The phenomenon of skin contraction in CO2 LASER surgical incisions using superpulse and continuous emission mode - preliminary study

The skin contraction phenomenon occurs due to the energy emitted by the surgical CO2 LASER affecting the collagen architecture and intracellular water content in tissues. The study aimed to assess how gender, age, breed, body-weight, CO2 LASER emission mode, and potency influence skin contraction following the incision. The study involved 80 dogs (N = 80) of both genders, multiple breeds, undergoing major surgery with CO2 LASER. Subjects were grouped based on LASER potency (12 or 15 Watts) and emission mode (Superpulse-SP or Continuous-CT): GSP12, GSP15, GCT12, and GCT15. A 10 mm incision was performed using the surgical CO2 LASER beam, consistently employing a focal point of 0.4 mm, positioned at a distance of 1 mm from the skin surface, and always maintained perpendicular to it, and resulting lengths measured with a digital caliper. Results were considered significant for p-value < 0.05. GSP12 showed minimal contraction, while GCT15 exhibited the most significant. Male subjects in GCT12, GCT15, and GSP12 experienced less contraction than females. Purebred dogs had greater contraction than mixed breeds. GSP12 individuals showed age-related contraction decrease (p < 0.01), with skin contracting by 0.09 mm per year. Weight and skin contraction trended towards significance (p = 0.06), with a 0.02 mm increase per unit weight. For a constant power of 12 W, the analysis of the relationship between the emission mode of the LASER beam and the final skin contraction (GSP12 vs. GCT12) revealed statistically significant differences (p < 0.01). This study suggests that the use of the Continuous mode of LASER emission, regardless of the power used, is associated with a higher level of final skin contraction. TRIAL REGISTRATION NUMBER AND DATE OF REGISTRATION FOR PROSPECTIVELY REGISTERED TRIALS: Project approval registration number by the Research and Teaching Ethics Committee (CEIE),Faculty of Veterinary Medicine-University of Lisbon (FMV_ULisboa), Lisboa-Portugal, N/Refª 015/2022.

A multimodality intervention to improve musculoskeletal health, function, metabolism, and well-being in spinal cord injury: study protocol for the FIT-SCI randomized controlled trial

BACKGROUND

A spinal cord injury (SCI) is a devastating, life-changing event that has profoundly deleterious effects on an individual's health and well-being. Dysregulation of neuromuscular, cardiometabolic, and endocrine organ systems following an SCI contribute to excess morbidity, mortality and a poor quality of life. As no effective treatments currently exist for SCI, the development of novel strategies to improve the functional and health status of individuals living with SCI are much needed. To address this knowledge gap, the current study will determine whether a Home-Based Multimodality Functional Recovery and Metabolic Health Enhancement Program that consists of functional electrical stimulation of the lower extremity during leg cycling (FES-LC) plus arm ergometry (AE) administered using behavioral motivational strategies, and testosterone therapy, is more efficacious than FES-LC plus AE and placebo in improving aerobic capacity, musculoskeletal health, function, metabolism, and wellbeing in SCI.

METHODS

This single-site, randomized, placebo-controlled, parallel group trial will enroll 88 community-dwelling men and women, 19 to 70 years of age, with cervical and thoracic level of SCI, ASIA Impairment Scale grade: A, B, C, or D, 6 months or later after an SCI. Participants randomized to the multimodality intervention will undergo 16 weeks of home-based FES-LC and AE training plus testosterone undecanoate. Testosterone undecanoate injections will be administered by study staff in clinic or by a visiting nurse in the participant's home. The control group will receive 16 weeks of home-based FES-LC and AE exercise plus placebo injections. The primary outcome of this trial is peak aerobic capacity, measured during an incremental exercise testing protocol. Secondary outcomes include whole body and regional lean and adipose tissue mass; muscle strength and power; insulin sensitivity, lipids, and inflammatory markers; SCI functional index and wellbeing (mood, anxiety, pain, life satisfaction and depressive symptoms); and safety.

DISCUSSION

We anticipate that a multimodality intervention that simultaneously addresses multiple physiological impairments in SCI will result in increased aerobic capacity and greater improvements in other musculoskeletal, metabolic, functional and patient-reported outcomes compared to the control intervention. The findings of this study will have important implications for improving the care of people living with an SCI.

TRIAL REGISTRATION

ClinicalTrials.gov :  ( NCT03576001 ). Prospectively registered: July 3, 2018.

Usefulness of the 6-minute walk test vs cardiopulmonary exercise test for exercise prescription in coronary artery disease patients going into a phase III cardiac rehabilitation program

Funding Acknowledgements

Type of funding sources: None.

Background/Introduction

Determining the intensity of exercise is a very important component to obtain the dose-benefits associated with exercise, while maitaining the safaty of the patient with coronary artery disease (CAD) in a cardiovascular rehabilitation (CR) programme. The cardiopulmonary exercise test (CPET) is the gols standard for exercise prescription according to the intend intensisty of aerobic workout. However, its availability is not a reality in many CR centres. The 6-minute walk test (6MWT) is a valid and widely used method because it is low-cost and simple to apply. Nevertheless, it is still unknown the corresponding intensity reached on a 6MWT compared to the one reached on a CPET in already physically active patients with CAD starting a CR phase III programme.

Purpose

To use the peak heart rate (HR) of the 6MWT as a method to prescribe the intensity of aerobic exercise in CAD patients starting a phase III CR programme and to compare it with the ventilatory threshold (VT) of the CPET.

Methods

In this retrospective study, a cohort of patients with CAD enrolled in a phase III CR programme. At the beginning of the programme, all patients performed a 6MWT and a CPET in the same week with at least 48-hour difference. The HR on the 6MWT was recorded continuously using a HR polar (H10 Polar) and on CPET using a twelve-lead ECG. Other parameters were assessed such as objective physical activity (accelerometer) and body composition.

Results

Eighty patients (87.5% males, 60.8 ± 9.4 years old) with CAD were included in this study. Patients were, on average, physically active (361 ± 182 minutes/week of moderate to vigorous physical activity) and overweight (body mass index: 27.7 ± 3.5 kg/m2). The VO2 peak reached on the CPET was 20.3 ± 5.4 ml/kg/min and the percentage of predicted maximum HR was 78.3 ± 11.4 %. The first and second VT corresponded to 75.6 ± 7.8% and 91.2 ± 4.5% of the peak HR obtained with CPET, respectively. The 6MWT HR peak was 113 ± 16 bpm (90.0 ± 13.0 HR peak CPET) and did not differ from the HR of the second VT with a mean value of 115 ± 16 bpm (91.2 ± 4.5% HR peak CPET), p&gt;0.05. Although, the 6MWT HR peak was significantly higher than the HR oh the first VT (95 ± 14 bpm, p&lt;0.001). In a subgroup analysis, the patients who, during the 6MWT, reached more the 90% of the HR peak CPET (n=35, 44% oof the sample) were the ones with lower functional capacity (VO2 peak: 18.4 ± 5.4 ml/kg/min vs 21.7 ± 5.0 ml/kg/min, p=0.006) and higher age (64.4 ± 8.7 years old vs 60.8 ± 9.4 years old, p=0.002).

Conclusion(s)

In the absence of a CPET, the use of a 6MWT HR peak in physically active patients with CAD starting a phase III CR programme has shown to be an efficient method to prescribe moderate to vigorous exercise intensity, corresponding to the second VT. Higher intensities on the 6MWT might be reached in active elderly patients with reduced functional capacity.

Cardiorespiratory fitness assessment on active patients who kept attending their phase III exercise-based cardiac rehabilitation during the COVID-19 era

Funding Acknowledgements

Type of funding sources: None.

Background

Cardiorespiratory fitness (CRF) is a powerful predictor of all-cause mortality among individuals with coronary artery disease (CAD). A structured community-based phase III cardiac rehabilitation (CR) is very important in lifelong maintenance of phase II CRF and health gains. During the COVID-19 pandemic, CR programs had to adapt, mainly using new technologies and remote follow-up. The CRF impact in patients (Ps) who kept going their phase III program, during this troubled era is still unknown.

Purpose

Assess the variation in CRF and prognostic parameters in Ps with CAD who maintain high adherence levels in their phase III CR before and during the COVID-19 pandemic.

Methods

A cohort of Ps enrolled in a community-based phase 3 CR program, with active participation at the end of 2019, was included in this retrospective study. The inclusion criteria for this study were high levels of attendance (>80%) to the CR program before and during COVID-19 and high levels of physical activity with more than 150 mins of moderate to vigorous physical activity (MVPA). All Ps were evaluated with transthoracic echocardiography (TTE) and a cardiorespiratory exercise test (CPET) in a cycloergometer in 2019 and between october and november of 2021. All Ps had used accelerometers to measure their physical activity levels and dual-energy absorptiometry (DEXA) scan to evaluate their body composition. Between 2020 and 2021, Ps had online (in lockdown periods) and face to face exercise training sessions, 3xtimes per week, 60 mins each exercise session.

A t-test paired two sample for means was used to compare CPET variables before the beginning of the first COVID lockdown (end of 2019) and after the removal of the majority of restrictions (end of 2021).

Results

A total of 30 Ps with high levels of adherence were included (99.6% male, 65 ± 9 years old). In this cohort, the majority had history of an ACS before the referral to the CR program (73.3%) and 55.6 ± 10.4% of left ventricular ejection fraction.

There was no significant difference in body mass index (27.9 ± 3.2 kg/m2 vs 28.1 ± 3.6 kg/m2, p=0.493 but there was a significant increase in the percentage of body fat mass (30.1 ± 5.7% vs 31.0 ± 6.6%, p= 0.042). There was a maintenance on MVPA levels (352 ± 137 minutes/week vs 313 ± 194 minutes/week, p = 0.106) during this period.

When comparing the 2 CPET results, Ps achieved higher exercise loads in the 2021 test (175 ± 51W vs 185 ± 52W, p=0.005), higher VO2 peak (25.3 ± 6.9 ml/kg/min vs 21.5 ± 6.3 ml/kg/min, p =0.001) and higher percentage of predicted VO2max (78.8 ± 16.8% vs 95.27 ± 20.8%, p = 0.001).

Conclusion

In spite of all the difficulties in maintaining a phase III CR program during the COVID-19 pandemic, we observed that in physically active CAD Ps, with the aid of new technologies and remote follow-up (during the lockdown periods) and face to face exercise sessions, it is still possible to have functional gains and improvements in CRF.

Effect of exercise training on amyloid-like protein aggregates among patients with heart failure

Funding Acknowledgements

Type of funding sources: Other. Main funding source(s): MG and CS were supported by a PhD FCT grant (SFRH/BD/128893/2017) and by an individual grant from CAPES [BEX 0554/14-6], respectively. This work was financially supported by the project POCI-01-0145-FEDER-030011, funded by FEDER, through COMPETE2020-POCI, and by national funds, through FCT/MCTES (PTDC/MEC-CAR/30011/2017). iBiMED is a research unit supported by the Portuguese Foundation for Science and Technology (REF: UID/BIM/04501/2020) and FEDER/Compete2020 funds).

Introduction

Amyloid-like protein aggregates play a decisive role in the pathology of heart failure. Alterations in protein homeostasis, in particular, the clearance of toxic amyloid-like aggregates are emerging therapeutic targets in cardiovascular medicine. The clinical benefits of cardiac rehabilitation and exercise training are widely accepted in heart failure; however, little is known about the potential benefit of exercise training in amyloid-like protein aggregates.

Purpose

To assess the effects of a moderate-intensity exercise training program on amyloid-like protein aggregates levels among patients with heart failure with reduced ejection fraction.

Methods

Eighteen subjects participated in the study; eight patients (age: 66.6 ± 5.9 years; FEVE: 38.4 ± 8.9%) with heart failure with reduced ejection fraction participated in a 3-month exercise training program (2 x 60 min sessions per week of moderate-intensity aerobic and resistance exercise). Ten healthy subjects (age: 68. 4 ± 3.1 years) were recruited to an age-matched reference group.  Amyloid-like protein aggregates were assessed before and after 3 months of exercise training. Clinical data, medication, anthropometrics, and cardiorespiratory fitness were also assessed. Thioflavin T (ThT) dye fluorescence was used to quantify the plasma levels of amyloid-like aggregates and the Fourier transform infrared spectroscopy (FTIR) was applied to evaluate the conformation of cross-β-sheet structures characteristic of amyloid protein aggregates.

Results

Exercise program improved cardiorespiratory fitness by 14.0 ± 17.1% (17.4 ± 3.2 to 19.7 ± 2.9 ml/kg/min) and reduced NT-proBNP levels by 16.5% (34.2) (median concentration of 632 pg/mL (720.8) to 517.5 pg/mL (707.0)) in the heart failure patients. A slight decrease of amyloid-like aggregates levels was observed in post-exercise training samples (a reduction of 3.1%); interestingly, after the exercise training program, the heart failure patients showed levels of amyloid-like aggregates similar to the reference group (1132.0 ± 114.2 vs. 1094.8 ± 132.9 a.u.). Additionally, the PLS-R multivariate analysis of the amide I region of the FTIR spectra revealed enrichment of antiparallel β-sheets (1693 cm-1) assigned to amyloid-like oligomers in the samples of heart failure patients before, but not after, the exercise program. Of note, oligomeric species, as intermediates of amyloid assembly, can contribute to the increase of amyloid burden, but also, some have been reported to be highly reactive and toxic to cells, being key elements of amyloid pathogenesis.

Conclusions

 Our preliminary results indicate that 3 months of exercise training may have significant effects on amyloid-like oligomers, and start hindering the formation of the larger ThT-positive aggregates among patients with heart failure.

Abstract Figure.

Patient deprivation and perceived scan burden negatively impact the quality of whole-body MRI

AIM

To evaluate the association between the image quality of cancer staging whole-body magnetic resonance imaging (WB-MRI) and patient demographics, distress, and perceived scan burden.

MATERIALS AND METHODS

A sample of patients recruited prospectively to multicentre trials comparing WB-MRI with standard scans for staging lung and colorectal cancer were invited to complete two questionnaires. The baseline questionnaire, administered at recruitment, collated data on demographics, distress and co-morbidity. The follow-up questionnaire, completed after staging investigations, measured perceived WB-MRI scan burden (scored 1 low to 7 high). WB-MRI anatomical coverage, and technical quality was graded by a radiographic technician and grading combined to categorise the scan as "optimal", "sub-optimal" or "degraded". A radiologist categorised 30 scans to test interobserver agreement. Data were analysed using the chi-square, Fisher's exact, t-tests, and multinomial regression.

RESULTS

One hundred and fourteen patients were included in the study (53 lung, 61 colorectal; average age 65.3 years, SD=11.8; 66 men [57.9%]). Overall, 45.6% (n=52), scans were classified as "optimal" quality, 39.5% (n=45) "sub-optimal", and 14.9% (n=17) as "degraded". In adjusted analyses, greater deprivation level and higher patient-reported scan burden were both associated with a higher likelihood of having a sub-optimal versus an optimal scan (odds ratio [OR]: 4.465, 95% confidence interval [CI]: 1.454 to 13.709, p=0.009; OR: 1.987, CI: 1.153 to 3.425, p=0.013, respectively). None of the variables predicted the likelihood of having a degraded scan.

CONCLUSIONS

Deprivation and patients' perceived experience of the WB-MRI are related to image quality. Tailored protocols and individualised patient management before and during WB-MRI may improve image quality.

Prediction of lithium response using clinical data

OBJECTIVE

Promptly establishing maintenance therapy could reduce morbidity and mortality in patients with bipolar disorder. Using a machine learning approach, we sought to evaluate whether lithium responsiveness (LR) is predictable using clinical markers.

METHOD

Our data are the largest existing sample of direct interview-based clinical data from lithium-treated patients (n = 1266, 34.7% responders), collected across seven sites, internationally. We trained a random forest model to classify LR-as defined by the previously validated Alda scale-against 180 clinical predictors.

RESULTS

Under appropriate cross-validation procedures, LR was predictable in the pooled sample with an area under the receiver operating characteristic curve of 0.80 (95% CI 0.78-0.82) and a Cohen kappa of 0.46 (0.4-0.51). The model demonstrated a particularly low false-positive rate (specificity 0.91 [0.88-0.92]). Features related to clinical course and the absence of rapid cycling appeared consistently informative.

CONCLUSION

Clinical data can inform out-of-sample LR prediction to a potentially clinically relevant degree. Despite the relevance of clinical course and the absence of rapid cycling, there was substantial between-site heterogeneity with respect to feature importance. Future work must focus on improving classification of true positives, better characterizing between- and within-site heterogeneity, and further testing such models on new external datasets.

P1466 Pacman heart documented by multimodality echocardiographic techniques

We report a case of a 78-year old female with hypertension, dyslipidemia, atrial fibrillation under warfarin therapy and previously diagnosed HFpEF. She also had a history of recurrent episodes of bilateral inferior limb acute ischemia requiring urgent embolectomy and one previous cardioembolic stroke. She had no history of ischemic heart disease.

She was admitted to our center due to acute decompensated heart failure (NYHA class III). On physical examination there was evidence of pulmonary congestion with bilateral crackles, without heart murmurs. ECG showed AF rhythm, without any other significant changes.

The transthoracic echocardiogram (TTE) showed moderate biventricular hypertrophy with apical predominance and good systolic function. A partial loss of myocardial tissue in the mid segment of the interventricular septum was noticed, with no left-to-right shunt on color Doppler, apparently without interventricular communication (figure A).

For further elucidation of this finding a contrast-enhanced TTE was performed, revealing a serpiginous route through the septum to a small contained cavity within it (figure B). 3D TTE en face views additionally clarified the semilunar shape of this septal defect and its movement during the cardiac cycle, closing during systole and opening during diastole (figure C).

At this point, clinical history and previous diagnostic exams were reviewed. A thoracic CT conducted 3 years before in another clinical context showed that the ventricular septal defect was already present, with similar characteristics (figure D).

As doubts persisted about the existence of interventricular communication, cardiac catheterization with oximetry and ventriculography was performed and interventricular shunt was excluded. There was no evidence of coronary artery disease. Cardiac MRI was not possible due to lack of patient collaboration.

Final diagnosis was a partial ventricular septal defect (PVSD), probably congenital. The patient was discharged under optimized medical therapy.

PVSDs, which are rarely reported in the literature, are thought to be congenital (sporadic or familial) or a consequence of myocardial infarction. They have been described as "Pacman" heart due to the shape changes during the cardiac cycle, becoming slit-like or even absent during systole, like an opening/closing mouth, resembling the Pacman video game. Related complications include conduction disturbances, rupture and disturbed systolic function.

We describe a rare case of a partial ventricular septal defect, documented by multimodality echocardiographic techniques: 2D TTE first showed an incomplete defect of the mid interventricular septum; contrast-enhanced TTE revealed its serpiginous route to a small cavity; 3D TTE en face views further illustrated its semilunar shape and characteristic movement during the cardiac cycle.

Abstract P1466 Figure.

P1718 Multi-modal imaging characterization of contained aortic subannular rupture after transcatheter aortic valve implantation

INTRODUCTION

Aortic annular rupture is a potentially catastrophic complication after transcatheter aortic valve implantation (TAVI), with an estimated incidence of 1%. Rupture occurs in the anatomical device landing zone, that extends from the aortic root to the distal left ventricular outflow tract (LVOT). It usually occurs in the context of highly calcified aortic valve and LVOT, implantation of balloon-expandable valves, valve oversizing and overdilation to treat paravalvular leakage.

CASE REPORT

An 80-year old woman with no past relevant medical history was admitted to our Cardiology Department with decompensated heart failure because of symptomatic severe aortic stenosis, moderate aortic regurgitation and mild left ventricular (LV) dysfunction. She was already in waiting list for TAVI procedure, after being refused for conventional aortic valve replacement due to a "porcelain" aorta. Her pre-operative angiography showed no significant coronary heart disease, and the cardiac computed tomography (cardiac-CT) revealed a severely calcified aortic valve (Agatston score = 4940). An Acurate neo L (27mm) valve was implanted after clinical stabilization with no immediate complications. Because of paravalvular regurgitation, sequential post-dilation was performed with 25mm and 26mm balloons. Post-procedural angiography showed no contrast extravasation (Panel A). In the first hours after the procedure, she was hypotensive with non-specific mild chest discomfort. The EKG showed sinus rhythm with left anterior fascicular block. A transthoracic echocardiogram revealed a moderate pericardial effusion, with no signs of tamponade, and a moderate "paravalvular leak "at the level of the non-coronary cusp to a pulsatile cavity, between the aortic root and the left atrium (Panel B and C). The patient evolved with haemodynamic and electrical stability with no recurrence of chest discomfort. A retrospective cardiac-CT was performed that confirmed the presence of a multilobular cavity below the left coronary artery in continuous with the LVOT, compatible with a contained subannular aortic rupture (Panel E and F), at the level of previous gross calcification in the pre-operative cardiac-CT (Panel D). The case was discussed in Heart Team and a conservative strategy was adopted due to clinical stability and inoperable condition. The patient was discharged at day 28, after CT reavaluation,, that demonstrate similar findings.

CONCLUSION

We report a rare and potentially fatal complication of TAVI with a self-expandable valve. This clinical case illustrates how balloon post-dilation to treat moderate post-procedural paravalvular regurgitation lead to tearing of a highly calcified aortic annulus. A multi-modality imaging approach, with echocardiography and computer tomography, was essential for full anatomical definition of the subannular rupture, clinical decision-making and for follow-up surveillance.

Abstract P1718 Figure. Panel A,B,C,D,E,F.

P1310 Prosthetic valve endocarditis or thrombus?

One cause of constitutional syndrome in patients previously submitted to valve replacement surgery is a prosthetic endocarditis; this occurs in 1-6% of valve surgeries and has an adverse prognosis. Although this is a likely etiology, it is important to keep other possibilities in mind. This clinical case is about a 61 years old male, with known history of smoking, atrial fibrillation anticoagulated with warfarin (with low TTR), and rheumatic fever in childhood, with severe aortic stenosis/regurgitation and moderate mitral regurgitation. In August 2018 he was admitted in our hospital with mitral valve endocarditis cause by Streptococcus agalactiae. He was submitted to an aortic and mitral valve replacement surgery with 2 bioprothesis. Three months later he was admitted again with weight loss, fatigue, dyspnea for small efforts and worsening anemia. The first diagnosis hypothesis was prosthetic endocarditis. The echocardiogram showed normo-functioning aortic bioprothesis; obstructive mitral bioprothesis with an image suggestive of a vegetation; and a de novo mass in the left auricle, compatible with a thrombus. This clinical case was discussed in Heart Team: as the patient was clinically stable, it was opted for an initial conservative approach; although there was a strong clinical suspicion that all the clinical case was due to thrombotic manifestations (assuming that the vegetations had a non-infectious origin), he was nonetheless medicated with vancomycin, gentamicin and rifampicin, as the diagnosis of early culture negative prosthetic endocarditis could not be discarded. He was anticoagulated with enoxaparin. In the reevaluation echocardiogram there was a significative reduction of the left atrial thrombus and disappearance of the mitral valve vegetation image, with improvement of the mitral valve prosthetic gradients. The case was discussed again in Heart Team: due to the clinical evolution, the hypothesis that this was all caused by a thrombotic manifestation grew stronger; it was opted not to submit the patient to a new surgery and the antibiotic therapy was suspended. To study the pro-thrombotic state and the constitutional syndrome, a full body CT was requested: "hilar-mediastinal and bilateral hilar adenopathy; right supraclavicular adenopathy; splenomegaly with infarcted area." The right hilar adenopathy was biopsied; the pathologic exam revealed non-small cells lung carcinoma. The patient was discharged, medicated with warfarin and oriented to outpatient Oncology consult. Any cancer can be associated with thrombotic manifestations. In this case, considering the heavy smoking burden, lung cancer is one of the first etiologies to consider. The thrombotic manifestations of the non-small cells lung carcinoma are due to a paraneoplastic mechanism and might precede the cancer diagnosis. This clinical case highlights the importance of thinking of different etiologies in the differential diagnosis of a constitutional syndrome.

Abstract P1310 Figure. Left auricle mass

P704 Mechanical complications of acute myocardial infarction in the era of early reperfusion therapy: a case report

Introduction

Left ventricular pseudoaneurysm is a rare mechanical complication of myocardial infarction, and its incidence has decreased with the widespread use of reperfusion therapies. Pseudoaneurysm is the result of a free wall rupture contained by pericardial adherences and mural thrombi, which contain the bleeding and prevent cardiac tamponade.

Clinical Presentation

A 68-year-old woman who had hypertension, diabetes mellitus and chronic kidney disease (caused by diabetic nephropathy) was first admitted with acute myocardial infarction of the inferior wall. Emergent coronary angiography revealed proximal occlusion of the right coronary artery. Primary angioplasty was performed with three stents implantation. However due to transitory no reflow, verapamil, nitrate and intracoronary abciximab were administered with recovery of coronary flow. Patient remained stable, without recurrence of symptoms. Echocardiography, at discharge, showed normal biventricular function and no mechanical complications.

Two months later, the patient was readmitted in the emergency room with constant chest pain, fatigue, prostration and loss of appetite beginning ten days earlier and an episode of syncope. Physical examination revealed fever, cardiac auscultation was rhythmic and without murmurs or pericardial friction rub, and pulmonary auscultation revealed crackles in inferior hemithorax. 12-lead electrocardiogram showed sinus rhythm, Q waves and negative T waves in inferior leads. Blood tests revealed leucocytosis, high sensibility troponin I was 28,8 ng/L and brain natriuretic peptide was 264,9 pg/mL. Chest-X-ray demonstrated enlargement of the cardiac silhouette and echocardiography showed moderate to large pericardial effusion with large amounts of fibrin close to right cardiac chambers and a basal inferior pseudoaneurysm with 23 mm x 24 mm; intracavitary contrast was administered without opacification of pericardial space; biventricular function remained normal.

Patient was promptly admitted on Cardiac Intensive Care Unit with diagnosis of pseudoaneurysm due to myocardial infarction. Therapeutic with ticagrelor was suspended and surgical correction was proposed, after discussion in Heart Team. False aneurysm correction was performed with a bovine pericardial patch without complications, and the patient was discharged asymptomatic eight days later.

Conclusion

Even with lower incidence, pseudoaneurysms remains as a potential life-threatening due to its high risk of rupture. Prompt diagnosis, usually with echocardiography and surgical referral are crucial.

Abstract P704 Figure. Inferior Pseudoaneurysm

P863 Large pericardial effusion two months after transcatheter aortic valve implantation: case report of a post-cardiac injury syndrome

We present a case of a 87-year-old female with a symptomatic severe aortic stenosis (aortic valve area 0.9 cm2, mean transvalvular pressure gradient 44 mmHg). She was refused to surgical aortic valve replacement due to marked aortic root calcification. A transcatheter aortic valve (ACCURATE neo™ 27) was electively implanted. In immediate post-procedure, the patient presented an episode of hypotension, rapidly reverted with supportive treatment. A transthoracic echocardiogram (TTE) showed a circumferential mild pericardial effusion (PE) without prosthetic valve disfunction and with preserved biventricular systolic function. Due to paroxysmal episodes of atrial fibrillation, it was decided to withdraw anti-aggregation and to start anticoagulation. Four days after transcatheter aortic valve implantation (TAVI) the patient presented newer intraventricular and atrioventricular conduction disturbance (left bundle branch block and type-I second-degree atrioventricular block). A definitive pacemaker was implanted without complications. PE maintained stable and seven days after TAVI the patient was discharged from hospital.

Two months after TAVI, the patient was admitted to Intensive care unit (ICU) with increasing asthenia, dyspnea and pleuritic thoracic pain over the preceding two weeks. Laboratory workup exhibited elevation of inflammatory markers (leukocytosis and C-reactive protein). A TTE was performed and showed a large circumferential PE (29 mm) with signs of hemodynamic impact (swinging heart, inferior vena cava dilation with &lt;50% inspiratory collapse, right atrial collapse &gt;1/3 of cardiac cycle, proto-diastolic right ventricular collapse and mitral respiratory flow variation &gt;25%). The patient started treatment with anti-inflammatory drugs (aspirin 1000mg every 8h plus colchicine 0.5mg twice daily) and pericardiocentesis was initially postponed. In spite of clinical and echocardiographic improvement, she maintained elevated inflammatory markers and a moderate PE. Prednisolone 30mg daily was added to initial therapy and serial evaluations showed a pronounced reduction of PE as well as of inflammatory markers. Two weeks after admission to ICU the patient was discharged with a residual PE measuring less than 5mm. The previous recent cardiac intervention and the effective response to anti-inflammatory treatment suggest a post-cardiac injury syndrome.

This case report wants to show that post-cardiac injury syndrome is a diagnosis that should be keep in mind after TAVI.

Abstract P863 Figure. TTE showing large pericardial effusion

P1750 Association of high-sensitivity troponin elevation and LVEF decline in anthracycline-treated breast cancer patients

Introduction

Cancer therapies have been linked to a wide variety of side effects, with cardiotoxicity being the most significant one. Early detection of subclinical cardiac dysfunction in cancer patients (pts) is necessary in order to prevent unfavorable outcomes. High-sensitivity troponin I (hsTI) levels have been proposed as predictors of cancer therapy related cardiotoxicity and may guide cardioprotective therapy initiation.

Purpose

To describe the incidence of cancer treatment related cardiac dysfunction (CTRCD) in a population of breast cancer pts under chemotherapy in a single center cardio-oncology unit and to assess its relationship with hsTI levels.

Methods

We retrospectively evaluated 83 women on anthracycline therapy for breast cancer, with or without anti-HER2 therapy, followed-up between January 2017 and July 2018.

CTRCD was defined as more than 10% absolute reduction of LV ejection function (LVEF) to a value below 50%. Elevation of hsTI was defined as at least one measurement above the 99th percentile upper reference limit during follow-up (&gt;34 ng/L).

Pts had an organized follow-up in our cardio-oncology unit, consisting of a clinical, laboratorial (with dosing of cardiac biomarkers) and echocardiographic assessment at 0, 3, 6 and 12 months (or more frequently in selected high-risk cases).

Results

A total of 83 women with a mean age of 49 years (26-76) were included. 4 pts (4.8%) developed CTRCD. 17 pts (20.5%) were considered at high risk of cardiac dysfunction due to hsTI elevation.

During follow-up, the percent increase in the hsTI level (from basal level) correlated with CTRCD (p = 0.02). On the other hand, the absolute maximum value of hsTI did not (p = 0.159).

In fact, pts who developed CTRCD had a significantly higher percent increase in the hsTI levels (142.9% +- 57.5%) vs those without CTRCD (14.29% +- 4.6%), p &lt; 0.001. On ROC curve analysis, percent increase in troponin was a good identifier of CTRCD (AUC of 0.986; 95% CI 0.95-1.00; p = 0.022) and the best cut-off value was a 79.8% increase in hsTI (sensitivity: 100%; specificity: 97.2%).

Conclusion

In our population, the percent increase in the hsTI levels correlated with CTRCD. Larger studies are needed to prove this parameter as a predictor of CTRCD.

Abstract P1750 Figure.

P656 Cardiac dysfunction in breast cancer patients treated with anthracyclines: a single-center experience

Introduction

Cardiac dysfunction is a well-documented side effect of cancer treatment, with significant morbidity and mortality. Cardio-oncology units play a vital role in the early identification and management of cancer therapy related cardiovascular side effects and provide a multidisciplinary care for cancer patients.

Purpose

To describe the incidence of cancer treatment related cardiac dysfunction (CTRCD) in a population of breast cancer patients (pts) under chemotherapy in a single center cardio-oncology unit, and to assess its predictors.

Methods

We retrospectively evaluated 83 women on anthracycline therapy for breast cancer, with or without anti-HER2 therapy, followed-up between January 2017 and July 2018.

CTRCD was defined as more than 10% absolute reduction of LV ejection function (LVEF) to below 50%. Pts with &gt;15% relative percentage reduction from baseline Global longitudinal strain (GLS) or with elevation of high-sensitivity Troponin I (hsTI) levels were considered to be at high risk for developing CTRCD and started cardioprotective treatment with an ACE inhibitor/ARB and a beta-blocker, as did pts with confirmed CRTCD. Also, in pts under antihypertensive drug therapy, switching drugs to cardioprotective ones was performed in the index consultation.

Follow-up was organized in our cardio-oncology consultation at 0, 3, 6 and 12 months (or more frequently in selected high-risk cases). Interruption of chemotherapy was a joint decision of the oncology and cardiology teams.

Results

A total of 83 women with a mean age of 49 years (26-76) were included. 4 pts (4.8%) developed CTRCD. 28 pts (33.7%) were considered to be at high risk due to GLS reduction during follow-up and 17 pts (20.5%) were at high risk due to hsTI elevation.

From all the baseline characteristics, only basal BNP correlated with CTRCD (p = 0.033). Other characteristics such as age, presence of cardiovascular risk factors and the previously proposed Cardiotoxicity Risk Score (CRS) did not.

There was a high percentage of pts (51.8%; n = 43) under cardioprotective drugs. 37% of the pts initiated cardioprotective drugs following cardio-oncology consultation. Chemotherapy was discontinued in only 2 pts (2.4%).

Conclusion

CTRCD is difficult to predict by baseline clinical characteristics. Monitoring and management of CTRCD by a multidisciplinary cardio-oncology team resulted in a high rate of cardioprotective drugs use and low rate of permanent discontinuation of chemotherapy. Further studies are needed to further analyze the relationship between these two variables.

1115 Ultra-slow low-dose thrombolytic therapy as an option of treatment in intracardiac thrombus: a case report

We present a case of a 57-year-old male with previously known primary severe mitral regurgitation, who was admitted to the ICU due to massive venous thromboembolism with associated right ventricle dysfunction and with two large mobile right atrial thrombi (2.4 x 1.5 cm and 3.6 x 3.7 cm). Despite of five days with a therapeutic aPTT achieved with unfractionated heparin (UFH), a TTE showed deterioration of the right ventricle systolic function, persistence of the right atrial masses with similar dimensions together with new mobile thrombi on the coronary sinus and on the right pulmonary artery. Due to deterioration of his clinical condition and given the refractoriness to the classical treatment with UFH, it was decided to administer an ultra-slow low-dose thrombolysis protocol, which consisted in a 24-hour infusion of 24 mg of alteplase at a rate of 1 mg per hour, without bolus. The treatment was continued by 48 consecutive hours, with clinical improvement and important reduction of the right atrial masses with resolution of the coronary sinus and right pulmonary artery thrombi. The patient started hypocoagulation with warfarin bridging with low molecular weight heparin (LMWH). Seven days after alteplase discontinuation there was complete resolution of the intracardiac thrombi. One month after ICU admission a successful mitral valve replacement surgery was conducted. Three months after discharge, the patient is in functional New York Heart Association (NYHA) class I with no cardiovascular events or hospitalizations. This case demonstrates that ultra-slow low-dose thrombolysis is a valid bailout treatment option in patients with large intracardiac thrombi refractory to anticoagulation.

Abstract 1115 Figure. TTE showing right atrial masses

Aging and Proteins: What Does Proteostasis Have to Do with Age?

The world is aging and we must face the challenges that this brings. One of the reasons for the increasing aging of the world's population is the increase in life expectancy and, since we live longer, it is of paramount importance to live well and to prevent age-associated diseases. In this way, it is crucial to improve knowledge of the aging process and of the mechanisms that contribute to it. Ideally it would be of great interest to have a panel of biomarkers of healthy aging that would allow an estimate of the biological age of an individual. One of the changes that greatly contribute to aging is the loss of protein homeostasis, also called proteostasis. To ensure the proper function of cells and to maintain cellular proteostasis, organisms have developed systems to control protein synthesis, folding and degradation. Loss or dysfunction of proteostasis is at the root of many well-studied human neurological diseases, such as Alzheimer's disease and, more recently, it has been implicated in the aging process with some reports showing long-lived animals to have improved proteostasis. Growing evidence suggests a strong link between modifications in the quantity and/or activity of several players involved in proteostasis and longevity. In this review, we give an overview of the main characteristics of aging with focus on proteostasis. We present how changes in components of proteostasis, during aging, impact the lifespan of model organisms. We also briefly review the current state of aging biomarkers and discuss the potential of proteostasis network components as markers of healthy aging.

In vitro susceptibility and multilocus sequence typing of Fusarium isolates causing keratitis

Fungal keratitis is recognized as a significant cause of ocular morbidity and blindness especially in developing countries. In this study, we aimed to present the molecular identification and susceptibility of Fusarium isolates causing fungal keratitis in a university hospital in southern Brazil. The samples were identified using the second largest subunit of the RNA polymerase gene (RPB2) and the translation elongation factor 1-alpha (TEF1), while the antifungal susceptibility was tested by the broth microdilution method according to the Clinical and Laboratory Standards Institute (CLSI) methodology. The majority of the isolates belonged to the Fusarium solani species complex (F. solani, F. keratoplasticum and F. falciforme) and Fusarium oxysporum species complex. Antifungal susceptibility has shown that amphotericin B and natamycin were the most effective antifungals across all isolates, followed by voriconazole. Variation among Fusarium complexes in their antifungal sensitivities was observed in our study. The identification of Fusarium species from human samples is important not only from an epidemiological viewpoint, but also for choosing the appropriate antifungal agent for difficult-to-treat Fusarium infections such as keratitis.

Abstract OT2-07-04: A phase 2 study of ONC201 in recurrent/refractory metastatic breast cancer and advanced endometrial carcinoma

Background: Advanced breast cancer (BC) and endometrial cancer (EC) have limited treatment options with no treatments improving survival. ONC201 is the founding member of a novel class of anticancer drugs called impiridones. The drug is orally bioavailable and crosses the blood brain barrier. Preclinical studies have demonstrated that ONC201 selectively kills various cancer cells, including all subtypes of BC and EC, while having little effect on normal cells. An on-going Phase 1 study of ONC201 has demonstrated clinical benefit in some solid tumors, including EC and glioblastomas.

Trial Design: Phase 2 single arm study of ONC201 with 3 cohorts: Cohort 1, female and male hormone receptor positive breast cancer (HR+BC); Cohort 2, female and male triple negative breast cancer (TNBC); and Cohort 3, EC. All patients will receive ONC201 at the recommended Phase 2 dose of 625mg by mouth q7 days (1 cycle = 28 days). Patients will undergo a baseline biopsy as well as a biopsy after 5 doses of ONC201 (C2D2). Patients will be evaluated for response every two cycles (8 weeks) by RECIST 1.1.

Eligibility Criteria: Measurable disease with &gt;1 biopsiable lesion, willing to undergo biopsies. Cohort 1 (HR+BC) requires prior treatment with &gt;2 lines of hormonal treatment. No prior treatment required for the other cohorts. Patients must have ECOG 0-1 and adequate organ function. Patients with asymptomatic or brain metastases treated &gt; 4 weeks from study entry are eligible. Exclusion criteria include: symptomatic CNS metastases, radiotherapy ≤ 4 weeks from study entry, HIV, Hepatitis B or Hepatitis C.

Specific Aims: Primary objectives for this study are progression free survival (PFS) at 8 months for Cohort 1 (HR+BC) and overall response rate (ORR) for Cohorts 2 and 3 (TNBC and EC). Secondary objectives include safety, clinical benefit rate (CBR = partial response + complete response + stable disease), and overall survival.

Statistical Methods: This study has been designed to pause prior to full accrual to allow for evaluation of futility prior to proceeding to full accrual. In Cohort 1, if &gt;1 of 5 patients is progression-free at 8 months, then we will recruit up to 24 patients. In Cohort 2, if &gt;2 of 10 patients has clinical benefit then we will recruit up to 29 patients. For Cohort 3, if 1 of 13 patients has clinical benefit, then we will recruit up to 25 patients. Additional evaluations of tumor or blood samples performed will be done in an exploratory fashion, with results presented without any formal adjustment for multiple comparisons.

Target Accrual: 24 patients with HR+BC, 29 patients with TNBC, and 25 patients with EC.This trial will open Summer 2017 at the National Institutes of Health (Bethesda, MD).

Contact Information: Principal Investigator Alexandra S Zimmer, MD; alexandra.zimmer@nih.gov

Citation Format: Gatti-Mays ME, Greer Y, Steinberg S, Soltani S, Collins J, Olson M, Ojemuyiwa M, Annunziata C, Lee J-M, Nunes A, Lipkowitz S, Zimmer A. A phase 2 study of ONC201 in recurrent/refractory metastatic breast cancer and advanced endometrial carcinoma [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr OT2-07-04.

Renal Transplantation in HIV-Infected Patients: The First Portuguese Review

INTRODUCTION

With the introduction of combination antiretroviral therapy (cART), prognosis of human immunodeficiency virus (HIV) infection has been improved and kidney transplantation (KT) in HIV-positive patients became possible.

METHODS

We reviewed the demographic, clinical, laboratory, and therapeutic data of all the HIV-infected patients who underwent KT between 2009 (first KT in Portugal in a HIV-infected patient) and May 2014. Case accrual was through all Portuguese KT centers where a KT in an HIV-infected patient was performed. Patients were transplanted following the American and Spanish guideline recommendations that included maintenance on cART, undetectable plasma HIV RNA copies, and absolute CD4 counts of ≥ 200 cells/μL in the last 6 months.

RESULTS

Fourteen KT were performed on men and 3 on women. The mean age of patients at the time of transplantation was 49.9 ± 11.7 years. HIV status was known for 12 ± 5 years. Eight patients had AIDS in the past and all patients received grafts from deceased donors. Twelve patients (64.7%) underwent induction therapy with basiliximab and 2 patients experienced early graft loss. In 2 patients, humoral rejection was diagnosed and in 3 patients, cellular rejection. Two patients died and an additional patient had early graft loss.

CONCLUSION

KT is a possible, but challenging, renal replacement therapy in selected HIV-positive patients. Even in those with AIDS criteria in the past, when the disease is controlled, and after the reconstitution of the immune system with cART, KT can be performed. Nevertheless, the risk-benefit ratio for each patient needs to be taken in consideration.

Sympatric occurrence of Culex pipiens (Diptera, Culicidae) biotypes pipiens, molestus and their hybrids in Portugal, Western Europe: feeding patterns and habitat determinants

Culex (Culex) pipiens (Diptera: Culicidae) has two recognized biotypes, pipiens and molestus, which differ in physiology and behaviour; this difference may influence vectorial capacity for West Nile virus (WNV). Our goal was first to determine the presence of Cx. pipiens populations in 31 locations in Portugal and to subsequently analyse their host-feeding preferences and habitat determinants. Molecular identification of Cx. pipiens forms and their hybrids was performed in 97 females; bloodmeal sources were identified in 59 engorged specimens. Overall, 61.9% of specimens were identified as Cx. pipiens f. pipiens, 20.6% as Cx. pipiens f. molestus, and 17.5% as hybrid forms. Culex pipiens f. pipiens fed preferentially on birds, and Cx. pipiens f. molestus on humans. Hybrid forms fed mostly on birds, but human bloodmeals were common. With reference to habitat, Cx. pipiens f. pipiens and hybrid forms were positively correlated with peri-urban habitats. Our results confirm the sympatric presence of different Cx. pipiens biotypes in 14 of the 31 locations studied. Peri-urban areas were a common habitat of all biotypes and may represent zones of hybridization. The feeding preferences and sympatric distribution of the Cx. pipiens biotypes observed in Portugal favour the epizootic circulation of WNV and the occurrence of disease outbreaks of WNV.

Assessment of paediatric CT exposure in a Portuguese hospital

In this study, the characterisation of radiation exposure of paediatric patients in computerised tomography (CT) procedures was performed for a Portuguese hospital. Dosimetric data and technical parameters used for CT examinations were retrieved, compiled and analysed over a period of 1 y. Five paediatric age groups were considered, covering the age interval from 0 (newborn) to 18 y old and, for each age group, the relative frequency of the most frequent CT examinations (head, ears, sinuses, chest and abdomen examinations) is analysed. The exposure settings used (kilovolt and milliampire) were compared with the values established in the local (hospital) clinical protocols for consistency analysis. Average CT dose index(vol) and dose length product values, per age group, are presented as well as the corresponding estimated mean effective dose values. Results showed an evident need for a protocol review, in order to adjust practices to international guidelines for performing optimised paediatric CT examinations. Also, an increased awareness of staff to Radiological Protection principles in CT in particular, these of utmost importance, seems necessary.

Phase lag in epidemics on a network of cities

We study the synchronization and phase lag of fluctuations in the number of infected individuals in a network of cities between which individuals commute. The frequency and amplitude of these oscillations is known to be very well captured by the van Kampen system-size expansion, and we use this approximation to compute the complex coherence function that describes their correlation. We find that, if the infection rate differs from city to city and the coupling between them is not too strong, these oscillations are synchronized with a well-defined phase lag between cities. The analytic description of the effect is shown to be in good agreement with the results of stochastic simulations for realistic population sizes.

Stochastic oscillations in models of epidemics on a network of cities

We carry out an analytic investigation of stochastic oscillations in a susceptible-infected-recovered model of disease spread on a network of n cities. In the model a fraction f(jk) of individuals from city k commute to city j, where they may infect, or be infected by, others. Starting from a continuous-time Markov description of the model the deterministic equations, which are valid in the limit when the population of each city is infinite, are recovered. The stochastic fluctuations about the fixed point of these equations are derived by use of the van Kampen system-size expansion. The fixed point structure of the deterministic equations is remarkably simple: A unique nontrivial fixed point always exists and has the feature that the fraction of susceptible, infected, and recovered individuals is the same for each city irrespective of its size. We find that the stochastic fluctuations have an analogously simple dynamics: All oscillations have a single frequency, equal to that found in the one-city case. We interpret this phenomenon in terms of the properties of the spectrum of the matrix of the linear approximation of the deterministic equations at the fixed point.

Stochastic effects in a seasonally forced epidemic model

The interplay of seasonality, the system's nonlinearities and intrinsic stochasticity, is studied for a seasonally forced susceptible-exposed-infective-recovered stochastic model. The model is explored in the parameter region that corresponds to childhood infectious diseases such as measles. The power spectrum of the stochastic fluctuations around the attractors of the deterministic system that describes the model in the thermodynamic limit is computed analytically and validated by stochastic simulations for large system sizes. Size effects are studied through additional simulations. Other effects such as switching between coexisting attractors induced by stochasticity often mentioned in the literature as playing an important role in the dynamics of childhood infectious diseases are also investigated. The main conclusion is that stochastic amplification, rather than these effects, is the key ingredient to understand the observed incidence patterns.