Cerebral microembolism in low-risk patients with paroxysmal atrial fibrillation before and after pulmonary vein isolationCerebral microembolism in low-risk patients with paroxysmal atrial fibrillation

BACKGROUND

Invasive treatment of atrial fibrillation (AF) becomes more suitable and effective therapy. There are no consistent data describing the occurrence of potential neurological complications in low-risk patients with paroxysmal AF.

AIM

to determine the occurrence, consequences and risk factors for brain white matter hiperintensities (WMH) assessed in magnetic resonance imaging (MRI) in low-risk patients before and after pulmonary vein isolation (PVI) treatment.

METHODS

Eighty patients with symptomatic paroxysmal AF (median age: 58 years (IQR 50-63), K/M: 30/50), CHA2DS2-Vasc ≤ 3 (CHA2DS2-Vasc: 2 (IQR 1-2.5)) were included in the study. Before and after a minimum of 6-month period after PVI-RF treatment (med. 9,9 months, IQR 7.6-11.8 months) a clinical evaluation with brain MRI and Mini Mental State Examination (MMSE) test were determined. Severity of brain WMH in MRI was assessed in the Fazekas scale (pic 1). The efficacy of PVI-RF treatment analyzed in a 7-day Holter monitoring was confirmed in 43 (53.8%) patients.

RESULTS

Baseline WMH lesions were found in 55 (68.8%) patients. Patients with baseline WMH lesion obtained similar results in the MMSE test, compared to patients with a normal brain image in the MRI study. There was a statistically significant more frequent occurrence of cerebral WMH lesions among older patients, with a higher CHA2DS2-Vasc score, with left atrial (LA) dilatation and dysfunction. Factors affecting the severity of the WMH were: the co-occurrence of the patent foramen ovale (PFO) and coronary artery disease (CAD).

After PVI-RF treatment there were no significant changes in the presence and severity of WMH lesions. Similarly, there were no significant changes in the cognitive abilities assessed with MMSE test compared to the pre-procedural evaluation. There were also similar factors predisposing to brain WMH changes: older age, higher CHA2DS2-Vasc score and higher BMI. In turn, the degree of the brain WMH severity after observation period was dependent on age, higher CHA2DS2-Vasc score, presence of PFO and CAD and the initial LA function.

CONCLUSIONS Cerebral microembolism assessed in MRI is often found in low-risk patients with paroxysmal AF, and its presence and severity are associated with LA dilatation and dysfunction, age and higher CHA2DS2-Vasc score. Additional factors affecting the severity of WMH lesions are: the co-occurrence of PFO and CAD. PVI-RF procedure and its efficacy does not influence on MRI lesions. In the population of relatively young AF patients with no significant cardiovascular disease burden, cerebral microembolism is not related to cognitive impairment.

Abstract P1816 Figure. pic 1

Cardiovascular risk factors among cancer patients qualified for systemic treatment. Analysis of a cardiovascular disease-free cohort from the Polish multicentre study ONCOECHO

INTRODUCTION

Cancer therapies are currently more efficient at increasing the survival of patients (pts) with cancer. Unfortunately, the cardiovascular (CV) complications of cancer therapies may adversely affect improving results of treatment. The aim of the study was to evaluate the prevalence of classical CV risk factors among pts with de novo diagnosis of cancer and thus identify the cohort of pts with potentially increased future risk of CV complications.

MATERIAL AND METHODS

The analysis is based on the database of the multicentre ONCOECHO study. Pts before systemic treatment (chemotherapy or targeted therapy) were included. The diagnostic datasets of resting electrocardiogram, blood samples, and transthoracic echocardiogram were analysed in 343 consecutive pts who were free from any cardiovascular disease that could adversely affect the introduced treatment.

RESULTS

Our cohort included 4.4% of pts with kidney cancer, 7.3% with colorectal cancer, 26.5% with haematological malignancies (HM), and 61.8% with breast cancer. The risk estimated by SCORE was 4.56 ±5.07%. Breast cancer pts had lower cardiovascular risk than those with HM (p = 0.001) and kidney cancer (p = 0.002). Additionally, the HM group had much higher levels of natriuretic peptides (p < 0.001) and creatinine (p = 0.008) than pts with breast cancer. The comparison with the NATPOL population data showed that our pts were more often smokers, hypertensives, and diabetics, but less frequently presented with hypercholesterolaemia.

CONCLUSIONS

Patients with new diagnosis of cancer, who are candidates for potentially cardiotoxic medical treatment, have increased prevalence of significant cardiovascular risk factors and therefore should be followed by a multidisciplinary team during the therapeutic process.

P805 Clinical and echocardiographic characteristics of Polish patients with Eisenmenger Syndrome - results of a snapshot registry

The first national registry of patients (pts) with PAH-CHD, predominantly with Eisenmenger Syndrome (ES), treated within national program was conducted. We studied clinical and echocardiographic characteristics of a group of adult patients including current therapy profile and mortality.

A multicenter observational study (snapshot registry) was conducted under auspices of Polish Cardiac Society, including pts with PAH-CHD, identified in centers, that treated &gt; 5 pts in the first 10 years of therapeutic program (2008-2018). This analysis included 322 pts (70 deceased), mean age 42 ± 2 years, 65% females. The registry included patients meeting the criteria of the Eisenmenger syndrome in echocardiography (right-left or aligned leak). The living patients were divided into 2 groups: Gr.1 (n = 227) – uncorrected and Gr.2 (n = 25) - after correction of the heart disease.

The average age in Gr.1 was 40 ± 2 years, in Gr.2 40 ± 6 years. The majority were women (68% and 62%). There was no significant differences for mean duration of treatment in groups: 60 ± 12 months vs. 66 ± 6 months (p = 0.42). Both groups didn’t differ in terms of clinical data, i.e. 6MWT 417 ± 50 m vs. 384 ± 15 m;p = 0.15, NT-proBNP level 869 ± 470 pg/ml vs. 901 ± 212 pg/ml;p = 0.57. There was no significant differences for mean LVd in groups: 41,24 mm [12-82] vs. 44,25 mm [30-55]. Mean LVEF was good (60% in gr.1 vs. 57% in gr.2). Mean TAPSE was slightly better in Gr.1: 19,36 mm vs. 17,09 mm. Pericardial effusion were present in almost 15% pts from Gr.1 and less than 1% pts from Gr.2.

Pts after correction were mostly in the II WHO FC, and those uncorrected in the II/III WHO FC. Pts from Gr.2 were more likely to receive polytherapy (60% vs. 47%). ERA were the most commonly used (near 90%).

The most common heart defect was VSD (46% in Gr.1 vs. 32% in Gr.2). Mortality was 22% in entire period, i.e. annual mortality rate of 2.2%. In the group of dead pts women accounted for 74%, the average age was 49 ± 4 years and mean length of treatment was 42 ± 13 months. About 9% of pts from this group had heart defect correction in the past. Monotherapy (66%) predominated among the deceased, mainly using ERA (77%). Pts receiving combination therapy had a longer survival (p = 0.04). It isn’t known whether this result confirms the greater effectiveness of such treatment, as some patients couldn’t wait until the polytherapy became possible within the framework of the Drug Program. Among the deceased, the most common heart disease was ASD (30%), slightly less VSD (29%).

In this first national snapshot registry we documented improving prognosis in PAH-CHD under specific therapies. No differences were present in the length of therapy, clinical data and quality of life depending on whether or not correction surgery was performed. Post-correction pts more often received a polytherapy. The annual mortality in this population is small estimated just over 2%. Targeted combination therapy may contribute to better survival.

Early Stage of Atherosclerosis in Aortocoronary Saphenous Vein Grafts: Intravascular Ultrasound Study

Introduction

Angiographically visible plaques in patent vein grafts are usually detected years after surgery. Our aim was to examine early plaque formation in vein grafts.

Methods

Bypass angiography and intravascular ultrasonography (IVUS) examination were performed on 77 aortocoronary saphenous vein grafts (SVGs) implanted in 36 patients during the first 2 years after CABG. In each graft, a good quality 25 mm ultrasound image was analyzed. We measured: plaque area, lumen area, external elastic membrane (EEM) area, graft area and wall area. For the comparative assessment of SVGs, the index plaque area/EEM area was calculated. Data were analyzed for the following 4 time periods: I – 0-4 months (22 grafts), II – 5-8 months (23 grafts), III – 9-12 months (19 grafts) and IV – 13-16 months (13 grafts) after CABG. Student’s t and Fisher-Snedecor tests were used for the purpose of statistical analysis in this retrospective study.

Results

In period I, plaque formation (neointimal) was observed in 10 grafts (45%), with a mean plaque area of 1.59 mm., in 6 grafts (26%) in period II, with a mean plaque area of 1.03 mm. and in 15 grafts (71%) in period III, with a mean plaque area of 1.41 mm., and in all (100%) grafts in period IV, with mean plaque area of 2,3 mm.. Average index plaque area/EEM area in periods I, II, III and IV were 0.12, 0.08, 0.13 and 0.22. We have showed a significant plaque increase between periods II and IV(P=0.038).

Conclusion

IVUS showed plaque in about 40% of venous grafts during the first year after CABG. Between 13-16 months plaque was visible in all studied grafts.

Pharmacological Cardioversion With Antazoline in Atrial Fibrillation: The Results of the CANT Study

Background Antazoline mesylate represents an antihistamine capable of rapid and safe cardioversion of atrial fibrillation, yet evidence concerning its efficacy in comparison to other medications is insufficient. The study aimed to evaluate the success rate and safety of pharmacological cardioversion of atrial fibrillation with intravenous antazoline ( CANT [Cardioversion With Antazoline Mesylate] study) in the setting of the emergency department. Methods and Results After reviewing 1984 medical records, 450 eligible patients (22.7%) with short-duration atrial fibrillation subject to pharmacological cardioversion were enrolled in a retrospective observational analysis. The choice of antiarrhythmic drug was left to the discretion of the attending physician. The primary end point was successful cardioversion in the emergency department. The safety end point comprised bradycardia <45 bpm, hypotension, syncope, or death. The study population (mean age, 65.5±11.9 years; 52.9% females) was characterized by a median atrial fibrillation episode duration of 10 hours. Antazoline, alone or in combination, was administered in 24.2% (n=109) and 40% (n=180), respectively; amiodarone was administered in 46.7% and propafenone in 9.3%, while ≥2 antiarrhythmic drugs were administered in 19.8% of patients. Antazoline had the highest success rate of pharmacological cardioversion among all drugs (85.3%), which was comparable with propafenone (78.6%; relative risk, 1.09, 95% confidence interval, 0.91-1.30; P=0.317) and higher than amiodarone treatment (66.7%; relative risk, 1.28, 95% confidence interval, 1.13-1.45; P<0.001; number needed to treat, 5.4). The rate of cardioversion with antazoline alone was higher than combined amiodarone and/or propafenone (68.1%; relative risk, 1.25; 95% confidence interval, 1.12-1.40, P=0.0001). No safety end points were reported in the antazoline group, while 5 incidents occurred in the non-antazoline cohort ( P=0.075). Conclusions Antazoline represents an efficacious and safe method of pharmacological cardioversion in a real-life setting.

Prospective multicenter Polish Stress Echocardiography Registry (PolStress-Echopro) - the role in clinical practice

BACKGROUND

Stress echocardiography (SE) is becoming an increasingly frequently performed diagnostic examination in Poland. After the published retrospective PolSTRESS Registry, this prospective study is the first one available so far.

OBJECTIVES

The aim of the study was to analyze SE tests, taking into account the clinical characteristics of the patients, indications, applied protocols, and diagnostic and therapeutic decisions.

MATERIAL AND METHODS

Reference cardiological centers in Poland were asked for a 1-month prospective analysis of the data obtained. The study included 189 SE examinations. To evaluate coronary artery disease (CAD) (178 tests), all 17 centers performed dobutamine SE (DSE) (100%), 3 centers (17%) performed pacing, while cycle ergometer and treadmill SE were performed by 1 (5%) and 2 (11%) centers, respectively. In patients with valvular heart disease (VHD) (11 tests), 3 centers (16%) performed SE to evaluate low-flow/low-gradient aortic stenosis (AS), 4 (22%) in asymptomatic AS and 1 (5%) to evaluate mitral regurgitation.

RESULTS

For CAD assessment, a positive result was found in 37 (20%) patients, negative in 109 (61%) and nondiagnostic in 32 (19%). In the CAD group, coronarography was performed in 41 (23%) people. The analysis of the significance of the SE results for decision-making on interventional measures revealed that 30 patients (from the total study population of 189) were referred for the intervention.

CONCLUSIONS

The most commonly used SE is the DSE. Negative test results allowed in almost half of the patients to resign from invasive coronarography. Stress echocardiography should be more frequently used in patients with VHD in the qualification for invasive treatment.